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Euthanasia in Belgium: Legal, historical and political review
Abstract
This article describes and evaluates the Belgian euthanasia experience by considering its practice and policy, both before and after the formal decriminalisation of euthanasia in 2002. The pre-legal practice of euthanasia, the evolution of euthanasia legislation, criticism of this legislation, the influence of politics, and later changes to the 2002 Act on Euthanasia are discussed, as well as the subject of euthanasia of minors and the matter of organ procurement. It is argued that the Belgian euthanasia experience is characterised by political expedition, and that the 2002 Act and its later amendments suffer from practical and conceptual flaws. Illegal euthanasia practices remain a live concern in Belgium, something which nations who are seeking to decriminalise euthanasia should consider.
... We identified a total of 59 reports that provided any type of guidance for organ donation after MAiD. 1,3,4,8, There are various legislations in place to regulate MAiD, but in our searches, we did not identify specific legislation regulating the practice of organ donation following MAiD. Also, we limited our discussions to the 3 countries where organ donation following MAiD is legal (Canada, Belgium, and The Netherlands). ...
... Organ donation following MAiD is considered a controlled donation (where the death is expected and under controlled conditions) rather than an uncontrolled donation (where the death is unexpected and occurs in uncontrolled conditions and/or settings). The Maastricht category is a classification system used internationally to categorize organ donation following circulatory-determined death (DCD) in controlled and uncontrolled death (DCD I to IV). 38 To keep updated with the practice of organ donation following MAiD, the Belgian Transplantation Society and Belgian Transplantation Council updated the definition of DCD to include euthanasia as a new controlled DCD category V. 1,48,56,65 The updated classification nomenclature can be found in Table 1. In The Netherlands, there is no official category for patients who request MAiD (eg, DCD-V in Belgium), and organ donors from MAiD are considered Maastricht category III. ...
... In Belgium, MAiD was endorsed by the Belgian Euthanasia Act 2002. 1,4,28,56,66,73,75 In The Netherlands, MAiD was enacted through the Dutch Euthanasia Act 2002 (Dutch Termination of Life on Request and Assisted Suicide Act). 3,4,28,69,70,73 More details regarding this legislation and the eligibility criteria can be found in Appendix III. ...
Objective:
The objective of this review was to collate and summarize the current literature on what is known about organ donation following medical assistance in dying (MAiD). Additionally, for this part I of a two-part series scoping review, the focus is on legal and ethical considerations regarding organ donation following MAiD.
Introduction:
Organ donation following MAiD is a relatively new procedure that has sparked much debate and discussion. A comprehensive investigation into the legal and ethical aspects related to organ donation following MAiD is needed to inform the development of safe and ethical practices.
Inclusion criteria:
In this review, we included documents that investigated legal and/or ethical issues related to individuals who underwent organ donation following MAiD in any setting (eg, hospital or home) worldwide. We considered quantitative and qualitative studies, text and opinion papers, gray literature, and unpublished material provided by stakeholders.
Methods:
This scoping review followed JBI methodology. Published studies were retrieved from databases, including MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), Web of Science: Science Citation Index and Social Science Citation Index, and Academic Search Complete (EBSCOhost). Gray and unpublished literature included reports from organ donation organizations in Canada, The Netherlands, and Belgium. Two independent reviewers screened all reports (both by title and abstract and by full text) against the inclusion criteria, extracted data, and completed a content analysis. Disagreements between the 2 reviewers were resolved through discussions among the reviewers and the first author.
Results:
We included 121 studies for parts I and II of our scoping review, 88 of which are included in part I. The majority of the 88 documents were discussion papers published in English (79.5%) and in Canada (39.7%) from 2019 to 2021. In the content analysis, we identified 4 major categories regarding ethical and legal aspects of organ donation following MAiD: i) legal definitions, legislation, and guidelines; ii) ethics, dilemmas, and consensus; iii) consent and objection; and iv) public perceptions. We identified the main legislation regulating the practices of organ donation following MAiD in countries where both procedures are permitted, the many ethical debates surrounding this topic (eg, eligibility criteria for organ donation and MAiD, disclosure of donors' and recipients' information, directed organ donation, death determination in organ donation following MAiD, and ethical safeguards for organ donation following MAiD), as well as the public perceptions of this process.
Conclusions:
Organ donation following MAiD has raised many legal and ethical concerns regarding establishing safeguards to protect patients and families. Despite the ongoing debates around the risks and benefits of this combined procedure, when patients who request MAiD want to donate their organs, this option can help fulfill their last wishes and diminish their suffering, and this should be the main reason to offer organ donation following MAiD.
... Secondly, the provisions of the Act are very detailed and also provide for many special cases in detail. Thirdly, the Belgian Euthanasia Act provides for an advance notice system for the first time [4]. The question of whether a doctor has the right to euthanize a patient who is already unconscious and whether someone else has the right to apply for euthanasia has been resolved. ...
The question of whether euthanasia is a means for the elimination of misfeasance has always been the focus of international attention and difficulty. Traditional studies on euthanasia have been devoted to exploring the rationality as well as the legality of euthanasia. Meanwhile, the legislative techniques of euthanasia were explored on the basis of the existing studies on euthanasia. Instead, this paper is dedicated to examining the reasons inherent in the legality of euthanasia in various countries. The current international situation with regard to euthanasia legislation was presented, and the background of countries in the world that currently have euthanasia legislation and their legal documents were described. The underlying reasons for the different attitudes towards euthanasia in countries with different development models were analyzed by comparing the attitudes towards euthanasia in developing and developed countries without euthanasia legislation, as well as the relevant drafts, proposals, and cases, and the corresponding recommendations were proposed to promote the way forward for euthanasia legislation in China. It is concluded that different factors, such as the economy, religion, and social risk-taking, have different influences on attitudes towards euthanasia in countries with different development models. For euthanasia legislation in mainland China, it is suggested that corresponding legislative proposals should be made in both substantive and procedural aspects, with Chinas national conditions taken into account.
... However, in 2014, euthanasia in Belgium was extended to severely ill minors. The regulation is significant because it breaks the traditional age limit for euthanasia [7]. ...
With the development of society, people's understanding of the right to life goes deeper and deeper. In order to alleviate the pain, people seek euthanasia more and more strongly. Through the methods of case analysis and comparative analysis, this paper summarizes the legal norms of China, the Netherlands, Belgium and other countries, studies the theories of the value of life, the source of rights, freedom of will, moral ethics, social development and other aspects. This paper also analyzes the practical obstacles to the legalization of euthanasia in combination with Chinese Confucianism, professional ethics and legal ethics, provide modest suggestions for the implementations of euthanasia in China from four dimensions of subject, subjective, objective, procedure.
... Even though the availability of organ donation following MAiD has the potential to decrease organ shortage and help patients on transplant waiting list, [1,3,6,[13][14][15][16][17][18][19][20][21]24,27,28,37,38,41,42,[46][47][48][49][50]56,57,[65][66][67][68][69]73] the impact on the donor pool may be minor since donation after MAiD is still relatively rare as only a few countries allow this process [37,58,63]. Some authors argue that even if small, the availability of donation after MAiD can save the lives of patients on the transplant waiting list [3,40]. ...
Aim:
To collate and summarize the current international literature on the transplant recipient outcomes of organs from Medical Assistance in Dying (MAiD) donors, as well as the actual and potential impact of organ donation following MAiD on the donation and transplantation system.
Background:
The provision of organ donation following MAiD can impact the donation and transplantation system, as well as potential recipients of organs from the MAiD donor, therefore a comprehensive understanding of the potential and actual impact of organ donation after MAiD on the donation and transplantation systems is needed.
Design:
Scoping review using the JBI framework.
Methods:
We searched for published (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Academic Search Complete), and unpublished literature (organ donation organization websites worldwide). Included references discussed the actual and potential impact of organ donation following MAiD on the donation and transplantation system. All references were screened, extracted and analysed by two independent reviewers.
Results:
We included 78 references in this review and our finding were summarized across three categories: (1) Impact in the donor pool: (2) statistics on organ donation following MAiD; and (3) potential and actual impact of MAiD on the donation and transplant system.
Conclusions:
The potential impact of the MAiD donor on the transplant waiting list is relatively small as this process is still rare, however, due to the current organ shortage worldwide the contribution of this procedure should not be disregarded. Additionally, despite being limited, the existing research provided scanty evidence that organs retrieved from MAiD donors are associated with satisfactory graft function and survival rates and that outcomes from transplant recipients are comparable to those of organs from donation following brain death and may be better than those of organs from other types of donation after circulatory determined death. Still, further studies are required for comprehensive and reliable evidence.
Objective:
The objective of this review is to collate and summarize the current literature on what is known about organ donation following. For this part II of a 2-part series scoping review, the focus is on the existing procedures and processes for organ donation following MAiD.
Introduction:
Organ donation following MAiD is a novel and contentious issue worldwide. To give direction for future research and initiatives, a comprehensive understanding of the available evidence of existing procedures and processes for organ donation following MAiD is needed.
Inclusion criteria:
For this review, our population of interest included all individuals who underwent organ donation following MAiD; our concept was defined as procedures and processes involved in organ donation after MAiD; and the context was reports of organ donation following MAiD at home or in any health care setting worldwide. We considered quantitative and qualitative studies, text and opinion papers, gray literature, and unpublished material provided by stakeholders.
Methods:
This scoping review was conducted in line with JBI methodology. Published studies were retrieved from MEDLINE (Ovid), Embase, CINAHL (EBSCOhost), PsycINFO (Ovid), Web of Science - Science Citation Index and Social Science Citation Index, and Academic Search Complete (EBSCOhost). Gray and unpublished literature included reports from websites and organ donation organizations in Canada, Belgium, and The Netherlands. Two independent reviewers screened all reports (both title and abstract, and full text) against the predetermined inclusion criteria, extracted data, and completed a content analysis. Any disagreements between the 2 reviewers were resolved through discussion or with another author.
Results:
We included 121 documents across the two-part series, and we are reporting on 103 in this part II. The majority of the 103 documents were discussion papers, published in English and in Canada from 2019 to 2021. In the content analysis, we identified 5 major categories regarding existing procedures and processes of organ donation following MAiD: i) clinical pathways for organ donation following MAiD; ii) organ donation following MAiD and the donor; iii) clinical practice tools for organ donation following MAiD; iv) education and support for health care providers involved in organ donation following MAiD; and v) health care providers' roles and perceptions during organ donation following MAiD.
Conclusions:
Findings from this review can be used to provide support and guidance for improvements in procedures and processes, as well as a rich resource for countries currently planning to establish programs for organ donation after MAiD.
Objective: To identify and describe requirements, recommendations, and templates for the documentation of sedation in adult palliative care. Introduction: International literature shows inconsistency in clinical practice regarding sedation in palliative care accompanied by legal, ethical, and medical uncertainties. Documentation in general serves as proof for previous treatments. In the context of intentional sedation to relieve suffering at the end of life, documentation provides a clear demarcation against practices of euthanasia. Inclusion Criteria: Articles with full-text version published in English or German since 2000, covering documentation requirements, recommendations, monitoring parameters or templates for sedation in adult palliative care were included. Methods: Scoping review following the JBI methodology. Search in online databases, websites of professional associations in palliative care, reference lists of relevant publications, the archive of the German "Journal of Palliative Medicine" and databases for unpublished literature were used. Search terms included "palliative care,' "sedation," and "documentation." The search was conducted from January 2022 to April 2022 with an initial hand search in November 2021. Data were screened and charted by one reviewer after conducting a pilot test of the criteria. Results: From the initial 390 articles (database search), 22 articles were included. In addition, 15 articles were integrated from the hand search. The results can be clustered in two sets of items, regarding either the documentation before or during sedation. The documentation requirements referred both to inpatient and homecare settings but in many cases, a clear assignment was missing. Conclusions: The guidelines analyzed in this study rarely cover setting-specific differences in documentation and often treat documentation as minor topic. Further research is needed addressing legal and ethical concerns of health care teams and, therefore, help to improve treatment of patients suffering from otherwise intractable burden at the end of life.
Background
Belgium is one of the few countries worldwide where euthanasia on the grounds of unbearable suffering caused by a psychiatric disorder is legally possible. In April 2010 euthanasia was carried out on a 38-year-old Belgian woman with borderline personality disorder and/or autism. After a complaint by the family, three physicians were referred to the Court of Assizes on the charge of “murder by poisoning”.
Methods
A content analysis of print and online news coverage of the euthanasia case in a selected sample of Flemish newspapers and magazines, published between December 1, 2019 and March 1, 2020, was conducted to analyze the prominence and framing of the euthanasia case, as well as the portrayal of key figures in this case. A quantitative analysis, as well as an in-depth qualitative analysis (with the aid of NVivo 1.0 software) was performed.
Results
One thousand two hundred fifteen news articles were identified through database searching. Of these, 789 articles were included after screening for relevance and eligibility. Mean prominence scores were moderate and did not statistically significantly differ between newspapers with a different historical ideological background or form (elite versus popular). The most frequent headline topics featured legal aspects (relating to the Belgian Euthanasia Law or the course of the trial). Headlines and content of most articles (90 and 89%, respectively) did not contain an essential standpoint on the euthanasia case itself or, if they did, were neutral. Historical ideological background, nor form of newspaper (elite versus popular) significantly influenced headline tone or article direction toward the euthanasia case. Despite this, our qualitative analysis showed some subtle differences in selection, statement or tonality of reports between certain newspapers with a different historical ideological background.
Conclusion
Although major Flemish newspapers and magazines generally were neutral in their coverage of the judicial case, major points of contention discussed were: the need for an evaluation and possible amendments to the existing Euthanasia Law, including a revision of the Belgian Control Commission and the system of penalties for physicians, and the absence of any consensus or guidance on how to define psychological suffering.
Many commentators today lament the politicization of bioethics, but some suggest distinguishing among different kinds of politicization. This essay pursues that idea with reference to three traditions of political thought: liberalism, communitarianism, and republicanism. After briefly discussing the concept of politicization itself, the essay examines how each of these political traditions manifests itself in recent bioethics scholarship, focusing on the implications of each tradition for the design of government bioethics councils. The liberal emphasis on the irreducible plurality of values and interests in modern societies, and the communitarian concern with the social dimensions of biotechnology, offer important insights for bioethics councils. The essay finds the most promise in the republican tradition, however, which emphasizes institutional mechanisms that allow bioethics councils to enrich but not dominate public deliberation, while ensuring that government decisions on bioethical issues are publicly accountable and contestable.
Organ donation after euthanasia has been performed more than 40 times in Belgium and the Netherlands together. Preliminary results of procedures that have been performed until now demonstrate that this leads to good medical results in the recipient of the organs. Several legal aspects could be changed to further facilitate the combination of organ donation and euthanasia. On the ethical side, several controversies remain, giving rise to an ongoing, but necessary and useful debate. Further experiences will clarify whether both procedures should be strictly separated and whether the dead donor rule should be strictly applied. Opinions still differ on whether the patient's physician should address the possibility of organ donation after euthanasia, which laws should be adapted and which preparatory acts should be performed. These and other procedural issues potentially conflict with the patient's request for organ donation or the circumstances in which euthanasia (without subsequent organ donation) traditionally occurs.
The 2012 and 2013 solid organ transplantation statistics were presented during the annual meeting of the Belgian Transplant Society.
All data presented were collected from Eurotransplant International Foundation and/or from all individual Belgian transplant centers.
It was demonstrated that the highest number of deceased donors detected (1310) from which 47.8% were an effective organ donor that corresponded to 29 per million inhabitants (pmi) in 2012 and 27.4 pmi in 2013. Out of 626 effective deceased organ donors, 491 (79%) were donors after brain death (DBD) and 135 (21%) donors after circulatory death (DCD), respectively. The majority (125/135; 93%) of DCD donors were DCD Maastricht category III donors and there were 7 (5%) donations following euthanasia. Family refusal tended to be lower for DCD (10.4%) compared to DBD donors (13.4%). Despite the increasing DCD donation rate, DBD donation remains stable in Belgium. The donor age is still increasing, reaching a median age of 53 years (range 0-90). Spontaneous intracranial bleeding (39.3%) and cranio-cerebral trauma (25%) remained the most frequent reasons of death. The number of living related kidney transplantations (57 in 2012 and 63 in 2013) followed the international trend albeit in Belgium it is still very limited. Nevertheless this activity could explain that the number of patients waiting for kidney transplantation (770) reached an absolute minimum in 2013. Except the reduced waiting list for lung transplantation (from 119 patients in 2011 to 85 in 2013), the waiting list remained stable for the other organs but almost 200 patients still died while on the waiting list.
Belgium demonstrated the highest number of effective organ donors that corresponded to 29 per million inhabitants (pmi) in 2012 and 27.4 pmi in 2013. Thus far, and in contrast with other countries, there is no erosion of DBD in the DCD donor organ pool, but it is the important responsibility of all transplant centers and donor hospitals to avoid a substitution from DBD by DCD donors.
Euthanasia was legalized in Belgium in 2002 for adults under strict conditions. The patient must be in a medically futile condition and of constant and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident. Between 2005 and 2007, 4 patients (3 in Antwerp and 1 in Liège) expressed their will for organ donation after their request for euthanasia was granted. Patients were aged 43 to 50 years and had a debilitating neurologic disease, either after severe cerebrovascular accident or primary progressive multiple sclerosis. Ethical boards requested complete written scenario with informed consent of donor and relatives, clear separation between euthanasia and organ procurement procedure, and all procedures to be performed by senior staff members and nursing staff on a voluntary basis. The euthanasia procedure was performed by three independent physicians in the operating room. After clinical diagnosis of cardiac death, organ procurement was performed by femoral vessel cannulation or quick laparotomy. In 2 patients, the liver, both kidneys, and pancreatic islets (one case) were procured and transplanted; in the other 2 patients, there was additional lung procurement and transplantation. Transplant centers were informed of the nature of the case and the elements of organ procurement. There was primary function of all organs. The involved physicians and transplant teams had the well-discussed opinion that this strong request for organ donation after euthanasia could not be waived. A clear separation between the euthanasia request, the euthanasia procedure, and the organ procurement procedure is necessary.
57 Dutch law came into force in
- Meulenbergs
- Op Cit Schotsmans
Meulenbergs, and Schotsmans, op. cit., p. 91.
57 Dutch law came into force in April 2002.