ArticlePDF AvailableLiterature Review

Euthanasia in Belgium: Legal, historical and political review

Authors:

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.
A preview of the PDF is not available
... Belgium's initial policies around minors receiving physicianassisted death in the 2002 Act on Euthanasia were more conservative than the Dutch in that minors were at first required to be at least 16 years of age and able to provide consent (Saad, 2017). The act was amended in 2014 to eliminate the age restriction for individuals allowed to receive MAiD and add the ability for parents to provide consent on behalf of their children. ...
... Following legalization of euthanasia, Belgium has undergone extensive data collection regarding the consequences of the new law. Although it is required by law for physicians to report all euthanasia cases, it was found in a review conducted by Saad (2017) that only about half of cases were actually being reported. The same review sought to understand why and found that approximately 76% of cases were not reported because the physician did not believe their case was euthanasia. ...
... Failure to comply with this rule could potentially be due to the misunderstanding of the definition of euthanasia in that physicians do not recognize the case as euthanasia and therefore do not believe they need to consult with another physician. Between June and November 2007 in the Flanders region in Belgium, it was estimated that euthanasia and physician-assisted suicide accounted for approxi-3 mately 2% of deaths (Saad, 2017). Of the 208 identified cases during this time frame, five were a result of physician-assisted suicide, which is illegal in Belgium, and 66 cases were carried out without the explicit consent of the individual. ...
Article
Full-text available
Individuals suffering intolerably from a medical condition are legally able to request medical assistance in dying (MAiD) under certain circumstances. MAiD can either entail a physician or nurse practitioner prescribing fatal drugs for the patient to self-administer (physician-assisted suicide) or a physician directly administering lethal drugs (euthanasia). Whereas laws regulating MAiD have been in effect in different areas of the world since 1942, Canada only recently decriminalized MAiD in 2016. Individuals under the age of 18 years are not permitted to receive MAiD in Canada. Because legislation exists in other countries that permit MAiD, the current review aims to (a) review legislation and data pertaining to MAiD in Canada and other countries with particular attention on legislation for minors; (b) address important ethical considerations for extending MAiD services to minors in Canada; and (c) provide recommendations for amendments to current MAiD legislation in Canada based on the findings. Combining data from other countries with ethical implications for offering all options to relieve suffering, it is recommended that Canada extend MAiD legislation to mature minors with the inclusion of psychologists in the assessment of decision-making capacity and informed consent.
... 4,[12][13][14][15] Sometimes, sedation is used (or abused) to hasten the patient's death (described as ''slow/passive euthanasia''). [16][17][18] However, palliative sedation in Belgium requires no formal reporting, in contrast to countries such as Canada, where registration of this practice is required by law and a written informed consent from the patient or representative must be obtained by the physician before initiating any form of palliative sedation, irrespective of its expected depth or duration. 14,17,19,20 Detailed reporting of concrete palliative sedation cases may possibly also be necessary in Belgium, to thoroughly evaluate the current practice of palliative sedation and subsequently plan actions for improvements wherever appropriate. ...
... [16][17][18] However, palliative sedation in Belgium requires no formal reporting, in contrast to countries such as Canada, where registration of this practice is required by law and a written informed consent from the patient or representative must be obtained by the physician before initiating any form of palliative sedation, irrespective of its expected depth or duration. 14,17,19,20 Detailed reporting of concrete palliative sedation cases may possibly also be necessary in Belgium, to thoroughly evaluate the current practice of palliative sedation and subsequently plan actions for improvements wherever appropriate. 16,21 In this pilot study, reporting was done retrospectively within two weeks after the death of the patient. ...
Article
Background: Palliative sedation requires no formal registration in Belgium. For euthanasia, however, there are clear guidelines in certain countries, including mandatory registration and evaluation of cases. Official guidelines have been developed for palliative sedation, but research still shows unskilled use of sedation and unclear demarcation between palliative sedation and euthanasia. Registration could be used to avoid unskilled use of sedation and to avoid use or abuse of sedation to hasten the patient's death (described as ''slow/passive euthanasia''). Objective: To evaluate the current practice of palliative sedation and use of opioids and sedatives at the end of life by using a registration document. Design: Retrospective observational study. Setting/Subjects: We included all in-hospital deaths at an academic hospital in Belgium of patients (age ‡18 years) who had received parenteral opioids, benzodiazepines, barbiturates, or other anesthetics during the last 24 hours. Measurements: We investigated indications for palliative sedation, patients' and physicians' characteristics, types of medication used, and the decision-making process with the patients and family. The questionnaires were collected between July 9 and November 25, 2016. The study was approved by the Biomedical Ethics Committee of UZ Brussel (B.U.N. 1432016293). Results: In a population of 124 patients, refractory symptoms were reported in 94.4%. All patients received parenteral opioids (intravenously). Benzodiazepines were used in 51.6%. In 75.8%, physicians reported no change in treatment plan during end of life. Hastening death by increasing analgesics and/or sedatives was mentioned in 19.3%. The treatment plan was discussed with patients in 26.6% of cases. In 6 cases, an explicit intention to hasten death was mentioned; in 36 cases, doses of opioids/sedatives may not have been strictly proportional to symptoms. Conclusion: This Belgian study shows that objective reporting of palliative sedation can be used as a tool to ensure good clinical practice where patients receive the most appropriate end-of-life care, avoiding abusive and injudicious or unskilled use of sedation.
... The Dutch law was the subject of an extensive public debate that had begun in the 1970s, whereas the Belgian euthanasia law was the result of a debate that lasted only three years, both in Parliament and within the Bioethics Advisory Committee (Deliens, 2003). Some go so far as to argue that "the 2002 Act on Euthanasia was a hasty and flawed piece of legislation which served to justify a preexistent practice" (Saad, 2017). ...
Article
Full-text available
The global pandemic situation created by COVID-19 leaves many questions open in areas as diverse as politics, economics, society and ethics. The scarcity of health resources and the use that has been made of these by some governments raises the question of whether the distribution of health resources has been equitable, or whether the allocation of health resources depended on criteria such as age. The present work investigates whether those countries or geographical areas where euthanasia is legalized, decriminalized or socially accepted, have followed selective policies limiting access to healthcare by the elderly, thus undermining what is understood as quality of life.
... The Oregon (USA) Death with Dignity Act was passed in 1994 and in at least another seven jurisdictions since then (Al Rabadi et al., 2019). In some cases, VAD has been accepted practice rather than via legislation, for example in Holland and Belgium, who legalised (or rather decriminalised) euthanasia in 2002, as it had been practiced and tolerated before then (Boer, 2018;Saad, 2017). Belgium was also the first country to legislate euthanasia for children in 2014 (Cohen-Almagor, 2018). ...
Article
The study aimed to describe views on Voluntary Assisted Dying (VAD), gleaned through qualitative analysis of participant responses to a set activity, run during the 2018 ‘Dying2Learn’ Massive Open Online Course (MOOC). Data from 508 participants, most of whom identified as health professionals, were analysed using thematic content analysis, and themes generated. A large proportion of participants discussed their personal views related to VAD, specifically around choice, control, dignity, palliative care and dying at home, medical intervention, societal factors, the impact on those left behind, laws and regulations, dying ‘naturally’, advance care directives, and being in pain. In this study, participants had many different views on the act itself, often divisive, but also with common concepts such as respecting the choices and decisions of others.
... Due to the objection of the Christian Democrats, support for the legal amendment was sought from the opposition, namely the green parties and the NVA (New Flemish Alliance, a Flemish separatist party). Proponents of the euthanasia extension for minors reiterated the principles of inclusion and anti-discrimination (Belgian Senate 2010, which were appealing to the general public who was largely supportive of extending the law to minors (Saad 2017). According to this view, patients should not be discriminated against on the basis of their age. ...
Article
Full-text available
In 2014, Belgium became the first country in the world to legislate euthanasia for children. The decision evoked questions and criticisms in Belgium and in the world at large: should children have the right to ask to die? Are children able to make reasoned and independent choices on such an important matter? Does maturity matter? Are children as autonomous as adults? Is it a logical move to grant terminally ill children who are in intolerable pain this right? What happens if there is a conflict of wishes between the child and parents? This article argues that these questions should be addressed while legislators are fully aware of the relevant medical data regarding child development. The article weighs arguments for and against euthanasia for children, dis cussing patients' autonomy, competence, age and maturity, pressure and abuse, and palliative care. It is suggested that the option of pediatric palliative care should be exhausted before proceeding to euthanasia, and that psychological counselling be made available to both children and guardians. It is further argued that the law should explicate the age of children, and that it should insist on consensus between children and parents.
Chapter
This article will analyze the notion of euthanasia and the proposal to decriminalize it, presenting three views on dignity that underlie the euthanasia debate. To start with, I will consider the vision that highlights autonomy as the main meaning of dignity. I will identify its inconsistencies and the problems that such a perspective presents in connection with unconscious individuals, and I will discuss whether a right to die exists. Secondly, I will look into utilitarian arguments in favor of legalizing euthanasia in those cases where the quality of life is not dignified. This will entail addressing the slippery slope argument. Finally, I will examine the position that sustains dignity as a value, inherent in the person, that implies the respect for the inviolability of human life, and I will present the distinctions that need to be made when making decisions at the end of life.
Article
Full-text available
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.
Article
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.
Article
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.
Article
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.