1. EUTHANASIA
Favouring legalisation, in line with the choises made by the Belgian legislator
Julie Leroy

2. “ I hope I shall never need to ask for it
“ I hope I shall never need to ask for it. But I also hope that if I do, no kind doctors will have to risk their own liberty to give me mine”
Janet R. Richards

3. OVERVIEW Defining euthanasia
Moral, ethical, philosophical and theological views on euthanasia
Legal view: the Belgian Euthanasia Law
The euthanasia debate – in favour of legalisation

4. I. DEFINING EUTHANASIA

5. Defining euthanasia
Greek: “eu” (well) and “thanatos” (death)  “good death”
Euthanasia is the intentional killing of a patient, by act or omission, as part of his or her medical care
Active euthanasia: direct interventions
Passive euthanasia: withholding of life-prolonging measures

6. Defining euthanasia
Voluntary euthanasia: patient expressly and consciously requested euthanasia  competent
Non-voluntary euthanasia: patient not aware of the euthanasia, no request or approval  non-competent, eg. coma, severe brain damage, senile
Euthanasia ≠ palliative care: c.f. discussion previous lecture

7. II. MORAL, ETHICAL, PHILOSOPHICAL AND THEOLOGICAL VIEWS ON EUTHANASIA

8. The ethical dilemma for doctors
Conflict between two fundamental duties
Perform euthanasia = violation of duty to preserve and prolong life
Refuse euthanasia = violation of duty to relieve pain and suffering
 Dilemma can be solved in two ways

9. The ethical dilemma for doctors
Institute of Medical Ethics: duty to relieve pain and suffering
“A doctor, acting in good conscience, is ethically justified in assisting death if the need to relieve intense and unceasing pain or distress caused by an incurable illness greatly outweights the benefit to the patient of further prolonging his life.”
World Medical Association: duty to preserve and prolong life
“Euthanasia, even at the patient’s own request, is unethical (…) in conflict with basic ethical principles of medical practice.”

10. Moral view HUMAN DIGNITY and value of human life
Opponents: justification for euthanasia is opinion of physician “that the patient lacks a worthwhile life”  violates both concepts  morally unacceptable
In favour: Human dignity only guaranteed when life is free of pain and suffering + sufficiently high life quality  suffering terminal patient : not fulfilled  morally acceptable

11. Moral view RIGHT OF SELF-DETERMINATION Opponents:
In favour: c.f. debate
Opponents:
Solidarity: rights of the relatives
Illusion to believe that there is no external pressure (c.f. debate)
Euthanasia violates the right: final decision in hands of the doctor, can refuse contrary to patient’s wish

12. Liberal view
Strongest defenders: power of the individual to decide over its own life and to make its own free choises
J. Harris: Prohibition of euthanasia = tyranny
“Making someone die in a way that others approve, but the patient believes a horrifying contradiction of his life, is a devastating, odious form of tyranny.” “Euthanasia should be permitted, simply because to deny a person control of what must be one of the most important decisions of life, is a form of tyranny, which like all acts of tyranny is an ultimate denial of respect for persons.”

13. Philosophical view Natural law: against euthanasia
Dignity and value of human life, right to life  euthanasia = request for suicide  unacceptable
Individual autonomy? No, 2 erroneous judgments
Human life has in certain conditions no intrinsic value and dignity
The world would be a better place if one’s life were intentionally terminated
 Risk for people in poor shape and/or whose existence creates serious burdens for others (c.f. debate)

14. Philosophical view Libertarian thinking: in favour of euthanasia
Adapted idea of liberal individual’s autonomy claim
Action acceptable if it promotes the best interests of everyone concerned and violates no one’s rights  euthanasia fulfills this  acceptable

15. Theological view Christian theological ideas against euthanasia
Sanctity of life: “life is a gift from God”
No human being has the authority and power to take the life of another person
Judgment that a life is not worth living anymore  violates intrinsic value and dignity of every person: made in God’s image + every human life has an equal value

16. Theological view
Individual autonomy and right of self-determination? NO!
Ill people are not freely choosing rational persons
Focus on individual autonomy is asocial
Not free to do whatever we please with our bodies and lives, take into account our calling from God, intrinsic morality of our choises and their self-constitutive effects

17. LEGAL VIEW: THE BELGIAN EUTHANASIA LAW

18. Legalisation of euthanasia in Belgium
Euthanasia legalised in 2002: Euthanasia Law of 28 May 2002
“the deliberate action to terminate life, done by someone else than the person involved, on request of the involved person” (article 2)
 Only for active, voluntary, euthanasia

19. Legalisation of euthanasia in Belgium
3 CORE CUMULATIVE REQUIREMENTS (article 3)
1. Severe and incurable disease
 physical or psychological
2. Continual physical or psychological suffering that cannot be relieved
3. Medical futurless situation (= according to actual medical knowledge and practice no recovery possible)

20. Legalisation of euthanasia in Belgium
NEXT TO THIS, PATIENT MUST MAKE A REQUEST (article 3)
Request made freely, without external pressure
Request must be considered thoroughly + repeated
Written request
Request can be replaced by previous declaration of intent (article 4): patient mentions that he wants to obtain euthanasia in case he is not capable anymore to express his will when he is in the situation that an euthanasia can be performed

21. Extension of the law to minors
Belgium Euthanasia law is very CONTROVERSIAL
2014: Law of 28 February 2014 modified 2002 Euthanasia Law  scope of application broadened to include minors

22. Extension of the law to minors
EUTHANASIA IS NOT POSSIBLE FOR “ALL MINORS OF ALL AGES” IN GENERAL
ONLY MINORS WITH JUDICIOUS ABILITY (oordeelsbekwaamheid)
Belgian legislator opted for criterion of judicious ability instead of an age limit, as in the Nthl
 Belgium first, and today only, country to allow euthanasia for minors without an age limit!!!

23. Extension of the law to minors
Judicious ability: not linked to a certain age, for every child different
Depends on mental development of the child: influenced by its experiences due to its disease and the choices he has been confronted with
Criterion supported by paediatricians: general age limit doesn’t provide enough flexibility

24. Extension of the law to minors
Requirements slightly adapted (article 2 Law 2014)
Judicious ability + conscious at moment of request
3 core cumulative requirements (c.f. adults)
Severe and incurable disease
Continual suffering that cannot be relieved
Medical futurless situation
 only physical disease and suffering, not psychological (≠ adults)!

25. Extension of the law to minors
3 additional requirements for minors, NEXT TO REQUIREMENT OF A WRITTEN REQUEST
1. child psychiatric or psychologist holds a conversation with the minor about the request, examines the child and decides if the child has the required judicious ability
2. parents agree with the request (written consent)
3. physical disease will lead to the death of the minor in a short period of time (≠ adults)

26. Extension of the law to minors
Impact of extension will be limited
Paediatricians: medical reality implies that the extension of the law will only apply to a very limited amount of minors
Confirmed: no case of euthanasia for a minor yet

27. Present debate about further extension
Belgian Euthanasia Law most liberal and progressive worldwide, however debate about new extension
Previous declaration of intent: replaces now only the request in case of an irreversible coma
Extend use of declaration to people suffering from dementia or another irreversible situation where the person lacks conscience or awareness of its own personality???
Extension will not take place soon…

28. Comparison with the Netherlands
Nthl first country to legalise active euthanasia: Euthanasia Law into force 1st April 2002
Also allowes euthanasia for minors but more restricted than Belgian Law
Be: judicious ability <-> Nthl: age limit - 12 years
Be: consent parents <-> Nthl: consent only from years / no consent required: only involvement of parents in the decision-making (article 2)

29. Euthanasia in Europe Only legalised in Be, Nthl and Lux
Study: division Western – Eastern European countries  difficult to create common European policy

30. Acceptance of euthanasia in Belgium
Flanders: increase in number of euthanasia’s: 1,9% of deaths (2007)  4,6% (2013, 2800 cases) + increase in performance rate of requests: 50%  75%
Flanders: highest level of euthanasia’s worldwide
Belgium: declarations of intent registered in 2014
 Euthanasia widely accepted in Belgium as a valid option at the end of life

31. Procedure before the ECHR
August 2014: appeal of Alliance Defending Freedom against the Belgian Euthanasia Law
Violation of article 2 (right to life): Belgium doesn’t protect its citizens from unacceptale presurre, leading to decisions that end their lives
Violation of article 8 (right to respect for private and family life): the violation of article 2 can violate the rights under article 8 of an immediate family member of the patient
Decision: important for the future of the Belgian Euthanasia Law

32. THE EUTHANASIA DEBATE – IN FAVOUR OF LEGALISATION

33. Legalisation of euthanasia in general
Opponents of euthanasia: 5 core arguments
1. “Life-worth-living” argument
A) Performed by a doctor: patient’s life not worth living anymore = no longer of value  risk for sick and disabled people to get euthanasia against their will
<-> Only euthanasia when patient requests this + only
open for patients at the end of their life
B) Make patients life worth living: relieve pain and make them feel valued
<-> If this would be possible there would be no desire to die, so no need for a prohibition + moral problem: it is the prohibition that makes an end to suffering impossible

34. Legalisation of euthanasia in general
2. Undermines the role of doctors and practise of medicine
Against duties of doctors to require them to kill
<-> Euthanasia is voluntary on both the side of the patient and the side of the doctor, doctors can never be obliged to perform an euthanasia against their will

35. Legalisation of euthanasia in general
3. No need for euthanasia when palliative care is qualitative and well regulated
<-> palliative care cannot be seen as an alternative for euthanasia, both must be considered as an option in the end of life care. They can supplement each other and be combined

36. Legalisation of euthanasia in general
4. “Slippery slope” argument
Legalisation of voluntary euthanasia will create a slippery slope to non-voluntary euthanasia, will end up in the routinely killing of people that are not considered useful in society
<-> voluntary euthanasia only after request of the patient, acceptance of it doesn’t create in any way a freedom to kill

37. Legalisation of euthanasia in general
5. Problem of unwanted pressure
Only serious and grounded argument
People can, intentionally or unintentionally, be put under pressure to request euthanasia
Elderly and dependant people: emotional and psychological pressure  feeling of guilt if they stay alive  request for euthanasia
 Laws must contain safety mechanisms to ensure free consent without any external pressure

38. Legalisation of euthanasia in general
IN FAVOUR OF EUTHANASIA: 3 core arguments
1. Right to die: right to choose the moment and method of your death, in order to die in dignity
Every person has the right to control his body  individual freedom and autonomy
Alternative: part of right to life: life with a minimum level of quality and value  freedom for people to make their life and death as qualitative as possible, e.g. by making a request for euthanasia

39. Legalisation of euthanasia in general
2. Right not to be forced to suffer
3. Freedom to commit suicide: suicide not punished under criminal law  freedom cannot be exercised by people suffering from pain  euthanasia illegal: forced to stay alive because others are not allowed to help them to do what they cannot do alone

40. Legalisation of euthanasia in general
“Why should it be a crime to help these people to do what would be perfectly within their rights if they did not need help?” “If people in general are entitled to do away with themselves when life has become intolerable, how can it be right to insist that some off the worst off – the ones with the most understandable reasons for wanting to die – must remain trapped?” Janet, R. Richards, Euthanasia: Should anyone be denied the freedom to commit suicide?, in “Nature Medicine”, vol 1, 1995, p. 618.

41. Legalisation of euthanasia for minors
Arguments in favour of euthanasia for minors
Belgian legislator: make an end to unjustified discrimination  no objective reason to make distinction between adults, who could request euthanasia, and minors, who did not have this possibility because of their age
Belgian paediatricians
End harrowing situations of suffering children
Possibility creates important rest and feeling of safety
Create debate about the end of life care for children

42. Legalisation of euthanasia for minors
One grounded contra argument: unwanted pressure
“requesting euthanasia for another”: parents hope that child will not suffer anymore  this behaviour can, intentionally or unintentionally, bring the child to see the euthanasia as an obligation, especially if the child feels that the parents cannot handle the pain anymore (c.f. argument 5: problem of unwanted pressure)
Law: insert safety mechanisms  Belgium: need to consult a child psychologist or psychiatric

43. Thank you for your attention.