Euthanasia in Belgium: Law, Practice, Pitfalls and Lessons Raphael Cohen-Almagor June 28, 2015June 28, 2015June 28, 20151

Euthanasia in Euthanasia in BelgiumBelgium: : Law, Law, PracticePractice, , PitfallsPitfalls and and

LessonsLessons

Raphael Cohen-AlmagorRaphael Cohen-Almagor

April 18, 2023April 18, 2023 11

Preliminaries: Comparative LawPreliminaries: Comparative Law

22April 18, 2023April 18, 2023

Preliminaries: Comparative LawPreliminaries: Comparative Law

33April 18, 2023April 18, 2023

MethodologyMethodology

• Critical review of the literature • Interviews with leading scholars and practitioners • The interviews were conducted in English, usually in the

interviewees’ offices. • The interviews were semi-structured. I began with a list

of questions but did not insist on answers to all of them if I saw that the interviewee preferred to speak about subjects that were not included in the original questionnaire.

• The length of interviews varied from 1 hour to 2.5. hours.• After completing the first draft I sent the papers to my

interviewees.

April 18, 2023April 18, 2023 44

Euthanasia - DefinitionEuthanasia - Definition

• Belgium accepted the Dutch definition:• (a) “euthanasia is the intentional taking of someone’s life

by another, on her request”. • (b) It follows that this definition does not apply in the case

of incompetent people; there the proposed terminology is “termination of life of incompetent people”.

• (c) More importantly, the act of stopping a pointless (futile) treatment is not euthanasia and it is recommended to give up the expression “passive euthanasia” in these cases.

• (d) What was sometimes called “indirect euthanasia”, forcing up the use of analgesics with a possible effect of shortening life, is also clearly distinguished from euthanasia proper.

April 18, 2023April 18, 2023 55

Belgian Euthanasia LawBelgian Euthanasia Law

• On January 20, 2001 the euthanasia commission of Belgium’s upper house, the Senate, voted in favour of proposed euthanasia legislation, which would make euthanasia no longer punishable by law, provided certain requirements are met.

• Nine months later, on October 25, 2001 Belgium’s Senate approved the law proposal, which was adopted on March 20, 2001 by the joint commissions of Justice and Social Affairs, by a significant majority.

• On May 16, 2002, after two days of heated debate, the lower house of the Belgian parliament endorsed the bill by 86 votes in favour, 51 against and with 10 abstentions.

April 18, 2023April 18, 2023 66

Belgium - Worrisome DataBelgium - Worrisome Data

• Prior the law, studies have shown that more than one in 10 deaths among the country’s 10 million people are the result of "informal" euthanasia, where doctors gave patients drugs to hasten their deaths.

• More than three in 100 deaths in Belgium's northern Flemish region every year were the result of lethal injection without the patient's request.

April 18, 2023April 18, 2023 77

Euthanasia v. PASEuthanasia v. PAS

• One way to address this issue of abuse is to advance physician-assisted suicide for all patients who are able to swallow oral medication.

• However, in Belgium and also in the Netherlands there is a tradition of doctors administering lethal drugs.

• In addition, there is the issue of taking responsibility. Physicians in both countries like to have control over the process.

• Consequently, in Belgium and the Netherlands there are relatively few cases of PAS.

• I suggest putting this issue on public agenda, speaking openly as people in Belgium like and appreciate about the findings and the fear of abuse, and suggest PAS as an alternative to euthanasia.

April 18, 2023April 18, 2023 88

The need for lawThe need for law

• In Belgium, there was/is strong support for euthanasia.

• The legal and social situation created confusion: Legally euthanasia was illegal; in practice it was conducted by many physicians.

• This is unhealthy situation. Law was needed to clarify the situation.

April 18, 2023April 18, 2023 99

OpennessOpenness

• As a result of the law, in both Belgium and Holland physicians speak openly about terminating life of dying competent patients.

• Dutch and Belgian experts believe that while in the world “physicians have probably the same practice but it is conducted behind close doors, we believe it is better to discuss things, in order to have exchange of ideas and expertise”.

April 18, 2023April 18, 2023 1010

Belgium - DataBelgium - Data

• In September 2004, the first major study into the effect of Belgium's new legislation that permits euthanasia had found that around 20 terminally ill people a month asked doctors to help them to die.

• The study found that 259 acts of legal euthanasia were carried out in Belgium up until the end of 2003.

• The Federal Control and Evaluation Commission for Euthanasia counted an average of 17 registered cases of euthanasia per month.

• About 60 per cent of euthanasia cases were administered in hospitals; the rest generally took place at the patients’ homes.

April 18, 2023April 18, 2023 1111


• The vast majority of people asking to be euthanized were suffering from terminal cancers.

• Euthanasia was more reported in Dutch speaking Flanders than in Francophone Wallonia.

April 18, 2023April 18, 2023 1212


• In December 2006 the Federal National Evaluation and Control Commission for Euthanasia issued its second report, covering the period 2004-2005.

• Its findings echo much of the results of the first report.• This report deals with 742 legal euthanasia cases, 31

per month, a significant increase compared with the 2002-2003 figures.

• 83% of cases involved cancer patients. • 45% of cases were dealt with by the General Practitioner

(GP) at the patient’s home.• Only 14 percent of all euthanasia requests were written

in French. 86% of the declarations were written in Flemish.

April 18, 2023April 18, 2023 1313

Palliative CarePalliative Care

• Until 2000, palliative care was under-developed in both Belgium and Holland.

• Palliation seemed to be opposed to euthanasia.

• Both countries preferred to develop the practice of euthanasia.

April 18, 2023April 18, 2023 1414


• Almost all the physicians I interviewed in both countries had no palliative care training.

• Most did not think they need such training. One head of department in Brussels spoke of palliation with disdain: Why should I consult a palliative care specialist?

• Since 2000, both Belgian and Dutch governments dedicate more funding to palliation.

April 18, 2023April 18, 2023 1515


• Most worrisome is to know that sometime when physicians administered life-shortening drugs in order to alleviate pain, they did not consult palliative care specialist or any other health care personnel.*

• Ganzini and colleagues reported that as a result of palliative care, some patients in Oregon changed their minds about assisted suicide.** * Veerle Provoost, Filip Cools, Johan Bilsen et al., “The Use of Drugs with a Life-shortening Effect in End-of-life Care in Neonates and Infants”, Intensive Care Med., Vol. 32 (2006), p. 136.** Linda Ganzini, Heidi D. Nelson, Terri A. Schmidt, Dale F. Kraemer, Molly A. Delorit, Melinda A. Lee, “Physicians’ Experiences with the Oregon Death with Dignity Act”, New Eng. J. of Med., Vol. 342, No. 8 (Feb. 24, 2000), p. 563.

April 18, 2023April 18, 2023 1616

Role of PhysiciansRole of Physicians

• In both Belgium and Holland, physicians are not obliged to carry out euthanasia if this practice contradicts their conscience.

• However, they are under tremendous amount of pressure to do it.

• They should tell their patients their reluctance so as patients should know beforehand that they cannot expect this service from them.

• They constitute a small minority.• They cannot serve on most prestigious

committees because euthanasia is on the menu of available medical practices.

April 18, 2023April 18, 2023 1717

Role of PhysiciansRole of Physicians

• In both Belgium and Holland, the physician is required to devote energies in the patient and her loved ones, to consult with other specialists, to spend time and better the communication between all people concerned.

April 18, 2023April 18, 2023 1818

ReportingReporting

• In Belgium, all cases have to be fully documented in a special format and presented to a permanent monitoring committee, the National Evaluation and Control Commission for Euthanasia, established by the government in September 2002.

• The Commission needs to study the registered and duly completed euthanasia document received from the physician.

• Members ascertain whether euthanasia was performed in conformity with the conditions and procedures listed in law.

April 18, 2023April 18, 2023 1919

ReportingReporting

• In Belgium, the names of the physicians remain anonymous. The Commission as a general rule sees only the open part of the physicians’ reports.

• Only when there are doubts about the practice, the Commission may decide to vote whether or not members should see also the discrete part.

• The Commission has limited information.

April 18, 2023April 18, 2023 2020

ReportingReporting

• According to the last report (2010) approximately half (549/1040 (52.8%) of all estimated cases of euthanasia were reported to the Federal Control and Evaluation Committee.

• Timme Smets, Johan Bilsen, Joachim Cohen et al., “Reporting of Euthanasia in Medical Practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases”, BMJ, Vol. 341 (October 5, 2010).

April 18, 2023April 18, 2023 2121

Palliative SedationPalliative Sedation

• Terminal sedation is not euthanasia, or as some people in Belgium and the Netherlands term “slow euthanasia”.

• Euthanasia requires the consent of the patient, while terminal sedation does not by definition requires consent.

• The fear of abuse is great. • Experts told me that terminal sedation happens frequently in ICUs.

Physicians conceive the practice as the middle approach between euthanasia and withholding treatment.

• It is estimated that 8% of all death cases in Belgium in 2001 were cases of terminal sedation, about 4,500 cases in Flanders alone.*

• * Johan Bilsen, Robert Vander Stichele, Bert Broeckaert et al., “Changes in Medical End-of-Life Practices during the Legalization Process of Euthanasia in Belgium”, Social Science and Medicine, Vol. 65, Issue 4 (2007): 803-808.

April 18, 2023April 18, 2023 2222

Palliative SedationPalliative Sedation

• There is no knowledge whether the patient's consent was sought or given.

• At present the Dutch and Belgian physicians do not have clear directives on this.

• There is no legal regulation, no public or professional scrutiny to examine to what extent the procedure is careful, and there is no knowledge whether consultation was provided

• This situation calls for a change. There should be clear guidelines when it is appropriate, if at all, to resort to this practice.

April 18, 2023April 18, 2023 2323

ConsultationConsultation

• In both Belgium and Holland, the physician practicing euthanasia is required to consult an independent colleague in regard to (a) the hopeless condition of the patient, and (b) the voluntariness of the request.

• Unclear to what an extent the independency requirement has been compromised.

April 18, 2023April 18, 2023 2424


• Since 2003, LEIFartsen in Belgium.• In Belgium, there are no rules regarding who

decides the identity of the consultant. • The only rule is that the consultant needs to be

independent.• Probably doctors approach like-minded

physicians. • Unclear what happens if there is disagreement

between doctors. This issue deserves attention and probing.

April 18, 2023April 18, 2023 2525


• In the Netherlands, sometimes consultancy was conducted over the phone, with only the GP.

• Mixed views whether this is happening today in both countries.

April 18, 2023April 18, 2023 2626

NewbornsNewborns

• In both Belgium and the Netherlands, administering lethal drugs to minors is against the law.

• Comparison between end of life decision making in Belgium and in the Netherlands shows that the practice regarding severely ill neonates and infants is rather similar.

• Parents and colleague physicians are more often involved in the decision making in the Netherlands.*

* Astrid M. Vrakking, Agnes van der Heide, Veerle Provoost et al., “End-of-life Decision Making in Neonates and Infants: Comparison of the Netherlands and Belgium (Flanders)”, Acta Paediatrica, Vol. 96 (2007): 820-824.

April 18, 2023April 18, 2023 2727

NewbornsNewborns

• A 2005 survey of Flanders doctors revealed three in four were willing to shorten the life of critically ill babies.

• In 17 deaths high doses of painkillers were explicitly administered to end the newborn's life.

• Of 121 doctors questioned, 79% thought it was their “professional duty”, if necessary, to prevent unnecessary suffering by hastening death.

• The vast majority (88%) also accepted quality-of-life ethics. 58% supported the legal termination of life in some cases.

• In most cases (84 percent) of the cases the decision was made in consultation with the parents. Still, in 22 deaths parents were not consulted.*

* Veerle Provoost, Filip Cools, Freddy Mortier et al., “Medical End-of-Life Decisions in Neonates and Infants in Flanders”, The Lancet, Vol. 365 (April 9, 2005): 1315-1316.

April 18, 2023April 18, 2023 2828

April 18, 2023April 18, 2023 2929

Suggestions for ImprovementSuggestions for Improvement

Physician-assisted suicide, not Physician-assisted suicide, not euthanasia, to ensure better control.euthanasia, to ensure better control.

April 18, 2023April 18, 2023 3030

Guideline 1Guideline 1

The physician should not suggest The physician should not suggest assisted suicide to the patient. assisted suicide to the patient. Instead, it is the patient who should Instead, it is the patient who should have the option to ask for such have the option to ask for such assistance.assistance.


• The request for physician-assisted suicide of an adult, competent patient who suffers from an intractable, incurable and irreversible disease must be voluntary. The decision is that of the patient who asks to die without pressure, because life appears to be the worst alternative in the current situation. The patient should state this wish repeatedly over a period of time.

• These requirements appear in the abolished Northern Territory law in Australia, the Oregon Death with Dignity Act, as well as in the Dutch and Belgian Guidelines.

April 18, 2023April 18, 2023 3131

April 18, 2023 32


At times, the patientAt times, the patient’’s decision might be s decision might be influenced by severe pain. The role of influenced by severe pain. The role of palliative care can be crucialpalliative care can be crucial. .

The The Belgian law Belgian law as well as the Oregon as well as the Oregon Death with Dignity Act Death with Dignity Act require the require the attending physician to inform the patient attending physician to inform the patient of all feasible alternatives, including of all feasible alternatives, including comfort care, hospice care and pain comfort care, hospice care and pain control. control.


• The patient must be informed of the situation and the prognosis for recovery or escalation of the disease, with the suffering that it may involve. There must be an exchange of information between doctors and patients.

• The Belgian law and the Oregon Death with Dignity Act require this.

April 18, 2023April 18, 2023 3333


It must be ensured that the It must be ensured that the patientpatient’’s decision is not a result s decision is not a result of familial and environmental of familial and environmental pressurespressures..

It is the task of social workers to It is the task of social workers to examine patients’ motives and examine patients’ motives and to see to what extent they are to see to what extent they are affected by various external affected by various external pressures.pressures.

April 18, 2023April 18, 2023 3434


• The decision-making process should include a second opinion in order to verify the diagnosis and minimize the chances of misdiagnosis, as well as to allow the discovery of other medical options.

• A specialist, who is not dependent on the first doctor, either professionally or otherwise, should provide the second opinion.

April 18, 2023April 18, 2023 3535

April 18, 2023April 18, 2023 3636


It is advisable for the identity of the It is advisable for the identity of the consultant to be determined by a consultant to be determined by a small committee of specialists (like small committee of specialists (like the the DutchDutch SCEN), who will review the SCEN), who will review the requests for physician-assisted requests for physician-assisted suicide. suicide.


• Some time prior to the performance of physician-assisted suicide, a doctor and a psychiatrist are required to visit and examine the patient so as to verify that this is the genuine wish of a person of sound mind who is not being coerced or influenced by a third party. The conversation between the doctors and the patient should be held without the presence of family members in the room in order to avoid familial pressure. A date for the procedure is then agreed upon.

April 18, 2023April 18, 2023 3737

3838April 18, 2023April 18, 2023


The patient can rescind at any time and in any The patient can rescind at any time and in any manner. manner.

This provision was granted under the abolished This provision was granted under the abolished Australian Northern Territory ActAustralian Northern Territory Act and under theand under the OregonOregon Death with Dignity Act.Death with Dignity Act.

The The Belgian Euthanasia Law Belgian Euthanasia Law holds that patients holds that patients can withdraw or adjust their euthanasia can withdraw or adjust their euthanasia declaration at any timedeclaration at any time..


• Physician-assisted suicide may be performed only by a doctor and in the presence of another doctor.

• The decision-making team should include at least two doctors and a lawyer, who will examine the legal aspects involved. Insisting on this protocol would serve as a safety valve against possible abuse. Perhaps a public representative should also be present during the entire procedure, including the decision-making process and the performance of the act.

April 18, 2023April 18, 2023 3939

Guideline 11Guideline 11 Physician-assisted suicide may be conducted in Physician-assisted suicide may be conducted in

one of three ways, all of them discussed openly one of three ways, all of them discussed openly and decided upon by the physician and the and decided upon by the physician and the patient together: (1) oral medication; (2) self-patient together: (1) oral medication; (2) self-administered, lethal intravenous infusion; (3) self-administered, lethal intravenous infusion; (3) self-administered lethal injection. administered lethal injection.

Oral medication may be difficult or impossible for Oral medication may be difficult or impossible for many patients to ingest because of nausea or many patients to ingest because of nausea or other side effects of their illnesses. In the event other side effects of their illnesses. In the event that oral medication is provided and the dying that oral medication is provided and the dying process is lingering on for long hours, the process is lingering on for long hours, the physician is allowed to administer a lethal physician is allowed to administer a lethal injection. injection.

April 18, 2023April 18, 2023 4040


• Doctors may not demand a special fee for the performance of assisted suicide. The motive for physician-assisted suicide is humane, so there must be no financial incentive and no special payment that might cause commercialization and promotion of such procedures.

April 18, 2023April 18, 2023 4141

April 18, 2023April 18, 2023 4242

Guideline 13Guideline 13 There must be extensive documentation in the There must be extensive documentation in the

patient’s medical file, including the following: patient’s medical file, including the following: diagnosis and prognosis of the disease by the diagnosis and prognosis of the disease by the attending and the consulting physicians; attending and the consulting physicians; attempted treatments; the patient’s reasons for attempted treatments; the patient’s reasons for seeking physician-assisted suicide; the patient’s seeking physician-assisted suicide; the patient’s request in writing or documented on a video request in writing or documented on a video recording; documentation of conversations with recording; documentation of conversations with the patient; the physician’s offer to the patient to the patient; the physician’s offer to the patient to rescind his or her request; documentation of rescind his or her request; documentation of discussions with the patient’s loved ones; and a discussions with the patient’s loved ones; and a psychological report confirming the patient’s psychological report confirming the patient’s condition. condition.

Guideline 14Guideline 14 • Pharmacists should

also be required to report all prescriptions for lethal medication, thus providing a further check on physicians’ reporting.

• This is not the case now in both Belgium and Holland.

4343April 18, 2023April 18, 2023

April 18, 2023April 18, 2023 4444


• Doctors must not be coerced into taking actions that contradict their conscience or their understanding of their role.

• This was provided under the Northern Territory Act.


• The local medical association should establish a committee, whose role will be not only to investigate the underlying facts that were reported but also to investigate whether there are “mercy” cases that were not reported and/or that did not comply with the Guidelines.

April 18, 2023April 18, 2023 4545


• Licensing sanctions will be taken to punish those health care professionals who violated the Guidelines, failed to consult or to file reports, engaged in involuntary euthanasia without the patient’s consent or with patients lacking proper decision-making capacity.

• Physicians who failed to comply with the above Guidelines will be charged and procedures to sanction them will be brought by the Disciplinary Tribunal of the Medical Association.

• Sanctions should be significant.

April 18, 2023April 18, 2023 4646

Thank youThank you

April 18, 2023April 18, 2023 4747

Documents

Euthanasia in Belgium: Law, Practice, Pitfalls and Lessons Raphael Cohen-Almagor June 28, 2015June 28, 2015June 28, 20151