Euthanasia: Should We Follow the Road Belgium Has Paved?

17 Jan 2018

Cambridge has published the first interdisciplinary study of the Belgian experience with end of life legislation. Euthanasia and Assisted Suicide: Lessons from Belgium examines the country’s experience from legal, medical and philosophical perspectives, by way of example.

STI Experts

Co-editor Dr. Calum MacKellar, Director of Research at the Scottish Council on Human Bioethics, discussed the work with the Social Trends Institute.

What drew you to edit a volume on these issues?

Belgium legalized euthanasia in 2002 and thus offers the possibility to examine the consequences on a society of such a practice over the years. This can then be used to predict what effects such an acceptance would have on other countries around the world where similar legislation is being considered. 

The subtitle makes clear that the focus of the book is the experience of Belgium and that the book is concerned not only with this experience considered in itself but also with what ‘lessons’ this experience may hold for other jurisdictions.

Why is this book important at this moment in time?

The debate over whether to legalize some form of physician assistance with suicide (PAS) or the direct ending of life by a physician (euthanasia) is of great importance politically, legally and ethically. Not only in the United Kingdom but in France, in the United States and in many countries, the decision whether or not to take this step hangs in the balance. These debates are highly contentious and often emotive while political, ethical, legal, and medical opinions are often deeply divided. This means that there is a clear need for evidence to inform this debate, though only a very limited number of countries exist in the world that can provide such evidence to guide the public policy choices faced by other jurisdictions.

Where is euthanasia taking place and why choose Belgium as an example?

Only the Netherlands, Belgium and Luxembourg permit euthanasia, with Switzerland permitting assistance in suicide and a few states in the United States of America (such as Oregon, Washington and Vermont) legalizing physician assisted suicide. Recently, however, both the Supreme Court of Canada and the Constitutional Court in Colombia have required their respective parliaments to enact legislation permitting assisted suicide and/or euthanasia. 

Belgium, in particular, has more than 15 years’ experience of euthanasia and has recently extended the scope of its legislation but, to date, there is no monograph or scholarly collection in English relating to what has actually taken place in this country over these years. 

Moreover, there is an increasing amount of research published in journals relating to euthanasia and end of life practices in Belgium but this research has not been brought together in a single volume.

The situation in Belgium, while in some ways similar to that in the Netherlands, is distinct. Unlike the development of law and practice in the Netherlands, the Belgian law was neither initiated nor supported by the medical profession. Instead, doctors and their representative organizations have been required to accommodate their practice to a new legal environment. In some ways the pace of change since 2002 has been greater in Belgium, as is evident from the recent extension in the law to cover children. 

What themes, concepts and ideas does the volume develop?

The aim of the book is to illustrate the different aspects of the euthanasia debate, and the different ways that a change in the law may impact upon a society such as Belgium. Rather than compare different countries and say only a little about each, by focusing on one country it is possible to provide a very wide range of perspectives on this experience.  

The book begins with legal perspectives - two from within Belgium and one from outside - on the use of evidence from Belgium in other jurisdictions. 

The focus then shifts to end of life care, with chapters on palliative care, sedation at the end of life, oncology, and organ transplantation subsequent to euthanasia.

Five chapters are then presented on groups of patients who might be affected adversely by such legislation.  The last set of chapters considers conceptual or philosophical issues.

Do the different chapters present different, or similar opinions of the practice in Belgium?

The different chapters are predominantly critical in one way or another of the practice of euthanasia in Belgium. But the contributors in this volume do not all take the same view on the ethics of euthanasia and assisted suicide. Where authors are critical of current practice this does not imply that they believe the euthanasia law should be abolished. There are differences of view about what should happen, though there is more agreement about the need to question the direction in which their country is currently travelling.

What lessons should we learn from Belgium?

Belgium offers clear lessons for other jurisdictions which are considering the legalization of assisted suicide or euthanasia. One of these is that legislation that was promoted as giving greater clarity, transparency and control to end of life practices, has not fulfilled expectations. Independent research into end of life decision making in Belgium offers some insight into what is occurring. This shows, for example, that the system of official reports and the work of the Federal Commission in Belgium offer neither transparency nor control. Instead, it seems to provide only the illusion of control.

The evidence from Belgium also demonstrates that once the barrier of legalization is passed, the practice tends to develop a dynamic of its own and that disturbing unforeseen consequences can follow. This was in line with what was predicted to happen despite reassurances to the contrary.

This means that the only secure way to avoid these consequences is to resist calls to legalize euthanasia or assisted suicide and instead invest in palliative care as well as research into end of life practices while re-emphasizing the preciousness of human life.

This book was put together with the aim of drawing lessons from the Belgian experience for other countries. But it also provides an opportunity for Belgian lawyers, philosophers, bioethicists and clinicians to reflect and discuss the topic while reaching out to a wider Belgian audience.

It is important to stress that, while the book has identified mechanisms in medical practice and society that encourage the expansion of euthanasia and the overcoming of restrictions, such changes are not inevitable. A change in direction is always possible and, if it should occur, this will happen because of the words and actions of people who have expressed dissatisfaction with the status quo. It is the hope of the editors that this book will promote renewed debate within Belgium and internationally about laws on euthanasia or assisted suicide and give heart to those who resist their normalization.

Euthanasia and Assisted Suicide: Lessons from Belgium, Cambridge University Press, 2017