The Slope Proves Slippery for Belgian Euthanasia Practice

16 Sep 2021

Three years after warning against the “disturbing unforeseen consequences can follow” legalization of euthanasia and assisted suicide, using the Belgian case as an example, Dr. Calum MacKellar revisits the case to discuss with STI whether his predictions have been realized.

STI Experts

In January 2018, STI interviewed, MacKellar, who is the Director of Research of the Scottish Council on Human Bioethics, about the 2017 book he co-edited entitled Euthanasia and Assisted Suicide: Lessons from Belgium. Has the situation changed?  Have his predictions come to pass?

STI: How has the practice of euthanasia and assisted suicide in Belgium developed over the last few years?

CMK: Interestingly, the way euthanasia and assisted suicide is considered in Belgium is evolving all the time. The reality is that the procedures are beginning to be viewed as normal and uncontroversial, with very few questions being raised among the general public. Ending someone’s life is increasingly considered to be a reasonable option for many people. However, there are a few dissonant voices raising very serious concerns about the way the procedures are taking place. 

For example, a new book was released in early 2021 entitled Euthanasia: Searching for the Full Story - Experiences and Insights of Belgian Doctors and Nurses. The volume covers some of the most recent developments as well as providing an honest recognition of concerns. This free-to-download volume, published by Springer, confirms some of the predictions that were made in the 2017 book. For instance, pressures already exist for a further extension of the law to include patients with psychiatric afflictions and disorders.

STI: What is really driving developments in euthanasia and assisted suicide in Belgium?

CMK: As mentioned in the 2017 book, Belgium has never really discussed the ethical challenges and possible consequences on society arising from the legalization of euthanasia and assisted suicide. It simply chose to decriminalize, and bring out into the open, a procedure that was already taking place illegally and covered up by some physicians before 2002. 

During the parliamentary discussions at the time, the argument of compassion towards physical suffering was used, as it resonated strongly with both the public and with politicians. However, with the development of appropriate palliative care, this original motive is no longer as relevant. Indeed, with such care, healthcare professionals are now able to generally control physical suffering. Furthermore, in the rare instances in which this suffering cannot be fully addressed, careful palliative sedation is a possibility. Of course, fatigue of lengthy treatments, loneliness, lack of family support, and experiences of dependency may be present, amongst other factors, but this is the realm of psychological and existential distress. which cannot be treated with medication. 

Thus, over the years, the main reason for euthanasia and assisted suicide has become a perceived right to autonomy - that persons should have the right to do what they want with their lives without anyone telling them what they can or cannot do. In this postmodern age, the right to autonomy has become one of the pillars of modern ethics. As the Belgium cancer specialist Dr. Benoit Beuselinck indicates in the 2021 book, “Autonomy, which has become a main concern, has replaced life as the fundamental value to be respected.” [1] That is to say, if a life is seen as unworthy of life, based on the concept of quality of life, then the right to end this life should exist.    

STI: What do you predict will happen in Belgium over the next decades?

CMK: In my 2018 interview with STI, I indicated that “The evidence from Belgium … 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 has certainly happened over the past few years, as the concept of a life unworthy of life has become more common. Thus, an ever-increasing number of individuals with an ever-increasing number of different kinds of dysfunctions will be given access to euthanasia and assisted suicide, including many people who cannot consent to such a procedure. It will also be possible to grade the value of everybody’s life in society on a scale of worthiness and quality. In other words, in Belgium, people will no longer be seen as being of equal and immeasurable value, robbing the country of one of the main foundations of civilization.   

Of course, some brave healthcare professionals and other individuals will continue to resist this moral decay while testifying to history that not all Belgians agree with the law. The philosopher Jacques Ricot, who works for the University of Nantes in France and who wrote a foreword to the 2021 book, indicates: 

The testimonies reported in this book are forward-thinking and prophetic: they are the words of “Resistance fighters” and watchers who do not believe that euthanasia can be a medical or a caring act, neither can it be a neutral option. As I said before, euthanasia does not complement palliative care, it ends it; it is not the pinnacle of care and support for the patient, it discontinues it; it does not relieve the patients, it takes their lives.

Moreover, if some in the Belgian media continue to take their responsibilities seriously, they will eventually uncover cases of serious misconduct and even scandal. The whole world will then look down in alarm and shock at the moral bankruptcy of Belgium – a country in which respect for the value and worth of life has deteriorated to such an extent that is has become a meaningless concept.    

STI: Are instances of euthanasia and assisted suicide being correctly reported in Belgium?

CMK: A recent article entitled Euthanasia in Belgium: Shortcomings of the Law and Its Application and of the Monitoring of Practice, which was published in the Journal of Medicine and Philosophy in 2021, indicated that in Belgium, the use of euthanasia is expanding, giving rise to a number of significant ethical difficulties. The authors note: “This is in part related to the fact that several legal requirements intended to operate as safeguards and procedural guarantees in reality often fail to operate as such.” 

One of these areas is the reporting of euthanasia cases to the Federal Control and Evaluation Commission for Euthanasia. Actually, in my past interview with STI, I indicated that: 

[The] legislation that was promoted as giving greater clarity, transparency and control to end of life practices, has not fulfilled expectations…. [T]he 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.

This situation has only worsened over the years. Indeed, the aforementioned 2021 article indicates that the Commission does not appropriately check the fulfilment of various legal criteria but seems to simply act, instead, as a shield to prevent possible problematic cases from being referred to the Public Prosecutor. Additionally, it sometimes reinterprets the euthanasia legislation as it sees fit, which is completely beyond its remit. Significant conflicts of interest also exist in the composition of the 16-member evaluation committee, including with the chairman, Dr. Wim Distelmans, who supports and regularly performs euthanasia. Ever since euthanasia was legalized in 2002, the Belgian Commission has only referred one case to the Public Prosecutor, who eventually acquitted the doctor in question. There is thus a very serious lack of accountability in Belgium relating to euthanasia and assisted suicide procedures, which can only end in disarray and a lack of protection of the most vulnerable. 

[1] Benoit Beuselinck, The Meaning of Suffering or the Meaning of Life Despite Suffering, p.76.