Belgium: 15 years After Legalizing Euthanasia

The Federal Control Commission has examined all the declarations submitted since the law was first passed in 2002. Until 2015, no cases were reported to the procurer, which casts a serious doubt on the commission’s impartiality. A significant number of its members advocate euthanasia, including the president of the Belgian association, the Right to Die in Dignity.

For the first time, on October 27, 2015, after having practiced euthanasia for 13 years and having examined 8000 cases, the Federal Commission submitted a file to the Court. It was Simona De Moor’s assisted-suicide case by Dr. Marc Van Hoeys, President of RWS “Recht op Waardig  Sterven” a partner association for Right to Die in Dignity. This 85-year-old lady, Simona, complained of experiencing “inconsolable grief” following her daughter’s death. It is likely that the media coverage for the film “Allow me to die” may have encouraged the family to file suit. According to Le Soir website, Simona’s doctor insists that she “doesn’t want to die because she is depressive. No. But because she has had enough”. In addition, when the patient is not faced with an imminent death, a third doctor must be consulted, a regulatory compliance which was not respected in her case.

This Federal Commission, perceived by an increasing number of observers as a mere rubber stamping registration office, has ended up having its role and purpose challenged, to the point of being declared as a failure, and has been unable to recruit the necessary members, as it was the case at the end of 2015.   

In an editorial published at the end of 2016, a group of ethicists and physicians deemed that the Federal Commission “unduly plays the role of a court”, by interpreting the law’s application in a “flexible” manner. Two examples were cited: that of assisted suicide, banned by law, but endorsed by the Federal Commission, and that of practicing euthanasia when the patient loses consciousness prior to euthanasia.

In March 2017, during a debate concerning the latest report filed by the Federal Control Commission, several MP’s called for public discussion on the sense of the law. They queried several recurrent problems, including the effectiveness of the Federal Control Commission, the media coverage of certain cases, the increasing amalgam between euthanasia and assisted suicide.  The members of the Federal Commission, who were present, supported this proposed assessment.

The Commission even acknowledges that all suspicious cases of euthanasia are not declared. During the documentary “Complement d’enquête” (Further Investigation) broadcast on France 2 Television at the end of 2014, the Commission’s President, Professor Wim Distelmans declared: “All the cases declared are in compliance with the law. There may be some small procedural mistakes, but all cases abide by the law. Obviously, since physicians do not report suspicious cases, we cannot verify them.”

Commenting on the report published in 2015, the same president recognized that officially reported euthanasia cases only account for part of the total number of acts performed in Belgium. According to the site “7sur7”, he stated: “One should recall that the total number still remains unknown since all cases are not declared, rendering it impossible for us to have a real grasp on the issue”.

In the previously mentioned editorial at the end of 2016, the group of ethicists and physicians deplored this situation and criticized the Federal Commission, especially its lack of resolve to evaluate and fight against non-declared cases of euthanasia, as well as its silence regarding numerous cases of “terminal sedation” (with high doses of morphine and sedatives) which should be analyzed as euthanasia cases to be declared.

As an example, in July 2012, a study carried out by scientists at the Université Libre de Bruxelles and the Gand University was published in Social Science & Medicine. Their results for a comprehensive investigation based on survey of 480 doctors in Flanders and 305 in Wallonia revealed that the Control Commission only included 73% of euthanasia cases reported by doctors in Flanders and only 58% of those reported in Wallonia. In other words, 10 years after legalizing euthanasia, 27% of the cases in Flanders and 42% in Wallonia remained undeclared.

The July 2012 study previously mentioned revealed that the legal requirement for the second medical consultation was not respected by 73% of the Flemish doctors and by 50% of the Walloon doctors.

Another major study carried out in 2009 by Professor Raphaël Cohen-Almagor from Hull University (UK), was published in the journal Issues in Law and Medicine. The study revealed several major difficulties, for example regarding the legal requirement for a second physician’s opinion: cases were reported where the doctor rendering his opinion by telephone without examining the patient. Doctors regularly call the same colleagues who are known for being amenable to euthanasia.

In 2012, the European Institute for Bioethics dedicated a major document to this issue, underlying the abuses observed by furnishing “euthanasia kits” sold in pharmacies. The doctor who performs euthanasia in the patient’s home must personally return the non-used surplus product to the pharmacy. In practice, the lethal substances are sometimes given to the family, and no control of returned surplus products is carried out, giving rise to the fear of unauthorized use of these products.

Recently the media cited an example of procedures which are not respected by the doctors. Tine Nys, 38 years-old, had euthanasia performed in April 2010 after a romantic break-up. In February 2016, her sisters pressed charges against the doctors for negligence. In an interview broadcast by channel “VRT”, they gave witness to the euthanasia procedure carried out at their sister’s home. The doctor “didn’t have the necessary material for the injection”, “he forgot the bandages”. According to the European Bioethics Institute, Tine’s euthanasia report was only reported to the Control Commission 2 months later, instead of within the required time limit of 4 days. The sisters decided to file a judicial complaint. 

This represents a potential new risk for breaking the law, even when the legal conditions are respected. Faced with an insufficient supply of donors, Belgian surgeons wish to advocate this practice for euthanasia cases, in order to increase the availability of organs for transplants.  On September 28 2012, a symposium entitled “Euthanasia and Organ Donation” was held in Brussels, initiated by the Belgian Transplant Society, LEIF and the “Maakbare Mens” association. By analyzing the data since 2005 they ascertained that 9 patients had accepted to donate organs. Some physicians want to encourage this practice, estimating that up to 10% of potential organ donations could be procured from euthanasia patients.

Highly publicized cases have illustrated a rising inclination towards so called “altruistic euthanasia”. In 2015, the debate was fueled by a Dutch man, when his liver, kidney and pancreas were procured following euthanasia in a hospital in the Netherlands. Faced with increasing demands for organ donations, the Maastricht University Medical Center and the Erasmus Medical Center compiled a manual to streamline the process: “Euthanasia – Organ Donation”. According to Professor Ysebaert, a Belgian doctor at Anvers Hospital quoted in La Libre: “Currently we don’t mention this option to patients since it could provoke an emotional shock”.  

A recent study by Dr. Jan Bollen at the Maastricht University Medical Center emphasized that at least 10% of individuals undergoing euthanasia could have donated at least one organ, meaning as many as 684 organs could have been made available for donation in 2015. A specialist in intensive care in Brussels, Professor Jean-Louis Vincent, confirms that he encourages organ donations from individuals who are “practically brain dead” (where the person is not completely dead) since the quality of the organs would be better.

Eddy and Marc Verbessem, two 45-year old twin brothers, born deaf and suffering from glaucoma which would eventually lead to blindness had euthanasia performed on December 14, 2012. The fear of blindness was considered as “unbearable mental suffering” thereby attributing legitimate access to euthanasia according to their attending physician.

Ann G., 44 years old, suffering from anorexia for many years, and was sexually abused by her psychiatrist, had euthanasia performed at the end of 2012 after declaring to have “cancer in her head”, thereby qualifying as suffering deemed sufficient enough to allow euthanasia to be legally performed.

A prison inmate, serving a long sentence and very ill, had euthanasia practiced in September 2012. This was the first case of euthanasia for an inmate in Belgium. Since then, a dozen more inmates have filed requests for euthanasia. Since the first incident known as the « Van Den Bleeken » case in 2014, (c.f. §V-2, refer to references), where euthanasia was permitted before finding an alternative solution, the debate has veered back to the return of the death penalty under the label of voluntary death sentences “for humanitarian reasons”. At the time, the European Bioethics Institute emphasized “an enormous failure in Belgian psychiatry” and denounced the Belgian penitentiary system which introduced “an inverted system of the death penalty”.   

Christian de Duve, 95-year old Nobel Prize winner, died by euthanasia on May 4, 2013.  His family stated that the famous scientist serenely prepared for the procedure after having a fainting at his home. Throughout the month preceding his death he wrote to his friends and previous co-workers, and his last act was to give an interview to be published after his death in a leading daily newspaper. This case is similar to that of the well-known writer, Hugo Claus, who also organized his euthanasia in a likewise manner in March 2008.

Nathan Verhest, 44 years old, “profited” from euthanasia on September 30, 2013, after an unsuccessful sex change operation. Born as a female, she was rejected by her parents who wanted another boy, in addition to their 3 other sons. Having dreamed of becoming male since adolescence, she followed many cumbersome treatments to achieve this objective. After the last unsuccessful operation, she attested “I abhorred my new body” and claimed being tormented by mental suffering in order to obtain permission to have euthanasia.

Kevin Chalmet, fireman, in his 30’s, chose to have euthanasia in 2014 “to move the controversial debate forward”. Suffering from a brain tumor, this Belgian man progressively lost his sense of taste, and smell… The fireman thus prepared his euthanasia down to the smallest details, visited his fellow firemen at the fire station, wrote letters on his considerations, and planned the day of his death. He attested: “Everything will take place at home but first we’ll have pastries.

Johnny Vaes, 59-year-old man with pancreatic cancer, scheduled his euthanasia procedure for Friday May 13, 2016, after a final farewell to his loved ones. According to the web site “be”, this father had no hope of recovery once his cancer had metastasized. At that point, he had announced his upcoming euthanasia procedure on Facebook and invited his loved ones to the hospital for a last get-together. The man declared:  “For lunch I’ve asked for French fries with mayonnaise and ketchup. Afterwards, I’ll have my shot, and I’ll leave.”

Laura Emily, 24 years old. In 2015, “The “Economist” broadcast a documentary of Laura Emilie’s story entitled « 24 and ready to die » who remained alive after having requested euthanasia. Following a difficult childhood, and suffering from depression, she requested euthanasia on September 24, 2014. Three doctors accepted her request, justifying that she suffered from “incurable mental suffering” a condition allowed by Belgium’s 2002 euthanasia law. On the appointed day, with journalists present to film her death, at the last minute, Laura Emily refused and declared: “I can’t go through with it. These past 2 weeks were relatively tolerable; there were no crisis situations. It’s unclear for me: did something change inside me, or did something change so that things have become tolerable?” The young lady is still alive today.

Franck Van Den Bleeken, prison inmate in his 50’s, had been convicted of murder and several rapes and had already spent 30 years being incarcerated. Although he was in good physical health, Franck attested that he could no longer stand being in prison. The legal system in Belgium denied his transfer to a hospital in the Netherlands. He then requested euthanasia and obtained permission from the doctors treating him, by invoking “incurable mental suffering”. Following a widely publicized debate which accused the Belgian government of being unable to propose an adequate medical treatment, the doctors reversed their decision, and ended up transferring him to a specialized psychiatric clinic in Gand.   

Sébastien, 39 years old, sought euthanasia in March 2016, for his 40^th birthday. During an interview for “20 minutes”, this pedophile explained: “I have been in therapy for 17 years. I spent 4 years in a psychiatric hospital. I’ve seen 8 psychologists, 4 psychiatrists, and a sexologist […] at this point, I don’t want anything”. To date, his request for euthanasia has not been authorized. According to the French television channel, France3, the psychiatrists estimate it will take 18 months before being able to verify the validity of his request.

• In June 2012, over 70 well-known figures, mainly health professionals signed a major text marking 10 years of euthanasia practice in Belgium. Their statement emphasized how this law, by opening “Pandora’s box” and transgressing the original founding prohibition, results in the public’s loss of trust, and in weakening individuals who are already the most vulnerable.
• In May 2013 an internet site euthanasiestop.be was created by doctors, professors and well-known Belgians to respond to draft bills aiming to extend euthanasia. This means of exchanging information is progressively creating public awareness.
• On February 12, 2014, over 172 pediatricians signed an open letter to the presidents of each of the Belgian political parties. At the time of the draft bill for extending euthanasia to minors, these professionals throughout Belgium considered that further discussion was needed. They emphasized the ambiguous terms in the draft bill: “In practice, there is no objective means to determine a child’s understanding and judgment.  The assessment is widely subjective and prone to influence.”
• In September 2014, Corinne Von Oost, director of a Palliative Care department in Belgium, published a book entitled “Catholic Physician, why I practice euthanasia”. When interviewed by “La Croix” (The Cross) newspaper, she declared that practicing euthanasia doesn’t have any particular meaning for her: “it’s a way of responding to nonsense, by nonsense”, and admitted that “the danger is to become accustomed to it”.  Retorts to this widely publicized work appeared rather quickly. In December 2014, Marie-Dominique Trébuchet, PhD in theology and volunteer for palliative care retorted in “La Croix”: “To answer Dr Van Oost’s question “Who am I to refuse to help someone die”, let’s ask ourselves “Who am I to put someone to death?” In January 2016, Catherine Dopchie, Catholic oncologist and director of an intensive care unit, also responded in “La Libre”: “The psycho-spiritual suffering of not finding any meaning in life, nowadays the root cause of most requests for euthanasia, is not a medical issue, strictly speaking.
• On September 10, 2015, a joint group of 38 university professors, psychiatrists and psychologists published in “Le Soir”. In their article, they expressed their serious concern due to the increasing number of euthanasia acts performed on individuals suffering from mental disorders. Referring to the case of Laura Emily, they emphasized that “experience confirms that the pertinent legal guidelines solely for mental reasons is questionable”. In fact, “unbearable mental suffering cannot be confirmed, since there are no measurable parameters, no tissue biopsy, nor any behavioral signs which can be objectively evaluated.”

• In September 2013, Professor Etienne Montero, dean at Namur University of Law, published a book: “Appointment with Death: 10 years of legal euthanasia in Belgium”. In his book, he gives a critical summary of the situation, underlining how legal guidelines are broadly interpreted, and warns of the “slippery slope” phenomenon: “The problem is that if the only criterion for euthanasia is based on an individual being able to give informed consent, Belgian law allows justifying euthanasia for almost any situation. The condition of suffering is subjective, and the concept of a serious illness is defined in various manners.”
• Pierre Barnérias, a French journalist, produced the film “Euthanasia: how far can we go?” which presented the violations of the law in Belgium. In October 2013, when interviewed by La Croix, he declared: “The main criticism is the lack of verification in spite of having a Federal Commission. Some of the witnesses, one of whom appears in the film, even accuse the practice as being homicides disguised as euthanasia!” Although his objective is not to take a position either for or against euthanasia, he nevertheless aims to demonstrate that in Belgium, “the practice of euthanasia is not free of abuses”.    
• On November 6, 2013, the main religious figures in Belgium  released a historical message. For the first time the 3 main monotheist religions, the representatives from Christianity (Catholics, Protestants, and Orthodox), Judaism, and Islam expressed their serious apprehension faced with the risk of trivializing euthanasia. They protested extending the law for minors or for dementia, because this would signify “an extreme contradiction to mankind’s existence” and concluded: “we cannot endorse this mentality which would lead to destroying society’s basic foundation”. The previous Finance Minister and head of the Flemish Christian Democratic Group (CD&V), Steven Vanackere called for a reevaluation of the law in February 2016. According to the Figaro newspaper, his intention was not to eliminate the law, but to “have the violations evaluated”. He also denounced the composition of the members in the Control Commission, because “there are members who perform euthanasia, representing a conflict of interest if they judge their own cases”. “We want to encourage a genuine social discussion, beyond ideology, and by involving the public. This kind of evaluation will certainly create public awareness of the transgressions of the law.”  Since 2001 the European Institute of Bioethics (EIB) has been monitoring the changes in the legislation, practice and mentality in Belgium. For example in January 2013 when the twin brothers had euthanasia performed, one of the directors emphasized how this was downplayed by the Belgian public. “The list of incurable diseases is practically endless (…) The definition of psychological suffering is left to the subjective interpretation of the person concerned (…) Finally, the legal condition is practically customized to authorize euthanasia if there is voluntary and persistent request from anyone suffering diverse pains, solitude, or who is tired of living (…) We are already witnessing how euthanasia is being considered commonplace in Belgium”. In 2014, during the discussion for extending the law to minors, the European Institute of Bioethics warned “today the population is ready to accept a situation that was considered reprehensive 10 years earlier. It is impossible to deny the genuine trivialization of euthanasia and assisted suicide…   Is this the manner that society wishes to relieve the distress and suffering of weak or ageing individuals who are sick or disabled?” On October 24, 2016, in a long interview with “Atlantico”, Carine Brochier gave an updated analysis of euthanasia violation, calling for a better accompaniment for the ageing rather than continually enlarging the legal criteria.
• More recently, on December 28, 2015, the new Belgian primate, Bishop Jozef De Kesel, was interviewed by the “Het Belang” He reaffirmed that healthcare institutions have the freedom to practice euthanasia or to refuse. One institution, in January 2016, refused to have euthanasia practiced on its grounds (c.f. §III-3). The cardinal declared: “I think that we have the right to decide as an institution whether or not to allow euthanasia. I am thinking of our institutions”.

• At the end of January 2014, 61 members from several different countries and political parties at the Parliamentary Assembly for the Council of Europe signed a declaration concerning a draft bill on euthanasia for Belgian children. This declaration especially noted that “euthanasia must remain prohibited whenever it consists of intentionally killing a dependant human being, presumably for his own interest, by an action or by an omission”. The European MP’s also remarked that Belgium “betrays its most vulnerable children by not attributing an intrinsic value to their lives”.
• On February 10-11, 2014, an International Congress for Pediatric Palliative Care was held in Mumbay, India.  At that time, as many as 250 experts from 35 countries published a statement to warn Belgium against extending the 2002 law to minors. The final statement “urgently called for the Belgium government to reconsider its recent decision”. These physicians “demand that all children at the end-of-life have access to the appropriate means to alleviate their symptoms and their suffering, as well as high quality palliative care specific for their needs”. The statement added:” We don’t consider that euthanasia should be included as part of pediatric palliative therapy; it is definitely not an option”.