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Child Euthanasia in Belgium: The Relentless Logic of “Dying with Dignity”

Monday, 7 April 2014  | Denise Cooper-Clarke

On 13 February 2014, Belgium made international headlines when it became the first country in the world to allow euthanasia for children of any age. There are only three countries where euthanasia has been legalized: the Netherlands (2001), Belgium (2002) and Luxembourg (2008). Initially, Belgium legalized euthanasia only for adults in "constant and unbearable physical or mental suffering that cannot be alleviated." In the Netherlands, euthanasia is legal for children over the age of 12 if the request is "voluntary and well-considered", the patient is “suffering unbearably” with no prospect of improvement, and there is parental consent.

It is important to note there that we are talking about ‘active euthanasia’ by a lethal injection, not the withdrawal of futile treatment or provision of adequate pain relieving medication which might sometimes hasten death.  

Under the new Belgian law, a child of any age can request euthanasia if they are ‘conscious of their decision’, have a terminal illness, and are in great pain with no treatment available to alleviate their distress. The request must be approved by their parents and their medical team. A psychiatric evaluation is also a requirement a to ensure that the child is not suffering any mental illness and has the required competence—that they understand the gravity of the request. It is argued that because of these strict criteria, Belgium will effectively have an age limit for children (probably similar to that in the Netherlands) and that the criteria are more stringent than for adult euthanasia.  

However there is a great deal of evidence from both Belgium and the Netherlands of the way that the practice of euthanasia is expanded to include more and more of those who would have been excluded from the initially strict criteria.  For example, in Belgium last year, Nathan Verhelst, who was born a girl and had been depressed for many years, was euthanased after gender reassignment surgery left him ‘disgusted with himself’. Another controversial case involved a pair of 45-year-old identical and ‘inseparable’ twins who were born deaf and euthanased after blindness began to threaten their ability to communicate with each other.

Even more alarming is the extension of euthanasia practice to very young children including infants and to people with dementia. In the Netherlands, the Groningen Protocol, created in 2004, specifies criteria under which physicians can perform "active ending of life on infants" without fear of legal prosecution. The final decision about "active ending of life on infants" is in the hands of the parents, with physicians and social workers agreeing to it. Criteria for euthanasia include "unbearable suffering" and an assessment of "expected quality of life". The Royal Dutch Medical Association (KNMG), which represents doctors in the Netherlands, has said that of the 175,000 babies born every year in The Netherlands,  about 650 might be cases which would warrant euthanasia.

The possibility of child euthanasia raises all sorts of pragmatic questions. How could a doctor be sure that a child’s ‘request’ was genuinely an expression of their own wishes? How could it be known that the request had not been suggested by the parents, perhaps motivated by their own suffering? And would doctors feel obliged to offer the ‘choice’ to children once it became legal? How do you ask a sick child if they want medical help to die?

Further, the fact that the child’s request must be agreed to by both parents could also be very problematic. What if there is passionate disagreement between the parents? Are “the parents” the biological or social parents? Siblings and grandparents might also have strong views on the matter. And at such a tragic time in the life of the family, such emotional and possibly legal wrangling would only add to the distress of the situation for everyone, including the sick child.

But the fact that the child’s request must be agreed to by the parents and the doctor indicates that the wishes of the child are really incidental to the decision. How could it be otherwise?

It is a well-recognised principle that the level of competence required for a decision increases with the seriousness of that decision. And a decision to be killed is a very serious decision.  We don’t allow minors to make financial decisions, to vote, or even to have their ears pierced without parental permission. Further, we are willing to override their expressed wishes when we deem it clearly in their best interests, medically. For example, we do not accept a minor’s refusal of a life-saving medical procedure but go ahead with what the parent/guardian and the medical staff agree is in their best interests. So, essentially under the new Belgian law, the decision is made by the parents (as in the case of infant euthanasia), though the requirement for a request from the child maintains an illusion of respect for the child’s autonomy, and is a safeguard against the truly horrific possibility of a child being killed against their expressed wishes.

Why is it that the legalisation of active euthanasia for competent adults with strict guidelines has so quickly led to the practice and eventually legalisation of active euthanasia for children and even (effectively) infants? Despite the fact that respect for patient autonomy is always front and centre of the argument, it is because advocacy for the legalisation of euthanasia is really not so much about respect for patient autonomy but about a society deciding that it can be—perhaps definitely is—in some people’s best interests to die. The new law in Belgium makes this abundantly clear.

But this is an uncomfortable admission for euthanasia advocates in Australia to make. Some have tried to distance themselves: “Belgium is literally on the other side of the world in terms of this issue, due in part to a different culture and history in this field.” But groups such as Dying with Dignity and Exit International have been uncharacteristically silent on the news from Belgium. If they disagree with this development, why not say so? Can we infer from their silence that, despite the rhetoric of euthanasia only being for competent adults with strict safeguards, the extension of the practice to other groups has actually been envisaged all along? And if this is so, will they continue with the fiction that the legalisation of euthanasia that they support is all about (and only about) respect for people’s autonomy, i.e. giving competent adults the right to choose?

The moral logic of the two justifications for euthanasia—respect for patient autonomy and the relief of suffering—demands the extension of the practice beyond both those who are suffering and beyond those who are able to decide for themselves. Typically the two arguments are spliced together as a justification (if someone is suffering unbearably AND they ask for help to die..), but they are separate. If the justification is respect for patient autonomy, then a request from a competent patient is all that should be required, and euthanasia cannot be limited to those who are suffering or are terminally ill. If the justification is the relief of suffering, surely this applies whether the patient is competent to request it or not.

Hence the argument runs: If adults can have it why can’t children who are judged to be sufficiently mature? And if older children, why not younger children and infants? And why not the intellectually disabled and those with dementia? If people who are terminally ill, why not the chronically ill or disabled who are suffering unbearably? If those with physical suffering, why not those with mental or emotional suffering such as severe depression? Why not, as euthanasia advocate Philip Nitschke  suggested, the elderly bereaved and the troubled teenager?

Christians have the strongest possible reason to respect human life, as each person, no matter what their age or cognitive ability, is a unique individual made in the image of God. But as Margaret Somerville says:

respect for life (a preferable term to sanctity of life to avoid religious connotations and associations) is not just a religious value, it is a foundational value of all societies in which reasonable people would want to live…. It is foundational to what German philosopher Jürgen Habermas calls "the ethics of the [human] species".


But, it seems, killing is in danger of being redefined from a moral wrong to an act which can be in the best interests of the one killed. Once that redefinition has taken place, as exemplified in the legalization of euthanasia (albeit initially with limited application and strict criteria), it is only a matter of time before it will be extended to many others in their ‘best interests’, whether or not they are ask for it, or are able to ask for it. Indeed, it already has been, in the Netherlands and in Belgium.


Denise Cooper-Clarke is convenor of the ETHOS bioethics task group.


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