Monday, September 19, 2016

Child euthanasia

On February 14, 2014, under the title of "advances in pediatrics" in another forum I wrote:

Belgium's parliament votes through child euthanasia.

An update:

The first case of a minor who was helped to die since a change in Belgian law has been reported, according to local media.

Professor Wim Distelmans, head of Belgium's federal euthanasia commission said he was informed about the death by a local doctor and that the child was in an "exceptional and hopeless" position.

Belgium is the only country in the world so far that permits minors of any age to choose to end their life, since the law was changed in 2014. They are required to have rational decision-making capacity and be in the last stages of a terminal illness.

If the minor is under 18, parents also need to give their consent.

Belgian law states that children must be "in a hopeless medical situation of constant and unbearable suffering that cannot be eased and which will cause death in the short-term.

"Only in very exceptional and hopeless cases (is) euthanasia of a minor really an option," Distelmans told Het Nieuwsblad.
"Fortunately there are very few children who are considered (for euthanasia) but that does not mean we should refuse them the right to a dignified death."

Distelmans revealed no other information about the minor, although Reuters reported that the deceased was 17 years old.
"It is difficult to give an age limit, however, as there is this condition that a child must understand his actions, euthanasia could only apply to a child who had a full understanding of what death means, and what their death would mean.

"We have however realised that children who suffer from incurable or terminal illnesses can have an impressive level of maturity."

A total of of 8,752 people were euthanised in Belgium between 2003-2013, according to the national euthanasia control committee.


  1. Wim Distelmans, head of the euthanasia commission, gave no details of the minor involved beyond saying it was an exceptional case of a child with a terminal illness, the Het Nieuwsblad newspaper reported.

    VRT public television said the incident involved an adolescent who was about to turn 18.

    "Fortunately, there are very few children who are considered (for euthanasia) but that does not mean we should refuse them the right to a dignified death," Distelmans told the newspaper.

    Since 2014, when its euthanasia legislation was amended, Belgium has been the only country in the world that allows terminally-ill children of any age to choose to end their suffering -- as long as they are conscious and capable of making rational decisions.

    The Netherlands also allows mercy killings for children, but only for those aged over 12.

    The Belgian amendment, which was passed after heated debate -- notably over the meaning of a "capacity of discernment" -- offers the possibility of euthanasia to children "in a hopeless medical situation of constant and unbearable suffering that cannot be eased and which will cause death in the short term".

    Any request for euthanasia must be made by the minor, be studied by a team of doctors and an independent psychiatrist or psychologist, and have parental consent.

    When amending the law, Belgian legislators had decided not to include psychological suffering in the list of factors determining whether euthanasia may be allowed for minors, though it is admissable for adults.

  2. Altogether over 2,000 mercy killings were declared in Belgium last year, a record number since the practice was made legal in 2002.

    Last weekend Belgian Paralympian Marieke Vervoort said in Rio that she is considering euthanasia to escape a life of unbearable physical pain -- only not quite yet.

    Vervoort, who won silver in the 400m wheelchair race at the Paralympic Games, played down earlier reports that she planned to be euthanized after her return from Brazil.

    "I have my (euthanasia) papers in my hand, but I'm still enjoying every little moment. When the moment comes when I have more bad days than good days, then I have my euthanasia papers, but the time is not there yet," she told a news conference in Rio, Brazil, where the Paralympic Games are taking place.

  3. At the time the law was being debated in the Belgian Senate, euthanasia opponent decried the proposal.

    “Currently the Belgian euthanasia law limits euthanasia to people who are at least 18 years old. This unprecedented bill would extend euthanasia to children with disabilities,” says Alex Schadenberg of the Euthanasia Prevention Coalition at the time. “The Belgian Socialist government is adamant that the euthanasia law needs to extend to minors and people with dementia even though there is significant examples of how the current law is being abused and the bracket creep of acceptable reasons for euthanasia continues to grow. The current practice of euthanasia in Belgium appears to have become an easy way to cover-up medical errors.”

    “Regardless of disability, life should be valued. To pass legislation that allows termination of life for people with disabilities who are minors is unacceptable,” he added. “Instead we must make every effort to use the research provided to us to provide attentive care to relieve their physical suffering in a moral way.”

    Dr Paul Saba of Physicians for Social Justice, was very concerned about the situation in Belgium.

    “They are already euthanising people who are depressed or tired of life because they have taken the interpretations of saying physical and/or psychological suffering – you don’t have to have both, if you have one, why is that not enough? If you are suffering, it’s a personal experience and it would be discriminatory for someone to judge what a person is suffering,” he said during that time. “What this teaches us is that despite the government’s assurances that they will set very strict criteria, that won’t work.”...

    Following the vote on Thursday, Tom Mortier, a lecturer in chemistry at Leuven University and an anti-euthanasia campaigner, called the vote “insanity.” Professor Mortier’s own mother, who was suffering from chronic depression at the time, was euthanized in 2012.

    “Her departure wasn’t the serene family gathering, full of peace and reconciliation, which euthanasia supporters gush about,” Mortier stated. “The University Hospital in Brussels phoned my wife the day after.”

    The leaders of Belgium’s Christian, Muslim, and Jewish communities put out a joint statement opposing the vote’s outcome. The statement read, “We mark out opposition to this extension and express our trepidation in the face of the risk of a growing trivialization of such a grave reality.”

  4. Chambaere K, Bilsen J, Cohen J, Onwuteaka-Philipsen BD, Mortier F, Deliens L. Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey. CMAJ. 2010 Jun 15;182(9):895-901.

    Legalization of euthanasia and physician-assisted suicide has been heavily debated in many countries. To help inform this debate, we describe the practices of euthanasia and assisted suicide, and the use of life-ending drugs without an explicit request from the patient, in Flanders, Belgium, where euthanasia is legal.
    We mailed a questionnaire regarding the use of life-ending drugs with or without explicit patient request to physicians who certified a representative sample (n = 6927) of death certificates of patients who died in Flanders between June and November 2007.
    The response rate was 58.4%. Overall, 208 deaths involving the use of life-ending drugs were reported: 142 (weighted prevalence 2.0%) were with an explicit patient request (euthanasia or assisted suicide) and 66 (weighted prevalence 1.8%) were without an explicit request. Euthanasia and assisted suicide mostly involved patients less than 80 years of age, those with cancer and those dying at home. Use of life-ending drugs without an explicit request mostly involved patients 80 years of older, those with a disease other than cancer and those in hospital. Of the deaths without an explicit request, the decision was not discussed with the patient in 77.9% of cases. Compared with assisted deaths with the patient's explicit request, those without an explicit request were more likely to have a shorter length of treatment of the terminal illness, to have cure as a goal of treatment in the last week, to have a shorter estimated time by which life was shortened and to involve the administration of opioids.
    Physician-assisted deaths with an explicit patient request (euthanasia and assisted suicide) and without an explicit request occurred in different patient groups and under different circumstances. Cases without an explicit request often involved patients whose diseases had unpredictable end-of-life trajectories. Although opioids were used in most of these cases, misconceptions seem to persist about their actual life-shortening effects.

  5. Dierickx S, Deliens L, Cohen J, Chambaere K. Euthanasia in Belgium: trends in reported cases between 2003 and 2013. CMAJ. 2016 Sep 12. pii: cmaj.160202. [Epub ahead of print]

    In 2002, the Belgian Act on Euthanasia came into effect, regulating the intentional ending of life by a physician at the patient's explicit request. We undertook this study to describe trends in officially reported euthanasia cases in Belgium with regard to patients' sociodemographic and clinical profiles, as well as decision-making and performance characteristics.
    We used the database of all euthanasia cases reported to the Federal Control and Evaluation Committee on Euthanasia in Belgium between Jan. 1, 2003, and Dec. 31, 2013 (n = 8752). The committee collected these data with a standardized registration form. We analyzed trends in patient, decision-making and performance characteristics using a χ2 technique. We also compared and analyzed trends for cases reported in Dutch and in French.
    The number of reported euthanasia cases increased every year, from 235 (0.2% of all deaths) in 2003 to 1807 (1.7% of all deaths) in 2013. The rate of euthanasia increased significantly among those aged 80 years or older, those who died in a nursing home, those with a disease other than cancer and those not expected to die in the near future (p < 0.001 for all increases). Reported cases in 2013 most often concerned those with cancer (68.7%) and those under 80 years (65.0%). Palliative care teams were increasingly often consulted about euthanasia requests, beyond the legal requirements to do so (p < 0.001). Among cases reported in Dutch, the proportion in which the person was expected to die in the foreseeable future decreased from 93.9% in 2003 to 84.1% in 2013, and palliative care teams were increasingly consulted about the euthanasia request (from 34.0% in 2003 to 42.6% in 2013). These trends were not significant for cases reported in French.
    Since legalization of euthanasia in Belgium, the number of reported cases has increased each year. Most of those receiving euthanasia were younger than 80 years and were dying of cancer. Given the increases observed among non-terminally ill and older patients, this analysis shows the importance of detailed monitoring of developments in euthanasia practice.

  6. Pousset G, Bilsen J, Cohen J, Chambaere K, Deliens L, Mortier F. Medical end-of-life decisions in children in Flanders, Belgium: a population-based postmortem survey. Arch Pediatr Adolesc Med. 2010 Jun;164(6):547-53.

    To estimate the prevalence of end-of-life decisions and to describe their characteristics and the preceding decision-making process in minors in Belgium.
    Population-based postmortem anonymous physician survey.
    Flanders, Belgium.
    All physicians signing the death certificates of all patients (N = 250) aged 1 to 17 years who died between June 2007 and November 2008 in Flanders, Belgium.
    Prevalence and characteristics of end-of-life decisions and the preceding decision-making process.
    For 165 of the 250 deaths, a physician questionnaire was returned (70.5%). In 36.4%, death was preceded by an end-of-life decision. Drugs were administered to alleviate pain and symptoms with a possible life-shortening effect in 18.2% of all deaths, nontreatment decisions were made in 10.3%, and lethal drugs without the patient's explicit request were used in 7.9%. No cases of euthanasia, ie, the use of drugs with the explicit intention to hasten death at the patient's explicit request, were reported. Poor clinical prospects (84.6%) and low quality of life expectations (61.5%) were important reasons for the physicians to engage in end-of-life decisions. Parents were involved in decision making in 85.2% of these decisions, patients in 15.4%.
    Medical end-of-life decisions are frequent in minors in Flanders, Belgium. Whereas parents were involved in most end-of-life decisions, the patients themselves were involved much less frequently, even when the ending of their lives was intended. At the time of decision making, patients were often comatose or the physicians deemed them incompetent or too young to be involved.