BELGIUM: Age restrictions lifted on euthanasia

[13 February 2014] - Belgium has amended its 2002 euthanasia law extending the right to die to children who are incurably sick and suffering extreme pain. The country's parliament voted through the amendment by 86 votes to 44, with 12 abstentions.
In 2002 Belgium became the second country in the world to legalise euthanasia after the Netherlands. But before the amendment, only people in Belgium who were 18 or older and in a “hopeless medical condition” could request to die. Children aged 15 and over who were “legally emancipated” from their parents could also request to undergo euthanasia. While the Dutch law sets a minimum age of 12 to request euthanasia, Belgium’s amendment removes any reference to the age of a patient altogether.

Responding to children’s reality 

Supporters of the amendment to Belgium’s euthanasia law say it responds to the reality of terminally ill children. It recognises that as human beings, children are prone to and suffer terminal illnesses and extreme physical pain just as adults do. Indeed ailments do not discriminate based on the age of a person. Accordingly, neither should health care.
Speaking to Euronews in 2013, Professor Dominique Biarent, who heads the intensive care unit at the Queen Fabiola Children’s University Hospital, said that “Some children need to have an answer to their demands because they are suffering so much. They are asking for this.” 
But the proposition to extend the right to die to under-18s caused strong reactions early on in opposition to the law. The notion that children, especially young children, can request to die shatters adults’ view of them as naive, ingenuous and inexperienced, unable to make such a decision. But terminally ill children have in fact been requesting this and, notably, without first being prompted by a doctor (as it was previously illegal). 
One Belgian mother whose son, Benjamin, died in 2004 of liver cancer at the age of seven supports the lifting of age restrictions on euthanasia, as she believes it should also be available to children. Speaking to FRANCE 24, she recalled how Benjamin had a heightened sense of awareness in his final days at hospital realising his life was coming to an end. Benjamin opted not to be transferred to the intensive care unit for intubation despite doctors’ warnings that he would lose the ability to breathe, and said he preferred to be cremated rather than a buried. 
There was strong support for the amendment in the largely liberal country before it was passed on Thursday. An opinion poll found 75 per cent of Belgians were all for extending the option of euthanasia to children. In December 2013 the Belgian senate voted 50-17 in favour of amending the 2002 law so it would apply to minors. And many doctors and paediatricians in Belgium also expressed their support for the amendment, which they see as a response to the reality of those suffering terminal illnesses.

Always as a last resort 

When confronted with opposition claims that Belgium’s bill will allow euthanasia to be rolled out to any and all child patients who simply express a wish to die, medical professionals are quick to refute this claim, emphasising that there will be strict procedural guidelines in place and that euthanasia is always seen as a last resort. “It’s a long process. You cannot just buy a ticket and say ‘OK I will go for euthanasia’,”  said Professor Dominique Biarent. “That’s impossible and nobody will accept that. … We have been raised so we will cure people first. Our aim is always to try and cure a patient. But of course, the second aim is to care for them. Caring is also giving them conditions to die in dignity.” 
"Death is coming quickly. It is therefore necessary to allow the child to express what he thinks of the end of life, about how to die," said Daniel Baquelaine, an MP who backs the new law and who is also a doctor. 
Supporters of the amendment affirm that it will apply to a very small number of children who are experiencing the advanced stages of cancer or other incurable illnesses and who are suffering extreme pain. The bill reads that patients 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." 
Safeguards will, of course, exist. The law will allow doctors to “decide on a case-by-case basis whether or not a child is mature enough to make the decision to end his or her own life, as well as whether a child's health is grave and hopeless enough to warrant euthanasia,” reported the International Business Times. A child must also be conscious at the moment of the request, be in severe pain with no treatment available to relieve their distress, a psychologist must evaluate the child’s “capacity of discernment”, and parental approval is also required, though it is not clear what will happens if two parents of a child disagree.

A question of maturity over age

One of the primary aspects of Belgium’s euthanasia law is that maturity - rather than age - is given consideration in evaluating if a patient has the capacity and discernment to make the decision to die. 
But by removing any reference to age in Belgium’s euthanasia law, it recognises that children are entitled to be actively involved in their own health care from the earliest possible age. This is in line with article 12 of the UN Convention on the Rights of the Child (CRC), which recognises the value of a child’s views and the need to give them weight in accordance with the age and maturity of the child. Article 5 of the Convention also acknowledges children’s evolving capacities and parents’ responsibility to provide guidance to a child in the exercise of his or her rights as enshrined in the Convention. 
The appropriate method of ensuring that a child’s views are heard in health-related matters will vary from child to child and should be assessed on a case by case basis. This approach clearly endorses the need to reject strict age requirements with regards to children’s health-care rights and instead adopt a more flexible approach that takes account of the individual characteristics of a child. For children who have the capacity to make decisions about their care, the respect for their views may be determinative of how they ought to be treated. These approaches are sanctioned by the UN Committee on the Rights of the Child in its General Comment No. 4 on adolescent health and development and General Comment No.12 on children’s right to be heard. 
Many of the Belgian MPs who voted for the bill in its initial stage "appear[ed] to agree on the fact that age should not be regarded as a decisive criteria in the event of a request for euthanasia," the Belgian daily newspaper De Morgen wrote. But opponents of the bill have said it is impossible to determine whether a child is capable of making such a decision. 
On this question, a group of pediatricians urged Belgian lawmakers in December to approve the legislation, saying that “experience shows us that in cases of serious illness and imminent death, minors develop very quickly a great maturity, to the point where they are often better able to reflect and express themselves on life than healthy people.”
Likewise, Socialist Party senator, Philippe Mahoux, a surgeon by training, who helped draft the 2002 Dutch euthanasia law, noted that “children and adolescents who are living in difficult circumstances with regards to death and illness, display greater lucidity [on this issue] than most adults.” 
Writing off all under-18s as incapable of making a decision of this type is to deny that the under-18 age bracket comprises various age groups, each attributed with varying levels of maturity, as well as the fact that maturity does not just depend on age, but on experience and circumstances. Setting an arbitrary age limit on a medical procedure which is available to over-18s but denied to under-18s because of their presumed immaturity, is ultimately age discrimination. 

Implications of denying appropriate care 

There has also been opposition to the amendment from some doctors and paediatricians, who believe that the answer to children’s suffering linked to incurable illnesses is not euthanasia but palliative care, as they say modern medicine is capable of alleviating the pain of even the sickest children.
Palliative care - health care that seeks to alleviate suffering of patients - is indeed fundamental in the treatment of many terminally ill children. It employs a multidisciplinary approach to patient care, allowing the care team to address a patient’s physical needs (through physicians, pharmacists, nurses) and their emotional, spiritual and social needs (through psychologists, chaplains and social workers, respectively). 
The UN Convention on the Rights of the Child (CRC) primarily recognises children’s health rights under article 24, which designates the use of health care for therapeutic and preventative reasons. But children’s rights are interrelated and cannot be viewed in isolation. The right to health in relation to terminally ill children should be considered alongside the best interests of the child (article 3), the right to be heard (article 12), and the principle of non-discrimination (article 2). 
While palliative care may certainly be the most appropriate treatment route in many cases, the blanket suggestion that it is the best treatment in all cases of terminally ill children provides a generalised view of suffering. Indeed, doctors "do not have control over all types of pain, either physical or moral", Dominique Lossignol, a palliative specialist at the Bordet cancer clinic in Brussels told the AFP news agency. Doing so could constitute a violation of individual children’s best interests, as suffering varies from patient to patient and therefore so does the appropriate kind of individualised treatment and care.
Furthermore, denying the option of euthanasia to terminally ill children who are suffering unbearable pain and express a wish to die, purely because they are under the age of 18, not only constitutes age discrimination and ignores their views on the matter, but could in future be considered a form of inhuman treatment, as it involves keeping a terminally ill child alive despite extreme suffering. Article 37 of the CRC enshrines children’s right to be protected from inhuman treatment; and although this provision mainly relates to children deprived of their liberty, it is nonetheless applicable here, as it sets out States’ requirement to ensure children are “treated with humanity and respect for the inherent dignity of the human person, and in a manner which takes into account the needs of persons of his or her age.” 


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