Proposed extension of Belgian euthanasia law: critical feedback from the Netherlands

Karianne Jonkers, policy adviser at the Professional Federation of Dutch Doctors, began by pointing out that in 2023, 8 people with dementia were officially euthanised on the basis of an advance declaration in the Netherlands. This figure raises the question of what will happen in Belgium, where the criterion of suffering, unlike in the Netherlands, is not included in the bill currently under discussion.

Karianne Jonkers was involved in drafting the Dutch law allowing people with an acquired disability to be euthanised. During her speech to the House, she emphasised the difficulty of applying such a declaration in a context where the person's condition no longer allows them to consent. In the Netherlands, the law is stricter than the Belgian proposal:

• The doctor must attempt to communicate with the patient (although the absence of oral confirmation by the patient of his or her wish to die by euthanasia is not required);
• A prior conversation must take place with the patient, while he or she is still capable of expressing his or her wishes, so that the patient clearly confirms his or her wish to die by euthanasia in such a case;
• The doctor must observe symptoms of irreversible suffering at the time of application of the advance declaration.

In practice, few Dutch doctors are prepared to carry out euthanasia on people who no longer remember having made such a request. As a precaution, therefore, the patient's current wishes are respected and take precedence over the declaration. A patient's refusal to die by euthanasia, even if formally considered incapable of consent, will lead to the patient not being euthanised on the basis of his or her advance declaration.

The proposed Belgian law envisages basing the advance declaration of euthanasia on the person's inability to express his or her wishes. In the opinion of Karianne Jonkers, it is dangerous to use the patient's incapacity as the only immediate criterion, as it is difficult to establish whether this is permanent and irreversible. Without the addition of a criterion linked to current suffering, the proposed Belgian law would open the way to numerous abuses and pressures.

The second expert to be heard on Wednesday is Theo Boer, professor of health ethics at the PThUniversiteit (Utrecht) and initially in favour of decriminalising euthanasia. Both experts now agree that ‘in practice, it will be extremely difficult to find doctors willing to euthanise a patient who is not really suffering, who has implicitly or explicitly indicated that he or she does not want to die, or who has no idea what happens when euthanasia is performed’, in the words of Theo Boer. We can therefore assume that the Belgian law would prove inapplicable in practice, given the probable refusal of most doctors to euthanise patients under such conditions.

A request for euthanasia or a cry for help: how can we discern the real request?

As one of the MPs present at the parliamentary health committee meeting pointed out, isn't this request for euthanasia really a plea to be heard rather than a genuine request for death? In response, expert Karianne Jonkers said that a study had shown that a large proportion of psychiatric patients who had requested euthanasia in the Netherlands had withdrawn their request when they had been able to be heard or properly cared for. While the expert points out that this is not always the case, this fact nevertheless raises questions about euthanasia as a response to the present or future suffering of people with dementia. The solution, as Theo Boer pointed out, could be to ‘improve care for people with dementia’ and not to ‘continue treatment indefinitely’ in an excessive manner.

The experts at the hearing also pointed to the risk of pressure being put on elderly patients to draw up an advance declaration of euthanasia and on the doctors who will have the heavy medical and legal responsibility of deciding to apply the advance declaration of euthanasia. This social pressure is already perceptible in the explanatory memorandum to the proposed law, which worries about a ‘tsunami of dementia cases’ in the years to come. In this context, a single euthanasia carried out under pressure would already be one too many, stresses Theo Boer, who points out that it is still ‘very difficult for a doctor to end a life’.