Belgium: euthanasia and palliative care - strange bedfellows

By Paul Russell, HOPE Australia 

In November 2013, I had the distinct pleasure of travelling to Brussels for the launch of the Euthanasia Prevention Coalition - Europe at the EU Parliament.

The following evening my colleague and EPC International Chair, Alex Schadenberg joined Carine Brochier in debating Belgian euthanasia founders Dr Jan Berheim and Professor Etienne Vermeersch.

There was nothing veiled in what Bernheim or Vermeersch said that night. There's a subtle arrogance, it seems, when speaking with the knowledge that virtually a whole country agrees.

Bernheim told the audience that it was he who first went to London, to visit Dame Cecely Saunders, with the intention to bring palliative care to Belgium precisely because he saw this as a way to usher in euthanasia. Whether his actions and intentions were publicly known at the time, whether he is 'gilding the lily' or whether in fact the Belgian medical system fell for the trojan trap or went willingly is moot, I guess.

Whether as a direct result of Bernheim's actions or whether simply a matter of pro-euthanasia spin, we often here the claim that euthanasia and/or assisted suicide are simply additional, complementary tools in a palliative physician's toolkit. We are being asked here to swallow a falsehood: that caring can include killing.

Reflecting upon the Belgian experiment, we are also told that euthanasia and assisted suicide would actually improve palliative care. Precisely how is never explained. But the reality that palliative medicine in Holland and Belgium is up there with the best in Europe tends to add credence to such a claim.

But does it?

This month in the Journal of Bioethical Inquiry, a paper entitled, Between Palliative Care and Euthanasia (Mortier, Leiva, Cohen-Almagor & Lemmens) looks at the most recent euthanasia data (2012-2013) and calls on "politicians, the medical profession, and juridical authorities soberly (to) reflect on the developments that have taken place since 2002."

Looking at all euthanasia deaths, the authors observe:

  • that only 40 percent (1,283 out of 3,239) of the euthanized patients had a visit by a palliative care team,
  • barely 12 percent (396 out of 3,239) had a visit by a palliative care specialist,
  • just 9 percent (307 out of 3,239) were consulted by a psychiatrist (Commission Fédérale de Contrôle et d'évaluation de l'Euthanasie 2014).

They conclude that, "almost 40 percent of the patients who received euthanasia did not see a palliative care specialist nor interacted with a palliative care team."

"The conclusion that Belgium is a palliative care role model for the world is an overstatement."

This data fits well with the observation of Dutch Professor, Theo Boer that, in his country, euthanasia is 'on the way to becoming a default mode of dying for cancer patients'. In 2012, a spokesperson for the Royal Dutch Medical Association admitted that, "Euthanasia has become the central point of conversation between a doctor and a patient who is suffering when it should be seen as a "last resort".

This is not difficult to understand. Ethically, doctors are required to spell out to a patient all of their options. If euthanasia or assisted suicide are 'medical acts', then a doctor is obliged to explain that it is an option. Because no one can be compelled to a particular course of treatment, if the entirely subjective qualifier of 'intollerable suffering' is the sole remaining criteria, it is not difficult to see how patient autonomy trumps all other concerns.

Yet time and time again the Australian public and our politicians have been told that euthanasia would only ever be a last resort. This implies that the door to being made dead by a doctor opens at a point where a all reasonable options have been tried and have failed. Even here there is no clear line; what is reasonable in one circumstance varies from every other and with every other patient.

We should not doubt that, for some, trying everything they can to cling on to life and to alleviate pain and suffering might preceed a request to be made dead. But implied in the term and understanding of 'last resort' is that care at the end can and does fail patients. This is the fear that is often peddled by euthanasia supporters; admitting that palliative care has come a long way but, you never know...

This, also is being proven false as more and more palliative specialists admit that they can and do deal with all pain and suffering. If there's a problem it lies in the fact that general medicine training does not equip GPs well enough and that specialist services are not yet universally available. Fixing these issues doesn't require the killing of patients.

Harkening back to the Brussels debate, both Bernheim and Vermeersch told the audience that there was 'too much suffering' in Belgium. Perhaps their palliative care isn't up to the standard they claim it is or perhaps as in Australia, there's simply a problem of access. Either way, Bernheim's claim, rebutted in the Journal of Bioethical Inquiry article, that 'Belgian palliative care system, including euthanasia, should serve as a role-model for the rest of the world,' cannot be sustained.