/Euthanasia tourism: “There is never an ethical truth”

Euthanasia tourism: “There is never an ethical truth”

BRUSSELS – If you are ill with no sight of getting better but are not allowed to end your life in your country, you can come to Belgium. Here, ‘euthanasia tourism’ has been a phenomenon on the rise for a few years. But it also brings with it ethical difficulties.

A woman from the south of France, in her thirties, is suffering from MS. She isn’t independent anymore and has to rely on the help of her parents and partner. She is suffering and there is no solution for her, but she doesn’t get the help she wants in France. Therefore, she came to Belgium to see if she could get euthanasia.

“She came to Brussels by train. From Avignon. And she stayed in a hospital in Brussels for a week. Here, an evaluation was made to see if there really weren’t any other solutions and to see if the woman hadn’t been for example pressured into a decision. After one week, the woman and the doctor came to the conclusion that euthanasia was allowed, so the woman made an appointment to come back and receive euthanasia.” explains Jacqueline Herremans, lawyer and president of the Right to Die Association (ADMD) in Belgium, who personally knew the story and struggle of the woman trying to put an end to the pain caused by her MS.

But this young woman isn’t alone. According to a report from the Federal Control and Evaluation Committee for Euthanasia, 23 patients who lived abroad received euthanasia in Belgium in 2016 and 2017. This happened both in the French and the Dutch-speaking part of the country. But this number could be higher, as patients are not obliged to name their nationality.

Jacqueline Herremans continues to tell the story of the French woman coming to Belgium. “I was involved in her case to give legal support and check if everything was legally okay. But also as a moral support for her, in my role as president of the ADMD.” The woman came back to Belgium a few days before her last appointment. Herremans took her around Brussels to see the sights. “She still had a couple of wishes, things she wanted to do or see. So I took her to the Grand Place and told her all about the history, like a proper guide. They also had dinner at a nice restaurant, and then the day was there. Her partner, parents, grandfather, sister, they were all with her in the hospital room when she died.”

Possible but not easy
Although the possibility is there to get euthanasia, it doesn’t happen in a matter of days. “In Belgium, it is possible to get euthanasia as a foreigner, but that doesn’t mean that you can come on Monday and get euthanasia by Friday,” Herremans warns. Belgium has three important terms you have to meet to qualify: request, the patient has to request the euthanasia themselves; medical condition, the patient has to be sick; and suffering, the patient needs to suffer clearly from his or her condition. To see if someone meets these terms, multiple conversations have to be had, she explains. “So someone would have to come to Belgium maybe two or three times or even stay in the hospital for a while”.

Another important aspect is the patient-doctor relationship. “Someone’s medical records may be clear,” Herremans says, “but to discover any other problems, for example pressure to request euthanasia or to find other ways to alleviate suffering, a doctor needs to have a relationship with their patient.”

Agreeing with this is Paul Cosyns, psychiatrist and member of the Advising Committee for Bio Ethics. “The spirit of the law on euthanasia is about a patient having a long history with a doctor,” he says. According to Cosyns, there is a risk of ‘euthanasia tourism’ and the Committee of Bio Ethics is strongly opposed that. “There has to be a long relationship between patient and doctor and a thorough investigation into the possibilities, so to just come to Belgium for a few days, just for euthanasia, would be a violation of the law.”

Doctor’s involvement is key
Currently, the only European countries where active euthanasia is legal are The Netherlands, Belgium and Luxembourg. But in four other European countries, Germany, Finland, Austria and Switzerland, physician-assisted death is legalized.

Although Belgium now has one of the most liberal laws on euthanasia, it didn’t happen overnight. Until 1999, all Belgian governments, with an exception of one period of four years, were with Catholic parties. This made it difficult for subjects like the end of life to be discussed. In 1999 there was a possibility to push the Catholic parties into minority and the so called ‘rainbow government’ was formed by the green, Labour and socialist party. Under this government, led by Guy Verhofstadt, who is now member of the European Parliament, the discussion started on the question of the end of life. In 2002, two laws were passed regarding palliative care, euthanasia and patients’ rights.

The different forms of euthanasia

The difference between the active euthanasia and physician-assisted death has to do with the involvement of the doctor. Physician-assisted death entails making lethal means available to the patient which can be used at a time the patient chooses themselves. Active euthanasia means that the doctor takes an active role in carrying out the patient’s request, for example by injecting a lethal substance. According to the World Federation of Right to Die Societies, physician-assisted death is usually seen as easier emotionally for the doctor than active euthanasia, because they do not have to directly cause the death of their patient.

A third method that is allowed in for example Spain and Sweden, under strict circumstances, is passive euthanasia. This means that when a patient suffers from an incurable disease, they can decide to not apply life-prolonging treatments, such as artificial nutrition.

The Catholic church and the Catholic parties have always been against the practice of euthanasia. The vicariate Brussels told Euroscope they could not comment on ‘euthanasia tourism’ specifically but refer to a declaration of the Belgian bishops in 2017, in which the church states: “There is a border and a prohibition that has been there from the earliest beginning of the human community. When we touch that, we touch the fundaments of civilization. Therefore, we call for great restraint and sustained dialogue.”

“There is never an ethical truth,” Herremans says. “But we have to accept that in society we are going to find different points of view. And we have to make it possible for all these people to live and to die conforming to their conceptions.”

Let them come for beer, not euthanasia
The Committee for Bio Ethics is concerned about ‘euthanasia tourism’ rising, Cosyns stresses. And Jacqueline Herremans also sees the difficulties with this phenomenon. “I’m not necessarily in favor,” she says. “We like France, we like to go to France, and I’m very sure that French people like to come to Belgium. We have excellent beers, we have excellent restaurants and culture, so come to Belgium for that, but not for euthanasia.” She emphasizes that the ADMD does not provide names of doctors to foreigners asking for those. They do send them to medical consultation for the end of life, which is provided in three places in Belgium.

French doctor
The most current question that Belgium is dealing with, when it comes to foreigners coming to the country for euthanasia, is a case of a French doctor who wanted a room in a nursing home in Wallonia to practice euthanasia there and in that way help his French patients to end their life. A minister from the Walloon region submitted the question to the Advising Committee for Bio Ethics on how to deal with this situation. “Personally, I was amazed that this was even possible,” psychiatrist Paul Cosyns says, “because when you want to provide a medical service in a country, you have to be affiliated with the order of physicians.” But apparently, Cosyns explains, you can provide an occasional service in another country when you are a member of the European Community. “But the fact that it is lawfully possible, does not mean that it is ethically correct,” he adds.

The case of the French doctor is currently also being discussed by the French board of physicians. Something that can have big consequences for French people wanting to come to Belgium for euthanasia. “I’m a little afraid for what they might say,” Herremans says. “It could be possible that the board in France, who are absolutely not progressive, are going to say that it will not be possible anymore for French doctors to collaborate with Belgian doctors when it comes to a euthanasia request.” That would mean that it would become harder for Belgian doctors to obtain medical records of foreigners and therefore to perform euthanasia. Therefore, in a few years, people like the French woman suffering from MS might not be able to get their chosen end of life in Belgium anymore.