Can we ask questions, at last?

A striking article concerning Belgium reached us by way of the Washington Post: 'Expert on euthanasia caught in the firing line' (DS, 28.10.2017). It is easy to understand and even a good thing for the Flemish press to focus on this article. And yet it seems rather difficult to catch the full implications of the elaborate article by the Associated Press. What is it all about? A journalist, committed to the Associated Press, managed to get hold of the correspondence in which Professor Distelmans, the leader of LEIF (Levenseindeinformatieforum) and of ULteam (het Centrum voor Uitklaring van Levensvragen te Wemmel), after several years of cooperation, dissociated himself from psychiatrist Lieve Thienpont, one of the leading proponents and providers of medical euthanasia in Belgium for patients suffering from psychiatric disorders. From now on, Distelmans refuses to consult on any requests for euthanasia, referred by the ULteam from Vonkel-- the Ghent open house for people with questions concerning life's end where Thienpont is the chief psychiatrist. Vonkel is also instructed not to work under the LEIF-doctors' umbrella any longer. Obviously, Distelmans' opinion on 'how a request for euthanasia needs to be treated' differs too much from Thienpont's approach. According to Distelmans, this compelling request to dissociate from Thienpont is also dictated by the fact that Vonkel is associated with "colleagues who repeatedly declared not to respect the law on euthanasia".

This conflict between doctors, both known for their fiery defense of the law on euthanasia and their advocacy for a lenient threshold for euthanasia, even with non-terminal patients suffering from unbearable psychic agony, is certainly looked upon with a deep frown. An attentive reader of the entire AP article will notice that at least one psychiatrist, Lieve Thienpont, provides euthanasia in a way that arouses many questions, and not just with family members. Thienpont herself considers this to be an internal dispute about procedure and media visibility. She underlines the fact that no medical nor clinical mistake was made. For example, she says she has never been put on the spot by the Federal Control Office and the Commission for Evaluation. In fact, good to know, Distelmans is since many years the chairman of this commission.

In the meantime, Distelmans himself has acknowledged the article in the Washington Post to be greatly exaggerated. Indeed, he himself considers the whole matter as an internal dispute on how to guide people suffering from unbearable psychic agony to the final death procedure. None of them fundamentally questions the law on euthanasia based on psychic suffering, which allows patients with mental disorders the potential to receive euthanasia.

This lack of questioning by the two most important protagonists of Belgium's euthanasia practice is absolutely worrying. For one thing, how is it possible that that Dr. Thienpont has never been put on the spot so far, knowing that Prof. Distelmans himself in his letter suggests that the law hasn't been properly followed? A doctor prepared to administer euthanasia and to be a reviewer, both functions exerted by the same person simultaneously, who wouldn't frown upon that? Some timid calls have been heard in recent years for a thorough screening of the commission in charge of the reviews. So far this hasn't occurred as Prof. Distelmans claims that everything is squeaky clean. Indeed, the fact that one case has been known to be referred to court, should be the proof that the commission is effective.

A much more worrying and even problematic evolution is to be found in the way euthanasia is administered in psychiatry. This is not merely about people who act in a negligent way, it is mainly about the radical impossibility to determine it as negligent according to the law. A thorough evaluation of both law and a need for more transparent information has become more than urgent. This is need for the policymakers and the society on the one hand, but also, as has become obvious now, for those in clinical work. Increasingly doctors, clinicians and nurses are starting to express their discomfort with the situation as it is today.

The Washington Post quotes KU Leuven Prof. Stephan Claes who in no uncertain terms emphasizes that too many requests for euthanasia and the actual provision of the lethal injection are performed by one and the same doctor. Dr. Claes, a psychiatrist, has often expressed his deep concern . The statement by KU Leuven Prof. Joris Vandenberghe pointing out that in Belgium euthanasia has been administered too easily and quickly these past years, resonates with many psychiatrists. Moreover, it is increasingly obvious that women are more likely to be granted euthanasia than men. Lacking courage or refusing to recognize these kinds of dangers seems like an ostrich policy.

There is no way to consider these aberrations apart from the logic of the euthanasia law itself. Euthanasia for unbearable and hopeless psychic suffering is very problematic. These are people who are not mortally ill and who in principle still have many years of life ahead. Extreme cautiousness with this patient population is appropriate both clinical and juridical. Significantly, a certain subjectivism in estimating the hopelessness of someone's suffering can' t be avoided. And yes, a patient in hopeless agony mentions this and often proposes an idea like "I don't want any of it anymore'. It is vital for many clinicians to stay close to their patients and their suffering, devoted to their patients and the conviction: "There's always another possibility, we won't let you down."

The law as it is today denies in a fatal way the necessity of this life-giving dynamism in psychic and psychiatric therapy. Every complaint concerning possible carelessness in this domain, can only end up in a legal no man's land. The law does not mention the exact criteria for the definition of unbearable and hopeless psychic suffering, the aberrations cannot be defined as negligence either. There is the possibility for an almost endless stretching of the criteria, allowed by the law. This is what the actual practice of euthanasia for psychiatric patients teaches us. It simply depends on the way in which the individual psychiatrist interprets, reads or tests the criteria, strengthened by the personal assumptions of the doctor and the presenting story of the patient's symptoms, whether a life is taken or not. However severe the suffering of their patients may be, this inevitable arbitrariness in deciding on euthanasia eligibility, is being found to be unacceptable by a great many clinicians lately. There has been mortality that could have been avoided. Remaining silent still is culpable negligence.

We call for tightening the criteria for psychic suffering, and to allow a commission to judge the case beforehand or preferably remove from the law unbearable and hopeless psychic suffering as a criterion for euthanasia. This would be a life-giving initiative.

We call for tightening the criteria for psychic suffering, and to allow a commission to judge the case beforehand or preferably remove from the law unbearable and hopeless psychic suffering as a criterion for euthanasia. This would be a life-giving initiative.

We also call to the professional community of psychiatrists to start an in-depth debate on euthanasia in cases of strictly psychic suffering. The fact that the Flemish Society for Psychiatry is at this moment considering the formal application of criteria concerning carefulness, is important, but insufficient by far.

Now is the time for an ethical reflection among all involved: professionals, patients, (surviving) relatives, families. It has become obvious that the law on purely psychic suffering as a criterion for euthanasia is allowing that which should not be countenanced.