Vlaams Belang criminaliseert asielzoekers systematisch door ze "asielbedriegers" te noemen. Voor mij is elke asielzoeker in de eerste plaats een mens in nood, die met respect moet worden behandeld. Dat is een zeer groot verschil. Etienne Vermeersch

'Risico's nemen is geen criterium voor asiel'

Interview met Etienne Vermeersch

Pieter LEURIDAN - Gazet van Antwerpen

GENT — "Medelijden, iets anders kun je als mens niet voelen, als je die sukkelaars uit de romp van dat schip ziet klauteren", zegt professor emeritus Etienne Vermeersch over de tien verstekelingen die woensdagavond in Kallo werden ontdekt. Als voorzitter van de werkgroep, die werd opgericht na de dood van de Nigeraanse asielzoekster Semira Adamu in 1998, pleitte de Gentse moraalfilosoof toen voor een humaan maar veel strikter uitwijzingsbeleid.

 'De Bijbel is en blijft mensenwerk. Het gaat niet om de letter van de tekst, maar om de inspiratie die je eruit puurt', zegt de schrijver met 'een' godsgevoel. 'Welke inspiratie? Dat je mensen mag uitroeien?', pareert de filosoof die jaren geleden al rationeel bewees dat de god van het christendom niet bestaat.

Etienne Vermeersch (71) wilde wel eens weten wie die Christophe Vekeman (33) was die zijn atheïsme zo op de korrel nam. De Morgen bracht ze samen voor een duel over geloof en rede. Bestaat Hij of bestaat Hij niet? En kan Vekemans God die van de liefde zijn, als Zijn Woord volgens Vermeersch in bloed geschreven werd? "U schijnt niet te beseffen dat u met uw vorm van godsgeloof gedurende achttien eeuwen vervolgd zou zijn door de godsdienst waarmee u zegt te sympathiseren." "Ik heb bij het begin van dit gesprek gezegd dat ik hier niet als spreekbuis van het katholicisme zit. Ik ben godbetert kardinaal Danneels niet!"

Op het VTM-nieuws van 2 februari 2005 kon iedereen horen dat - volgens Vermeersch - van nu af aan politiegeweld tegen uitgeprocedeerde asielzoekers verboden was. Een verantwoordelijke van de politievakbond reageerde hierop dat dit tot gevolg zou hebben dat men de uitwijzingen zou stopzetten. Even later las ik bij de hoofdredacteur van Knack dat diezelfde Vermeersch als eerste (“Het mag nu”) beslist heeft dat het ethisch verantwoord is die personen onder dwang te verwijderen; hij plaatst deze visie op dezelfde lijn als de anti-jodenpolitiek van de Europese landen voor de oorlog, die mede tot de holocaust heeft geleid.

Technisch gezien geniet professor Etienne Vermeersch al geruime tijd van een welverdiend pensioen na een lange carrière als hoogleraar aan de Gentse universiteit. Toch is vandaag geen academicus bekender bij het grote publiek dan hij. Als moraalfilosoof heeft Vermeersch bijna overal een mening over, en hij verkondigt die graag en met verve. "Krijg je veel lezersbrieven?" vraagt Vermeersch terwijl hij een nummer van Guido Campus Magazine doorbladert. "Nee? Dan zal het niet controversieel genoeg zijn." Laten we daar dan maar vlug verandering in brengen. Shoot, professor! Shoot, by all means!

Patrik Vankrunkelsven is een verstandig, integer en sociaal voelend man. Zijn pleidooi om de deur op een kier te zetten voor het Blok is dan ook een gebeurtenis, zij het een heel pijnlijke. Wij die dachten dat het cordon sanitaire helemaal niets met tactische overwegingen te maken had, maar alles met ethiek, zijn nu een illusie armer: als dit met het groene hout gebeurt, wat dan met het dorre?

Het cordon is geen tactiek maar een ethische stellingname: je verkoopt je ziel niet aan predikers van de haat.Etienne Vermeersch, 2004

In een recent opiniestuk over euthanasie stellen heel wat prominenten dat een arts niet kan gedwongen worden om euthanasie toe te passen (DS 17 november 2004): 'De patiënt heeft het recht om aan euthanasie te vragen, maar hij kan niet eisen dat aan zijn vraag wordt voldaan.' Dat is juist. Maar jammer genoeg bevat de rest van hun tekst pijnlijke vergissingen, zegt Etienne Vermeersch.

Hippocrates' probleem

Het gebod "gij zult niet doden" zou aan elke menselijke beschaving ten grondslag liggen. De waarheid is dat bijna alle beschavingen in veel situaties doodslag formeel opleggen. Zo staan er in de bijbel talloze aansporingen tot doden. Denk aan de overspelige vrouw, maar ook aan de man die hout sprokkelt op de sabbat en moet gestenigd worden. Zelfs nu nog zijn er culturen waar eremoord als morele plicht geldt. Sommige intellectuelen weten blijkbaar niet dat men al 63 jaar geleden heeft aangetoond dat het gebod in Exodus "lo tirtsah" niet betekent "gij zult niet doden", maar "gij zult geen moord plegen". Dat wil zeggen dat je niemand mag doden die volgens de regels van de maatschappij niet mag gedood worden, wat nogal evident is.

Het is naïef om problemen van de 21ste eeuw te willen verhelderen met teksten van meer dan 2.000 jaar geleden. De Eed van Hippocrates verbiedt immers ook elke vorm van chirurgie. Onze maatschappij moet, op basis van de waarden die nu voor de meerderheid belangrijk zijn, de normen voor het handelen vastleggen. Terecht onderstrepen de ondertekenaars dat het respect voor de individuele autonomie en vrijheid daarin een centrale rol moet spelen. Maar die autonomie geldt dan blijkbaar niet voor de gewichtigste beslissing die men ooit kan nemen: uit het leven stappen, omdat het op objectieve gronden en in de subjectieve belevenis ondraaglijk geworden is.

Respect is moeilijk

Velen vinden dat ook de ultieme beslissing om van het leven afstand te doen legitiem kan zijn, anderen hebben daar problemen mee. Is het zo moeilijk de opties van de medemens hierin te respecteren? Voorstanders van euthanasie en zelfdoding dringen anderen niets op; waarom moeten de tegenstanders wel hun mening opdringen? Waarom zegt men dat euthanasie uitsluitend de verdwijning van de patiënt op het oog heeft, terwijl men goed weet dat de deernis om de lijdende mens de voornaamste motivering is?

Waarom suggereert men dat grote groepen in de samenleving vinden dat het menselijke leven in bepaalde gevallen geen respect meer verdient, waarbij de problemen rond het embryo en de foetus in één adem vermeld worden met die rond gehandicapten en ongeneeslijk zieken? Kan het nog verwarrender en tendentieuzer? En dan nog de kwetsende uitspraak dat volgens de voorstanders van euthanasie bepaalde mensenlevens minder waarde zouden hebben, hoewel het bij euthanasie alleen gaat over het als ondraaglijk inschatten van het eigen leven.

Sommige intellectuelen weten blijkbaar niet dat men al 63 jaar geleden heeft aangetoond dat het gebod in Exodus "lo tirtsah" niet betekent "gij zult niet doden", maar "gij zult geen moord plegen". Dat wil zeggen dat je niemand mag doden die volgens de regels van de maatschappij niet mag gedood worden, wat nogal evident is.

Etienne Vermeersch

Fun in Fallujah

De ondertekenaars zeggen dat volgens de wet een verzoek van de patiënt geen verplichting tot euthanasie bij de arts inhoudt. Na deze vaststelling, waarover geen discussie bestaat, gaan ze volledig uit de bocht. Uiteraard mag een instelling een arts niet tot euthanasie dwingen, niemand heeft dat ooit beweerd. Maar de auteurs denken dat een instelling een arts wel kan verbieden euthanasie toe te passen.

Euthanasie is slechts aanvaardbaar als zowel arts als patiënt in geweten tot het besluit komen dat het de enige uitweg is. In plaats van die gewetensbeslissing te respecteren, zou een ziekenhuisbestuur - dat bij definitie geen geweten heeft, alleen individuele mensen hebben dat - de arts kunnen verbieden zijn geweten te volgen in de meest aangrijpende en intieme beslissing die hij ooit kan nemen. Dat is een totale negatie van het respect voor de patiënt en voor de arts.

Iedereen neemt aan dat een patiënt het recht heeft een arts te vragen die nooit euthanasie toepast. Maar dat hij zelfs het recht zou hebben te eisen dat in een heel ziekenhuis - of een ziekenhuisnetwerk? - geen euthanasie wordt uitgevoerd, is te gek voor woorden.

Het enige argument dat deze tekst schijnt te schragen, is de suggestie dat de euthanasiewet het respect voor het leven vermindert. Dat is puur speculatieve sociologie, waarvoor nooit een bewijs werd geleverd. De Amerikanen in Fallujah die een adrenalinestoot krijgen bij het doden van hun medemens, hebben nooit over euthanasie gehoord. Als ze onze debatten hierover hadden meegemaakt, zouden ze dan nog meer 'fun' beleven? Ik durf het betwijfelen.

Volwaardige autonomie

De kluisters van de huidige euthanasiewet moeten inderdaad springen. Volwassenen kunnen nu, op eigen verzoek, uit hun lijden verlost worden; minderjarigen niet: die mogen wel zinloos blijven lijden.

Voor mij persoonlijk zou het eindstadium van Alzheimer een ontluistering zijn. Maar de huidige wet laat de uitvoering van mijn wilsbeschikking daarover niet toe. Mag ik die gedachte ondraaglijk vinden?

Medische hulp bij zelfdoding was in België ook voor de wet niet strafbaar, maar er hangt wel een sfeer van onduidelijkheid over. Voor de rechtszekerheid is het beter dat de criteria daarvoor met die van euthanasie worden gelijkgesteld. Hetzelfde zou trouwens moeten gebeuren voor de terminale verdoving, die nu in een juridisch vacuüm wordt uitgevoerd.

Ten slotte zijn we het er allemaal over eens dat we de palliatieve zorg verder moeten ontwikkelen. Maar ieder eerlijk mens weet ook dat, ondanks de beste zorg, de euthanasievraag niet altijd verdwijnt. Laten we, zeker als het over de lijdende medemens gaat, respect hebben voor de waarheid, de hele waarheid en voor de autonomie, de volwaardige autonomie.

Etienne Vermeersch

De auteur is filosoof en emeritus hoogleraar van de Universiteit Gent.

Ethiek bestond REEDS vOOr godsdienst

De opvatting dat er een noodzakelijk een nauwe band bestaat tussen godsdienst en ethiek is niet alleen Voltairiaans of Dostojevskiaans ("als God niet bestaat is alles toegelaten"): ze is volgens mij ook fout.

Indien de ethiek het gedurende zoveel millennia zonder godsdienstige ondersteuning heeft kunnen stellen, is er geen enkele reden om te denken dat dit nu, zelfs bij de doorsnee mensen, niet meer het geval zou kunnen zijn.

Etienne Vermeersch

De misvatting die aan de basis van deze meningen ligt, is de overtuiging dat godsdienst en ethiek als van nature iets met elkaar te maken hebben. Historisch gezien is dit onjuist. In de Griekse, Romeinse, Babylonische, enz. godsdiensten vallen de goden niet op door hun ethisch hoogstaande gedragingen. Reeds Xenophanes (6de/5de eeuw v.C.) schreef dat de Griekse goden niets liever deden dan "kleptein, moicheuein te kai allèlous apateuein": stelen, hoereren en elkaar bedriegen. Niet alleen was er weinig verband tussen godsdienst en ethiek, ook bestond er geen geloof aan een beloning of straf na de dood. Dat geldt niet alleen voor deze godsdiensten, maar ook voor de Israëlitische: het Oude Testament is gedragen door de overtuiging dat er geen beloning of straf na de dood bestaat; dat kan heel gemakkelijk bewezen worden. Pas in het boek Daniël dat dateert van rond het midden van de 2de eeuw v.C., dringt deze gedachte in de Bijbel door. De standaard-overtuiging staat reeds in het boek Genesis: "gij zijt stof en tot stof keert ge terug".

Afgezien van de Egyptische cultuur die een heel aparte ontwikkeling heeft doorgemaakt, kan men zeggen dat alle godsdiensten ter wereld geen algemene beloning of straf na de dood kenden, tenzij zij, direct of indirect beïnvloed zijn door Zarathoestra of door de Upanishaden.

In de loop van het eerste millennium vόόr Christus worden de mensen in verschillende culturen geconfronteerd met de ondraaglijke gedachte dat boosaardige mensen soms een heel succesvol en gelukkig leven hebben en deugdzame mensen soms zeer ongelukkig kunnen zijn.

Dit probleem van het geluk van de bozen en het ongeluk van de goede mensen heeft tot twee oplossingen geleid. 

In Indië komt in de loop van de 9de  eeuw v. C. de gedachte naar voren (in de Upanishaden, bv. Chandogya Upanishad) dat de mens tijdens zijn leven een soort karma op zich laadt: de gevolgen van zijn goede en slechte daden; je kunt het verdienste of schuld noemen. Na de dood blijft de nawerking daarvan doorgaan en dat leidt tot een wedergeboorte in een toestand  - beter of slechter - die door dat karma wordt bepaald.  Dit is een meesterlijke oplossing voor het probleem van het geluk van de bozen: wie in dit leven onschuldig lijdt, moet beseffen dat hij dat te wijten heeft aan het negatief karma van een vroeger leven en kan de hoop ontwikkelen dat, als hij deugdzaam wordt, het in een volgend leven al zoveel beter zal hebben. Op wie gelukkig is en boosaardig, moet je niet jaloers zijn, want er staat hem  in een volgend leven nogal wat te wachten.  In het Hindoeïsme, maar ook in het Boeddhisme en het Jaïnisme is die basisgedachte (met varianten) overgenomen en heeft zich zo over het grootste deel van Azië verspreid.

De overtuiging dat godsdienst en ethiek als van nature iets met elkaar te maken hebben is historisch gezien onjuist.

Etienne Vermeersch

De andere oplossing komt van Zarathoestra  (vermoedelijk ook rond de 9de  eeuw v.C.). De basisgedachte is dat er in de wereld twee fundamentele krachten of godheden zijn: de god van het licht, de waarheid, de reinheid, het goede,  en de god van de duisternis, de leugen, de onreinheid, het kwade (Ahura Mazda, Ormuzd tegenover Agra Mainyu, Ahriman) en hun volgelingen: engelen en duivelen. Zowel in de maatschappij als in het individu is er een blijvende strijd tussen die twee krachten, waarbij nu eens de ene, dan weer de andere het lijkt te halen. Er komt echter een eindstrijd waarbij de goede god de overwinning zal behalen; al degenen die partij gekozen hebben voor het goede, zullen uit de dood opstaan en de eeuwige beloning krijgen; de bozen zullen gestort worden in de poel van het verderf, de hel (volgens sommige bronnen de totale vernietiging). In sommige bronnen is er ook sprake van een ziel die onmiddellijk na de dood een beloning of straf krijgt; de gedachte van de wederopstanding lijkt echter de oudste en de meest succesvolle.

Mede door de Perzische veroveringen werd deze visie in het Midden-Oosten verspreid en in de loop van de tweede eeuw voor Christus drong ze ook door in het Judaïsme, vooral bij de Farizeeën en de Esseniërs en via hen ook bij Jezus en in het Christendom. De Sadduceeën (de priesters) bleven echter de orthodoxie handhaven en geloofden niet in een leven na de dood.

Na het Christendom werd deze opvatting ook overgenomen in het Manicheïsme en in de Islam.  Zarathoestra is dus een van de invloedrijkste figuren uit de wereldgeschiedenis, zoniet de invloedrijkste.  Zijn opvatting lost het probleem van het geluk van de bozen op,  maar heeft tevens een sterk wervende kracht omdat de mensen worden opgeroepen om zich aan te sluiten bij het leger van de goeden en dat van de bozen te bestrijden (Gott mit uns).  Daar staat tegenover dat het een simplistische, ongenuanceerde visie is omdat ze alleen leidt tot eeuwig gelukkigen en eeuwig verdoemden; de Indische oplossing is veel rechtvaardiger omdat men beloond en gestraft wordt,  exact in de mate waarin men goed of kwaad gedaan heeft.

Naast de Egyptische traditie moet ik ook nog melding maken van de leer van Plato over de onsterfelijke (eeuwige) ziel die als roeping heeft ooit de vormenwereld te aanschouwen.  Ook die opvatting heeft het Christendom beïnvloed, o.m. via het ‘Boek der Wijsheid’ of ‘Wijsheid van Salomo’ (Sapientia Salomonis) vermoedelijk uit de tweede helft van de eerste eeuw v.C..

Slotbeschouwing

Ik herhaal mijn thesis dat de culturen die niet door een van de hier vermelde oplossingen beïnvloed werden, geen algemene beloning of straf na de dood kenden.

De gedachte dat deze culturen dan ook geen ethiek zouden gehad hebben, lijkt mij totaal absurd en strookt niet met de historische feiten. De Romeinen bv. hadden - zeker tijdens de republiek - een strenge moraal zonder dat die door een godheid of een gedachte aan een beloning of straf na de dood moest worden ondersteund.

Het is pas onder invloed van de twee genoemde stromingen dat de gedachte aan een verband tussen godsdienst, eeuwige beloning of straf, en ethiek, ontstaan is.

Indien de ethiek het gedurende zoveel millennia zonder godsdienstige ondersteuning heeft kunnen stellen, is er geen enkele reden om te denken dat dit nu, zelfs bij de doorsnee mensen, niet meer het geval zou kunnen zijn.

The ethical and historical background of the Belgian and Dutch laws on euthanasia 

After a general introduction to ethics and the ethics of euthanasia, a survey is provided of the genesis of the euthanasia laws in Belgium and the Netherlands, with the intent to provide a clear idea of the concepts involved and of the rationale for their introduction.  The role of the Belgian Consultative Committee on Bioethics in the development of the ethical discussion in Belgium is explained as well as the essence of the profound ethical divide between the ‘coalition’ and the Christian Democrats. After a summary of the basic points of the Belgian law, a comparison is made between the Belgian and the Dutch laws and their ethical foundations.

ETIENNE VERMEERSCH

Published in Kurt Pavlic & Burkhart Bromm (ed.), Neurologie und Philosophie zum Schmerz, Göttingen, Vandenhoeck & Ruprecht, 2004. 

1. The ethics of euthanasia: general introduction

 1. 1.  Since the discussions concerning euthanasia engage some of the most fundamental values and norms of our individual and social life, it seems necessary to say a few words about the questions what these values and norms are and how we can find a foundation for our ethical views.

Morally relevant conduct, as distinguished from behav­iour in general, consists of activities that cause approval or dis­ap­proval. Such conduct can sometimes be governed by explicit maxims lear­ned from others or formulated for ourselves; but most­ly the rules are interiorized as ‘values’ or ‘norms’. They may then elicit either a posi­tive emo­tion or a moral pain when we are confronted with the results of our own acti­ons, or they may provoke feelings of admir­ation or indig­nation when we obser­ve the doings of others. Values and norms, which control the acti­vities of indi­viduals and groups, are of a fac­tual nature: their presence or absence can be ascertained by empirical pro­cedures.

Ethical research may consist of looking for information about the existence (or absence) of particu­lar norms (or values) wit­hin a group, but it is concer­ned primarily with the ques­tion of how a foun­dation can be laid for them. Such founda­tional pro­blems arise when gen­erally ac­cepted norms are sudden­ly chal­len­ged or when the need to intro­duce new ones imposes itself.

1.2.    In the course of the centuries, philosophers have realized that there is a difference between facts and values, between ‘is’ and ‘ought’, ‘Sein’ and ‘Sollen’.  Many of them were also convinced that both domains have an objective character: there is objective truth about facts and there are objective values which should be accepted by everybody. In one opinion, the objectivity of the values and norms was based on the thesis that ethical propositions could be deduced from factual ones (Sollen from Sein); in the other one, both had their own independent foundation.

The thesis proposed here is different from the aforementioned. It starts from the observation that values and norms develop in human societies as a means to organize them and to regulate the partially compatible and partially conflicting drives of the individuals in such a way that the stability and survival of the whole is guaranteed. It follows that morals necessarily change with the development of the economic, social, cultural, etc. components of the society.  There is no absolute foundation for ethics, but it is still sensible to ask which type of ethics is most compatible with a peaceful and prosperous state of a society in a given period, including ours.

 1.3.  More specifically, when studying the his­tory of the et­hical attitudes and prin­ci­ples since the oldest civi­lisa­tions which in­fluenced Wes­tern thought (Egypt, Meso­po­ta­mia, Israel and the Greco-Roman world), one cannot but be struck by the impression of an ever gro­wing im­por­tan­ce and ex­ten­sion of the con­cept of the fel­low human being.

Anthropo­lo­gical stu­dies sug­gest that people of Palaeolithic and early Neolithic tribes only iden­ti­fied with the members of the own tribe or clan: in many cul­tures the term ‘human being’ was only ap­plied to kin­smen or members of one’s own tribe.

But with the development of larger kingdoms (e.g. in Egypt and Meso­po­tamia), in which many tri­bes were uni­ted, the need for broa­der types of identifi­cation with the others gra­dual­ly arose. As a conse­quence, there developed an awa­reness that ethi­cal obli­ga­tions ex­tend to all the inha­bitants of the same king­dom.  In the Bible, we notice that the con­cepts of ‘neigh­bour’ (the ‘nearest’, ‘Nächtste’) and ‘love for one’s neighbour’, which initially only refer­red to the clo­sest re­la­tives or friends, are extended to in­clude all Israe­li­tes.

Near the end of the first millennium BCE, there is a growing tendency in a number of civilisations to widen even more these feelings of solidarity and identification, to human beings in general (e.g. in Buddhism, Maz­deism, Chris­tiani­ty, Greco-Roman Stoi­cism and, somewhat later, in Islam). This attitude was crystalli­sed in a moral norm: the so called Golden Rule, the first for­mu­la­tion of which one finds with Con­fucius (about 500 BCE) but which we know better in the form it took in the Gospel of  Matthew  (7, 12) : “All things whatsoever ye would that men should do to you, do ye even so to them.”

It seems to me that the growing complexity of human societies and the need for pa­ci­fied relationships over ever larger domains, con­tributed to the spread of this moral atti­tude and to its gaining so­li­dity and per­sua­sive­ness.

In the eighteenth and nine­teenth cen­tu­ries, this development has led to a clarification and sys­tematisa­tion of this initially rather vague clus­ter of atti­tudes and fee­lings.

 1.4.   Without going too much into detail, one can safely say that at least three important principles, which I call ‘values in progress’ were cla­ri­fied in the course of this development.

First, we observe the spread of the concept of ‘love of one’s neighbour’ or ‘iden­ti­fying with our fel­low human being’, which leads to acts of solidarity and it means that we consi­der him as our equal.

Second, this notion of equa­li­ty implies that we grant him the same rights we claim for our­selves, especially the rights to life, freedom and self-deter­mination or autonomy. In Kant’s formulation, every per­son has the right to be tre­ated as his own end and not merely as a means to another’s ends. For him, the quintessence of the Enlightenment was the emergence of the right to self-determination. “Aufklärung… ist der Ausgang des Menschen aus seiner Selbstverschuldeten Unmündigkeit…: das Unvermögen sich seines Verstandes ohne Leitung eines anderen zu bedienen”  (1)

In a third, no less important, component the Gol­den Rule re­fers to the idea of caring for other people, especially for those who suf­fer. Already in the Egyp­tian ‘Book of the De­ad’, we find the touching phrases: "I have not made anyone weep, I have not cau­sed any­one suffering”. (2)  This growing sensitivity to pain and suffering  - even of animals -  was beautifully expressed by Bentham: “The question is not, Can they reason? or Can they talk? but, Can they suffer?”. (3)

My first point is that the ‘values in progress’ we observe  in the course of the development of our civilisation are:  (1) the right to autonomy or self-determination of every individual and  (2) the love of one’s neighbour, or solidarity and (3) the obligation to protect from harm all beings liable to suffering.

 1.5.  In the 20th century we witness a number of mentality changes which lead to some adaptations and reformulations of these values.

Because of the desacralisation of the worldviews, the secularisation of the society and the tendency towards a consumer mentality, the ethical attitudes of the large public evolved from what one would call in German, a Jenseitsmoral to a Diesseitsmoral.  There is a growing belief that every human being has the right ‘to pursue happiness’ here and now and to avoid meaningless pain and suffering.

In the same movement of thought, a marked tendency could be observed, especially during the second half of the 20th century, which led to a change of age-old ethical standards and contributed to the break-down of traditional taboos. This manifested itself clearly in the acceptance of new standards concerning contraception, sterilisation, abortion, homosexuality, etc.

A third mentality change was the emergence of the idea of the rights of the patient and the rejection of paternalism. The acceptance of the right to ‘informed consent’ before the medical doctor intervenes for diagnosis and treatment is a major example of this development.

As far as the impact on the discussions about euthanasia is concerned, a very important step was the realisation of the link between paternalism and suffering.

Paternalism consists in the restricting of the self-determination of an individual, without his consent or without adequate information, but with the intention to preserve the individual’s own well-being.  Contrary to a time-honoured tradition in medical circles, there is a growing awareness now that paternalist acts and attitudes are no longer justified towards persons capable of taking autonomous decisions. This is especially the case when pain and suffering is involved.

The most radical arguments for this thesis have been put forward by J.S. Mill  (4) .

• Since pain and suffering can only be experienced by the suffering subject himself, nobody knows better than he does, when and to what extent he suffers.
• Nobody has more interest concerning his own well-being and suffering than the subject himself.

It follows that  - paternalist -  decisions by others may be wrong because they lack adequate information and/or real commitment.

 1.6.  On the basis of the foregoing considerations, the ethical problem concerning euthanasia can be approached as follows. Consider the case of a person, in full possession of his mental capabilities, who endures unbearable suffering due to an incurable illness, and who asks his doctor consistently to terminate his life.

According to the above mentioned  “values in progress”:  ‘human solidarity’,  ‘self-determination’, ‘sensitivity to suffering’;  and the   “mentality changes”:  ‘Diesseitsmoral’, ‘break-down of dated ethical standards’, and  ‘rejection of paternalism’;  it would be an act of high ethical value when the doctor, provided he respects some due care criteria, complies with this request.

 1.7. The possible objections to this approach are the following.

“The ‘right to life’ is a fundamental ethical value which an individual cannot give up.”  But ‘right to life’ has been introduced by societies as a protection of the individual against those who would want to take his life against his will. What could be the rationale of introducing a ‘duty to live’ for persons suffering hopelessly?

“Only God or Society has authority over life.”  But reference to God is not persuasive for those who do not believe in God. Hence, in an enlightened democratic era, society should put forward generally persuasive reasons to forbid euthanasia, which brings us back to the first point.

“It is the duty of the physician to preserve human life, not to terminate it.” But the duties of physicians, as of all professions, are determined by those who ask for their services. The ethical aspects of these duties should be determined by society. Except for reference to professional standards and a ‘clause of conscience’, doctors have to comply with what society asks from them.

“Introducing euthanasia could provoke abuses.”  This objection should be taken seriously and in every specific legislation the advantages and disadvantages should be carefully weighed up against each other.

2. The Belgian and Dutch laws on euthanasia: a brief history

2.1. In Belgium, the ethical and legal problems concerning euthanasia have occasionally been treated in the media since de seventies, there was, for instance, a one hour debate on the Flemish television in 1971. Organized action in favour of legislation started in the eighties with the foundation of the “Association belge pour le droit de mourir dans la dignité” (1981) and its Flemish counterpart “Vereniging voor het recht op waardig sterven” (Association for the right to die with dignity) (1983).

By then, the debate had already been launched in the Netherlands by doctor Geertruda Postma  in 1971.  She had given a lethal dose of morphine to her 78-year-old mother who was deaf and partly paralysed and who had asked her daughter repeatedly to end her life.  Afterwards, doctor Postma reported her act to the authorities. The groundbreaking verdict of the Court of Leeuwarden stated that a medical doctor cannot be blamed for shortening a patient’s life if she/he has observed certain due care criteria and if the following conditions are met:  incurable illness, unbearable suffering, request by the patient.  This ‘shortening of a life’ was not yet equated with euthanasia – the court gave doctor Postma a light sentence – but the debate on the topic was definitely opened.

After some other trials, a State Commission was set up (1982) to give advice on future government policy concerning euthanasia and assisted suicide.  The advice (1985) defined the concept of euthanasia as “the intentional taking of someone’s life by someone else, at his explicit request”. A majority of 13 to 2 advised that some articles of the penal code should be changed to make euthanasia permissible, if it is performed by a medical doctor who is following a specific procedure.

In October 1990, the attorney-generals agreed on a ‘notification procedure’:  the doctors who performed euthanasia, had to report it to the municipal coroner with a detailed account of the circumstances of the act.  The doctor would not be prosecuted if the prescribed conditions were met.  The real euthanasia law was only adopted on April 10th  2001 and became effective on April 1st  2002. (5)

2.2.   The impact of these ten years of factual impunity of a specific euthanasia practice on the ongoing discussion in Belgium was undeniable.  There the political discussion started in the mid 1990’s.  During the parliamentary session 1995-1996, euthanasia bills were submitted to the senate by four members of parliament. In 1996, the Belgian Comité consultatif de Bioéthique  (Consultative Committee on Bioethics) was founded to advice the federal and ‘community’ governments and parliaments on bioethical problems.  This Committee is composed of 35 members and 35 substitute members: medical doctors (two times 11), nurses, magistrates, lawyers, and specialists in the social sciences and moral philosophy and theology.  The very first assignment, proposed by the presidents of the Chamber and the Senate, was to give an ‘advice’ concerning the submitted euthanasia bills.

Two such advices were issued: the first one on May 12th 1997, which dealt with ‘euthanasia’ proper  (on competent people), the second one on February 22nd 1999  on ‘termination of life of incompetent people’ and on ‘advance instructions’ (‘living wills’).

It is very important to notice that, although the members disagreed on the fundamental questions, there was complete unanimity on the following topics.

(a) The Dutch definition was adopted: “euthanasia is the intentional taking of a person’s life by another, on this person’s own request”.  (b)  It follows that this definition does not apply in the case of incompetent people: there the proposed terminology is:  “termination of life of incompetent people”.  (c)  More importantly, the act of stopping a pointless (futile) treatment is not euthanasia and it is recommended to give up the expression ‘passive euthanasia’ in these cases.  (d) What was sometimes called ‘indirect euthanasia’, viz. to increase the use of analgesics with its possible effect on shortening life, is also clearly distinguished from euthanasia proper.

It is a pity that some medical doctors, even among those confronted on a daily basis with the situations falling under (c) and (d), still take the view that the Belgian euthanasia law is relevant for such decisions. There was agreement among the members of the Committee that the ‘end of life decisions’ of this type are not to be considered as ‘taking the life of someone’. Although some of them pleaded for enacting a law prescribing the procedures of decision making in these ‘end of life’ cases, others were confident that the specialists could be trusted when drawing up a system of rules in collaboration with their local ethical committees (e.g. Not To Resuscitate directions).

On the core question, three basic views came to the fore. Some members advanced that euthanasia could be allowed under no circumstances because it would compromise the inviolable value of the life of a fellow human being. Others were of the opinion that, out of compassion and respect for self-determination, euthanasia should be allowed. A middle group  - some of them doubtless of Christian conviction -   proposed that euthanasia should be allowed in cases of ‘force majeure’ where two conflicting duties of the doctor are involved (preserving life and relieving unbearable suffering).

These views were expressed in four proposals: (a) a revision of the law so that euthanasia is no longer punishable; (b) an agreement between the attorney generals not to prosecute in some cases:  i.e. a proposal similar to the regulation prevailing at that moment in the Netherlands. In both cases the doctor should take advice from a colleague and afterwards fill in a certain form describing the circumstances and hand it over to the legal authorities; this is the a posteriori procedure. (c) In what is called the a priori procedure, before any decision is made concerning euthanasia, an ethical debate should take place between the doctor, a second doctor, the family, the nursing team and an ethicist. If euthanasia follows, the doctor gives notice to the legal authorities with a plea of ‘force majeure’.  Of course, in all of these three proposals the euthanasia could only be executed by a medical doctor who made certain that the patient was in a state of unbearable suffering and that his request was completely free and well informed. (d) The fourth proposal rejected every form of euthanasia and hence any change of the law.

This Advice stimulated a debate in the Senate on December 9th and 10th 1997, but the discussion did not lead to any result until the elections of 1999.  The major problem was that the Christian Democrats could not accept a regulation that would change the penal law; they were only prepared to leave room to an appeal to ‘force majeure’ in extreme situations, whereas most of the other parties wanted to go much further.  Only the ultra-right ‘Vlaams Blok’ did not accept any change.

After the elections, a coalition of Liberals, Socialists and Greens formed the government banishing the Christian Democrats to the opposition bench.  Very soon, a number of senators, each representing one of the coalition partners, introduced a bill that was partly inspired by proposal nr 1 of  the two Advices of the Consultative Committee on Bioethics.  The Christian Democrats also introduced a bill inspired by proposal 3 of the first Advice.

Some party leaders feared that this euthanasia law would be the first in the world and therefore they hoped that a compromise was possible in order to arrive at a larger majority. But even a reflection period introduced during the months of April and May 2000, and about forty hearings of experts, only resulted in a number of amendments to the majority bill. The ‘great compromise’ did not succeed.

It is true that proposal 3 of  Advice nr 1 of the Consultative Committee, where the ideas of  a priori procedure and ‘force majeure’ were proposed, did open up a possibility of an agreement with the Christian Democrats.  However, it turned out that part of the rank and file of this party remained opposed to every form of euthanasia and certainly against a change of the law.  It is true that some progressive Christian Democrats were aware of the fact that a rather large majority of the population had a positive attitude towards euthanasia:  many have been confronted with unbearable suffering of relatives or friends.  But the majority of the Christians Democrats wanted to stand by what they considered a basic value of the Christian tradition: the absolute respect for human life.  In the Explanation of the proposal of the CVP (Flemish Christian Democrats) we read: “This age-old tradition of respect for life has become a norm for our Western civilisation, also for those denying the belief in God.  Each life is unique and deserves esteem, respect, protection.  The need to protect life is felt in the keenest way during the process of dying. The value of a life does not depend on its individual assessment.” (emphasis supplied). (6)

2.3.  Characteristic of this approach is a fundamental option for heteronomy  -  in contradistinction to those who see the autonomy of the person as the central value -  : the origin of the value of human life and of the human person is not found in this person himself  (autos), but in another authority (heteros).  Since the thesis that God is the other authority is no longer universally accepted, there is a tendency to replace it by society:  “Like birth, dying is a social event.  When the human being approaches death when a helping hand is missing, there is a denial of the social character of crossing over from life to death.” (ibidem)

Whoever starts from this point of view cannot agree with the proposal that a text with universal impact such as the articles on killing in the penal law could allow the taking of a life.  This would mean that the autonomy, the right to self-determination, would become a value in itself in some circumstances, which would eliminate the prevalence of the heteronomous authority.  “The duty of the authorities to protect human life…is founded on the belief that human life is valuable from the perspective of human dignity alone, that means that it is good in itself, regardless of its endorsement or denial of it by the individual.”  (ibidem).

Even a life that has become meaningless and unbearable for the person concerned, imposes itself on him as an inescapable matter of fact, adorned by the aureole of ‘human dignity’. As far as the foundations are concerned, this is also the view of those absolutely opposed to euthanasia. However, in the aforementioned third proposal of the Advice and in the bill of the Christian Democrats, it received a more humane expression. There it is accepted that, in some exceptional circumstances, the doctor could be confronted with a situation of emergency, which generates a conflict between the two values that he should, but cannot, realize at the same time.  Nevertheless, we have to emphasize that, in this context, the right to self-determination of the patient is not mentioned:  the euthanasia issue is considered essentially as a moral dilemma of the medical doctor. In this way, the basic principle of heteronomy is upheld.

The fundamental disagreement concerning the essence of the human condition: the central role of the heteronomous authority on the one hand, and the emphasis on autonomy and on respect and reserve in front of human suffering on the other hand, explains why a compromise was impossible, unless one of the two groups accepted to become unfaithful to its basic principles.  For, whatever nuances there may have been among the opinions of the members of the majority, there was a general agreement that the admission of euthanasia was founded:  (a) on the fundamental right of everybody to autonomy:  every person has the right to self-determination with regard to his own health and life, especially when confronted with unbearable suffering.  (b)  In so far as the doctor, in performing euthanasia, expresses his compassion and solidarity with the suffering person, this can be considered an act of high ethical standing. (c)  Even those who have a different vision of human life, should, in a pluralistic society, respect the values of the others and let them act according to these values as long as they do not harm others.

Once the latter values are admitted as basic principles, the only problem for the lawmaker is to find a set of rules that take into account the rights implied by them, while ruling out all possible forms of abuse.

The bill in which the majority tried to meet these requirements was approved by the joint Senate commissions of  Justice and Social affairs on March 20th  2001 (after having discussed 687 amendments);  in the Senate  on October 25th  2001 and finally in the Chamber on May 16th  2002  (with 86 votes pro, 51 contra and  10 abstentions). The law came into force on September 23rd  2002.

3. The Belgian law on euthanasia

The essential points of this law are that euthanasia can be performed by a physician (and only by a physician) without committing a crime, when the patient who requests it is of age, legally competent and conscious; when the request is voluntary, well-considered and repeated and the patient is enduring unbearable and consistent physical or psychological suffering as a result of an incurable pathological situation, caused by illness or accident.  The patient needs to be informed about his health situation and his life expectancy and the doctor must be convinced of the authenticity of the patient’s request.  Another physician should be consulted to verify the elements mentioned above.  If possible, the request should also be discussed with the nursing staff and the relatives of the patient.

When the patient is not in a so called ‘terminal’ state, i.e. when it is not expected that he/she will die naturally in the near future, a second doctor should be consulted and at least one month should elapse between the written request of the patient and the act of euthanasia.

Termination of the life of unconscious persons is also possible when the patient has made a ‘living will’ (advance instructions) concerning euthanasia, which is maximally five years old.

After performing euthanasia, the doctor is obliged to report this act to the Federal Commission of Control and Evaluation.

4. Comparison of the Belgian and Dutch laws

Since the ethical discussions  – including the publications concerning the relevant facts and figures –  preceding the approval of the laws in Belgium and in the Netherlands were similar in many respects, it seems instructive to compare the two laws. (7)  In my opinion, the Dutch law is by far the superior one; not only because it is the most ‘liberal’  - a fact which, although undeniable, has been denied repeatedly in the common place political discussion -   but also because it is more consistent from the ethical and the legal point of view.

4.1. The first aspect appears clearly from the divergent treatment of children and minors in general.  According to the Dutch law, a request for euthanasia can be complied with on an autonomous basis from the age of 16;  for people between the ages 12 and 16, the consent of the parents is required.  This takes into account that the senseless suffering of minors might be as horrible as that of adults and that the capacity to self-determination is a variable quality, which gains in relevance the more one progresses in age and the more one is confronted with unbearable suffering.  In Belgium nothing is possible for minors, although no one has ever given an ethically sound reason for that.

4.2. The superiority from the legal point of view lies in the fact that in the Netherlands the concept (although not the term) of euthanasia is clearly introduced in the penal law. Of course, this is the most honest thing to do: if a society decides that there is an important exception to the general interdiction of killing (apart from the case of legal self-defence), it should be added explicitly as a restriction of the general rule. At the same time, this makes it possible to mention specific penalties for negligent application of the rules.  In Belgium, euthanasia is introduced in a separate law with the (less than honest) aim of seeming to uphold the general interdiction and with the undesirable side-effect that every breach of the rule is to be prosecuted as murder.

4.3. Another remarkable distinction between the two laws, which depends on divergent appreciation within the public opinion of the two countries, concerns the so called ‘non terminal’ patients. In the Netherlands, the central issues in the euthanasia discussion have always been the autonomy of the patient and the compassion with his suffering: whether the natural death is close or not does not really matter;  neither does the law introduce this distinction.  In Belgium, the most fierce opposition to the coalition bill was aimed at the fact that euthanasia would also be possible for the ‘non terminal’ patients. Again, the reason seems to be related to the (Christian) attitude towards self-determination. In the ‘terminal’ case, the death is caused by a ‘heteronomous’ agent, viz. Nature, and the sole effect of euthanasia is to accelerate the process of dying. In the ‘non terminal’ case, the decision lies completely with the patient himself. The opposition to this was so strong that the lawgiver had to introduce the requirements of the advice of another physician and a waiting period of one month.

4.4. A final matter of intense debate in Belgium was the clause that the physician could take into account “unbearable and consistent physical or psychological pain or suffering” (emphasis supplied).  The objection, especially in medical circles, was that this proviso would pave the way to the practice of euthanasia in cases of extreme distress or depression without a somatic cause.  This, however, was a misinterpretation, since the law lays down explicitly that an incurable pathological situation, caused by illness or accident should be present. Furthermore, when the patient is not in a terminal phase, a third physician (in cases of depression, a psychiatrist) should give advice and it is clear that in most cases of this type he would have to conclude that there is no incurable illness and hence that euthanasia is not permitted.

Why then does the law take ‘psychological suffering’ into account?  Because, as soon as an incurable illness is diagnosed, whether such a situation is experienced by the patient as unbearable and hopeless depends also on psychological aspects. The prospect of dragging on a tarnished and humiliating form of life for example, can be experienced as a sufficient reason to ask for a mercy death for a number of persons.

The Dutch law does not mention ‘psychological suffering’, but it is evident from the court decisions and from the reports of the evaluation committees that these aspects of the patient’s experience are fully taken into account. (8)

5. Conclusion

It is understandable that the Netherlands, where a thoroughgoing discussion of the euthanasia problem started ten years earlier, could bring about a more consistent and well-considered law.  In Belgium, there is also the opinion that the actual law has serious shortcomings and that a change is advisable, especially as far as children and minors are concerned. Nevertheless, in spite of its inadequacies, we may hope that even as it is now, the law provides the last expedient to most of those who prefer a self-elected death to unbearable suffering.

Notes

1. Beantwortung der Frage: was ist Auklärung (1784)  Akademie-Ausgabe, VIII, 35.
2. Pritchard, James, B. (ed.), Ancient Near  Eastern Texts relating to the Old Testament, 1955, Princeton U.P. Princeton, p. 34.
3. Bentham, Jeremy,  Introduction to the Principles of Morals and Legislation, Chapter 17, footnote.
4. Mill, John Stuart, On Liberty, (1860), Fontana Library Edition, pp. 206-207.
5. For a good detailed exposition of the history of the euthanasia law in the Netherlands, I refer to a study  by Alina Fazal:  Death on Demand, which I received trough E-mail: alina_fazal@hotmail.com.
6. Sénat de Belgique, Session de 1999-2000 ,  Proposition de loi relative à l’euthanasie, déposée par Mr. Hugo Vandenberghe.
7. The debate concerning the euthanasia laws in Belgium and the Netherlands was influenced in a significant way by a series of studies concerning the end-of-life decision making and the practice of euthanasia and physician-assisted suicide. These studies were based on a methodology developed by van der Maas et al. and were characterized by their comprehensiveness and by their rigorous method, which guaranteed complete anonymity to the physicians and the patients, and hence reliable significance.  Before the study of  June 17, 2003, such studies were only available for the Netherlands, the Flemish part of Belgium and part of Australia. It has to be stressed that general statements concerning the frequency of euthanasia in other countries have no sound scientific basis and certainly cannot be used in comparison to the former ones. The most impressive difference between the Dutch and the Flemish results was the following. These studies on euthanasia were undertaken during the period when it was completely forbidden in Belgium, whereas it was admissible in practice in the Netherlands.  Nevertheless, the percentages of termination of life by the physician were comparable, with the remarkable exception that termination of life without request by the patient was four times higher in Belgium than in the Netherlands.

The studies I am referring to are the following.

• van der Maas , PJ, van Delden JJM, Pijnenborg L, Looman CWN,  “Euthanasia and other medical decisions concerning the end of life.” Lancet 1991; 338: 669-74.
• Van der Maas, PJ, van der Wal, G, Haverkate I. et al. “Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995.” N Engl. J Med. 1996; 335: 1699-705.
• Deliens L, Mortier F,  Bilsen J et al. “End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey.” Lancet 2000; 356: 1806-11.
• Kuhse H, Singer P, Baume P, Clark M, Rickard M.  “End-of-life decisions in Australian medical practice.” Med.J Aust 1997; 166: 191-96.
• Van der Heide A, Deliens L, Faisst K, Nilstun T, Norup M, Paci E, van der Wal G, van der Maas PJ. “End-of-life decision making in six European countries: descriptive study.” Lancet, published online, June 17, 2003.
• The misunderstanding concerning this ‘psychological suffering’ has led some journalists to the conclusion that a great number of cases of euthanasia in the Netherlands are only psychologically motivated. This is totally wrong. In the yearly report of the Evaluation Commission Euthanasia (www.Minbuza.nl/default.asp?CMS_ITEM=MBZ414060 ), we read that for the year 2000,  2123 cases of euthanasia or physician-assisted suicide were reported to the Commission. In 1893 cases, the illness was cancer; in 28, cardiovascular disease; 51 were diseases of the nervous system; 45 lung diseases other than cancer; 10 cases of AIDS and 96 other diseases. There is no indication of euthanasia in cases without illness.