Belgium, where death becomes the norm, living the exception

"Belgium, where death becomes the norm, living the exception" was written by Margaret Somerville and published on www.mercatornet.com on November 7, 2013.

A documentary about ten years of legal euthanasia is a touchstone for radically different approaches to suffering.

Recently I received an invitation to fly to Calgary in mid-November to attend the North American première of a film called End Credits at the Marda Loop Justice Film Festival. I was asked to lead a post-screening conversation with the audience and was given access to a copy of the film with English subtitles, which I viewed once. My access has since been blocked and my invitation to attend the festival withdrawn. The scenes from the film, which I describe below, are accurate to the best of my recollection.

End Credits is directed by Alexander Decommere and written by Marc Cosyns. It’s a documentary on the practice of euthanasia in Belgium 10 years after it was legalized in 2002. It follows the dying and death of two people, whom the film makers describe as follows: “Adelin, 83, and Eva, 34, two very different people, who are at the dawn of the end of their lives, ask for help with and care for a decent passing away.”

The most striking commonality shared by the old man, Adelin, and the young woman, Eva, is that they are profoundly lonely.

We first meet Adelin in the nursing home where he lives. He is physically fragile and cognitively impaired. At one point, he describes his life as a “dead life” — a powerful phrase that must be heard and which should raise questions of how to improve his situation. It brings to mind lung specialist, Dr Donald Boudreau’s words in speaking about euthanasia: “These euthanologists — if they have their way — will create a moral ecosystem where we will all be traversing through a sort of ‘living death’. Life is the qualifier. Death is the unshakable and primary reality.” At a certain point, death becomes the norm or basic presumption, living the exception.

Adelin has given his consent to euthanasia in an advance directive executed when he was competent. His physician is trying to determine whether Adelin still wants to go ahead with the procedure. Adelin’s nephew, a middle-aged man, is sitting beside his bed. He urges the physician to administer a lethal injection, because, he says, his uncle is no longer mentally competent, so can’t validly change his mind about euthanasia. The physician continues to try to clarify with the old man whether he wants euthanasia.

Suddenly, Adelin has a burst of energy and seeming lucidity, and shouts, “You want to kill me,” and is clearly horrified by the thought. He is not euthanized and some time later dies a natural death.

Eva is a young Belgian woman, who suffers from mental illness (probably severe depression), who wants euthanasia and, subsequently, to donate her organs. Medical journal articles report organs being taken from euthanized people in Belgium for transplant. In at least one of these cases, a woman donor was mentally ill, but not physically ill.

However, Eva is refused permission to donate by the relevant authority, but she still chooses to go ahead with euthanasia.

We see shots of Eva with her beautiful dog and learn that her brother is in the house, but not with her when she dies, which says so much. Eva says to the physician, “Let’s get on with this.” Wearing sweat pants and a jersey, she lies down on her living room couch and rolls up her sleeve, as though she is going to have her blood pressure taken.

Watching the physician euthanizing her is a chilling experience: The lack of any human warmth. The lack of any sense of the momentousness of what is being done — one human being, and a physician at that, intentionally killing another human being who is his patient. The mundaneness of it all, which is reinforced by the scenes of the physician sitting at Eva’s kitchen table, after he has killed her, routinely filling out the necessary reporting forms.

I was puzzled by what stance on euthanasia the film makers were taking, but my overall impression was it was probably one of neutrality and, I thought, the film might function as a very powerful cri de coeur against euthanasia.

So I tried, although unsuccessfully as the film makers ignored my emails, to get permission to show the film to others, in particular, the students in my Medical Law class. I recommended to the Quebec National Assembly committee holding hearings on legalizing euthanasia in Quebec that they try to see the film to understand why they should reject euthanasia and Bill 52.

To my absolute astonishment and distress, I subsequently learned from Belgian colleagues that the film is intended to promote euthanasia and was funded by “Recht op Waardig Sterven,” a pro-euthanasia movement comparable to “The right to die with dignity” movements in Canada and that its writer, Dr Marc Cosyns, is a strong supporter and practitioner of euthanasia in Belgium. How could I have been so confused?

The explanation is the different ways in which pro- and anti-euthanasia adherents would view the two deaths featured in this film.

We see Adelin gradually deteriorating and dying over a period of time. This is difficult to watch, but he is empathetically and compassionately attended by those caring for him, until he dies naturally. They manifest the virtue of patience in their “deathwatch” of Adelin. We all want his dying to be over, but that is very different from making it be over with a lethal injection. I see his human dignity as being respected and his death as a “good death.” He, himself, and not someone else, completes his life cycle and the mystery of life and death is not violated.

Pro-euthanasia advocates would regard Adelin’s dying trajectory as an unacceptable loss of autonomy and control on his part. They would see him as having lost his dignity and his state as making him less of a person or even a non-person — an incomplete, diminished, or even faulty, decaying, tarnished human being — who should be put out of his undignified state through euthanasia.

I saw the physician’s relationship with Eva as cold, clinical and overly rational (which can be a characteristic of a failure of good ethical judgment), and her death as horrifying and unethical. Pro-euthanasia advocates would see it as respecting her right to autonomy and, thus, her dignity, and putting her out of her mental misery.

End Credits provides an opportunity to understand some of the ways in which people who are pro-euthanasia and those who are anti-euthanasia radically differ in how they view both dying and death, and what euthanasia involves. And those differences reflect profound differences in what we believe it means to be human and what respect for both individual human life and upholding the value of human life, in general, in our society requires that we not do.

Margaret Somerville is the Samuel Gale Professor of Law and director of the McGill Centre for Medicine, Ethics and Law and is a leader in the discussion of ethical questions in medicine.