European Network of Health Care Chaplaincy
Academic Centre for Practical Theology, Belgium
Axel Liégeois and Anne Vandenhoeck
1. What are the legal regulations on end of life choices in your country?
The legal regulations on end of life choices in Belgium are twofold. On the one hand the choices with regard to curative or life-sustaining treatment and with regard to pain or symptom control and palliatieve care or sedation are considered as normal medical interventions and are regulated by the Act on Patient’s Rights. This implies that interventions can only be carried out after the patient has given free and informed consent. Beforehand, the caregivers give appropriate information as to the purpose and nature of the intervention as well as on its consequences and risks. If the patient has not the capacity to consent, the legal representative should give informed consent. The representative can be appointed by the patient. If the patient did not designate, other persons are representatives in the following order: the spouse or cohabiting partner, a child, a parent and a brother or sister, if they attained the required age for consent.
On the other hand the choices with regard to euthanasia are regulated by the Act on Euthanasia. The act states that euthanasia is not a criminal offence under certain conditions. Among the conditions and procedures of the act, three are fundamental: (1) the patient is of age, (2) the request is voluntary, well-considered, repeated and free of any external pressure, and (3) the patient is in a medically futile condition of constant and unbearable physical or psychic suffering that can not be alleviated, resulting from a serious and incurable disorder caused by illness or accident. The act includes euthanasia in a situation of physical or mental suffering and in a terminal or non-terminal situation. Assisted suicide, on the contrary, is not regulated by this or another act and should be considered as murder.
2. What is the view of your church in your country on end of life choices?
On the one hand, the Roman Catholic Church accepts the above mentioned normal medical interventions. For withdrawing or withholding curative or life-sustaining treatment the Church argues in terms of a proportionate reason between the prolongation of life and the quality of life. With regard to pain or symptom control and palliatieve care or sedation, the Magisterium argues in terms of the act with double effect, in which the shortening of life is a non-intended effect.
On the other hand the Magisterium condemns euthanasia as murder. The Magisterium gives a philosophical foundation, namely the inviolability of life. The sanctity and the dignity of human life are the basis and condition for all goods and values. The Magisterium adds theological arguments for the philosophical view. God is the Creator and Lord of life. Consequently, life is a gift and human beings may not decide on it. Finally, the fifth commandment ‘Thou shalt not kill’ forbids making an end to somebody’s life.
The Belgian Bishops add some arguments. They give a deontological argument that medicine is in service of life, and not of death. They doubt about the meaning of the request for euthanasia: is it really a request for death or rather a request for less suffering? The bishops stress the limits of human autonomy: human persons are related to and responsible for other persons. They hold a strong plea for palliative care instead of euthanasia as an answer to unbearable suffering.
Caritas Flanders, an umbrella organisation of Catholic care services in the Flemish part of Belgium, subscribes to this standard. Caritas opts for respect for the dignity of the human person and for a relational view of autonomy. Therefore, the general rule of conduct is against euthanasia and pro palliative care. Palliative care should be available for all patients in a situation of unbearable suffering. Nevertheless, Caritas accepts exceptions. Caritas respects the physician’s decision for euthanasia, made in good conscience, if three additional requirements are fulfilled. First, the physician should apply the filter procedure of palliative care, which means that a specialised palliative support team should discuss and offer the palliative possibilities to alleviate the patient’s suffering. Secondly, euthanasia can only be applied to patients in a terminal situation. Finally, there should be a physical cause, and not only a mental cause of unbearable suffering.
3. What are the main tensions in the chaplain’s general practice concerning quality of end of life?
From an ethical perspective, the chaplains experience a tension of values. On the one hand, they make a fundamental option for the value of the inviolability of life, based on their Christian faith. The Roman Catholic Church interprets this option in an absolute way as a condemnation of euthanasia. On the other hand, the chaplains have a relationship of trust with the patient and wish to respect the value of patient’s autonomy as much as possible. A majority of chaplains try to integrate these values. Through the relationship of trust they try to combine the respect for the patient’s autonomy and the advocacy of the inviolability of patient’s life. They endeavour to empower the patient to achieve a valuable and responsible option. They respect the moral diversity and the patient’s decision. It is not a comfortable situation for pastors to stand in the tension of values without distancing themselves from the patient.
From a spiritual perspective, the chaplains experience a tension of images of God. Sometimes, patients have more traditional views of God. They see God as a judge, who decides on life and death, whose will is the incomprehensible cause of suffering or who punishes human beings because of sin. Such views of God can enhance the spiritual suffering of patients and diminish their quality of life. A majority of chaplains try to accept these views on God. The relationship to God is intimately linked with life history of the patients. For many patients, it is a last hold in their suffering and it would be unethical of the chaplain to condemn it and to deconstruct it. It is a challenge for chaplains to deal with these views through a process of pastoral counselling. Chaplains can confront the more negative images of God with more positive images. They can invite the patient to look at his or her situation from the perspective of another view of God. They respect the spiritual diversity and the patient’s faith.
From a liturgical perspective, pastoral care for patients who decide to step out of life as a result of euthanasia, challenges chaplains liturgically. What kind of ritual can the chaplain do if the patient or the family wishes to have a ritual goodbye? In the Roman Catholic Church the sacrament of anointing the sick is not allowed to patients who request for euthanasia because this request is conflicting with the necessary repentance on the sin of euthanasia. In some countries bishops advise against the sacrament in those circumstances. The Belgian bishops leave this decision to the conscience of the chaplains. A majority of chaplains does not refuse a ritual or the sacrament of anointing.
Literature
J. Griffiths, H. Weyers & M. Adams, Euthanasia and Law in Europe, Oxford/Portland: Hart publishing, 2008.
A. Liégeois (Ed.), Schroomvol nabij. Pastorale begeleiding bij euthanasie [Diffident presence. Pastoral accompaniment in euthanasia] (Leuvense Cahiers voor Praktische Theologie 7), Antwerpen, Halewijn, 2008.
P. Schotsmans & T. Meulenbergs (Eds.), Euthanasia and Palliative Care in the Low Countries (Ethical Perspectives Monograph Series, 3), Leuven/Paris/Dudley: Peeters, 2005.