Euthanasia-White-Paper 2022 DIGITAL

The Legalization
of Euthanasia and
Assisted Suicide:
An inevitable slippery slope
Jean-Paul Van De Walle
Sophia Kuby
ADF International White Paper
The Legalization of
Euthanasia and
Assisted Suicide:
An inevitable slippery slope
Jean-Paul Van De Walle

Sophia Kuby
©2022 ADF International. All rights reserved.

Summary
This paper makes the case for the protection of life and the societal
norms of caring for one another through the prohibition of euthanasia and
assisted suicide. Rather than requiring the legalization of these troubling
practices, international law robustly protects the right to life – particularly
for the most vulnerable. The threat posed by a number of legislative
proposals across Europe is highlighted through the example of those
countries which have already gone down this road. An investigation into
the most recent developments in Belgium, the Netherlands and Canada
shows that where euthanasia and assisted suicide are legalized, the
number of people euthanized, and the number of qualifying conditions
increase with no logical stopping point. The paper concludes by refuting
the main arguments relied upon in support of legalization.
About the Authors
Jean-Paul Van De Walle serves as legal counsel, Europe, for ADF

International in Belgium (Brussels), advocating for religious freedom, life,
and the family at the European Union. Prior to joining ADF International,
Van De Walle served as a lawyer before the Brussels Bar, handling lawsuits
in torts law, insurance law, and contract law. Having a long-time interest
in bioethics, Van De Walle has been closely monitoring, from a legal and
bioethical perspective, the life-related issues in Belgium during the last
decade, in particular the debate on the end-of-life and the debate on the
possible legalization of surrogacy. He has regularly spoken on those
topics in the media and as a guest speaker at conferences.
Sophia Kuby serves as director of Strategic Relations & Training for ADF
International and is based in Vienna, Austria. She oversees and develops
the organization’s training programs and alliance relations internationally.
From 2015 to 2018, Kuby served as the director of European Union
Advocacy in Brussels, Belgium, where she built up the EU advocacy
team and led the advocacy work of ADF International at the various EU
institutions. She holds a M.A. and B.A. in philosophy.
This is an updated version (July 2021) of the White Paper originally

published by ADF International in 2017 and authored by Sophia Kuby and
Alexandra Tompson.
Table of Contents
1) Introduction........................................................................................... 9
2) Terminology.......................................................................................... 11
A. Euthanasia – Active and passive........................................................11
B. Euthanasia – Voluntary, non-voluntary, and involuntary...............11
C. Euthanasia and (medically assisted) suicide...................................12
D. Sedation – From intermittent to terminal.........................................12
E. Euthanasia and (aggressive life-sustaining) treatment.................13
3) Overview of Laws and Current Proposals.......................................15

A. Europe.......................................................................................................15
B. United States...........................................................................................16
C. Rest of the world....................................................................................16
D. Recent legislative proposals and ongoing debates in Europe......16
4) Legal Competences in the Area of Euthanasia..............................19

A. United Nations........................................................................................19
B. The European Union..............................................................................20
C. Parliamentary Assembly of the Council of Europe.........................21
D. Medical associations.............................................................................21
E. European Court of Human Rights Jurisprudence...........................23
5) Examples of Countries Where Euthanasia has been

Legalized............................................................................................... 27
A. Belgium....................................................................................................27
B. The Netherlands.....................................................................................36
C. Canada.....................................................................................................41
6) Legal Exceptions, Safeguards and Controls: A slippery slope.. 45
A. Amendments expanding the euthanasia legislation......................45
B. Ineffective ‘safeguards’ and control mechanisms..........................46
C. Constant increase in numbers............................................................50
7) Refuting the Main Arguments for Legalizing Euthanasia..........51

A. The right to ‘Die with Dignity’...............................................................51
B. Respect for Individual Autonomy........................................................52
C. Euthanasia does not harm others......................................................53
D. Euthanasia is properly regulated........................................................53
E. Economic pressure................................................................................54
8) Conclusion............................................................................................ 55
1) Introduction
This White Paper presents the main legal provisions and arguments in
favour of the prohibition of euthanasia and assisted suicide under the
following headings:
(1) It first clarifies the terminology used.
(2) Second, it gives a short overview of current legislation and

proposals for the introduction of euthanasia or assisted suicide.
(3) Third, it determines to whom belongs the legal competences

in the area, and reviews the positive wording that exists in
international law concerning the right to life of all persons.
(4) Fourth, it illustrates with national experiences in Belgium, the

Netherlands and Canada how laws legalising euthanasia and/or
assisted suicide function in practice.
(5) Fifth, it shows how the legalization of euthanasia inevitably leads

to further liberalisation with no logical stopping point.
(6) Sixth, it outlines and answers the main arguments in favour of

legalization. This brief will mainly focus on Europe, although
examples beyond the European continent will be drawn
occasionally.
2) Terminology
Euthanasia comes from the Greek words Eu (good) and Thanatosis (death)
and means ‘good death’.1 In contemporary medical practice, laws, and
publications, however, this term is often used in different, equivocal ways,
and the relation or distinction with other end-of-life related concepts tends
to be blurred. This overview2 therefore aims at providing clarification on
some key terminologies in this field. 3
A. Euthanasia – Active and passive
Euthanasia can be commonly defined as ‘every act or omission that, as

such and with that intent, ends the life of a sick person in order to release
him or her from suffering’.4
Active euthanasia occurs when the means used to induce death
consist in the oral or intravenous administration of a substance or
combination of substances. Passive euthanasia, also called euthanasia
by omission, occurs when the lethal outcome results of the refusal to
give life-preserving treatment for the purpose of hastening death, as a
primary end.
The common point between active euthanasia and passive
euthanasia, which is also the main characteristic of any euthanasic act, is
the intention to end someone’s life in order to release them from suffering.
B. Euthanasia – Voluntary, non-voluntary, and involuntary
A distinction can further be made with regards to who makes the decision
to euthanize, and if that decision accords with the concerned person’s
will.
Voluntary euthanasia occurs when the concerned person gives
their explicit consent to be euthanized. The consent can be given orally
or in written form and can be given in advance (typically through an
anticipatory euthanasia declaration).
12 The Legalization of Euthanasia
Non-voluntary euthanasia is sometimes used to refer to situations

in which the concerned person does not give their explicit consent, and
thus another person makes the decision on their behalf.
Involuntary euthanasia is used by some to describe euthanasia
performed against the explicit will of the concerned person.
C. Euthanasia and (medically assisted) suicide
Suicide is commonly understood as being the act by which

someone deliberately ends their own life.5 Assisted suicide occurs when
another person provides assistance or aid in doing so.
In the context of ending the life of a person with a medical condition,
medically or physician assisted suicide refers to the situation in which
the lethal act as such, rather than being performed by a healthcare
practitioner, is performed by the concerned person him- or herself,
whether by releasing a lethal substance intravenously or by swallowing a
lethal product. The assistance, to be distinguished from the lethal act as
such, provided by the healthcare practitioner can be of various natures,
such as prescribing the lethal drug, setting up an intravenous infusion
(without releasing the lethal substance), helping with the person’s self-
injection, etc.
Euthanasia and (medically or physician) assisted suicide only differ
slightly in nature: they both take place in a similar context, have the same
life-ending purpose, and use similar means to achieve that purpose. As
a result, legal, ethical, and medical analyses often consider them similar
enough to be considered together.
D. Sedation – From intermittent to terminal
Euthanasia has to be carefully distinguished, both from a medical and

ethical point of view, from sedation, which is characterized by the absence
of any intention to deliberately end someone’s life: its goal is to relieve the
The Legalization of Euthanasia 13
patient’s suffering while respecting the natural process that leads to

death.6
Sedation is, more precisely, a pain-management technique, used in
the context of palliative care, which consists of ‘deliberately administering
well defined doses and combinations of well-chosen drugs in order to
reduce the level of consciousness of a patient in preterminal or terminal
stages, to the extent that is necessary to appropriately relieve refractory
symptoms, with the patient’s explicit, implicit or delegated consent.’.7
Intermittent sedation can vary in intensity and is normally
reversible. The application of the technique is constantly monitored
and adjusted in order to achieve the degree of pain management most
suitable to the person’s actual condition and response to the technique.
As an ultima ratio of pain management, provided that intermittent
sedation is no longer appropriate, at the very final stage of a patient’s
life, and when the patient manifests symptoms that resist all other forms
of treatment and cause severe pain, terminal sedation, which consists
of inducing and maintaining sedation until the patient dies, without
deliberately provoking death, may carefully and proportionately, on a
case-by-case basis and only at the patient’s request, be applied by the
medical team. This can be distinguished from continuous deep sedation
which, when applied with the intention to shorten life, could be considered
a form of euthanasia.
E. Euthanasia and (aggressive life-sustaining) treatment
A treatment is aimed at relieving the patient condition. Aggressive life-

sustaining treatment consists of implementing disproportionate means
in order to extend the life of a patient at the end of their life.
If the patient’s life is shortened as an unintended side effect of a
(reasonably justified and proportionate) treatment, it cannot be considered
as euthanasia (not even indirectly), since there was no intention to end
someone’s life in order to release (them) from suffering.
Likewise, the reasonably made decision to stop existing therapeutic

treatment cannot be called (passive) euthanasia since, in allowing a
person to die in the absence of aggressive life-sustaining treatment, there
is no intentional ending of the patient’s life.
3) Overview of Laws and Current Proposals
A. Europe
The national parliaments of three countries8 have adopted a law

specifically authorizing euthanasia: the Netherlands (2001),9 Belgium
(2002),10 and Luxembourg (2009).11 The Dutch and Luxembourg laws also
expressly authorize assisted suicide, while the Belgian law does not.12
In three other countries, recent court decisions marked a
significant step towards the (indirect) legalization of euthanasia and
assisted suicide. In Italy, the Constitutional Court declared a provision
criminalizing assistance to suicide in certain circumstances as
unconstitutional (2019).13 The Court’s decision concerned the case of
an Italian celebrity disc jockey who, with the help of a friend, travelled
to Switzerland for assisted suicide after being left blind and tetraplegic
in a car crash.14 In Germany, the Constitutional Court similarly ruled
(2020)15 that a law banning so-called commercial assisted suicide
services was unconstitutional, thereby recognizing a ‘right to a self-
determined death’. Most recently (December 2020),16 in Austria, the
Constitutional Court partially struck down a provision of the Austrian
Criminal Code that would punish those who provide assistance to
‘someone ending his own life’.17 These decisions are paving the way for
a legislative intervention that, in each of those three jurisdictions, would
most likely move towards legalizing euthanasia or (and) assisted suicide.
Although it has no law formally authorizing these practices,
Switzerland is nevertheless known for having permissive criminal
legislation (since 1937), under which assisting someone to commit
suicide is only criminalized when the assistance is offered out of a selfish
motivation.18 Moreover, recent guidelines for physicians (2018) expressly
declared it ‘admissible under certain conditions’19 for physicians to offer
assistance to suicide to unbearably suffering patients who have no
other therapeutical options left.20 Those same guidelines in turn, quite
paradoxically, also state: ‘A patient’s request for euthanasia is to be

refused, even if it is genuine and insistent’.21
B. United States
In the United States,22 the Supreme Court ruled (1997)23 that States
could, without violating the Constitution (14th Amendment), either
prohibit or allow assisted suicide or euthanasia. To this day, eight states
and Washington DC have adopted legislation decriminalizing assisted
suicide: Oregon (1994), Washington (2008), Vermont (2013), California
(2015), Colorado (2016), Washington D.C. (2016), Hawaii (2018), New
Jersey (2019), and Maine (2019).
C. Rest of the world
Colombia legalized euthanasia (2015)24 long after the practice was

decriminalized through a decision of its Supreme Court (1997).25
Similarly, following a Supreme Court decision (2015)26 partially
invalidating a prohibition on assisted suicide, Canada27 adopted a law
legalizing euthanasia and assisted suicide (2016). In Australia, the State
of Victoria legalized both euthanasia and assisted suicide (2017).28 Most
recently, following the parliamentary adoption of a proposed law29 and a
subsequent national referendum, both euthanasia and assisted suicide
have been legalized in New Zealand (2020).30
D. Recent legislative proposals and ongoing debates in Europe
The debate on the end of life has made its way into the political agenda
of many countries. Legislative proposals have been announced or are
currently under discussion inter alia in several European countries.
In France, the Parliament rejected legalizing euthanasia and
assisted suicide in January 2016, and a compromise was reached through
adopting an amendment of the existing legislation31 that allows doctors
to keep terminally ill patients sedated until death. Two law proposals were
nevertheless tabled (201732 and 202033) regarding the recognition of a so-

called ‘right to die in dignity’ which, in practice, would encompass ‘active
help in dying’ through either euthanasia or assisted suicide.
In Portugal, the Parliament initiated a debate on the
decriminalization of euthanasia and assisted suicide in 2019, and a bill
was passed in January 2021.34 However, in March 2021, it was declared
unconstitutional by the Constitutional Court, for reasons related to lack of
clarity, rigour, and controllability of the legal conditions.35 The President of
Portugal furthermore vetoed the bill.
In Spain, in March 2021, the Congress of Deputies adopted a
bill36 ‘regulating euthanasia’, legalizing both euthanasia and assisted
suicide. However, in June 2021, an appeal was lodged before the Spanish
Constitutional Court,37 which rejected the request to temporarily suspend
the application of the bill, and is expected to issue a final ruling in 2022.
In Ireland, a bill aimed at legalizing euthanasia and assisted suicide
was presented to the National Assembly in September 2020.38
In the United Kingdom, both assisted suicide and euthanasia
remain illegal.39 However, repeated private member’s bills have been
proposed in recent years and lobbying organisations have increased their
efforts.40 Most recently (2021), a bill41 to ‘enable adults who are terminally
ill to be provided at their request with specified assistance to end their
own life’ was tabled before the House of Lords.
***
In light of the most recent developments in Europe, seemingly disclosing

a more or less coordinated movement seeking to achieve the legalization
of euthanasia and assisted suicide, it must be recalled that the vast
majority of countries, both in Europe and worldwide, do not consider that
euthanasia and assisted suicide should be made available.
Given that euthanasia and assisted suicide are legal in only a
handful of countries throughout the world, the principle hence firmly
remains that ending one’s life intentionally, even when this would be an
expression of an alleged ‘right to self-determination’ or motivated by an

alleged intent to ‘release from suffering’, is unacceptable.
4) Legal Competences in the Area of Euthanasia
No international institution is competent to legislate on the matter of

euthanasia. In the absence of an international agreement or binding treaty
obligation, the competence to legislate on the matter pertains exclusively
to national parliaments.
However, helpful language can be found in international law, non-
binding international resolutions, and international jurisprudence, that
rather supports the right to life of all persons as being incompatible with
the practices of euthanasia and assisted suicide. As demonstrated in
the most notable legal provisions below, international human rights law
upholds the right to life. This right to life cannot, by definition, include a
right to the diametrically opposed outcome. It is evident that a so-called
‘right to die’ has no basis in international human rights law.
A. United Nations
The International Covenant on Civil and Political Rights (ICCPR), Article

6(1): ‘[e]very human being has the inherent right to life. This right shall be
protected by law. No one shall be arbitrarily deprived of his life.’42
The Convention on the Rights of the Child (CRC), Article 6(1): ‘every
child has the inherent right to life’.43
The Convention on the Rights of Persons with Disabilities (CRPD),
Article 10: ‘States Parties reaffirm that every human being has the inherent
right to life and shall take all necessary measures to ensure its effective
enjoyment by persons with disabilities on an equal basis with others.’44
Moreover, rather than recognizing a ‘right to die’, UN treaties
implicitly reject this notion by including strong protections for the sick,
disabled, and elderly – the people most often affected by the legalization
of euthanasia and assisted suicide. For example, Article 23 of the CRC
recognizes: ‘[a] mentally or physically disabled child should enjoy a full
and decent life, in conditions which ensure dignity, promote self-reliance
and facilitate the child’s active participation in the community.’
Alongside the absence of a ‘right to die’ within international treaties,

the bodies in charge of interpreting these treaties have never produced
any analysis or opinion lending support for euthanasia or assisted suicide.
On the contrary, UN treaty monitoring bodies have expressed
concerns regarding the practice of euthanasia, despite its legality in only a
small minority of countries. For example, the Concluding Observations of
the Human Rights Committee on the Netherlands state: ‘[t]he Committee
remains concerned at the extent of euthanasia and assisted suicides in
the State party. The Committee reiterates its previous recommendations
in this regard and urges that this legislation be reviewed in light of the
Covenant’s recognition of the right to life’.45
B. The European Union
Article 2 of the Charter of Fundamental Rights of the European Union

recognizes that ‘everyone has the right to life.’ The EU only has the
power to legislate where competence has been conferred on it by the
EU treaties. Where the treaties do not confer competence, they remain
with the Member States.46 The EU treaties determine that health policy
belongs to the Member States:
Union action shall respect the responsibilities of the Member

States for the definition of their health policy and for the
organisation and delivery of health services and medical care.47
This excludes the possibility of harmonizing national legislation in the

field of health policies (even assuming it could be contended that this
is the sphere into which it would fall). The regulation of it falls within
Member States’ competences, and EU institutions cannot therefore take
any direct action in this area.
C. Parliamentary Assembly of the Council of Europe
In 1999 the Parliamentary Assembly of the Council of Europe, comprised

of national parliamentarians from 47 nations, stated that Member States
should ‘respect and protect the dignity of terminally ill or dying persons
in all respects […] by upholding the prohibition against intentionally taking
the life of terminally ill or dying persons’.48
In 2012, the Assembly reaffirmed its categorical opposition
against any form of legalized euthanasia: ‘[e]uthanasia, in the sense of
the intentional killing by act or omission of a dependent human being for
his or her alleged benefit, must always be prohibited’.49
D. Medical associations
The World Medical Association (WMA) has consistently and categorically

refused to condone or accept the practice of euthanasia and assisted
suicide as a justifiable medical activity:
Euthanasia, that is the act of deliberately ending the life of a

patient, even at the patient’s own request or at the request of
close relatives, is unethical. This does not prevent the physician
from respecting the desire of a patient to allow the natural
process of death to follow its course in the terminal phase of
sickness.50
Physicians-assisted suicide, like euthanasia, is unethical and

must be condemned by the medical profession. Where the
assistance of the physician is intentionally and deliberately
directed at enabling an individual to end his or her own life, the
physician acts unethically. However the right to decline medical
treatment is a basic right of the patient and the physician does
not act unethically even if respecting such a wish results in the
death of the patient.51
BE IT RESOLVED that:
The World Medical Association reaffirms its strong belief that

euthanasia is in conflict with basic ethical principles of medical
practice, and
The World Medical Association strongly encourages all

National Medical Associations and physicians to refrain from
participating in euthanasia, even if national law allows it or
decriminalizes it under certain conditions. In 2013, at its 194th
World Medical Association Council Session in Bali, Indonesia,
the WMA, reaffirming a number of earlier resolutions and
affirmations (from 1987 onwards to 2005), resolved that it
reaffirms its strong belief that euthanasia is in conflict with
basic ethical principles of medical practice, and strongly
encourages all National Medical Associations and physicians
to refrain from participating in euthanasia, even if national law
allows it or decriminalizes it under certain conditions.52
In 2019, the WMA, on the occasion of its 70th General Assembly, adopted
the following Declaration53 on euthanasia and physician-assisted suicide:
The WMA reiterates its strong commitment to the principles of

medical ethics and that utmost respect has to be maintained
for human life. Therefore, the WMA is firmly opposed to
euthanasia and physician-assisted suicide.
For the purpose of this declaration, euthanasia is defined as

a physician deliberately administering a lethal substance or
carrying out an intervention to cause the death of a patient
with decision-making capacity at the patient’s own voluntary
request. Physician-assisted suicide refers to cases in which,
at the voluntary request of a patient with decision-making
capacity, a physician deliberately enables a patient to end his
or her own life by prescribing or providing medical substances
with the intent to bring about death.
No physician should be forced to participate in euthanasia or

assisted suicide, nor should any physician be obliged to make
referral decisions to this end.
Separately, the physician who respects the basic right of the

patient to decline medical treatment does not act unethically in
forgoing or withholding unwanted care, even if respecting such
a wish results in the death of the patient.
E. European Court of Human Rights Jurisprudence
The European Court of Human Rights (ECtHR) has been asked a number
of times to consider possible breaches of Articles 2 (right to life), 3
(prohibition of torture) and 8 (right to respect for private and family life)
of the Convention regarding the legal prohibition of euthanasia as well as
the limits of the law within the countries where it is legalized.
The Court has repeatedly affirmed that a ‘right to die’ is not
contained in the foregoing Articles.
In the case of Pretty v. United Kingdom,54 Diane Pretty was suffering
from a motor-neurone disease and wanted her husband’s assistance in
committing suicide. UK law regards assistance in suicide as a crime.55
She asked the Director of Public Prosecutions to agree not to prosecute
her husband. After her request was refused and her appeal failed in the
House of Lords, she took the case to the ECtHR. The Court ruled that
there is no ‘right to die’ under the Convention and that countries are
not in breach of the Convention if their national legal order prescribes
prosecution for aiding or abetting suicide. Furthermore, the Court upheld
that the right to life (Article 2) cannot be read as to include the exact
opposite, a so-called ‘right to die’:
Article 2 cannot, without a distortion of language, be interpreted

as conferring the diametrically opposite right, namely a right to
die; nor can it create a right to self-determination in the sense
of conferring on an individual the entitlement to choose death
rather than life. The Court accordingly finds that no right to die,
whether at the hands of a third person or with the assistance
of a public authority, can be derived from Article 2 of the
Convention.56
The Court was also asked to examine whether prohibiting euthanasia

amounts to torture as prohibited under Article 3 of the Convention. The
Court reasoned that, because it was not the State itself that was inflicting
any kind of ill-treatment nor was it withdrawing adequate medical care,
Article 3 was not engaged. Furthermore, it emphasized that Article 3
must be read in harmony with Article 2 of the ECHR:
Article 2 of the Convention is first and foremost a prohibition

on the use of lethal force or other conduct which might lead to
the death of a human being and does not confer any right on
an individual to require a State to permit or facilitate his or her
death.57
The attempt to create a ‘right to die’ under Article 8 also failed. In Pretty,
while the Court accepted that Article 8 could be read as including the
‘choice to avoid what [the applicant] considers will be an undignified and
distressing end to her life’,58 ultimately no violation of Article 8 was found.
The Court held that the ‘law in issue’ (the State’s prohibition on assisted
suicide) had the legitimate aim of protecting vulnerable people.59
Although subsequently in Haas v. Switzerland,60 the Court
recognized that an individual’s decision on how and when to die may
fall within the scope of Article 8,61 the Court concluded that there may
be a legitimate interest in protecting individuals from exercising their
autonomy, for example, to protect individuals from harm, and especially,
to protect vulnerable persons.62
In the case of Lambert and Others v. France63 referred to the French
Conseil d’Etat judgment from 24 June 201464 to discontinue Vincent
Lambert’s artificial nutrition and hydration. Mr Lambert was left tetraplegic
following a road traffic accident in 2008. In 2013, a decision was made
to withdraw his nutrition and reduce his hydration. The applicants,

Lambert’s parents, half-brother and sister, lodged an application to the
ECtHR. They advanced arguments that to withdraw the artificial nutrition
and hydration from Mr Lambert would constitute a breach of the Member
State’s obligation to protect life under Article 2 of the Convention, and that
such a course could amount to a breach of Articles 3 and 8.
By twelve votes to five, the Grand Chamber held that implementing
the Conseil d’Etat’s judgment would not constitute a violation of Article 2
(right to life). The ECtHR held that, in relation to life supporting treatments,
Member States are to be afforded a wide margin of appreciation. However,
this margin of appreciation is not unlimited, and the Court reserves the
power to review whether or not the State has complied with its obligations
under Article 2. In this case the ECtHR seemed content to assess artificial
nutrition and hydration as ‘life sustaining treatment’. This interpretation
has been widely criticized as undermining both the wording and spirit of
Article 2 of the Convention.
The case of Mortier v. Belgium,65 in which the Court is due to deliver
its decision, concerns the euthanasia of Mr Mortier’s (applicant) mother
that took place in 2012.
After years of depression, she received a lethal injection in 2012,
although she was not terminally ill, but rather suffered from a psychiatric
condition. The circumstances surrounding her death raise particularly
serious questions regarding the (in)adequacy of the protection of her
right to life under the Belgian euthanasia law.
The doctor performing euthanasia had only relatively recently met
her and neither knew nor treated her prior to her request for euthanasia.
Furthermore, he had no specialization in psychiatric conditions (he
was an oncologist) and failed to consider the potential influence of the
medication she was taking (which, as side effects, include an increased
risk of suicidal thoughts). To fulfil a legal requirement, the doctor sought
two ‘independent’ opinions on the request for euthanasia. However, these
doctors appeared to have clear links with the physician performing the
euthanasia, as well as with the euthanasia-promoting association (‘LEIF’),
founded by said doctor, which had received a donation of 2,500 EUR from
the applicant’s mother.
The applicant, on his side, was never informed by the physician that
his mother had made a request for euthanasia and was never involved in
the decision-making process that eventually led to the euthanasia.
Belgian law does not formally require the relatives to be informed
of a request for euthanasia, which appears to be problematic in regard to,
amongst other things, the right to private and family life of those relatives.
This also contributed, in this case, to a violation of the right to life of the
applicant’s mother, given that her depression, which was characterized
by regular ups and downs, was partially rooted in family tensions that
could potentially have been addressed through a dialogue, which might
have prevented the euthanasia from being requested or carried out. One
can also question whether all reasonable therapeutic options had truly
been exhausted, as required by the Belgian euthanasia law, in this case of
psychological suffering by a non-terminally ill patient. 66
The Court will have to assess whether the right to life of Mortier’s
mother was adequately protected under Belgian law and by the Belgian
authorities, and whether the right to respect for private and family life of
the applicant has been violated.
5) Examples of Countries Where Euthanasia has been
Legalized
Wherever euthanasia has been legalized, a steep increase in the number

of cases and an extension of possible reasons for euthanasia can be
observed, as illustrated not only by the national examples of Belgium and
the Netherlands, where euthanasia was legalized twenty years ago, but
also by the more recent example of Canada.
A. Belgium
1. Decriminalization in 2002
The Belgian law on euthanasia passed on 28 May 2002.67 Belgium

became the second country in the world to legalize euthanasia, defined in
the law as the ‘deed by which a third person intentionally ends the life of
another person at the request of the latter’.68
The legalization consists in a partial decriminalization of
euthanasia: while intentionally ending someone’s life remains punishable,
no criminal offence is committed in the case of euthanasia, provided that
all the applicable legal conditions are met, and a physician performs the
euthanasia.69
The Belgian law stipulates70 those seeking euthanasia must be
conscious and legally competent at the moment of making the request to
end their lives and must be, as a result of a severe pathology or accident,
in a condition of durable and unbearable physical or mental suffering that
cannot be alleviated. The request must be voluntary and made without
any external pressure.
The physician handling the euthanasia request must inform the
patient about their medical condition and life expectancy and possible
therapeutic treatments, including palliative care. The physician must
have several conversations ‘spread out over a reasonable period of time’
in which he (the physician, with the patient) must ‘come to the belief that
there is no reasonable alternative to the patient’s situation’.
The physician must also ‘consult another physician about the
serious and incurable character of the disorder’, who must be ‘independent’
in respect of the patient as well as the physician handling the euthanasia
request and must be qualified with regard to the concerned pathology.
Euthanasia can be performed on patients whose death is
estimated to occur ‘at short notice’, as well as on patients that, in the
opinion of the physician, are not expected to die ‘at short notice’. In that
case, the law requires a waiting period of one month prior to executing
the euthanasia, and a consultation with another physician (in addition of
the first consulted physician), who must be specialized in the concerned
pathology.
After performing euthanasia, the physician is required to report
the case for review to the Federal Control and Evaluation Commission
(hereafter: the Control Commission).71 The Control Commission
determines whether the ‘euthanasia was performed in accordance with
the conditions and procedure stipulated in the Act’.72
2. Vague, subjective and uncontrollable conditions: no real ‘safe-

guards’
Although the decriminalization of euthanasia was said to be surrounded

by so-called strict conditions, intended to act as ‘safeguards’ against
any abuse of the law, it rapidly became clear that their vagueness and
subjective nature made it nearly impossible to effectively control the
practice.73
For instance, the law requires the patient to be in a state of
‘unbearable’ physical or mental suffering for the euthanasia to be legally
performed.
However, the Control Commission’s first report, following the
adoption of the euthanasia law, considered that ‘although some objective
factors may contribute to the assessment of the unbearable nature of the
suffering, the latter is largely subjective and depends on the personality,

the views and the values of the patient’74 – the Control Commission is
in essence admitting that it is, in practice, impossible to objectively
determine whether the threshold of ‘unbearable’ suffering is (or had been)
reached.
Other aspects of the law similarly render an objective assessment
of the fulfilment of the legal conditions very hard, if not impossible, both
for the concerned physician (prior to the euthanasia) and the Control
Commission (after the euthanasia took place).
For example: what is to be considered a ‘severe’ pathology? What
does the requirement of ‘independence’ of the consulted physician entail?
How can one determine that no ‘reasonable’ alternative to euthanasia is
available? How can one ensure that a request for euthanasia is in no way a
result of any ‘external pressure’? How is it possible to affirm with certainty
that mental suffering cannot be alleviated through other treatments?
The main legal conditions then appear to be useless to achieve any
real control of the euthanasia law and practice.
This is all the more evident in the context of criminal law (euthanasia
being an exception to the criminal offence of murder by poisoning75): if the
exact meaning of the legal terms is unclear, doubt can easily be cast on
the criminal intent of the person charged of unlawful euthanasia, which
then leads to acquittal.
As a matter of fact, three physicians, accused of collaborating in
the (allegedly) unlawful euthanasia on Tine Nys, a 38-year-old lady who
suffered from chronical depression and autism, were acquitted in 2020
by a jury on the basis of reasonable doubt as to their criminal intent.76
To this day, this remains the only trial for unlawful euthanasia in
almost twenty years of legalized euthanasia in Belgium, which not only
raises questions about the ability of the Control Commission and the
Prosecutor to effectively control if the (unclear) legal conditions were
met, but also about their willingness to do so.77
The Control Commission furthermore seems, without any authority
or mandate to do so, to decide by itself how legal conditions are or are not
to be interpreted—and one can observe that those interpretations lead to

a more permissive approach towards euthanasia.78
For instance, the Control Commission found no objections in cases
of euthanasia performed absent a severe pathology (legal requirement),
indicating that in those cases a so-called ‘polypathology’ could be
considered as a sufficiently severe medical condition to lawfully resort
to euthanasia. ‘Polypathology’, a term used by the Control Commission,
was recently described by its president, Dr Distelmans, as being related to
‘people who are often of an advanced age and have an accumulation of
all kind of minor conditions that as such are maybe not truly serious but
when added one upon the other become unbearable for the concerned
person’.79 The examples cited by the Commission’s president included
people who requested euthanasia for suffering of ‘conditions’ such as
‘less good sight, less good hearing, incontinence, needing help to drink or
to eat, a walking frame, etc.’.80
One can easily observe the aforementioned ‘symptoms’, rather
than being the result of a pathology, let alone a ‘severe’ pathology, are
often and primarily related merely to ageing—a phenomenon that, in the
context of euthanasia, in the Control Commission’s reasoning, would
nevertheless end up (being perceived) as a lawful reason for euthanasia.
The fact that, even in cases where it clearly appeared that objective
conditions were not met, no action was undertaken by the Control
Commission to refer those cases to the Prosecutor, nor by the latter to
open an investigation, raises even more concerns.
One of the objective legal requirements concerns the euthanasia
request itself, which must be established in writing by the patient,81 as
an (alleged) guarantee against involuntary euthanasia. Euthanasia cases
have been reported to the Control Commission without the latter finding
any trace of a written request upon examination of the documents.82
Despite the clear violation of an objective legal requirement, the cases
were not referred to the Prosecutor.
Similarly, while the wording of the law only permits physicians to
perform the lethal act, cases of physician assisted suicide—characterized
by the patient him- or herself performing the lethal act with the assistance
of a physician, which is in clear violation of the law—were reported to
the Control Commission. Nevertheless, the Control Commission found
no reason to refer these cases to the Prosecutor, but on the contrary,
considered physician assisted suicide as falling inside the scope of the
law.83
Given the particularly permissive approach of the Control
Commission, it is of no great surprise that, despite reviewing more
than 22,000 (declared) euthanasia cases in about twenty years of its
legalization, only once did it refer a case to the Prosecutor, in 2015.
The said case concerned the euthanasia of a healthy, 85-year-old
lady, grieving about the death of her daughter from a heart attack. Her
euthanasia was filmed and recorded in a documentary by the Australian
SBS TV Network,84 and consisted in drinking a lethal substance with the
assistance, and in the presence, of her physician, who was literally sitting
at her side.
The formal grounds of the referral to the Prosecutor by the Control
Commission are unknown, although its president later unofficially
admitted the concerns were related to the absence of a severe medical
condition.85
Following an investigation, the Prosecutor ultimately decided
in 2019 not to refer the physician to a criminal tribunal for sentencing,
but rather to dismiss the charges on the grounds that this was a case
of physician assisted suicide which, in the view of the Prosecutor, fell
outside the scope of euthanasia and therefore did not require meeting
the legal conditions set forth by the euthanasia law.86 It is worthy to note,
in this regard, that the physician reported this case as a euthanasia case
to the commission.
This case highlights, inter alia, that even the fulfilment of an
objectively verifiable legal condition—namely the lethal act having to
be performed by a physician and not by the patient him- or herself—
leads to a contradiction between the two main Belgian bodies tasked
with preventing any abuse of the euthanasia law (Control Commission
and Public Prosecutor). Although adopting two incompatible stances

as to whether physician assisted suicide falls within the scope of the
euthanasia law, the two nevertheless, in practice, amounted to the same
consequence of impunity for the physician deliberately “helping” a person
not affected by a severe condition to die.
3. Most recent numbers
The Belgian euthanasia law stipulates that the Control Commission is to

present a report to the legislature every two years.87
According to the most recent report (issued in 2020), covering the
years 2018 and 2019, since 2002, 22,082 persons have been euthanized
in Belgium.88 This number however does not include euthanasia cases
not declared to the Control Commission.89
As a way of comparison, during the first eight years following the
legalization, an average of 493 euthanasia cases per year were recorded.
This number more than tripled during the 2010-2014 period (an average
of 1,450 cases), and further increased to an average of 2,275 cases per
year over the 2015-2019 period. The numbers have been consistently
increasing each year, with a 14% increase in 2017, compared to 2015,
and another 14% increase in 2019, compared to 2017.
In 2019, euthanasia accounted for 2.5% of all deaths in Belgium
(2,656 euthanasia cases). The vast majority of cases (76%) concerned
60 to 90-year-old persons. In 17% of the cases, natural death was not
expected to occur in the near future.
During the 2018-2019 period, the most frequently invoked
conditions for euthanasia were cancer (62%), ‘polypathologies’ (17.9%),
diseases of the nervous system (8.5%), of the circulatory system
(3.6%) and of the respiratory system (2.8%), with psychiatric conditions
accounting for 1.1% of the cases. About 2.1% of all cases were related to
‘mental or behavioural disorders’.
The Control Commission furthermore indicates in the 2020 report
that, in the cases in which euthanasia was performed on the basis of
mental suffering, the suffering was characterized as: ‘related to current

life and vision of the future (e.g. awareness that no improvement is
possible, feeling of weakening), the loss of autonomy, and dependency
(e.g. others need to take care of me), the impossibility of maintaining
social contacts (e.g. due to the loss of mobility, hearing ability, sight),
a feeling of anxiety (e.g. I am alone), my system of values has become
useless (e.g. my references disappeared), my life has no sense anymore
(I can’t continue, this is the end).’90
Regarding ‘polypathologies’, the Control Commission mentioned
the number will likely increase in the future ‘given the growing ageing
population and the mechanism of appearance of polypathologies.’91
Regarding the control of the (declared) euthanasia cases for the
2018-2019 period, the Control Commission mentions that ‘75.2% of the
euthanasia declaration forms were correctly filled in, and have thus been
straightaway accepted’, with no violation of the law found upon a short
analysis of the remaining 24.8% of the cases, and no cases referred to the
Prosecutor for further investigation.
In March 2021, the Control Commission issued a press release92
regarding the numbers for the year 2020. A total of 2,444 cases of
euthanasia have been declared to the Control Commission in 2020,
which represents a 7.9% decrease compared to the year 2019, and the
first decrease ever since the legalization.
The Control Commission’s President considered, in a subsequent
interview,93 this decrease to be related to a criminal trial regarding
a euthanasia case that was held in January 2020,94 which allegedly
rendered physicians ‘less keen to perform euthanasia’, as well as to the
period of lockdown due to the Covid pandemic: ‘Non-terminal patients in
particular postponed euthanasia, in order to wait for the moment where
they could receive visit again from their family.’. No evidence of those
alleged reasons has been provided, however.
The Control Commission furthermore stated all ‘essential’ (sic)
conditions of the law had been respected in every case – hence no case
was referred to the Prosecutor.
4. Successive enlargements of the euthanasia legislation
Although upon adoption of the law, it was said that euthanasia would
only be accessible to adults, the Belgian euthanasia law was amended
in 2014,95 making Belgium the first and only country in the world to allow
the euthanasia of children without any age limit.96 Parental consent is
required, though it remains unclear what would be done in the event of a
serious and persisting divergence in views between the minor requesting
euthanasia, and their parents, or in the event one of the parents disagrees
with the request while the other agrees.
The amendment was motivated by the allegation that there was an
urgent need to allow children to access to euthanasia, with the underlying
idea that numerous children were facing unbearable suffering. Seven
years later, the (reported) numbers show that this was obviously not the
case: only five cases of child euthanasia have been recorded since the
practice was legalised.
Making euthanasia available to children marked, however, another
step, some argue, towards the recognition of an emerging general ‘right
to euthanasia’—although such a right, in theory, was said not to exist at
the time euthanasia was decriminalized.
In 2020, six years after its first amendment, and eighteen years
after the euthanasia law was adopted, the Belgian law was amended a
second time,97 in a way that treats the practice as if it were now just an
ordinary medical procedure.
One of the modifications concerned the anticipatory declaration—a
document through which a person pre-emptively gives their consent
to euthanasia, in the event that he or she should be in a situation of
‘irreversible unconsciousness’98 (provided the other applicable legal
conditions are also met). While this document previously had a five-year
validity, and as a matter of consequence had to be renewed every five
years, the amended law now automatically grants an indefinite validity to
the document, generating the idea that once euthanasia is ‘anticipatorily’
requested, the principle is that it should be carried out no matter how

much time or what events might have occurred in the time elapsed since
the initial request.
The initial version of the euthanasia law expressly intended to protect
the right to conscientious objection regarding euthanasia, indicating that
‘no physician can be held to perform an euthanasia’ and that ‘no other
person can be held to collaborate to an euthanasia’.99 This provision,
allegedly with the purpose of guaranteeing ‘access to euthanasia’ for
those ‘in need’, was modified in order to oblige the physician, who might
refuse to perform an euthanasia for conscientious reasons, to provide the
patient with the contact details of a ‘centre or association specialized in
the right to euthanasia’.100
This amendment formally introduced the concept of a ‘right to
euthanasia’ in Belgian legislation. However, in principle, when the law was
originally adopted, euthanasia was said to be, and intended to remain, an
exception to criminal law.
It furthermore appears to be highly problematic in that it largely
diminishes, if not renders useless, the protection initially granted to the
physician objecting to euthanasia for reasons of conscience—a protection
the physician is entitled to enjoy through international human rights law.
Under the current legislation, an objecting physician can nevertheless be
forced to collaborate in euthanasia, by having to refer the patient to a
centre that actively promotes euthanasia.101
Finally, an article was added, following which ‘no written or
unwritten provision can prevent a physician to perform a euthanasia
with due respect for the legal conditions’. This article tends to prevent
healthcare institutions from, by way of general policy, objecting to an act
of euthanasia being performed within their walls.
In practice, this means that under current legislation, even care
institutions which have had a long tradition of refusing euthanasia based
on ethical, philosophical, or religious convictions, or another reason, can
no longer effectively prevent euthanasia from taking place inside their care
units—or they could be sanctioned for doing so. It goes without saying
this provision poses a clear threat not only to the very identity and ethical
stances of the concerned institutions, and therefore to the institutions
themselves, but it also poses a threat to the personal decisions of inter
alia staff and patients who, for various legitimate reasons, do not wish to
collaborate or engage in euthanasia.
In the most recent legislative sessions, proposals were made to
further extend the scope of the euthanasia law to people suffering from
dementia, and calls were made to authorise assisted suicide for people
who are ‘tired of life’.
B. The Netherlands
1. Decriminalization in 2001
The Netherlands became the first country in the world to legalize

euthanasia in 2001, with the adoption of the ‘Termination of Life on
Request and Assisted Suicide (Review Procedures) Act’,102 which entered
into force on 1 April 2002. Since then, both euthanasia and assisted
suicide were no longer punishable under the criminal offence of murder,
provided that the six so-called legal ‘care criteria’, listed hereafter, were
followed.103
The law states104 the need for a ‘voluntary and well-considered’
request. The patient’s suffering should be ‘lasting and unbearable’, the
patient should be informed about his/her situation and prospects, the
physician and patient must ‘hold the conviction that there was no other
reasonable solution’, an independent physician must be consulted, and the
life has to be ended, or the suicide must be assisted, ‘with due care’.
Minors may request euthanasia from the age of 12, although the
consent of the parents or guardians is mandatory until they reach the
age of 16. Sixteen and seventeen-year-olds do not need parental consent
in principle, but their parents must be involved in the decision-making
process.105
In cases of termination of life on request and assisted suicide,

doctors notify a regional review commission which assesses whether the
physician acted in accordance with the requirements of due care.106
2. Some numbers
Beginning in 2003, the Dutch Regional Review Commission (hereafter:

‘the Dutch Euthanasia Commission’—a national body bringing together
the five regional review commissions) has published annual reports
on the number of cases of euthanasia and assisted suicide107. Those
numbers do not include the unreported cases.
In 2019, 6,092 euthanasia and assisted suicide cases were
recorded, amounting to 4.2% of all deaths. By way of comparison, in 2009,
2,636 cases of euthanasia and assisted suicide were recorded, which
means that, in ten years, the number of cases has more than doubled—
and even more than tripled in a fifteen-year period, if we consider the
number of cases recorded in 2004 (1,886 cases).
In 2019, 67.3% of cases concerned patients with cancer, 4.1%
with cardiovascular disease, 6.7% with neurological disorders, 3% with
pulmonary disorders, 2.7% with dementia, 1.1% with other psychiatric
conditions, 13.9% for a ‘combination of conditions’, and 1.8% for multiple
geriatric syndromes.
There has been a notable increase in euthanasia cases for
dementia. In 2012, 41 persons affected by dementia were euthanized. By
2016, this number had tripled, accounting for 141 people. In 2019, this
number further increased to 162, out of which 160 were ‘at the beginning
stages of dementia’ while two others were at an ‘advanced stage of
dementia’.108
Concerning euthanasia for psychiatric conditions, 68 people were
euthanized in 2019, a sharp rise in contrast to the 14 individuals in 2012.
The 2016 report also highlighted the increasing involvement
of doctors from the so-called ‘End of Life Clinic’, which collaborated in
euthanizing around 400 people in 2016, compared to 107 in 2013. In 2019,
this institution changed its name to the ‘Euthanasia Expertise Centre’, to

emphasize its core activity, which is stated to be ‘to assess euthanasia
requests’.109 The centre claimed it received 3,122 requests for euthanasia
in 2019, equalling an average of 13 requests per day, which constitutes a
record number and represents a 22% increase from 2018.110 Out of those
requests, 898 were carried out, amounting to one out of three requests.111
According to one of its directors, the constant increase in numbers over
the years demonstrates there is ‘an increasing need for an organization
specialized in euthanasia care’.112
3. An increasingly permissive approach towards euthanasia
The Netherlands euthanasia and assisted suicide law has, to this day, not
been amended, unlike the Belgian law.
However, Dutch policy makers, including the (outgoing) minister in
charge of Health, recently committed to amending the law. The law would
be modified to permit access to euthanasia to children under the age of 12
in order to prevent ‘unnecessary suffering’.113 In July 2020, a proposal was
furthermore tabled in the Dutch Parliament, aimed at legalizing ‘ending
the life of elderly people on request’114 in cases where a person could,
from the age of 75, claim their life was ‘complete’. No formal agenda has
been set on how to move forward with those proposals.
In 2018, the Dutch Euthanasia Commission published the first
version of a ‘Euthanasia Code’, which provides a set of guidelines (not
legally binding) on the practice and control of euthanasia and assisted
suicide, based on the findings and views expressed by the Dutch
Euthanasia Commission until 2018.115
Amongst other things, the Code mentions the possibility for couples,
to request a so-called ‘couple euthanasia’116—where both individuals are
euthanized simultaneously, provided that conditions of the law are met
for both. The 2018 report of the Dutch Euthanasia Commission mentions
18 cases of ‘couple euthanasia’ were reported, a number that almost
doubled in 2019 (34 reported cases).
In 2020, this Code was amended, following a euthanasia case

known as the ‘coffee euthanasia’.117
The case concerned the euthanasia of a 74-year-old lady suffering
from dementia (Alzheimer’s disease), who had anticipatively requested
euthanasia to be performed if she were to be admitted to a nursing
home.118 After she had effectively been admitted, it appeared she gave
contradictory signals as to whether she still truly desired euthanasia
during her stay there: on some occasions, she asked to die; while on other
occasions, she expressed she did not want to die. The euthanasia was
eventually carried out in 2016, at the request of her husband, based on
the anticipatory declaration.
The physician, who had been taking care and observing the lady
since her admission to the nursing home seven weeks prior to the
euthanasia being performed, was later heard by the Dutch Euthanasia
Commission.
He explained that in order to tranquilize the lady before the
euthanasia, a sedative was added to her coffee around 10 am without
her knowledge, because the lady, who ordinarily took no medication,
might have refused were she asked to take the sedative by herself. About
45 minutes later, after she finished drinking her coffee ‘in a pleasant
atmosphere’, the physician nevertheless found that a second dose of
sedative had to be administered. The record notes that the lady, who
already started to feel tired, experienced the injection as ‘unpleasant’. Half
an hour later, the lady was finally in a state of lowered consciousness, and
an intravenous perfusion was administered—it was noted that she ‘slightly
retracted’ when this was done. When the lethal substance (thiopental)
was eventually injected, the lady attempted to get up and withdraw her
hands, which frightened the physician. He indicated that, at the sight of
the infusion, the lady ‘got scared and looked at it with anxious eyes’, yet
he did not think of interpreting this ‘as a sign that the patient possibly did
not want the euthanasia’. The physician added in that regard, that even if
the lady had, at that time, said, ‘I don’t want to die’, he would nevertheless
have continued the ongoing life-ending procedure and did not consider it
‘appropriate’ to interrupt the process at that stage.
The family of the lady then intervened to hold her still while the
physician rapidly injected the rest of the lethal substance, after which the
lady’s life came to an end.
That morning, prior to the euthanasia, the physician had not
spoken with the lady about the euthanasia, nor about adding a sedative
to her coffee. He claimed to do this in order to avoid provoking her, and
because the physician did not believe she had mental capacity. That
morning, while the patient was with her family, she expressed intent and
made plans to have dinner with them outside the facility—which, to the
physician, illustrated the inconsistency of her utterances.
After the Dutch Euthanasia Commission examined the
circumstances of the case, it found that the physician had not respected
the euthanasia law, as the anticipatory declaration did not clearly indicate
the patient’s intention to be euthanized while in a state of lacking mental
capacity.119 It also concluded the euthanasia had not been performed
with due care.120
Criminal proceedings were then initiated. However, the Dutch
Supreme Court eventually acquitted the concerned physician on the
basis ‘that an anticipatory request for euthanasia, in the case of a patient
suffering from dementia, had to be interpreted not only with regard to the
wording of the declaration, but also with regard to other circumstances
from which the patient’s will can be deduced.’121
Following that decision, the Dutch Euthanasia Commission,
although having previously considered this to be an unlawful euthanasia,
aligned its view with the Supreme Court’s ruling and, without expressing
any further concerns, subsequently amended the Euthanasia Code.
Whereas the initial Code (2018) required that euthanasia in
the case of dementia would only be performed in the presence of an
anticipatory declaration that was ‘clear and without any doubt applicable
to the present situation’ (2018),122 the new requirement (2020) imposed
the responsibility upon the physician to (independently) interpret the
declaration, taking ‘into account all circumstances and not only the literal
words of the written request’123—thus facilitating the euthanasia of people
suffering from dementia, even in a context where doubt could reasonably
arise as to the patient’s current will.
The other amendments similarly tended to make it easier to carry
out a euthanasia request.
For instance, it clarified that in the case of dementia and in the
presence of an anticipatory declaration, provided the patient is unable
to express their wishes, it is no longer mandatory for the physician to
inquire about a patient’s ‘current wish to live or to die’.124 It furthermore
detailed that ‘counter-indications’ to the euthanasia, which can consist
in utterances or particular behaviours of the patient, ‘that originated in
the period in which the patient was unable to express his will, cannot be
understood as a withdrawal or modification of the written request’.125
The physician performing the euthanasia is also officially allowed
to resort to so-called ‘pre-medication’ (i.e. sedatives) when there are
indications ‘agitation or unrest’ may occur during the execution of
euthanasia.126
The final amendment, which concerns all euthanasia cases
(not only dementia), confirms that the performing physician is to be
considered as the sole authority needed to determine, based on a
‘medico-professional’ analysis, whether or not ‘unbearable’ suffering
exists, and that the Commission can only exercise limited oversight in
that regard127—this despite the requirement of unbearable suffering as
being one of the central requirements of the euthanasia law, as well as
the main reason for the legalization of euthanasia in the Netherlands,
twenty years ago.
C. Canada
In the province of Quebec, an Act ‘respecting end-of-life care’ was adopted

by the National Assembly on 5 June 2014. The act grants every person
the right to receive ‘end-of-life care’, which includes ‘the administration by
a physician of medications or substances to an end-of-life patient, at the

patient’s request, in order to relieve their suffering by hastening death’.128
The Act thus allows a person to request euthanasia (euphemistically
called ‘medical aid in dying’).
The patient needs to be ‘of full age and capable of giving consent to
care’, be ‘at the end of life’, ‘suffer from a serious and incurable illness’, ‘be
in an advanced state of irreversible decline in capability’, and ‘experience
constant and unbearable physical or psychological suffering which
cannot be relieved in a manner the patient deems tolerable’.129
A Canadian Federal Government challenge to this Act failed
following the Canadian Supreme Court’s ruling in Carter v. Canada in
February 2015.130
The Court ruled that the provision criminalizing help provided to
a person in committing suicide, as contained in the Canadian Criminal
Code, infringed on the Canadian Charter of Rights and Freedoms (Part I
of the Canadian Constitution) by prohibiting the ‘physician-assisted death
for a competent adult person who (1) clearly consents to the termination
of life and (2) has a grievous and irremediable medical condition (including
an illness, disease or disability) that causes enduring suffering that is
intolerable to the individual in the circumstances of his or her condition’.
A one-year period was granted to the Canadian Federal Government to
legislate on the matter in order to amend the Criminal Code.
On 17 June 2016, a bill to legalize and regulate euthanasia and
assisted suicide nation-wide passed in the Canadian Parliament.131
Under that law, individuals qualify if they are at least 18 years of
age, ‘have a grievous and irremediable medical condition’, ‘have made
a voluntary request for medical assistance in dying’, and ‘give informed
consent to receive medical assistance in dying after having been informed
of the means that are available to relieve their suffering, including palliative
care’.132 Grievous and irremediable medical conditions are further defined
as being ‘serious and incurable’, causing the person to be in ‘an advanced
state of irreversible decline in capacity’ with ‘natural death … reasonably
foreseeable’. The person providing or administering the lethal substance,
in the case of euthanasia, must be a medical practitioner or a nurse

practitioner.
Following a law proposal introduced by the Minister of Justice and
Attorney General of Canada, subsequent to a decision of the Superior
Court of Quebec declaring unconstitutional the ‘reasonable foreseeability
of natural death’ eligibility criterion,133 the House of Commons passed an
act to amend the regulation of euthanasia and assisted suicide on 10
December 2020, adopted by the Senate on 17 February 2021.134
The amendment opened the possibility for persons whose natural
death is not foreseeable to resort to euthanasia or assisted suicide. It set
forth specific conditions that must be met in each case (depending on
whether or not natural death is foreseeable).
It also specified that euthanasia may be carried out in the event
a person loses their capacity to consent, provided the person and the
medical practitioner made an agreement prior to the loss of capacity.
Under current law, as amended, resorting to euthanasia is furthermore
also allowed in the event a person loses the capacity to consent due to
the self-administration of a lethal substance prescribed to that person
with the aim of committing assisted suicide (under the conditions of the
legislation).
Regarding the requirement of an irremediable medical condition,
the amended legislation specifies that persons whose sole underlying
medical condition is a mental illness are not eligible for 24 months,
i.e. until 17 March 2023. During this two-year period, the Canadian
Government must ‘cause an independent review to be carried out by
experts respecting recommended protocols, guidance and safeguards to
apply to requests made for medical assistance in dying by persons who
have a mental illness’.135
One can observe that all but one of the amendments entail a
significant enlargement of the 2016 conditions for euthanasia and
assisted suicide, which moreover comes less than five years after those
practices were first legalized.
In December 2018, the Council of Canadian Academies issued a

report entitled ‘The State of Knowledge on Medical Assistance in Dying
for Mature Minors’ as a response to a request from the Canadian Ministry
of Justice on whether euthanasia and assisted suicide of minors should
(or could) be legalised in Canada in the future.136 Until now, no legislative
action has been taken, although calls have been made to amend the
legislation.
Although euthanasia and assisted suicide were legalized in 2016,
it took the Canadian authorities one-and-a-half years (until January 2018)
to put the so-called ‘federal monitoring system for medical assistance
in dying’ in place under the auspices of the Ministry of Health, which
was tasked with gathering data and reporting on the application of the
legislation. Prior to the system being in place, data was provided by
territories and provinces on a ‘voluntary’ basis, raising doubt as to the
accuracy of the data.
The first report137 covered the year 2019. In that year, 5,361 cases
of euthanasia and assisted suicide were reported, which accounts for 2%
of all deaths in Canada, and represents an increase of 26.1% compared to
the numbers available for the year 2018. The second report138 covered the
year 2020. In that year, 7,595 cases of euthanasia and assisted suicide
were reported, which accounts for 2,5% of all deaths in Canada and
represents an increase of 34.2% compared to the numbers available for
the year 2019.
It is estimated, since the adoption of the federal legislation, 21,589
persons died as a result of either euthanasia or assisted suicide.
6) Legal Exceptions, Safeguards and Controls: A
slippery slope
The ‘slippery slope’ argument asserts that one exception to a law is

followed by more exceptions until a point is reached that would initially
have been considered unacceptable.139
When applied to the legalization of euthanasia and assisted suicide,
the slippery slope implies that whereby the introduction of euthanasia is
normally predicated upon it being very rare and truly exceptional, albeit
gradually, an overarching acceptance and approval for euthanasia and
assisted suicide can be observed.
A. Amendments expanding the euthanasia legislation
This trend can be observed particularly in the successive amendments

made to the Belgian euthanasia law over the course of just under twenty
years. Where initially, only adults could request euthanasia, this has now
been extended to minors. Where initially, no physician could be compelled
to collaborate with euthanasia; now, even a physician who conscientiously
objects is obliged by law to refer their patient to an organization favourable
towards euthanasia. Upon legalization, euthanasia was to be considered
an exception to the criminal offence of murder; but a ‘right to euthanasia’
is now considered among the patient’s basic rights.
Although the Dutch euthanasia law has not been formally amended,
proposals have been put forward to extend euthanasia and assisted
suicide to minors below the age of twelve, and the guidelines issued
by the Dutch Euthanasia Commission are illustrative of an increasingly
permissive approach towards euthanasia and assisted suicide.
The existence of a ‘Euthanasia Expertise Centre’ in the Netherlands,
formerly known as the ‘End-of-Life Clinic’, shows that, twenty years after
its legalization, euthanasia is offered as an ordinary medical service with
a provider specialized in (euphemistically called) ‘euthanasia care’, thus
further trivializing the fact that euthanasia is the intentional ending of a

life.
Prof. Theo Boer, a Dutch ethicist, and a nine-year-member of a
Netherlands regional euthanasia review committee writes that:
under the name ‘End-of-Life Clinic’ the Dutch Right to Die

Society NVVE founded a network of travelling euthanizing
doctors. Whereas the law presupposes (but does not require)
an established doctor-patient relationship, in which death might
be the end of a period of treatment and interaction, doctors
of the End-of-Life Clinic have only two options: administer
life-ending drugs or send the patient away. On average, these
physicians see a patient three times before administering
drugs to end their life.140
When it comes to Canada, as illustrated in the previous section, recent

amendments entailed a significant enlargement of the 2016 law, less
than five years after the legalization of euthanasia and assisted suicide.
B. Ineffective ‘safeguards’ and control mechanisms
Furthermore, in all jurisdictions in which euthanasia or assisted suicide,

or both, have been legalized, regulations were put in place to prevent
abuse. These measures have included, among others, explicit consent
by the person requesting euthanasia, mandatory reporting of all cases,
administration only by physicians, and consultation by a second or third
physician.
As previously highlighted, there is evidence141 to show that these
laws, setting forth so-called strict conditions and safeguards, are regularly
ignored and transgressed, and that transgressions are not followed with
prosecutions, as it has also been confirmed by former members of the
Belgian and Dutch euthanasia commissions.
Prof. Boer was a member of a regional euthanasia review
committee in the Netherlands from 2005 until 2014. In 2007, he wrote
‘there does not need to be a slippery slope when it comes to euthanasia’,

further indicating that ‘a good euthanasia law, in combination with the
euthanasia review procedure, provides the warrants for a stable and
relatively low number of euthanasia’.
In 2014 however, based on his first-hand experience as a member
of the regional review committee, and after having reviewed thousands
of euthanasia cases, he changed his position. He wrote a public appeal
to the British House of Lords, warning: ‘We were wrong, terribly wrong’.
He mentioned the escalation in numbers of euthanasia demands, the
development of End-of-Life Clinics, the shift in patients who receive
euthanasia (i.e. more cases of loneliness, depression, and bereavement),
and the development from an exception in law to public opinion
considering euthanasia a ‘right’, with corresponding duties on doctors to
act.
In 2017, Dr Ludo Vanopdenbosch, a neurologist, palliative physician,
and visiting university professor, although being in favour of euthanasia,
resigned from his position as a substitute member of the Belgian Control
Commission. In a letter142 sent to the President of the Belgian Parliament,
he provided the following reasons for his resignation:
(…) The Federal Control and Evaluation Commission is indeed

not independent nor objective. Whenever declarations are
[found] not to be in conformity with the law, they are not, as the
law prescribes, transferred to the Prosecutor for investigation,
but [the Commission] plays the role of judge.
The most striking example of this took place on 5 September

2017, in a case under review at the request of the family of a
patient severely affected by dementia and Parkinson’s disease.
The incompetent general practitioner who performed the
euthanasia was ignorant of palliation, and had an intent to kill
the patient, who did not request the euthanasia. The means
used to relieve pain were disproportionate, and the advice
given by the other physician was most likely not independent,
and retroactively given. None of the legal conditions, except for

the euthanasia to be [afterwards] declared, were met.
The commission held a recorded hearing with the physician.

Video footage of the patient’s situation was submitted prior to
the hearing, and hours of debate ensued culminating with a
vote. However, the two thirds majority required to transfer the
case to the Prosecutor for investigation was narrowly missed.
The motivations of those that did not want to transfer the

case to the Prosecutor are fundamentally of a political nature:
defending euthanasia in whatever circumstances, there is now
fear that in Wallonia [red. French speaking part of Belgium],
euthanasia cases will decrease again, [and] a desire to [allow]
euthanasia for persons with dementia. (…) The Control
Commission does not enlarge the scope of the law: it violates
the law.
I do not want to be part of a commission that deliberately

violates the law and tries to hide it. The lawyers that were
present indicated that it is not up to the Commission to interpret
the law. After the meeting, members of the Commission were
instructed not to communicate about this debate and this
decision. This is unacceptable (…).
A third element that I noticed (…) is that I, being a neurologist,

expressed concerns about the particularly vulnerable group of
persons, the late-stage neurological patients, such as those
affected by multiple sclerosis. One cannot lightly consider
euthanasia in such cases. Following this I have been silenced
by a [Commission] member of a ‘right to die in dignity’-
organization. The Commission’s president and vice-president
did not intervene to guarantee my right to freely speak out. I do
not want to be a member of such a commission.
Fourthly, the Commission does not possess the ability to verify

the factual accuracy of the declared data. I, as a practitioner,
now know how to fill in a euthanasia registration form in

such a way that it will be without any doubt approved by the
Commission, without any control of the facts. Numerous
euthanasia [procedures] are performed by the members of
the Commission themselves; they know that they can always
protect each other. This impunity is frightening. (…)
This letter, despite its particularly clear warnings, was not followed by any
political or judicial action, and was given very little attention in the public
sphere.
In a documentary143 broadcast by a Belgian public television
channel in September 2020, Dr Robert Rubben, a former member of the
Belgian Control Commission, expressed similar concerns:
The Commission never decides that something wrong was

done. The Commission merely has to determine whether the
rules were observed and whether there are no reasons to
doubt. My fundamental dissatisfaction with this was that even
in case of doubt, it was nevertheless always approved by the
Commission. And secondly, and this is a statistical reality, that
out of the first 10,000 evaluated cases, not one was referred for
further investigation.
In that same documentary, Prof. Sigrid Sterckx, a Belgian professor of

ethics and political philosophy, also highlighted that following the research
she conducted for over fifteen years on the matter, one out of three
euthanasia cases are never officially declared to the Control Commission
in the Dutch-speaking part of Belgium.144 Prof. Sterckx posited, ‘Some
physicians are very open about this. Have they ever been challenged by
the judiciary? No’.
For instance, in a 2014 interview with a Belgian newspaper, Dr
Marc Cosyns, a general practitioner, admitted he generally does not
declare his cases, despite having a legal obligation to do so, because he
considers euthanasia to be a ‘normal medical procedure’.145 Even though
such statements constitute public confessions of unequivocal, deliberate
violations of the euthanasia law, they are not followed by any judicial
action.
In the twenty years since the legalization of euthanasia in both
Belgium and the Netherlands, there has not been a single case of a
physician being found guilty of performing unlawful euthanasia.
C. Constant increase in numbers
The number of cases of euthanasia and assisted suicide have seen a

consistent increase in Belgium and the Netherlands since its legalization.
Given those official numbers only account for declared cases, it is likely
that the real numbers are significantly higher than the official numbers.
There is little reason to think a similar trend would not be observed in
Canada in the forthcoming years.
Looking at those developments, it seems inevitable that the availability
of legalized euthanasia stirs demand, and euthanasia and assisted suicide thus
tend to become less ‘exceptional’ as time passes. The demand for euthanasia,
originally limited to cases of extreme physical suffering, quickly expanded to
non-extreme physical suffering, mental and psychological suffering, and even
to cases of physically healthy people with symptoms of old age.
With such developments, it seems justifiable to ask whether the
availability of on request euthanasia and suicide does eventually not turn
into a duty not to be a burden on society, the family and the health care
system in case of illness, suffering and ongoing medical care.
***
The amendments broadening euthanasia legislations, the ineffectiveness

of safeguards and control mechanisms, as well as the constant increase
in numbers illustrate that a slippery slope, leading to a broader acceptance
of euthanasia and assisted suicide, can indeed be observed in every
country that has pursued legalization. The slippery slope is therefore not
just a hypothetical concern but a plainly demonstrable reality.
7) Refuting the Main Arguments for Legalizing
Euthanasia
A. The right to ‘Die with Dignity’
The compassionate argument for a ‘good death’ is one whereby supporters

of euthanasia believe that respect for human dignity demands an end
to the suffering of a particular person, even if this means the intentional
ending of his or her life. It is argued that the option of choosing euthanasia
is required to respect the ‘dignity’ of suffering people.
However, dignity is intrinsic to the human person not dependent on
the person’s circumstances. The 1948 Universal Declaration of Human
Rights enshrined this principle in its preamble: ‘recognition of the inherent
dignity and of the equal and inalienable rights of all members of the human
family is the foundation of freedom, justice and peace in the world’.
The vulnerable are becoming victims of a ‘euthanasia culture’.
Legalizing euthanasia leads directly to the creation of a ‘duty to die’ when
one’s life becomes a burden on society. This is a form of direct harm to
patients and a violation of their inherent dignity.
Furthermore, the availability of euthanasia is likely to lead to less,
instead of more and better, training of doctors in pain management.146
The goal of palliative care is to ease suffering and improve the patient’s
quality of life. While 98% of the pain can medically be controlled today,
more than 65% of cancer patients still die in pain, because doctors lack
the necessary training.147
Studies show that patients who receive palliative care report
improvement in pain, improved communication with patients’ healthcare
providers and family members, as well as improved emotional support,
among other benefits.148 To uphold the inherent dignity of each human
life, we need to further invest into palliative care.
B. Respect for Individual Autonomy
In medical ethics and medical law, patient autonomy is a central concept.

Patients generally have the right to refuse treatment even if this refusal
leads to their death. It is therefore argued that people should also have
the right to determine the moment of their death if they are in a situation
which is unbearable, and without prospect of improvement.149
This is troubling for a number of reasons. Firstly, the ‘choice’ of
euthanasia is never autonomous. It always involves a counterpart—the
doctor or nurse—who needs to assist or carry it out; the autonomy of the
patient frequently clashes with the autonomy of the doctor who refuses
to intentionally kill.
Secondly, there is a notable increase in euthanasia requests
coming from patients who have been diagnosed with dementia.150
Some of them were diagnosed with the illness but had not yet suffered
fully from the symptoms. Nevertheless, an increasing number of such
patients asked for their life to be ended out of fear of future suffering and
loss of autonomy.151 It is questionable whether one can really speak of an
autonomous choice when a person is in a situation of fear, vulnerability,
and the onset of a serious mental health condition.
In a similar manner to suicide, the choice of euthanasia has
deep implications on others around the person concerned including
family, friends, and colleagues. According to the UK charity Survivors of
Bereavement by Suicide,152 a suicide can even affect people who did not
know the person who died.
Finally, the existence of consent does not necessarily mean
that human dignity is thereby respected. For instance, although a trite
example, in the French case of Commune de Morsang-sur-Orge, the
Conseil d’Etat ruled that the ‘sport’ of ‘dwarf throwing’ was in breach of
respect for human dignity and banned it, even though the persons of
short stature involved consented.153 In the name of humanity, a society
needs to protect the vulnerable.154
C. Euthanasia does not harm others
This argument says that euthanasia is a private, individual choice. It does

not infringe the rights or freedoms of someone else, and therefore doesn’t
negatively impact on anyone else or society.
However, such an argument ignores the harm inflicted upon
family members, friends, the medical staff, and society at large (as
discussed above). The foundational societal value of respect for human
life is damaged. In the words of American philosopher, Daniel Callahan:
‘Euthanasia is an act that requires two people to make it possible and a
complicit society to make it acceptable.’155
D. Euthanasia is properly regulated
This public policy argument says that euthanasia can be safely regulated
by government legislation. This is covered in more detail in sections 4 and
5, above.
Yet, looking at the developments in Belgium and the Netherlands,
it is clear that the availability of legalized euthanasia stirs the demand. As
discussed in sections 4 and 5, the examples of legalized euthanasia show
that legal restrictions and safeguards do not prevent abuse.
In the words of Dutch ethicist Prof. Theo Boer, ‘whereas assisted
dying in the beginning was the odd exception, accepted by many
— including myself — as a last resort… [P]ublic opinion has shifted
dramatically toward considering assisted dying a patient’s right and
a physician’s duty’.156 He insists that not even the Dutch Review
Committees, despite trying to keep euthanasia within the limits of the
law, have been able to halt these developments. Once legalized, there is
no logical stopping point to euthanasia.
E. Economic pressure
It is undeniable that there are huge economic implications at stake. A study

by the Canadian Medical Association Journal from January 2017157 shows
that if euthanasia became more widely available, it would considerably
unburden the public health care budget, potentially reducing the annual
health care spending across Canada by between $34.7 million and $138.8
million, significantly exceeding the $1.5–$14.8 million in direct costs
associated with its implementation.158
Concerns over a link between economic pressure and the
legalization of euthanasia is shared by disability groups. For example, the
UK-based association ‘Not Dead Yet’ warns:
[d]isabled and terminally ill people fear that calls to legalize

assisted suicide and euthanasia are likely to intensify. Our
concerns are heightened by the current economic climate and
calls from politicians from all parties for cuts in public services.
We, and our families, rely upon such services to live with dignity....
We face a bleak situation as calls for assisted suicide to be lawful
are renewed, whilst vital services are being withdrawn or denied.159
8) Conclusion
Without exception, the experience of legalized euthanasia shows

that a slippery slope is unavoidable. No matter how apparently strict
the law is designed to be, it is bound to fail to protect the vulnerable
members of society as well as medical practitioners and society at
large. The abovementioned examples show the inherent dynamic of a
growing demand for euthanasia, once legalized. Furthermore, laws and
safeguards are regularly ignored and transgressed in all the jurisdictions
where euthanasia has been legalized, and those transgressions are rarely
prosecuted even when they come to light. The mere existence of such a
law is an invitation to see assisted suicide and euthanasia treated as a
normal part of healthcare. It is therefore essential to oppose any pressure
for legalization of euthanasia based both on principled and pragmatic
considerations.
ADF International is a faith-based legal advocacy organization that
protects fundamental freedoms and promotes the inherent dignity of all
people. With headquarters in Vienna, and offices in Brussels, Geneva,
Strasbourg, London, New York City, and Washington DC, we are at the
forefront of defending religious freedom, the sanctity of life, and marriage
and family worldwide.
Working on an international level, we have a full-time presence at all the

institutions of strategic international importance. We are accredited by
the UN Economic and Social Council (ECOSOC), the European Parliament
and Commission, and the Organization of American States (OAS).
Additionally, we enjoy participatory status with the EU’s Agency for
Fundamental Rights (FRA) and engage regularly with the Organization for
Security and Co-operation in Europe (OSCE). On a national level, we work
with local allies to provide training, funding, and legal advocacy.
ADFinternational.org
Notes
1 Merriam-Webster Dictionary, verbo ‘Euthanasia’, available on www.merriam-webster.

com (accessed 9 January 2021).
2 With a view of briefly clarifying the most frequently encountered concepts in the field of
the end-of-life, this section deliberately does not enter into nuances or controversies
that could legitimately be expressed regarding the concepts and the related
classifications or distinctions between them.
3 Unless otherwise mentioned, the definitions and considerations in the present section
are either taken from or inspired by several sources, which can be consulted for
a more comprehensive overview and more detailed insights in the terminology,
i.a. University of Missouri – Center for Health and Ethics, verbo ‘Euthanasia’,
available on https://medicine.missouri.edu/centers-institutes-labs/health-ethics/
faq (accessed 9 January 2021) ; British Broadcasting Channel, ‘Euthanasia and
Physician assisted suicide’, available on http://www.bbc.co.uk/ethics/euthanasia
(accessed 9 January 2021) ; Debois, B., ‘End-of-life: let’s agree on semantics’,
European Institute of Bioethics, Teaching Card no. 12, 2016, available on www.ieb-
eib.org (accessed 9 January 2021) ; Guerra, Y. M., ‘Ley, Jurisprudencia y Eutanasia’,
Revista Latinoamericana de Bioetica, ed. July-December 2013, pp. 73-75, available
on https://www.redalyc.org/pdf/1270/127030498007.pdf (accessed 9 January
2021) ; Montero, E., ‘Repères éthiques pour accompagner la personne en fin de
vie’, European Institute of Bioethics, Dossier, 2010, available on www.ieb-eib.
org (accessed 9 January 2021) ; Medical News Today, ‘What are euthanasia and
assisted suicide?’, available on www.medicalnewstoday.com (accessed 9 January
2021) ; United Kingdom National Health Service, ‘Euthanasia and assisted suicide’,
available on https://www.nhs.uk/conditions/euthanasia-and-assisted-suicide
(accessed 9 January 2021).
4 Montero, E., Rendez-vous avec la mort – Dix ans d’euthanasie légale en Belgique,
Anthemis, 2013, p. 13 (quote translated from French).
5 Merriam-Webster Dictionary, verbo ‘Suicide’, available on www.merriam-webster.com
6 On this topic, cf. in particular Dubus, C., ‘La Sédation’, European Institute of Bioethics,
Teaching Card no. 13, 2019, available on www.ieb-eib.org (accessed 9 January
2021).
7 Montero, E., Rendez-vous avec la mort – Dix ans d’euthanasie légale en Belgique,
Anthemis, 2013, p. 20-21 (quote translated from French).
8 Regarding the situation in Spain and Portugal, cf. infra, section D.
9 Dutch Act of 12 April 2001, on the end-of-life on request and assisted suicide review,
available on https://wetten.overheid.nl/BWBR0012410/2020-03-19 (accessed 21
December 2020).
10 Belgian Law of 28 May 2002, on euthanasia, available on http://www.ejustice.just.fgov.
be/eli/wet/2002/05/28/200200959d0/justel (accessed 21 December 2020).
11 Luxembourg Act of 16 March 2009, on euthanasia and assisted suicide, available on
http://legilux.public.lu/eli/etat/leg/loi/2009/03/16/n2/jo (accessed 21 December
2020).
12 On this particular question, cf. infra, section no. 5.

13 Italian Constitutional Court, 25 September 2019, available on https://www.
cortecostituzionale.it/actionSchedaPronuncia.do?anno=2019&numero=242
(accessed 21 December 2020).
14 British Broadcasting Channel, ‘DJ Fabo ruling: Italy’s top court backs assisted dying
in extreme cases’, 26 September 2019, available on https://www.bbc.com/news/
world-europe-49837610 (accessed 21 December 2020).
15 German Constitutional Court, 26 February 2020, available on
h t t p s : / / w w w. b u n d e s v e r f a s s u n g s g e r i c h t . d e / S h a r e d D o c s /
Entscheidungen/EN/2020/02/rs20200226_2bvr234715en.
html;jsessionid=A9D657B025B92DF52822A7C72EA8B2A8.1_cid386 (accessed
21 December 2020) with official press release, available on https://www.
bundesverfassungsgericht.de/SharedDocs/Pressemitteilungen/EN/2020/bvg20-
012.html (accessed 21 December 2020).
16 Austrian Constitutional Court, 11 December 2020, available on https://www.ris.bka.
gv.at/Judikatur/ (accessed 19 January 2021).
17 Austrian Criminal Code, section 78, available on https://www.ris.bka.gv.at/
GeltendeFassung.wxe?Abfrage=Bundesnormen&Gesetzesnummer=10002296
18 Swiss Criminal Code, article 115, available on https://www.admin.ch/opc/fr/classified-
compilation/19370083/index.html (accessed 21 December 2020).
19 Swiss Academy of Arts and Sciences, Management of Dying and Death, pp. 22-
24, available on https://www.samw.ch/dam/jcr:25f44f69-a679-45a0-9b34-
5926b848924c/guidelines_sams_dying_and_death.pdf (accessed 21 December
2020).
20 Invoking a lack of clarity of the new guidelines, the Association of Helvetic Physicians
however refused to adapt its own deontological guidelines. Cf. Swiss Info, ‘La
Fédération des médecins refuse d’adapter les directives’, 26 October 2018, available
on https://www.swissinfo.ch/fre/aide-au-suicide_la-f%C3%A9d%C3%A9ration-
des-m%C3%A9decins-refuse-d-adapter-les-directives/44499986 (accessed 21
December 2020).
21 Swiss Academy of Arts and Sciences, op. cit., p. 25.
22 For a more detailed analysis of the situation of the United States, cf. World Youth
Alliance, ‘Assisted Suicide & Euthanasia – White Paper’, 2019, pp. 48-65, available on
https://www.wya.net/press-release/wya-releases-new-white-paper-on-assisted-
suicide-and-euthanasia/ (accessed 21 December 2020).
23 United States Supreme Court Decision, Washington v. Glucksberg, 26 June 1997,
available on https://www.supremecourt.gov/opinions/boundvolumes/521bv.pdf
24 Colombian Act of 20 April 2015, to render effective the right to die in dignity, available
on https://www.minsalud.gov.co/Normatividad_Nuevo/Resoluci%C3%B3n%20
1216%20de%202015.pdf (accessed 21 December 2020).
25 Colombian Constitutional Court, 2 October 1997, available on https://www.
corteconstitucional.gov.co/relatoria/1997/c-239-97.htm (accessed 21 December
2020).
26 Canadian Supreme Court, Carter v. Canada, 6 February 2015, available on https://
scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do (accessed 21
December 2020).
27 Canadian Act of 17 June 2016, on medical assistance in dying, available on https://
laws-lois.justice.gc.ca/PDF/2016_3.pdf (accessed 21 December 2020).

28 Victoria State Act of 29 November 2017, on voluntary assisted dying, https://
content.legislation.vic.gov.au/sites/default/files/68b6d184-e46e-38fb-b098-
16b6e9768698_17-61aa001%20authorised.pdf (accessed 21 December 2020).
29 New Zealand Act of 16 November 2019, on the end-of-life choice, available on https://
www.legislation.govt.nz/act/public/2019/0067/latest/DLM7285905.html
30 The referendum was held on 17 October 2020. The End-of-life Choice Act will enter into
force on 7 November 2021, according to the official governmental website https://
www.health.govt.nz/our-work/regulation-health-and-disability-system/end-life-
choice-act (accessed 21 December 2020).
31 French Act of 2 February 2016, creating new rights in favor of ill persons and persons
at the end of their life, available on https://www.legifrance.gouv.fr/jorf/id/
JORFTEXT000031970253/ (accessed 21 December 2020).
32 French Law Proposal of 17 October 2017 (Assemblée Nationale), on the right to a free
and chosen end-of-life, available on https://www.assemblee-nationale.fr/dyn/15/
textes/l15b0288_proposition-loi (accessed 14 July 2021).
33 French Law proposal of 17 November 2020 (Sénat), aimed at creating the right to
die in dignity, available on http://www.senat.fr/dossier-legislatif/ppl20-131.html
34 The Portugal News, ‘Euthanasia law approved’, 30 January 2021, available on https://
www.theportugalnews.com/news/2021-01-30/euthanasia-law-approved/58003
(accessed 14 July 2021).
35 The Portugal News, ‘Euthanasia: A door closes but a window opens’, 19 March 2021,
available on https://www.theportugalnews.com/news/2021-03-19/euthanasia-a-
door-closes-but-a-window-opens/58835 (accessed 14 July 2021).
36 Spanish Law of 18 March 2021, regulating euthanasia, available on https://www.
congreso.es/public_oficiales/L14/CONG/BOCG/B/BOCG-14-B-46-8.PDF
(accessed 15 July 2021).
37 Grupo Parlamentario Vox, Official website, ‘Abascal presenta el recurso de
inconstitucionalidad de VOX a la ley de eutanasia’, available on https://www.
voxespana.es/grupo_parlamentario/notas-de-prensa-grupo-parlamentario/
recurso-inconstitucionalidad-vox-ley-eutanasia-texto-integro-20210616 (accessed
15 July 2021).
38 Irish law proposal of 15 September 2020 (Irish National Assembly), ‘to make provision
for assistance in achieving a dignified and peaceful end of life to qualifying persons and
related matter’, available on www.oireachtas.ie/en/bills/bill/2020/24/ (accessed 28
January 2021).
39 United Kingdom National Health Service, Euthanasia and assisted suicide, available
on https://www.nhs.uk/conditions/euthanasia-and-assisted-suicide (accessed 9
January 2021).
40 Sky News, ‘Assisted dying could be legalized in the UK within four years, leading MP
predicts’, 24 August 2020, available on https://news.sky.com/story/assisted-dying-
could-be-legalised-in-the-uk-within-four-years-leading-mp-predicts-12055523
41 United Kingdom Law proposal of 26 May 2021 (House of Lords), ‘to enable adults who
are terminally ill to be provided at their request with specified assistance to end their
own life ; and for connected purposes’, available on https://bills.parliament.uk/
bills/2875 (accessed 15 July 2021).
42 The ICCPR was adopted by the United Nations General Assembly on 16 December
1966 and entered into force on 23 March 1976.
43 The CRC was adopted by the United Nations General Assembly on 20 November 1989
and entered into force on 2 September 1990.
44 The CRPD was adopted by the United Nations General Assembly on 13 December 2006
and entered into force on 3 May 2008.
45 Ninety-sixth session (CCPR/C/NLD/CO/42), 5 August 2009, at § 7.
46 Article 5 (2) TEU.
47 Article 168 (7) TFEU.
48 Recommandation 1418 (1999) § 9.
49 Resolution 1859 (2012) § 5.
50 WMA Declaration on Euthanasia, adopted by the 39th World Medical Assembly, Madrid,
Spain, October 1987 and reaffirmed by the 170th WMA Council Session, Divonne-
les-Bains, France, May 2005, and the 200th WMA Council Session, Oslo, Norway,
April 2015.
51 WMA Statement on Physician-Assisted Suicide, adopted by the 44th World Medical
Assembly, Marbella, Spain, September 1992 and editorially revised by the 170th
WMA Council Session, Divonne-les-Bains, France, May 2005.
52 WMA Resolution on Euthanasia, reaffirmed with minor revision by the 194th WMA
Council Session, Bali, Indonesia, April 2013.
53 WMA Declaration on Euthanasia and Physician-Assisted suicide, adopted by the 70th
World Medical Assembly, Tblisi, Georgia, October 2019.
54 Pretty v. the United Kingdom, no. 2346/02, ECHR 2002 III.
55 Section 2(1) of the Suicide Act 1961.
56 Pretty v. United Kingdom (2002) 35 E.H.R.R. 1 §§ 39-40.
57 Ibid., § 54.
58 Ibid., § 67
59 Ibid.
60 Haas v. Switzerland, no. 31322/07, 20 January 2011, ECHR 2011.
61 Ibid., § 51.
62 Ibid., § 56.
63 Lambert and Others v. France, [GC] no. 46043/14, 5 June 2015.
64 French Conseil d’Etat Ruling, Mme. Lambert, June 24th, 2014.
65 Mortier v. Belgium, no. 78017/17.
66 For an overview of some other issues relating to this case and, more broadly, euthanasia
in Belgium, cf. Clarke, R., ‘7 ways Belgium didn’t even follow its own euthanasia law’,
Mercatornet, available on https://mercatornet.com/7-ways-belgium-didnt-even-
follow-its-own-euthanasia-law/67112/ (accessed 11 June 2021).
67 Belgian Law of 28 May 2002, on euthanasia, available on http://www.ejustice.just.fgov.
be/eli/wet/2002/05/28/200200959d0/justel (accessed 21 December 2020).
68 Belgian Law on euthanasia, art. 2.
69 Belgian Law on euthanasia, art 3 (1).
70 Belgian Law on euthanasia, art 3.
73 With respect to this, for a particularly relevant analysis of the Belgian situation as from
the legalization up to the year 2013, cf. Montero, E., Rendez-vous avec la mort – Dix
ans d’euthanasie légale en Belgique, Anthemis, 2013.
74 Control Commission, First report (2004), p. 16, available on https://
organesdeconcertation.sante.belgique.be/fr/organe-d%27avis-et-de-
concertation/commission-federale-de-controle-et-devaluation-de-leuthanasie
75 Belgian Criminal Code, art. 397, available on http://www.ejustice.just.fgov.be/cgi_loi/
change_lg_2.pl?language=fr&nm=1867060850&la=F (accessed 6 January 2021).
76 Ghent Assize Court, 31 January 2020, available on https://www.standaard.be/cnt/
dmf20200131_04829478 (accessed 8 January 2021).
77 The Prosecutor of Leuven (Belgium) recently announced the investigation of several
cases of alleged unlawful euthanasia (no further information being provided). Cf.
De Standaard, ‘Gerecht onderzoekt tiental euthanasie-cases’, 21 November 2020,
available on https://www.standaard.be/cnt/dmf20201120_98096902 (accessed 7
January 2021).
78 About the Control Commission, cf. also infra, section no. 5.
79 Quotes literally taken from Dr Distelmans’interview, in his capacity as president of the
Control Commission, on the Belgian prime-time magazine ‘De Afspraak’ on 26 April
2019, hosted by the Official Public Belgian channel Vlaamse Radio- en Televisie (VRT),
available on https://www.vrt.be/vrtnws/nl/2019/04/26/arts-buiten-vervolging-
gesteld-in-euthanasiedossier/ (accessed 4 January 2021 – quotes translated from
Dutch.).
80 Ibid., emphasis added.
81 Belgian Law on euthanasia, art. 3 (4).
82 Control Commission, First report (2004), p. 16. Example drawn from Montero E., op. cit.,
p. 47.
83 Cf. Montero E., op. cit., p. 81, with references (2002-2012 period). Most recently, cf.
Control Commission, Ninth report (2020), p. 25, as well as in particular pp. 29-30.
84 Mason B., Weitenberg C., ‘Allow me to Die’, SBS News Documentary, 24 November
2015, available on www.sbs.com.au/news/dateline/tvepisode/allow-me-to-die
85 Cf. Dr Distelmans’interview, in his capacity as president of the Control Commission,
on the Belgian prime-time magazine ‘De Afspraak’ on 26 April 2019, hosted by
the Official Public Belgian channel Vlaamse Radio- en Televisie (VRT), available
on https://www.vrt.be/vrtnws/nl/2019/04/26/arts-buiten-vervolging-gesteld-in-
euthanasiedossier/ (accessed 4 January 2021).
86 De Morgen, ‘Arts niet vervolgd wegens toedienen gifbeker: Geen illegale euthanasie,
maar hulp bij zelfdoding’, 26 April 2019, available on www.demorgen.be (accessed
15 January 2021) ; De Standaard, ‘Arts niet vervolgd voor hulp bij zelfdoding’, 26
April 2019, available on www.standaard.be (accessed 15 January 2019) ; Control
Commission, Ninth report (2020), pp. 29-30.
88 The reports of the Control Commission, some of which have been cited supra, can be
consulted on its official website (https://overlegorganen.gezondheid.belgie.be/nl/
advies-en-overlegorgaan/commissies/federale-controle-en-evaluatiecommissie-
euthanasie). The number of euthanasia cases mentioned in this section are to be
found in or deduced from the respective reports issued by the Control Commission.
89 Cf. also infra, section 6, b.
90 Control Commission, Ninth report (2020), p. 20.
91 Ibid., p. 36. Emphasis added.
92 Control Commission, ‘Euthanasia – Numbers of 2020’, Press release, 2 March 2021,
available on https://overlegorganen.gezondheid.belgie.be/sites/default/files/
documents/fcee-cijfers-2020_persbericht.pdf (accessed 15 July 2021).

93 VRTNWS (Official Public Belgian channel Vlaamse Radio- en Televisie), ‘2.444 mensen
kregen vorig jaar euthanasie, een opvallende daling: Door het euthanasieproces en de
lockdown’, 2 March 2021, available on https://www.vrt.be/vrtnws/nl/2021/03/02/
euthanasiecijfers-2020/ (accessed 15 July 2021 – quotes translated from Dutch ;
emphasis added.).
94 Cf. supra, section 4.A.(ii).
95 Belgian Law of 28 February 2014, amending the Law of 28 May 2002 on euthanasia in
order to extend it to minors, available on http://www.ejustice.just.fgov.be/cgi_loi/
change_lg.pl?language=fr&la=F&table_name=loi&cn=2014022803 (accessed 4
January 2021).
96 On this topic, cf. Van De Walle, J.P., ‘Euthanasia of Minors in Belgium’, European Institute
of Bioethics, Dossier, 2015, available on www.ieb-eib.org (accessed 4 January 2021).
97 Belgian Law of 15 March 2020, amending the law on euthanasia, available on http://
www.ejustice.just.fgov.be/cgi_loi/change_lg.pl?language=fr&la=F&table_
name=loi&cn=2020031502 (accessed 4 January 2021). The constitutionality of the
2020 amendments is currently being challenged before the Belgian Constitutional
Court, which will also have to assess their compatibility with fundamental human
rights.
100 Belgian Law on euthanasia, art. 14. Cf. also the Preparatory Works to this amendment, no.
55K0523/012, available on www.dekamer.be/FLWB/PDF/55/0523/55K0523012.
pdf (accessed 22 January 2021).
101 In practice, according to the preparatory works, only two associations are currently
considered being ‘specialized’ in the ‘right to euthanasia’: ‘LEIF’ (www.leif.be – Life
End Information Forum) and ‘ADMD’ (www.admd.be – Right to die with dignity
society). Both associations are known for actively lobbying in favor of facilitating
the application and further extension of the current euthanasia law. For instance,
amongst other things, ADMD actively advocates for the recognition of a ‘right to
assisted suicide’ in case of ‘completed life’. LEIF in turn recently initiated a petition
with a view of legalizing euthanasia of persons suffering from dementia.
102 Act of 12 April 2001, on the Termination of Life on Request and Assisted Suicide (Review
Procedures), https://wetten.overheid.nl/BWBR0012410/2020-03-19 (accessed 21
December 2020).
103 Dutch Criminal Code, articles 293 and 294, https://wetten.overheid.nl/
BWBR0001854/2020-07-25/#BoekTweede_TiteldeelXIX_Artikel294 (accessed 8
January 2021).
104 Dutch Act on the Termination of Life on Request and Assisted Suicide (Review
Procedures), article 2 (1).
105 Ibid., article 2 (2), (3) and (4).
106 Ibid., article 8.
107 Those reports can be consulted on the website of the Dutch Euthanasia Commission
(https://www.euthanasiecommissie.nl/de-toetsingscommissies/jaarverslagen).
The number of euthanasia cases mentioned in this section are to be found in or
deduced from the respective yearly reports issued by this Commission.
108 Dutch Euthanasia Commission, 2019 report, p. 12.
109 Expertisecentrum Euthanasie, News release, 3 September 2019, available on https://
expertisecentrumeuthanasie.nl/actueel/ (accessed 8 January 2021). Cf. also infra,
section 5, B.
110 Het Parool, ‘Recordaantal verzoeken om euthanasie in 2019’, 7 February 2020, available
on www.parool.nl (accessed 8 January 2021).
111 Het Nieuwsblad, ‘Recordaantal verzoeken om euthanasie in Nederland in 2019’, 7
February 2020, available on www.nieuwsblad.be (accessed 8 January 2021).
112 Expertisecentrum Euthanasie, op. cit., emphasis added.
113 Trouw, ‘Actieve levensbeëindiging straks toegestaan voor kinderen met uitzichtloos
lijden’, 13 October 2020, available on www.trouw.nl (accessed 8 January 2021).
Some consider, however, that merely amending medical protocols, rather than the
law on euthanasia, might be sufficient to authorize physicians to perform euthanasia
on children below the age of twelve.
114 Law Proposal – Law on the ‘review of ending the life of elderly people on request’,
tabled on 17 July 2020, available on www.tweedekamer.nl (accessed 8 January
2021).
115 Dutch Euthanasia Commission, Euthanasiecode, 2018 and 2020 versions, available
on https://www.euthanasiecommissie.nl/euthanasiecode-2018 (accessed 11
January 2021).
116 Dutch Euthanasia Commission, Euthanasiecode, 2018 version, art. 3.6, available
January 2021). The provision refers to ‘duo-euthanasie’ (‘duo-euthanasia’).
117 About this case, cf. Trouw, ‘Uitspraak over “koffie-euthanasie” zet de deur open naar
dubieuze praktijken’, 20 April, 2020, available on www.trouw.nl (accessed 11
January 2021); NRC, ‘Niemand is blij met de koffie-euthanasie uitspraak’, 13 May
2020, available on www.nrc.nl (accessed 11 January 2021) ; Brabants Dagblad,
‘Huiveren over “koffie-euthanasie”’, 26 May 2020, available on www.bd.nl (accessed
11 January 2021).
118 The facts of this case, as mentioned in this section, are taken from the official
ruling of the Dutch Euthanasia Commission, no. 2016-85, in particular pp. 5-8,
available on the Commission’s website https://www.euthanasiecommissie.nl/
uitspraken/publicaties/oordelen/2016/niet-gehandeld-overeenkomstig-de-
zorgvuldigheidseisen/oordeel-2016-85 (accessed 11 January 2021).
119 Ibid., p. 11-12.
120 Ibid., p. 13-14.
121 Hoge Raad der Nederlanden, 21 April 2020, case no. 19/04910, section no. 6.1,
available on https://www.rechtspraak.nl/ (accessed 11 January 2021).
122 Dutch Euthanasia Commission, Euthanasiecode, 2018 version, art. 4.4, available
January 2021). Emphasis added.
123 Dutch Euthanasia Commission, Euthanasiecode, 2020 version, art. 4.1.a, available
November 2020). Emphasis added.
124 Ibid.
125 Ibid., emphasis added.
126 Ibid., art. 4.1.f.
127 Ibid., art. 4.1.b.
128 Quebec Act of 5 June 2014, respecting end-of-life care, version updated to 10 December
2015, art. 3 and 4, available on http://legisquebec.gouv.qc.ca/en/showdoc/cs/S-
32.0001/20151210 (accessed 5 January 2021).
129 Ibid., Chapter IV, Division II, Article 26.
130 Canadian Supreme Court, Carter v. Canada, 6 February 2015, available on https://
scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do (accessed 21
December 2020).
131 Canadian Act of 17 June 2016, to amend the Criminal Code and to make related
amendments to other Acts (medical assistance in dying), available on https://www.
parl.ca/DocumentViewer/en/42-1/bill/C-14/royal-assent (accessed 5 January
2021).
132 Canadian Criminal Code, art. 241.1, available on https://laws-lois.justice.gc.ca/eng/
acts/c-46/page-53.html#h-119953 (accessed 5 January 2021).
133 Superior Court of Quebec, Truchon v. Canada, 11 September 2019, available on https://
www.canlii.org/fr/qc/qccs/doc/2019/2019qccs3792/2019qccs3792.html
134 Canadian Act of 17 March 2021 to amend the Criminal Code (medical assistance
in dying), available on https://parl.ca/DocumentViewer/en/43-2/bill/C-7/royal-
assent?col=2#ID0EBAA (accessed 15 July 2021).
135 Ibid., Art. 3.1 (1).
136 Council of Canadian Academies, ‘The State of Knowledge on Medical Assistance in Dying
for Mature Minor’, Report, December 2018, available on https://cca-reports.ca/wp-
content/uploads/2018/12/The-State-of-Knowledge-on-Medical-Assistance-in-
Dying-for-Mature-Minors.pdf (accessed 11 January 2021).
137 Federal Government of Canada, Department of Health, ‘First annual report on Medical
Assistance in Dying in Canada 2019’, published July 2020, available on https://
www.canada.ca/en/health-canada/services/medical-assistance-dying-annual-
report-2019.html (accessed 15 July 2021).
138 Federal Government of Canada, Department of Health, ‘Second annual report on
Medical Assistance in Dying in Canada 2020’, published June 2021, available on
https://www.canada.ca/content/dam/hc-sc/documents/services/medical-
assistance-dying/annual-report-2020/annual-report-2020-eng.pdf (accessed 15
July 2021).
139 Pereira, J., ‘Legalizing euthanasia or assisted suicide: the illusion of safeguards and
controls’, National Center for Biotechnology, 2011, available on www.ncbi.nlm.nih.
gov/pmc/articles/PMC3070710/ (accessed 20 January 2021).
140 The Daily Mail, ‘Don’t make our mistake: As assisted suicide bill goes to Lords, Dutch
watchdog who once backed euthanasia warns UK of ‘slippery slope’ to mass deaths’,
9 July 2014, available on https://www.dailymail.co.uk/news/article-2686711/
Dont-make-mistake-As-assisted-suicide-bill-goes-Lords-Dutch-regulator-backed-
euthanasia-warns-Britain-leads-mass-killing.html (accessed 20 January 2021).
141 Cf. section 5, as well as, inter alia, Pereira, J., ‘Legalizing euthanasia or assisted suicide:
the illusion of safeguards and controls’, National Center for Biotechnology, 2011,
available on www.ncbi.nlm.nih.gov/pmc/articles/PMC3070710/ (accessed 20
January 2021).
142 Vanopdenbosch, L., Letter to the President of the Belgian Parliament, 2017, available
on https://www.ieb-eib.org/ancien-site/pdf/20180226-vanopdenbosch.pdf
(accessed 22 January 2021 – quote translated from Dutch.).
143 Quotes literally taken from Dr Rubben’s interview, in his capacity as former member
of the Control Commission, on the Belgian prime-time magazine ‘Panorama’ on 30
September 2020, hosted by the Official Public Belgian channel Vlaamse Radio- en
Televisie (VRT), available on https://www.vrt.be/vrtnws/nl/2020/09/30/pano-
onrust-om-euthanasie/ (accessed 21 January 2021 – quotes translated from
Dutch).
144 Raus, K., Vanderhaegen, B. and Sterckx, S., ‘Euthanasia in Belgium: Shortcomings of
the Law and Its Application and of the Monitoring of the Practice’, The Journal of
Medicine and Philosophy, Volume 46, Issue 1, February 2021, pp. 80-107, spec. p. 95.
145 Knack Magazine, ‘Marc Cosyns : Ik doe geen euthanasie meer’, 5 February 2014,
available on https://www.knack.be/nieuws/gezondheid/marc-cosyns-ik-doe-
geen-euthanasie-meer/article-normal-127433.html (accessed 22 January 2021).
146 Vermeer, E., ‘Apaiser en fin de vie’, European Institute of Bioethics, Dossier, 2015,
available on www.ieb-eib.org/fr/dossier/fin-de-vie/soins-palliatifs/apaiser-la-
douleur-en-fin-de-vie-402.html (accessed 21 January 2021).
147 Ibid.
148 National Institute of Nursing Research (U.S.), ‘Palliative care, the relief you need when
you’re experiencing the symptoms of serious illness’, available on www.ninr.nih.
gov/newsandinformation/publications/palliative-care-relief-for-serious-illness
149 Widdershoven, G., ‘Beyond Autonomy and Beneficence; The Moral Basis of Euthanasia
in the Netherlands’, Maastricht University, available on https://pubmed.ncbi.nlm.
nih.gov/15712440/ (accessed 24 January 2021).
150 The Telegraph, ‘Netherlands sees sharp increase in people choosing euthanasia due
to mental health problems’, 11 May 2016, available on https://www.telegraph.
co.uk/news/2016/05/11/netherlands-sees-sharp-increase-in-people-choosing-
euthanasia-du/ (accessed 21 January 2021).
151 The Catholic Herald, ‘Relaxation of Dutch rules opens euthanasia to dementia sufferers’,
12 January 2016, available on www.catholicherald.co.uk/news/2016/01/12/
relaxation-of-dutch-rules-opens-euthanasia-to-dementia-sufferers (accessed 19
January 2021).
152 Survivors of Bereavement by Suicide, ‘How suicide affects others’, available on www.
uksobs.org/we-can-help/suicide-bereavement/how-suicide-can-affect-you/how-
suicide-affects-others/ (accessed 19 January 2021).
153 French Conseil d’Etat Ruling, Commune de Morsang-sur-Orge et Ville d’Aix-en-Provence,
27 October 1995, available on https://www.conseil-etat.fr/ressources/decisions-
contentieuses/les-grandes-decisions-du-conseil-d-etat/conseil-d-etat-27-octobre-
1995-commune-de-morsang-sur-orge-et-ville-d-aix-en-provence (accessed 25
January 2021).
154 Not Dead Yet, ‘Not Dead Yet UK launches The Resistance Campaign’, 2010, available
on www.notdeadyet.org/2010/06/not-dead-yet-uk-launches-resistance.html
155 Somerville, M, ‘Euthanasia would hurt doctors and society’, The Nathaniel Centre,
available on http://www.nathaniel.org.nz/bioethics-politics-and-slovenly-
language-lessons-from-history/16-bioethical-issues/bioethics-at-the-end-of-
life/214-euthanasia-would-hurt-doctors-and-society (accessed 25 January 2021).
See also The Ottawa Citizen, ‘Physician-assisted dying will hurt medical profession,
ethicist argues’, 4 February 2016, available on https://ottawacitizen.com/news/
politics/physician-assisted-dying-will-hurt-medical-profession-ethicist-argues
156 Boer, T., ‘Dutch Experiences on Regulating Assisted Dying’, Catholic Medical Quarterly,
2015, available on http://www.cmq.org.uk/CMQ/2015/Nov/dutch_experiences_
on_regulating.html (accessed 21 January 2021).
157 Trachtenberg, A.J., ‘Cost analysis of medical assistance in dying in Canada’, Canadian
Medical Association Journal, 2017, available on https://pubmed.ncbi.nlm.nih.

gov/28246154/ (accessed 25 January 2021).
158 Ibid.
159 Not Dead Yet, ‘Not Dead Yet UK launches The Resistance Campaign’, 2010, available
on www.notdeadyet.org/2010/06/not-dead-yet-uk-launches-resistance.html

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The Legalization

Jean-Paul Van De Walle

©2022 ADF International. All rights reserved.

Jean-Paul Van De Walle serves as legal counsel, Europe, for ADF

This is an updated version (July 2021) of the White Paper originally

3) Overview of Laws and Current Proposals.......................................15

4) Legal Competences in the Area of Euthanasia..............................19

5) Examples of Countries Where Euthanasia has been

7) Refuting the Main Arguments for Legalizing Euthanasia..........51

(1) It first clarifies the terminology used.

(2) Second, it gives a short overview of current legislation and

(3) Third, it determines to whom belongs the legal competences

(4) Fourth, it illustrates with national experiences in Belgium, the

(5) Fifth, it shows how the legalization of euthanasia inevitably leads

(6) Sixth, it outlines and answers the main arguments in favour of

A. Euthanasia – Active and passive

Euthanasia can be commonly defined as ‘every act or omission that, as

B. Euthanasia – Voluntary, non-voluntary, and involuntary

Non-voluntary euthanasia is sometimes used to refer to situations

C. Euthanasia and (medically assisted) suicide

Suicide is commonly understood as being the act by which

D. Sedation – From intermittent to terminal

Euthanasia has to be carefully distinguished, both from a medical and

patient’s suffering while respecting the natural process that leads to

E. Euthanasia and (aggressive life-sustaining) treatment

A treatment is aimed at relieving the patient condition. Aggressive life-

Likewise, the reasonably made decision to stop existing therapeutic

The national parliaments of three countries8 have adopted a law

paradoxically, also state: ‘A patient’s request for euthanasia is to be

C. Rest of the world

Colombia legalized euthanasia (2015)24 long after the practice was

D. Recent legislative proposals and ongoing debates in Europe

nevertheless tabled (201732 and 202033) regarding the recognition of a so-

In light of the most recent developments in Europe, seemingly disclosing

expression of an alleged ‘right to self-determination’ or motivated by an

No international institution is competent to legislate on the matter of

The International Covenant on Civil and Political Rights (ICCPR), Article

Alongside the absence of a ‘right to die’ within international treaties,

B. The European Union

Article 2 of the Charter of Fundamental Rights of the European Union

Union action shall respect the responsibilities of the Member

This excludes the possibility of harmonizing national legislation in the

C. Parliamentary Assembly of the Council of Europe

In 1999 the Parliamentary Assembly of the Council of Europe, comprised

The World Medical Association (WMA) has consistently and categorically

Euthanasia, that is the act of deliberately ending the life of a

Physicians-assisted suicide, like euthanasia, is unethical and

The World Medical Association reaffirms its strong belief that

The World Medical Association strongly encourages all

The WMA reiterates its strong commitment to the principles of

For the purpose of this declaration, euthanasia is defined as

No physician should be forced to participate in euthanasia or

Separately, the physician who respects the basic right of the

E. European Court of Human Rights Jurisprudence

Article 2 cannot, without a distortion of language, be interpreted

The Court was also asked to examine whether prohibiting euthanasia

Article 2 of the Convention is first and foremost a prohibition

to withdraw his nutrition and reduce his hydration. The applicants,