In is morally worse than for adults

In 2016, Belgium had its
first child euthanization, only two years after passing a law allowing it. In
December 2013 the Belgian Senate and in February 2014 the Belgian Chamber of
Representatives voted in favour of extending the legislation to minors, making
it the first euthanasia legislation in the world that does not specify any age
limit. The conditions of the euthanasia law for minors are more restrictive:
The young patient’s ailment must be incurable and caused by accident or
illness; the suffering must be physical (rather than mental) and impossible to
alleviate; the expectation of death must be short term; consent of the legal
representatives (often the parents) is required; and the youth psychologist or
psychiatrist must determine that the patient is capable of discernment. There
are three types of opponents of the extension of the euthanasia legislation to
minors. First, some believe that euthanasia is morally impermissible in general
and that lifting age restrictions just extends a morally reprehensible
practice. I will not deal with arguments against euthanasia in general here.
Second, some believe that euthanasia for minors is morally worse than for
adults and hence legislation should not be extended to minors. We find this
position represented in the popular press and in an Open Letter signed by
Belgian paediatricians. I identify five arguments in support of this position
and show that these arguments do not have much force. Third, some wish to
retain the age restriction and keep the issue maximally out of the public
debate, while hospital ethics boards should deal with requests from minors and
exercise discretion. This position is represented in press 3 interviews with Dr
Marleen Renard, an oncologist in the University Hospital in Leuven (Belgium),
and in an Opinion Text of a working group of the University Hospital of Leuven.
David Velleman has defended a similar policy for euthanasia in general in his
seminal article ‘Against the Right to Die. I show that Velleman’s argument
against legalising euthanasia has more traction for minors than for adults and
can provide qualified support for retaining the age restriction in the
legislation while letting ethics board exercise discretion in rare cases,
though the costs of this position remain substantial.

One argument that
euthanasia for minors is morally worse than adults is that minors should not be
asked to make decisions in matters as weighty as euthanasia. . This
argument has rhetorical appeal, but it does not cut much ice. Consider the
decision to withhold or withdraw treatment from a terminally ill minor when the
benefit is minimal and the treatment is burdensome. This is also a weighty
decision—maybe not as weighty as a euthanasia decision, but certainly much more
weighty than voting or buying cigarettes and alcohol. Nonetheless, minors are
very much involved in such decisions. This involvement is justified on grounds
of a right to determine what happens in and to one’s body, which underlies the
2002 Law on Patient Rights in Belgium and in other legislations6. Hence,
considering current legal practice, the sheer weightiness of a decision is not
enough of a reason to take it out of the hands of minors. We do not let minors
vote or buy cigarettes and alcohol. Why should we let them make decisions about
matters of life and death?

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Parents and guardians
will pressure minors in more or less subtle ways into making euthanasia
decisions to find relief from their own emotional or financial needs. A second
line of argument is that adolescent minors are not capable ofdiscernment
because they make decisions on ground of norms that are handed downfrom their
parents and have not been subjected through a process of critical scrutiny. Young
adults typically come to form an identity with respect to world views in their late
teens and early twenties. It is only at this later stage that they subject
norms from parents and loved ones to critical scrutiny and come to act from a
more deeply held

conception of the good. However,
condition on capability of discernment, i.e. authorship over one’s decisions,
should not be confused with identity formation and critical scrutiny. Critical
scrutiny of norms is not required for authorship of one’s decisions and is not

what makes an end-of-life
decision authoritative. If a minor who grows up in a

socially conservative
home adopts her parents’ anti-euthanasia values, without

subjecting them to much
critical scrutiny, then we would be respectful of her rejection

of euthanasia in favour
of palliative care. So why should we not be equally respectful

of a euthanasia request
from a minor who grew up in a humanist home, even if she

has not had the
opportunity to subject her values to much critical scrutiny? Critical

scrutiny is a Socratic
ideal that, arguably, is constitutive of a life that is lived well, but

it is not an aspect of
capability of discernment in virtue of which decisions are to be

considered authoritative.

For a euthanasia request
to be granted an assessment is required that the minor is capable of
discernment. But minors are not capable of discernment. If medical care is

socialised then a child’s
illness is typically less of a financial drain on a parent,

whereas the cost of a
parent’s care facilities chip away from an inheritance. Third, a

third party might reason
that the elderly have had their fair innings, whereas a child

has seen so preciously
little of life. For all these reasons, I would expect pressure on the elderly
towards euthanasia to be greater than on minors. Furthermore, with sufficient
oversight one would also expect that the medical team would be able to recognise
whether a minor is being pressured or not and block the euthanasia request on
these grounds. A minor will opt for euthanasia due to her sensitivity, i.e. her
desire to satisfy expectations from parents who can no longer bear the
situation. Euthanasia for minors is unnecessary: Physical
suffering at the end of life can always be made bearable by means of palliative
care; Requests for euthanasia come about due to poor palliative care. Opponents
of the extension of the euthanasia legislation in Belgium argue that euthanasia
for minors is worse than euthanasia for adults because such end-of-life decisions
are too weighty for minors, because they are not capable of discernment,

because they will be
subject to pressure, because they are particularly sensitive, or

because there is
sufficient palliative care for them. None these arguments provide

sufficient reason to
refrain from extending euthanasia legislation to minors.

Overall, all of the lines
of arguemtn go in hand for with one another There is another line of
argumentation in the Belgian debate: We should not

extend legislation to
minors but we should deal with individual requests in ethics

boards who may grant requests
in particular cases even if this contravenes the age

restriction. Velleman
provides a utilitarian argument to the same effect for euthanasia

in general based on the
fact that less choice may be better than more given particular

preference structures. As
utilitarian arguments go, it is not easy to balance the costs and benefits of this
position. The position has more traction for minors than for adults due to the
low

number of requests and
the greater acceptance of fiduciary decision making for

minors and hence it can
provide some qualified support for not extending the

legislation to minors.
The costs remain substantial though, viz. the legal uncertainty,

the accountability of
ethics boards, the variability in their decisions, and the lack of

transparency of
procedures when there is no public discussion