Marije Brouwer, MA,a, b Christopher Kaczor, PhD, c Margaret P. Battin, MFA, PhD, d ShouldEls Maeckelberghe, PhD, Pediatric a John D. Lantos, MD, e Eduard Euthanasia Verhagen, MD, JD, PhDb be Legalized? abstract Voluntary active euthanasia for adults at their explicit request has been legal in Belgium and the Netherlands since 2002. In those countries, acceptance of the practice for adults has been followed by acceptance of the practice for children. Opponents of euthanasia see this as a dangerous slippery slope. Proponents argue that euthanasia is sometimes ethically appropriate for minors and that, with proper safeguards, it should be legally available in appropriate circumstances for patients at any age. In this Ethics Rounds, we asked philosophers from the United States and the Netherlands, and a Dutch pediatrician, to discuss the ethics of legalizing euthanasia for children. Voluntary active euthanasia for to discuss the ethics of legalizing adults at their explicit request euthanasia for children. aInstitute for Medical Education and bDepartment of Pediatrics, University Medical Center Groningen, University has been legal in Belgium1 and the THE CASE of Groningen, Groningen, Netherlands; cDepartment of Netherlands since 2002. Euthanasia, Philosophy, Loyola Marymount University, Los Angeles, voluntary or nonvoluntary, remains California; dDepartment of Philosophy, University of Utah, Salt Lake City, Utah; and eChildren’s Mercy Hospital, Kansas illegal in the United States, although Adults and children of 12 years of City, Missouri several states have legalized age and older can legally request physician-assisted aid in dying for euthanasia in the Netherlands under All authors contributed to the design of this article, the drafting of the manuscript, and the review of adults. No US state permits assisted the 2002 Euthanasia Law. Requests for the manuscript and approved the final version. dying or euthanasia for minors. euthanasia often come from patients DOI: https:// doi. org/ 10. 1542/ peds. 2017- 1343 Opponents of assisted suicide and experiencing unbearable suffering euthanasia often claim that the with no prospect of improvement. Accepted for publication Apr 25, 2017 legalization of such practices for Their requests must be made earnestly Address correspondence to John D. Lantos, MD, competent adults will begin a slide and with full conviction and are only Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: [email protected] down a slippery slope, leading to the honored if patients and their doctors legalization of voluntary euthanasia see euthanasia as the only escape PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). or physician-assisted death for from the situation. Acts of euthanasia patients who cannot consent. are reported to the Ministry of Health Copyright © 2018 by the American Academy of Pediatrics In Belgium and the Netherlands, and are reviewed to ensure that they comply with the law. In addition, since FINANCIAL DISCLOSURE: The authors have acceptance of the practice in adults indicated they have no financial relationships has been followed by acceptance of 2005, neonatal euthanasia for infants relevant to this article to disclose. <1 year of age has been permitted by the practice for children. But is that FUNDING: No external funding. a slippery slope, and is it necessarily a policy known as the 2005 Groningen Protocol. POTENTIAL CONFLICT OF INTEREST: The authors a bad thing? Proponents argue that have indicated they have no potential conflicts of euthanasia is sometimes ethically In the past 10 years, 2 cases of interest to disclose. appropriate and that, with proper neonatal euthanasia were reported, safeguards, access to it should not be and in the last 15 years, 7 cases of To cite: Brouwer M, Kaczor C, Battin MP, et al. limited by age. Others disagree. In this euthanasia in minors between 12 and Should Pediatric Euthanasia be Legalized?. Pedi­ Ethics Rounds, we asked philosophers 18 years old have been reported. The atrics. 2018;141(2):e20171343 from the United States and the majority of cases concerned children Netherlands, and a Dutch pediatrician, with terminal cancer. All cases were Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 141, number 2, February 2018:e20171343 ETHICS ROUNDS retrospectively assessed by a but certain side effect. Although it the end of life, especially those who multidisciplinary review committee is true that increasing the dosage choose not to kill themselves. and considered appropriate. Nobody of the sedatives may be necessary “ ” was prosecuted. over time to continue to relieve Moreover, euthanasia is not properly suffering, relieving suffering in this Dutch pediatricians and several described as relieving suffering. way is ethically permissible, even parent groups have argued that A suffering person who is relieved if death as a side effect occurs. (For severely ill children between 1 and of suffering is in a position to more on why this distinction is 12 years of age and their families are ’ experience the relief of suffering. But legally and ethically important, see denied access to the same provisions Euthanasia Examined a person who is killed is dead, and the legal philosopher John Keown s as newborns and older children so such a person no longer has any , Cambridge without good reason. They suggest bodily experiences. The corpse of a University Press.) reevaluation of the current legal person who has been killed neither situation and propose to extend the All people of good will agree that we feels pain nor the relief of the pain. A newborn regulation to all children should alleviate suffering. It is the corpse feels nothing. Indeed, human who are 1 to 12 years of age. The legalization of euthanasia and its beings who are killed no longer exist Minister of Health is considering expansion to new classes of persons, at all, so euthanasia does not relieve transformation of these propositions not its criminalization, that hampers their suffering. into new regulation. achieving this goal. If we kill patients You are asked to advise the Minister rather than relieving their pain, the Moreover, most philosophers draw practice of euthanasia undermines of Health. What advice would you ’ an important distinction between the practice of palliative care. Why Christophergive? Kaczor, PhD, Comments voluntary and nonvoluntary worry about alleviating someone s euthanasia. In voluntary euthanasia, pain, when we can simply kill the a competent patient chooses to die on person? The more people who the basis of his or her own evaluation I would advise the Minister of Health choose euthanasia and the more of his or her life. In nonvoluntary not to expand the range of cases in euthanasia is nonvoluntarily imposed euthanasia, no such consent is which intentional killing of innocent on patients, the less incentive given. Children <12 years of age are human beings is permitted by law. there is to improve methods of incapable of giving informed consent Defenders of the Dutch law palliative care. The more physicians for meaningful life decisions. For this permitting intentional killing practice euthanasia, the less these reason, we do not permit children of infants as well as adults and physicians practice relieving pain. <12 years of age to consent to their children 12 years of age and older The more people there are who “ own sterilization, to vote in elections, presuppose an empirical claim: die of euthanasia, the fewer people to join the military, to get married, ” ’ killing a person is the only escape there will be who demand greater or to have sexual intercourse. The from the situation of unbearable palliative care. If demand for choice to end one s own life or ’ suffering. This claim is false. Terminal palliative care is dampened, there is to authorize another person to sedation is a contemporary technique less financial incentive for developing end one s own life is much more of palliative care in which a person new methods of alleviating pain. The serious than the choice to join the who was suffering is relieved of pain more euthanasia is expanded, the military, to get married, or to have entirely by the continuous infusion less pressure there will be to improve sexual intercourse because those ’ of sedatives that entirely relieve palliative care, because killing will be decisions can be reversed and do not all pain. Terminal sedation can be seen as a simpler, cheaper option. completely change an individual s administered to infants, children, or Perhaps worst of all, expanding life in every respect. Current Dutch adults who are suffering and cannot the scope of legalized euthanasia law does allow for nonvoluntary be cured of their disease. If we care undermines compassion for those euthanasia of infants, an allowance about suffering people, let us relieve “ who suffer. Some people will think, incompatible with the principles of their suffering rather than killing or even say, Euthanasia is legal, justice because such infants do not them. but this person did not choose it. consent to have their lives ended. If Eventually, terminal sedation leads If she is refusing euthanasia and is all persons are to have equal rights to death. Over time, the dosage of choosing to suffer rather than die, and deserve equal protection of the that is her problem. Why should we law, then disabled persons (whether sedatives must be increased. At a ” certain point, the dosage may be so help her when she is not even helping they are infants, children, or adults) high that the death of the patient herself? Legalizing euthanasia deserve the same basic protections may be foreseen as an unintended endangers and undermines those at from intentional homicide. Downloaded from www.aappublications.org/news by guest on October 2, 2021 2 BROUWER et al Margaret P. Battin, PhD, Comments That allowing this practice would understanding, and the willingness lead to wholesale killing of children to help someone who wishes to avoid My Dear Minister of Health, 1 to 12 years of age.