• Euthanasia
• Palliative Care
• Children
• Informed Consent

In his article, ‘Child Euthanasia: Should We Just Not Talk about It?’, Luc Bovens argues that if we accept euthanasia for adults, we should also accept voluntary euthanasia for children.1 Bovens examines five arguments against extending euthanasia to minors and finds each of them wanting.2

First, the argument from weightiness notes that we do not let minors vote, buy cigarettes or alcohol. A fortiori, we should not let them make even more serious decisions, such as whether to live or to die.

Bovens finds this argument deficient since children are already involved in decisions about whether to withdraw or not to begin life-sustaining treatment. ‘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 legislations’.1

What does ‘involvement’ mean here? It is one thing to allow minor patients to remove what they consider to be burdensome treatment. It is another thing entirely to hold that minors may give informed consent to authorise someone to intentionally kill them. Unless we presuppose that discontinuing a medical treatment (even a life-supporting one) is ethically the same as intentional killing (begging a major question in the euthanasia debate), we can recognise that allowing minors to make a decision about continuing treatment is consistent with not allowing minors the choice to kill.

Second, Bovens takes up the argument from capability of discernment. A minor seeking euthanasia is incapable of giving informed consent because minors lack the capability of discernment, the ability to make authoritative decisions. But if informed consent cannot be obtained, then voluntary euthanasia for minors is impermissible.

Bovens rejects this argument as well, ‘I propose that what makes a decision authoritative is (1) that the decision is responsive to reasons and (2) that the agent is the author of her decision, that is, she does not relinquish responsibility and defer the decision to others’.1 If someone is capable of being responsive to reasons and being the author of his or her own decisions, this person is making authoritative decisions, giving informed consent. True, minors may typically have decision-making styles that differ from most adults in being more emotional and impulsive. Yet, an impulsive decision may very well be reason-responsive in a way that a calmly deliberated decision is not.

This construal of informed consent surely proves too much. Even very small children, say 6 year olds, can be responsive to reasons, ‘Don't turn on the T.V. very loud because mommy's trying to sleep’. Even very small children consider themselves to be the authors of at least some of their decisions. ‘I did it myself!’ says the preschooler of his colour crayon rainbow drawing.

In response, a defender of euthanasia for children might argue that preschoolers can make decisions responsive to reasons about drawing or turning off the TV, but they cannot make decisions responsive to reasons about more weighty matters, such as deciding for euthanasia.

The weightiest decision of all is the choice to die. Virtually all other choices may be reversed or mitigated. If Bovens is right about minors being capable of making authoritative decisions including the choice to die, then minors should also have rights to vote, to join military service, to receive the same punishment as an adult for the same crime, have sexual intercourse with whomever they choose and drop out of school when they decide to do so. This is hard to believe.

Third, Bovens considers the argument from pressure. Parents, guardians and perhaps siblings or others can apply psychological pressure on minors so that they decide for euthanasia. These parents, guardians and others may be seeking to alleviate their own emotional suffering, financial pressure and time constraints pressuring a sick child to choose euthanasia.

Bovens finds fault with this argument for a variety of reasons:First, parents typically cling more to the lives of their children than adult children to the lives of their parents. Second, 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.1

The supposition is that the argument from pressure applies more to adults than it does to children. If euthanasia is permissible for adults, despite likely greater risks of pressure, it should also be licit for minors, given likely lower risks of pressure.

Bovens’ response to the argument from pressure captures some but not all cases. The particularities of parent–child pressure dynamics admit a wide range of variance. A child's illness is not always less of a financial drain than a parent's illness. The expense of an illness depends more on the kind of illness than the age of the patient. Third, a sick child who might otherwise live has a greater need for euthanasia than an elderly person who will die typically sooner. This reasoning would lead to greater pressure on minors than on the elderly.

This brings us to the fourth objection, the argument from sensitivity. Rather than making a free, autonomous decision, minors will likely want to satisfy what they rightly or wrongly view as the expectation of parents. Even if pressure is not explicitly put on children to authorise someone to intentionally kill them, children may very well feel a greater sensitivity to the sufferings of their parents, and hope to relieve this suffering by authorising voluntary euthanasia.

According to Bovens, the argument from sensitivity also fails because minors are less likely than adults to be pressured, and so there is less to engage their sensitivities. Indeed, minors may choose palliative care because they are more sensitive to how hard it typically is for parents to see their children die.1

Bovens overlooks that even a small amount of pressure by an authority figure will typically have disproportionate actual force on any child, particularly a sick child. Some parents will exert pressure on a sick and sensitive child in order to make their own lives easier. Children rightly merit extra protection because they are generally more sensitive than adults.

Finally, Bovens considers the argument from sufficient palliative care. According to this view, euthanasia is unnecessary for minors because the physical and mental sufferings that a minor may undergo at the end of life can be alleviated by palliative care rather than intentional killing.

Bovens responds, quite rightly, that if palliative care is effective, then this argument applies to both minors and adults. So, this argument is not really about child euthanasia specifically but euthanasia as such.

Bovens goes on to say, ‘legalisation of euthanasia will provide the proper incentive structure for its opponents. They will need to make the kind of palliative care that can alleviate the suffering accessible and affordable to minors, lobby the health sector, and educate palliative care providers in hospitals and hospice care’.1 If euthanasia is an option, opponents of euthanasia have extra incentive to ensure better palliative care.

Everyone agrees that the suffering should be alleviated. We do not now know the long-term effects of legalisation of palliative care. Arguably, however, if euthanasia is legal, it is the advocates of euthanasia who would have extra incentive to secure more effective palliative care. Doctors who kill their patients rather than relieving their pain have less incentive to learn about and less practice in administering palliative care. This relative lack of expertise adversely affects the majority of dying patients who do not choose euthanasia. The legalisation and use of euthanasia also deflates the incentives for investing money and effort into increasing the quality of palliative care. The more people who choose euthanasia instead of palliative care, the smaller is the market for palliative care. Once there is a legal option for ending pain other than palliative care, the pressure from patients, families and doctors to improve palliative care is lessened. Finally, legalised euthanasia may dampen sympathy for many patients suffering at the end of life. Some people may think, ‘She had a way out of this suffering, but she refused euthanasia. Her suffering is self-inflicted. Why should I feel sorry for her? Why should I make efforts to alleviate her suffering when she refuses to end her own suffering?’ In the event of legalisation, it is not opponents of voluntary killing but advocates of euthanasia who would have special responsibilities to improve palliative care.