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Euthanasia embedded in palliative care. Responses to essentialistic criticisms of the Belgian model of integral end-of-life care
  1. Jan L Bernheim,
  2. Kasper Raus
  1. End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussel, Belgium
  1. Correspondence to Professor Jan L Bernheim, End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Louisastraat 24/32, Oostende 8400, Belgium; jan.bernheim{at}


The Belgian model of ‘integral’ end-of-life care consists of universal access to palliative care (PC) and legally regulated euthanasia. As a first worldwide, the Flemish PC organisation has embedded euthanasia in its practice. However, some critics have declared the Belgian-model concepts of ‘integral PC’ and ‘palliative futility’ to fundamentally contradict the essence of PC. This article analyses the various essentialistic arguments for the incompatibility of euthanasia and PC. The empirical evidence from the euthanasia-permissive Benelux countries shows that since legalisation, carefulness (of decision making) at the end of life has improved and there have been no significant adverse ‘slippery slope’ effects. It is problematic that some critics disregard the empirical evidence as epistemologically irrelevant in a normative ethical debate. Next, rejecting euthanasia because its prevention was a founding principle of PC ignores historical developments. Further, critics' ethical positions depart from the PC tenet of patient centeredness by prioritising caregivers' values over patients' values. Also, many critics' canonical adherence to the WHO definition of PC, which has intention as the ethical criterion is objectionable. A rejection of the Belgian model on doctrinal grounds also has nefarious practical consequences such as the marginalisation of PC in euthanasia-permissive countries, the continuation of clandestine practices and problematic palliative sedation until death. In conclusion, major flaws of essentialistic arguments against the Belgian model include the disregard of empirical evidence, appeals to canonical and questionable definitions, prioritisation of caregiver perspectives over those of patients and rejection of a plurality of respectable views on decision making at the end of life.

  • End of Life Care
  • Euthanasia
  • Palliative Care
  • Right to Refuse Treatment
  • Prolongation of Life and Euthanasia

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  • Contributors JLB conceived the problem statement, the general structure of the paper and did most of the writing. KR contributed ethical sections, reviewed successive versions and participated in the writing.

  • Funding KR was funded by the Ghent University Research Fund.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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