Cultural differences affecting euthanasia practice in Belgium: One law but different attitudes and practices in Flanders and Wallonia

Abstract

Since 2002, Belgium has had a national law legalising euthanasia. The law prescribes several substantive due care requirements and two procedural due care requirements, i.e. consultation with an independent physician and reporting of euthanasia to a Federal Control Committee. A large discrepancy in reporting rates between the Dutch-speaking (Flanders) and the French-speaking (Wallonia) parts of Belgium has led to speculation about cultural differences affecting the practice of euthanasia in both regions. Using Belgian data from the European Values Study conducted in 2008 among a representative sample of the general public and data from a large-scale mail questionnaire survey on euthanasia of 480 physicians from Flanders and 305 from Wallonia (conducted in 2009), this study presents empirical evidence of differences between both regions in attitudes towards and practice of euthanasia. Acceptance of euthanasia by the general population was found to be slightly higher in Flanders than in Wallonia. Compared with their Flemish counterparts, Walloon physicians held more negative attitudes towards performing euthanasia and towards the reporting obligation, less often labelled hypothetical cases correctly as euthanasia, and less often defined a case of euthanasia having to be reported. A higher proportion of Flemish physicians had received a euthanasia request since the introduction of the law. In cases of a euthanasia request, Walloon physicians consulted less often with an independent physician. Requests were more often granted in Flanders than in Wallonia (51% vs 38%), and performed euthanasia cases were more often reported (73% vs 58%). The study points out some significant differences between Flanders and Wallonia in practice, knowledge and attitudes regarding euthanasia and its legal requirements which are likely to explain the discrepancy between Wallonia and Flanders in the number of euthanasia cases reported. Cultural factors seem to play an important role in the practice of (legal) euthanasia and the extent to which legal safeguards are followed.

Introduction

Cultural differences can be an important factor explaining differences in the health behaviour of patients as well as of physicians (Kawamura et al., 2000, Mitchell, 1998, Perkins et al., 2002, Stromgren et al., 2004, Vincent, 2001). Physicians’ compliance with health care guidelines or regulations is for instance susceptible to cultural values. Belgium makes an interesting case in this respect. The country consists of two culturally different regions: Flanders, the northern Dutch-speaking part making up 56% of Belgium’s population, and Wallonia, the southern French-speaking part (33% of Belgium’s population), with the first historically more related to the Germanic culture within Europe and the latter more to the Latin culture within Europe. With the political crisis the country has been undergoing for several years in which the political representatives of its two major language communities are failing to achieve political unity, the perception about the significance of these cultural differences is peaking (Arnoudt, 2006, Reigrotski and Anderson, 1959). These stereotypical differences are a lot less pronounced in actual empirical research findings (Billiet et al., 2006, Coffé, 2005, Dobbelaere, 2003).

In the medical field, particularly with regard to end-of-life care, differences between regions have been subject to speculation about their relationship to differences between cultures (De Bondt et al., 2008, Smets et al., 2010, Smets et al., 2011). This speculation is reinforced by the fact that, while various aspects of health care are a federal i.e. national matter, Wallonia and Flanders have autonomous responsibility for various organisational health care matters such as health promotion and prevention, aspects of care for older people, home care and coordination and collaboration in palliative care (Corens, 2007). The ministries of health of the different regions and communities decide on the amount of subsidy given to home care and services and to health promotion, prevention and education and they also supervise and regulate these matters.

In regard to the practice of euthanasia – which is legal in Belgium and subject to legal safeguards – there are particularly strong reasons to suspect cultural differences between Flanders and Wallonia. The euthanasia law in Belgium specifies several substantial due care criteria (e.g. unbearable suffering without prospect of improvement, explicit and repeated requests) which have to be met in order for euthanasia to take place as well as two procedural due care requirements: a second independent physician has to be consulted beforehand to evaluate whether the euthanasia request of the patient can be granted and, once performed, the euthanasia case has to be reported to the Federal Control and Evaluation Committee for Euthanasia (Smets et al., 2008). It has been found that only 17% of the euthanasia cases reported to the Committee had come from French-speaking physicians (Smets et al., 2010). While some have concluded from this that euthanasia is actually a much more frequent practice in Flanders, it is also often assumed that this very large difference does not, in fact, reflect a very large difference in actual practice but rather a reluctance to report euthanasia cases. However, other studies indicate a tendency towards more performance of euthanasia by Flemish (Dutch-speaking) physicians and more continuous deep sedation by French-speaking physicians (Chambaere et al., 2010, Van den Block et al., 2009). Patients in the French-speaking community also receive life-prolonging treatment more often (Van den Block et al., 2009). While the statistical power of some of these studies is insufficient to warrant strong conclusions, they seem to suggest that differences in reporting rates may indeed be due partly to actual differences in the extent to which euthanasia is performed.

It seems interesting, however, to also examine whether different attitudes and approaches between Dutch- and French-speaking physicians exist towards the procedural due care criteria included in the law, such as the mandatory requirement beforehand to involve a second independent consulting physician to ascertain that the substantial due care criteria are met (e.g. request etc), and the mandatory requirement afterwards to report a case of euthanasia to the Committee. The legalisation of euthanasia in 2002 was particularly endorsed in Flanders, which can – speculatively – be attributed to the fact that the Flemish are culturally closer to the Germanic culture of the Dutch making it easier to adopt a similar legalisation. Examining differences in practices and attitudes regarding euthanasia and the euthanasia law between Flanders and Wallonia could therefore also provide useful insights into the question to what extent euthanasia legalisation is culturally transferable.

This article tries to present empirical evidence from several data collections concerning differences in attitudes to and practice of euthanasia. It will address the following questions:

• do attitudes towards euthanasia in the general population differ between Wallonia and Flanders?

• do attitudes towards euthanasia and towards the procedural due care requirements of the euthanasia law differ between physicians from Wallonia and Flanders?

• do Walloon physicians receive fewer euthanasia requests from their patients?

• do Flemish and Walloon physicians deal differently with euthanasia requests, and if they grant a request do they respect the procedural due care requirements (i.e. consulting an independent second physician and reporting the euthanasia case) differently?

• do Walloon and Flemish physicians have a different understanding of euthanasia and of the obligation to report?