Dear Sir,

We are delighted that our "Viewpoint regarding medical decisions on the end of life and euthanasia" has attracted your particular attention. We are, therefore, pleased to reply to your comments.

With respect to your first comment: when a physician has conscientious objections to euthanasia, a patient still maintaining his or her request for euthanasia has no other choice than to seek out another doctor. This search is no easy matter for patients who are not so well informed. A free telephone helpline was opened recently with the support of the Belgian government, available for the use of anyone with questions about the end of their life. We believe that a physician with conscientious objections should at least inform the patient of the existence of this helpline in order to avoid the patient being left in the lurch.

With regard to your second comment: in this respect we refer to the text of "Omgaan met euthanasie en andere vormen van medisch begeleid sterven (Dealing with euthanasia and other forms of medically assisted death)", published by the Federatie Palliatieve Zorg Vlaanderen (Flemish Palliative Care Federation) in September 2003:

"Palliative care and euthanasia are neither alternatives nor opposites. When a doctor is prepared to accede to the euthanasia request of a patient who continues to find life unbearable despite the best treatment, then there is no gap between the palliative care given previously by the doctor and the euthanasia he applies now; on the contrary. In such a case, euthanasia forms part of the palliative care with which the doctor and the care team surround the patient and his or her nearest"

Further on in the text, we read:

"Carers can address all their questions regarding the end of life to the palliative teams. Therefore, in the context of a euthanasia request, carers and patients can expect the palliative teams to do more than merely inform them about potential palliative alternatives and palliative support where necessary. Carers and patients can also address themselves to the networks and teams for information and support directly related to euthanasia and the Euthanasia Act. Team doctors can take on the role of the 'other' or 'second' doctor in the euthanasia procedure. However, what can and may not be expected from organised palliative care is that is should adopt the role of the practicing doctor and, in the case in point, carry out the euthanasia in his or her stead. This would be completely in contradiction with the emphasis we wish to place on the continuity of the healthcare and emancipatory concern incorporated into the organisation of Flemish palliative care: the basic principle that organised palliative care exists to informer and to support and not to act in the place of normal healthcare"

Thus the definition of palliative care we use is broader than the dichotomous vision (palliative care versus euthanasia) that you have formulated. It is our belief that more justice can be done to the patient's perception. We are, indeed, entirely aware - more even, we confidently hope - that this vision has a strong influence on all concerned in the field.

With respect to the third comment: when we postulate that euthanasia teams or euthanasia centres are not desirable, it is by no means our intention to make euthanasia part of normal healthcare provision. Also, we certainly do not want to compel anyone with conscientious objections to participate in euthanasia. Precisely to the contrary, we argue for loco-regional agreements to be made in order to seek solutions to situations where a conflict arises between a doctor's conscience and a patient's request for euthanasia. Taking into account the fact that the modalities of this euthanasia request are laid down in a democratically voted law.

With regard to the fourth comment: the "Patients' Rights Act" compels doctors in our country to inform patients fully about all possible therapeutic options. In this situation, the doctor is at liberty to inform the patient of his or her personal moral objections. Thus moral neutrality does not exist in respect of a euthanasia request. However, this gives the doctor at least the right to express his or her opinion on whether he or she believes that the patient's choice is or is not morally acceptable.