Ethics of terminal care come under focus in Belgium

Raymond Rouelle was dying. Of that there is no disagreement. But, to the horror of his family, the manner of his death, a few days after being hospitalised for the last time, has led to the controversial arrest and charging of two Liege doctors with intentional homicide.

The arrests, the result of an anonymous tip-off to the prosecuting authorities from a hospital worker, have set in train a trail of events that Rouelle's son, Raymond, says has robbed his father's death of the quiet dignity he so wanted and traumatised the grieving family.

They have also cast a shadow over the debate in Belgium over the ethics of terminal care at a time when Parliament is debating the legalisation of active euthanasia. The case will focus attention on the ambiguities in the grey area between the morally and legally acceptable withdrawal of needless medical care and the illegal act of positive intervention to end the life of a patient.

It must also raise serious questions about the appropriateness of the application of the criminal law of murder to complex medical ethics dilemmas.

Rouelle had only days to live when they brought him to the hospital of La Citadelle in Liege in early January. His irreversible pulmonary fibrosis meant he could no longer breathe independently and intubation to a ventilator would be necessary to prolong his life, largely in what his family would describe as a "medically induced coma".

A feisty former legionnaire, Rouelle had on many occasions made clear to his family and the medical team that he did not want to be kept alive artificially. Now his life was wholly dependant on a machine.

With speech impossible, Rouelle scrawled a few ambiguous words to his son which the family see as a final plea to be allowed to die with dignity. But the decision would be one by the medical staff a few days later.

Intubation was not making him any better. Attempts to reduce the level of breathing support simply led to dangerous falls in the level of oxygen in his blood. The time had come, the doctors agreed, to end active medical intervention.

But it was not simply a question of switching off the ventilator. The doctors decided that in order to reduce the likelihood that the cut-off of air would result in the dying body involuntarily thrashing about, they would administer morphine and barbiturates to ease the process. The ventilator tube was also removed.

Rouelle died peacefully and was buried by a family which expressed their relief that he had not suffered any longer.

Within days, however, a massive police investigation was under way and 48 hours later the two doctors were arrested and charged.

To compound the family's agony, the story was leaked inaccurately by the anonymous informer to the local paper, La Meuse. According to its front page headline, Rouelle had been assasine, and, inside, the paper insisted that the doctors had in error killed the wrong patient, despite denials from the family.

The latter have been further distressed by an exhumation during which Rouelle's son-in-law had to assist in transferring his body from a broken casket into a new coffin.

The doctors' medical colleagues have been outraged by the arrests, insisting that the two men followed standard procedures.

But among some of the attending nurses there are clearly mixed feelings. More than one described to police one of the two doctors as arrogant and "playing God". They say they had never before seen extubation carried out in such haste and express concerns that the injections may have crossed the line between withdrawal of care and active euthanasia.

The hospital's director of medicine, Dr Christian de Landsherre, backs the doctors, vehementlty insisting that homicide charges are deeply inappropriate. But he acknowledges communication failures between the doctors and nurses and admits that the hospital must learn from the controversy the importance of extensive internal "debriefing" and discussion after all such cases.

The Liege prosecutor is adamant, however, that even if euthanasia had been legalised in the form being discussed she would still have prosecuted the doctors. Rouelle, she says, could have survived for a significant period and the doctors could not demonstrate that they had acted out of the "necessity" that the law requires. Dr Francois Damas, the doctors' departmental head, warns that there is a danger some doctors will react to the charges by arguing that because of the legal uncertainty they can no longer manage the dying process. "My only response," he says, "is to continue to do as we have done, the best we know how."

The problem, he argues, is that they are operating in a period of legal flux. The concept of euthanasia is clear, he says, as is the obligation on doctors not to prolong life needlessly. "But I don't believe there are clear frontiers between the two. My fear is that the judicial authorities came into an area that they only know about in a theoretical way."

Another doctor contacted by The Irish Times argues that, ironically, the problem the doctors now face stemmed from the initial decision to intubate. Failure to do so in a case of advanced fibrosis would be normal and perfectly ethical. Reversing the process, once undertaken, could and has led into an ethical and legal quagmire.

The prosecuting authorities are criticised for excess of zeal by the philosopher, Dr Edouard Delruelle, an ethicist and member of a government working group on the issue. Their failure to use their discretionary powers, he believes, is not unconnected to the national debate.

As for the Rouelles, they still insist that, to date, they have seen no evidence that would suggest they should lay a complaint against the doctors. They complain bitterly that the authorities' over-reaction has not allowed them to grieve with dignity.