Deliberately taking a small child's life is unlawful everywhere in the world, even when the child is terminally ill and asks a doctor to end his or her suffering once and for all.
There is an exception to this rule: Belgium. In 2014, that country amended its law on euthanasia, already one of the most permissive in the world, authorizing doctors to terminate the life of a child, at any age, who makes the request.
For a year after the law passed, no one acted on it. Now, however, euthanasia for children in Belgium is no longer just a theoretical possibility.
Between Jan. 1, 2016, and Dec. 31, 2017, Belgian physicians gave lethal injections to three children under 18, according to a July 17 report from the commission that regulates euthanasia in Belgium.
The oldest of the three was 17; in that respect, Belgium was not unique, since the Netherlands permits euthanasia for children over 12.
Belgian doctors, however, also ended the lives of a 9-year-old and an 11-year-old. These were the first under-12 cases anywhere, Luc Proot, a member of the Belgian commission, told me in an interview.
Everywhere else in the world, the law reflects powerful human intuitions, moral and practical: that it is wrong to abandon hope for a person so early in life, no matter the illness; that it is absurd to grant ultimate medical autonomy to someone too young to vote or legally consent to sex; and that even the best-intentioned fallible human beings should not be entrusted with such life-and-death power.
In Belgium, a kind of libertarian technocracy has conquered these qualms. Euthanasia advocates insist that some children, even very young ones, may possess the same decisional capacity as some adults, and it's therefore discriminatory to deny them the freedom to choose euthanasia based on an arbitrary age limit.
Meanwhile, Belgian law trusts experts to prevent mistakes or abuses. Doctors must verify that a child is "in a hopeless medical situation of constant and unbearable suffering that cannot be eased and which will cause death in the short term." After a child makes his or her wish for euthanasia known, in writing, child psychiatrists conduct examinations, including, Proot told me, intelligence tests, to determine that the youngster is capable and "not influenced by a third party." Parents can, however, prevent the request from being carried out.
Once any euthanasia - for a child or an adult - has occurred, a six-member commission examines the case file to make sure everything was done properly.
Medical privacy, however, limits what the commission can review. Names of patients and doctors are redacted. If concerns about the lawfulness of a procedure arise, the commission can vote to look at identifying information, but this rarely happens. (Most of Belgium's 4,337 euthanasias in 2016-2017 involved adults with cancer.) The commission's public reports contain mainly overall statistics, with limited details of individual cases.
We do know the 11-year-old euthanized last year had cystic fibrosis. This congenital respiratory disease is incurable and fatal, but modern treatments enable many patients to enjoy high quality of life well into their 30s or even beyond. Median life expectancy for new CF cases in the United States is now 43 years, according to the Cystic Fibrosis Foundation.
Proot assured me that everything was in order, not only with the 11-year-old's case but also with the other two: a 17-year-old with Duchenne muscular dystrophy and a 9-year-old with a brain tumor. "I saw mental and physical suffering so overwhelming that I thought we did a good thing," he told me.
Proot was of course relying on reports by the anonymous physicians who participated in the euthanasias, and we, in turn, must take Proot at his word: Journalists and other members of the public are not permitted to review the case files independently, even in redacted form.
What, exactly, convinced doctors that these children's cases were hopeless, that their deaths were imminent - and that the kids fully understood not only euthanasia but also the treatment options that might have alleviated their condition?
Such questions seem especially pertinent for Belgium, given the problems it has experienced since legislators allowed euthanasia for patients with cognitive and psychiatric illnesses, such as dementia, depression or schizophrenia, even if they have no terminal physical ailment.
Last year, a member of the euthanasia commission resigned in protest because it refused to recommend prosecution when a woman with dementia who had not requested euthanasia was nevertheless put to death at her family's request.
Since then, 360 Belgian doctors, academics and others have signed a petition calling for tighter controls on euthanasia for psychiatric patients.
For now, however, the policy remains the same, and the Belgian public's support for euthanasiaremains undiminished. The precedent for euthanizing children has been established, and more will almost certainly receive lethal injections this year, next year and the year after that.