Actively assisted suicide

Occasionally, a wish for actively assisted suicide (as differentiated from “indirectly assisted suicide” [symptom and pain-reliving measures which unintentionally lead to death] and “passively assisted suicide” [limiting treatment, resulting in death]) is expressed in concrete situations of dying. While a healthy person cannot imagine herself as bedridden, completely dependent on others, and possibly incontinent, and may see this as incompatible with human dignity, dying people often speak of moments of joy and fulfillment. From the outside, and therefore from the perspective of healthy people, human dignity is seen as synonymous with the preservation of normal bodily functions. In fact, it encompasses much more, as it actually has to do with our spiritual being.

What motives lead to the wish for actively assisted suicide? Based on observation, there are several categories. The first can come about when the diagnosis is given. Some patients have chosen suicide after receiving proof of a liver metastasis. These rare cases point to the importance of the quality of the physician’s delivery when relaying a diagnosis. This conversation must relay the truth, and at the same time bear in mind the patient’s ability to process the news.

As a matter of principle, the delivery of a serious diagnosis should always be accompanied by concrete agreement on a next step, and therefore a helping gesture.

Other patients list complaints such as pain and respiratory distress as reasons for requesting actively assisted suicide. Although this reason has found the most popular resonance and the horrific scenario of pain-tortured, dying patients is often used as an argument for active measures leading to death, it must be made clear that this type of complaint, more than any other, can be relieved with suitable treatment. Therefore, in practice, the wish for actively assisted suicide is almost never expressed for this reason.

A third category relates to the soul experience of the patient. Deep depression, in which the patient doesn’t recognize any other way out, can develop. In such cases, empathetic accompaniment of the patient is especially important, in order to recognize this sometimes hidden inner world in time.

Many patients also express the wish for actively assisted suicide in order to avoid becoming a burden to their relatives and friends. Clearly, as we can see from this wish, illness is not limited to an individual dimension, but rather always affects those around us. They can be helpful and supportive, but also overwhelmed and needy themselves. Often, terminal patients seem to be more advanced in their understanding and processing of the illness than those around them, who frequently demand a “fight” and further oncological treatment.

An especially common reason for the wish for actively assisted suicide is a patient’s experience of the loss of purpose in his life. The patient cannot see any purpose in the limited time left him on earth. One patient with amyotrophic lateral sclerosis, who required outpatient artificial respiration, requested life-sustaining measures until a legally regulated deadline having to do with inheritance concerns was met. Afterward, without any appreciable deterioration of his condition, this patient requested actively assisted suicide.

Reasons for requesting actively assisted suicide

• Loss of purpose: the remaining life is experienced as devoid of meaning
• Becoming a burden to others
• Depression
• Unchecked symptoms (pain, respiratory distress)
• “Hopelessness” of the diagnosis

An increasing narrowing of consciousness lies at the root of suicide: in spite of other perspectives which might relativize this step, the idea of suicide reigns immovable and dominant as the only possible way out. From this perspective, it is not a “free” or autonomously determined deed, as the term “premeditated” suicide suggests, but rather the dictate of a dominant idea. If a person can free herself from this dictate, the perspective will broaden and other possibilities and alternatives will become visible.

This narrowing comes about not only in the world of thoughts, but also in the experience of a situation as unbearable. Perception becomes limited to personal circumstances and loses sight of the people around us who would have to live with the consequences of our suicide or assisted suicide.

CASE STUDY:

An older patient with a very advanced tumour was admitted for hospice care. What he experienced as the hopelessness and burden of symptoms led him to the clearly formulated intention to take his own life. Any urging to examine this intention in a critical light fell on deaf ears. Finally, a nurse confronted him with the question: “Do you know how it will affect your family, and us, if you take your own life?” At a visit soon after, the patient spoke with tear-filled eyes of his father’s suicide, which he had had to live through as a child, and the heavy burden that this event had been his whole life. From then on, the question of suicide was no longer on the table.

In summary, three forces urge toward suicide, death wish and the longing for death. The first is doubt, which cannot see any meaning in the present situation and causes a narrowness of vision that sees suicide as the only option. The second is rejection or even hate toward the present life situation. And finally, anxiety and fear of the expected suffering, which “can only get worse”, urge toward suicide. They narrow human consciousness and lead not to self-determined action (freely chosen suicide), but rather darken the consciousness of judicious individuals, who would otherwise be capable of level headed decision-making.

Just as important as the reasons for wishing for actively assisted suicide, are, on the other hand, the sources that lead to an affirmation of a life full of suffering. Here, observation has allowed us to differentiate between various ways in which patients handle this.

There are patients who develop a sort of surrender or resignation in these outer circumstances, with the feeling, “I have to go through this, so I will.”

CASE STUDY:

A business owner with CUP (cancer of unknown primary origin) was admitted for palliative inpatient care. His family is deeply distressed at the diagnosis and the imminent death, and in its mourning expresses deep gratitude to the husband and father. The patient himself has a determined and decisive personality. In his first appointment, he spoke of an automobile accident in which he, trapped in the car, told the rescue team to free his passenger first, and then himself. He is not affiliated with any religion. The possibility of an afterlife did not lie within his realm of imagination. He prepared to meet his death without clinically remarkable symptoms or recognizable depression, and with the attitude “I have to get through this time.”

In this “surrender”, other patients experience a deep gratitude for the interesting and many-sided life they have lived, or for their relationship to their spouse, which has carried them.

Mention of the suffering caused by suicide to those around one—suffering which sometimes cannot be processed in a lifetime, can also become a source of strength to bear the suffering in one’s destiny. Stable human relationships are essential in this phase, in which a patient often feels helpless, misunderstood and abandoned.

Other patients have access to a second source. They have lived through certain inner, spiritual experiences that make clear the value of the present phase of life with irrevocable certainty.

CASE STUDY:

A patient with metastasized nasopharyngeal carcinoma spoke of her childhood in the former DDR. She described how her childhood pictures of angels “were suddenly taken down” to make way for a “reality-based” life. Now, in the night, she had seen an angelic being, and felt “as if held by powers of good.” A strong sense of security streamed from this experience and accompanied her until her death.

Near-death experiences , which, once experienced, give a deep inner sense of security until death, are also among those that make up this source.

A third important source is deep life convictions and a religious orientation. Here, we can differentiate between theoretical convictions and internalized values. Patients can develop a “healthy intuition” in this situation, which confirms the meaningfulness of this phase of life.
And finally, the active search for meaning represents a fourth source at this time in a patient’s life. In conversation, we can discover how hardly any other phase of life “can allow the truth to emerge.” Everything that is external, inauthentic, and foreign to one’s being falls away bit by bit like sheaths, so that the gaze becomes free to see the true and essential in humanity. “One learns what is truly important in life,” said a 26-year-old patient with an advanced brain tumour. It is a phase of maturing and becoming oneself, which can be crucial both for the individual and for the people around her. One receives the impression that many developmental steps are condensed and conquered almost simultaneously. This also mirrors the beginning of life.

Just as we can marvel at the speed of growth in children’s motor development, language acquisition and development of thinking, which occurs within a timeframe that can never be equalled in adult life, it appears that a concentrated and accelerated development of capacity occurs at the end of life. In addition to increasing physical limitations and care dependency, maturity and individuation develop as deeper purpose in this time of life.

This can lead to an intensely experienced affirmation of the illness. To the extent that this affirmation of the period of illness is found by the individual herself, she acts with self-determination despite outer limitations. Human dignity is immediately perceptible to caregivers. In this sense, actively assisted suicide hinders an essential developmental phase. The dying person is robbed of an important period of development.

The physician must respect the autonomous self-determination and will of the patient. In this situation, however, she must ask herself whether she is hearing the real intentions of the individual or an expression of illness and depression. On the other hand, the physician must be respected for her deeds, in her autonomy and responsibility. Out of the conviction of her vocation, she must do everything in her power to minimize the suffering of the ill person.

In this sense, there is a duty to help, but no duty to kill in the sense of compassionate killing.

From the above perspective, the ostensible shortening of the illness actually takes away essential developmental steps from both the patient and the people around her, and leads her prematurely and unprepared over the threshold and into the spiritual world, like a “premature spiritual birth.”

Actively finding meaning; development of capacities; gratitude for the inner development; inner knowledge of the task of this phase of life, from which there is no “stealing away”, because it must be “mastered”.

Reasons for affirming the destiny of the illness

• Development of deep human relationships
• Life convictions and religious orientation
• Inner experiences, i.e. near death experiences
• Stable, supportive human relationships (and the knowledge of the suffering one’s suicide would bring to the people around one)