Assisted Suicide

The desire for physician-assisted suicide (PAS) is not prohibited in discussion and not even for organizations operating as businesses, according to current rulings of Germany’s Federal Constitutional Court. In several European Union countries (Netherlands, Belgium, Luxembourg) and worldwide (Switzerland, Colombia, Canada, USA), the ban on physician-assisted suicide has long since been lifted in favor of patient autonomy. The frequency of this form of dying is between 0.3% and 4.6% of all deaths and it increased after legalization. People who want assisted suicide are often older and well educated. Pain is usually not mentioned as the primary motivation (1). Rather – according to a study from Germany – frequent reasons for suicide are a loss of life perspective because of a serious illness, a fear of long-term care, and being tired of living (2). Of these, “71% were women, 67% were 70 years or older, 25.6% suffered from metastatic cancer, 20.5% had a severe neurological illness, 23% suffered from age-related diseases or disabilities, 14.5 % had a predominant psychiatric diagnosis, 7.7% were physically and mentally healthy.” (2)

The desire for physician-assisted suicide is not new in the history of medicine. Since the 16th century, the desire for euthanasia, which was mostly expressed by non-professionals, has led to social and scientific debates with professional actors such as nurses and physicians, the results of which advanced not least palliative care. However, euthanasia was instrumentalized in the Third Reich, paving the way for absolute inhumanity in dealing with life and death.

While some see the legalization of assisted suicide as a long-awaited opportunity for self-determined death, others fear a relapse into times of euthanasia and disposability of human life. There are questions that touch on different dimensions. For example, there is a need behind every suicide wish and every suicide intention. It is the task of differentiated assessment and consultation to recognize that need. If the suicide wish is an expression of a profound need, it should not be understood to be free and autonomous, but rather as need-driven. In this respect, the answer is not to extinguish someone’s life, but to help with their need. It is possible to alleviate that need, offer support, enable different perspectives, change the situation and contribute to prevention through trustful and competent accompaniment.

Providing suicide assistance is not one of the tasks of palliative and hospice care. Conversely, however, all people who wish to commit suicide should have a right to palliative medical advice (and help). As far as possible, the relatives or loved ones should be involved in consultations on questions of assisted suicide, including the permanence and seriousness of the person’s desire for it. Because suicide as an unavoidable action never takes place for itself alone, it stands in connection with the people around the person and has substantial consequences for them. Not only he but also the survivors will have to live with the traces that the suicidal person leaves behind. The person’s social circumstances and their relationship to relatives and the circle of people around them are important criteria for understanding the suffering person, as well as for recognizing the need itself.  From a palliative medical point of view, this raises a further question: is a death brought about by one’s own hand a “good death”, a death in dignity?

In public discussion on assisted suicide, people often describe seemingly hopeless situations that identify assisted suicide as the only option, making it a “plausible” idea. From this perspective, failing to assist with the suicide would border on “failure to provide assistance” and would also be incompatible with the Hippocratic precept of “do no harm”. After all, every day of postponement would mean an immediate detriment for the patient. Such challenging situations require an individual response due to their individual nature. Often, with good care and a reliable relationship of trust, a reduction of suffering is possible that does not consist in assisted suicide, a form of death which is perceived to be “without dignity” or even as a way of “putting the person down”. However, a trusting relationship between the people around the patient and the people treating him or her will not always develop to a sufficient extent. In such situations, it is then not a legal claim to assisted suicide that is helpful or should be demanded, but rather professional and ethically competent care, possibly supported by the people accompanying the patient. An example often given is amyotrophic lateral sclerosis (ALS), which can lead to complete paralysis – including respiratory paralysis – when fully conscious. Such a justification for assisted suicide, which at first glance is quickly convincing, can be put into perspective by opposing assessments by other affected patients: Thus a Canadian family doctor, who suffered from ALS at the age of 42, decided against assisted suicide and for life with the severely restrictive and stressful disease. His reasons were his loving relationship with his wife, the circle of people around him and the available external, also economic possibilities for living without being a burden to others. (3) This highlights the importance of the interpersonal and thus social dimension of decision-making. The wish to die is not only an articulation of a need caused by illness or other circumstances, it is also a social question that is directed not only at the individual, but at society as a whole. In order to accompany people in a way that gives meaning, we are challenged not just as therapists and doctors, but also as human beings.

Three dimensions

Three dimensions are crucial in the context of assisted suicide: the desire for active euthanasia is often based on a loss of meaning, lack of emotional support accompanied by a feeling of being a burden to other people, and a fear of unbearable consequences of the illness – and not based on real and uncontrollable somatic symptoms, as one might think (2).

• The first dimension refers to the individual search for meaning. The person sees no more perspective and feels increasing doubt about the sense of suffering in this phase of life. In contrast, the neurologist and psychiatrist Viktor Frankl (1905–1997), as a Holocaust survivor, described the establishment of meaning in painful times with words reminiscent of Friedrich Nietzsche: “Anyone who has a Why to live can stand almost any How” (4). It is important to develop new perspectives within the one-dimensionality and exclusivity of the suicide wish. An need-driven suicide wish is never free and it narrows the field of vision to the seemingly only possible “solution”: assisted suicide. In contrast, new perspectives and meaning can have a liberating effect, because “suicide is a no to the question of meaning” (Frankl). With the loss of meaning people lose the meaningful relationship to themselves. Because meaning is individual and cannot be generalized. It is “my” meaning and my values in my biography. Finding meaning is also a “coming home”, it is reconnecting with one’s own individuality and destiny. “Each person is new, unique, irreplaceable, and there is a correspondence between the meaning and the person that I am.” (Frankl). From every sense of meaning, even from initial and simple answers as to the “why”, forces arise to continue on the further path, to develop and discover new values. In the terms of Hölderlin we might say that where there is danger, there is also something growing that can save us.
  
  
• The second dimension is interpersonal relationships. When a patient receives attention and an affirmation of her situation, she can experience new values and it reduces her desire for assisted suicide. Self-experience and self-awareness develop in our encounters with other people. The meaning and significance of our own existence are experienced through the circle of people around us. Already the term “meaning” in German (“Bedeutung”) contains the idea of interpreting and thus an activity which does not involve self-interpretation but interpretation by the people around us. The meaning of someone’s life is often not conscious to that person himself. It is rather felt by his surroundings and it is especially experienced when a parting is approaching or has happened. People become an “I” through a “you”, as Martin Buber described it. Vitality and the feeling of having a task, of being needed, disappears without this becoming of oneself in connection with other people. The desire for assisted suicide is then an understandable consequence. Against this background, the fear of seriously ill or elderly people of dying an unworthy and painful death in a nursing home, hospital or at home has social consequences, such as ensuring that care facilities are sufficiently funded. It shows the need for comprehensive palliative and hospice care. The desire for assisted suicide is a call for the development of humanity. According to Cicely Saunders (1918–2005), founder of the modern hospice movement and palliative care, it is about the elimination of suffering, not about the elimination of the suffering person in the sense of “deadly compassion” (5). To achieve this it helps to have positive relationships in which there is appreciation for the other person and gratitude for his or her existence.
  
  
• The third dimension is professionally competent (possibly palliative) medical treatment. In modern palliative medicine most symptoms can be controlled by medication. The prerequisite is an integrative approach to treatment that does justice to the patient in several dimensions. Anthroposophic palliative medicine has extensive experience in this regard. Particularly important in addition to medication are external applications as used in anthroposophic nursing and various forms of body therapy. Art therapies open up experiences in the soul and awaken inner activity in patients. Talk therapy enables us to address questions about the patient’s individual values and biographical goals, including the patient’s spiritual and religious beliefs, as well as questions about destiny and life after death. The decisive characteristic of anthroposophic palliative medicine is its orientation towards the person’s future development and viability as a being whose soul and spiritual nature are not bound by the physical limits of birth and death.

For more information, see: https://www.anthromedics.org/PRA-0561-EN  

Ethical aspects

To achieve this requires active professional and ethical development in the people treating the patient, as well as support for the patient’s companions. As professional practitioners, we may ask ourselves whether our ethical professionalism is trained to the same extent as our medical professionalism. The basic pillars of the patient-doctor relationship in palliative care are professional competence and empathic relationship management, as well as therapeutic commitment. As soon as the patient experiences our will to heal and help, he feels supported on his path and can develop new perspectives. Experience shows that the desire for active euthanasia then often disappears.

The topic of assisted suicide touches the core of a medical and therapeutic self-understanding that gives people room to develop their soul and spirit in every phase of their lives, also and especially in a phase of palliative care. This topic has moral-ethical aspects that must be considered. Thus, a physician providing sodium pentobarbital is involved in the process and the destiny of the affected person and is confronted with a task that has nothing to do with his original healing mission (6). Challenges and requirements arise for doctors and other accompanying people, which each individual must ultimately reconcile with his or her own conscience. Palliative patient care depends on our understanding of the human being. Is it solely about controlling distressing symptoms in a terminally ill person? Or can future-oriented perspectives still be developed at the end of life? Is the patient mentally and spiritually accompanied and supported? In addition to symptom-oriented treatment, this situation also requires a salutogenic approach that considers the patient’s individual resources. In addition, people have to feel that they are not alone in phases of doubt, rejection and existential fear, and that they are emotionally supported. Thirdly, every human being and even more so palliatively ill patients live from perspectives and hope, i.e., from future prospects. This attitude must be credibly communicated by doctors and nurses. A somatically oriented view of the human being will see the aspect of release in assisted suicide. An understanding oriented towards body, soul and spirit, on the other hand, must include further dimensions and view biography as a developmental dimension and task – in contrast to a hedonistic understanding of life. If the actual, spiritual nature of a human being is indestructible and not identical with his somatic dimension and finiteness, then questions of pre-existence and an afterlife arise. Birth and death are then not start and end stations, rather places of transition and threshold that require special ethical-spiritual attention and guidance. Acting in the nearness of death is then characterized by special responsibility, especially since the simplistic idea of an unconscious end does not do justice to the ethical questions that arise, not only against the background of the numerous near-death experiences that we know of, but also considering millennia-old world views and life convictions. In addition, a person’s thoughts about the “where from” and “where to” change during their biography: Many children remember a time before birth (7), and near-death experiences are reported by people of all ages, indicating the likelihood of life after death (8). Waking and sleeping, as well as phases of life that are “dying” or coming to an end, and phases of beginning anew can become images for the great turning points in life, for birth and death, for a here and a beyond. This gives such thresholds a special dignity, depth of understanding and thus a spiritual-ethical basis. Just as we know pregnancy as a path of preparation and development for the becoming human being, so the necessity arises to see a period of development preceding the moment of death. Here we distinguish the dying process from the moment of death. Both are distinctly individualized, differ from person to person and receive inviolable dignity from the imprint of the individuality.

Developing autonomy: self-development and autogenesis

While from an external point of view a phase of illness with suffering and pain should finally come to an end, so that the patient is “liberated”, there are completely different aspects to consider from the point of view of soul and spirit.  If one understands the human being to be a spiritual entity in a mortal body, predisposed to future existence and development, then assisted suicide deprives the patient of the most essential thing, namely the chance of development, self-realization, i.e., autogenesis. We often witness amazing developments in the palliative phase of illness or generally in the time of dying: patients suddenly find that they have a lot of confidence and energy; but stressful emotions may also increase. Again and again there may be phases of perceiving a different level of reality (9). According to a Swiss study, such experiences at the end of life are perceived as a source of spiritual comfort by the dying and their families.

Fig. 1: Yes answers to the question: “Have you observed any of the following phenomena in patients in the last weeks of their lives?” (9)

The time of preparation for dying, in the broader sense of the dying process, sometimes begins unnoticed by the person affected and by those around him or her. Only in retrospect does it become clear how a dying person might have said goodbye to many people before leaving. Other people intuit with amazing accuracy their coming destiny and sometimes also even the time of death (9). They then speak of it as an essential moment of birth, which represents a moment that is similar to birth and which is appropriate to their biography. Assisted suicide prevents such developments. Perhaps the apparent cessation of pain and suffering can bring new pain, a sense of loss, deprivation and suffering after death. The suffering would then merely be shifted, possibly even into an area not intended for it. Many things are recognized in their actual value only when we have to part with them or they are lost. A finality that knows no return can be particularly painful.

Again and again we may experience patients who have a desire to die, even in anthroposophic hospitals. Experience shows that with good palliative and hospice treatment, and with mental and spiritual support, this desire can almost always be transformed into new meaning and newly acquired autonomy. The patient then “has” an illness rather than “being” ill, he experiences himself as capable of autonomy even in the palliative phase of the illness and even in a time of perhaps maximum dependence. His dignity is then by no means taken away from him, leaving him at the mercy of “undignified suffering”. Rather, he gains dignity in a special way especially in this phase of illness. Assisted suicide is not an option for palliative care that focuses on the individual and his or her ability to develop even in the late stages of illness. Instead, it is about accompanying people intensively in terms of their physical, as well as mental and spiritual needs. In rare cases, of course, palliative sedation may be necessary if the symptoms cannot be controlled. However, even in this situation, active help with dying is not one of the tools that are needed.

Practical aspects of the wish for assisted suicide

Assisted suicide has been legalized under certain conditions in several European countries and also worldwide. It is therefore necessary to offer competent counseling to people with a desire for assisted suicide, counseling which includes different perspectives, including ethical and spiritual aspects. From scientific studies we know retrospectively that the control mechanisms that were originally meant to precede PAS have increasingly no longer been adhered to in the Netherlands and Belgium. For example, lethal drugs have been administered without the patient’s consent, there has been no terminal illness and mental illness has remained untreated (10). 

The S3 guideline on palliative care takes a very differentiated view of the phenomenon of a death wish. In particular, to understand the often ambivalent feelings of the people concerned it helps to consider the different degrees of experience ranging from life satisfaction to life tiredness to completed suicide, as well as the fact that a person with a death wish can also simultaneously feel a desire to live. Professional (palliative medical) helpers are explicitly advised to adopt an attitude of openness, interest and respect, without necessarily agreeing to the death wish. Thus, it is not always necessary to take active measures, but rather to “actively endure the suffering”, to stand by the person. The “existence of helplessness, hopelessness, senselessness, lack of perspective, demoralization and loss of faith” should be noted and treated (11). For this purpose, palliative medicine is necessary and required.

Karl Jaspers also speaks of fellow sufferers: “The existence of a reasonable man with the power of the spirit, and the convincing effect of an absolutely benevolent being, awakens in the other, and so also in the sick, unpredictable powers of trust, of the will to live, of truthfulness, without a word being said about it. What man can be to man, is not exhausted in what can be comprehended.” (12)

• Establishing offers to talk: This is about our common understanding of the patient’s present situation and suffering. Is it a loss of prospects? Is it suffering in experiencing one’s situation and the challenges of one’s surroundings (I am a burden to my relatives so that they can no longer live their lives), is it uncontrolled symptoms of physical or mental illness? Such conversations require the professional competence of people in different occupations, in order to better understand the person concerned, his or her life situation and the people around him or her, and to be able to bring different perspectives to the advice given. This includes consideration of the patient’s values, his spiritual or religious convictions, from an attitude of helping rather than instructing.
  In countries where counselling is mandatory, those who ask for assisted suicide must be given access to multi-professional, ethical and spiritual expertise. This includes a professional conversation about the person’s biography, individual values that distinguish the essential from the unessential, spiritual perspectives and support, as well as advice on suitable meditation and prayer.   meaning and values are conceptual, non-material and therefore need spiritual support and attention.
  
  
• Involvement and support of the community: We must clarify the social dimension of the desire for assisted suicide. Lack of care, as well as overstrained companions, indirectly signal the burden that the person concerned is “imposing” on the people around him or her. This concerns questions of support for the circle of relatives and accompanying people. If there are too few people to help or if they lack expertise or feel overstrained, this must be recognized as a reinforcing factor and must be compensated for. Otherwise the person will die due to conditions that can and should be altered, which signal the senselessness and burden of his existence in need of care. There is a considerable need for social action regarding this. Not only does it require a well-developed network of palliative care, it requires appreciation and recognition of human attention, nursing assistance and the contribution of institutions working in this field (nursing homes, care facilities, hospices). Against this background, the desire for availability of assisted suicide is a call for humanity in medicine, in the healthcare system and in society.
  
  
• Providing professionally competent or palliative medical care: The sometimes considerable burden of symptoms of people with palliative illnesses requires comprehensive palliative care. This can alleviate the physical complaints in most cases in a satisfying way and can also counteract the person’s mental suffering, as well as meet spiritual questions of meaning.