A doctor employed at a Danish hospice told me (OH) that a patient, close to death, might well ask him to put an end to his miserable existence, but when he replied that he was not allowed to kill, the patient slumped back onto his pillow with relief and asked: “So what can you do for me then?”

How can the patient find it reassuring that the doctor has not been granted the powers to allow him to kill the patient? Reflecting on our many conversations with dying people over many years, we propose that it has to do with the fact that providing assisted dying can, at the same time, be interpreted as abandoning the patient. Thus, the dialogue conducted when the doctor remains with the patient on the side of life originates from a different source than a scenario in which the doctor is in a position to help the patient to take their own life.

The debate on assisted dying revolves around the two arguments: the possibility of relieving unbearable suffering and respect for self-determination (autonomy). 

The idea of autonomy appears convincing because it reflects our concepts of free will and independence. However, there are inherent problems with autonomy in connection with assisted death. A law on assisted death is often predicated on freedom of choice, but—at the same time—involves a fundamental problem: the patient is not exempt from having to choose. 

If assisted death is legalised, the possibility would inhabit everyone’s consciousness—the patient’s, the doctor’s, the relatives’, the care staff’s—even if not formulated as an out-and-out offer. [1] How autonomously can the weakest people act when the world around them may deem their ill, dependent, and pained life unworthy? 

In this debate, we seem to forget the adage of John Donne that, ”no man is an island.” [2] Such serious decisions influence other people and are influenced by other people. The American philosopher, Daniel Sulmasy, commented on an uttered wish for assisted dying by saying: “… Since the words come out of the mouth of the patient the request may seem autonomous, but it may well be, in reality, merely the introjection of the disdain in which the patient is held by a community that fears its own suffering and wants to eliminate reminders of that possibility from the environment. The physician accedes to the request and, on the surface, all seems well. Yet an ominous fracture in the moral bedrock of society has taken place deep beneath the tranquil surface.” [3]

Human beings construct meaning not only rationally, but also emotionally, perhaps invoking the neocortex and the limbic system respectively [4]. Poetry, metaphors, and even logical paradoxes may carry emotional weight more valuable than superficial rationality. Two languages are available to us, an emotional and a rational language, and part of these may not even be verbal. Both languages may be in play at the same time and we need to be listening to both. 

Among others, moral philosophers can argue rationally that suffering defined as unbearable must be ended and that self-determination must be respected. It may be difficult to disagree when relying on neocortical cognition within the conventional parameters of rationality. A patient may already feel redundant when he or she, racked with despair, makes a rational request for assisted dying, but this feeling of redundancy can be reinforced when he or she is met with a rational understanding that seems to exclude emotional understanding 

In a country with legalised assisted dying, the message is: “You are requesting your own death. That is understandable; you have an unbearable condition, and we cannot do that much more. But you must consider your request carefully. I will return to hear whether you still mean it. I also need to run it past a colleague before we can proceed with such action.” The reply, therefore, is based on a well-intentioned and rational evaluation of what best serves the patient. But at the same time—and less intentionally—the reply will include: “We can help you from here on out, because we agree that your life is now valueless. No one speaks with such outright callousness, but what does the patient hear in that resolute offer in the midst of his or her wretchedness? 

In a country with a sustained ban on assisted dying the message might read: “You are requesting your own death. That is understandable, because you find yourself in a terrible predicament. We will do whatever we can for you, and we will also be with you now that things are so bad.” The patient may repeat his or her wish to die perhaps, but the final barrier in law need not, as is sometimes claimed by rational minds, be merciless; rather, it can be an undertaking that we dare to be with the patient in their and our powerlessness, and that they must remain part of the community—that is this life. Humanity’s response to the challenge of unbearable suffering must be more than simply eliminating the sufferer.

Iona Heath, medical doctor, general practitioner, and former president of the Royal College of General Practitioners.

Ole Hartling, medical doctor, professor, and former chairman of the Danish Council of Ethics.

Competing interests: None declared.

References:

1. Beuselinck, B. 2002-2016: Fourteen years of euthanasia in Belgium. First-line observations by an oncologist. In: Euthanasia and Assisted Suicide. Lessons from Belgium. Jones DA, Gastmans C, MacKellar C (editors), Cambridge University Press. 2017: 101-13.
2. Donne J. Meditation XVII. Devotions Upon Emergent Occasions and Several Steps in my Sickness. 1624.
3. Sulmasy DP. Ethics and the psychiatric dimensions of physician-assisted suicide. In: Euthanasia and Assisted Suicide. Lessons from Belgium. Jones DA, Gastmans C, MacKellar C, editors. Cambridge University Press. 2017: 49-64.
4. Lewis T, Amini F, Lennon R.  A General Theory of Love.  Vintage Books, 2000.