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Euthanasia Debate (II)

Joachim Jung’s “Withdrawing from Life” challenges Tim Chappell.

I believe that no man ever threw away life, while it was worth keeping.
David Hume, On Suicide

In no country is the application of euthanasia as widely accepted as in the Netherlands. As early as 1984 the Dutch Supreme Court sanctioned individual cases of euthanasia, some of them dating back to the 1970s. The progressive liberalization of assisted suicide culminated in a comprehensive euthanasia law passed by the Dutch Parliament on 10 April 2001. This Act stipulates that physicians can prescribe death-inducing drugs for patients who want to end their lives because they are “facing incurable and unendurable suffering” (uitzichtloos en ondraaglijk lijden). A commentary on this law by the Dutch Ministry of Foreign Affairs admits that “the extent to which suffering is unbearable is a highly subjective matter.” Although the physician “attempts to assess the patient’s suffering objectively,” he is not in a position to track down the real motives underlying the patient’s suicidal intentions.

Since the Dutch euthanasia act places high significance on the subjective feelings of the patient, it comes as no surprise that the law does not explicitly rule out the application of assisted suicide in cases of ‘psychological suffering’. To date, only one case of this kind has become known. In 1993 the physician Boudewijn Chabot gave lethal medication to his patient Hilly Bosscher, a fifty-year-old woman who had suffered from severe depression for several years. Mrs Bosscher died in the presence of Dr Chabot and two witnesses. The Dutch Supreme Court subsequently disapproved of Chabot’s actions but did not impose a penalty.

In this article I aim to demonstrate that Dr Chabot was on the right path and that it is even necessary to go a step further. Once you have acquiesced in the practice of making it possible for patients in pain to gain access to lethal drugs, you will have to concede this right to anybody who wishes to end his life, irrespective of whether or not he has any health problems. This is evident for a variety of reasons: first you have to consider that pain is to a degree subjective and thus isn’t precisely measurable by the physician. Second, the hardships of life can cause more anguish and distress than bodily pain.

“The most intense suffering can occur in the absence of physical pain – for example, upon the death of a child, the news of a fatal but not painful illness, the sufferings of a loved one, rejection by one’s peers, separation or divorce, loss of reputation, or a traumatic lawsuit. The range of possibilities of suffering without physical pain is as broad as the range of untoward events that may affect any human at any time,” writes the American bioethicist Edmund Pellegrino. The third reason for challenging undue emphasis on physical pain is that pain abatement has made great strides in the past few decades. According to a report by the World Health Organization, the pain of cancer patients can be sufficiently relieved in over 90 percent of all cases. In fact, pain only ranks second among the motives listed by Dutch patients who want to terminate their lives. The reason cited most frequently in a survey is the loss of dignity. In most cases the emotional stress prevails over the physical. This explains why paralyzed people who do not feel pain at all frequently think of suicide. Their quality of life is extremely reduced because they are divested of any privacy, which is an elementary prerequisite for the preservation of human dignity.

These considerations throw doubt on whether it is defensible to confine physician-assisted suicide to terminally ill patients. I shall argue that assisted suicide should become a civil right, granted to all human beings. Anyone who wants to end his life should be entitled to seek the support of a person who can procure the necessary drugs and accompany him on his last journey. People who, for whatever reasons, have come to the conclusion that their lives have lost all meaning should not be treated worse than patients suffering from cancer or AIDS. All of them have the same interest, namely to arrange for themselves a death that is as painless and peaceful as possible.

Goodbye, Cruel World

It is unbearably hard to depart this life alone. To do so requires resoluteness, taciturnity and iron discipline. The horror excited by this design is markedly alleviated if the would-be suicide finds a congenial partner, someone who has arrived at the same convictions, encourages him in his intention and is willing to depart this life together with him. Suicide pacts aim at reassuring each other in the common goal and dissipating doubts that might frustrate its realization. One such pact aroused international attention when in February 2000 a young couple plunged from a cliff east of Stavanger in Norway.

The joint suicide was triggered by a twenty-year-old Norwegian whose name was not released. Seeking a partner ready to join him in death, the young man had posted an advertisement on a suicide web site. From among the people who showed interest, the Norwegian selected a woman of his own age from Upper Austria. After they had exchanged several emails, they became convinced that they were destined for each other. The girl travelled to Norway and met her new friend near Stavanger. On 19 February 2000, according to the Oslo daily Aftenposten, they headed for the Prekestolen, a projecting rock rising 1000 feet above the Lysefjord. The taxi driver who took them there later recalled that the girl was too lightly clad for the season and that the two of them wanted to camp at the site. Their tent was later found near the summit plateau. How long they stayed there, what they spoke of in their last hours and when exactly they executed their deed, nobody will ever know. Two days later, their corpses were discovered on a rubble field 500 feet beneath the Prekestolen.

When the rescue crew advanced to them, it discovered that they lay 22 yards from each other. This shows how difficult it is to die jointly. Probably the two gripped each other’s hands and leaped together into the abyss. But the great shock that must have seized them in this moment and the resistance of the air tore them apart … Certainly, partner suicides are extreme instances. But they prove that on the brink of death most people do not like to be left alone, particularly if they are to quit life of their own free will. Providing assistance in suicide is a precept of charity, implying advantages for both the perpetrator and society.

In the first place it is an asset for the suicide if a physician or a friend can attend or accompany him without facing legal restrictions. “It is crucial to have a companion with you in selfdeliverance to give moral support and prevent mistakes or interruptions … Having somebody present at this time … is absolutely essential. Isolation at such a time is an inhuman experience,” writes Derek Humphrey in his counselling book Final Exit. In most countries it isn’t an offence to observe a person committing suicide without interfering. However, if the companion passes a glass of orange juice to the suicidal person to dissolve the death-inducing pills, or turns off the heating in order to accelerate the dying process, then he is assisting a suicide, which is a criminal offence in the majority of states. Therefore a suicide can rarely reckon on the support of his friends. They shy away from rendering him the services any dying person badly needs: having his hand held, his temples wiped, and hearing a few comforting words before he loses consciousness. Any act of solidarity with him risks a prison sentence. For this reason the suicidal individual is forced to die in solitude and to steal away from society like a thief.

The introduction of public support for suicidals would secondly have the advantage that death could be brought about in a swift and painless manner. Physicians or dependents who had been instructed accordingly would make sure that the suicide departed in a peaceful and decent way. He would be spared any recourse to violent methods which leave his body maimed, crushed or burned. Before somebody exits from life, he ought to consider for a moment the troubles his act might cause to uninvolved persons. Leaping from a cliff with a beloved partner is a romantic deed. Scratching the smashed corpses from the ground is far less romantic. Notwithstanding the numbing agony in which the suicide finds himself he should avoid shocking those who are in charge of salvaging his remains. Carrying out the act in a hospital or at home, under legal protection, would defuse its acuteness and render it a normal procedure, comparable to surgery or a birth.

This practice would thirdly make sure that the suicide really succeeds. There is probably nothing worse in the world than a failed suicide attempt that ends up in lasting and irreparable damage. The Austrian physician Eberhard Deisenhammer, who has investigated this issue for several years, records an array of tragic incidents. In one case a girl became a paraplegic when she jumped out of the window. A young woman who leaped in front of a train survived blinded and with severe facial lesions. A woman who sprang from a building endured multiple fractures and has suffered excruciating pain ever since. In all these cases it would have been best to dissuade the victims from their intention in time. Suicide counselling should aim at drawing endangered people back into life. It should imbue them with a new appetite for life. But if this fails, if the suicidal person has made the irrevocable decision to quit this world, it is better to help him carry out his deed perfectly, rather than to expose him to the risk of botching his suicide and surviving in a hopeless, wretched state.

Fourthly: A successfully accomplished suicide is also the least problematic solution for society. The cost of a burial is minimal compared with that of the lifetime care of a person who survives an attempted suicide crippled and incapacitated. Unlike the victim of an accident, the survivor can blame nobody but himself for his mishap. This is a shaming and depressing experience that in the worst case could overshadow the rest of his existence and makes life hell for himself and his loved ones. Professional suicide assistance would ensure that the interests of all parties were equally safeguarded.

The Gentle and Easy Death?

Physician-assisted suicide is nothing to be dreaded, as the practice in the Netherlands shows. Patients whose suffering has become unbearable are administered a potion consisting of pentabarbital, pure alcohol, water, propylene glycol, sugar syrup and a drop of aniseed oil. The bitterness of the liquid is offset by the sweeteners and its fishy taste is reduced by the aniseed oil. Normally the patient dies within thirty minutes, but in some cases the dying process lasts several hours or days, so if the patient is still alive after five hours the doctor administers Pavulon by injection. Pavulon, incidentally, is a derivative of curare, the poison used by South American Indians on the tips of their hunting arrows.

The patients making use of this treatment do not sense more than the bitter-sweet taste of the barbiturates or the prick of the syringe. Their death is swift and painless. There is no reason why this treatment should not be made accessible to any person applying for it. For this purpose public or private counselling boards for euthanasia should be established, which would advice their clients and help them master the technicalities of self-deliverance. The desire to put an end to life should be sufficient to process an application. During this procedure it would not even be necessary to infringe upon privacy by asking the clients for their motives. As the Hume quotation at the start of this article suggests, anyone with a fixed intention to withdraw from life must have compelling reasons for this step. However, some safeguards should be incorporated into this mechanism.

Firstly, precautions should be taken to rule out any misuse of the fatal drugs. The lethal injection should be administered or at least checked by a person in charge. Secondly, the counselling committee should make sure that the applicant persists in his intention over a specified period. A person suffering from some temporary malady or short-term depression, however intense, should not be eligible for assisted suicide. Support should only be rendered to someone who is imbued with the firm determination to turn his back on this world. Thirdly, universal suicide assistance can only be realized in a welfare state. It is always appalling to hear about people who try to terminate their lives because they are no longer in a position to earn a living. To be sure, no society can provide complete protection against poverty. Debts, unemployment or wretched living conditions can occur even in the most affluent states, but welfare institutions at least minimize the danger of somebody’s contemplating suicide for financial reasons. One of the centre-pieces of the welfare state is a system of health insurance that encompasses all citizens. Universal health insurance ensures that no patient is forced into assisted suicide, however lengthy and costly his treatment may be.

Of course, a comprehensive system of voluntary euthanasia will only be possible when a broad social consensus has been achieved. A person who is tired of life can demand to be put out of his misery, but no physician can be obliged to comply with his wish. The free decision of a doctor must be as much respected as the decision of the patient. Even in Holland a number of physicians steadfastly refuse to be drawn into euthanasia. Universal suicide assistance won’t be established from one day to the next. It must be preceded by an extended discussion in the course of which it will become clear whether society is mature enough for this solution. All that is necessary today is to start the debate on this crucial topic and to overcome the taboo that surrounds it.

The Fate of Pioneers

This article shouldn’t close without mentioning a man who has fuelled public debate on this issue in an unparalleled way: Dr Jack Kevorkian. From 1990 to 1998 Kevorkian assisted the suicides of some 130 people. According to press reports (Associated Press, 7 Dec 2000) the majority of them were not terminally ill. Five of them only simulated a disease to obtain Kevorkian’s help. In September 1998 the retired pathologist induced the death of 52-year-old Tom Youk, who had been diagnosed with Lou Gehrig’s disease. This action was recorded on video and broadcast by CBS. The tape showed something that Kevorkian did not deny, namely that it was he himself who administered the lethal injection to the paralyzed patient. This case of active euthanasia was classified as murder by the competent court in Pontiac, Michigan. In March 1999 Kevorkian was convicted of second-degree murder and given a prison sentence of 10-25 years. At present he is serving his term in a Michigan penitentiary, awaiting the first parole opportunity, which is due in 2007.

Jack Kevorkian shares the fate of numerous pioneers who were denigrated and derided when they came up with ways of thinking not in line with the views of their time. Mary Wollstonecraft was ridiculed when she published her Vindication of the Rights of Women in 1792. John Stuart Mill fared only marginally better when he claimed the suffrage for women in the middle of the 19th century. His stance was dismissed as a personal whim of an otherwise serious author. When in 1821 the Irishman Richard Martin put forward the idea of drafting a law against the cruel treatment of animals, his proposition was met with guffaws in the British Parliament. Nevertheless Parliament enacted a law on this matter a few months later. Soon afterward the Royal Society for the Prevention of Cruelty to Animals came into being, the first association of its kind in the world.

Today the masterminds of the right-to-die movement find themselves in the situation of the spurned pioneers of the past. In the face of all opposition they are trying to convey the message that every individual is an autonomous being, who may decide on his own on the continuation of his life. The freedom of choice includes the right to give up if the troubles someone has to endure far outweigh the pleasures life normally involves. If the balance of life is negative, suicide is one possible resort. Trapped in this situation, a potential suicide should not be exposed to the incalculable risks of ‘going it alone’. He should be granted the right to benefit from the most advanced methods and devices of medicine – a right that is a matter of course for any other dying person.

© Dr Joachim Jung 2003

Joachim Jung is a Lecturer in Philosophy at the University of Innsbruck, Austria.

Further Reading

• Derek Humphrey and Mary Clement, Freedom to Die: People, Politics, and the Right-to-Die Movement (St Martin’s Griffin 2000)

• Derek Humphrey, Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying (Dell Publishing 1996)

• Linda Emanuel (ed.), Regulating How We Die (Harvard Univ. Press 1998). See particularly the chapters by Edmund Pellegrino, ‘The False Promise of Beneficent Killing’,and Paul van der Maas and Linda Emanuel, ‘Factual Findings’.

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