Euthanasia for existential reasons

Winter, 2006

G. K. Kimsma, MD, MPh

Center for Ethics and Philosophy of Life Vrije Universiteit Medical Center Amsterdam, Netherlands

Euthanasia for existential reasons is an issue of public debate in the Netherlands. Advocates of voluntary active euthanasia (VAE) and physician-assisted suicide (PAS) believe that individuals should have the right to choose the time and manner of their death. Both VAE and PAS represent a conflict between the physician's duty to protect life and to alleviate unbearable suffering.

Existential suffering occurs in the absence of severe physical or mental illness. Requests for existential euthanasia come mostly from elderly people who suffer from age-related physical ailments and have lost the appetite for living because they experience life as meaningless and empty. For example, in a recent and typical case, a 69-year-old man who lost his wife said that he was lonely and wanted to join her in the afterlife. A psychiatric consultation found him competent and not depressed. He asked me for euthanasia.

In a philosophical sense, the terminology of existential suffering requires clarification, because all suffering, mental or physical, presupposes a mind and an existence capable of perceiving suffering and is existential. For pragmatic reasons, we adopt the distinction of suffering as physical, mental or existential. People who request VAE for existential reasons are usually not adherents of the philosophy of existentialism as expressed by Jean Paul Sartre, Albert Camus or Sören Kierkegaard.

In a recent publication of representative interviews, 410 physicians (GPs, specialists and nursing home physicians) reported about 400 requests

yearly to end a life from patients who did not have serious disease. These were mainly from patients over 80 years old, a minority of whom had ailments but no serious medical disease, and almost all after losing a spouse or being single with social problems. In this sample, only 3% of the physicians said they had ever complied with such requests; most had refused, suggesting alternatives to VAE or PAS.¹ If legalized, VAE for existential reasons could become an option for anyone, because these existential motives are entirely subjective and not amenable to objective evaluation.

VAE and PAS in the Netherlands

VAE is legally practiced in the Netherlands, Columbia and Belgium, and PAS is legally practiced in those countries as well as the state of Oregon. PAS is not a crime in Germany nor Switzerland, which allows it if accomplices have no personal interest. The position of the Dutch arose from legal cases involving seriously ill patients and was not based on a public discussion of the principles of VAE/PAS. ² The first prominent court case dates from 1974 when a physician ended the life of her ailing mother after repeated requests and was found guilty on technical charges and sentenced to a week of probation. This case was soon applauded as a landmark case in favor of VAE because the verdict outlined, for the first time, the requisite conditions to help someone die.

The Dutch legal definition of euthanasia is ending the life of a person, at his or her voluntary request, who suffers unbearably without hope of improvement. Contrary to popular belief, VAE and PAS are technically a crime in the Netherlands, even though the Dutch Voluntary Euthanasia Society ³ attempts to decriminalize assisted suicide. A law called the Law Review Procedures for Termination of Life on Request, active since April 1, 2002, defines the conditions a physician must follow to help a patient die without being prosecuted. The physician (1) must be convinced of the presence of a voluntary and carefully considered request, (2) must be convinced that the patient's suffering is unbearable without prospect for improvement, (3) must have informed the patient of their medical situation and future prospects, (4) must have concluded with the patient that reasonable alternatives are absent, (5) must have consulted with at least one other physician not otherwise connected to the case and (6) must end the life of a patient effectively and carefully.

Each case of VAE or PAS must be reported as a case of unnatural death to a civil servant, comparable to a local medical coroner, who conducts an immediate investigation, consults with prosecutors about the case, and allows burial or cremation, or refers the case to the local prosecutor. The most formal evaluation is conducted afterward by one of five regional Euthanasia Evaluation Committees that determines whether the law has been upheld. These Committees have three members: a judicial expert, a physician and an ethicist. I am a physician-member in one of these committees.

VAE and PAS are performed primarily by family physicians with long-term patient relationships; most patients suffer from a terminal malignancy. VAE and PAS were performed on 2.7% (3,600 cases) of patient deaths in 2001. Of the 1,886 cases in 2004 for which data is available, 1,647 persons suffered from an end-stage malignancy; 81% of the VAE/PAS acts took place in private homes with family physicians, and 3.5% of the cases took place in nursing homes. The dominant age bracket in cases of VAE/PAS is between 65 and 79, conforming with cancer statistics on age.

Ninety percent of the Dutch population supports the option of VAE and PAS. Eighty-eight percent of Dutch physicians approve of VAE/PAS, while 8% are personally opposed but support the option for others, and 4% oppose it under all circumstances. For American readers, these figures may seem surprising, but keep in mind that the Dutch Courts have allowed the option of VAE/PAS since the early 1970s and the number of supporters has risen steadily since that time.

VAE/PAS are not just interventions to end a life at a particular moment, but more the end of a long process with an intensely emotional culmination. ⁴ Patients usually cite several reasons for ending their life: unbearable and hopeless pain and suffering, avoidance of further deterioration and meaningless suffering, death without dignity, dependence, fatigue, fear of suffocation and being a burden to their family. ⁵ In most cases that pass the Euthanasia Evaluation Committees, the descriptions of suffering are focused on medical symptoms such as unbearable pain despite treatment, nausea despite anti-emetics, extreme fatigue and breathing difficulty. Additional problems include insomnia, poor concentration and impaired communication.

Relevant court cases

Two important cases are relevant to the discussion of euthanasia for existential reasons. In 1994 the Supreme Court acquitted psychiatrist Dr. Boudewijn Chabot for assisting a woman in suicide who did not suffer from a terminal somatic or bodily disease. The woman wanted to end her life after she was alone following a divorce and both of her sons had died. The Court argued that unbearable suffering could be due to life experiences in the absence of physically debilitating diseases, ending the discussion that terminal illness should be conditional for euthanasia.

Unbearable suffering

What complicates an assessment of unbearable suffering is the complexity and intricate nature of human experience. What people experience and what they find unbearable is not 'simply pain' but pain as shaped by their character and biography. The difficulty for a physician is to grasp this complexity and understand why the patient's experience leads to a request for assistance with dying. Each assessment becomes a delicate journey to respect and explore the thoughts of an individual, to understand why the totality of symptoms result in a patient's conviction that life is meaningless and prolonging it undesirable. Meaninglessness tends to become a final personal assessment, leading to a decision that "enough is enough."

Conclusion

VAE or PAS for existential reasons is not formally possible in the Netherlands, nor do physicians in general see a justification for it at this time. However, there are attempts to politicize the issue by demanding the decriminalization of assistance in suicide through a change of law in Parliament, which will not be successful in the present climate. As a physician, I support the present limitations on VAE/PAS and find these realistic and justified. As a philosopher, I support the position that euthanasia for existential reasons may be acceptable. But I find it difficult to justify the professional participation of physicians - these decisions are beyond the expertise of the medical profession.

In the instance of the 69-year-old man who asked me for existential euthanasia, although I was sympathetic, I told him that his case fell beyond the scope of the law. He decided to commit suicide with sleeping pills and a bag that would cause him to suffocate. I gave him my advice on the effectiveness of his choice, and days later he ended his life. I supported his sons afterwards. If Dutch society chooses euthanasia for existential reasons, though it would pain me, I would refuse to participate.

I would, however, consider it my professional duty as a family physician to help and support the patient during the process, and the family afterwards.

Footnotes

¹ Rurup M, Muller MT, Onwuteaka-Philipsen BD, Van derHeide A, Van derWal G, Van der Maas PJ. Requests for euthanasia or physician-assisted suicide from older persons who do not have a severe disease: an interview study. Psychol Med. 2005;345: 665-71.

² Kimsma GK, van Leeuwen E. Euthanasia and assisted suicide in the Netherlands and the USA. Comparing practices, justifications and key concepts in bioethics and law. In: Thomasma D et al, eds. Asking to Die. Inside the Dutch Debate about Euthanasia.Dordrecht/ Boston/London: Kluwer Academic Publishers; 1998:35-71.

³ http://www.nvve.nl/nvve/pagina.asp?pagnaam=english

⁴ Norwood F. Euthanasia Discourse, General Practice and End-of-Life Care in the Netherlands. Dissertation presented at: University of California; July 2005; San Francisco, Calif.

⁵ Van derWal G, van der Maas PJ. Euthanasie en anderemedischebeslissingenrondhetlevenseinde.De praktijk en de meldingsprocedure (Euthanasia and other decisions at the end of life.The practice and the procedure to report). Den Haag, Sduuitgevers, 1996:57.

Additional reading

Van derWal G, van der Mass PJ. Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands. N Eng J Med. February 24, 2000;342:551-556.