On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.101 n.11 Cape Town Nov. 2011
Death with integrity
To the Editor: Dignity SA was launched on 25 September. Its stated intention is to lobby for legal doctor-assisted suicide in South Africa, to allow individuals with terminal illnesses this choice. The debate, which will follow in our profession, should be undertaken in the correct ethical framework.
The ethical debate about doctor-assisted suicide assumes an ethic of radical individualism: rationalising the use of medical 'care' to relieve suffering by taking life. The contractual model of care (which refers to 'clients', not 'patients') is based on this ethic, and emphasises the right to self-determination as paramount in decision-making. Thus, the caregiver holds correlative duties, such as confidentiality and informed consent, to guarantee the free exercise of the right to self-determination.
However, the contractual model of care has serious deficiencies in tending to people who suffer at the end of their lives, as the notion of informed consent becomes very difficult to apply in practice. Dying individuals are extremely vulnerable; their problem-solving skills are frequently impaired, and it is very difficult for an observer to assess them accurately.
It is easy for doctors who are granted permission to take life to become ambivalent in their work. Value judgements may be made on patients' lives, and their lives may be taken without their consent, as is happening in the Netherlands.1 Doctors risk being drawn into acts of maleficence, which involve the worst forms of paternalism.
Rather than needing an emotionally distant caregiver with a contractual relationship, suffering terminal patients require an empathetic presence from a team of individuals who are willing and trained to challenge despair and build hope.
'Suffering is not a question that demands an answer; it is not a problem that demands a solution; it is a mystery which demands a presence' (Anonymous).
It is certainly never true to say that 'There is nothing that can be done for you' (except perhaps to kill you!); there is always something that can be done for terminal patients, by those who are prepared to be present compassionately, and to enter into the suffering of another, without being drawn into their despair. Caring is the essential requisite for the ability of the patient and their family to cope; it helps a person to recover a sense of worth, and to appropriate meaning.
Death with dignity is only possible if the relational, existential and spiritual issues at the end of life are addressed - including offering and receiving forgiveness, and dedicating time for a family to gather around a dying member, to celebrate their life, and affirm their worth. Good hospice care is death with this kind of integrity that allows the patient to reach for wholeness, and brings dignity. Encouraging a rapid escape from these issues by doctor-assisted suicide implies defeat, and not dignity.
The almost unopposed concept of autonomous individuality as a basis for decision-making in end-of-life decisions is further flawed: we must fully embrace the ethical principle of 'do no harm' to other family members. Decisions for voluntary euthanasia will inevitably draw others into them; spouses, siblings, children, grandchildren and friends must be allowed to grieve a death freely and healthily, without subverting their grief by deciding on doctor-assisted suicide. This is particularly important in the case of adolescents and young adults; subverted grief can manifest as emotions of denial, diffuse anger, self-contempt and depression, which can be destructive to others and to self.
The incidence of suicide, especially among adolescents, is a significant public health issue in our country. With active euthanasia, we risk adding deaths by 'suicide contagion'2 - suicides that follow the previous incidence of a suicide in a family or peer group. This is well documented in relation to abortion, and is likely to occur in the case of doctor-assisted suicide. Young individuals, in particular, have an intuitive, God-given sense of the sanctity of human life. Collectively, this evidence suggests that introducing doctor-assisted suicides, even in 'havens', will lead to additional suicides, resulting in compounded grief for their families.
Doctors should take an active stance in this debate, as its outcome will involve all of us. Health care ethics must not be subverted by people who will never have to break their oaths, and deliberately give someone a lethal prescription or injection.
We must be honest about our fallibility as diagnosticians and prognosticators. We must refuse to allow society to give health care professionals the power that it refuses to give to the legal system, which has more checks and balances in place to prevent wrongful deaths.
As health care professionals, we must ensure public sector support for the hospice movement. We should also ensure that training in terminal care is an effective part of our undergraduate and postgraduate instruction.
Jonathan Victor Larsen
Private Bag X010
1. van der Wal G, van der Maas PJ, Bosma JM, et al. Evaluation of the notification procedure for physician-assisted death in the Netherlands. N Engl J Med 1996;335(22):1706-1711. [ Links ]
2. Canterbury Suicide Project. Suicide Clusters and Suicide Contagion. Bulletin No. 10, February 1997. New Zealand: Canterbury Suicide Project, 2007. [ Links ]