Assisted dying for healthy older people: a step too far?
BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2298 (Published 19 May 2017) Cite this as: BMJ 2017;357:j2298
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I used 'life complete' in a different way when, after the untimely death from cancer of my brother-in-law, I wrote for his wife, on his behalf, the following lines after a well known unknown poet. He loved sailing and was loved by everyone.
As you held my hand
Do not stand at my grave and weep,
I am not there - I do not sleep.
Grounded fast in silt and sand,
I blessed you as you held my hand.
But came high tide I had to weigh,
To catch the wind and sail away.
Freed from razor rocks at last,
I hoist bright colours to the mast.
Flying fish skim and soar,
As I leave this jagged shore.
With steely voice I hail the fleet,
Saddened not - my life complete.
Forever bronzed on cobalt blue,
Gone - but never far from you.
I sail the line that loops the poles,
I sail the loop that links our souls.
Although intended as private verse, after reading this article I have decided to share it.
Competing interests: No competing interests
For the guiding value to be autonomy is correct, we don’t need a physician to either show compassion or to assist in the process itself.
Listen to our patients (we should all be ‘listening doctors’) who are, in the vast majority (>70% of those likely to be affected), keen to have assisted suicide/dying available to them when they deem it to be the right time thereby ensuring their autonomy.
Rather than this autonomy, however, suffering, assessed and managed by the medical establishment of course, continues to be promoted as the right way to go. First class palliative care as the patient might wish it must be available as must also the next step of assisted dying; the compassionate and enlightened way forward,
Later it may well be appropriate to extend a right to die to older people who are distressed by life without quality, whether or not in the future society is engineered to make them feel less useless and marginalized, and would like to die with dignity in a manner and at a time of their choosing.
Competing interests: No competing interests
Congratulations to the Dutch on at least considering whether old age can ever be grounds for an assisted death or euthanasia. Many of us in the relevant age group will be aware of a growing interest in this and with an ageing population it can only become more relevant. There is already a high suicide rate of those in their 80s which is seen more as reflecting on the medical health of the individual rather than on the health of Society as a whole. Wijngaarden et al stress this need to look at social context but their weakness is in seeing marginalisation of the very old as preventable. Paternalistic attempts at integration are likely to have limited and only temporary benefits whilst the use of skills following retirement is a minefield. One of her study group was a retired lecturer who felt that earlier skills were being wasted but this has to be validated against competence rather than nostalgia. Insight in old age can wane, and objective as well as subjective assessment is needed if a previous position in Society is to be continued into advanced old age. Her identification of emotional factors in an apparently rational decision about ending life is important but just what would one expect? Few, if any, of our decisions are free from emotional components - this does not invalidate them from being appropriate. One point arising out of the Dutch surveys is that some of the highest level of support (over 60%) for a change in the law comes from the relatively young, the age group of Wijngaarden herself. That does not bode well for the incorporation of the very old into an inclusive society.
Currently in the UK there seem to be increased pressures to see CPR, if not ITU admission, and all life preserving (as opposed to life enhancing) interventions as part of “normal death” and the elderly are particularly vulnerable. Families - whatever their motives - are given an increased say in decisions. At the other extreme I met a Swiss doctor recently who provides assisted dying or euthanasia for those over 85, when she and the old person consider it appropriate, for humanitarian reasons: DIY attempts she finds messy and distressing for those involved. Interest in DIY will persist either because of a terminal illness or for reasons related to advanced age, despite attempts to limit the options available. Henry Marsh opens his new book “Admissions” with a comment on his suicide kit being amongst his most treasured possessions and this will strike a chord with many of his readers. It remains difficult to envisage medical care in the UK taking on this aspect of old age, whether it is for reasons of existential suffering or a sense of “completion”. Those who wish to be in control, a likely characteristic of this group, will have to take responsibility for the methods as well as the timing of their death – but Society must learn that in old age mere length of existence is not the main goal for everyone.
Competing interests: Member of Health Professionals for Assisted Dying
Here are some principles I have put together regarding the care of severely ill patients:
1. Never give words of reassurance.
2. The challenge is not just allowing, but enabling the patient to articulate his feelings.
3. Often the patient has strong feelings about his relatives: probe, discuss, but don’t correct or contradict or give suggestions.
4. The pain of the present will usually be coloured, shaped, influenced by pains in the past. And this means that
5. The patient may wish to reminisce, recount, revisit the past – this is not a denial of the present, but a “trip down memory lane” before it is too late for this.
6. Good mood, even jokes, are not to be treated as a denial, but an invitation for a warm, close few minutes – proof that the illness has not decimated all personal qualities.
AND THE CARER?
1. The carer must be seen as equally in need of comfort/support.
2. He/she also experiences pain, but will usually feel “not entitled” to it.
3. Important to investigate what is the carer’s interpretation of the patient’s condition and, above all, what he/she anticipates is the prognosis.
4. Most carers will feel guilty for not giving sufficient support or, even, for being a factor in the patient’s condition and/or present state. Again, reassurance should not be given. Putting it in a formula “he knows he is not guilty, but he feels guilty.” Therefore, questions must be put forward, allowing the carer to recognize how complex and contradictory are his feelings.
Dr A H Brafman, MRCPsych.
Competing interests: No competing interests
Having only been able to read the 'open access' introduction, and without any familiarity with the Dutch law, my initial thought is that there is still the use of the word 'euthanasia' as well as the term assisted-suicide: it is assisted-suicide that I support, because 'euthanasia' covers rather wider concepts. The Nazis 'euthanised' many people - murdered is a better word there.
I think that extending assisted-suicide to 'healthy people' is something which can be argued over in the future: the first step, to my mind, is to settle the issue of whether assisted-suicide, if it is to be available, should be available to people whose lives are intolerable because of pain or some other factor(s), but who are not actually 'dying'. In other words, to question why this '... and the patient is expected to die within 6 months' [or a year, or whatever] intrudes on the assisted-suicide debate: if my life is intolerable because of unbearable pain which could not be relieved, and my life seemingly stretches ahead for decades, then doesn't that look like a stronger reason for suicide than if I'm dying as well as being in agony?
Competing interests: No competing interests
Undoubtedly, “Dutch euthanasia practice is considered to be careful, safe, verifiable, and transparent” [1]; but the world is larger. In many other places, conflicts of interest would prevail over integrity [2].
1. van Wijngaarden E, Ab Klink A. Assisted dying for healthy older people: a step too far? BMJ 2017;357:j2298
2. https://www.researchgate.net/publication/317036805_Scientific_misconduct...
Competing interests: No competing interests
Re: Assisted dying for healthy older people: a step too far?
Sorry to be late to the debate.
The argument put forward in favour of this proposal is patients' autonomy and self determination. Within a secular view point it is difficult to argue against this. People do want to maintain their belief of control of their lives.
Can I ask why limit it to older people? Surely any adult has the same autonomy and right to self determination.
If a 45 year old, otherwise healthy, decides their life is "complete" why should they be denied their right to self determination and not allowed to die with assistance?
Am I the only one thinking the wedge is getting a lot thicker?
Competing interests: I am an Anglican priest and don't favour assisted dying.