The Suicide of Seneca, Manuel Domínguez Sánchez, 1871

Exploring the Moral Implications of Euthanasia

Early in April, BBC Ideas shared a video entitled ‘Should we be able to choose our own death?’, where philosopher Nigel Warburton imagines a future where we choose how and when we die.

The video brings us into a dream-like, cartoon world, with singing birds and serene background music. Here we are shown ‘the good death centre’, a place where those who do not want to ‘descend into the indignity of extreme dementia’ or those who ‘doubt the ability of palliative care to ease their exit from life,’ go ‘when the time is right’. ‘They will choose the moments of their own deaths’. The video goes on to state that euthanasia has been available to pets for so long, but before the good death centre, we forced our friends and relatives into enduring suffering and indignity. Now that the good death centre is here, past practices of not providing people with a chance to end their own suffering or relieve their indignity, seem so cruel and pointless. ‘Life is much better now, its reassuring to know you don’t have to endure it, even when you have lost the power to take your own life’.

Within euthanasia, assisted suicide and assisted dying laws, a primary criterion is that the patient must be experiencing unbearable suffering with no prospect of improvement.

The specifics vary; in US states the patient must be terminally ill, in the Netherlands and Belgium, the patient does not. People suffering from psychiatric conditions can avail of euthanasia/ assisted suicide in the Benelux countries; US states require a terminal diagnosis, which psychiatric conditions alone do not carry. The Netherlands and Belgium give minors the right to access euthanasia, no other country or state does. However, the unbearable suffering experienced by the patient and the lack of prospective improvement is the common criterion among the different specifications and requirements spanning from country to country. But how do we define suffering? And at what point does one decide that suffering outweighs the value of life?

Ancient Greek philosopher, Epicurus, advocated for an elimination of pain in the pursuit of pleasure, the attainment of which he believed to be the ultimate goal.

He thought that pain and suffering was to be found in almost every aspect, desire and endeavour of life. Pleasure was to be found when physical pain, and all other, was removed; ‘Our one need, is untroubled existence’. Before his death however, he wrote a letter to a friend; ‘I have written this letter to you on a happy day to me, which is also the last day of my life. For I have been attacked by a painful inability to urinate, and also dysentery, so violent that nothing can be added to the violence of my sufferings. But the cheerfulness of my mind, which comes from the recollection of all my philosophical contemplation, counterbalances all these afflictions’. This ability to endure suffering and to find within it, value, is echoed from his predecessors to his successors. In his final moments, Epicurus mirrored the essence of the other main Hellenistic school of philosophy; the Stoics.

The Stoics saw suffering and death as an inevitable part of living, and unlike Epicurus, believed it is not something to shun.

Speaking of the difference between the Stoics and Epicureans, the famous Stoic, Seneca, said ‘our wise man feels his troubles but overcomes them, while their wise man does not even feel them’. The Stoics saw that suffering and misfortune befalls us all and a lot of it may be outside of our control. They believed that with moral strength, we could achieve calmness within the inevitable sufferings of life. Seneca believed ‘It is better to conquer our grief than to deceive it’. The Stoics acknowledged suffering and death, and invited people to face them with moral strength and wisdom; to find value in suffering; ‘In like manner, all those who are called to suffer what would make cowards and poltroons weep may say, “God has deemed us worthy instruments of his purpose to discover how much human nature can endure”’- Seneca.

Viktor Frankl, 1965. Attribution: Prof. Dr. Franz Vesely

Is there value to be found in suffering like Seneca and the Stoics believed?

Warburton’s BBC Idea video describes a world where the suffering of impending death is cruel and pointless to endure. Viktor Frankl, professor and concentration camp survivor faced death every day for the 3 years he was a prisoner in various Nazi concentration camps. In his book, ‘A Man’s Search for Meaning’, he describes how everyday brought the possibility of death. Shipments to various alternative camps were often ploys resulting in a journey instead to the gas chambers. He describes in detail the physical torture the prisoner endured; constant deprivation, physical abuse, and incessant labour; resulting in complete physical decay and agony. Having endured this hell, Frankl concluded that it mattered greatly how people face and perceive suffering; that there is transcendental, life-sustaining and life affirming meaning and value to be found in suffering and in facing death. He saw even a human’s very final suffering and facing of cruel death as anything but pointless- “In accepting this challenge to suffer bravely, life has a meaning up to the last moment, and it retains this meaning literally to the end”. Even more earnestly on the value of suffering, German philosopher, Friedrich Nietzsche proposed; “To those human beings who are of any concern to me I wish suffering, desolation, sickness, ill-treatment, indignities — I wish that they should not remain unfamiliar with profound self-contempt, the torture of self-mistrust, the wretchedness of the vanquished: I have no pity for them, because I wish them the only thing that can prove today whether one is worth anything or not — that one endures.”

Friedrich Nietzsche, Photograph: Friedrich Hartmann, 1875

Taking responsibility for suffering allowed Frankl to sustain his life while he could and affirm it in moments of extreme suffering and close death-

“…it did not really matter what we expected from life, but rather what life expected from us.” Frankl thought that he in fact owed something to life, rather than life owing him anything. So even in times of such extreme suffering, he could find meaning and value because the suffering wasn’t pointless. On his sense of tragic optimism, he said that human potential at its best includes ‘turning suffering into a human achievement and accomplishment’. Reading Frankl’s words, there is a profound sense of heroics. Suffering provided an opportunity to show real heroism, an opportunity which would have obviously not existed in a tensionless state. If there is a constant insistence on eradicating suffering, or lessening the burden of death, will there be any opportunities left for people to reach the most celebrated archetype in Western culture?

I don’t think any of these philosophers who speak of value in suffering are craving a sadistic world.

It is not a desire to see people suffer, but a suggested retort to the inevitable sufferings of life, as well as an extremely compelling study of the value to be found in suffering. Euthanasia and assisted suicide laws are no longer there to only reduce physical pain in final moments of approaching death. In many ways, they offer to dissolve what our philosophers would have known as inevitable sufferings of life.

Who defines the suffering; and how much is enough?

In the highlights of 2017’s findings (full report not available as of yet), The Dutch regional euthanasia review committee (RTE) report 83 cases of euthanasia for suffering based on a psychiatric disorder in the Netherlands (this figure was 60 in RTE’s 2016 annual report). They also report 293 cases of euthanasia for suffering based on geriatric symptoms; visual and hearing problems, osteoporosis, problems with balance, decrease in cognitive ability etc (In 2016 ‘there were 244 notified cases involving patients with multiple geriatric syndromes’.)

In the same 2016 report, Case 2016–41 details a woman in her 40’s diagnosed with Post Traumatic Stress Disorder; “At the physician’s request, a clinical psychologist assessed whether any further treatment was possible. Starting with treatment again would require strong motivation on the patient’s part, because despite a lengthy history of treatment, no progress had been made. She indicated she was unable to summon the motivation. The physician also asked an independent psychiatrist to assess whether there were any other solutions. In the opinion of the psychiatrist, everything possible had been done. After consulting the psychiatrist, the physician was satisfied that this suffering was unbearable to the patient and with no prospect of improvement according to prevailing medical opinion”. The woman’s lack of motivation and dejection are provided as reasons in favour of prescribing euthanasia/assisted suicide. It is understandable that after years of psychiatric turmoil one would become despondent and make such a statement. But regarding onto who the decision falls; how can one measure such psychiatric or psychological suffering, and does it take precedence over the intrinsic value of life?

Under the ‘Judgements’ title of the RTE website, they detail a similar case of a woman suffering from anorexia, depression, personality disorder and a somatoform pain disorder; ‘In the opinion of the psychiatrist, treatment was theoretically possible. However, she believed it was extremely doubtful that the patient would be able to tolerate the treatment or be able to enter into and maintain an appropriate treatment relationship. This doubt was partly rooted in the fact that the patient had indicated that she was no longer motivated to undergo treatment. The physicians thus came to the conclusion that there were no other means to alleviate the patient’s suffering that were acceptable to her.’ We see here that the determinate factor is not the exhausting of treatments, rather than the patient’s motivation to engage.

The level of suffering is subjective; assessed according to each patient and what is bearable to him or her.

It is an immeasurable indicator; relying on reasonable and sensible evaluation from the patient in order to fulfil reasonable duty of care. In these types of cases, which are increasing; these same patients expected to make reasonable and well assessed decisions have suffered from decades of psychiatric issues.

In Case 2016–44, the report gives details of a man in his 80’s suffering geriatric symptoms; ‘Because he had become almost totally blind, the patient could no longer read (which was extremely important to him) or pursue his other hobbies. He was suffering from the loss of these activities, which were essential to him. He also suffered from the loss of self-reliance caused by his impaired vision, and the fact that he knew that there was no prospect of improvement whatsoever. The patient, who had always had a wide range of interests and a great intellectual appetite, experienced his suffering as unbearable.”

Growing old would have fallen into the inevitable suffering philosophers so often urged people to find ways of managing.

The loss of a passion as this man experienced, is the loss of meaning. Frankl’s Logotherapy believed meaning to be central to a person’s survival. Following this, logotherapy says that we can discover meaning in life in three different ways: (1) by creating a work or doing a deed; (2) by experiencing something or encountering someone; and (3) by the attitude we take toward unavoidable suffering. The third point is there to maintain that even if the first 2 are extinguished, there is still, always, meaning to be found. As Nietzsche concludes; “he who has a why to live for can bear almost any how”. Re-evaluating meaning and the value of life in the later stages, bodes more productive than an elimination of the sufferings associated with those years.

Euthanasia and Assisted Suicide have become far more about autonomy than about a compassionate bid to ease the pain of imminent death.

Defining suffering isn’t necessary because all that is required is a subjective experience of suffering, and for ourselves to deem it unbearable. We have the right to decide when life ceases to have value. It is problematic to create boundaries and decide life has no value outside of that. It seems even more problematic not to include suffering within those boundaries, when it is a fundamental and inevitable part of life. Is it unwise to be releasing people of suffering in such a final way, when historically people were encouraged to face suffering and even excel in it? It seems that in our bid to rid life of suffering and take control over our finite existence, we could be dismantling the interdependence between suffering and meaning that philosophers held so delicately in their hands as sacred.

“We must never forget that we may also find meaning in life even when confronted with a hopeless situation, when facing a fate that cannot be changed. For what then matters is to bear witness to the uniquely human potential at its best, which is to transform a personal tragedy into a triumph, to turn one’s predicament into a human achievement”- Viktor Frankl.