Paul Kioko, Doctoral Student, Pontificia Università della Santa Croce
Pablo Requena, Professor of Moral Theology and Bioethics, Pontificia Università della Santa Croce
24 January 2018

In the article by Verhofstadt et al, the authors rightly observe that the concept of ‘unbearable suffering’ in relation to euthanasia remains poorly defined in the medical literature (1). We wish to make three observations which may contribute towards a better understanding of ‘unbearable suffering’ and highlight the incongruency of considering euthanasia as psychotherapeutic.

First, suffering in one form or another is part and parcel of being human. It is the time-tested signal that something is going wrong. It is also the moment to test the limits of character and affective maturity. This is not to say that suffering is always welcome. Indeed, a sign of human progress is the alleviation of many forms of suffering and medicine certainly plays a key role in this. Nevertheless, medicine alone cannot be expected to shoulder the burden of relieving all forms of human suffering. Verhofstadt and colleagues identify five categories of unbearable suffering in psychiatric patients: medically related, intrapersonal, interpersonal, societal, and existential. It is a fact that modern psychiatry is able to treat many psychiatric disorders, but asking psychiatrists to treat all forms of suffering including existential doubts may be actually leading the profession away from medicine.

Second, suffering is a normal human affective-emotional reaction to a perceived or real threat to the integrity of personhood following the classic definition by Cassell (2) and adapted by Dees et al in their proposal for defining ‘unbearable suffering’ (3). We would argue that suffering is bearable when a person is able to rationalise the perceived threat to integrity in view of a higher end or good. Indeed many of the greatest figures in history are admired precisely for having suffered for a cause. On the other hand, suffering is unbearable when a person is unable to rationalise the suffering. In other words it is a suffering that has no meaning for that person. It is unreasonable. The humanization of suffering is about restoring meaning to suffering, not annihilating the person (4).

Third, adding euthanasia to the therapeutic repertoire of psychiatry is in truth an alteration of psychiatry and not an advancement of science. Twenty five centuries ago Hippocrates finally managed to separate science from hocus pocus, the doctor from the sorcerer, curing from killing (5). Readmitting this vanquished foe to the fold is to change the very character and goals of medicine. Psychiatrists should shun euthanasia as a ‘treatment’ for suffering-in-want-of-a-reason and instead concentrate on what they do best – treating psychiatric disorders and helping patients find meaning for their suffering.

(1) Verhofstadt M, Thienpont L, Peters GJ. When unbearable suffering incites psychiatric patients to request euthanasia: qualitative study. Br J Psychiatry 2017; 211: 238-45.

(2) Cassell EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982; 306: 639-45.

(3) Dees M, Vernooij-Dassen M, Dekkers W, van Weel C. Unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: an integrative review. Psychooncology 2010; 19: 339–52.

(4) Frankl VE. The feeling of meaninglessness: a challenge to psychotherapy. Am J Psychoanal 1972; 32: 85-9.

(5) Levine M. Psychiatry & Ethics. Braziller, 1972. ... More

Conflict of interest: None declared

Eugene G Breen, Adult Psychiatrist, Mater Misericordiae University Hospital, Dublin.
10 October 2017

This series of 26 vignettes with copious surrounding soft speak about how awfully important it is to get it right about euthanizing psychiatric patients, looks like poacher becoming game keeper, "We must really care for our unbearably suffering patients and end their suffering with this new treatment called euthanasia" type of attitude. What is touted is a tick box - lets call it "Unbearable Suffering" - that once ticked clears the way for comfortable acceptable and squeaky clean legal euthanasia of vulnerable people. This is pseudo science all the way with tacit implication that everyone caring and reasonable agrees that euthanasia is a legitimate respectable pathway for "care at the end of life." It isn't, and most health professionals strive to palliate suffering and not shoot the patient.

It is ironic that a clinic that supposedly carries out "end of life care" has such a high mortality figure. Nine of the 26 presenting with letters dies by euthanasia. In the rest of the world (except the countries mentioned who euthanize) criminal proceedings would be instigated against such "clinics." To embed euthanasia or physician assisted suicide into the medical world as a standard "regulated" and supervised procedure is to undermine the doctor patient relationship. Doctors and patients would now think of cosmetic death as a definite option and societal pressure would torment dependent elderly or disabled into requesting it "because the doctor says its the right thing to do (the doctor is not offering hope or any other form of treatment) and "it would take the burden of my relatives." These are very vulnerable and easily manipulated people that need our protection and advocacy.

The American College of Physicians have again endorsed their respect for life and opposition to euthanasia and physician assisted suicide (Oct 2017). They mention the reality of the "slippery slope" (which is occurring in Holland - report of a Dutch geriatrician on criminal charges for unlawful death of demented 74 year old woman BMJ: 2017; https://doi.org/10.1136/bmj.j4639). They also cite their opposition to engagement in suicide. Lastly they express the real fear of involuntary euthanasia becoming a reality.

"Unbearable suffering" is a wolf in sheep's clothing. It is impossible to justify killing innocent life. ... More

Conflict of interest: None Declared

John M Clifford, Consultant Psychiatrist, BCUHB North Wales
07 October 2017

I do concur with the position laid down by Brendan D. Kelly (1) in response to the paper by Verhofstadt et al (2) and his conclusion that 'we should not kill our patients'. However, one argument he has surprisingly not used is that of a 'slippery slope' (3). In particular Beauchamp and Childress specify two versions of this argument. The psychological-sociological one is well known and is often cited as arguments against euthanasia. However, the conceptual slippery slope is by far the more dangerous and exemplified here so succinctly. Here in Verhofstadt et al we have 'unbearable suffering' as a concept leading almost effortlessly and uncritically to the euthanasia of psychiatric patients who have no terminal disease. What is so shocking is that this is no sterile philosophical debate but is in action in a European country and has led to patient deaths. This subjugation demonstrates the biggest risk in the euthanasia debate and should be actively resisted.

(1) Kelly, B. Invited commentary on... 211,248-249

(2) Vorhofstadt, M. et al 'When unbearable suffering incites psychiatric patients to request euthanasia' 211, 238-245

(3) Beauchamp, T. et all 'Principles of Biomedical ethics Fourth Edition' Oxford. ... More

Conflict of interest: None Declared