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The concept of ‘unbearable suffering’ is central to legislation governing whether euthanasia requests may be granted, but remains insufficiently understood, especially in relation to psychiatric patients.
To provide insights into the suffering experiences of psychiatric patients who have made a request for euthanasia.
Testimonials from 26 psychiatric patients who requested euthanasia were analysed using QualiCoder software.
Five domains of suffering were identified: medical, intrapersonal, interpersonal, societal and existential. Hopelessness was confirmed to be an important contributor. The lengthy process of applying for euthanasia was a cause of suffering and added to experienced hopelessness, whereas encountering physicians who took requests seriously could offer new perspectives on treatment.
The development of measurement instruments to assess the nature and extent of suffering as experienced by psychiatric patients could help both patients and physicians to better navigate the complicated and sensitive process of evaluating requests in a humane and competent way. Some correlates of suffering (such as low income) indicate the need for a broad medical, societal and political debate on how to reduce the burden of financial and socioeconomic difficulties and inequalities in order to reduce patients' desire for euthanasia. Euthanasia should never be seen (or used) as a means of resolving societal failures.
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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
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