Suffering and Dignity in the Twilight of Life

Dr. Bernard Ars, PhD, is an ENT surgeon working mainly in private practice. He is attached to the Edith Cavell Institute and the Temporal Bone Foundation in Brussels, and is also Professor at the Marie Haps Institute-Leonardo da Vinci Academy. Moreover, he acts as a consultant and post-doctoral researcher at the University of Antwerp. He is the editor of eight books, and has written more than 150 articles for international journals. His interest in otology is both clinical and scientific. Dr. Ars takes part in many international postgraduate courses, is also involved in various humanitarian and educational missions throughout the world, and is an active member of numerous international societies world-wide. He has won many scientific awards, among which the 1990 Politzer Prize, and is Honorary Doctor at the University Carol Davila in Bucharest, Romania. Dr. Ars also has a degree in philosophy. His main hobbies are classical music and history. He is married and has three children.

The impending death of a patient means that the physician has four therapeutic choices: passive assistance, over-intensive treatment, palliative care, and even active euthanasia.

Passive assistance is no longer an option in our modern society. A legacy of the past, when the main support came from loved ones whose aim it was to be present and to provide comfort, it was often accompanied by the well-meaning support of religion, which tried to calm, if not the body, then at least the mind and the heart of the dying patient. Today, this absence of treatment is condemned as long as medicine has the means to take appropriate and opportune action.

At the other end of the spectrum is a medical world which is confident of its know-how and which refuses to admit failure in the face of certain and inevitable death. The temptation for over-intensive treatment is the other side of the coin to the extraordinary progress made in medicine, especially in the field of intensive care. It pushes certain physicians to start or continue futile or disproportionate treatment in a relentless and desperate battle against inevitable death. It takes the form of refusing the limits of the art of healing and the finite nature of the human condition. At present, unreasonable over-intensive treatment is severely condemned, and rightly so.

After having conscientiously tried everything in the therapeutic arsenal and having seen that this does not work, modern medicine can offer the dying person a positive and constructive solution: palliative care, which advocates the overall care of a person with a progressive or incurable disease. Instead of refusing to admit to inevitable death, amidst useless treatment and devices that are painful and difficult to bear, the accent is placed upon high quality accompaniment of the patient and his or her loved ones. The aim of palliative care is to relieve physical pain and other signs of discomfort, to take into consideration psychic suffering, and as much as possible to preserve a good relationship between the patient and those close to him or her. This means, in fact, providing a positive environment – with material and moral support – in order to ease and make the most of the final moments of life.

By relieving the discomfort and trials of the end of life, palliative care can provide a rewarding serenity and dignity that, by its very nature, will remove any temptation to shorten the last moments of life.

And yet voices have recently been heard loudly demanding the legalization of active euthanasia. This appears to be another way out for patients who are terrified of too much pain and/or unbearable suffering, or who refuse helplessly to watch their own gradual deterioration. It is paradoxical that this demand should come now, when medicine has become so efficient, when it can provide so much more comfort to the patient than it could in the past, when techniques to control symptoms and pain have improved so greatly, when palliative care has been developed, and when there is a general consensus against the deviation of over-intensive treatment. In fact, it would seem that the right to euthanasia is basically a philosophical or ideological question; for certain people, the real issue of the debate is to assert the autonomy of the individual who alone may judge the quality of his or her life and his or her dignity: this would also mean recognizing the freedom to freely dispose of oneself – of another, in reality(!) – as the ultimate expression of autonomy.

In any case, the idea has taken hold and, in a just few years, approval of euthanasia has greatly increased among the collective consciousness. Among other indications is the amazing change in the National French Advisory Committee of Ethics. In Opinion No. 26, dated June 24th, 1991, the CCNE stated that, “The legalization of euthanasia, even for exceptional cases, would be a source of abusive and uncontrollable interpretations”, and it emphasized, in particular, the profound ambivalence of the request for euthanasia, the risk of interference from “economic, hospital-related, familial or ideological considerations that have nothing to do with the patient”, as well as the incompatibility of legal euthanasia with the medical calling and the finality of the “art of healing”. Its conclusion was categorical: “As a result, the Committee disapproves of a legislative or regulatory text to legitimate the act of putting a patient to death.” Less than ten years later, in Opinion No. 63 dated January 27th, 2000, this same Committee pronounced itself in favor of “An agreement that supports…” and that “could be legally translated into an introduction of the notion of exception(al) euthanasia”.

This example illustrates an important tendency in most industrialized countries – most of which are also engaged in the vast public debate on the question of euthanasia and, more generally, on the conditions of the end of life. Within this context, there are numerous publications on the subject: scientific articles, books, and opinions in the popular press. But we are forced to admit three things: firstly, philosophical publications all too often remain limited to the world of philosophers, and legal publications to the world of lawyers…; secondly, the general public remains relatively uninformed on the subject, confining itself to flippant slogans, confusions, misinterpretations, and approximations of all sorts…; and finally – and this probably explains the last-mentioned observation – it is clear that, in the debate on euthanasia, rigorous and disciplined analysis often gives way to the passions, fantasies and fears that surround death.

This book is intended for everyone, but in particular for caregivers who are in the front line of the problem regarding the end of life and euthanasia. By presenting a critical analysis of the debate from a multidisciplinary perspective, the aim of this work is to provide a positive message about the therapeutic relationship at the end of life. Far from presenting an impenetrable tome or encyclopedia on the subject, our goal was to provide food for thought with sufficient information presented in what we hope to be a sober, thoughtful, and pedagogical manner. Thus, we have chosen not to discuss numerous very interesting questions that would have been beyond our goals. You will not find anything in the following pages about the etymology or history of the term ‘euthanasia’, or about the religious point of view, medical codes of ethics, opinions of national ethics committees, or even about the laws of countries where euthanasia was legalized before being outlawed (Australia), or is being seriously considered, sometimes in a bill that is already before parliament.

In these pages, we are hoping to achieve a multidisciplinary book which will be regarded as a synthesis, offering a serene and positive vision of the end of life.

The book is divided into three parts: the first, written by various physicians and a nurse, describes the different medical approaches to the ‘end of life’ now in existence, as well as possible treatments against pain and suffering. The second part, written by lawyers, provides a critical analysis of existing legislation in the only countries/states that have legalized euthanasia or assisted suicide: the State of Oregon in the USA, The Netherlands, and Belgium. The third and final part is a philosophical reflection on the dignity of the ‘end of life’ and places euthanasia in its anthropological, ethical, and sociopolitical context.

Finally, we sincerely wish to thank each of the authors for their important contribution to this difficult debate, and all those at Kugler Publications for their confidence and support.

Bernard Ars and Etienne Montero

Introduction, Bernard Ars and Etienne Montero

Medical Professionals Faced with the End of Life

Between abandonment and over-intensive treatment, Xavier Mirabel

Pain and suffering, J. Menten, Y. Lievens, A. Dijck, F. Bogaerts and L. Lissnijder

Living the end of life in a hospital: discourse and reality, Bernadette Wouters

The Legalization of Euthanasia in Comparative Law

Assisted suicide in Oregon: piercing the myth, Wesley J. Smith

Euthanasia in The Netherlands. National legislation and international law,
Martin A.J.M. Buijsen

The regulation of euthanasia under Belgian law, Bruno Dayez

A Philosophical Look at the End of Life

Can illness deprive a human being of all dignity?, Thomas De Koninck

The socio-political stakes of euthanasia, Etienne Montero