For some time now, I have been growing, in spite of myself it seems, ever more attuned to human frailty and vulnerability. I have also been entertaining a most curious question: what topic could be so dark that it must be approached (at least at first) with a friendly curiosity?
This would not be a topic that I alone could address and resolve.
And this would not be a topic that I dare address without humility.
Nor would it be a topic addressed without patience and diligence.
But I ask you: could this be a topic that is worthy of persistence?
I’ll broach this topic with a deceptively simple question with a pure intention to deepen your appreciation of life and love: for one and all, how best to pass in peace and thereby fulfill a request to die?
If you read my recent post, A Vision for Your Passing, you may have wondered about the fate of your body, your soul, your spirit, your life, but the depths of darkness lurking in the question immediately above only appear on the surface in the light of these four words: for one and all.
For one and all, how best to pass in peace and thereby fulfill a request to die?
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Suppose a clinic of compassionate deliverance, where people go to die, opens in a neighbourhood near you. You know someone who might benefit, and so you pay a visit to inform yourself about the requirements of passing in peace by your own hand or by the hand of another.
Upon arriving, you’re told that candidates of all ages must pass a rigorous screening process before they can even be considered as a client for compassionate deliverance. Upon passing successfully through this process, the candidate is granted the status of a client at the clinic.
As a client, you’re given to understand that if you’re awake and alert to your own competence, you have the option to die by your own hand with assistance, but the final decision to die must be yours alone. If not, then you must be prepared to have someone do it for you.
This clinic derives some of its inspiration from Soylent Green, a film that was released in the early 1970s, at a time when interest in “the population bomb” was high. Another sci-fi film with a similar sub-theme, Logan’s Run, was released a little later in the decade (in 1976).
Two questions go begging in the wake of this scenario: (1) as a candidate, how does one become a client for a medically-assisted passing or for a procedure of euthanasia?, and (2) as a client, how might one pass from this world in peace in the most meaningful way possible?
Human ingenuity could no doubt answer the second question with relative ease. The bottleneck lies in the first question, and for good reason: once a person becomes a client, the main hurdle that prevents a meaningful passing in peace has been cleared for the would-be spirit.
At present, however, not just anyone can become a client, especially in light of the strictest criteria that you can possibly imagine being applied to the transition between candidate and client. I explored this matter of criteria in my post, How Best to Pass in Peace, where I wrote …
The most strict criteria conceivable are interesting to contemplate and are six in number: (1) be at least 18 years of age; (2) have a serious, incurable illness, disease, or disability; (3) be at an advanced stage of irreversible decline in capability; (4) endure physical and psychological suffering that is intolerable; (5) be in a state where a natural death is reasonably foreseeable; and (6) be capable of giving informed consent at the time assistance is rendered by a physician or a nurse practitioner, either to do the deed or make this deed possible for the patient to do.
These criteria were made after considerable consultation with the experience of other countries in medically assisted dying and were formulated, not with the intent to make it as difficult as possible for anyone to pass peaceably from this life with legal sanction, but with the intent to safeguard the most vulnerable from being unduly influenced into consenting to an ill-considered or premature passing.
Still, in view of someone who has a serious, intractable mental illness or a long-time disability that meets most of the criteria stated above, the criterion, “to be in a state where a natural death is reasonably foreseeable,” seems almost draconian, even with the prospect of advances in medical science and technology. Is any hopefulness of a long-term view that is baked into this criterion truly reasonable and defensible? In the meantime, wide swaths of needless suffering continue unabated.
The criterion of being in a state where a natural death is reasonably foreseeable could also be viewed as the ultimate hedge against working through a slew of difficult and challenging cases where it is not always clear to medical and legal practitioners what to think or how to proceed.
Here, I present two fictitious accounts for your thoughtful consideration …
An 18-year-old man can no longer see the point in living, having descended into a nihilistic point of view from long hours spent in front of a computer doing conspiracy research, making it virtually impossible for him to function in any meaningful way. He sleeps long hours and rarely eats, putting himself at risk of an early death. He would like to fulfill a wish to die and knows that he is quite capable of giving consent.
Who is to say his dis-ease is curable? Who is to say his decline in capability is reversible? Who is to say his suffering cannot possibly be intolerable? Who is to say his natural death is not reasonably foreseeable? Who is to say he’s not capable of giving informed consent?
Yes or no?
An 18-year-old woman can no longer see the point in living, having been bullied (yet again) into submission to the nth degree by one of her female friends for having the gall to question her taste in boyfriends. Rather than risk a failed suicide attempt, she cuts back on her eating to the point where she becomes dangerously anorexic. She applies to die and knows that she is quite capable of giving consent.
Who is to say her dis-ease is curable? Who is to say her decline in capability is reversible? Who is to say her suffering cannot possibly be intolerable? Who is to say her natural death is not reasonably foreseeable? Who is to say she’s not capable of giving informed consent?
Yes or no?
These two accounts highlight the daunting challenge of bringing legitimate criteria, no matter how strict, to a request for a medically-assisted passing, even as a delay to buy time to assess further would likely be taken by most as a wise precaution rather than a cruel imposition.
We can always hope and trust that society at large improves, evolves, and matures far enough and fast enough in its culture and wisdom to prevent these sorts of cases from ever occurring, but until then?
don’t react; don’t even change the way you react;
just expand your capacity for understanding and acceptance
so that any sort of reaction is no longer an option
The alarmingly high annual rates of suicide and attempted suicide around the world are fair indicators that (1) a pent-up demand exists for this type of service, and (2) many if not most of the nations in this world are not doing a very good job at supporting their respective citizenry.
To the leaders of this world, you can’t have it both ways: either support your citizens to live their lives the best way they know how or support your citizens to die in the most meaningful ways possible. But then, with enough insight and oversight, maybe you can have it both ways.
Unfortunately, humanity has not yet evolved far enough to treat this matter purely as a competitive venture. Competition with strict oversight, however, is likely the best option, with competing clinics and the public at large bringing their standards of care up to speed very quickly.
The various cultures around this service would likely grow more slowly in response.
One type of clinic might serve the geriatric population; another might serve those diagnosed with a terminal illness; another might serve those who suffer an incapacitating, unendurable illness, disease, or disability; another might serve those subject to unbearable, uncontrollable pain.
In making these distinctions, uppermost in my mind is the “scrupulous monitoring” that would be required to safeguard against this predatory danger: those who would terminate lives without proper consent, i.e., without consent that is both informed and express (see below).
don’t react; don’t even change the way you react;
just expand your capacity for understanding and acceptance
so that any sort of reaction is no longer an option
At present, I can give you at least two reasons why this topic is so interesting to me:
- I have a keen, enduring interest in quality of life in relation to personal fulfillment; and
- I have a keen, enduring interest in coping with a lack or loss of personal meaning
Anyone who has lived a life rich with meaning understands that a sense of meaning ebbs and flows. A spiritually savvy person already knows that life is meaning-less, and I hyphenate here for emphasis to indicate that life has no inherent meaning; we ourselves supply the meaning.
That is, from my point of view (or yours), life can only seem incredibly meaningful. Consequently, life itself can never be meaningful; only a life can be meaningful to the extent to which it can be lived and lived well, with a sense of balance and discipline, satisfaction and fulfillment.
Furthermore, a spiritual initiate can share intimations of what it means to forgo the ego (at least for a time) and settle into the Self, to move above and beyond preoccupations with personal meaning so as to welcome and receive an enduring experience of impersonal freedom.
In this light, I offer you these questions for your considersation: is the spiritual adept someone who can forgo the ego at will or someone who can forgo the ego forevermore? Could it be that a spiritual adept is someone who has no choice but to forgo the ego forevermore?
Or is a spiritually adept someone who can forgo the ego at will and summon personal meaning with the agility of a ninja, depending on the encounter or interaction, the situation or the circumstances?
In view of these questions, the concerns of caregivers are likely served when they can distinguish the need for meaning of someone in an advanced state of decrepitude from that of someone who has been diagnosed with a terminal illness, from that of someone who suffers an incapacitating, unendurable illness, disease, or disability, from that of someone subject to unbearable and uncontrollable pain.
In my view, quality of life is recognized by two subjective measures: (1) the extent to which I feel satisfied (or dissatisfied) with the material comforts that support my life and (2) the extent to which I feel fulfilled (or unfulfilled) by the moral and spiritual lessons that inform my life.
A meaningful life is one in which I feel reasonably (defensibly) confident that I can (a) sustain or improve, and/or enjoy, the material supports and comforts of my life in perpetuity, and (b) explore, engage, express, and enjoy the moral and spiritual lessons of my life in perpetuity.
Again, life is meaning-less: life itself can never be meaningful; only a life can be meaningful to the extent to which it can be lived and lived well, with a sense of balance and discipline, satisfaction and fulfillment, and so, one is well advised to ask: what is meaningful to me?
In the heart of a caregiver: what is meaningful to this patient with a request to die?
Let us revisit the criteria to get a taste of what this question could mean in practice.
The Criterion of Age (Can this Patient Keep Giving Informed Consent to Die?)
By the criterion that a patient with a request to die must be at least 18 years of age, what if a child or teen meets all of the other criteria? I can well imagine there are at least a few children and teens who have a serious, incurable illness, disease, or disability, who are at an advanced stage of irreversible decline in capability, who endure physical and psychological suffering that is intolerable (and cannot be relieved under conditions they consider acceptable), who are in a state where a natural death is reasonably foreseeable (taking into account all of their medical circumstances, even without a prognosis having been made as to the specific length of time they have remaining); and who are still able to maintain informed consent from the time that the request is made to the time that the means of death is administered.
Again, what is meaningful to these patients with a request to pass in peace?
The criterion of age is meant to serve as a hedge against uninformed or misinformed consent, but interestingly, where giving and maintaining informed consent is concerned, some rather strict safeguards are already in place to protect vulnerable persons over the age of 18.
The Criterion of Serious Incurability is Not Enough to Meet a Request to Die
By itself, the criterion of serious incurability is not enough to meet a request to die.
This is another of saying that those who are diagnosed with a serious, incurable illness, disease, or disability can still (potentially at least) explore, engage, express, and enjoy their lives in ways that are meaningful to them with a quality of life that supports them meaningfully.
One might reasonably argue, in light of the sections that follow, that Serious Incurability is not so much a criterion as it is a linchpin condition around which the other criteria can revolve. One might also consider expanding or refining the medical definition of serious incurability to include or at least take account of what is personally meaningful to a patient with a serious request for a peaceful passing.
The Criterion of Irreversible Decline in Capability Requires a Diagnosis
Suppose someone you know and love dearly enters a state of irreversible decline in capability, but without a proper diagnosis of a serious, incurable illness, disease, or disability, either because a diagnosis was incorrectly made or because a diagnosis cannot be made at all.
By the same token, without a proper diagnosis, how can one know for sure whether someone has entered a state of irreversible decline in capability? Might this state of affairs not preclude making and/or fulfilling a meaningful request to receive a medically assisted passing?
These questions are especially relevant to an apparent mental illness with a biological cause.
A mentally healthy and vital person is a person whose sense of meaning is almost assured.
The Criterion of Enduring, Intolerable Pain and Suffering
For myself, through my own experience, I know all too well the meaning of pain and suffering that is both enduring and intolerable, and so I would venture to say that the hallmark of enduring, intolerable pain and suffering is simply this: it seems as if it is going to last forever.
Only someone with strength of character can be reminded in the midst of enduring, intolerable pain and suffering that said pain and suffering cannot last forever. I would also venture to say that those who casually say that “suffering is a resistance to pain” have not really suffered.
The problem with this criterion lies with its insistence that the enduring, intolerable pain and suffering be both physical and psychological. On the one hand, if said pain is physical in nature and origin (and therefore ascertainable), any psychological suffering that goes with it is easy to grasp and therefore accept as valid. On the other hand, if said pain is psychological in nature and origin (and not so easily ascertainable), any physical distress that accompanies it can be easily downplayed with the cruel reassurance that “at least you’re not in any real pain.”
Or worse: “it’s all in your head.”
There’s also a danger of spiritual fascism with its tyranny of positivity having its way with patients who make requests to die, insisting that “you create your own reality” and therefore “with proper attention and training, you can heal thyself and relieve thyself of thy pain and suffering.”
For those who cannot begin to fathom what it means to create their reality, or even create their own experience of reality, might their lives not feel at least somewhat devoid of meaning in the face of enduring, intolerable pain and suffering that is both physical and psychological?
One consolation under this heading is that patients who suffer psychologically from physical pain at least have a say in what constitutes relief under conditions that they themselves can deem acceptable or not.
The Criterion of a Reasonably Forseeable Natural Death
Of all of the criteria put forth to meet a request to die, this one is the most restrictive.
Patients making such a request must be in a state where natural death is reasonably foreseeable, taking into account all of their medical circumstances, even without a medical prognosis having been made as to the specific length of time they have remaining in this world.
I addressed this criterion earlier in this post. Here it is again for ease of reference … Still, in view of someone who has a serious, intractable mental illness or a long-time disability that meets most of the criteria stated above, the criterion, “to be in a state where a natural death is reasonably foreseeable,” seems almost draconian, even with the prospect of advances in medical science and technology. Is any hopefulness of a long-term view that is baked into this criterion truly reasonable and defensible?
In the meantime, wide swaths of needless suffering continue unabated.
The criterion of being in a state where a natural death is reasonably foreseeable could also be viewed as the ultimate hedge against working through a slew of difficult and challenging cases where it is not always clear to medical and legal practitioners what to think or how to proceed.
In the meantime, is this criterion really fair to those who feel their lives have lost all meaning and who cannot reasonably and defensibly expect to restore any sense of meaning in and for their lives?
The Criterion of Informed Express Consent is Fraught with Difficulty
Imagine a world where anyone could meet a request to die by simply making the request.
With no criteria to meet, with no difficult discussions to endure, and with no complicated laws to follow, you could simply book an appointment, get your affairs in order, walk into a clinic of compassionate deliverance, say your good-byes, and be delivered into the Great Beyond.
How fast do you suppose this planet would empty of people if such a state of affairs obtained? And how fast do you suppose the standard of living would rise in the wake of such an exodus, to the point where most clinics of compassionate deliverance went out of business?
As a baseline libertarian possibility, it might serve as a robust counterpoint to prevailing authoritarian structures of “we know best.” One can imagine advocates, both public and private, coming out of the authoritarian woodwork to serve the most vulnerable members of society.
Now imagine a world where no one could meet a request to die regardless of condition or circumstance. At one time, suicide was considered illegal, no matter the reason. Today, doors are beginning to open around the world to having a choice to die with some measure of dignity.
The matter of informed express consent, where a medically assisted death with dignity is concerned, is not without its difficulties. The brief examples that follow are barely scratching the surface, but in my mind, they are fairly representative of the real-world challenges …
A suffering child can be coached to consent to a dignified passing, a consent that could qualify as being informed, but would such consent be fully informed, even if this child is recognized as precocious?
A wealthy elder in an advanced state of decrepitude can be unduly influenced into giving consent to a death right up to the moment of death, but would such consent be recognized in a legal dispute?
A terminally ill woman consents to a medically assisted suicide, but without being properly informed about palliative care. Could such a consent hold up in a court of law in the face of a legal challenge?
A severely disabled man consents to euthanasia, but when the time comes, he is no longer able to give his express consent. Is the attending practitioner liable if the procedure is completed as requested?
A rapist subject to unbearable, uncontrollable pain consents to being euthanized. If, at the last minute, and for the third time, he withdraws his consent, might it still be okay to go ahead and euthanize under the guise that a mild sedative and a painkiller are being adminstered?
A mature man is spotting signs of dementia in his person and contemplates signing an advanced directive to be euthanized when he can no longer give consent, only to realize this directive holds no legal force in his country because it obviates express consent. Would you accept having advanced directives to legally die with dignity in your country, even if this means not being able to give consent at the time of death?
We have all had moments when something agreeable to us became disagreeable, or vice versa. Acts of assisted suicide or euthanasia are irrevocable, and so it would be understandable to have second thoughts about going ahead with a procedure that would end your life.
Express consent implies being able to withdraw your consent at any time between the time you initially give your consent to die and the time you give your consent for the last time before you die, but it especially applies to being able to withdraw your consent before you can die.
Express consent is a strict legal safeguard against error and abuse in the provision of a medically assisted death, so as to protect vulnerable persons from being induced, in moments of weakness, to end their lives, but in light of the examples above, it does have its challenges.
Giving and taking informed consent is also not without its challenges.
In view of a medically assisted death, what is informed consent for (a) a suffering child who is not very bright? (b) an inconsolable teen who wants to see grandma in the afterlife? (c) a morally infirm elderly person of means being unduly influenced in the direction of death by family members? (d) any infirm adult of means being unduly influenced? (e) a terminally ill person not being informed (or being misinformed) about caregiving alternatives to dying? (f) a savvy adult who signs an advanced directive at a time when medical technology is not so advanced.
Educating and Entertaining the Public about Death with Dignity
This would not be a topic that I alone could address and resolve.
And this would not be a topic that I dare address without humility.
Nor would it be a topic addressed without patience and diligence.
But I ask you: could this be a topic that is worthy of persistence?
I surprised myself in going as far as I did in writing this post. Where my personal fulfillment is concerned, I would rather keep my focus on life, and on living the best way I know how, and most people would likely prefer to do the same, but in writing on this topic that is too dark for words (at least at the current state of humanity’s collective evolution), I gained a much deeper appreciation of my life, and of life in general.
Although I tend to favor the approach of my country (Canada) to apply the most strict criteria and safeguards possible to requests to fulfill acts of assisted suicide or euthanasia (with the possible exception of the criterion of a reasonably forseeable natural death), it is also my hope, as society improves, evolves, and matures in this area of law, that the inclusivity and stringency of these criteria and safeguards be relaxed over time to accommodate, assess, manage, and fulfill the requests of those who would truly benefit from the blessing of a peaceful passing.
But I ask you: could this be a topic that is worthy of persistence?
Of course, in the grand scheme of things, it is certainly worthy, but what I mean to ask is more personal: could this be a topic that is worthy of persistence, of exploring and expressing in depth and with considerable breadth, without having any truly compelling reason to persist?
Here, I could simply say “I don’t know” and be done with it, and move on, but I know deep down that this would be a cop-out in light of what I know about consciousness on both sides of the murky, mirthless, and mysterious divide between life and what we keep calling death.
This post is already too long and so I will save this question for another time.
Just know that a wealth of literature on many subjects could be tapped meaningfully to bring this dark topic into the light. In the meantime, I would invite you (encourage you even) to explore and examine this topic for yourself, if you feel so inclined (or compelled).
Maybe in plumbing the depths of death, we can also explore the depths of life.
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