Headings:
Relationship to the Last Breath
Guidelines for Assisted Death
Unbearable Pain and the Future
Reflection and Meditations on Death
The Politics of the End of Life
To Be or not To Be
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Relationship to the Last Breath
I saw the four-day old corpse of my mother, who died peacefully in Brisbane, Australia in March 2015, aged 94 years, 11 months and 11 days. She was the last dead person I saw. She died peacefully. In the Home for the Aged at Windsor, Brisbane, Australia, she asked one of the staff to make her a cup of tea. It was around 8 am.
Just as the staff person left the room, my mother said to her: “Oh, I am ready to die.”
The staff smiled and said “Oh, Peggy.” (my mum’s name).
A few minutes later, the young woman returned to my mum’s room with the cup of tea. My mother has passed away. She had lived free from Alzheimer’s, cancer, a stroke and other major afflictions of old age although she had many operations – heart, knees, hips, shoulder blades. The day before died she was planning to go to the cinema with my sister and make a cake for the staff and residents for her upcoming 95th birthday.
For others, the transition from life to death is long and painful.
Some people have to endure unbearable and untreatable sickness and pain. Medication offers little respite or, at best, a short relief, from the intensity of pain or constant nagging aches. Some lose all motivation for living and wishes to bring their life quietly to an end through what has come to be called self exit. Such people understandably prefer the term ‘self-exit’ to the word ‘suicide’ since to commit suicide carries the sense of a reaction to circumstances rather than a quiet, sustained reflection on the wisdom of self-exit.
After due consideration, he or she wishes to self-exit from this world owing to their painful physical realities or major decline in neurological/mental faculties or both. The law does not support any kind of assistance for those who wish to terminate their life. The law does not give support to loved ones, such as husband, wife, partner, family or friends, who would be willing to be present at the time the person wishes to terminate their life.
Research shows an inconsistency in the current law. Engaged in palliative care, doctors and staff may take the decision to allow the person in unbearable and untreatable circumstances to die by not insisting on food nor drink for the patient, even though it could cause distress and anguish for family, partner and loved ones, as well as the patient, even if mostly unconscious. While other patients no longer have any wish for a nutrient.
There are a growing number of requests to change the law to enable doctors to administer the necessary drugs to enable the patient to pass quietly out of life. This approach expresses a voluntary assistance of doctors in the transition from life to death of a tiny number of their patients. Currently, doctors will administer painkillers knowing full well that it might well terminate a life.
Euthanasia is the deliberate intention to cause death of another to protect the person from further suffering. Assisted suicide means that the person receives assistance for their wish to die. She or he fully agrees to the process leading up to death and takes the final step themselves for their self-exit. Under the Suicide Act of British law (1961), a person who engages in euthanasia can receive a life sentence. A person who assists a self-exist or suicide can receive a prison sentence of up to 14 years.
I saw an elderly woman in the gym in Totnes, Devon, where I live, with a tea shirt that said on the back: “82% of people in Britain support assisted deaths.”
It is time to change the law.
People opposed to assisted death or euthanasia frequently express concern that family members, subtly or grossly, might employ forms of coercion to encourage a person to self-exit. Such opponents express a genuine concern that family members or friends may have become tired of supporting the suffering person. They may regard an assisted death by the doctors for a patient as a way out of their commitment to provide care for the suffering person. There are concerns that it is gradually becoming easier for patients to opt for assisted termination of their life when their circumstances do not merit such a final action.
Those who advocate assisted death state repeatedly that the sickness or injury of the client must have reached the point that the patient’s condition is both untreatable and unbearable. If two doctors agree to this determination, they could regard the decision to prescribe the necessary drugs for self-exit as an ethical step, rather than collaboration to take the life of another human being.
The vast majority of countries have not provided the necessary legislative framework to enable a person to choose to bring their life to a close. Holland, Belgium and the state of Oregon in the USA have passed laws stating that doctors will not be punished for offering the medication for a patient to end their life. The doctors are obliged to provide information to a review committee, as well as to the coroner, whenever they issue the medication for such a step. The doctor must be present at the time of death.
The Dutch government has granted permission for assisted death for young people, aged between 12 and 16 years, provided there is full permission from the parents.
Guidelines for Assisted Death
Under the Dutch law, the two doctors have to interview the person to check that the patient has the capacity to express a clarity of mind, a competence to take the drug to terminate his or her life and the ability to make clear to the doctors that there is very little quality of life left owing to their unresolvable painful circumstances.
Once the person has made the decision to terminate their life, the patient has to make a written application on two separate occasions to both doctors for their support. The doctors have to address the possibilities with regard to palliative care for the patient so he or she becomes fully aware of other possibilities besides self-exit.
If necessary, doctors in Holland, Belgium and Oregon can consult a psychiatrist to determine the psychological condition of the patient. There are meetings with family members who have the opportunity to offer their perceptions, as well as the arrangement of the practical steps towards self exit of the patient.
Loved ones may not be aware of their underlying motives and honestly believe they act in the best interests of the loved one. Others may harbour secret thoughts of the benefits from the person’s last will and testimony. They fear a long drawn out period of years before the loved one dies with the costs and time involved. Again, they may conclude that assisted death offers a peaceful exit while avoiding their own thoughts of self-interest. The belief in the interests of the suffering individual may obscure the depth of self-interest. These are realistic concerns. Others oppose self-exit and euthanasia on moral and religious grounds.
Those who resist supporting the law for assisted death and availability of medication to end life find themselves blocking the circumstances the way other people with incurable pain and sickness who wish to die.
Sickness and pain can overwhelm the individual to the degree that he or she has lost their peace of mind, natural happiness and the capacity for creative expression. The residue of pain and anxiety sustains itself on the daily basis until the person can see no possible point in prolonging their own life. Such people see nothing in the way that is positive with regard to the future. Others have neither anxieties nor fears but simply see no point in continuing life with ongoing pain in the body.
The Buddha took a sympathetic view in such circumstances as a small number of his Sangha “took to the knife” to terminate their pain.
The approach of death has the potential to make a considerable impact on the deepest vulnerabilities of the individual. As people get closer and closer to death, some experience degrees of emotional, spiritual and existential anguish, if not crisis. Pain and insecurity make the greatest challenge on a person rapidly approaching the end-of-life.
Unbearable Pain and the Future
The decision to self-exit requires step-by-step planning to engage in the act of quiet determination to put an end to an intolerable situation.
Based on their past experience with other patients, as well as the application of medication, the doctor may get a sense in terms of days, months and years of how long the patient has left to live.
Even with years of experience in offering palliative care and prescribing necessary medication for health, doctors cannot offer any accurate assessment of how long a patient will live. They can only make predictions; sometimes these predictions prove accurate and sometimes they have totally miscalculated the patient’s life expectancy.
Three or four doctors or more can come to radically different conclusions about a patient’s life expectancy ranging from weeks to years. Doctors will share their projections into the future if the patient wishes to hear the views of the physician. It is not unusual for a doctor to express a broad view from weeks to years. It is another way of saying “I don’t know.”
The condition of the body/mind can change. A person can experience a sudden change releasing much energy that sometimes contributes to a healing. Many factors, physical, emotional, medication, spiritual, religious, the relationship with loved ones, environment and life itself can extend life by years. The health of the body can also slump in dramatic ways so death gets much closer than anyone, including the consultants, expected.
Patients may reach the point of wishing to free themselves from the dependency on doctors, priests, family and people engaged in palliative care. Patients reach the conclusion that the termination of their life takes priority. There is a need for legislation to acknowledge the deep wishes of such people.
The knowledge of engaging in a process culminating in self exit can also have a major impact on the patient. Assisted death may offer a temporary lease of life once the patient and doctor have fixed the day of death. Others may respond differently knowing that they have a limited time left on this earth. This can trigger despair at the thought of losing their loved ones, their life on this earth and ending their self existence but they have no wish to change their mind because of their incurable circumstances.
Reflections and Meditations on Death
Doctors can face a major moral dilemma in terms of their relationship to the Hippocratic Oath if they were legally permitted to offer medication to determine the end of a person’s life. Under the Hippocratic Oath, doctors must act in the best interests of their patients and ‘uphold ethical standards in the names of the Greek gods.’ The doctors also take the oath to pass on to others their knowledge.
Doctors should apply ‘dietetic measures for the benefit of the sick according to ability and judgment.’ He or she vows to “keep patients from harm and injustice.”
The Oath states: “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. I will guard my life and my art.”
Doctors have taken the oath to do no harm but the blind pursuance of using medication and technology to keep somebody alive may harm the psychological, spiritual and existential issues of their patients. I gave my doctor in Totnes a note in 1982 that stated that under no circumstances should a hospital keep me alive through use of electricity. I have no assurance that a hospital would respect my wishes. I regard use of such machinery as a waste of time and energy at my age.
Instead of trying to keep dying people alive, we need to develop skilful means to explore the end of life processes and make our wishes clear to doctors long before we find responsibility for our life totally out of our hands. We can express in writing our determinations for our treatment to our physicians, specialists and family to ensure our wishes as much as possible are carried out.
We need to discuss life and death. Conversations about pain, dying and death, extinction or life after death challenges us to go out of our comfort zone. There are meditations, yoga exercises, breathing practices and postures that can form part of the process of an authentic palliative care that can transform the lives of those dealing with untreatable and enduring pain.
There are reflections and meditations on death. In alphabetical order:
- abiding in the unknown
- appreciative joy in the face of impending death
- coming and going,
- duality of life and death.
- emptiness of self
- existence and non-existence, one giving rise to the other
- freedom from clinging
- Impermanence, change, gradual and sudden
- letting go,
- moment to moment unfoldment
- rising and falling of experiences and events
- staying in the ground of equanimity.
- timelessness
We can develop skilful ways to reflect on the past and come to terms with our strengths and failings.
We can develop a valuable practice of living fully one day and one night at a time. We can experience time going by very quickly, very slowly or at no particular speed.
We can see and know the relativity of time.
Those facing death can offer and share their profound insights with those with ears to hear.
We need to bring death into life rather than reject it. Teachers need to take schoolchildren and young adults to visit hospitals homes for the elderly, to hospices, funerals and cemeteries. People of all ages need to have the opportunity to talk with doctors, nurses and people involved in palliative care. We need to arrange visits to the funeral parlour and the mortuary to see corpses and ask staff questions.
We need to share our experiences of witnessing sickness, pain and death. We need more Death Café groups, where people meet for a coffee weekly to discuss death. We need more End of Life groups. We need to invite people, young and old, to view and meditate on our corpse when we die.
Our medical profession, hospices and family support systems engage in precious care for those moving towards death but, generally speaking, lack the skilful means, methods and techniques to enable a dying person to move fluidly and freely through major transitions. Treatment between patients in a hospital or hospice may vary. Patients with loving family members who frequently visit the hospice may receive more loving and caring treatment than a patient who has no visitors or only an occasional visitor. The quality of palliative care often varies from one patient to another and from one hospice to another.
The willingness to address death and share our observations starts the process to taking the fear out of death – regardless of any secular, spiritual or religious beliefs. Death starts to lose its sting when we face it. Death remains inseparable from birth. There is the birth and death of every moment, of every experience, of every day, every month and year.
Realisation of the deathless takes priority, namely a freedom from living in the fearful spell of death. Society needs to explore the development of a whole host of practices to dissolve the scale of perceived differences between life and death. Attraction and aversion to life or to death exaggerate the differences between life and death.
The Politics around the End of Life
Governments, society, health insurance companies, religions, hospitals, doctors, families, patients may have a range of motivations with regard to their view of the continuity of life and the cessation of life. Health insurance companies might collapse overnight if they were seen to advocate a change in the law permitting assisted death and euthanasia. People would feel concern that the motivation of such insurance companies would show they value profit before people by saving money on an early death. Health insurance companies have a vested interest in shortening the length of time of treatment.
Aged from around 16 years to around 65 years, the working population develops the economy that helps support an ageing population. There is a growing threat to this principle due to the fragile state of the economy, massive tax avoidance by the biggest corporations and deaths per annum outnumbering births. There needs to be a 2% increase in birth rate to offset the number of deaths. For example, a crisis looms in Japan with the birth rate at 1.3% with the potential for a drop of one third of the working population in the next generation. How will a country support a very elderly population of millions of people?
At the behest of governments and political parties, the media regularly express concern that the economy does not contain the resources to support an ageing population. We are told that we face huge health bills due to the costs of prolonged disease and treatment used to keep people alive even with a low quality of life.
It is not unusual for Western governments to show publicly a negative attitude towards refugees. Economists knew there is the potential for a crisis if we reject the hard working presence of refugees, often employed on low hourly rates, who keep the financial system running. Economic realities have a greater influence on motivation of governments than political ideology. Immigrants, refugees and asylum seekers make a vitally important contribution to the economy along with their payment of taxes to support the system and the elderly.
Western governments may pass the law within the next few years for doctors to administer medication to terminate life to save significant sums of money in palliative care. They will present their decision to pass the law as an act of ethical responsibility or compassion rather than an economic decision.
Patients can quickly assimilate the idea that termination is the preferred and better option. Some patients fail to receive the appropriate medication whether biological or neurological. It is not possible to palliate loss of the particular functions of various parts of the body nor palliate the deep spiritual/existential issues on facing death.
Some doctors, families and patients reject the introduction of passing a law for assisted death or euthanasia in case, slowly and insidiously, it leads to the normalisation of assisted death or euthanasia to avoid long-term care. Yet, the final need of those with untreatable and unbearable pain needs recognition and support for their self-exit.
A key factor in the very last stages of life also revolves around motivation. There appears to be a general agreement that doctors working in palliative care regularly find themselves making a decision to bring a patient’s life to a close without their consent. The doctor provides the medication to reduce any pain that the patient is experiences but the doctor also can knowingly provide sufficient medication, such as painkillers that bring an end to the life of the patient.
Some doctors do provide terminal sedation to enable a person to fade out of life. The person receives sedation until they fall asleep and quietly slips into death.
Some doctors find themselves giving rise to the inner question of motivation: Was my intention to end suffering or to end life? Their inner response to such a question may determine their peace of mind or give rise to self-doubts and remorse. The same principle applies to family, friends and the loved one enduring pain. What is the motivation that shapes the thinking around self-exit, assisted death, euthanasia and suicide?
Many people assume that euthanasia applies specifically to patients with a terminal illness. This is not the case. The application of euthanasia applies to those patients experiencing unbearable and untreatable illnesses. The pain and the illness have the potential to last for many years.
To be or not to be
Perhaps the most important decision that a person can ever make involves the termination of their life.
Some fear that if government passes a law to support assisted death, the people experiencing pain and the frailty of old age might start thinking that doctors and family will turn their back on them leaving no alternative but to request medication to end their life.
It is common knowledge that some people especially the elderly, do not wish to be a burden upon others, particularly as life draws to its close. One part of the mind may wish to have the opportunity to terminate one’s life while another part, sometimes a deeper voice, wishes to allow life to draw to its close in the coming days, weeks or months, without any kind of interference in the process.
Some may consider self-exit, assisted dying, euthanasia purely as an ethical issue going against spiritual, religious and existential views. Others simply lack the strength of motivation. Other patients will say: “I have no wish to interfere in any way with the unfolding process leading to my death at some point in the future.”
Human beings regularly gets measured by their value in terms of personal wealth. People regularly regards themselves as an economic unit. They can experience a loss of self-worth through sickness that prevents them from the opportunity to work. The combination of appreciation of the worth of the family and friends by the patient matters as much the appreciation for the loved one enduring continuous pain.
More than anything, the power of love contributes to the fading away of fears of pain and death.
May all beings be free from fear
May all beings know the power of love
May all beings live with wisdom
Next: Part Three of four