Death represents the only certitude we have in life. Our hour will inevitably come and each person must ask himself how he wishes to die. Doctors, like everyone else, are vulnerable beings and they are subjective and emotive, and have personal ethics based on religious beliefs and philosophies. We identify with each other and are faced with our own death and the questions: when will it occur and how?
We know very well that there is no age for dying and that death can knock on our door at any moment and under the most unexpected circumstances.
Death is not like the farmer who waits for the wheat to ripen before he cuts it; it does not always wait for man to take hold of his life before taking away that life. Unexpected departures, premature and sudden, profoundly affect us, which is totally understandable, and leave us with the feeling of injustice and incomprehension.
There are other situations where the fight against illness can be won; everything must then be done to win that battle. That is the responsibility and the honour of the doctor. But when illness is incurable and cannot be overcome, the doctor and the patient gradually understand that the fight is lost. That evolution can lead to a slow decline, which is accompanied by inevitable physical and psychological deterioration. We are then left with the fundamental duty to accompany the patient to his death.
We were trained at a time when medicine seemed to be able to push the limits of life further and further back. Because of our therapeutic relentlessness we have often managed to prolong the quantity, to the detriment of the quality of life. The courses we followed in medical psychology at that time did not deal with the fact that man is finite. We did not learn to speak to our patients about the end of life or the approach of their own death.
Today, palliative care deals with this to some extent, but only to a limited extent. The discussion can be opened in certain cases when death is inevitable, expected by the patient, his family and even his doctor. Death is no longer considered to be the enemy, but rather as a friend who will deliver the patient. Doctors will react differently, depending on their personality, medical specialty, and personal and human experience. In addition to this, the contact established between the doctor and the patient will influence the choices and therapeutic decisions. The discussion about the problem of death is obviously difficult because the doctor must accept and recognize his professional limits and the end of his being “all powerful”.
Nowadays the doctor may find himself faced with a lucid patient, one who is perfectly serene as regards his own departure, one who wishes to decide on the moment of that departure. If the patient wishes to let go of life, his moral competency must take precedence over other skills possessed by his doctor, because he is the person who is going to die. He alone possesses the necessary criteria to know if the quality of the remainder of his life is adequate or not.
Exit ADMD, an association in the French-speaking area of Switzerland, (association for the right to die with dignity) offers help to its members who wish to have assisted suicide if they fulfill the following five conditions:
- discernment
- repeated serious requests
- incurable illness
- intolerable physical or psychological suffering
- terminal prognosis or serious disability in cases of non – oncological pathology.
These criteria represent a coherent whole, because they are understandable from a human point of view; they can be defended medically, are legally justifiable and are politically acceptable. In addition, they were debated by the National Council on 11th December, 2001 and the Vallender initiative which aimed at stopping assisted suicide was rejected. In a press communiqué of 1st October, 2001 (www.SAMW.ch) the Swiss Academy of Medical Scientists (ASSM) declared that “contrary to its former position, the ASSM maintains today that, in certain cases, assisted suicide can be considered to be part of a doctor’s activity : competent, comprehensive help on the path towards the last major step from life to death. The dying person cannot delegate this step to the doctor, but can carry it out himself, of his own free will”.
As president of EXIT ADMD in the French-speaking region of Switzerland and as a person who accompanies, I have accepted the heavy burden of assisting several people in their suicides. These sick people granted me the privilege of being included in their close family circle in the preparation and organization of their departure. The moments I shared with them and their families have been the most intense, deep and truest moments I have ever come across in my life. Each time I accompanied people it has been a moment of exceptional emotional density, a moment which transformed me. In these unique instances, spirituality is privileged. I remember, in particular, an accompanying instance when a pastor, a long-standing friend of the family, agreed to be present for the departure. First of all, the pastor read psalms which the sick person loved, and then he bade farewell, praying that the light of Christ would illuminate the valley of death he was preparing to cross…..
I do not regret any of the assisted suicides I have carried out; because on each occasion I have done something for someone else that I hope someone would do for me.
The taboo of “the good death” should be broken in our medical faculties. Courses in Thanatology could be introduced in the framework of teaching medical psychology. In this way, our young colleagues could acquire, if they so wish, the correct approach regarding the problem of assisted suicide. It is necessary to be prepared for death and it could be approached in a serene way. For certain people, death represents something which is as natural as life and which opens a door to new hope.
Transl. from “Médecine & Hygiène” 2442, 18 juin 2003