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The Right to Die and Government Intervention

stained glass depicting two figured displaying mercy to dying man

On June 14th 2022, 44-year-old Federico Carboni became the first person to die as a result of physician-assisted suicide in Italy. Carboni was paralyzed in a car accident in 2010 and fought for many years for access to death with dignity. In 2019, Italy’s Constitutional Court ruled that assisted suicide is constitutional under the conditions that the patient seeking it is capable of making autonomous decisions and is in overwhelming and persistent pain. Health authorities granted permission in November 2021 for the death to take place. Carboni died in his own home as a result of taking a prescribed lethal drug.

Euthanasia is very controversial in Italy; it is opposed by the Catholic Church. Indeed, in a dominantly Catholic place like Italy, some are concerned that religious values are unduly influencing the extent to which people can behave autonomously. A debate about this general issue is raging across Europe:

Should people be able to choose the conditions of their own death? Should doctors ever assist patients in bringing about death? If so, how and under what conditions?

There are two general types of euthanasia: passive euthanasia – the withholding of life preserving treatments – and active euthanasia – administering a lethal drug to directly cause the death of the patient. Active euthanasia is legal in Belgium, Luxembourg, and the Netherlands. Passive euthanasia is legal in those three countries and also in Finland, Sweden, Norway, and Austria. Euthanasia of any form is illegal in France, but they allow patients who are terminally ill and in terrible pain to be kept under “deep sedation” until they die.

In 2014, Belgium became the first country to provide access to active euthanasia to children with parental consent. To qualify, the child must demonstrate that they understand what will happen when they are euthanized and they must be in serious pain. In Belgium and in the Netherlands, patients can request euthanasia if they feel that they can no longer live with mental illness. In 2016, Mark Langedijk, a patient in the Netherlands, became the first person to be euthanized because he no longer wanted to suffer from alcoholism, a problem for which he unsuccessfully sought treatment in rehab twenty one times (for discussion, see Marko Mavrovic’s “What It Means to Legalize Euthanasia”).

Euthanasia is controversial in the United States as well. Physician-assisted suicide is legal in ten states: California, Colorado, Hawaii, Maine, New Jersey, New Mexico, Oregon, Vermont, Washington. The practice is illegal in 33 states.

Those who support euthanasia often argue that respecting the conditions under which a person wishes to remain in existence and those under which they don’t is fundamental to treating that person with dignity. What’s more, governments shouldn’t be in the business of preventing these kinds of decisions. Human beings are not the property of any government; it should not be in a position to answer for a person what is, at its core, perhaps the most deeply personal question there is: the question of whether to continue to have subjective experiences at all.

If this is the case, whether someone is permitted to die humanely and on their own terms shouldn’t vary from one country or region to the next. Instead, it should be understood as a universal human right.

Many who agree with these points about respect and dignity argue that there continues to be a role for the state in all of this.

Even if governments ought not to get involved in answering the general question of whether patients have a right to die, it might be important for them to have a set of laws and policies in place that lay out the conditions under which it can happen.

If governments have an obligation to protect their citizens, some patients might need protection against manipulation, coercion, and impaired thinking. For instance, a person who is suffering from a lengthy disease might be concerned that they are too much of an emotional and financial burden on their family. Though they might not actually want to die, they may choose euthanasia to save their loved ones’ time and money. Another person might, in a moment of frustration and pain, make a decision to end their own life that they might not have made at a later time. A person may be too young or incapacitated to make a truly autonomous decision. These might all be legitimate reasons for state intervention.

We might also consider the issue from perspectives other than suffering individuals who might have their preferences thwarted. A country’s health care system is one of its central human services. The government has an interest in making sure that people are well cared for, and that doctors and other medical professionals have the kinds of values to do their jobs well. They want medical professionals who have respect for life and don’t have inclinations to do their patients harm.

In response, advocates of death with dignity argue that respect for life entails more than extending any given life as long as possible. When we say that life is valuable in the case of a human person, it is because there is a subject present who is capable of valuing their own existence and of having positive experiences in the world. Real respect for life entails empathy for living things when what is valuable about life for a given person is forever beyond their reach. Sometimes, death is a health care decision.

In the United States, twenty-seven states still use the death penalty as punishment. In most of these states, euthanasia is illegal. This sends the message that the state is in a position to judge when a person should die before the natural termination of their life, and is even justified in executing the person itself, but a suffering patient, in consultation with their doctor, is not in a position to make the same decision about their own life in accordance with their own values. This set of policies suggests that such governments value retribution more than mercy and control more than autonomy.

“Unbearable Suffering” and Mental Illness

Photograph of a single bed with a curtain and chair

Trigger warning: suicide attempts, multiple mental illness mentions

This article has a set of discussion questions tailored for classroom use. Click here to download them. To see a full list of articles with discussion questions and other resources, visit our “Educational Resources” page.

List of international suicide hotlines: http://ibpf.org/resource/list-international-suicide-hotlines

Aurelia Brouwers’ Instagram bio is terse and pointed: “BPD, depression, PTSD, anxiety etc. Creative. Writer. Gets euthanasia Januari [sic] 26. Fights till then for this subject.”

Brouwers was a twenty-nine year old Dutch woman who suffered from multiple mental disorders. She received her first diagnoses of depression and Borderline Personality Disorder at the age of twelve. As she recounts: “Other diagnoses followed – attachment disorder, chronic depression, I’m chronically suicidal, I have anxiety, psychoses, and I hear voices.” After an estimated twenty failed suicide attempts, Brouwers thought she found the solution to her suffering via euthanasia or physician-assisted suicide (EAS). EAS has been legal in the Netherlands since 2002, but Brouwers faced obstruction as her request was refused by multiple doctors. She finally turned to The Hague’s End of Life clinic, which approved her request and set a date for January 26 of this year. Scenes from Brouwers’ last fortnight of life were recorded by RTL Nieuws journalist Sander Paulus, who noted the young woman’s ongoing mental distress as well as the conviction with which Brouwers anticipated her euthanasia date. Footage featured by the BBC shows Brouwers collectedly making plans for her cremation ceremony with a funeral consultant. On January 26, surrounded by loved ones and two doctors, Brouwers consumed a liquid poison and “went to sleep.”

Brouwers’ case stoked vigorous debate in the Netherlands and elsewhere regarding the intent of euthanasia legislation. Her youth is one point of contention. Another factor is the nature of her affliction. In the discourses following Brouwers’ life, we see evidence of an assumed distinction between physical and psychiatric disorders. Journalist Harriet Sherwood went so far as to note in the tagline for her Guardian article that ”there was nothing wrong with her [Brouwers] physically.”

While psychiatric disorders are still primarily diagnosed via mental and behavioral markers, it is not strictly correct to assume that mental health disorders lack physical foundations. Often, the ways in which we speak of mental disorders reveal our imperfect knowledge of the biological elements (as differentiated from the more traditionally observed psychosocial components) of mental disease. This relative ignorance exists in part because researching biomarkers for psychiatric disease is a complex undertaking. What is known is that mental illnesses can often be life-long conditions that require ongoing treatment, treatment that appears to have been provided in Aurelia Brouwers’ situation.

The 2002 Dutch act exempting physicians from prosecution in specific EAS cases requires ”due care” by the attending doctor. This includes ascertaining unbearable suffering on the part of the patient without hope of improvement. The Netherlands is joined in this relatively open model by other European nations, including Belgium, Luxembourg, and Switzerland. Several American states, the Australian state of Victoria, and Canada also allow EAS, but in much more restricted circumstances mirroring the “Oregon model,” which stipulates a terminal illness with established life expectancy.

Arguments in favor of euthanasia often rest on the basis of respect for individual autonomy and on compassionate grounds. Here, for the sake of simplicity, I assume ethical assent to these grounds in support of voluntary euthanasia or physician-assisted suicide which is at the informed, long-standing behest of the patient. This is the only form of active euthanasia currently legal anywhere (whereas what some call ”passive” euthanasia or the withdrawal of futile treatment is considered to be normal medical practice). These moral justifications – autonomy and compassion – are taken as reasonable in states in which EAS is legalized. In the Netherlands, however, where EAS has been legal for sixteen years, Brouwers was initially refused by several doctors, and garnered national attention. Why?

Brouwers’ example seems to challenge notions of what constitutes “unbearable suffering,” impossibility of improvement, and “terminal” conditions. Popular conceptions of mental illness present it as something that one can “overcome” through patience or willpower, although the same perceptions do not apply to a broken bone or a cancer diagnosis. Dutch psychiatrist Dr. Frank Koerselman, speaking to the BBC, notes that Borderline Personality Disorder, from which Brouwers suffered, is known to decline in severity after the age of 40. But BPD was only one of Brouwers’ multiple diagnoses, which taken together, caused her immense suffering. Along these lines, some argue that her mental disease was itself terminal, as does Kit Vanmechelen in the BBC article. Brouwers had already engaged in numerous, though incomplete, suicide attempts.

What happens, though, when we allow EAS for psychiatric suffering as well as physical suffering (the more traditionally accepted justification)? As a society, our understanding of mental suffering does not seem to be as advanced as that of physical suffering (only recently was it discovered that emotional pain activates neural correlates similar to physical pain).

Many believe that it is a mistake to open this door. Dr. Koerselman opposes EAS for psychiatric disorders, in part because he posits it is not possible to distinguish a rationalized decision to die from a symptom of mental disease itself. On the other hand, a recent study of Belgian mental health nurses’ attitudes toward euthanasia for unbearable mental suffering found a widely positive response. Nurses were the subjects for this study because of their closeness to patients’ lives and frequent role as intermediate and advocate between patients and doctors.

Ethics is about individual cases, as well as the general principles that they reveal or elicit along the way. The case of Aurelia Brouwers is undeniably a tragic one, although Brouwers herself appeared to find some peace in her capacity to make an informed choice, supported by medical care. But what her life surely reveals is that we need to invest more in exploring the genesis and maintenance of mental disorders within our societies. One in four people world-wide will suffer from some form of mental illness. We need to invest more in understanding the biological bases of mental illness, as well as the social structures that are implicated in psychiatric disorders’ psycho-social components.  In the words of Brouwers, “I think it’s really important to do this documentary [of Brouwers’ life] to show people that mental suffering can be so awful that death, in the end, is the lesser of two evils.” As a society, we need to do better by those who experience mental pain.