“A patient can ask to die without wanting to die”

Why do possible changes concerning a right to euthanasia or assisted suicide arouse so much resistance? Should active assistance in dying be legalized? As for clinical psychologists working in palliative care, we wonder. The opportunity for those who collect daily distress and questions from patients to share their thoughts. And more than ever to know how to hear and guess, well beyond words.

On January 23, 2023, Régis Aubry and Alain Claeys (co-rapporteurs of CCNE Opinion No. 139) were heard with Annabel Desgrées du Loû by the National Assembly for the study of new rights for patients and people at the end of life. Developing palliative support for the most vulnerable would be the first of the ethical prerequisites.

In the debates on euthanasia and assisted suicide, they recall, on the one hand, the necessary respect for the ambivalence of patients and, on the other hand, the difference between the request and the will to die. The chairman of the National Assembly commission explains his misunderstanding of the concept of ambivalence and the idea of ​​a possible coexistence of the development of palliative care with that of new rights in favor of induced death.

Ambivalent request

However, ambivalence is well known among sick people as allowing very legitimately to express requests for death in reaction to the unlivable of the disease, and at the same time this desire to live the best longer. It explains this important semantic difference between the terms “request” and “will”. A patient can ask to die without wanting to die. The request is rational, intellectual, without affect.

Who asks to see themselves die? Eugene is 40 years old. Suffering from a degenerative disease, the doctors predict him an agony by respiratory distress. He faces the situation as a problem to be solved by a pragmatic solution. He doesn’t want to be a burden on his family, doesn’t want to live with dependency at home and looks for ways to avoid it. Suicide is the best option. After much research on the different means of ending it, he opts for poisoning with a product that he obtains. He wishes to be helped in drafting the advance directives in the highly unlikely event that he “mess up”.

Shedding light on palliative care

Advised by his neurologist, he meets a doctor from the palliative care unit in the neighboring town. He obviously doesn’t want to be revived. He presents his project. With great humility, the doctor respects his project while having the objective of enlightening him on the proposals for palliative care. The ethical challenge is to offer a real alternative to this short-term death project, that the latter eventually be a real choice. He accepts several consultations then, to experience the human, technical and medicinal aids, hospitalization in the service.

The gradual loss of walking, swallowing and speech is a real torture that he gradually integrates into his identity because he feels like a “man” for everyone. Proudly, despite the ravages of illness, he still feels like himself. The request for death persists until the end without his wanting to die. The medical team respects his ambivalence and he enjoys in his territory the luxury of hospitalization in palliative care throughout the four months of his illness with a death accompanied by sedation so that he does not feel suffocation.

Euthanasia does not respect ambivalence

Suicide requires the subject to take action to kill himself. You pull the trigger, you jump off the bridge, you drink the potion… Eugene had found the necessary products and yet his ambivalence made him choose life until the end, a life accompanied by palliative care and the insurance of being sedated at the time of terminal choking.

What would have happened if doctors had been able to respond with euthanasia? Four more months, four months less, the time to die… Very different from suicide, even from assisted suicide as in Oregon with the medical prescription of a lethal product, euthanasia does not respect the ambivalence . The act is carried by someone other than the subject. How could the doctors have resisted his demands for death so as not to euthanize him and believe in his ability to live an identity transformed by the disease? Could Eugene have stopped this other, this doctor, at the last moment, during the act of euthanasia? How can we not let ourselves be carried away by this act, by our natural trust in others, which makes us think that they will always do the best for us?

Not an act of care

Euthanasia will never be an act of care since it will remain an act that kills, an act carried out by a professional who will never be certain of the ultimate choice of the subject. Cosmetic surgery can erase the wrinkles of aging. Euthanasia effectively avoids dying… The difference? If you made a mistake, the surgeon can try to fix it.

If Eugene had been able to administer the product alone, would he have done so? Eugene has not given up on committing suicide. Until the end he retains the reassuring thought of it, with a passage to the act which never took place… His four months were priceless! His 10-year-old son and his wife were able to continue their lives with the assurance that they had made the most of his intelligence, his exceptional presence… Let’s not want to die: these nuances and a real development of palliative care are a prerequisite for the examination of new rights.

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