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Should older people who are not severely ill have the right to ask for assisted dying?

This summer, on 17 July 2020, Dutch parliamentarian Pia Dijkstra submitted a controversial legislative proposal that would allow healthy older people to have assistance with dying if they consider their life to be ‘completed’.

Dijkstra argues that there are significant numbers of relatively healthy older people (75+) who are ready to give up on life; they go to bed every night with the hope that they won't wake up again the next morning. These people do not suffer from a medical condition (i.e. something that can be cured or in some way treated), but rather they suffer quite simply from being old. They feel they have outlived themselves and have a persistent well-considered wish to die, she states. Dijkstra: “I want to make assisted dying possible for this group."

Hitherto, under Dutch law, only physicians are allowed to perform euthanasia or assisted suicide (EAS), and they do so in strictly specified circumstances. And although these circumstances need not include one single, dominant or life-threatening medical problem, to date the law has required that the suffering should always have a medical dimension. This means that in some cases, Dutch older people who suffer unbearably from multiple geriatric syndromes can be eligible for EAS. Aid in dying for older people without severe illness, however, is currently unlawful in the Netherlands. Dijkstra, therefore, wants to extend the law: even in cases without medical conditions or unbearable suffering, she proposes, it should be lawful for older people to ask for dying assistance.

The underlying issue has given rise to a contentious debate that is not restricted to the Netherlands. Chris Gilleard, for example, also addressed the topic in a recent talk at a virtual conference of the McDonald Centre on ‘Ageing and Despair’. In his presentation, he reflected on the legalisation of assisted dying in cases of older people whose suffering is mainly existential, induced by the weight and purposelessness of life itself, as he puts it. To support (or perhaps illustrate) his argument, he refers to the so-called ‘rational suicides’ of writers Jean Améry and Carolyn Heilbrun and quotes a question asked by the latter: “Is it not better to leave at the height of well-being rather than contemplate the inevitable decline?”

Much can be said about this issue. Drawing on research we conducted recently, I just want to underline four critical issues that in my view highly complicate Dijkstra’s proposal:

  • First, our survey highlights the fact that the proportion of older people (55+) who have a wish to die while not severely ill is very small.  They tend also to share certain socio-demographic characteristics: lower socio-economic status, lower education, living in highly urbanized areas, and female. And many respondents who could be said to have a death wish - although not severely ill - report considerable mental and physical health problems and possible prevalence of mild or moderate depression. What is more, the wish to die is often driven by anxiety, feelings of loneliness and burdensomeness, and money problems. Without underestimating the complexity of addressing such vulnerabilities, these outcomes suggest that the death wish at stake may often be linked to social and positional problems, and it is at least possible that these could be alleviated by policies targeting better support and care for those concerned.
  • Secondly, there is very often an element of ambivalence in the views of those people who do express a death wish. Some of the people who reported having a persistent and active wish to die also reported a desire to live or a wish to find life worthwhile. This suggests that even a persistent death wish may be highly elusive and qualified. What we shouldn’t ignore is that some individuals in this position may feel caught between having a wish to end their lives, as well as a (dormant) hope that life might become worth living again.
  • Thirdly, death wishes in people who are not severely ill are not limited to people aged over 75. Indeed, our study has shown that also among those aged 55 up to 75, similar death wishes are prevalent. The case for targeting legislation on those over 75 is based purely on age: people older than 75 may ‘reasonably’ be judged to have ‘completed’ their lives, and there has to be some age at which ‘old age’ itself is seen as a warrant for requesting expecting assistance with dying.  Besides the possible consequences of this age threshold for stigmatising the aged population, we should ask whether it is really that straightforward a matter to justify suicide prevention for those under 75 and assisted dying for those above.
  • Last but not least, it is important not to play down the major legal and ethical differences between suicide as a possible rational choice for an individual, and the involvement of another (medically qualified?) person in assisting that choice. The underlying reasons for both might be similar but the practices have a considerable distinct ethical weight and nature.

To conclude, the social phenomenon regarding older people who sense an absence of meaning, emptiness and value in later life is recognizable in several countries around the world. However, the fact that it has become highly political in the Netherlands is quite unique. The question whether older people who are not severely ill should have the right to ask for assisted dying raises crucial questions about the role of the state: should the government facilitate assisted dying in these cases or should they focus on prevention of meaninglessness and loneliness in old age? Supported by the findings of our new study presented above, I would suggest what we should prioritize the latter.

About the author: Els van Wijngaarden is an Associate Professor in Care Ethics, University of Humanistic Studies, Utrecht, The Netherlands. She was an Academic Visitor at the Oxford Institute of Population Ageing in 2018.

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