Death Wishes, Aging Patients, and Euthanasia

The authors are searchers in psychopathology and communicate here about the dead wishes in relation to euthanasia. In Europe, the question comes regularly up to know if the law should be changed concerning the prohibition of euthanasia. The health system obeys progressively a modern idea of comfort and the “good life”. The authors are psychotherapists and their methodology is based mainly on phenomenological psychology, psychoanalysis, and psychopathology. Statistics of the French Ministry of Health will support their statements. Different clinical experiences with young patients, aging patients, or near-to-death patients are crossed and compared to those marked by heavy experiences like rape or amputation. The unbearable nature of their suffering makes them ask frequently to stop the pain. They would prefer being dead. This contribution examinates this kind of demand to find a helpful position for the caregiver and the patient. We should consider that near-death patients may often be at the climax of anxiety and depression is likely to switch over to dementia. In asking to finish with life, this purpose may change one day to another – sometimes it just highlights the wish to see things changed. The position of society and the medical staff has a high influence as well. Asking for euthanasia shows the variety of the same words that have different meanings from a medical, psychological, or psychopathological viewpoint. The purpose is to consider these aspects with the patient’s demand.

The difficulties faced by healthcare teams when being confronted with requests for euthanasia are often mentioned by professionals from different disciplines: “Being confronted with a request for euthanasia often causes great distress to the caregiver. This request has an unbearable nature for the patient, but also for the patient’s family and for the caregivers. There is a risk of being overwhelmed by this feeling of being unbearable and no longer being able to think or put words to what is happening.” (SFAP/ French Society Support and Palliative Care) [1]. Dr. Chalaye [2], a palliative care doctor, also writes about a request for euthanasia made by a patient he had been seeing for 9 months: “I cannot describe the immense feeling of helplessness and powerlessness I felt at the time...”.

Physicians are not always prepared to speak about suffering, anxiety, and death. Therefore, the authors, clinical psychologists, and psychotherapists, working with a methodology of phenomenological psychology, psychoanalysis, and psychopathology want to contribute with their research about clinical situations with patients. They belong to the Laboratory of Psychoanalysis, Medicine, and Society (University of Paris City/France) and are used to explore interactions between different disciplines for the evaluation of clinical situations. Being psychotherapists, psychoanalysts, clinical psychologists, and physicians too, working sometimes in pairs, they put their research together to enlighten psychical processes in a transnosographical cross-reading. Witnesses and autobiographies are used too. The results are compared with actual international research. In this way, they started to compare the dead wishes exclaimed by their patients in distinguishing the situation in which they occur: age, illness, violence, and trauma. The suicide risk is also compared to the demand for euthanasia. This kind of comparison helps to realize the semantical switch from unbearable suffering to death wishes and to the demand for euthanasia. They pay also attention to unconscious motivation according to Freud’s advice that complaints are hidden accusations.

Being submitted to suffering, faith, and staying alive

In a former research M. Wolf-Fédida, et al. [3] showed that situations persons have to stand, wait for a judgement, or be obliged to support difficult conditions of life as crowded prisons near Paris in France increase considerably the risk of suicide [4,5]. Mental health is threatened because the ego splits accusing oneself of the own responsibility leading to this situation. Therefore, it is important to explore how somebody experiences himself in time and space in the present to be able to anticipate reactions. This kind of questioning is typical from a phenomenological viewpoint [6,7]. The former study showed that foreign prisoners were less vulnerable to suicide because they did not feel injustice in the same way as those being judged in their own country. They improved the punishment as a bad treatment of their “enemy” – even if they stayed already in this country. Small prisons on an island like Martinique helped to feel like being together and the risk factor was minimal. In the same, depression and anxiety increase when persons are in front of an incurable disease, a trauma after rape or amputation, or being near death. It is not possible to take any distance from what happens to oneself. They cannot come out of it, losing their liberty like a prisoner. They feel as if their body is becoming a jail. The feeling of having no choice may lead to a rush, an acting up to finish with the situation, and the risk of suicide becomes very high [8-11].

Whereas, in this research, the authors treat the demand of euthanasia which is supposed to come from the other one. It is a demand to the Other and a reminder of obligations in a caring relationship. This implies, on the one hand, that the person feels too weak to commit suicide, and, on the other hand, that the person feels it as his right to be relieved by a medical way making the end of a long dying and helping to expire without suffering [12-15]. This is the point where things get complicated because suffering and pain are experienced in very different ways [15]. Rating scales cannot really appreciate cultural influence, family habits, or mind. Some people are likely to give up quickly and others are able to endure pains they should not bear.

When looking for a definition of euthanasia, the searcher remarks that there are quite different definitions. All of them emphasize an important aspect like “mercy killing” or the uncurable nature of the illness. Some of them assimilate euthanasia to assisted suicide which emphasizes the active participation of the patient. It is not the place here for a semantical study to realize the implications of the different meanings. Anyway, the fact that there is not only one definition could be interpreted that the situations of the demand for euthanasia occur always in a singular context, this is why prohibition seems to be the only solution. It is to protect the physician in the same way as the patient.

The exercise of care implies empathy with the patient. If many professionals and authors agree on the fact that asking for euthanasia is an expression of suffering addressed to the Other, the way to help remains still puzzling, particularly among patients expressing symptoms or suffering “most often existential, purely and simply refractory to all available medicinal and non-medical approaches, and which happens to be too early for deep and continuous sedation maintained until death to be offered”, Chalaye [2].

The case of Kareen shows this problematic situation, where the request for euthanasia occurs early in the treatment, and remains, although in a fluctuating manner until the end of life. This phenomenon is rare and it is still insufficiently studied. Thus, the so-called refractory symptoms and suffering remain for the moment quite enigmatic and poorly elucidated in their content and the meaning they have for the particular subjects in question.

According to the SFAP [1], in the majority of cases, if the patient’s situation is carefully examined and improved over time, the request for euthanasia will disappear: “Poor control of symptoms, and its unbearable nature (concept of refractory symptoms) can explain a request for euthanasia from the patient or those close to them. Rigorous assessment of pain and symptoms is essential and includes assessment of the patient’s emotional state (anxiety, depressive syndrome) and cognitive functions.”

A rigorous examination of the patient’s clinical situation is therefore necessary. The problem that arises here comes also from the institutional context, which is not evident. Elderly patients with serious illnesses often change services or establishments and therefore they change their caregivers. The psychologist in palliative care, Le Jamtel [16], for example, describes the case of a patient who met with several teams and had “six psychologists and a psychiatrist since the start of her illness”. This kind of situation is not rare, we may ask the question of whether this kind of treatment is favorable to a real insight into psychological symptoms and if a stable transference relationship is possible under those circumstances.

It is often considered, on the one hand, the objective clinical situation, which caregivers can therefore evaluate and try to improve, and, on the other hand, the request for euthanasia, is likely to disappear if caregivers improve the situation and the quality of life of the patient. The idea of ​​an unbearable situation to improve is exactly the definition given of euthanasia by the National Consultative Ethics Committee [17]: “The act of a third person which deliberately ends the life of a person with the intention of putting an end to a situation deemed unbearable.”

Obviously, this third person gives a judgment according to the demand of the patient. However, caregivers should not forget about the intimate sense that this request would have for the patient. Psychoanalysis [8] teaches that speaking has a function for the subject, or mostly the becoming subject, who expresses an unconscious demand taking place in his psychic dynamics. The case of Kareen shows that finally, it is not the objective situation that the caregiver has to examine but the subjective one; in other words: the intimate meaning that the subject gives to this request for euthanasia. Indeed, if complaints are accusations according to Freud, Kareen denounced the lack of engagement in the past of her family and her friends and the hospital became the theater of the repetitions of the past. There is no exit even in a care situation in a hospital. This kind of imprisonment in a psychical situation increases when being chronically ill and weighs on morale for Kareen. Once the psychologist made her speak about it, she was much more interested in considering her own life than in finishing with it.

Last but not least, in considering the euthanasia question, caregivers are too likely to suppose that this requirement does not imply psychopathology. But the World-Wide Health Organization, OMS says [18]:” Psychological and pharmacological treatments exist for depression. However, in low- and middle-income countries, treatment and support services for depression are often absent or underdeveloped. It is estimated that more than 75% of people suffering from mental disorders in these countries do not receive treatment.” France is one of the biggest consumers of pharmacological treatments of depression but the risk of suicide persists and the prohibition of euthanasia is questioned. In other words, psychopathology rising up when aging is another factor to consider, and when the body is suffering psychopathology may appear too in the meanwhile [19-24].

Therefore, the authors propose the comparison with the suicide risk in the prisoner’s study. Some of them had psychological trouble before coming to prison and others became psychopathological in prison. The searcher or caregiver should be allowed to think that death wishes could be in relation to this kind of psychological disturbance [25]. The mind is not stable forever. Freud reminded the Thanatos drive and the nirvana concept which explain the destructivity or the pleasure in sadism and masochism. The body becomes the scene of infantile impressions and puts them to life. Indeed, all these elements take part in dead wishes.

What is the place of dead wishes in psychic life?

Patients could mean that they agree to the fact that they should die one day and gratify the medical staff for their efforts to keep them alive. But this is certainly an ideal and romantic vision to consider their mention of suicide and euthanasia as a consolation for caregivers. Dependence in a treatment situation leads to regression and the patient becomes mad at the physician or caregiver. Freud explained the situation in the psychoanalytical cure where transference mobilizes hate and love to a strong extent.

In the past, Kareen was a medical caregiver too and the fact that she became dependent on others in the meanwhile did not fit with her image of herself. In addition, COVID-19 ordered isolation in hospitals. This was the beginning of her isolation from her family and her friends. Some of them died and she felt abandoned. Claiming for euthanasia every day meant keeping closer to the medical staff and assuring herself to keep in touch. She said also that she wanted to die in full conscience and not completely diminished.

An example is placing the reasonings of Kareen into the cultural context of nowadays. Several years ago, in France, old people were considered smart (from whom exactly, themselves?) when showing a certain detachment about their own death and anticipation for a “clean” disappearance. Organizing funerals oneself was recommended and as euthanasia is not allowed in France, it was easy to go to Switzerland to obtain it. To do so, does it mean the desire for euthanasia? Could it not be a moment of rebellion when facing a time in a future where decisions from others might be taken without consent or to ensure oneself of being modern and beloved after death? Some years later, after COVID-19, after a lot of victims of old persons, and maybe, with the rising of an economic crisis in the meantime, the possibility to go to Switzerland did not become an interesting purpose anymore. People of eighty, ten years ago, do not speak about this “opportunity” anymore when being ninety - yet it should be mostly true. Some of them, think about the possibility of suicide by starvation or sedation with pills, feeling finally too aged for travelling to Switzerland. Caregivers should understand this kind of communication as a signal of keeping a “good organization” of their own life, maintaining funerals in their own hands. So, the idea of a “good life” means to choose the “good moment” to “disappear”. Definitely, the culture and economy of a country influence the idea of death [26-28].

Ralf T. Vogel [29] listed all the differences between culture and religion concerning the ideas of death. In his manual about the end of life, death, and mourning, he studies different attitudes we can encounter with patients near death. He observed that in palliative care stations, most patients are not really fond of speaking about death. They prefer all kinds of other distractions.

When asking the people in France what is associated with aging, they will generally mention first, a wheelchair or Alzheimer’s disease. Elders even say that they don’t admit it and they will suicide if one of these two eventualities happens to them. They do not even consider that dementia will make them forget about suicide. This current example shows the illogical part of the statement because there are certainly worse ways to suffer than sitting in a chair and forgetting about everything. Obviously, the idea about it, the image given to oneself, hurts much more than objective reasons. This aspect is the one that caregivers have to work on to enable their patients to overcome the feeling of being diminished. This is exactly the point when working in psychotherapy with patients suffering from amputation.

Working with young people being amputated provokes dead wishes for themselves. They feel broken and do not deserve attention or love. The psychotherapist has to work on their ideas about beauty. The reconstruction of the body is indissociable from the reconstruction of the psychic body image [30]. Without psychological counselling and psychotherapy, it will be nearly impossible to go well. So, the risk of suicide must be considered seriously. This is the same for victims of rape, being raped, or being the child of a rape. Here, it is also the image of oneself that is broken. Family and environment are summoned to deplore the attack on all their generation by a broken family member. So even if there are no medical reasons moreover, the situation risks getting worse.

Meaning of words in suffering and psychical conflict

Psychoanalysis showed that patients need a place to complain. According to Freud’s “Complains are accusations”, the demand for euthanasia could be also interpreted as an accusation: incapacity of the physician, of caregivers, or of medicine. The patient suffers by feeling that an enormous mistake has been committed to himself. To understand the psychical conflict psychogenesis of the child has to be considered. The young child is overwhelmed by the ambiguity of emotions or by too strong emotions. Especially, the absence of a beloved person is an experience like a dead experience [31]. Being hurt by somebody might provoke dead wishes because the narcissism or self-love was damaged. In the same way, the expression of extreme demands as euthanasia may be understood as an effect of regression where the disappointment about the care of the other [30,32,33] is expressed in a paradoxical way. In order to ask for more care by being close to him, the patient asks for organized death. Violence is turned to oneself as to the others. Suffering hinders the patient from conceiving closeness in being near to others and at the same time the patient and the caregiver feel like a confusion about love. In psychoanalysis, it is well known that the capacity to support transference from the analyst is important for the cure of the patient [34-36]. It is a reminder of the hospital’s situation where relationships might be considered as a disturbing factor. This is the matching point for training caregivers to be available for a close relationship with suffering patients.

Phenomenological psychology points out the importance for somebody to have a project, which means moving forward. Asking for euthanasia signifies a breakup with time and space [19]. Being here in this place is unbearable and to think back is without pleasure. In other words, it would be helpful to have still a pleasure and to enjoy a situation to investigate. If the patient gets rid of the situation because he is, for example, uncurable, even thinking about death means still going forward in imagining preparation [29]. Speaking about death is speaking about life too. Of course, it is especially difficult to introduce these ideas to persons [37] who cannot respond to themselves (coma, dementia, mutism). The question will be if there is definitely no possibility to be a subject facing time and space but mostly the caregiver has to invent opportunities to do so. The wish of euthanasia witnesses as the same time for the will of being subject to this very difficult situation about the own life and death. It is important to value this wish of subjectivation for the patient and let it take place in the care pathway.

The authors highlight the importance of permitting the exploration of the subjective meaning for the patient when death wishes and the demand for euthanasia occur. They recommend the training for caregivers, physicians, and psychologists for a better understanding of psychic life in extreme experiences for the patient and to explore their own capacities to stand the situation. Conflictual situations lead often to shortening protective meanings without consideration for a hidden unconscious meaning. This contribution emphasizes the role of the caregiver to help the patient translate his demands by himself and to be much more active in his life than organizing only his own funerals. It will be important for the patient to explore all the emotions and to relate them to his own vision of his life. The ambiguous feelings about emotions when speaking about death wishes and euthanasia should be explored with the patient. Subjectivity and psychical vivacity may always be a source of enlightening in this situation.

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