Dying with dignity: a question of definition?

November 19, 2008 | by Derek Miedema , Researcher, Institute of Marriage and Family Canada

With the passing of Washington State’s Death with Dignity Act on November 4, 2008 euthanasia and assisted suicide are back in the news. Some are calling for the victory in Washington State to spill over into British Columbia.

The debate is already in Canada, however. In the last two sessions of Parliament, Bloc Québécois Member of Parliament Francine Lalonde introduced the same Private Member’s Bill; both would have allowed the “right to die with dignity.”

In these bills, dignity means the ability to decide how and when you’re going to commit suicide. [1] But what if dignity is actually multifaceted, involving physical, emotional, psychological and spiritual dimensions? This is what Dr. Harvey Chochinov, palliative care research chair at the University of Manitoba argues:

"Loss of dignity is often associated with feelings of being a burden to others and not feeling worthy of respect or esteem. These latter issues have been cited time and again with a loss of will to live, a desire for death and interest in euthanasia and assisted suicide. Hope, or more specifically loss of hope, has also been connected to the construct of dignity, and is a highly significant predictor of suicidality. Within our studies, however, we have found that amongst dying patients, hope is based on the ability to find or maintain meaning and purpose in living." [2]

A study in the Netherlands in 2005 found that “the risk of a request for euthanasia by patients with depressed mood was 4.1 times higher than that of patients without depressed mood at inclusion.” [3] And a research paper published in October 2008 questions whether the Oregon Death with Dignity Act’s provisions for people suffering from depression are actually being carried out. [4]

Depression need not lead to assisted suicide. Chochinov and his colleagues have in fact designed and tested an individual palliative care treatment called dignity therapy:

"To decrease suffering, enhance quality of life, and bolster a sense of meaning, purpose and dignity, patients are offered the opportunity to address issues that matter most to them or speak to things they would most want remembered as death draws near. An edited transcript of these sessions is returned to the patient for them to share with individuals of their choosing." [5]

Chochinov tested this therapy with terminally-ill patients and found that

"Ninety-one per cent of participants were satisfied with dignity therapy; 76% reported a heightened sense of dignity; 68% reported a heightened sense of meaning; 47% reported an increased will to live; and 81% reported that it had been or would be of help to their family. [6]

Dignity therapy is just one scientific voice which shows that death need not be the solution to a loss of meaning, dignity and/or will to live."

Dr. Margaret Cottle, palliative care physician and clinical instructor at the University of British Columbia is another such voice. She describes the arguments (based on the idea of death as the solution for pain and suffering) in favour of assisted suicide and euthanasia as scientifically baseless:

"There's not one shred of evidence to show that you are better off dead. Many people believe things about what happens after death. We do not know, scientifically, whether when you die you don't go into screaming agony someplace." [7]

The role of the family

If a person has lost the will to live, what is the role of their family in response? Should the family agree with the wishes for death? What if the wish to die is actually a cry for help? What if, with the proper supports and counseling, that loved one could regain hope, reclaim some small purpose for living? Dr. Chochinov et al.’s research into dignity therapy shows that simple yet profound steps can be taken to help the terminally-ill patient regain a sense of purpose and meaning, even in their final days before death. [8]

Depression is treatable; death is final. Affirming life in dying and sick loved ones is not tidy or easy. But defining death as a dignified solution is nothing more than opinion or belief. Science shows both that we can restore hope in dying patients, and that requests for assisted suicide could be viewed as a cry for help. Since that could be the real question when a loved one asks for assisted suicide isn’t “what can I do to help you to live” the dignified answer?

PDF:  Dying with dignity: a question of definition?

Endnotes

  1. House of Commons of Canada. (2008) C-562: An Act to Amend the Criminal Code (right to die with dignity). Ottawa: Public Works and Government Services Canada. Retrieved November 12, 2008 from http://www2.parl.gc.ca/HousePublications/Publication.aspx?DocId=3570851&Language=e&Mode=1&File=14
    House of Commons of Canada. (2005) C-407: An Act to Amend the Criminal Code (right to die with dignity). Ottawa: Public Works and Government Services Canada. Retrieved November 17, 2008 from http://www2.parl.gc.ca/HousePublications/Publication.aspx?DocId=2333717&Language=e&Mode=1
    Both bills were created to allow “any person” (C-407) or “any medical practitioner” (C-562) to offer death to those experiencing incurable pain and suffering, or a terminal illness, who request it.
  2. Dr. Harvey M. Chochinov, personal communication, November 10, 2008
  3. van der Lee, M.L., van der Bom, J.G., Swarte, N.B., Heintz, A.P.M., de Graeff, A., van den Bout, J. (2005). Euthanasia and Depression: A Prospective Cohort Study Among Terminally Ill Cancer Patients. Journal of Clinical Oncology, 23:27, 6607-6612. Retrieved November 13, 2008 from http://jco.ascopubs.org/cgi/reprint/23/27/6607.pdf
  4. Ganzini, L., Goy, E. R., Dobscha, S. K. (2008) Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey. BMJ 2008;337:a1682 Retrieved November 13, 2008 from http://www.bmj.com/cgi/reprint/337/oct07_2/a1682
    Oregon’s Act requires that patients requesting assisted suicide be screened for depression. If they are found to be depressed, their doctor must refer them for treatment.
  5. Chochinov, H.M., Hack, T., Hassard, T., Kristjanson, L.J., McClement, S., Harlon, M. (2005) Dignity Therapy: A Novel Psychotherapeutic Intervention for Patients Near the End of Life. Journal of Clinical Psychology, 23(24), 5520-5525
  6. Ibid.
  7. CBC News. (2008) B.C. group calls for legalization of assisted suicide. Retrieved online November 17, 2008 at
  8. http://www.cbc.ca/health/story/2008/11/05/bc-right-to-die-initiative-1000-assisted-suicide-death-with-dignity- oregon.html#articlecomments
  9. Chochinov, H.M. et al. Dignity Therapy.
  10. Rodriguez v. British Columbia (Attorney General), [1993] 3 S.C.R. 519 Retrieved November 12, 2008 from http://csc.lexum.umontreal.ca/en/1993/1993rcs3-519/1993rcs3-519.html