Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies

Scientific Contribution

Abstract

It is not uncommon for patients with advanced disease to express a wish to hasten death (WTHD). Qualitative studies of the WTHD have found that such a wish may have different meanings, none of which can be understood outside of the patient’s personal and sociocultural background, or which necessarily imply taking concrete steps to ending one’s life. The starting point for the present study was a previous systematic review of qualitative studies of the WTHD in advanced patients. Here we analyse in greater detail the statements made by patients included in that review in order to examine their moral understandings and representations of illness, the dying process and death. We identify and discuss four classes of assumptions: (1) assumptions related to patients’ moral understandings in terms of dignity, autonomy and authenticity; (2) assumptions related to social interactions; (3) assumptions related to the value of life; and (4) assumptions related to medicalisation as an overarching context within which the WTHD is expressed. Our analysis shows how a philosophical perspective can add to an understanding of the WTHD by taking into account cultural and anthropological aspects of the phenomenon. We conclude that the knowledge gained through exploring patients’ experience and moral understandings in the end-of-life context may serve as the basis for care plans and interventions that can help them experience their final days as a meaningful period of life, restoring some sense of personal dignity in those patients who feel this has been lost.

Keywords

Wish to hasten death Dignity Autonomy Values Qualitative studies Medicalization 

References

  1. Ariès, Philippe. 1975. Western attitudes toward death: From the Middle Ages to the present (trans: Patricia M., Ranum), vol. 3. Baltimore: JHU Press.Google Scholar
  2. Aristotle. 1995. The Politics (trans: Ernest, Barker). New York: Oxford University Press.Google Scholar
  3. Brody, B.A. 1989. Suicide and euthanasia: Historical and contemporary themes. Dordrecht: Kluwer Academic.CrossRefGoogle Scholar
  4. Callahan, Daniel. 1989. Can we return death to disease? Hastings Center Report 19: 4–6.CrossRefGoogle Scholar
  5. Chochinov, Harvey Max, T. Hack, S. McClement, L. Kristjanson, and M. Harlos. 2002. Dignity in the terminally ill: A developing empirical model. Social Science and Medicine 54: 433–443.CrossRefGoogle Scholar
  6. Clark, David. 2002. Between hope and acceptance: The medicalisation of dying. BMJ (Clinical Research Ed.) 13: 905–907. doi:10.1136/bmj.324.7342.905.CrossRefGoogle Scholar
  7. Conrad, Peter. 2008. The medicalization of society: On the transformation of human conditions into treatable disorders. Baltimore: JHU Press.Google Scholar
  8. Coyle, N., and L. Sculco. 2004. Expressed desire for hastened death in seven patients living with advanced cancer: A phenomenologic inquiry. Oncology Nursing Forum 31: 699–709.CrossRefGoogle Scholar
  9. Dees, M.K., M.J. Vernooij-Dassen, W.J. Dekkers, K.C. Vissers, and C. van Weel. 2011. “Unbearable suffering”: A qualitative study on the perspectives of patients who request assistance in dying. Journal of Medical Ethics 37: 727–734. doi:10.1136/jme.2011.045492.CrossRefGoogle Scholar
  10. Ferrara, Alessandro. 1998. Reflective authenticity. Rethinking the project of modernity. New York: Routledge.Google Scholar
  11. Gorer, Geoffrey. 1955. The pornography of death. Encounter 5: 49–52.Google Scholar
  12. Guerrero-Torrelles, Mariona, C. Monforte-Royo, A. Rodríguez-Prat, J. Porta-Sales, and A. Balaguer. 2017. Understanding meaning in life interventions in advanced illness patients: A systematic review and realist synthesis. Palliative Medicine. doi:10.1177/0269216316685235.Google Scholar
  13. Guo, Q., and C.S. Jacelon. 2014. An integrative review of dignity in end-of-life care. Palliative Medicine 28: 931–940. doi:10.1177/0269216314528399.CrossRefGoogle Scholar
  14. Illich, Ivan. 1976. Medical nemesis: The expropiation of health. London: Alder and Boyars.Google Scholar
  15. Jors, K., S. Adami, C. Xander, C. Meffert, J. Gaertner, H. Bardenheuer, D. Buchheidt, R. Mayer-Steinacker, M. Viehrig, W. George, and G. Becker. 2014. Do the circumstances allow for a dignified death? Cancer 120: 3254–3260. doi:10.1002/cncr.28702.CrossRefGoogle Scholar
  16. Kellehear, Allan. 2007. A social history of dying. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  17. Kelly, B., P. Burnett, D. Pelusi, S. Badger, F. Varghese, and M. Robertson. 2002. Terminally ill cancer patients’ wish to hasten death. Palliative Medicine 16: 339–345. doi:10.1191/0269216302pm538oa.CrossRefGoogle Scholar
  18. Kemp, Peter, and J.D. Rendtorff. 2008. The Barcelona declaration. Towards an integrated approach to basic ethical principles. Synthesis Philosophica 46: 239–251.Google Scholar
  19. Lavery, James V., J. Boyle, B.M. Dickens, H. Maclean, and P.A. Singer. 2001. Origins of the desire for euthanasia and assisted suicide in people with HIV-1 or AIDS: A qualitative study. Lancet 358: 362–367.CrossRefGoogle Scholar
  20. Le Breton, D. 1999. Antropología del dolor [Anthropology of pain], 1st edn. Barcelona: Seix Barral.Google Scholar
  21. Leung, D. 2007. Granting death with dignity: Patient, family and professional perspectives. International Journal of Palliative Nursing 13: 170–175.CrossRefGoogle Scholar
  22. Mak, Y.Y.W., and G. Elwyn. 2005. Voices of the terminally ill: Uncovering the meaning of desire for euthanasia. Palliative Medicine 19: 343–350.CrossRefGoogle Scholar
  23. Monforte-Royo, Cristina, C. Villavicencio-Chávez, J. Tomás-Sábado, and A. Balaguer. 2011. The wish to hasten death: A review of clinical studies. Psycho-Oncology 20: 795–804. doi:10.1002/pon.1839.CrossRefGoogle Scholar
  24. Monforte-Royo, Cristina, C. Villavicencio-Chávez, J. Tomás-Sábado, V. Mahtani-Chugani, and A. Balaguer. 2012. What lies behind the wish to hasten death? A systematic review and meta-ethnography from the perspective of patients. PLoS ONE 7: e37117. doi:10.1371/journal.pone.0037117.CrossRefGoogle Scholar
  25. Morris, David B. 1991. The culture of pain. Oakland: University of California Press.Google Scholar
  26. Nilmanat, K., C. Promnoi, T. Phungrassami, P. Chailungka, K. Tulathamkit, P. Noo-urai, and S. Phattaranavig. 2015. Moving beyond suffering: The experiences of thai persons with advanced cancer. Cancer Nursing 38: 224–231. doi:10.1097/NCC.0000000000000169.CrossRefGoogle Scholar
  27. Nissim, R., L. Gagliese, and G. Rodin. 2009. The desire for hastened death in individuals with advanced cancer: A longitudinal qualitative study. Social Science and Medicine 69: 165–171. doi:10.1016/j.socscimed.2009.04.021.CrossRefGoogle Scholar
  28. Noblit, G., and R. Hare. 1988. Meta-ethnography: Sinthesizing qualitative studies. Newbury Park: Sage.CrossRefGoogle Scholar
  29. Ohnsorge, Kathrin, H. Keller, G. Widdershoven, and C. Rehmann-Sutter. 2012. Ambivalence’ at the end of life. How to understand patients’ wishes ethically. Nursing Ethics 19: 629–641. doi:10.1177/0969733011436206.CrossRefGoogle Scholar
  30. Ohnsorge, Kathrin, H. Gudat, and C. Rehmann-Sutter. 2014a. Intentions in wishes to die: Analysis and a typology—A report of 30 qualitative case studies of terminally ill cancer patients in palliative care. Psycho-Oncology. doi:10.1002/pon.Google Scholar
  31. Ohnsorge, Kathrin, H. Gudat, and C. Rehmann-Sutter. 2014b. What a wish to die can mean: Reasons, meanings and functions of wishes to die, reported from 30 qualitative case studies of terminally ill cancer patients in palliative care. BMC Palliative Care. doi:10.1186/1472-684X-13-38.Google Scholar
  32. Östlund, U., H. Brown, and B. Johnston. 2012. Dignity conserving care at end-of-life: A narrative review. European Journal of Oncology Nursing 16: 353–367. doi:10.1016/j.ejon.2011.07.010.CrossRefGoogle Scholar
  33. Parens, Erik. 2013. On good and bad forms of medicalization. Bioethics 27: 28–35. doi:10.1111/j.1467-8519.2011.01885.x.CrossRefGoogle Scholar
  34. Pearlman, Robert A., C.H. Hsu, A.L. Starks, A.L. Back, J.R. Gordon, A.J. Bharucha, B.A. Koenig, and M.P. Battin. 2005. Motivations for physician-assisted suicide. Journal of General Internal Medicine 20: 234–239. doi:10.1111/j.1525-1497.2005.40225.x.CrossRefGoogle Scholar
  35. Pestinger, Martina, S. Stiel, F. Elsner, G. Widdershoven, R. Voltz, F. Nauck, and L. Radbruch. 2015. The desire to hasten death: Using grounded theory for a better understanding “When perception of time tends to be a slippery slope.” Palliative Medicine 29: 711–719. doi:10.1177/0269216315577748.CrossRefGoogle Scholar
  36. Pullman, Darryl. 1996. Dying with dignity and the death of dignity. Health Law Journal 4: 197–219.Google Scholar
  37. Quill, Timothy E., and M.P. Battin. 2004. Physician-assisted dying: The case for palliative care and patient choice. Baltimore: The Johns Hopkins University Press.Google Scholar
  38. Rehmann-Sutter, Cristoph. 2015. End-of-life ethics from the perspectives of patients’ wishes. In The patient’s wish to die. Research, ethics, and palliative care, eds. C., Rehmann-Sutter, H., Gudat, and K., Ohnsorge. Oxford: Oxford University press.CrossRefGoogle Scholar
  39. Rendtorff, J.D. 2002. Basic ethical principles in European bioethics and biolaw: Autonomy, dignity, integrity and vulnerability. Towards a foundation of bioethics and biolaw. Medicine, Health Care and Philosophy 5: 235–244. doi:10.1023/A:1021132602330.CrossRefGoogle Scholar
  40. Rodríguez-Prat, Andrea, C. Monforte-Royo, J. Porta-Sales, X. Escribano, and A. Balaguer. 2016. Patient perspectives of dignity, autonomy and control at the end of life: Systematic review and meta-ethnography. PLoS ONE 11: e0151435. doi:10.1371/journal.pone.0151435.CrossRefGoogle Scholar
  41. Rodríguez-Prat, Andrea, Albert Balaguer, Andrew Booth, Cristina Monforte-Royo. 2017. Understanding patients’ experiences of the wish to hasten death: An updated and expanded systematic review and meta-ethnography. BMJ Open (accepted).Google Scholar
  42. Schroepfer, T.A. 2006. Mind frames towards dying and factors motivating their adoption by terminally ill elders. Journal of Gerontology 61: 129–140.CrossRefGoogle Scholar
  43. Steinhauser, K.E., N.A. Christakis, E.C. Clipp, M. McNeilly, L. McIntyre, and J.A. Tulsky. 2000. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA: The Journal of the American Medical Association 284: 2476–2482.CrossRefGoogle Scholar
  44. Stiel, Stephanie, M. Pestinger, A. Moser, G. Widdershoven, U. Lüke, G. Meyer, R. Voltz, F. Nauck, and L. Radbruch. 2010. The use of grounded theory in palliative care: Methodological challenges and strategies. Palliative Medicine 13: 997–1003. doi:10.1089/jpm.2010.0050.CrossRefGoogle Scholar
  45. Street, A.F., and D.W. Kissane. 2001. Constructions of dignity in end-of-life care. Journal of Palliative Care 17: 93–101.Google Scholar
  46. Sulmasy, Daniel P. 2005. Death, dignity, and the theory of value. Ethical Perspect 9: 103–130. doi:10.2143/EP.9.2.503850.CrossRefGoogle Scholar
  47. Taylor, Charles. 1989. Sources of the self: The making of the modern identity. Cambridge: Harvard University Press.Google Scholar
  48. Taylor, Charles. 1992. The ethics of authenticity. Cambridge: Harvard University Press.Google Scholar
  49. United Nations. 1948. Universal Declaration of Human Rights. http://www.un.org/es/documents/udhr/index_print.shtml. Accessed 14 Oct 2016.
  50. van Wijngaarden, E., C. Leget, and A. Goossensen. 2016. Disconnectedness from the here-and-now: A phenomenological perspective as a counteract on the medicalisation of death wishes in elderly people. Medicine, Health Care and Philosophy 19: 265–273. doi:10.1007/s11019-016-9687-4.CrossRefGoogle Scholar
  51. Varga, Somogy, and Charles Guignon. 2016. Authenticity. Stanford Encycl. Philos. http://plato.stanford.edu/archives/sum2016/entries/authenticity. Accessed 15 Nov 2016.
  52. Walker, Margaret Urban. 2007. Moral understandings: A feminist study in ethics. New York: Oxford University Press.Google Scholar
  53. Walter, T. 1994. The revival of death. London; New York: Routledge.CrossRefGoogle Scholar
  54. White, M., and D. Callahan. 2000. Oregon’s first year: The medicalization of control. Psychology Public Policy, and Law 6: 331–341. doi:10.1037//1076-8971.6.2.331.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2017

Authors and Affiliations

  1. 1.Faculty of HumanitiesUniversitat Internacional de CatalunyaBarcelonaSpain
  2. 2.Department of IQ, Section Ethics, Philosophy and History of MedicineRadboud University of NijmegenNijmegenThe Netherlands

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