Abstract
This paper is concerned with the nature of suffering and its judged intractability and unbearability, with relevance to debates about assisted dying and the place of age in this wider debate. Framed by the idea that thoughts about death, and the experience of suffering become more common in later life, the paper addresses the assessment of suffering, the sources of suffering and the distinction between suffering experienced and suffering witnessed in the context of those older people seeking medically assisted death. While suffering can be seen to challenge human dignity, the capacity to bear suffering is widely held both by people of faith and those of none to reflect some admirable aspect of the human spirit. The distinction between what is and what is not bearable suffering is complex and contingent. It is not reducible to a split between secular and religious views, nor is it likely to be resolved through better psychometric delineation of degrees of suffering. Acknowledgement of the possibility of unbearable suffering, whatever its source, is needed however before any consensus can be achieved in how best to address it.
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Améry, J, (1997). On aging: Revolt and resignation. [Trans. J.D. Barlow]. University of Indiana Press, Bloomington, Ind.
Améry, J. (1999). On suicide: A discourse on voluntary death. [Trans. J.D. Barlow]. University of Indiana Press, Bloomington, Ind.
Aminoff, B. Z., Purits, E., Noy, S., & Adunsky, A. (2004). Measuring the suffering of end-stage dementia: Reliability and validity of the mini-suffering state examination. Archives of Gerontology and Geriatrics, 38(2), 123–130. https://doi.org/10.1016/j.archger.2003.08.007.
Beauchamp, T. L., & Morton, D. B. (2015). The upper limits of pain and suffering in animal research. Cambridge Quarterly of Healthcare Ethics, 24(4), 431–447.
Beekman, W. (2011). The self-chosen death of the elderly [trans. Y. Boerup and R. Jonquiere] (accessed via: https://www.worldrtd.net/sites/default/files/newsfiles/UVW%20engels%20definitief%201.1_0.pdf).
Blanke, C., LeBlanc, M., Hershman, D., Ellis, L., & Meyskens, F. (2017). Characterizing 18 years of the death with dignity act in Oregon. JAMA Oncology, 3(10), 1403–1406. https://doi.org/10.1001/jamaoncol.2017.0243.
Boston, P., Bruce, A., & Schreiber, R. (2011). Existential suffering in the palliative care setting: an integrated literature review. Journal of Pain and Symptom Management, 41(3), 604–618.
Buiting, H. M., Deeg, D. J., Knol, D. L., Ziegelmann, J. P., Pasman, H. R. W., Widdershoven, G. A., & Onwuteaka-Philipsen, B. D. (2012). Older peoples' attitudes towards euthanasia and an end-of-life pill in The Netherlands: 2001–2009. Journal of Medical Ethics, 38(5), 267–273. https://doi.org/10.1136/medethics-2011-100066.
Cassell, E. J. (1991). Recognizing suffering. Hastings Center Report, 21(3), 24–24. https://doi.org/10.2307/3563319.
Cassell, E. J. (1999). Diagnosing suffering: A perspective. Annals of Internal Medicine, 131(7), 531–534.
Chakraborty, R., El-Jawahri, A. R., Litzow, M. R., Syrjala, K. L., Parnes, A. D., & Hashmi, S. K. (2017). A systematic review of religious beliefs about major end-of-life issues in the five major world religions. Palliative & Supportive Care, 15(5), 609–622. https://doi.org/10.1017/s1478951516001061.
Cheung, G., Merry, S., & Sundram, F. (2015). Late-life suicide: Insight on motives and contributors derived from suicide notes. Journal of Affective Disorders, 185, 17–23. https://doi.org/10.1016/j.jad.2015.06.035.
Crandall, M., Luchette, F., Esposito, T. J., West, M., Shapiro, M., & Bulger, E. (2007). Attempted suicide and the elderly trauma patient: Risk factors and outcomes. Journal of Trauma and Acute Care Surgery, 62(4), 1021–1028. https://doi.org/10.1097/01.ta.0000229784.88927.6e.
Dees, M., Vernooij-Dassen, M., Dekkers, W., & Van Weel, C. (2010). Unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: An integrative review. Psycho-Oncology, 19(4), 339–352. https://doi.org/10.1002/pon.1612.
de Lange, F. (2013). Loving later life: Aging and the love imperative. Journal of the Society of Christian Ethics, 33(2), 169–184. https://doi.org/10.1353/sce.2013.0027.
Descartes, R. (1998). Discourse on Method and Meditations on First Philosophy, 4th edition (trans. D.a. cress) Hackett publishing co., Indianapolis, Ind.
Evenblij, K., Pasman, H. R. W., Van Der Heide, A., Hoekstra, T., & Onwuteaka-Philipsen, B. D. (2019). Factors associated with requesting and receiving euthanasia: A nationwide mortality follow-back study with a focus on patients with psychiatric disorders, dementia, or an accumulation of health problems related to old age. BMC Medicine, 17(1), 39. https://doi.org/10.1186/s12916-019-1276-y.
Fleming, D. (2019). The compassionate state? Voluntary assisted dying, neoliberalism and the problem of virtue without an anchor. ABC Religion and Ethics, march 25th, 2019. (accessed via https://www.abc.net.au/religion/compassionate-state-voluntary-assisted-dying-neoliberalism-and/10937504).
Heilbrun, C. G. (1997). The last gift of time: Life beyond sixty. Dial Press.
Heilbrun, C. G. (2004). From rereading to reading. PMLA, 119(2), 211–217.
Hendry, M., Pasterfield, D., Lewis, R., Carter, B., Hodgson, D., & Wilkinson, C. (2013). Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying. Palliative Medicine, 27(1), 13–26. https://doi.org/10.1177/0269216312463623.
Holzman, T. J. (2021). The final act: An ethical analysis of pia Dijkstra’s euthanasia for a completed life. Bioethical Inquiry, 18, 163–175. https://doi.org/10.1007/s11673-020-1-84-x.
Huertas, P., Moreno-Küstner, B., Gutiérrez, B., & Cervilla, J. A. (2020). Prevalence and correlates of suicidality in Andalusia (Spain): Results of the epidemiological study. Journal of Affective Disorders, 266, 503–511. https://doi.org/10.1016/j.jad.2020.01.115.
Jackson, W. C. (2002). Palliative sedation vs. terminal sedation: what's in a name? The American Journal of Hospice & Palliative Care, 19(2), 81–82. https://doi.org/10.1177/104990910201900202.
John Paul, I. I. (1995). Evangelium vitae: Encyclical letter addressed by the supreme pontiff Pope John Paul II to all the bishops, priests and deacons, men and women, religious lay faithful, and all people of good will on the value and inviolability of human life. Vatican Library, Rome., 97, 141–143. https://doi.org/10.1177/0040571x9409700225.
Jones, D. A. (2016). Apostles of suicide: Theological precedent for Christian support of ‘assisted dying’. Studies in Christian Ethics, 29(3), 331–338. https://doi.org/10.1177/0953946816642994.
Kim, S. Y., De Vries, R. G., & Peteet, J. R. (2016). Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry, 73(4), 362–368. https://doi.org/10.1001/jamapsychiatry.2015.2887.
Kious, B., & Battin, M. P. (2019). Physician aid-in-dying and suicide prevention in psychiatry: A moral crisis? American Journal of Bioethics, 19(10), 29–39. https://doi.org/10.1080/15265161.2019.1653397.
Krikorian, A., Limonero, J. T., & Corey, M. T. (2013). Suffering assessment: A review of available instruments for use in palliative care. Journal of Palliative Medicine, 16(2), 130–142. https://doi.org/10.1089/jpm.2012.0370.
La Cour, P., & Hvidt, N. C. (2010). Research on meaning-making and health in secular society: Secular, spiritual and religious existential orientations. Social Science & Medicine, 71(7), 1292–1299. https://doi.org/10.1016/j.socscimed.2010.06.024.
Ladwig, K. H., Klupsch, D., Ruf, E., Meisinger, C., Baumert, J., Erazo, N., Wichmann, H. E., & Investigators, K. O. R. A. (2008). Sex-and age-related increase in prevalence rates of death wishes and suicidal ideation in the community: Results from the KORA-F3 Augsburg study with 3154 men and women, 35 to 84 years of age. Psychiatry Research, 161(2), 248–252. https://doi.org/10.1016/j.psychres.2008.03.011.
Lewis, P. (2006). Assisted dying in France. The evolution of assisted dying in France: A third way? Medical Law Review, 14(1), 44–72. https://doi.org/10.1093/medlaw/fwi033.
Materstvedt, L. J., Clark, D., Ellershaw, J., Førde, R., Boeck-Gravgaard, A.-M., Muller-Busch, H. C., & Porta i Sales, J. and Rapin, C-H. (2003). Euthanasia and physician-assisted suicide: A view from an EAPC ethics task force. Palliative Medicine, 17(2), 97–101. https://doi.org/10.1191/0269216303pm673oa.
May, W. E. (2003). Philosophical anthropology and Evangelium vitae. Acta Philosophica, 12(2), 311–322.
MacIntyre, A. (1984). After Virtue: A study in moral theory. University of Notre dam Press, Notre Dam, Ind.
Mishara, B. L., & Weisstab, D. N. (2016). The legal status of suicide: A global review. International Journal of Law and Psychiatry, 44, 54–74. https://doi.org/10.1016/j.ijlp.2015.08.032.
Murata, H., & Morita, T. (2006). Conceptualization of psycho-existential suffering by the Japanese Task Force: The first step of a nationwide project. Palliative & Supportive Care, 4(3), 279–285. https://doi.org/10.1017/s1478951506060354.
Olsson, I. A. S. J, Nicol, C., Niemi, S. M., & Sandøe, P. (2020). From unpleasant to unbearable—Why and how to implement an upper limit to pain and other forms of suffering in research with animals. ILAR Journal, online first https://doi.org/10.1093/ilar/ilz018.
Papavasiliou, E. S., Brearley, S. G., Seymour, J. E., Brown, J., Payne, S. A., & on behalf of EURO-IMPACT. (2013). From sedation to continuous sedation until death: How has the conceptual basis of sedation in end-of-life care changed over time? Journal of Pain and Symptom Management, 46(5), 691–706. https://doi.org/10.1016/j.jpainsymman.2012.11.008.
Pasman, H. R. W., Rurup, M. L., Willems, D. L., & Onwuteaka-Philipsen, B. D. (2009). Concept of unbearable suffering in context of ungranted requests for euthanasia: Qualitative interviews with patients and physicians. BMJ, 339, 1235–1237. https://doi.org/10.1136/bmj.b4362.
Raijmakers, N. J. H., van der Heide, A., Kouwenhoven, P. S. C., van Thiel, G. J. M. W., van Delden, J. J. M., & Rietjensal, J. A. C. (2015). Assistance in dying for older people without a serious medical condition who have a wish to die: A national cross-sectional survey. Journal of Medical Ethics, 41, 145–150. https://doi.org/10.1136/medethics-2012-101304.
Rietjens, J. A., van Tol, D. G., Schermer, M., & van der Heide, A. (2009). Judgement of suffering in the case of a euthanasia request in the Netherlands. Journal of Medical Ethics, 35(8), 502–507. https://doi.org/10.1136/jme.2008.028779.
Riisfeldt, T. D. (2019). Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation. Journal of Medical Ethics, 45(2), 125–130. https://doi.org/10.1136/medethics-2018-105074.
Schulz, R., Monin, J. K., Czaja, S. A., Lingler, J. H., Beach, S. R., Martire, L. M., Dodds, A., Hebert, R. S., Zdaniuk, B., & Cook, T. B. (2010). Measuring the experience and perception of suffering. The Gerontologist, 50(6), 774–784. https://doi.org/10.1093/geront/gnq033.
Schuman-Olivier, Z., Brendel, D. H., Forstein, M., & Price, B. H. (2008). The use of palliative sedation for existential distress: a psychiatric perspective. Harvard Review of Psychiatry, 16(6), 339–351. https://doi.org/10.1080/10673220802576917.
Smets, T., Cohen, J., Bilsen, J., Van Wesemael, Y., Rurup, M. L., & Deliens, L. (2011). Attitudes and experiences of Belgian physicians regarding euthanasia practice and the euthanasia law. Journal of Pain and Symptom Management, 41(3), 580–593. https://doi.org/10.1016/j.jpainsymman.2010.05.015.
Steck, N., Egger, M., Maessen, M., Reisch, T., & Zwahlen, M. (2013). Euthanasia and assisted suicide in selected European countries and US states: Systematic literature review. Medical Care, 51(10), 938–944. https://doi.org/10.1097/mlr.0b013e3182a0f427.
Strang, P., Strang, S., Hultborn, R., & Arnér, S. (2004). Existential pain—an entity, a provocation, or a challenge?. Journal of Pain and Symptom Management, 27(3), 241–250. https://doi.org/10.1016/j.jpainsymman.2003.07.003.
Van Hooft, S. (1998). Suffering and the goals of medicine. Medicine, Health Care and Philosophy, 1, 125–131.
van Tol, D., Rietjens, J., & van der Heide, A. (2010). Judgment of unbearable suffering and willingness to grant a euthanasia request by Dutch general practitioners. Health Policy, 97(2–3), 166–172. https://doi.org/10.1016/j.healthpol.2010.04.007.
Varelius, J. (2014). Medical expertise, existential suffering and ending life. Journal of Medical Ethics, 40, 104–107. https://doi.org/10.1136/medethics-2012-100812.
WHO. (2014). Preventing Suicide: A global imperative. World Health Organisation.
Wiebe, E. R., Shaw, J., Kelly, M., & Wright, A. (2019). Suicide vs medical assistance in dying (MAiD): A secondary qualitative analysis. Death Studies, online, 44, 1–6. https://doi.org/10.1080/07481187.2019.1614110.
Winterrowd, E., Canetto, S. S., & Benoit, K. (2017). Permissive beliefs and attitudes about older adult suicide: A suicide enabling script? Aging & Mental Health, 21(2), 173–181. https://doi.org/10.1080/13607863.2015.1099609.
Young, R. (2014). ‘Existential suffering’ and voluntary medically assisted dying. Journal of Medical Ethics, 40(2), 108–109. https://doi.org/10.1136/medethics-2012-101101.
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Gilleard, C. Bearable and unbearable suffering in later life. Population Ageing 14, 343–355 (2021). https://doi.org/10.1007/s12062-021-09333-7
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DOI: https://doi.org/10.1007/s12062-021-09333-7