Keywords

Being a doctor is my vocation; it is my calling to be an active member of society, to have my place in the world. It is not an end in itself, but a way to exist and to flourish personally and in solidarity with others. I am deeply convinced that I have a mission to combat illness with skill, to support the sick and their loved ones with all my heart, and to experience the compassion that alone makes it possible for us all to live together.

Given all this, since the therapeutic relationship is a human relationship, I am convinced that the doctor must be completely committed, with the three dimensions that constitute his being. He engages his body by the expression on his face, the way he speaks, and the movement of his hands; but he engages also with his heart, by his ability to experience emotion, his sensibility, and his intelligence; and lastly, he engages with his mind through his will and his liberty. In all this, he is called to open himself to the other person, all the while respecting her as different. In answering this call, he labors so that the life that dwells equally in both of them may flow within them, between them, and beyond them, and so may weave the bond of humanity that binds all of us. That way, the doctor can reach out to a sick person in a human way, in the entirety of her suffering. He can help the sick person to get moving again, to evolve, so as to heal whatever in her body or mind needs healing, but he can also help her get beyond her losses and reorient her expectations. Independently of the treatments we give, sometimes without our knowing it, simply because we open the door to the life within us, good things pour forth from this inner life whose goodness we cultivate. If a person agrees to detach herself from the superficial, if she refocuses on what ultimately counts, she nurtures what is perennial, what transcends the relationship and gives a taste of eternity. A lasting human society is built.

Isabelle is 62 years old, with sparkling blue eyes and a smile from ear to ear. For her husband, her children, their spouses, and her grandchildren, she is the conductor of a family symphony who cannot help but touch those who meet her. Mistress of her life, sure of her choices and resolves, she knows how to guide her little world gently and firmly. In two weeks, jaundice fell upon her like a storm from a summer sky. Unfortunately, its cause is a particularly aggressive cancer of the pancreas that has already spread to the liver. The prognosis is extremely somber. The liver is functioning very poorly, allowing at best a very low dose of chemotherapy, which may be sometimes difficult to tolerate and whose effectiveness seems uncertain. Is it wise to undertake it? Isabelle takes in the news by shedding a few tears that are quickly wiped away and by letting her “better half” hold her hand without saying a word. In one evening, she’s made up her mind that there is to be no question of dying: her son is getting married in three months—she’s got to get better and be in shape for the wedding. In this chaos, scientific truth shall not have the last word. Isabelle’s resolve is wholehearted; the only thing she can do is to silence this damn cancer that wants to interfere with her plans. Everything will go well. With teeth clenched under a revived smile, Isabelle suffers, alone and in silence, the anguish of a dying person that is imposed on her. Mirroring her resolve, without a word said, each of her loved ones obeys the mute order and puts up a good front. The love that flowed so well freezes. Like a colorless, odorless poison, death insidiously settles among them. I suffer to see them like that. Confident in her strength, I suggest to Isabelle that she does not repress the reality of serious illness, that she give it a place in her life and in that of her loved ones. Happily, Isabelle lets herself be guided and agrees to open the door to another way of being. Instead of being the one who shows the way, she learns to listen to the advice given to her. Instead of confining herself to the role of the strong woman who controls everything and imposes a smooth and joyful ambiance, she is willing to both relinquish control and fight on. Accepting her vulnerability implies acknowledging her finiteness. But finiteness is scary. It implies saying good-bye, leaving those one wants to protect. This requires time and inner struggle. Progressively taming reality can allow ties to be firmed up more, to show confidence in loved ones, to leave messages, and to find peace. In these situations, the doctor is inspired by the hope that the sick person may experience a transformation of her life, may accept it and make it her own, to regain the wholeness that opens her to inner healing. Isabelle dares to freely speak the truth. She learns to cry with her loved ones and to let them cry, without for all that becoming discouraged. She becomes willing to not control everything, all the while remaining herself. Bestirring herself to prepare both her son’s wedding and her own burial, she makes more room for those she loves and who love her to support her, to surround her, and to care for her.

She learns how to receive in addition to how to give, to welcome whatever happens instead of denying it. This is stimulating and salutary for her and her loved ones. Thanks to this new equilibrium, like a reed that bends but does not break, she expresses even more vividly her personality that is so full of life and will leave her imprint in the hearts of her loved ones to remain there forever, devoting the end of her life to snubbing the death that wanted to crush her. Drawing on this new wealth she discovers in herself, Isabelle finds the necessary force to snatch enough time in remission to let her be truly in shape for her son’s wedding. Then she dies quickly but in the joy of a shared victory.

The lessons she taught confirmed the reality of “a life fully lived right to the end,” not only for her loved ones but also for the healthcare professionals, and for me in particular. The tiny spark I gave lit a fiery blaze that shone far and wide. Through alert listening and loving presence, I experienced how, if one simply gives of oneself in this therapeutic alliance, there is a chance of touching the mystery present in each one of us. Mutual self-giving can be painful, or at least destabilizing since such giving often has the feel of powerlessness. One is tempted to flee rather than to live. That is what I would risk doing if I believed that I could not rely on anything. I would then flee to protect myself and remain effective. I would succumb to the temptation of wanting to manage the problem one way or another. But then I would cease to see the sick person. I would see only her illness and her suffering, which repel me. Yes, everything depends on how I see the sick person and how she sees me. Her truth, which escapes her, just as my own escapes me, can only be approached in the communion of our two frailties. This requires confidence and perseverance. Ordinarily, we seek independence, for we think we are free only by being independent. We seek effectiveness, strength, and autonomy, devoted as we are to individualism. As death approaches or when illness brings it to mind, we become aware that this way of seeing things alienates us from our nature and weakens us rather than strengthens us.

Unlike Isabelle, Corinne struggled for five years, with long remissions and relapses. But just like Isabelle, she has a fiery temperament, she is decisive, independent, and combative. She clings to her autonomy in deciding and acting. Losing her hair, or part of her lung or liver, is nothing as long as she can attend to her business and live without depending on others. Her oncologist, who works in the same hospital as I do, has just told her he can only offer to keep her comfortable. She does not want to go home. She wants to stay a while at the clinic. My colleague requests her transfer to palliative care, with no particular plan. She acts a bit distant toward me, but is polite and smiling. She keeps to technical questions—symptoms, explanations, and medication—and does not pick up on any hint I offer for a deeper dialog. I am at her side for a few days only. Very quickly she understands that the fatigue that is starting to hinder her mobility and makes even getting dressed an effort is here to stay. She understands that the appetite she has lost will not return. Without the palliative care team’s knowledge, she makes sure that her referring oncologist will keep his promise to euthanize her. She informs her loved ones; it has to be done quickly. The referring oncologist, who knows that the palliative care team does not practice euthanasia, remains silent about this plan and asks his patient and her loved ones to do the same. They avoid the idea of possible support and concentrate on imagining what they view as inevitable. For them, there is only useless suffering. The patient is in a hurry. I am absent that day; my oncologist colleague is replacing me and is a little overloaded. Without saying a word to the palliative care team he has just left, he asks a nurse on the oncology team to free a room and get the patient so she can be euthanized. Without stating any reason, the nurse in oncology telephones the palliative care unit to say she is coming to get the patient. The healthcare staff in palliative care find these odd doings disturbing. For her part, the patient appears calm. She has got what she decided on, what suits her; the rest means nothing to her. Upon my return, I am pained to see my team treated like furniture. In this assignment, I feel amputated. Nonetheless, I met this patient’s expectations within the framework she defined: I thwarted whatever physical symptoms there were and I did not force upon her a relationship she did not want. She knew that I did not perform euthanasia and freely chose not to speak to me about her difficulties. Yes, at that moment in any case, the only possibility she could see to maintain what she considered her autonomy was to stick to this image of herself that she had forged and shown to everyone else, that of the patient in charge. As for myself, it was my duty to take in and let resonate in me the mute cry of her suffering, her revolt, her denial, her anger, and her discouragement, even if nothing was said or shared. In the Belgian medical context of the decriminalization of euthanasia, I had no choice but to accept this interpersonal void and let her choose an induced death.

This way of applying the law on euthanasia is widespread. To me it is abusive. Originally, the law removed the fundamental prohibition of killing, but only in certain circumstances deemed extraordinary. The legislature confirmed that killing—even out of compassion, even at the express request of the patient—remained a grave act that the doctor could perform only in an exceptional circumstance. This law sought to protect the doctor against possible indictment. But its application was quickly extended. Thus, in what way did Corinne, in fearing the progressive loss of her autonomy, display suffering that was making her lose her dignity? Or that of those who supported her?

In giving citizens the so-called right to choose when their life is no longer worth living, society turns the doctor into an instrument.

Euthanasia has become a life plan, and the doctor is asked to grant the citizen what she asks of him. Instead of considering euthanasia a transgression, an evil that is tolerated under strict conditions, current ethical thinking seeks to impose a new paradigm of care, under which the doctor must consider it a lesser evil, indeed a simple therapeutic option, in planning care in advance. As for myself, it is only by means of my right to conscientious objection that I can attempt, at the bedside of a sick person, to shed light on the situation from another perspective. This is possible only if the patient leaves me free to do so, because euthanasia has made it difficult to talk about and maintain this perspective. To make myself more available to the person who truly requests euthanasia, I must overcome my own fears and ground myself in my values in order to risk the encounter, to dare to venture into unknown territory, where I will be defenseless, at a loss for an answer, where I will have to give yet more of myself, relying on what lies deepest in me, on the spark of life that sustains me. None of us has created himself, and so I know that this spark also dwells in Corinne, as in every human being. I know, not from theory but from experience, that the spark of life remains alive and can help us. It beckons us to give ourselves up to it with confidence and to let drop the image of what until then we had thought ourselves to be, like an empty shell. Is not that what it means to live? To dare to place real confidence in our untapped resources, without looking to hang onto the image we have constructed of ourselves over time. The doctor knows he must remain by the side of the suffering person, to help him realize he can find himself anew instead of losing himself, that he can again be himself, even if he is different, even if he is afraid he will not be recognized. The person whose suffering seems unbearable and unappeasable sees herself trapped where she thinks she can no longer live. Her suffering reaches out to me in the deepest place of my own frailty, where I too experience my powerlessness as an impasse. The person who is at the end of her rope is a call to me, a summons. The only way, for both of us, to get out of the impasse where suffering wants to trap us, is to recenter ourselves, not on our achievements, not on the quest for a solution, but on our common humanity, our complicity as allies, by making our relationship strong and loyal, by being willing to live through the difficulties together. The person who is suffering will feel she has been reached out to only if the person who cares for her lets himself be touched where he too is fragile and vulnerable, where he accepts that he too can live through this suffering. Supporting the person is more important than solving a problem, without for all that forgetting that “expertise is the foremost solidarity.”

Accepting this fragile situation provides an opportunity for us to approach the intimate and mysterious place where the life force flows in us like a free gift.

If I consent to be powerless, in a spirit of silence, struggle, confidence, and patience, I can let well up in me a life-giving spring that makes me a better person and allows me to show another person that I have faith in her. It is often from the powerlessness I take on that in my heart there arises the compassion that can reach the suffering person and give her new strength. A shared peace, a gift of life for both of us.

This is what Corinne refused. By turning in on herself, she demanded a contractual commitment rather than a therapeutic alliance. All that is left is the confrontation between the right to request euthanasia and the right to accept or refuse to carry it out. Since Belgian society imposes this confrontation on me, the exercise of these rights must at least respect the vulnerability inherent in human nature. The person who suffers and experiences the feeling of no longer being able to live must be acknowledged in her suffering. Yet are not certain sick people, in a situation of extreme frailty, often exploited for the benefit of a macabre ideology? It in fact is not rare that the press depicts them as horrors to be eliminated since they call into question the concept of an ideal life without suffering, our society’s utopia, which contradicts our life in the flesh. If, like Corinne, the patient sticks to her point of view, to the point of repelling any dialog, there remains only loneliness, on one side and on the other. The therapeutic relationship can only be cut off. And humanity swept aside.

But is this what to expect of a doctor? To step back when he has left only what is essential, his humanity, to place at the service of the person who is suffering?

Should one infer that our country has imposed on us an act that denatures our profession?

In any event, insofar as I am involved, given how I view my medical commitment to the therapeutic relationship, I do not feel respected. It is as though I were but a machine equipped with some good software, producing an act that issues from the meeting of an intellect and a will. Besides, the law does not even require that the doctor know the person he is to euthanize; he must only verify that the person belongs to the “euthanizable without prosecution” group. This law is deluded about its foundation: it purports to be the exercise of a right to autonomy, whereas it is only a conditioned reflex in the face of a double impasse: the impasse of the patient drowning in her suffering as though she no longer has it in her to exist, and the impasse of the doctor locked into the omnipotent efficacy that the other person demands of him.

It is not a question of a responsible and free autonomy but rather of a desperate act of two people trapped in powerlessness.

The resolve to promote autonomy as an absolute good results in a perverse fusion where the roles of master and slave are interchanged.

The sick person, reduced to her suffering, thinks she knows what is good for her and wants to impose her vision. The doctor exists only in his capacity to respond to the patient’s expectations. He loses his own identity and commits an act of mistaken mastery to fulfill the other’s aggrieved wish. The way they have defined themselves, one cannot continue to exist without the other; they are accomplices forever.

Attempting to take control of the situation by an act that interrupts life is for me false compassion since it denies the fact that the person always remains a force for the good to be protected, whatever her situation—a person with whom, together, we jointly form humanity. Of course, inducing death effectively turns the one who suffers away from a difficult road, but this irreversible act gives the last word to suffering. It prevents the person who suffers from discovering in herself the living force that both renews the one who finds it and strengthens the one who witnesses it. Giving the doctor the power of death over the utterly defenseless person who requests it of him pushes him into a position where he becomes the idol, the one who can do everything. This way of thinking forces the doctor to abandon the therapeutic goal of caring for humans as they really are, to veer toward a promise to improve the human condition, which has been conceived as a subjective ideal, detached from reality, freed from any dependence, from any shared point of reference.

This unbridled quest for total mastery, which denies the finiteness inherent in man and denies man as a transcendent being, is appalling since it cannot do other than sacrifice a weakened person in favor of an idealized and abstract image. Suffering in one’s own identity is a painful wound that impairs a person’s health. The doctor has no solution to offer; he can only accompany the person along her way, in solidarity with her in this suffering that can touch any person. This is the glory of his vocation of caregiving.

If Corinne does not agree to take the journey of seeking what remains of herself after her losses and what truly defines her as a unique and irreplaceable human being, if she refuses to take the risk of waging this fight and if Belgian society gives her the right to find a doctor who cancels this fight before it can start, it is to be feared that the humanity of both patient and doctor will be erased.

The doctor becomes the instrument that satisfies a resolve, the executor of a contract. Through his skill and the power society bestows on him, he masters the natural life from which the patient wants to be freed…, whereas, for me, the doctor is there, with his expertise of course, but also with his whole person, to place himself at the service of the suffering person, in the most balanced interpersonal relationship possible, recognizing each one’s limits.

To demand that medicine master all suffering is to reduce it to solving problems, instead of taking an interest in the person who is suffering.

Suffering certainly must be fought with skill and perseverance, but it does not encompass the whole of a human being. The patient cannot be reduced to her suffering; she is more than that. The doctor cannot be reduced to his expertise or his function; he is more than that.

Requesting death and giving it when suffering persists is neither a courageous act nor an act of love, but a flight and a desertion. Courage and love do not lead to these impasses: the fear of suffering together, turning in on oneself, and turning the other into an instrument. In these difficult cases particularly, but also generally, I plead for recovering and permanently entrenching a humble and human medicine, almost in spite of its effectiveness, a medicine centered on human beings and not on their problems.

From experience, I know that this attitude can give birth to a new inner freedom. For the sick person who is no longer alone, who is acknowledged as a companion for the journey, as someone important, capable of acting and of giving herself in spite of her extreme frailness, it is a matter of seeing the unexpected surface, of discovering unknown resources within oneself, of tending toward inner healing and wholeness of being. For the healthcare professional, it is a matter of being received by the person who needs him, without having anything else to give but the main thing, which is himself. For loved ones also, it is a matter of growing in humanity by remaining present for the person who is suffering: her suffering upsets them, but they acquiesce in suffering with her.

Only the painful confrontation of this reality makes it possible to affirm the existence of the “kalon kakon,” that is, the beauty of love concealed in the ugliness of suffering.

Whether we want it or not, all that we experience rebounds in one way or another on those who surround us. To want to escape, by means of a radical technical solution, from the formidable experience of suffering and dying leaves us more and more defenseless, more and more vulnerable, whether we are the one cared for or the healthcare professional, the loved one, or simply a member of society. This growing inability to live with suffering will make people say, more and more, as we are already hearing, that only an induced death, at the chosen time, is a dignified, peaceful death suffused with humanity, and that only the doctor who agrees to induce the death of his patient who has requested it has any heart. Whereas euthanasia is in fact surrendering to fear, to prevailing despair, to the attitude of “what good is it anyway?” that clips our wings.

Lili writes to me: “Before experiencing the accompaniment you offered my mom, I was rather in favor of euthanasia. Now, not any more. Without making a crusade out of it, I know that I would not want it for myself. I have learned, from the final moments lived with my mother, to tame death. It is a wonderful gift, for I no longer fear death now. That is for me the key: if our society had not set death aside by making it a supreme taboo, euthanasia would not exist. And you are not heartless, on the contrary!”

The growing incapacity to live with suffering affects not only our humanity but also our professional expertise and our ethical bearings. Many healthcare professionals today have not acquired or are losing their expertise in dealing with great suffering instead of improving it. Their threshold of tolerance has fallen greatly.

Euthanasia kills not only the patient but also the therapeutic imagination.

Palliative care, as established by Dr. Saunders, has fallen out of favor, whereas it should be better taught and developed. Instead of taking this route toward progress, certain healthcare professionals, notably members of the Commission for the Control and Evaluation of Euthanasia, ask that directors of public health services henceforth promote the form for the advance declaration of euthanasia, believing that there are far too few people enrolled. Yet we know well that it is difficult to make decisions when the patient is unconscious,Footnote 1 and even more so in the current context where the pressure for euthanasia from suffering loved ones can be great. The Commission’s request can only lead to escalation, to the point where euthanasia will become a panacea, applied in any difficult situation. Is that the medicine people want for tomorrow?

2.1 The Therapeutic Alliance

In being born male or female, human beings must acknowledge that they are they are not by themselves alone sufficient to express humanity. This complementarity is also to be found in the doctor–patient relationship. For human beings to be, to live, to grow, and to build humanity, they must accept complementarity and dependence. Being a doctor means forging a therapeutic alliance. This has nothing to do with a therapeutic contract that seeks only to place sophisticated technology, applied by a qualified professional, at the disposition of an anonymous client who gives or does not give her consent. In the alliance, there is a promise of loyalty to always provide care in an impartial way. I have witnessed the way in which many men and women, in situations of great distress, have found in themselves resources they were not aware of and that flourished by their accepting difficult circumstances.

Marie-Thérèse is 84 years old. I find her very agreeable. Yet she upsets me in our first meetings. She suffers from a metastasized ovarian cancer and we speak about a treatment plan. In a very crude, flippant way she tells me how she is for eliminating the elderly in retirement homes and the handicapped at birth, all those useless people who can do nothing with their lives. If she becomes helpless, she is sure she will request euthanasia. She knows that I am a conscientious objector to this act, but just the same, she wants me to take her as a patient for chemotherapy. We get along well. At the end of life, bedridden and completely dependent, to gain time, she fights all the forces arrayed against her, telling her daughter: “It’s my old age.” Reasoning as a woman in good health, she had reduced her body to its organic aspect, but she had no doubt forgotten the fact that a person exists in relation to others, through her body—this frail body that is herself, and not mere matter that belongs to her. Tirelessly attended by her loving daughter, she came to give renewed value to the body that was abandoning her, to maintain her relationships, and to live through them to the end.

Marie-Thérèse and her daughter, and so many other examples I have seen, show a reality that forbids us to despair of human beings. Human beings can evolve endlessly while always remaining themselves, and can do so much better with an alter ego that accompanies and supports them, and they can invent new norms for themselves that integrate their difficulties. Their acknowledged vulnerability becomes a life force that helps them detach themselves from the idea that they had of themselves and that imprisoned them.

Jacques is only around 50 years old. A kind of sullenness and listlessness, a fatalistic carelessness along with a certain resourcefulness in social dependency, drew him into a downward spiral of debt from which there seems to be no return. Fortunately, he is taken into the care of the district’s social assistance team and a medical institution that supports him in his new hardship, metastatic lung cancer. Unfortunately, the illness has got the upper hand: chemotherapy is no longer effective. In pain and diminished by an inability to function that is getting worse, he needs to be taken into the care of a palliative care team. Little by little, the core of his person comes to the fore; he shows himself to be particularly plucky with the physiotherapist who is teaching him to walk again; he works hard, like an athlete who wants to win the gold medal. He involves himself, to the point of literally being out of breath, in relating to his new “friends,” the healthcare staff, the volunteers, or his fellow unfortunates. From this loyal support, he draws the strength he had lost when he was in good health but abandoned by everyone.

Living this medical relationship, where the doctor and patient agree to have a real responsibility for one another, does not deprive them of autonomy, but on the contrary opens a way to an authentic freedom that is cohesive and human. From this abiding fraternal relationship is born the confidence that makes a therapeutic alliance lived out in everyday life possible. That is the humanist medical paradigm that respects the human being, simply because he/she is human, independently of everything else. Suffering and death than lose their false supremacy. Human life is truly respected to the very end, unconditionally. Human society can rely on and remain firm on this sure foundation.

Yes, euthanasia remains a temptation which is right and good to resist.

We can transform death by living it as an act of love, by welcoming our spirituality that comes to the aid of our wounded flesh. It is no doubt this transformation that makes those who care for the seriously ill say they receive more than they give. In the therapeutic alliance, the patient and doctor weave a bond between themselves by both trusting, in the same manner, in the life force that was given them and that unites them, what I undergo by the violence of suffering is transformed by love. By honoring the life received in us, our flesh is reborn from its ashes. This life force can transform everything from within much better than a solution imposed from without.

Annita is seriously handicapped due to anoxiaFootnote 2 at birth. Monitoring her is complicated since she hardly speaks. One has to know her well to interpret her symptoms. So the diagnosis comes too late: paralysis of the lower limbs linked to compression of the bone marrow by metastasis. Recovery is not possible, only a treatment that relieves her pain and prolongs her life. Several visits to reevaluate her treatment have made her well-known in the palliative care department, where she is happy. Through interdisciplinary collaboration and ongoing discussion, the team seeks what is good for Annita, while respecting her wishes and her frailty. At the very end of life, greatly weakened, turned in on herself due to incorrect positionsFootnote 3 slowly acquired despite the efforts of healthcare professionals, from the intense gaze of fraternal communion she draws the strength to die calmly, with a dignity that compels wonder and makes those who tend to her stronger.

I hope that in reading this you will have understood that its content does not come from theoretical reflection. I am a doctor and it is as such that I express myself. My thinking is rooted in what I experience as a professional in the field.

The doctor is there to “sometimes heal, often relieve, always console.” Yes, to always console, since it is as a human being that the doctor is close to the person that illness isolates, worries, makes suffer, and plunges into doubt. In all these lived experiences of deaths great or small, where life asks only to triumph, but where the light has dimmed, where its fire has turned cold, the doctor and the sick person are two similar links in the same chain. When the body is tired, too weak to be lifted up, the doctor is there to tell his fellow traveler that she is unique and thus irreplaceable and that her dignity is immutable.

With all my heart, I wish the doctor–patient relationship to be a therapeutic alliance and not a contract. Even if I want to be completely dedicated to the person who turns to me, I do not accept being turned into an instrument, trapped in an idolatry that would make me a seemingly almighty savior. Through our presence before one another, patient and doctor, we can make life flow between us and unite us in one and the same humanity.