Editorial: Opportunities at the End of Life

Michael McCabe
Issue 8, November 2002

"We who lived in concentration camps can remember the men who walked through huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a person but one thing: the last of the human freedoms – to choose one's attitude in any given set of circumstances, to choose one's own way."

--Victor Frankl (1959)

In New Zealand there has been considerable discussion recently about euthanasia, or more correctly, assisted suicide. Proponents of assisted suicide argue that it is the ultimate choice and promote it as helping the individual achieve "death with dignity". The debate has focussed around two recent events both highlighted in the media – the advent of the so-called "exit bag" and publication of a book by Lesley Martin entitled, "To Die Like a Dog."

Spokesman for the Auckland Voluntary Euthanasia Society, Jack Jones, has described the plastic "exit bag" as a "watershed for people wanting to achieve a dignified exit." The "exit bag" is "made of 'robust' plastic" and has a "velcro strapping device to tie it shut. It is vacuum packed and comes with a warning, 'Do not put this bag over your head. It could kill you..." The bag was obtained from Australian euthanasia advocate Dr Philip Nitschke.

In her book, "To Die Like a Dog", Lesley Martin describes the death of her mother in 1998. She had been terminally ill for some five months. At the time of her mother's death, Lesley, a trained intensive care nurse and the primary care giver, was alone and exhausted from sleep deprivation. She had been unable to have her mother admitted into the local hospice and had become deeply distressed at her mother's suffering from end-stage cancer. Because of a "promise" made earlier to her mother she felt compelled to hasten her mother's death by "suffocating her with a pillow."

Chicago physician, Dr Mike McDonnell, has recently given a timely reminder to pay close attention to the language being employed in the assisted suicide debate. The "media has moved euthanasia from 'mercy killing' to an 'easy, painless death' and now to a 'Right to die' or 'Death with dignity.' This is because Americans strongly support things attached to rights and dignity. Now something distasteful seems palatable." He uses the phrase, "verbal engineering", to describe the process whereby we use language to cloak the nature of certain actions in a way that disguises the deeper reality of what is being done.

Proponents of assisted suicide often equate the project of death with the death of a pet animal - "to die like a dog" has become a catch-cry. However, we are much more than household pets. We should not lose sight of the fact that it is precisely those things that differentiate us from animals that define us as persons. The phrase "dying like a dog" suggests a certain blindness to those things that truly make us human, and implies a diminished understanding of personhood. This approach to the assisted suicide debate is itself an indication that the practice of assisted suicide ignores or short-circuits many fundamental personal needs and that it relies on a reductionist and impoverished view of what it means to be fully human.

Doubtless, there are times in life of great stress and suffering which all impact on the way we approach death and dying. Indeed, the experiences of suffering can be so profound that those who have journeyed through them want to make a pre-emptive strike against any or all similar forms of suffering. Frequently this factor influences the motivation for assisted suicide. During my time working as fellow-in-ethics at Memorial Sloan-Kettering Hospital in New York, I recall meeting a husband and wife, both concentration camp survivors, who had made a pact with each other to seek physician-assisted suicide should either of them become terminally ill. In my initial meeting with them I was deeply moved to see the tattooed serial numbers on their wrists – a poignant reminder of the unspeakable suffering they had already endured. In the light of their past experiences it was hardly surprising that they did not wish to endure any further unnecessary suffering and that they should speak of assisted suicide as being a logical way of dying with dignity. Their story left the palliative care team with a renewed understanding of the very real and profound nature of existential suffering, and of the way in which our experiences of and attitudes towards suffering add to the layers of complexity in the assisted suicide debate.

As the palliative care team and other healthcare professionals explored treatment options with the couple there was considerable discussion about their desire for assisted suicide. However, within the caring environment of Memorial Sloan-Kettering Hospital, as their physical, spiritual and emotional needs were actively explored and met, the couple arrived at a different perspective on death. They began to see that dying with dignity had another and richer meaning. Through the holistic focus of the palliative care team they were gradually reassured that their very real fears could be faced in a different way from assisted suicide – a way that brought them healing and enabled growth at a deeper personal level than they had previously thought. Not only was it now possible for them to die with dignity, it was also possible to die in a way that made the act of death the ultimate act of healing and integration. The reality and darkness of death had become transformed – for them and also for their family and for their caregivers. In their terminal illness and dying they witnessed the full flowering of their love for each other, were reassured of their place and value in the community and achieved a peace that would not have been possible had their lives been short-circuited by assisted suicide.

In the courageous flowering of their personhood I came to witness what Victor Frankl meant when he spoke about the capacity to remain our own person, even in the face of great adversity, as being "the last of the human freedoms." Frankl equates this choice of attitude as living with dignity. For him, dignity involves living according to deeply cherished desires, desires not dependent upon the physical or emotional circumstances that an individual finds him or her self in. Such an understanding of personhood is a truly holistic one.

In keeping with this, Frankl would describe a dignified death as one where the individual experienced him or herself as being cared for, and where he or she had their spiritual, relational and emotional needs met, together with their physical needs. In the presence of such holistic care those dimensions that most fully characterise us as persons, far from being denied or extinguished, are actively nurtured and cherished. Moreover, in living out the philosophy of palliative care we are able to clearly demonstrate the giving and experiencing of love and care that is at the heart of the Christian tradition – the golden rule. The onus to provide effective palliative care remains, of course, a significant challenge for both the hospice movement and for the wider community to provide. The media's recent focus on assisted suicide underscores this challenge.

Assisted suicide makes eminent sense when death is viewed as being meaningless; when we see it as nothing more than the full stop at the end of the sentence called life. Proponents of assisted suicide are challenging us to rediscover and communicate the deeper meanings within death and dying or even that there is a meaning. To yield to the logic of assisted suicide is to rob the individual and community of wonderful possibilities for growth through the exercise of caring and to give up on the deeper dimensions of personhood. Dying with a plastic bag over your head is not death with dignity.


In 1940 Viktor Frankl was made head of the neurological department of Rothschild Hospital, the only hospital for Jews in Vienna during the Nazi regime. He made many false diagnoses of his patients in order to circumvent policies that required euthanasia of the mentally ill.


Rev Michael McCabe, PhD
The Nathaniel Centre