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• Comment Buiting et al on the suffering criterion
  Henri Wijsbek
  Published on: 18 May 2017

• Published on: 18 May 2017

  Comment Buiting et al on the suffering criterion

  • Henri Wijsbek, Department of Philosophy

  In a study on the six due care criteria for lawful euthanasia in the Netherlands, H.M. Buiting and others found that the requirement that a physician should convince herself that her patient was suffering hopelessly and unbearably was by far the most difficult to meet. [1] Of the physicians who reported to have experienced problems with the criteria, 79% reported difficulties with that criterion; in particular they foun...

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  In a study on the six due care criteria for lawful euthanasia in the Netherlands, H.M. Buiting and others found that the requirement that a physician should convince herself that her patient was suffering hopelessly and unbearably was by far the most difficult to meet. [1] Of the physicians who reported to have experienced problems with the criteria, 79% reported difficulties with that criterion; in particular they found it difficult to convince themselves that the suffering was unbearable, and only to a lesser extent that it was hopeless. Actually, the authors locate the difficulties even more precisely. 53% of the physicians indicated problems in assessing whether they themselves were convinced that the patient suffered unbearably, whereas 28% reported difficulties in assessing whether the patient experienced his own suffering as unbearable. Other criteria that were mentioned to cause problems relatively often were the requirement that the patient’s request should be voluntary and well-considered (58%), and that there should be no reasonable alternative available (33%).

  The authors explain their findings by drawing attention to the fact that these three requirements are framed as open norms; ‘well-considered’, ‘unbearable’ and ‘reasonable’ all three requiring interpretation which has to take the specific circumstances of the case into account. Moreover, ‘well-considered’ and ‘unbearable’ (and to a lesser degree ‘reasonable’) refer to subjective aspects and are to a large extent a matter of the patient’s experience and personal perspective. This implies that physicians have to adopt an empathising role in order to ascertain whether the material criteria relating to the request are indeed fulfilled. But this need to empathise can get in the way of the physicians’ professional medical role, making their performance on the reasonable alternative criterion worse than it would be if their task were confined to the their medical role alone.

  As a solution for the physicians’ problems, therefore, the authors suggest that ‘It should be clearly communicated [by the Dutch government, HW] that the patient’s suffering and request (apart from judging the patient’s competency) can be assessed objectively only to a very limited extent and that, accordingly, these aspects need to be left to the patient to a great extent.’ Physicians could then concentrate on their medical professional judgement to assess whether any reasonable alternatives are available. What the authors suggest, effectively, is solving the problem by eliminating it. Since it is difficult for physicians to assess whether a patient suffers unbearably to confine myself to the most troublesome criterion it would be better if they were spared the trouble and were permitted to leave the decision to the patients themselves. But that suggestion has some unwelcome consequences. It would, in the first place, turn the suffering criterion into a sham; a physician would satisfy the criterion simply by asking the patient if he suffered unbearably. If he answers ‘Yes’ that would be the end of the matter. But obviously, merely saying so does not make it so. Secondly, it would not turn just any old criterion into a sham, but the most fundamental one, the one on which the Dutch euthanasia regulation is actually based. To quote the authors once more: ‘Although self-determination of the patient is a necessary condition to justify termination of their lives, in the final analysis the physician’s responsibility to alleviate the patient’s suffering is the most important principle underlying the Act.’ Indeed it is, as has been convincingly argued by Den Hartogh. [2] If it took a physician no more to satisfy herself that her patient was suffering unbearably than simply to ask him if he did, if credibility on this score could be had for the asking, self-determination would be the fundamental moral ground of the Dutch euthanasia act after all, and not alleviation of suffering.

  How, then, can a physician ascertain that her patient was suffering unbearably? Is it indeed a requirement she can only meet either by leaving it to the patient to decide or by abandoning her medical-professional role as the authors claim? That would be the case only if the medical- professional role is conceived in an inappropriately restricted way. As Cassell has argued extensively, among other places in the paper the authors refer to [3], medical knowledge consists of a lot more than knowledge of physiology, diseases and symptoms. Instead of directing all its attention to diseases and symptoms, ‘medicine should concern itself with illness, the set of disordered functions, body sensations and feelings by which persons know themselves to be unwell.’ [4] No general practitioner would dispute this view. At the very least, then, physicians always need to have particular knowledge about their individual patients, and if they have to assess their patients’ suffering, they have to know something in general about what makes a life go well, and hence, when it has deteriorated to a point at which it is conceivably not worth living any longer. Suffering is not a raw feeling, like pain or shortness of breath, but a complex state of being dependent on the particular meaning symptoms and losses have for this particular patient.

  If it takes general knowledge about what makes lives go well and particular knowledge about this individual patient’s biography and character to assess his suffering, what does it take to know whether his suffering is unbearable? Does not that requirement draw essentially on the patient’s own point of view? Is not he the final arbiter on the unbearableness of his own suffering? No, again, saying that one suffers unbearably does not make it so. Rather it invokes a norm. The truth conditions of the sentence ‘I suffer unbearably’ are not met as soon as the patient believe they are, but when we, the Dutch political community, do. We determine which suffering we consider to be unbearable and which we expect anyone should be able to cope with. Such a norm is public, and no more subjective than any other public norm. Needless to say, what patients experience as unbearable and what we consider to be so overlap to a very large extent, but that does not rule out disagreement or conflict. In such cases, physicians should apply the open public norm, rather than taking her patient’s request at face value or foist her own norms on him.

  In addition, then, to strict medical knowledge, physicians who have to decide whether to comply with euthanasia requests should have general and particular knowledge about what makes lives go well, and moreover, they must be acquainted with the public norm governing the application of the concept of unbearableness. Only this latter type of knowledge could possibly be called non-medical, since the norm in question is a societal norm in the sense that it is laid down in the Dutch criminal code, and interpreted by the courts and the regional review committees for euthanasia in which not only a physician, but also a lawyer and an ethicist serve as members.

  References 1 Buiting HM, et al., Dutch criteria of due care for physician-assisted dying in medical practice: a physician perspective. JME 2008;34;e12. 2 den Hartogh GA, Het Nederlandse euthanasierecht: Is barmhartigheid genoeg? (in Dutch) Tijdschrift voor Gezondheidsrecht 2007;31:180-198. 3 Cassell EJ, The nature of suffering and the goals of medicine. N Engl J Med 1982;306:639-45. 4 Cassell EJ, The nature of suffering and the goals of medicine. New York: Oxford University Press, 1991: 49.

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  Conflict of Interest:
  None declared.

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