Should I have played death’s advocate? ======================================== * Michael Sanatani I’ve just had my first patient receive medical assistance in dying (MAiD). He had lived with metastatic cancer for 11 years, but I had never really asked him how and why he kept going all these years. Nor do I feel now, despite having questioned him about his decision, that I truly understand why he chose MAiD. Many of my palliative care colleagues reassure me that good palliative care and alleviation of suffering can be (and some say, should be) a viable alternative to MAiD. But he had received good palliative care, as many of my patients do, cared for by our hospice or community team, and yet not all choose MAiD. Some do, and some don’t. Why do most of my patients *not* choose MAiD? Nobody likes to suffer, either themselves or by compassion, and, on the surface, MAiD appears to be a quick and simple solution to visible suffering, both physical and existential. So why not do it, when you develop stage IV cancer or another severe illness? Exploring this may lead us to discover what is different in the lives and attitudes of patients seeking MAiD compared with those who do not. Exploring the attitudes toward death of patients who are severely chronically ill may actually enlighten us about life; as the poet Christian Morgenstern wrote, “Who [the] living wishes to understand, must go into death’s land.”1 I have developed several hypotheses about why one would perhaps not choose MAiD despite being severely ill from something like cancer. First and foremost would simply be that despite the cancer, one’s desire to hold onto life might be stronger than the desire to leave it. For example, this could be the desire to spend more time with and share experiences with loved ones, even if (or especially if) the experiences are difficult. As the old folklore saying goes, a sorrow shared is sorrow halved; shared joy is twice the joy. This sharing could be comforting and balance the threat and fear that cancer presents. ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/189/46/E1422/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/189/46/E1422/F1) Image courtesy of GitteMoller/iStock In the past, there would also be another argument against MAiD: it was forbidden by criminal law. It is also forbidden in certain religious or spiritual communities, and for those submitting themselves to certain religious laws, it is forbidden by a deity beyond questioning. However, some may not turn to laws in such a situation. As Adam Phillips wrote provocatively in his book *Unforbidden Pleasures*, “... the law forbids being open to an open future; the open future of who we may be, and of who we may want to be.”2 For some patients, the drive to do what is really “right” for oneself might lead to a disregard of laws. But even those who do not recognize external moral or criminal laws as binding may have some concern based on the unknown aspects of the process of ending one’s life. What if there existed consciousness beyond death, and what if actions before death had an effect on one’s state of consciousness or experiences after death? > Who would fardels bear, > > To grunt and sweat under a weary life, > > But that the dread of something > > after death, > > The undiscovered country from whose bourn > > No traveller returns, puzzles the will > > And makes us rather bear those ills we have > > Than fly to others that we know not of? 3 Finally, those in whom the adversity of cancer has served as a “call to arms” may not contemplate turning to MAiD. Instead, it may be a matter of personal pride and character as to how and how long they fight what is seen primarily as an opponent. And some may find a way to see the cancer challenge and suffering as an opportunity for growth or another personally existentially meaningful process. But these are all theories. Do we really know if that’s what our patients who go on with life are actually thinking and feeling? Perhaps not. The next question that came up in my mind was, “How, as physicians, do we explore patients’ approaches to life and death in a responsible fashion, while leaving them free?” We should really be thankful for the emergence of MAiD, which gives us this unique opportunity to rediscover reasons to live on despite struggle, irrespective of external constraints, compulsions and directives — if indeed such reasons exist. As Viktor Frankl said about the approach to new-found liberties, > Freedom, however, is not the last word. Freedom is only part of the story and half of the truth. Freedom is but the negative aspect of the whole phenomenon whose positive aspect is responsibleness. In fact, freedom is in danger of degenerating into mere arbitrariness unless it is lived in terms of responsibleness. That is why I recommend that the Statue of Liberty on the East Coast be supplemented by a Statue of Responsibility on the West Coast.4 So how should we approach the new liberty of MAiD with responsibility? Certainly, the medical community has a responsibility to provide good palliative care. But good palliative care must mean more than alleviation of suffering, not only because it’s impossible to truly relieve 100% of suffering, but also because this pursuit — in my current opinion — will not offer patients a sufficient alternative to the desire for medically assisted expedited death. Good palliative care (and good oncology care) should include taking responsibility for exploring with patients the question of why they would not choose MAiD even in the face of suffering. In a sense, playing death’s advocate in this way, early on, may challenge patients to articulate their reasons for living. I think that exploring and debating the question of why patients would not choose MAiD is urgently needed, because the existing external scaffolding surrounding life-and-death decision-making is being taken down. It’s no longer possible to reply to a patient’s question about MAiD with a reminder that it is forbidden. Conversely, we should also no longer accept a priori that the experience of grievous and irremediable suffering is an unquestionable and sufficient motivation for MAiD in all individuals. That would, in my opinion, be irresponsible. Only if a society or an individual ponders the question, “Why not MAiD?,” just as fervently as, “Why MAiD?,” will we find free human beings making their individual decisions guided by two questions — pro and contra. If, over the last 10 years, I’d been more of death’s advocate in my discussions with my patient, rather than just focusing on relieving his suffering, would he have chosen death sooner? Or, paradoxically, having over the years articulated, examined and reaffirmed his reasons for living with suffering and loss, would he still be alive today? I’ll never know, but I certainly would be more comfortable now knowing the decision he took would have been truly his own and that I had actually guided him to his freedom in a responsible fashion. ## Footnotes * This is a true story. The patient’s widow has given her consent for this story to be told. ## References 1. Morgenstern C. Stuttgarter Ausgabe der Werke und Briefe, Lyrik II. Stuttgart (Germany): Urachhaus; 2013:511. 2. Phillips A. Unforbidden pleasures. New York: Farrar, Straus and Giroux; 2015:43. 3. Shakespeare W. Hamlet. Stratford-upon-Avon (UK); 1603:3.1.76–82. 4. Frankl V. Man’s search for meaning. New York: Beach Press; 2006.