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Grief flieth to it: euthanasia and the recently bereaved
"Revenge triumphs over death; love slights it; honour aspireth to it; grief flieth to it." Francis Bacon
A healthy young woman dies in a manner which could scarcely be more horrific. A crowd of several hundred spectators, including members of her own family, sing and chant in encouragement. And ten years on, doubts remain as to the voluntariness of her actions. In almost every conceivable respect, it would be difficult to imagine an end further removed from the ideal of voluntary euthanasia supporters. Yet the death of Roop Kamwar throws into stark relief certain issues with which the right to die movement should be concerned.
The precise details will almost certainly remain shrouded in ambiguity. In September 1987, in observance of the ancient Hindu rite of sati, Roop Kamwar burned to death atop the funeral pyre of her husband. According to the only available witnesses (including several of her relatives) she went to her death entirely of her own free will, in the belief that in so doing she would ensure her husband's successful rebirth and bring good fortune to her family and village for seven generations. Although illegal since 1829, widows who give up their lives in this way are revered in some parts of India. Since her death, Roop has been elevated in the eyes of many to the status of goddess, and within a fortnight of her suicide, 750 000 people had made the pilgrimage to the pyre on which she perished.
There are, however, other versions of the events leading up to the sati. Allegations have been levied that Roop was at very least acting under intense pressure from her family, and may even have been forced to mount the pyre while heavily sedated by opium. Any prospect of learning the truth has not been helped by the politicisation of the issue - it has come to be perceived as a manifestation of the on-going clash of values between the increasingly secular India of the cities and the traditions to which many of those in rural areas continue to adhere. Viewing the prospect of a young woman in the 1990s choosing to burn herself to death in the hope of pleasing a goddess as somewhat less than plausible, the authorities charged 32 men with her death. Indeed, so determined were they to stamp out the practice that, rather than invoking the colonial laws prohibiting sati, the men were charged with Roop's murder. The prosecution, however, proved considerably more problematic than the police had anticipated, not least due to the wall of silence which they encountered when interrogating suspected witnesses. The trial was to last ten years, and concluded with all 32 men being acquitted in October of last year. The state government of Rajasthan has, however, appealed against the verdict, and a new prosecution is anticipated.
Even if it is accepted for the moment that Roop Kamwar was not forced onto the flames against her will, the circumstances of her death will almost certainly present problems for even the most vociferous advocate of voluntary euthanasia. Self-immolation is certainly not a painless means of self-deliverance, and if the objective of euthanasia is to ensure a 'good death', it seems difficult to imagine how this might qualify. Furthermore, even if she was not exactly forced, a doubt persists that her decision was not free from coercion or, at very least, pressure - again, factors incompatible with most conceptions of 'voluntariness'. Indeed, the whole episode was played out against a background which could scarcely be further removed from a western conception of a dignified death.
Aside from illustrating the extent to which other cultures differ from the Judeo-Christian tradition in their perception of suicide, then, what relevance does the Roop Kamwar case have to the campaign to legalise euthanasia in the developed world? This was certainly not an example of euthanasia; depending on which version is believed, her death was either an instance of murder or suicide, in all probability not even assisted suicide. But although the details are unusual and the setting alien, it is submitted that many of the issues which arise from the practice of sati could equally arise in more familiar contexts. In particular, the ritual poses a rather awkward question for supporters of v.e.: how should we view the case of an individual whose desire for death results from the grief of losing a loved one?
The archetypal candidate for v.e., guaranteed to evoke sympathy from the majority of the public, is incurably (perhaps terminally) ill and is suffering intolerable pain which cannot be satisfactorily alleviated. The person whose wish to die is not attributable to some physical cause - in the case of the sati, who wishes to follow their spouse into death - presents certain problems for the advocate of legalised voluntary euthanasia.
Absence of physical illness
Should the fact that the person requesting euthanasia is not physically ill make a difference to whether or not their wishes are adhered to? To some extent, the answer to this may lie in our reasons for supporting euthanasia in any circumstances. If our support is predicated upon a respect for the autonomy of persons - that is, a belief that they should (ordinarily) be free to make decisions about their own lives and deaths - then it is possible to argue that mental suffering should be treated no differently. If respect for autonomy demands that the timing and manner of my death are matters over which I should be allowed to exercise control, then would not this respect for autonomy be undermined if a condition were imposed restricting this control to certain circumstances (i.e. if I am physically ill) or requiring my decision to conform to someone else's standards?
Alternatively, euthanasia could be defended from a utilitarian viewpoint. This is ordinarily taken to be that school of philosophy which has as its moral objective the maximising of 'happiness' and minimising of suffering. (In truth, most contemporary utilitarians have abandoned talk of 'happiness' in favour of the language of wants and preferences, but it shall be retained here as a convenient shorthand). Most utilitarians would argue that the ending of a life is justified when that life has ceased to contain a balance of happiness over suffering, this balance being something over which each individual is uniquely qualified to determine about his own life. Most utilitarians would not attempt to make qualitative distinctions between different kinds of suffering, being exclusively concerned with the degree of suffering. It is, therefore, difficult to see how making an exception for emotional suffering could be justified according to adherents of this philosophy.
Furthermore, it is worth bearing in mind that in reality all suffering is psychological. When I stub my toe, the toe sustains a physical injury, but the sensation of pain is actually experienced in the brain. Bearing this in mind, it is difficult to escape the conclusion that any distinction between physical and mental suffering is artificial, arbitrary and unsustainable.
This was certainly the view taken by the Dutch Supreme Court in Office of Public Prosecutions v Chabot. The case concerned a psychiatrist who faced prosecution after acceding to the request of a physically healthy patient who, following the deaths of both her sons, had sought assistance in ending her life. Addressing itself specifically to the fact that the suffering was psychological rather than physical, the Court held that assisted suicide in such circumstances may be permissible in Dutch law, observing that 'the cause of the suffering does not detract from the extent to which the suffering is experienced.'
Permanence of the condition
Should euthanasia be legally available to those whose suffering is likely only to be temporary? This question would certainly seem to be relevant when considering the recently bereaved, whose acute grief reaction is likely to diminish with the passage of time. Prof Grethin Morgan, head of mental health at Bristol University has claimed that all grief reactions are transient and resolvable. (Guardian, 28 July 1994).
An important distinction should be drawn here between the individual whose competence has been temporarily undermined by their loss, and, on the other hand, the person who, although distraught, retains the capacity for autonomous action. In the latter case, a respect for autonomy would surely dictate that their wishes be respected, even if it were known, or strongly suspected, that they would change their mind at some future time. Indeed, the whole concept of respect for autonomy requires that a competent person be allowed to retain control over his life, even when in the opinion of some other party he would be 'better off' were those wishes to be ignored; to do otherwise would be to adopt a paternalistic approach which would almost certainly be deemed inappropriate in any other medical context.
Would a utilitarian approach give rise to a different conclusion? After all, if the objective here is to maximise happiness, then could it not be seen as more logical to keep alive a temporarily unhappy person if this unhappiness would be outweighed by some subsequent happiness? The problem here lies in the fact that an existing individual will be subjected to actual suffering in the hope that this will be more than compensated for by some potential future happiness. Not only does this present the problem of someone other than the sufferer trying to gauge the intensity and likely duration of the present suffering, it further necessitates a considerable degree of guesswork as to his future state of mind. Even if the mental suffering is likely not to be permanent, then, there would appear top exist grounds for allowing a competent and informed individual to avail himself of voluntary euthanasia.
A further problem may arise if certain treatment options which may allow the suffering to be alleviated are refused. What if our grief-stricken individual refuses counselling or anti-depressant medication? Precisely this situation arose in the Chabot case; indeed, the fact that his patient refused treatment offered to her by Dr Chabot was one of the factors which undermined his defence. Should such a refusal constitute a barrier to the provision of aid in dying?
In considering this question, it should be borne in mind that, in the U.K., a patient's legal right to refuse treatment is beyond doubt, even where such refusal would result in his death. It could be seen as somewhat strange, therefore, to make acceptance of all medical advice a precondition of euthanasia or assisted suicide. Whether the pain be mental or physical, it is surely for the sufferer to decide when to continue the struggle for cure or acceptable amelioration, and when to concede that enough is enough. Indeed, in some cases of mental anguish, it may not be possible to render the pain tolerable without fundamentally altering the mind of the sufferer - a condition which some may not be willing to accept.
Capacity of the individual to give valid consent
This is certainly the most difficult ethical problem to arise from this area. Among advocates of legalised euthanasia, there is more or less universal agreement that its provision should be restricted to those cases where a request has been made by a competent person, either immediately before the act or, if the individual is presently incompetent, in the form of an advance directive. Where the reason for requesting assistance in dying is psychological, however, does this not cast some doubt upon the competence of that person to give valid consent?
There can be no doubt that of the 5000 or so individuals who take their own lives every year in the United Kingdom, many do so under the influence of psychological disorders which would render their purported consent to any medical treatment of dubious validity. However, caution must be shown if we are to avoid drawing an inference of mental incompetence from the mere fact of wishing to die. Indeed, it should be remembered that the presumption in common law is in favour of competence. Although as with all legal presumptions this can be rebutted, it is submitted that a preference for death over suffering of a certain degree should not be sufficient for this purpose, particularly when it is borne in mind that anyone can refuse life-sustaining medical interventions without being assumed incompetent.
It is certainly the case that in dealing with those whose desire for death is motivated by mental anguish rather than physical pain, care must be exercised in making a determination as to the competence of the person making the request. Such caution may seem especially appropriate if the mental distress is of a particularly acute nature, as in the case of the recently bereaved. But to make the assumption that recent bereavement renders someone incompetent is to make a somewhat crude generalisation. It may be that the individual in question had long been considering this course of action, and was delaying it until such time as they were predeceased by a partner or child. A couple may have had the opportunity, either due to chronic illness or advancing years, to contemplate their future when separated by death, and the survivor may now wish to join their mate. Equally, the request may come from an overwrought teenager, in the throes of an acute grief reaction.
Each case, then, must be assessed upon its individual merits. Factors such as the age of the party making the request, and any evidence as to the duration and consistency of their wishes, may be factors to be taken into account when assessing competence - that is a matter for those specialised in such fields. In addition, the period of time which has elapsed between the death and the request may be relevant; certainly, a desire to die evidenced on the day of the funeral - as in the sati ritual - would give rise to doubts as to the mental state of the bereaved person at that time. But while the proximity of the events should perhaps be taken into account, it should not be sufficient in itself to rebut the presumption in favour of competence.
The question of the grief-stricken individual presents unique problems, but only in terms of ascertaining their competence. If we believe that it is for the competent person to determine for himself when the burden of suffering has become intolerable, the imposition of distinctions as between kinds of suffering seems inappropriate and arbitrary. Grief may for a while be blind, in the words of Shelley, but we must be very wary of assuming that it renders those afflicted by it incapable of knowing their own minds.
© 1997 VESS