How to deal with cases of patients with advanced disease who express a wish to die? To shed light on this question, the cross-cutting group 'Ethical and anthropological foundations of palliative care' of the Institute for Culture and Society (ICS) organized the seminar 'Desire to die and right to die'.

The activity, moderated by Nunziata Comoretto, bioethicist at the Pontifical Academy for Life, brought together experts in Palliative Medicine, Philosophy and Psychology. Specifically, Carlos Centeno, researcher principal of the ICS and of the Pontifical Academy for Life, took part in the event. ATLANTES Program of the ICS and director of the Palliative Medicine Unit of the ICS. Clínica Universidad de Navarra José Pereira, Professor of Medicine at the University of Ottawa and Head of Palliative Care at the Ottawa Hospital (Canada); Alfredo Cruz, Professor at the University of Navarra; and Marina Pereira, Head of Palliative Care at the University of Navarra. department of Philosophy of the University of Navarra; and Marina Martinez, psychologist at the Palliative Medicine Unit of the Clínica Universidad de Navarra.

An appeal to the healthcare professional

First of all, Carlos Centeno narrated his experience staff as a Palliative Care specialist in a clinical case of a patient who, faced with advanced cancer, stated that she wished to end her life.

On the one hand, Dr. Centeno acknowledged that he appreciates and is grateful that patients trust him to share "such a deep reflection and concern". However, he recommended "lowering the semantic load of this subject of requests", since "they are not always rooted in a strong conviction".

"Sometimes it is a primary, immediate response, a verbalization that you want to change the status, but in reality there is no real desire to die," he said.

According to Dr. Centeno, medicine has begun to search in depth for "other ways of approaching these situations of profound suffering that sometimes have their roots in a lack of vital meaning". Thus, he pointed out that "therapies are being developed based on the contributions of existentialist philosophers such as Viktor Frankl to stimulate the search for meaning in the terminally ill status ".

On the other hand, he stressed that in these cases "there is always a questioning of the professional" and recommended "to review everything that is being done to see if we can work better or if we have not made the right decisions...".

Recovering the meaning of life

This was followed by José Pereira, who shared his experience with the requests from terminally ill patients that he has had to deal with during his professional career.

"One of the things I teach students is that if someone asks them to end their life they should not base their response on the illegality of this internship; they should ask the sick person to help them understand why they feel the way they do and why they have come to the point of asking for death," he emphasized.

Dr. Pereira recalled that there is research showing that among the reasons that lead patients to apply for euthanasia are depression, hopelessness, lack of meaning, the feeling of being a burden to family, friends, healthcare system... "Sometimes the problem is the difficult control of the symptoms, but others it has to do with seeking control of what is happening," he said.

As an example of therapy, he mentioned the case of a patient with whom he worked on the search for meaning by asking him what he was most proud of in his life. As he related, the patient was highlighting memories of his life in which he had managed to overcome himself and the difficulties he faced.

Subject autonomy and dignity

The next intervention was given at position by Alfredo Cruz, professor at department of Philosophy, who highlighted two ways of approaching topic: from an ethical viewpoint and from a legal viewpoint. According to Professor Cruz, what was happening with the patient in the clinical case presented in the session was that the patient "did not accept his status. The request for death is a desperate reaction when the patient feels that he is not in control of status".

For him, the patient's "rebelliousness" was motivated "by the modern concept of dignity - or the more common concept of dignity nowadays - in which dignity consists of individual autonomy". From agreement with this, the status of dependence appears as a contradiction for the patient's dignity. However, he stressed, human dignity is not found in the autonomy of the subject but in "being subject to the care and love of others". "Dignity," he stressed, "has a more passive than active condition.

From the legal point of view, Professor Cruz argued that the right to life "is not simply a right of liberty that implies that others simply refrain from doing so. According to him, it is a positive right that requires positive care on the part of others. 

Recover everything that is important to the patient.

The last panelist, Marina Martínez, a Palliative Care psychologist at Clínica Universidad de Navarra, agreed that the patient described in the clinical case did not accept the status in which he found himself. "It has been seen that when the patient expresses a desire to die, most often he is actually saying that he wants to control status".

Depression, hopelessness and feeling like a burden are the main points detected in those patients who express their desire to die, said the psychologist.

goal In her speech, Marina Martínez explained what Dignity Therapy consists of, an intervention subject that allows "rescuing or recovering everything that is important to the patient" with the aim of inducing a reflection in the patient to "preserve his dignity" financial aid .

Finally, the psychologist shared the results of a study with almost 400 patients with advanced disease in which it was concluded that 70% had no desire to die, 20% occasionally expressed this desire and 12% directly expressed their wish to die. "Of the latter," she emphasized, "almost half suffered from depression.