Thinking About Well Dying

Disclaimer: This article covers topics that may be sensitive to some individuals and does not provide any advice or recommendations in this regard. Furthermore, this article recommends that you meet and adhere to current social, legal, and ethical standards.

As the world and humanity change, what will be the difference between a healthy life as we define it today and a healthy life as humanity defines it in the future?

We want to live longer.

Life expectancy is increasing. Long life, then what?

We want to live long and healthy.

Healthy life expectancy is increasing. Healthy, long life, then what?

We want to have fun and live longer.

Attractive life expectancy is increasing. Have fun, be healthy, and live long, then what?

Imagine the following:.

• This is year 2100.

• Life expectancy: 200 years, healthy life expectancy: 190 years, attractive life expectancy: 170 years.

People now have fun, interact with each other, and stay young until age 170; live in good health, without major physical illness, until age 190; and live until age 200.

If I were living in the year 2100, what would I want next?

First, I would want to reduce the gap between attractive life expectancy, healthy life expectancy, and life expectancy. In the article above, where I first encountered the term "attractive life expectancy," we find the following passage:

The narrower the gap between attractive life expectancy, healthy life expectancy, and life expectancy, the healthier and more energetic people will be, and the higher their quality of life will be, and the more popular will be the businesses that reduce that gap.

I agree, then what?

One possibility is to continue to extend lifespan as much as possible, and a second possibility is to aim for Well Dying. I don't think these two directions contradict each other, and I think the human race of the future will eventually pursue them together.

For the purpose of this article, I define Well Dying as ‘dying peacefully and painlessly, at a time of my choosing’.

In the future, I believe that the need for Well Dying will increase regardless of health status of the human. Using the aforementioned hypothetical as an example, the following two cases may exist.

A (age 195).

A is currently between life expectancy and healthy life expectancy, and although A is alive, A is suffering too much from her condition and her quality of life has diminished significantly. She may wish to pursue Well Dying for self-determination and dignity.

B (age 185)

B is still energetic and living a healthy life. However, B is tired of living and wants Well Dying so that B can die painlessly and comfortably, rather than slowly becoming ill and dying.

While I can relatively empathize with A's needs, B's desire for Well Dying is difficult to understand at this point. However, I suspect that as life expectancy gradually increases to 200 or 300 years, the number of people who are tired of being physically alive, regardless of their health status, and want to make their own decisions, rather than wait for death, will increase. These needs may seem ethically controversial by today's standards, but they may not be by future ethical standards.

So, could a service emerge in the future that could fulfill the needs of A and B?

First of all, as of 2024, the service that fulfills A's needs is called "assisted dying" and is legal in some countries, while the service that fulfills B's needs is a very serious crime. In the latter case, depending on the method, it could be murder upon request or with consent or the crime of abetting and betting suicide. This is the case in most countries, with the exception of Switzerland, where assisted suicide is not a criminal offense unless it is motivated by self-interest (e.g., inheritance).

So, let's take a look at assisted dying first.

In this article, we will define assisted dying as a concept that includes physician-assisted suicide (PAS) and voluntary euthanasia (VE). What PAS and VE have in common is that they involves a patient's voluntary, informed consent to die with the assistance of a medical professional. The difference is who is ultimately responsible for the act that causes death: while PAS involves the patient ingesting a drug prescribed by a physician, VE involves the physician ultimately injecting the drug with the patient's consent. VE can be further divided into active and passive VE, depending on how active the doctor's behavior is. For example, injecting a drug is an active VE, while withdrawing life-sustaining treatment is a passive VE.

There is also a view of withdrawal of life-sustaining treatment as seperate from euthanasia, according to which withdrawal of life-sustaining treatment does not always lead to death and is not included in euthanasia because it respects the patient's wishes to minimize unnecessary burden and suffering.

As its data by 2020, as of 20234, Austria, Spain, New Zealand, and all states in Australia have passed partial assisted dying legislation.

As of 2023, assisted dying was legalized in about 19 jurisdictions. However, each jurisdiction has slightly different forms of assisted dying and different conditions:

• In Switzerland and some US states, PAS is legal, but VE is not; in Quebec and Belgium, the opposite is true.

• In the case of Switzerland, there are no requirements regarding the patient's health status, while US states only allow assisted dying for patients who are permanently ill and within six months of death.

• Most countries specify that a person must be at least 18 years old to apply for assisted dying, but the Netherlands sets the age at 12, and neither Switzerland nor Belgium has an age requirement.

• Most countries do not allow assisted dying for mental illness, but Belgium, the Netherlands, and Luxembourg do.

Despite these differences, the general requirements for a request for assisted dying are as follows:

• The patient's request must be voluntary and repetitive.

• The patient must have a very serious illness.

• The patient must be suffering with no sign of recovery.

• The doctor must explain to the patient in detail the patient's current situation, the medical options available, and the consequences of those options.

The arguments for and against assisted dying are easily available on the internet, and can be summarized as follows:

First, those in favor of legalizing assisted dying typically cite reasons such as respect for the individual's right to self-determination and relief of unbearable suffering. Opponents typically cite violations of the Hippocratic Oath and the purpose of medicine, a breakdown of trust in the patient-physician relationship, a slippery slope effect on society, and the sanctity of life.

It's interesting to note that different stakeholders may be equally supportive of assisted dying, but their main arguments in favor of it may differ. Assisted dying involves two stakeholders, the patient and the physician, and for the patient, respect for self-determination and dignity are the most important reasons, while for the physician, relieving the patient's suffering is the most important rationale.

Why do patients want assisted dying?

While we generally assume that the number one reason patients want assisted dying is "relief or liberation from unbearable suffering," this does not appear to be the case. In this study of assisted dying in Oregon and Washington in the United States, loss of autonomy, loss of dignity, and decreased quality of life were cited as the primary reasons for requesting assisted dying, more than unbearable suffering. In another study, loss of dignity was the reason for 61% of requests for assisted dying in the Netherlands and 51% in Belgium.

Why are doctors in favor of assisted dying?

First of all, I would like to emphasize that doctors' opinions on assisted dying are just as important as patients'. When assisted dying is legalized and implemented, doctors are the ones who make the decisions and bear the legal and emotional responsibility for it, so their opinions are very important. Also, the act of assisted dying itself can be very stressful, so we should legally guarantee doctors' conscientious objection to patients' requests for assisted dying.

Based on the above arguments against assisted dying, many official physician organizations currently oppose assisted dying. However, physicians who are in favor of assisted dying seem to consider it as an option when palliative care is unable to reduce a patient's suffering.

According to this study of Korean physicians, physicians were relatively supportive of passive voluntary euthanasia, such as withdrawal of life-sustaining treatments, and cited relief of suffering or reduction of the patient's financial burden as their rationale, rather than respect for patient autonomy or self-determination.

Also, according to this study of Dutch pediatricians, physicians feel it is their responsibility to relieve the suffering of their patients, regardless of age, and may consider PAD when palliative care is unable to do so. However, they were skeptical about performing PAD on patients who were not near death.

With the exception of Switzerland, all countries where assisted dying is legal still criminalize murder or participation in suicide for requesting and consenting to it, which raises the question of what logic led to the legalization of assisted dying.

With the help of the GPT, it seems that assisted dying is viewed as an exception or a special case, mainly for the following reasons:

• Assisted dying is a medical practice involving medical professionals.

• Assisted dying is centered on the patient's clear voluntariness and informed decision about their request.

• In assisted dying, legal protections and safeguards are in place to ensure the safety and rights of the patient.

So, will there be a service in the future that meets the well-being needs of healthy people? Just as assisted dying is currently accepted as an "exception" in some countries, it is possible that this could happen if increased longevity changes overall social, cultural, and ethical standards and increases people's need for Well Dying

In fact, it may already be happening in Switzerland, as the country allows foreigners to have assisted dying and does not specify health conditions for assisted dying, so it may not be possible to prevent it entirely globally. Unless there is a concerted global ban on Well Dying services, it is likely that people with Well Dying needs will seek to fulfill them through regional arbitrage. Limited access to these services can lead to a case which people with money will go to Switzerland and die in comfort, while people without money will die in misery.

So, if 1) the overall human need for Well Dying is growing exponentially due to increased longevity, and 2) it is impossible for the world to collectively prevent the emergence of Well Dying services, we can consider a future where these services are legalized on a limited basis. This future is by no means straightforward, and the first question that arises is: who is appropriate to provide these services?

Is it appropriate for physicians to provide, or should they provide, services for the Well Dying of people who are not seriously ill, as opposed to the current practice of assisted dying? There are two possible answers to this question. The first is the emergence of a new profession. Non-physicians, or specialized types of physicians, could emerge with specialized knowledge about death, mental health, medications, and other aspects of Well Dying. The second is the expanding role of physicians. Just as Francis Bacon first used the word euthanasia in the 17th century, arguing that "a physician should not merely cure his patients, but relieve their suffering," someone in the future may argue that a physician's responsibilities should include "helping human beings to face death in peace.

The future of Well Dying still has many assumptions and limitations. For example, we may still be centuries away from closing the gap between life expectancy, healthy life expectancy, and attractive life expectancy, and the need for Well Dying may not be large enough to trigger any social or legal changes. However, given that there are few needs that are as universal as "dying peacefully and painlessly," we can expect to see more discussions about Well Dying in the future.

• Assisted dying around the world: a status quaestionis

• An international expansion in voluntary euthanasia/assisted dying: The implications for nursing

• Euthanasia and assisted suicide: An in-depth review of relevant historical aspects

• Historical Approaches to Euthanasia: the Unfinished Story of a Concept

• Physician-Assisted Suicide and Euthanasia in the Intensive Care Unit: A Dialogue on Core Ethical Issues

• Euthanasia and assisted dying: what is the current position and what are the key arguments informing the debate?

• Pros and Cons of Physician Aid in Dying

• Physician-assisted dying for children is conceivable for most Dutch paediatricians, irrespective of the patient's age or competence to decide

• Euthanasia for people with psychiatric disorders or dementia in Belgium: analysis of officially reported cases