A recent study published in JAMA Psychiatry looked at physician-assisted suicide (PAS) cases in Belgium that were approved because the patient had an unbearable psychiatric illness. The study found that in more than half of the cases, the patient declined treatment that could have helped. Often the patient sought approval for euthanasia after visiting with a doctor for the first time, some patients even visiting a mobile clinic that is funded by a euthanasia group. Forty-six of the 66 cases were women. Importantly, loneliness was cited as a common theme.
Last year, Rachel Aviv wrote a poignant and insightful article in The New Yorker on euthanasia for non-terminal people in the Netherlands. In it she recounts the story of Tom whose mother suffered from depression and eventually elected to undergo euthanasia. Tom did not know about it until after the fact and was angry that he was not called so he could talk to his mother. His mother died with three photographs in her pocket: one of her holding Tom as a baby, one of her feeding her granddaughter ice cream, and one of her and her daughter in a field. She had just broken up with her boyfriend and was estranged from her daughter. Tom and his wife could visit her sometimes, but career and children took much of their time. Furthermore, her lifelong struggle with depression and inability to form close relationships contributed to her isolation. She was lonely and she elected to die alone.
Loneliness is pervasive. This is not the idea of someone being by themselves. Many people can be alone and not be lonely. Also, many people can go to parties, have friends, and still feel utterly alone. As social commentators have pointed out, loneliness is part of the trifecta of modern angst: loneliness, boredom (hyperboredom) and fragmentation. Greg Monbiot in an insightful column in The Guardian dubs our time as the “Age of Loneliness.” One of the Dutch psychologists mentioned in Rachel Aviv’s article says that euthanasia for psychiatric disorders is a response to the nihilism pervasive in the Dutch culture. He says that people ask “What is life worth when there is no God?” or “What is life worth when I am not successful?”
In Japan, the incidence of dying alone, and sometimes not being discovered for weeks, has become so common that the Japanese have a word for it: kodokushi. There is an entire industry dedicated to cleaning after the discovery of someone who has died a lonely death with no friends or relatives. In Japan, many of these lonely deaths are men who had dedicated their lives to their jobs only to be laid off or forced into early retirement. They had no relationships outside of work. Their jobs were the essence of their identity. Without it, they were lost.
A 2014 report showed that loneliness has greater negative health effects than obesity, and a Washington Post article from this past January reported more studies on the health effects of loneliness. In sum, scientists have found that loneliness leads to physiological changes and is more damaging to one’s health than cigarettes, diabetes, and obesity. Studies have shown a correlation between loneliness and early death, onset of Alzheimer’s and dementia, and increased risk for cancer and heart attacks. This is likely due to increased activity in genes that cause inflammation coupled with decreased activity in genes that produce antibodies.
Canada recently legalized physician-assisted suicide, and in the U.S., California recently joined Oregon, Vermont, Washington, and Montana as states where PAS is legal. Most of these places have stringent guidelines for who qualifies for euthanasia. The U.S. laws specify that the patient have a terminal illness and some of them require that the patient have less than six months to live. While “slippery slope” arguments can sometimes be spurious, in this case, we do have two examples of what happens when suicide is medicalized and re-framed as a dignified death. Belgium and The Netherlands continue to open up euthanasia to more and more people. They are not required to be terminal and the age limit continues to decrease with some advocating for no age limit for qualifying for euthanasia.
But, if loneliness is a pervasive problem in our culture, medically-endorsed suicide does little to help and may contribute to the sense of isolation. There was a time when suicide was a cry for help. Now, for the depressed and lonely, it affirms their fears that they are unwanted. Mother Teresa is quoted as saying that “the biggest disease today is not leprosy or cancer or tuberculosis, but rather the feeling of being unwanted, uncared for and deserted by everybody.” Rather than trying to care for people who are struggling, doctors are helping lonely people to end it all. Suicide is not a “solution” for someone struggling with a mental health issue. It is abandoning someone in their time of need.