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Assisted dying

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22 October 2024

9 min read

Assisted dying's language points to all our futures

Translating ‘lethal injection’ from Dutch releases the strange power of words.

Henna Cundill

Henna is a researcher with the Centre for Autism and Theology at the University of Aberdeen.

A vial and syringe lie on a blue backdrop.

Markus Spiske on Unsplash.

In the coming weeks and months, MPs at Westminster will debate a draft bill which proposes a change in the law with regards to assisted dying in the UK. They will scrutinise every word of that bill. Language matters.

Reading the coverage, with a particular interest in how such changes to the law have been operationalised in other countries, I was struck to discover that the term in Dutch for dying by means of a fatal injection of drugs is “de verlossende injectie.” This, when put through the rather clunky hands of Google translate, comes out literally as either “the redeeming injection” or “the releasing injection.” Of course, in English the term in more common parlance is “lethal injection”, which at first glance seems to carry neither of the possible Dutch meanings. But read on, and you will find out (as I did) that sometimes our words mean much more than we realise.

Writing for Seen & Unseen readers, I explained a quirk of the brain that tricked them into thinking that the word car meant bicycle. Such is the mysterious world of neuroplasticity, but such also is the mysterious world of spoken language, where certain combinations of orally produced ‘sounds’ are designated to be ‘words’ which are assumed to be indicators of ‘meaning’. Such meanings are slippery things.

This slipperiness has long been a preoccupation for philosophers of language. How do words come to indicate or delineate particular things? How come words can change their meanings? How is it that, if a friend tells you that they got hammered on Friday night, you instinctively know it had nothing to do with street violence or DIY? Why is it that in the eighteenth century it was a compliment to be called ‘silly’, but now it is an insult?

Some words are so pregnant with possible meaning, they almost cease to have a meaning. What does “God” mean when you hear someone shout “Oh my God!”? Probably nothing at all, or very little. It is just a sound, surely? And yet no other sound has ever succeeded in fully replacing it. We are using the term “God”, as theologian Rowan Williams points out in his book The Edge of Words, as a “one-word folk poem” to refer to whatever we feel is out of our control.

Both of these first two interpretations look at death, in some sense, ‘from the other side’ – evaluating the end of someone’s life in terms of speculation over what will happen next.

This idea of an injection being verlossende seems to me to be the opposite. I find myself hearing it in four different (and not mutually exclusive) ways, each to do with taking control of this very uncertain question of dying. The first, releasing, sounds to me like an echo of the neo-platonic ideas that still infuse public consciousness about what it means to be dead. As we slimily carve our pumpkins for Halloween and the children clamour to cut eyeholes into perfectly good bedsheets, we see a demonstration of society’s latent belief that humans are made up of body and soul, and that at death the soul somehow leaves the body and floats into some unknown realm (or else remains, disembodied yet haunting). If we translate verlossende as releasing then we capture that idea – that of the soul, which longs to be at peace, trapped inside suffering, mortal flesh.

Google’s second suggestion for verlossende was redeeming. This could be heard theologically. Christians believe in eternal life, that the death of this earthly body is only the start of something new – a life where there will be no crying or pain, and people will live forever in the glorious presence of God. In the bible, the apostle Paul encourages those who follow Christ to trust that they have been marked with a ‘seal’, meaning that they are like goods which have been purchased for a price, and that God will ‘redeem’ this purchase at the appointed time. Death, therefore, is not a fearful entering into the unknown, but a faithful entering into God’s promises.

Both of these first two interpretations look at death, in some sense, ‘from the other side’ – evaluating the end of someone’s life in terms of speculation over what will happen next. But there is the view from this ‘side’ also. We do not need to speculate about what death means for some of those who experience acute suffering due to terminal illness, and who wish to hasten the end of their lives because of it. They too might want to speak of a releasing injection or a redeeming injection – given that both terms hint at the metaphor of life as a prison sentence. To be in prison is to have one’s rights and freedoms severely limited or entirely taken away. It is not uncommon to hear a sufferer refer to incapacitating illness as being ‘like a prison sentence’, and one can empathise with the desire to have the release date set, back within the sufferer’s control.

This is the strange power and pregnancy of words – verlossende is able to carry all these meanings or none of them. Until I began researching this article, I had always assumed that the English term, lethal injection, simply meant an injection of some substance that is deadly. This is how the term is commonly understood, therefore, in a sense, this is its meaning. Yet, when I came to consider the possible origins of the word, I realised its likely etymology is from the Greek word lēthē, meaning ‘to forget’. In the Middle Ages, if something was lethal it caused not just death, but spiritual death, placing one beyond the prospect of everlasting life. By contrast, something could be fatal, meaning only that it brought one to one’s destiny or fate.

With this in mind, as we try to speak clearly in the assisted dying debate, the term fatal injection might be a more precise way to describe this pathway to death that is in want of a name. After all, whether you believe in an afterlife or not, dying is everybody’s fate, and I can see that choosing to take control of one’s fate is, for anyone, an act of faith with regards to what comes next.

This article was part-inspired by Theo Boer’s original article Euthanasia of young psychiatric patients cannot be carried out carefully enough, in Dutch newspaper Nederlands Dagblad. Theo is a professor of health ethics at the Protestant Theology University, Utrecht.

Read the original article in Dutch or an English translation below. Reproduced by permission.

Euthanasia of young psychiatric patients cannot be carried out carefully enough

Theo Boer

How is it possible to determine that patients who have suffered from psychiatric disorders for five or ten years and who are between the ages of 17 and 30 have ‘completed their treatment options’, wonders Theo Boer. It also conflicts with perhaps the most important task of psychiatrists: ‘offering hope.’

The patients we are talking about now are not physically ill and therefore do not have the ‘comfort’ of an impending natural death.

A letter was recently leaked in which leading psychiatrists ask the Public Prosecution Service to investigate the course of events surrounding euthanasia of young psychiatric patients.

One death mentioned by name concerns seventeen-year-old Milou Verhoof, who received the redeeming injection from psychiatrist Menno Oosterhoff at the end of 2023. It will not have escaped many people's attention how much publicity the topic has received in the past year or so. Together with a colleague and a patient (who later also received euthanasia), Oosterhoff wrote the book Let me go.

The tenor was: it is good that euthanasia is possible for this group of patients, the taboo must be removed, their suffering is often terrible, they have already had to undergo countless 'therapies' without effect - can one time be enough?

Or would we rather have these patients end their lives in a gruesome way? And who really thinks that psychiatrists make hasty decisions when they decide to comply with a euthanasia request?

To be clear: we are talking about something completely different than what has been called 'traditional euthanasia' for years: euthanasia for physically ill patients with a life expectancy of weeks or months. Given the excellent palliative care that has become available, such euthanasia will actually be less and less necessary in 2024.

Panic

No, the patients we are talking about now are panicky, anxious, confused, depressed, lonely, often unemployed, poorly housed, without prospects. But they are not physically ill and therefore do not have the 'comfort' of an impending natural death.

I have heard several of them say: if only I were terminal, then euthanasia would not be necessary. The fact that there is now attention for this group of patients, with whom we in our hurried and solution-oriented society know so little how to deal, is a gain. At the same time, I am happy with the leaked letter. You can criticize Oosterhoff's procedural approach ('why not an ethical discussion instead of a legal one?'), the lack of collegiality, this perhaps underhanded action ('why did you go straight to the Public Prosecution Service?'). But in my opinion, the letter writers are definitely hitting the mark with this crooked stick. Firstly: how is it possible to determine that patients who have suffered from psychiatric disorders for five or ten years and who are between the ages of 17 and 30 have ‘completed their treatment options’ (a criterion from the Euthanasia Act)?

Review Committee

Nobody disputes that their suffering is unbearable. At the same time, I know from my time on a Regional Euthanasia Review Committee that an illness becomes unbearable when all hope is gone.

A psychiatrist who gives euthanasia to a young adult is also undeniably sending the signal that, like his patient, he has given up all hope of improvement. That is actually risky, because even patients who have suffered for years sometimes recover and, moreover, our brains are not fully developed until we are 25. But it also conflicts with perhaps the most important task of psychiatrists: offering hope. In their training, the risk of transference-counter-transference is consistently pointed out: a patient takes his therapist with him into despair, the psychiatrist transfers those feelings to this and other patients: ‘this kind of suffering is untreatable and cannot be lived with’.

In the recent NPO television documentary A Good Death we see an embrace between a psychiatrist and her emotional patient. In doing so, this psychiatrist offers a unique form of involvement. But does she provide sufficient resistance to the cynicism, despair and negative vision of the future that is also widespread outside psychiatry?

Sensible decisions?

That brings me to a second objection: is it sufficiently recognised how much a psychiatric illness can affect someone’s ability to make sensible decisions? The hallmark of many psychiatric illnesses is a deep desire to die and an inability to think about it in a relative way. As a result, many are unable to think in terms of a ‘possibly successful therapy’.

Boudewijn Chabot

The main character in the book Zelf heeft by Boudewijn Chabot, Netty Boomsma, responds to Chabot's suggestion that there might be a life after depression: 'Yes, but then I won't be it anymore.' She wants to go down with her depression. I know differences. The people with a death wish who remark about a possible therapy: ‘I hope it is not effective, because then I will have to go through it again.’

Another hurdle

If a second psychiatrist is consulted and, for example, suggests trying one or two more therapies, many patients see this as yet another hurdle on the road to euthanasia. They do not see it as a serious opportunity to be able to cope with life again. There are no easy answers here. Nor are pillories appropriate. But let euthanasia remain complicated here, and let us continue to look for hope.

Reproduced by kind permission

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Fun & play

1 December 2023

8 min read

Table-top philosophy: role playing games and the identities they help construct

A once derided fantasy genre now influences creative media - from The Big Bang Theory to Stranger Things.

Harry Gibbins

Harry Gibbins is a doctoral researcher at the University of Aberdeen. His PhD concerns the intersection between autism and Christian ministry.

Three teenage boys rise up from a table-top game and celebrate a victory.

Playing D&D in Stranger Things.

Picture this: no longer are you sitting at a computer desk or staring at your phone during your commute. Instead, you are an intrepid explorer, a noble warrior, or a cunning thief. You have left behind the mundanity and anxieties of the 'real world'. Now, you are a protagonist in a new story.

Your choices will shape the world around you; your actions will be written into legend and recounted for centuries. But this is not done in isolation. You are together with friends. You work as a team; you bond, laugh, and celebrate each other’s achievements as a unit. You are not alone; you are an adventuring party.

Behind the grey skyline through the condensation-heavy glass of the train window is a world of infinite possibilities. Here, in your mind’s eye, you shape reality. Here, you become the person that, right now, you want to be. There are no limitations beyond what you believe is possible. You are the captain steering the ship into uncharted waters where the aim is to share a good yarn with your friends.

There's a fine line between fantasy as a genre and escapism as a psychology. As we parade myth and legend within our respective cultures and contexts, we find something of ourselves. We read of Frodo Baggins, the underdog who takes on a responsibility of epic proportions, and see qualities we want to inhabit. We hear of Iron Man's sacrifice to save friends and see something of our own relationships. This is not to say we literally aim to overthrow a dark lord or defeat a purple space utilitarian, but we see the humanity reflected within relatable moments through the fiction. The story we read or watch somewhat touches the cadence of the 'real world' no matter how fantastical.

In an age where this cadence and its story-focused elements are twisted to become more marketable, where is the authenticity? How do we begin to tell our own stories? Is there a way in which our stories can speak of this cadence of the ‘real world’ without the necessity to satisfy business?

As the game creates a safe environment in which players can enact hypothetical scenarios. In other words, to fantasise about who they are and the world around them. Consequently, there is an opportunity to ask again: "What story do I want to tell".

Enter stage left: Table-top Role-playing Games (TTRPGs). The picture painted in the opening paragraph is steeped in my experience of commuting. Although not a universal experience, I found commuting sucked all life from my world. If there is a hell, perhaps it is a continuous never-ending loop of the Northern Line. I found myself recounting the previous evening, time spent with friends playing the fantasy TTRPG Dungeons and Dragons, reflecting on what I had learnt from such an experience. As a theologian, I would ask if there was something of myself that I was seeing in the stories told. When I returned next time, where did I want this story to take me next? What story do I want to tell?

Dungeons and Dragons, or D&D, has been propelled into the cultural zeitgeist in the last decade. Featured in popular television shows such as The Big Bang Theory and Stranger Things, D&D has emerged out of nerd basements and into the mainstream. No longer is D&D seen as something exclusively for 'mega-nerds'. It now stands shoulder-to-shoulder with other culture-shaping fictions, such as The Lord of the Rings and the Marvel Cinematic Universe.

In 2014, the fifth edition of D&D and aimed to streamline and tighten up the accessibility of the game whilst promoting creative and complex storytelling as a valued method of playing. In its earliest editions, D&D didn't care for character backstory or where the dungeon came from. A player’s aim was simply to kill some baddies and find treasure. However, today’s D&D aims for more nuance. Psychologists Sören Henrich and Rachel Worthington highlight that this has allowed D&D to have a genuine therapeutic application. As the game creates a safe environment in which players can enact hypothetical scenarios. In other words, to fantasise about who they are and the world around them. Consequently, there is an opportunity to ask again: "What story do I want to tell".

Perhaps the most obvious example of this philosophy in action is the role D&D takes in Netflix's Stranger Things. The show is not explicitly about D&D. Rather, the game is used as an illustrative tool, showing the actions of the characters, as well as providing a metaphor for the mystery they uncover and the journey they go on.

The show opens with four young boys playing a game of D&D in their parents' basement. The players discover a Demogorgon, a classic D&D monster, and they must work together to defeat it. However, their immaturity gets the better of them and they fail. In D&D, player characters take on different roles; it is only by working together that their various weakness can be supported, and the villain defeated. This is the lesson that the boys learn: teamwork. It is only when they learn to support one another that are they able to defeat the 'real-life' Demogorgon they discover in their small American suburb.

Nine belonged with his friends, he was not simply 'put up with'. His style of encountering problems and solving puzzles strengthens the whole team. Nine was not a burden.

In Stranger Things we find D&D acting not just as a thematic motif, but also as illustrative of a journey the young people go on. So, what are the philosophical mechanics behind this? How is D&D as a phenomenon transformative and illustrative in our present reality? Philosophers describe this sort of thinking as 'Phenomenology'. In simplistic terms, it concerns the lived experience of a phenomenon, seeking to uncover its essence. What actually makes that 'thing' you experience a 'thing' at all? Are there attributes that are common across all experiences of that phenomenon? Or, more likely, is there a rich and informative complexity to its innermost workings?

Whilst I am far from describing what the essence of D&D as a phenomenon is, I can speak of my own lived experience in the hope that it demonstrates how D&D is the transformative tool Stranger Things positions it to be. I hope that this not only illustrates my argument, even if it is as simple as “D&D is good”, but also provides a window in which my own story can be understood.

I have written elsewhere about the role D&D has played in my theological evaluation of complex theoretical ideas. It has ultimately shaped the way I research and encounter complex questions. However, I want to highlight something different. In my other work, I spoke of a character I played for three years, a Tabaxi Paladin named 'Nine'. Nine was somewhat of an experiment. After I was diagnosed as autistic, I found great difficulty in knowing who I was. Are there parts of me that are not autistic? Am I being autistic subconsciously? Or am I actively choosing to act in a way that a clinical professional has decided is autistic? Who am I? Nine was to be a method of exploring such questions. I wrote Nine as autistic in a way that was a somewhat exaggerated version of myself. Yet, there was a distinct difference. Nine was the 'me' who had come to terms with being autistic; Nine knew who he was and was proud of it; Nine just simply was Nine.

This was obviously not a perfect solution; the world of D&D does not have the clinical vocabulary to describe autism. In fact, whether autism exists in a fantasy world is kind of a fuzzy question. Was I inventing autism within the world by playing a character in such a way? Or is there ever a way I could not play a character as autistic due to being autistic myself? What emerged through Nine's interactions was something that, on a very personal level, I found deeply satisfying, illuminative, and transformative.

Nine developed, some might say unsurprisingly, relationships among the other player characters. He lived as I do, as a social creature in a social world. Whilst his interactions were sometimes unusual, perhaps in much the same way as my own, his friend still came to love him. Following the framework of theologian John Swinton, Nine was more than just included; Nine belonged to this group simply because in his absence he would be missed. Once I had realised this I was taken somewhat by surprise. The differences between Nine and the other characters still mattered, but they were not barriers. Nine was valued, not someone who just was difficult to approach, off in his own little world, or obsessed and hyper-fixated. Rather, he was one part of the whole. Nine belonged with his friends, he was not simply 'put up with'. His style of encountering problems and solving puzzles strengthens the whole team. Nine was not a burden.

D&D highlights the strength storytelling, narrative building, and art in all its forms, have for those who are coming to terms with their identity.

This was where the transformation occurred. I realised that I was the Nine who did not have this understanding. Harry erroneously believed that he did not belong when really he always did. Harry was embarrassed about his challenges with social engagement, his obliviousness to the world around him, and his inability to get through a conversation without talking about Doctor Who. Yet, here I was, among friends who cherished and valued me. Here, I truly did belong, and it was Nine who taught me that.

I hope that this illustrates just a snippet of the potential this game, and games like it, have to offer. I believe there is much more to be said about the philosophical truth spoken through D&D in much the same way we talk about other forms of art or narrative. This is just a portion of what is possible, and I hope I learn much more about myself as I continue along these adventures with my friends. I would encourage anyone reading to give D&D a go. Although, I am aware I have had a very specific and positive experience that is not universal among players of the game. Perhaps the focus should not be that D&D is the best tool for therapeutic action. Rather, D&D highlights the strength storytelling, narrative building, and art in all its forms, have for those who are coming to terms with their identity. Whilst we may be tempted to describe ourselves simply, as I was when I was diagnosed as autistic, D&D reminds us that the stories our lives tell will always demonstrate more depth. Our lives our simply stories that we are constantly engaged with and that we are always telling.