esanum: Dr Maier, why is the debate about assisted suicide so difficult and still far from reaching a consensus?
Dr. Maier: [In the German case] we have a clear legal starting position: namely that there is no explicit legal regulation. The Federal Constitutional Court [In German: Bundesverfassungsgericht ] has established that self-determined death is a fundamental right. Therefore, if suicide is not a criminal offence, assisted suicide cannot be punishable by law. Freedom of action is therefore not restricted in relation to assisted suicide. But at the same time, there is a longing for legal certainty. And this will not be fulfilled without binding legal regulation. I think that the draft laws discussed so far have not shown any real competence in dealing with this particular issue. That's why I think it's good that none of them have been implemented so far. In addition, there is also a debate about values in the background of it all. It's about self-determination, about living a life of dependency and, last but not least, resources. Together, this makes the debate very emotional at times.
esanum: So there is no need for a law on assisted suicide?
Dr. Maier: We have a legal basis, but many people are struggling with this liberal regulation. The question remains: how can this be handled responsibly? The widespread uncertainty also means that we are quite rightly approaching this topic with caution. There is no algorithm here, as there is in other areas of medicine. There is also no prescription for assisted suicide.
esanum: How can a doctor deal with a patient's wish to die?
Dr. Maier: It is always the doctor's job to try to understand the wish to die; to question: Why have you, my patient, come to this point? Often it is physical stress, often fears about the future, also relationship difficulties. These are issues that can certainly be influenced. The undisputed task is to prevent suicide. The question is then: What can we do together to improve your [the patient's] situation? The doctor can show you: 'It touches me that you feel death is more important than being alive'. And the second question is whether it can be the doctor's task to help realise the dying wish - if it persists despite all attempts to improve the situation. There is a reservation about co-operation here: no doctor can be obliged to do so. Because if there were such an obligation, it would also apply to other people. This cannot be left to doctors alone, just because they have the medical knowledge.
esanum: How many medical colleagues are prepared in principle to help with assisted suicide under certain circumstances?
Dr. Maier: This varies greatly depending on the questions asked in the relevant surveys - which are often methodologically flawed. It fluctuates between 10 and 30 per cent. The majority are unsure and are still looking for a position [on the issue]. The focus of doctors' self-image continues to be on suicide prevention. In contrast to the Suicide Assistance Act2, the Suicide Prevention Act was passed. This includes, for example, ensuring that sufficient hospice services and effective palliative care are available throughout the country.
esanum: What is needed for good counselling when it comes to the end of life?
Dr. Maier: Firstly, it is important to remember: How can I take precautions for myself? This touches on the power of attorney and the living will. The doctor can help to maintain self-efficacy. This involves counselling on issues that are also related to care.
People will be referred to support services in their social environment. A simple example: If very elderly people can no longer drive, they lose their mobility and social integration. If I think well in advance about how to organise a transport service, neighbourhood help and the like, a lot can be done to improve the situation. Of course, it is also important to provide information about dying and to show where and how support can be found in the immediate end-of-life phase. And if the wish to commit suicide is expressed, the topic of assisted suicide should not be left out or be treated as a taboo.
esanum: That sounds like time-consuming discussions. Are their financial costs adequately assessed?
Dr. Maier: Not in the way that would be desirable, of course. But efforts are being made to improve this with the Suicide Prevention Act. However, I also see it this way: if I take the time to communicate the fundamental issues thoroughly, consistently and in the necessary depth, I save a lot of time in other areas. I don't need endless time, but I need to proceed effectively.
esanum: What can palliative physicians really do for their patients?
Dr. Maier: Firstly: take the patient seriously. For once, we don't have the biological knowledge advantage with which we can make clear statements. In palliative care, the relationship is reversed in that we actively enquire and listen in order to then see what fits? What strengthens, what brings comfort? The attitude is: shift away from findings and towards well-being. On the one hand, we need clinical rigour and, on the other, the curiosity to get to know this one person so that we can find the best possible individualised concept for them. You don't live for therapy, you do therapy to live. We need to remember that. And also talk about it with the patient and ask: How do you define vitality for yourself?
esanum: How do you become a palliative care doctor? What was it like for you personally?
Dr. Maier: There is an additional qualification for palliative physicians, and we are campaigning for this to be recognised as a specialist. Palliative medicine is also increasingly recognised as a compulsory subject.
I myself had the first impulse for this path when I was a medical student and my grandmother was dying. The discrepancy between what would be desirable and what I experienced in my family environment aroused my curiosity to reconcile these seemingly incompatible things.
esanum: What do you wish for from society, how can it deal better with the end of life?
Dr. Maier: In addition to the idolisation of self-reliance that we are currently experiencing, I would like to see us show solidarity as a society. Weakness and dependency should be perceived less as a flaw, so that there are clear and strong offers to support each other. I don't see that happening enough. It would be nice to have more courage to be tender.
Dr Bernd Oliver Maier is Chief Physician of the Medical Clinic III - Palliative and Oncology, St. Josefs-Hospital in Wiesbaden, Germany [Medizinischen Klinik III - Palliativ und Onkologie, St. Josefs-Hospital]. As a specialist in internal medicine, haematology, internal oncology and palliative medicine, he specialises in the care of seriously ill patients. At the JoHo Cancer Centre, also a part of the Medical Clinic III, Dr Maier is a member of its clinical ethics committee.