Dignity in death: reflections on assisted suicide and human suffering

“Dear friends. I am in Switzerland, about to commit euthanasia. My life has become unbearable. I'm suffering from Alzheimer's. [...] I hope to have lived with dignity and I hope to die with dignity.” This is a short excerpt from the letter written by poet and immortal of the Brazilian Academy of Letters (ABL) Antonio Cicero, 79, who underwent an assisted suicide procedure in October 2024 in Switzerland, a country where it is legal. His decision once again ignited the debate on euthanasia, assisted suicide and the dignity of death. Was it an act of courage, as some have pointed out? Does such a death really bring dignity?

On this subject, we spoke to Luís Gustavo Mariotti (photo), a geriatrician with a specialty in Palliative Medicine, assistant physician at the Palliative Care Service at HC Unesp/Botucatu and at the Support and Palliative Care Center at Hospital Beneficência Portuguesa, member of the Botucatu Medical-Spiritist Association and coordinator of the AME-Brasil Palliative Care Department.

Folha Espírita - How do you see the decision for assisted suicide by Antonio Cicero, immortal poet of the ABL?

Luís Gustavo Mariotti - First of all, I think it's very important to send our deepest condolences and best wishes to the family, friends and fans of the poet, philosopher and writer Antonio Cicero. I imagine that this decision must not have been easy in every sense. This is not the place to judge the person, but rather a brief reflection on human suffering. Assisted suicide, which is characterized by helping a person with the information or means necessary to commit suicide, including counselling on lethal doses of drugs and prescribing or supplying these drugs, is a medically assisted practice that is legalized in some countries, such as Switzerland, Colombia, Canada and some states in the United States. In countries such as Belgium, the Netherlands and Luxembourg, both euthanasia and assisted suicide are legalized. From the point of view of human suffering, I understand that people who ask for their physical lives to be cut short are actually asking for relief from the multidimensional suffering that afflicts them. Human beings carry with them a natural sense of self-preservation that directs their lives. Suffering can be intolerable when there is no adequate care for this suffering, including physical, emotional and existential suffering.

FE - Could you comment on this line from the poet: “The thing is, my life has become unbearable. I'm suffering from Alzheimer's. So I can't even remember some things that happened not only in the distant past, but even things that happened yesterday. With the exception of close friends like you, I no longer recognize many of the people I meet in the street and used to live with. I can no longer write good poems or philosophy essays. [...] I hope I have lived with dignity and I hope to die with dignity”.

Mariotti - The psychic and existential suffering (with the loss of meaning) seems to me to be present in his speech. For those with cognitive impairment, especially in the milder stages of dementia, the perception of memory failures is very significant and can cause anguish. On the other hand, resources to mitigate these losses, such as cognitive rehabilitation, readjusting routines, social support and emotional and spiritual support, are valuable tools for coping with this condition. Dignity is a state or quality related to feeling worthy of honor and respect or self-esteem. In the context of serious illness, loss of dignity is associated with concerns about “unfinished business”, changes in identity and the functioning of one's social role, loss of independence, legacy, purpose in life, feeling spiritually disconnected or even feeling unsupported or misunderstood by family, friends or healthcare providers. In addition, factors such as uncontrolled physical symptoms (pain, nausea, weakness, shortness of breath), depression, anxiety and cognitive changes also result in a loss of a sense of dignity.

We therefore need to make a clear distinction between living with dignity and dying with dignity. I think about something that is fundamental in these conditions: the relationship between the health professional and the patient. It can be an important source of comfort and security for patients and their families. There must always be good communication to provide the necessary support and sense of security, while also helping to relieve suffering.

“According to the Spiritist medical view, a good death means the disintegration of the physical body in natural time, in which the patient and family are well cared for, therapeutic obstinacy is avoided, with the understanding that the phenomenon of death is accompanied by disincarnation, in which the Spirit leaves the physical body naturally and returns to its true homeland - the spirit world.”

FE - Writer, poet and literary critic Silviano Santiago mourned Cicero's death, saying: “Cicero had to face death in an almost Socratic way, as if he had been condemned by death beforehand. Courage emerges, which is very important in his poetry. The courage of an elegant act in the face of the inexorability of death. This letter, his dialog with death, will inspire very profound reflections, especially among those who are approaching this moment.” How do you rate this statement?

Mariotti - Socrates was denounced as a subversive, for not believing in the gods of the city, and was accused of corrupting the youth. He was sentenced to death. He invited young people to reflect and meditate for themselves and was therefore feared by the politicians of the time. He was a forerunner of some Christian principles that would later be brought and clarified by Jesus, such as the immortality of the soul and the existence of a future life. Socrates' death in no way resembles the writer's request for an abbreviated death. Living with or having Alzheimer's disease it's not a death sentence, as some want to signal to society. If that were the case, having diabetes, especially insulin-dependent diabetes, chronic kidney disease, lupus, heart disease and cancer would also be considered intolerable. And that's not true. Courage and elegance are characteristics that perhaps many of us don't have in the face of suffering, especially when it's not welcomed, endured, when we're alone, without support, desperate or hopeless. There is a phrase by Viktor Frankl, an eminent psychiatrist who lived in the concentration camps during the Second World War, which makes us reflect more deeply on suffering and courage: “Suffering is not the indispensable way to find meaning in life. Inevitable suffering, embraced with courage, is heroism”. So I ask the readers: what does materialism invite us to: a meaningless life or a life of true heroism? Because living is also associated with some degree of suffering.

FE - The newspaper The Globe described that Antonio Cicero mentions the word “euthanasia” in his letter and says: “The origin of the word comes from Greek and means ‘good death’. It consists of a doctor administering a lethal dose of medication to a terminally ill patient with no prospect of improvement. What is actually allowed in Switzerland, and in other countries too, is assisted suicide, when the patient takes the lethal drug themselves. Most of the time it is also used by terminally ill patients suffering from incurable diseases.” In other words, he took a lethal drug. How does that work?

Mariotti - The definition of a good death can be used in different ways. According to Portuguese nurse and palliativist Patrícia Coelho, “the good death needs to be treated individually, if it is without pain or symptoms, if it is in a familiar environment in the company of friends and family. It is the mission of health professionals not only to fight the disease, but also to alleviate suffering until the end of life.”.

Generally, cancer patients are the main ones requesting euthanasia or assisted suicide, although there has been an increase in requests from patients with neurodegenerative diseases. Among the main reasons are loss of autonomy, financial burdens, inability to engage in pleasurable activities, loss of dignity, loss of control of bodily functions and concerns about being a burden to others, as well as the presence of uncontrolled symptoms.

According to the Spiritist medical view, a good death means the disintegration of the physical body in natural time, in which the patient and family are well cared for, therapeutic obstinacy is avoided, with the understanding that the phenomenon of death is accompanied by disincarnation, in which the Spirit naturally leaves the physical body and returns to its true homeland - the spiritual world. And we can go further: the good death should be understood as the temporary journey of the Immortal Spirit that ends in matter after individual efforts to achieve moral improvement, leaving a legacy of love for others and respect for the divine will and laws.

FE - I'd also like you to comment on this sentence of his: “Well, since I've been an atheist since I was a teenager, I'm aware that I'm the one who decides whether my life is worth living or not.”.

Mariotti - We need to understand that there are discrepancies between what we think is right and what is established by divine law. There are religious people who are more verbose and less compliant with Christ's lessons than atheists. They all deserve our respect and understanding. However, as Brother Jacob tells us in the book I'm back, Chico Xavier: “If man knew the extent of the life that awaits him beyond the death of the body, he would certainly choose other ways of behaving on Earth!” A true understanding of life requires humility and individual effort in the school of human existence. The decision as to how long we stay on the physical plane is not entirely dependent on our will.

FE - How does news like this impact on patients, especially geriatric patients? Nowadays, elderly people are connected to social networks. What message do you have for people who are living in the same situation?

Mariotti - I am very frustrated by the idea that an entire life with its achievements and potential should come to an end in such a tragic way, where there is a predominance of a materialistic and hedonistic view of life and the mistaken belief that suffering ends with the death of the physical body. How many well-lived stories, how many bonds and re-significances, how many experiences of love, care, renunciation and humility often occur where cognitive illness is present.

When we refrain from living meaningfully, we lose our own humanity. I heard a phrase the other day and I'd like to share it with you: “inexplicable sadness awaits us all”. The meaning of life, according to Albert Camus, is the most urgent existential question of our humanity and is linked to how we accept destiny. If we have an existential void, we need to give ourselves the opportunity to fill it. Developing affection, healthy and supportive relationships, hope, empathy, solidarity and offering multidimensional care to patients, their families and caregivers to better cope with the condition of illness are resources that can be instituted by society as a whole.