November 21, 2021
Why do people want to die? The Meaning of Life from Perspective of Euthanasia
Royal Institute of Philosophy Supplements
Why do people want to die is the title of a new academic article by Fredrik Svenaeus and published in the Royal Institute of Philosophy Supplements.
Editor’s Note – jump to section 7 about Long Lives – for a discussion on the tired of life phenomenon.
Notable Exit Members have expressed such a sentiment include:
One way to examine the enigmatic meaningfulness of human life is to ask under which conditions persons ask in earnest for assistance to die, either through euthanasia or physician assisted suicide. The counterpart of intolerable suffering must consist in some form of, however minimal, flourishing that makes people want to go on with their lives, disregarding other reasons to reject assisted dying that have more to do with religious prohibitions. To learn more about why persons want to hasten death during the last days, weeks or months of their lives, what kinds of suffering they fear and what they hold to be the main reasons to carry on or not carry on living, the paper offers some examples from a book written by the physician Uwe-Christian Arnold. He has helped hundreds of persons in Germany to die with the aid of sedative drugs the last 25 years, despite the professional societies and codes in Germany that prohibit such actions. The paper discusses various examples from Arnold’s book and makes use of them to better understand not only why people sometimes want to die but what made their lives meaningful before they reached this final decision.
1. Euthanasia in the modern world
A possible way to examine the enigmatic meaningfulness of human life – what does it consist in, really? – is to ask under which conditions persons ask in earnest for assistance to die, either through euthanasia or physician-assisted suicide (PAS). Such measures are currently allowed in eight countries of the world – The Netherlands, Belgium, Luxemburg, Switzerland, Colombia, Canada, Spain, New Zealand and some states of the USA and Australia – and in many other countries changes in law to legalize euthanasia and/or PAS are being considered. What is currently allowed in many more countries to deal with pain is so-called terminal sedation, by which patients are allowed to sleep through the final days or hours of their life. An even more common practice, which is legally supported in most countries world-wide, is patients asking for and getting granted withdrawal of life sustaining treatments, what is sometimes (rather misleadingly) referred to as ‘passive euthanasia’.
The reason why death wishes in the final stages of life have come to the fore and why many countries and states are moving towards including euthanasia or PAS in their jurisdictions is not only or even mainly that citizens of these countries have become less religious. The main reason is that modern medicine has prolonged life with the help of new drugs and advanced technologies which not only make people live longer but also live under conditions in which their bodies are fraught and damaged by diseases. Before the second world war people generally suffered rather swift deaths whereas the modern death is prolonged and negotiated by way of therapeutic and life sustaining measures, such as antibiotics, insulin, pacemakers, CPR, feeding tubes and ventilators (Warraich, Reference Warraich2017). The pre-modern, swift death was often more painful than contemporary death in the sense that dying persons did not have access to palliative drugs, such as morphine, to the same extent that patients have today, but it was less painful in the sense that they did not survive long enough to experience all the forms of suffering I will explore below.
Although the rising demand for euthanasia and/or PAS cannot be explained only by secularization, it is clearly related to a late-modern life ideal, which is centered upon being in control of one’s own life and choosing how to enact it (including how and when to die). To end up in a position in which one becomes more or less fully dependent upon other persons will increasingly be experienced as a meaningless and undignified in such a culture, whereas it will be easier to tolerate in societies that put emphasis on family-bonds and duties in relationship to collective strivings.
2. Suicide and physician assisted dying
Pleas for assistance to die in end-of-life care overlap with a much broader category of life situations, in which persons have suicidal thoughts or try to kill themselves for all sorts of reasons related to suffering, and may ask for support in doing so. However, the situations in end-of-life care are arguably rather different than the situations in which non-terminally ill persons attempt to kill themselves, so different that supporters of physician-assisted suicide rarely want to call this suicide but opt for other labels, such as ‘physician-assisted dying’ or ‘self-determined dying’. I will stick to the term ‘physician-assisted suicide’ (PAS), since this description fits with what is literally taking place and also makes it possible to separate PAS from euthanasia – in which the doctor is doing the killing – in contrast to labels such as physician-assisted dying, which sometimes refer to both practices.
There has been a strong tendency to medicalize suicidal thoughts and attempts to end one’s life ever since such thoughts and actions slipped out of the prohibitive web of religious dogma. Presently, if a person who does not suffer from physically painful and disabling disease says she wants to die, not only doctors but also relatives and friends will most often think of this person as suffering from a depression. If the living conditions and recent life-history of the person in question are bad or unlucky enough we may deem the suicidal thoughts understandable under current circumstances. Nevertheless, if there is hope for a change, we will try to prevent the person from taking her life by measures such as compulsory psychiatric care. Perhaps we still find some room for philosophically motivated suicides in contemporary society, in which the persons who want to end their lives are deemed sane. However, suicides being looked upon as rational and for the best are very rare things outside the confines of end-of-life care and patients suffering from intolerably painful diseases. Depression and other severe psychiatric conditions could possibly in some cases be counted among such ailments, despite being categorized as mental disorders rather than physical diseases, but in such cases the suspicion that the person in question is not able to judge her own situation rationally is always lingering.
3. Why do people want to die? – Some German stories about the wish to die
To learn more about why persons want to hasten death during the last days, weeks or months of their lives, what kinds of suffering they fear and what they hold to be the main reasons to carry on or not carry on living, I will offer some examples from a book written by a physician who has done much during the last 15 years to create a public discussion about euthanasia in Germany and who has pushed the opinion towards making PAS legal in this country. Uwe-Christian Arnold in the book Letzte Hilfe: Ein Plädoyer für das selbstbestimmte Sterben (Last Aid: A Plea for Self-Determined Dying) proudly confesses to having helped hundreds of people to die with the aid of sedative drugs made available by him in response to their requests and after having consulted their medical and personal history. (Footnote 1)
Starting out secretly he increasingly ceased to hide these activities but rather made use of them in order to test the legal situation regarding PAS in Germany and create a public discussion.
The legal situation in Germany is complicated due to conflicting laws and professional codes of conduct on the national level and in the Bundesländern, but the base line according to the constitution is that assistance with suicide is not forbidden if carried out for altruistic reasons.
This has recently (26 of February 2020) been confirmed after a period of five years during which a supplement to the constitution was in force, prohibiting professional assistance in attempts to kill oneself. The supplement was put in place to stop physicians – and the most well-known of them was clearly Uwe-Christian Arnold – from carrying out such business, but the Bundesverfassungsgericht (26 February 2020) found this ‘Lex Arnold’ to be unconstitutional. (Footnote 2)
Arnold himself did not live long enough to see the ban lifted, he died by his own hand in April 2019 after suffering from progressed cancer. It will be interesting to see how things will now develop in Germany and other countries – like Finland and Sweden – in which the legal situation regarding assisted suicide is more or less the same as in Germany and in which the public opinions are increasingly supporting PAS (Jersild, Reference Jersild2020).
I have chosen four cases out of Arnold’s book which he claims to be typical and in which he has helped patients to die. His book contains a lot more than case studies: biographical details from his own life, a brief history of suicide and euthanasia, philosophical arguments to make PAS legal and criticism against those who resist this development and claim the only thing needed in Germany is improved palliative care. (Footnote 3)
Arnold supports palliative developments, but he also claims that in some situations, particularly in end-of-life care, the most humane thing to do is to help the patient to take his own life. Euthanasia is also discussed in the book, but Arnold thinks that institutionalizing PAS would be sufficient in the case of Germany and that the constitution of the country already supports this move (Arnold, Reference Arnold2020, p. 209).
4. Neurological diseases
So, what do such situations look like and what may we learn from them regarding the meaningfulness of human life?
My colleague Mr. S., a respected specialist in medicine, ran a successful private clinic in southern Germany. He was already looking forward to his retirement, during which he wanted to catch up with a lot of things that he had not been able to pursue due to his hectic working life, when, after having abruptly stumbled a couple of times, he was diagnosed with amyotrophic lateral sclerosis (ALS) at the age of 61. …
What I witnessed when first visiting Mr. S. was shocking even for an experienced physician like me: the spindly patient sat strapped to a special nursing chair, his head was also fixed, otherwise it would have fallen to the side. The muscles of the arms and legs as well as the entire body had largely regressed. Mr. S. answered to my ‘How do you do?’ with an indefinable noise, causing a large amount of mucus to flow out of his mouth.
Mrs. S. asked me to read a letter that her husband had with the greatest effort of will laboriously tapped into the computer with one finger. … Vividly Mr. S. in the letter described various aspects of his torments, such as the problems with the face mask that was supposed to make his breathing easier. The secretions that were constantly forming in the mouth, throat and lungs, and which had to be suctioned off every 45 minutes, caused him the greatest problems. ‘Fight longer and longer under the mask against the bad slime’.
At night, Mr. S. continued in his letter, he lies awake every hour, he is in pain, and communication with others is becoming increasingly impossible. Every day his exhaustion is growing and he notices how his motor skills continue to dwindle – a state to which he no longer wants to be exposed: ‘I can’t do this anymore. I’m finished. Everything is just a great effort. I drag myself forward, hour by hour’. (Arnold, Reference Arnold2020, pp. 27–30)
What makes life no longer worth living for Mr. S are painful feelings pervading his entire existence. Not only bodily pains but also difficulties to breathe and the inability to move around, and even to move his arms or neck. These bodily inabilities include not being able to eat or drink – this is being managed by way of a PEG tube – or going to the toilet. On top of this, Mr. S suffers from insomnia because of the pains and breathing difficulties and because of anxiety and fear of more pains to come. He also, as the source of his suffering, mentions his increasing inability to make himself understood and communicate with others. This matters a great deal to him, since he fears this inability might make it impossible for him to communicate his wishes (including the wish to die) in the near future.
Neurological diseases such ALS or MS in some cases lead to very painful dying-processes if not shortened by way of sedating drugs. In the case of Mr. S, the drugs had to be administered via his feeding tube, since he did no longer have the ability to swallow. By having the patient turning a switch to let the drug infusion into the tube – in this case with the help of his finger – the case could be classified as PAS rather than euthanasia. Another possibility for Mr. S would have been to refuse the administration of liquid and nutrition via the tube altogether, but this would have led to a more protracted and probably painful dying-process.
So, to sum up the case, life is not worth living if negative physical experiences – pain, ‘air hunger’, the inability to move, itches or nausea (the last two not being mentioned in this particular case, but in many other cases of ALS or MS) – are making it intolerably painful and unbearable to continue. An interesting question is if positive physical experiences – various forms of bodily pleasures – could in such situations even out the physical suffering and make it more bearable. Probably not in the case of Mr. S, since the negative physical feelings tend to fill up every second of his life and leave no room for bodily pleasures. To press things further, one could ask if other forms of experiences than bodily ones could count as positive and turn the numbers in such accounts of life-meaning. I am not suggesting that a balance of negative versus positive future life experiences would be possible to carry out in practice, only that it might be an interesting philosophical project to pursue, since other things than bodily experiences matter a lot in a human life, although bodily sufferings characterized as intolerable or unbearable tend to make them significantly less important. In order to see this more clearly, let us turn to another case from Arnold’s book.
Helene C. did not want to live anymore. The metastases had spread throughout her body. It was difficult for her to breathe. For weeks, she had not been able to walk for long. In the meantime, she was so weakened that even the few meters from her bed to the toilet required an almost superhuman effort. Soon, she feared, she would not be able to get up at all.
The elegant but resolute elderly lady had long since come to terms with death, but to be tied to the bed and being diapered by others was a regular nightmare for Mrs. C., who had always valued a neat appearance. ‘It is out of the question! I don’t want to face my Creator in diapers!’, she told me on the phone in her inimitable way shortly before our last meeting. …
While I was chopping up the medication I had brought with me, Mrs. C. told me about her husband Paul, who had died of cancer 13 years ago – three years before she was diagnosed with the same disease. Mrs. C. had lovingly cared for him at home, it had been three months in total, which Mrs. C., as she said, never wanted to be without. But for her Paul the last few weeks, which he could only spend in bed, were pure torture. …
I glanced at the daughter, who until then had listened to the conversation largely without contributing. When I asked how she felt about her mother’s decision, she replied that it was a great shock to her when she found out about it. At first she was strictly against it. However, she knows all too well how difficult it is to change her mother’s opinion once she has made up her mind. Since she also knows how miserably her father died, she can well understand that her mother wants to choose a different way. She might have made the same decision in her position. Unfortunately, this will not change the fact that it is now, at this very moment, incredibly difficult for her to let her mother go. …
She didn’t get any further. She started to sob horribly. Despite everything I’ve experienced in recent years, this scene touched me deeply. It is difficult to comfort those close to you. Fortunately, Mrs. C. responded right away. She stretched out her arms to her daughter: ‘My darling, come here, everything is just as it should be!’ (Arnold, Reference Arnold2020, pp. 19–23)
Mrs. C does not suffer intolerable pain – morphine and other drugs have made it possible to ease her pains despite the metastatic cancer spreading in her body. The vignette mentions difficulties to breathe – as in the case of Mr. S – but it is mainly other things than pain or ‘air hunger’ which make her ask for assistance to die. Important matters, that are further developed in parts of the story not included in the quote above, are that it is no longer possible for Mrs. C to get out for walks, meet with friends or take care of her own cooking. Everyday activities are becoming increasingly limited, something that was true also to an ever greater extent for Mr. S, who was no longer able to even eat or care for his own hygiene as an effect of the ALS. Being able to do everyday things matter a lot for our ability to experience life as meaningful, exactly what is important beyond basic things such as eating or taking care of one’s own bodily hygiene may vary significantly between persons. If the most important thing in life is to read books or listen to music, the loss of sight or hearing may lead to depression and/or the wish to die. (It may also do so because these losses make it much harder to meet and communicate with other people.)
In the case of Mrs. C, reading and listening to music are things she still can do, but this is not enough for her in the current situation. She is bored. However, the main reason she wants to die appears to be neither physical pains nor being precluded from everyday meaning-inducing activities, but the threatening scenario of losing her independence and being nursed by others. This is something she provided for her own husband during his last three months in life, but she cannot imagine ending up in a similar situation herself, irrespective of being nursed by professionals or relatives (her daughter is more than willing to do this, but the mother will not allow it to happen).
The main reason for wanting to die in the case of Mrs. C is most adequately described as a threatening loss of dignity. She does not want to be nursed by others since this would make her appear in the eyes of others – according to her own impression – as a person she cannot bear to self-identify with. This includes her appearance in the eyes of the Almighty, who she, more or less jokingly, ‘does not want to face in diapers’. Perhaps such things as wearing diapers matter more or less to different people, depending on how essential finding independence and self-control or appearing neat and tidy is to their self-image, but the experience of losing one’s dignity in the eyes of others appears to be an important and rather common reason for why people with different life-constraining diseases ask for PAS or euthanasia (Rehmann-Sutter, Gudat and Ohnsorge (eds.), Reference Rehmann-Sutter, Gudat and Ohnsorge2015). Dignity is not only reached or lost in the eyes of specific other people that the patient (fears to) encounter(s), but also in the self-understanding process established by way of imagined view-points of general others (not only their gazes but also their thoughts). This is brought out even more comprehensively in another case found in Arnold’s book.
Henning M. had suffered severe paraplegia due to a motorcycle accident. He had been in a wheelchair for ten years and could only move things with the help of his mouth. A diaphragmatic pacemaker enabled him to breathe. He was always in pain. But what bothered him the most was the constant, medically necessary care-taking of his body. Although it was done with extreme tenderness, the mere fact that he had to be handled and touched by others for several hours every day meant the ‘loss of all privacy’ for Henning.
Despite this stress, Henning was by no means depressed. … Viewed from the outside, he lived with his disability under conditions that one could hardly have imagined more ideal: He had a loving and understanding family and lived at home in a comfortable room that was equipped with all technical refinements. Henning could operate his computer with a mouth control, and he spent a lot of time surfing the Internet and keeping up to date with developments in the world. …
So why did he want to die? Henning justified his decision in his typical straight yet thoughtful way: ‘I have lost my dignity, I have lost my sense of self, I hate my body, I hate my appearance. And being in the position of still accepting myself as a person, I want to go. I don’t want to wait until I not only hate my body, but also my whole being’. (Arnold, Reference Arnold2020, pp. 103–104)
After having consulted with Henning and his family, Dr. Arnold ends Henning’s life by first putting him to sleep and thereafter turning off the diaphragmatic pacemaker. This is legally classified as refusing life-saving treatment, but as Arnold admits himself, in disentangling the ethics, it comes very close to performing euthanasia (Arnold, Reference Arnold2020, p. 107). What the case of Henning may teach us, in addition to bringing up ethical issues regarding assistance to die for non-terminally ill patients, is to what degree a positive self-understanding is involved in experiencing one’s life as meaningful or even bearable to live.
Chronic bodily pains represent a great challenge to finding meaning in life and so does the inability to perform everyday tasks that matter to the person in question. Pleasurable bodily experiences and meaningful daily activities make a person flourish, we could say with terminology borrowed from Aristotle and other virtue ethicists. But most important of all to the experiences of suffering or flourishing is probably the identity a person develops during her life in the process of various forms of self-understanding procedures (Svenaeus, Reference Svenaeus2017, ch. 2). Such self-interpretation is not mainly an intellectual matter, but rather the perceived, emotional quality of appearing as such and such in the eyes of others. Although Henning talks about hating himself, not about others hating him, it is clear that his hate stems from comparing his life to the lives of other people, and what he is able to contribute or rather not contribute to the good things that we may achieve in this world together. He is very interested in world politics, but also, more than others, unable to do anything that matters to the course of things in the world. The project of developing a virtual identity by setting up a web page dedicated to some project and/or self-presentation is not mentioned in the book, but it may increasingly be a possibility for people in Henning’s situation who want to ease their boredom and find new ways to flourish in and via the virtual world (achievements in the virtual world may in many cases also matter to what happens in the real world).
Perhaps Henning’s case is similar to Mrs. C’s in the sense that he feels to have ‘lost all privacy’ in being nursed by others. He hates his paralyzed body, the situation it creates for him, and the person it threatens to turn him into. It is clear that a person’s bodily state is deeply connected to their self-appearance, and, accordingly, to the meaning they assign to their life. Not being able to move one’s body tends to be equated with being dependent upon and exposed to other people, which is perceived as humiliating by Henning as well as by Mrs. C. Henning faces this problem for all foreseeable future, but even when we are talking about the final, perhaps rather short chapter of a long life, becoming like an infant appears to be difficult to deal with for those who are still adults in mind (cases of progressed dementia are arguably different).
7. Long lives
Mrs. P. was 99 years old, her 100th birthday was just around the corner, but with the best will in the world you would never have thought that. … Certainly, even Mrs. P. was plagued by a few ‘little ailments,’ as she called them: heart failure, deteriorating eyesight, and osteoarthritis. But that wasn’t something she complained about. However, walking really was a problem. Both hips had been replaced by artificial joints many years ago. In the meantime, these had loosened, but Mrs. P. did not want to go through another operation with subsequent rehab at her age, and her physician had also advised against it.
Mrs. P. lived on the ground floor of a rental building in a nice area of Berlin with lots of green spaces. Despite her walking difficulties, she was still able to take care of her own basic housework and she paid for additional cleaning help out of her own pocket. … Overall, Mrs. P. was ‘socially well integrated,’ as she confirmed to me. … So why did she want to die?
Mrs. P. told me that a few weeks ago she had stumbled again and ‘my whole body turned green and blue’. Fortunately, she hadn’t broken anything … but the doctors in the hospital had suggested she should go to a suitable ‘facility’ as soon as possible. Mrs. P. categorically refused.
Far too often, she explained to me, she had seen friends and acquaintances in nursing homes or care facilities approaching death under unworthy conditions: ‘That is the fate of people who have lived as long as I have: we have to watch how everyone around us is dying’. Many of her friends had spent their last years in old people’s homes – and that was almost always ‘hell’: ‘Wild horses couldn’t drag me there!’ …
That is why she interpreted the accident a few weeks ago as a sign that the time had come to draw a line. If she broke something next time she fell, her fate would no longer be in her own hands. And that, according to Mrs. P., would be ‘absolutely unbearable’ for her. So she wanted to go as soon as possible. I asked emphatically whether she was really quite sure. Given her excellent health, she would definitely have the chance to experience another ten good years of life.
Mrs. P. gave a short laugh: ‘Mr. Arnold, you are still a young man. When you get to my age, you will understand that after a certain point life is no longer a gift, but a burden. The past seven years have been far from good, and the next are sure to be a lot worse. I can happily do without that. I have always attached great importance to being able to determine the course of my own life, and that should also apply to my death’. (Arnold, Reference Arnold2020, pp. 195–97)
The case of Mrs. P raises questions about how many people will in the near future end their lives by way of PAS if no qualifying condition of suffering from a disease that will lead to death within a foreseeable future is stated – the way it is legally organized in Oregon and eight other states of the USA (remaining life expectancy being specified to about or less than six months). As the life-ending medical practices in Benelux show – in which euthanasia or PAS has become a matter of choice for all patients who experience ‘unbearable suffering’ irrespective of prognosis – the number of deaths are more than tenfold when arranged in this manner compared to the situation in Oregon (4.6% of all yearly deaths in the Netherlands in comparison with 0.4% of all yearly deaths in Oregon).(Footnote 4)
What will likely increase the number of deaths through euthanasia even further in Benelux in the near future is the possibility of signing a living will declaring not only that one wants to abstain from life-saving treatment in case of contracting diseases (such as pneumonia), but also that one wants to be euthanized in the case of becoming severely senile due to dementia. Alzheimer’s disease is an exploding problem in the Western world and will likely join cancer diseases and neurological diseases as the main reason for euthanasia in countries that make such living will solutions possible or that allow PAS or euthanasia measures in earlier stages of the disease by way of deeming the suffering in question “unbearable” (this is the defining condition in Benelux).
But the case of Mrs. P is different still, since she does not suffer from dementia in any stage, she is rather tired of living and, in addition to this, fears ending up in a nursing home. Such cases have also been discussed in the Netherlands and Belgium, but so far they have not been deemed cases of intolerable suffering.
Dr. Arnold obviously means that PAS should also be allowed in such cases, since he helped Mrs. P to die under the current circumstances. He also does not think legalizing PAS will make old people feel pushed to die in order to not become a burden to others, a fear that many critics of PAS and euthanasia have expressed (Arnold, Reference Arnold2020, pp. 203–206).
Since the purpose of this paper is not to argue for or against making PAS or euthanasia legal with or without certain restrictions, I will not dwell further on Mr. Arnold’s actions but rather ask why Mrs. P wants to die. It is not because of physical pains, such as in the case of Mr. S. It is not because of physical immobility, such as in the case of Henning (and Mr. S).
It is also not because of not being able to do everyday things that matter for her in life, as it was the case with Mrs. C. (and Mr. S and Henning), although Mrs. P’s life is developing in this direction and she fears that this will happen soon. It is rather that she feels her life is drawing to a close and she wants to take this matter into her own hands (with the help of Dr. Arnold’s hands).
She feels one, two or even seven more miserable years would make her life as a whole worse, not only in the sense that she would not enjoy the extra years, but that the extra years would increasingly transform her into a person which she does not want to include in her own and others’ living memory.
8. The meaning of life in the shadow of death
Studying the reasons patients give when asked why they want to die, one can roughly divide them into three different yet connected forms of human suffering.Footnote 5 First, we have the feeling of pain and other bodily afflictions, such as difficulties to breathe, nausea, itches or the inability to move. Such bodily suffering could become constant and intense enough to invade the entire life of the person, making her life unbearable if it cannot be ameliorated. The body, in such situations, becomes a source of evil that brings torture to the person and alienates her from her own bodily being.
Second, we have the effects of bodily sufferings in terms of making activities that matter to the person in question impossible to engage in. We could discuss what to include exactly in such vital everyday doings, but I am thinking about basic actions necessary to tend to one’s everyday needs and also what is favored by a particular person in terms of being pleasurable and important to her. Being alienated from carrying out such projects I would call everyday suffering.
Third, we have an alienating form of self-understanding, related to painful bodily feelings and being prevented from activities that matter, which articulates how these two other forms of suffering lead to becoming dependent upon or a burden to others, rather than representing a resource or source of joy for them.
Existential suffering includes the pain of loneliness, lacking friends or close family members, who have died or disappeared during the course of one’s life. Existential suffering can be phrased in terms of not having a valuable place and purpose in the world anymore.
Existential suffering is brought to its height by the feeling of lost dignity in becoming bodily exposed and helpless and is further illustrated by the fears of losing one’s memory and sanity, as it happens in cases of dementia. Existential suffering is a feeling of shame or vulnerability in the eyes of others, being exposed to their (imagined) gazes or appearing in their (imagined) thoughts as flawed, to be pitied and seen as better dead than alive.
In analogy to these three forms of suffering, the meaning of life brought to us by listening to people living in the shadow of death could be described as bodily, everyday and existential flourishing. To flourish means to develop one’s potentials as a human being in being the particular person one happens to be. Flourishing is both passive and active in the sense that it falls back on experiences that are developed into accomplishments. Flourishing can be understood in terms of feelings, actions and thoughts.
Bodily flourishing includes bodily pleasures and the enjoyment of existing as the kind of body that one is by nature. It does not exclude all pains, but merely includes them to the extent that they are necessary to intensify experience and make the contrast to pleasure more vivid. Pain and other bodily ailments may make a person more present in her own body, but beyond limits and self-control bodily suffering will also alienate a person from her own body.
Everyday flourishing begins with the little things, doings and accomplishments connected to bodily needs – hunger, thirst, physical exercise, hygiene, etc. – and after such needs have been satisfied may turn to play, education and working projects in and through which a person may develop her potentials during her lifetime.
Existential flourishing engages intellectual capacities, thoughts and theories, but it is also, just as bodily and everday flourishing, rooted in feelings and a kind of activity in itself. To become the person one endeavors to be through the things that one accomplishes in the world, and in relationship to other people, is the goal of existential flourishing. This may include various forms of suffering, since experiences of lack and loss could sharpen the focus on the meaning of life and lead to changes in a person’s way of living.
But the hardships brought to us by the stories in Arnold’s book should also teach us to cherish the moments when we do not suffer but merely enjoy being alive, bodily present in the world together with others engaged in everyday projects and attempting to be if not good, then at least decent to each other.
Maybe such things as lasting love and making a difference in the world are the ultimate meaningful projects of life, but it is also nice merely to not be in pain and to be able to move around in the company of others doing little things. We should not forget such pleasures since we will surely be reminded of them and cherish them when they are eventually beyond our reach.
They are also forms of human flourishing even though they do not include the existential quest we often intend when using the phrase ‘meaning of life’.
1 Arnold (2020, p. 9). All translations of quotes from this book in the following are my own.
2 See: https://www.bundesverfassungsgericht.de/SharedDocs/Pressemitteilungen/EN/2020/bvg20-012.html
3 For a different picture of the state of palliative care in Germany and what is needed in the future, see Reimer and Heller (2014).
4 SMER (The Swedish National Council on Medical Ethics), Dödshjälp: en kunskapssammanställning (Stockholm: Smer rapporter, 2017) 96, available at: https://www.smer.se.
5 Besides Arnold, Letzte Hilfe, see also: Gawande (2014); and Christoph Rehmann-Sutter et al. (2015).