Thinking About ‘Completed Life’ Euthanasia in the Netherlands from the Generativity Perspective: A Reflexive Exploration

In this reflective essay, we explore the concept of generativity and propose it as a more positive interpretation of the experience of ‘completed life’ and its bearing on the wish to die. In 2010, more than 100,000 people in the Netherlands signed a petition requesting an extension of the existing euthanasia legislation. They asked the government to grant euthanasia to older persons who feel tired of life and who regard their lives as complete, in the absence of physical or psychic sickness. Debates about ‘completed life’ euthanasia have continued since then, but the various factions in these debates have been unable to reach consensus or conclusion. In this paper, we analyse the concept of generativity and use this to interpret statements by supporters of ‘completed life’ euthanasia. Next, we disentangle common idioms that people use when they grow older and feel that death is approaching yet still out of reach. The aim of this article is to invite readers to reflect on the wish for ‘completed life’ euthanasia as a meaningful end-of-life reaction.


Introduction
In 2010, 116,871 Dutch citizens signed a petition asking the national government to amend the existing legal framework for euthanasia to create the possibility of a dignified death for older citizens who consider their lives to be complete (Uit Vrije Wil 2010). The petitioners proposed that new laws regarding euthanasia should be based on the principle of self-determination and free will and should apply to people age 70 and older who have a consistent and well-considered wish to die in the absence of unbearable suffering due to illness (Peters et al. 2011). The petition prompted widespread debate about the ethical, medical, and legal implications of 'completed life' euthanasia, both within professional circles and among the Dutch population. This reflexive essay aims to contribute to the ongoing discussion by examining the concept of 'completed life' from the perspective of generativity.
Experts on the art of growing old often use adjectives like 'successfully,' 'gracefully,' 'vitally,' or 'actively' to emphasise the crucial importance of finding meaning in later life -of having a purpose. Following this logic, should we thus regard those who say that their life has no more meaning as depressed or emotionally unstable? Rather, we argue that -paradoxically -choosing to die because life no longer has meaning or purpose may actually be a sign of a deeply-experienced sense of meaning and purpose at the end of life. Using the concept of generativity, we examine what some people may mean when they state that their life is complete. Furthermore, we explore the contextual significance of common Dutch expressions such as "I don't want to be a burden on my children (or others)" and "I'm waiting for the Big Boss to call me." This essay aims to invite readers to consider the wish for 'completed life' euthanasia as a simultaneously rational and emotional decision once a person has determined that their life has lost its generative capacity. Through our reflections, we hope to encourage colleagues in various professions and academic disciplines to consider 'completion' as a meaningful experience among older people who believe that continuing to live no longer serves a purpose -either for themselves or for those to whom they were devoted in life.

Background
The aforementioned petition, 'Of Free Will,' was set forth eight years after the Dutch government issued the 'Termination of Life on Request and Assisted Suicide Act,' which stated that euthanasia would not be punished if the attending physician acted in accordance with the criteria of due care (Dutch Ministry of Security and Justice 2002). This law stipulates in part that, in order to allow euthanasia, there must be unbearable suffering without the prospect of improvement as well as an explicit, voluntary, and wellconsidered request from a critically ill patient who is capable of expressing their will. A second, independent physician must be consulted, and the euthanasia must be carried out with due medical care and attention. Patients, however, do not have a right to euthanasia (de Jong and van Dijk 2017).
The 2010 petition was based on the principle of self-determination, and it introduced the concept of 'completed life' as a valid reason for requesting euthanasia. At the same time, the petition recognised the existential encumbrance of making the decision to end one's life and emphasised the importance of a 'dignified death.' The petition's three central tenets were as follows: Self-determination Our Constitution guarantees every Dutch citizen the freedom to organise their life according to their own insight and preference, and to make decisions about it. This freedom also includes the final phase of life and decisions about dying and death. No one has an obligation to live. Self-determination, an essential principle of our civilisation and anchored in our culture, is the foundation of this citizens' initiative. Uit Vrije Wil (Of Free Will) focuses on the self-determination of the elderly. It is up to the free person, who regards their life as complete, to decide for themselves how and when they want to die.

Completed life
We are all getting much older than before, usually to our pleasure. But at some point, we may reach the conclusion that the value and meaning of our lives have decreased so much that we would choose death over life. The reasons for this vary. Sometimes, we no longer see opportunities to continue our lives in a meaningful form, and we have the feeling of outlasting ourselves. Everything of value is behind us, and only emptiness remains. Sometimes, we become completely dependent on the help of others, and we lose any form of control over our own lives. Sometimes, we are also confronted with physical abuse and an irreversible loss of our personal dignity.

Self-chosen end of life
The decision to end one's own life is far-reaching; our attachment to life is great. This makes it difficult to balance the continuation of a life experienced as unliveable, and death. However, when it becomes clear to us that our circumstances can no longer be changed, we may reach the conclusion that our life is complete. We want to die, die in dignity and peace, and preferably in the presence of loved ones. In many cases, help is needed. This also prevents suicide attempts from failing and/or having terrible consequences, also for others. (Uit Vrije Wil 2010) The Dutch government reacted to the citizens' petition with hesitation, stating that it did not relate well to the current euthanasia legislation but that further consideration of the issues raised was important. Medical professionals were mostly critical and saw the petitioners' call for completed life euthanasia as an intrusion into their professional tasks and responsibilities. Even more, they perceived it as a threat to the quality of medical care. Religious organisations were squarely against the petition, calling it a step toward the weakening of respect for the value of human life. Legal experts concluded that extending the present euthanasia legislation to include completed life euthanasia would require drastic changes to the law. Ethicists pointed to the diversity of interests and views among the various participants in a potential completed life situation. The reaction of the wider public is not well known, but the Central Bureau of Statistics (CBS 2019) later reported that more than half of the Dutch population was in favour of a new law to make completed life euthanasia possible.
The government decided to conduct a study of the legal possibilities for -and the social and ethical dilemmas of -euthanasia for people who deem their life to be complete. An advisory committee was established to conduct the study, and in January 2016, the members returned with their advice, recommending against any modifications to the current law (Schnabel et al. 2016). The committee also remarked that the number of people who may wish to die while still in a relatively good state of health is probably quite small. Furthermore, the committee argued that the wish for euthanasia usually comes with a serious accumulation of physical and/or mental complaints in old age; as such, they recommended further research about the existing possibilities within the current law to allow for euthanasia in such cases.
In January 2020, the results of this research were presented in an extensive report to the Dutch Ministry for Health, Welfare and Sport (van Wijngaarden et al. 2020). The purpose was to explore in more detail the size, characteristics, and circumstances of elderly people with a desire to die, without serious illness. More than 21,000 older adults age 55 and over had completed a comprehensive questionnaire, and the researchers had conducted in-depth interviews with dozens of older people. Over 200 requests for euthanasia, both fulfilled and rejected, were also analysed. Finally, 1,600 general practitioners from across the Netherlands participated in a survey.
From this investigation, the researchers estimated that 0.18% of all people age 55 and over have a wish to end their life in the absence of serious illness (van Wijngaarden et al. 2020, 79-85). This amounts to just over 10,000 people. The researchers also found that slightly more than one-third of this group would like to receive help to die while two-thirds would prefer to end their life by themselves. Similar to the previous advisory committee, the 2020 report emphasises that the term 'completed life' (as described in the petition above) is problematic -primarily because it presents a too-rosy picture of the state in which an older person might request euthanasia, but also because it obscures the reality leading up to such a request. This reality includes, for example, emotional suffering, loneliness, poverty, and the fear of total dependency and an undignified death. The overall policy suggestion that the media drew from the report is that it would not be a good idea to adopt a new law that would facilitate completed life euthanasia. Nevertheless, the D66 political party announced that it would present a proposal for such a new law in 2021.

Generativity and a completed life
The term 'completed life,' as described in the 'Of Free Will' petition, reflects a person's wish to die with dignity. We examine this wish from the perspective of generativity. The concept originates from the work of developmental psychologist Erik Erikson (1997Erikson ( [1982), and it refers to the human drive for continuity. Inspired by Erikson, psychologist John Kotre further defined generativity as "a desire to invest one's substance in forms of life and work that will outlive the self" (1984,10). The basic assumption is that people hope to 'live on' in their children or others who will continue their work and take care of their properties in the future. These children, friends, or students will remember them for their ideas, personality, achievements, activities, or gifts (including money). Kotre distinguishes four types of generativity: biological (bringing forth), parental (bringing up), technical (teaching skills), and cultural (passing on ideas, values, and symbols) (1984,(11)(12)(13)(14)(15)(16). We could add a fifth type: economic, i.e., the drive to continue a business or enterprise that would be the materialisation of emotional and symbolic values. As Erikson suggests, generativity occurs in all stages of life (except, perhaps, the first) but it becomes more acute towards the end of life when the biological self is approaching its natural end. This threat to continuity thereby produces a sharper awareness of the need to look for alternative forms of continuity. Developmental psychologist Feliciano Villar (2002) has called for the addition of generativity to the concept of 'successful' ageing, thus moving it to the social level (instead of the strictly personal level). He draws attention to the contributions that older people can make to the well-being of family and others in their social network in addition to the intrapsychic processes that are usually seen as characteristic of 'successful' ageing.
Following Erikson, Kotre indicates that people attempt to give meaning to their lives by creating continuity through the next generation (1984,7). If everything that a person has produced over their lifetime were to stop with their death, this would probably be considered to be a derogation of the meaning of their life. Generativity therefore has two complementary but also somewhat conflicting meanings. On the one hand, according to Kotre, it is about care for the formation and management of the next generation ('communal mode'); on the other hand, it is the older person's desire to produce something through which they will live on after their death ('agentic mode') (1984,(16)(17)(18). While the first thought's emphasis on investing in the well-being of the next generation can be understood as altruistic, the second is self-centred and focuses primarily on the desire of an older person to 'live longer' through the memory (and admiration) of their successors. Rubinstein et al. remark that "both narcissism and generativity might be thought of as forms of self-fulfilment that can be, for some, closely related in that generative action provides distinctive personal gains" (2015, 549). We also acknowledge thesepotentially conflicting -nuances of difference and their moral implications but, following other scholars, we simultaneously believe that altruism and self-fulfilment or self-gratification are nearly always intertwined (Ambrose 2009;Dawkins 1976;Rand, Greene, and Nowak 2012).

Interpreting quotations
In this essay, we explore the concept of generativity through our analysis of the personal narratives of nine people who signed the 2010 petition for completed life euthanasia. The quotations included here are taken from interviews by Priya Satalkar, in which these interlocutors explained why they supported the idea of completed life euthanasia (Satalkar and van der Geest 2019). It should be pointed out that, at the time of these interviews, none of the study participants had yet turned 70, the age at which they could obtain completed life euthanasia. However, as they explained, signing the petition was a way for them to take a stand in the public discussion and express their views on the issue of completed life euthanasia. Several of them made it clear that they might never arrive at the point where they feel their life is completed, but they strongly believed that it should be possible to request euthanasia and die in a dignified way for those people who do reach such a point.
The signatories of the petition have tended to be the most outspoken proponents of the proposed law that aims to avoid what they regard as a gloomy and miserable end of life. They hope that the completed life law will prevent them (and others) from enduring a situation of useless living, loneliness, and total dependency. In our interviews, two interlocutors expressed their resistance to total dependency, abiding by the decisions of others -particularly doctors: I do not want to be dependent on doctors who keep me alive when my body wants to die. But the medical profession doesn't want me to die. I want to decide that for myself. I want to be more in balance, instead of doctors having a total say over how my life should continue or end. (MJG, F, age 64) It's crucial to not just look at technical ways of keeping people alive but also to think whether life still has meaning, a sense of belonging. Your body might be fixed, but your mind can't cope with life anymore. You're tired. Your energy to go on is depleted. But you're expected to go on living because your body is still functioning thanks to technology. Your body is alive, but you've lost the meaning of life -you've lost the energy and spirit to go on living. (JVB, F, age 65) The concept of generativity -and its loss -help us foreground what remains unsaid in the above quotations. As seen from a generativity perspective, these two interlocutors imply that their own parents had reached a point where they (the parents) felt they had become useless. They had worked hard to raise successful children, and their own 'successful' ageing was demonstrated in the successes of their children (cf. Villar 2002). But at a certain point, the tables turned. The older people became unable to continue their parental task of helping their children and grandchildren. Instead, they realised that they might become an obstacle to their children accomplishing what they hoped to achieve. These are painful considerations that may be hard to express openly, particularly by the younger generation.
From the perspective of generativity, living on while depending on the help of one's children or other members of the next generation is the opposite of what many older people wanted their life to be: i.e., passing on their most precious material properties and spiritual values to the next generation. For some people, the ultimate act of generativity would be leaving the scene and 'making room' for others. Instead, the end or loss of generative living may correspond to an experience of uselessness and a loss of meaning.
When people consider the slow, interminable decline experienced by some older people, they may project themselves into the future and develop various concerns. For example, they may feel determined to no longer live when their life has become 'useless' and they have become a burden to others. They may also worry about their life ending in misery and total dependency, a condition that would be the opposite of what their life has otherwise been. Completed life euthanasia would prevent this and allow their end to be a confirmation and a reflection of the quality of their life. Moreover, it would support their wish to be remembered for their achievements and vitality, rather than for prolonged suffering and dependency at the end.
One signatory of the petition, BTK, who is severely disabled due to multiple sclerosis, explained his views on this matter: Until this point in time, I feel that I'm useful to others; I'm able to do things for others. I can see what my contributions are. I'm able to connect and influence situations around me.
[But] the minute that connection and ability to influence is gone, my purpose in life is gone. I need a purpose to live. When that purpose is lost, however small or big that may be, I want to call it an end. (BTK, M, age 61) In the interview, he explicitly linked his condition of progressing disability to a sense of diminishing purpose in life; he related this to his future wish for death after a completed life.

'Completed' -a misleading term?
As research specialists in care ethics and perspectives on death and dying, Els van Wijngaarden and her colleagues emphasise that the term 'completed life' suggests a too-rational and well-considered view about end-of-life quality (e.g., 2015, 2016). In their most recent report for the Dutch government (2020), they repeat this claim in even stronger terms: the concept of completed life includes feelings of depression, loneliness, and anxiety about dying without dignity. In an earlier paper, van Wijngaarden et al. (2019) explored ten disparaging metaphors about aging used by 25 older people who wished to die; these metaphors include 'emptiness,' 'breakdown,' 'redundancy,' 'burden,' and 'return to childhood.' Let us look more closely at one such metaphor, which is directly related to our reflections on (lost) generativity: Participants also talked about the process of aging in terms of being a burden to themselves but even more to others and to society. They felt [they were] foisting [themselves] upon others, putting pressure on their children, and costing too much (money or time) (van Wijngaarden et al. 2019, 257, italics in original).
We argue that such negative qualifications of a life that does not enhance but rather obstructs other people's lives (particularly children and successors) are the logical consequence of a deeper wish to promote others' well-being and quality of life. As one of van Wijngaarden et al.'s interlocutors said: "You know, that's not the reason why we live on this earth: to greatly complicate each other's lives" (2019, 257). Such emotions regarding others seem to make the feeling of 'life completed-ness' more intense and unbearable for some people.
As we suggested earlier in this essay, a person's decision that life has lost its meaning and the subsequent decision to end their life before it becomes (more) unbearable -for both the person and those around them -is in itself a meaningful conclusion. In other words: expressing the experience of 'meaninglessness' can be a demonstration of meaningfulness. Making room for the next generationand no longer being a burden to them -is an act that is repeatedly required from older people during their lives. For example, a farmer hands over their farm to a child or another family member and withdraws from their leading position. The farmer may remain available to do odd jobs but should not interfere with the successor's way of management. Everyone praises the farmer for this act of making room. The same thing happens in countless other businesses, institutions, and family settings. Asking for euthanasia because one's life feels complete could be seen as a logical and final step in this process of withdrawal.
Such withdrawal is a laudable principle, especially with respect to other issues that are at play in today's debates about the older generation's legacy (e.g., the rising costs of pensions and care institutions, the responsibility for climate change and the environment). 'Completing life' should be more than a sense of 'I have accomplished what I had to do.' It should also include a feeling of 'I won't stand in the way of the next generation.' Many contemporary Western societies are already at their breaking point due to the care and support that the working generation is supposed to deliver to its elders (cf. Foner 1993; Salazar 2017) -with some researchers even speaking of an ideology of 'apocalyptic demography' (Gee, Thomas, and Gutman 2000). Falling birth-rates in countries such as Japan, Canada, Italy, and South Korea are leading to an imbalance between available caregivers and care-receivers. In Italy (among other southern European countries), families have started to employ informal caregivers from lowincome countries to take care of their older relatives (Da Roit 2007).
In Ghana, where older people are respected and typically cared for until death, there is also a growing belief that they should not go on living longer and longer at the expense of the young. When young people die and the old refuse to die, suspicions and accusations may arise that the old are witches who are reversing the normal course of life. As we have described in earlier work, these elders may be considered to be selfish evil people who destroy others to increase life for themselves (van der Geest 2002). The end-of-life discussions in Dutch society may contain different terms and metaphors but, in some ways, they resemble the Ghanaian reaction. There is a certain egoism in the desire to live long and burden others with the practical and emotional consequences of that desire. Even when children assure their parents that they want them to 'stay' and that they are not at all a burden, we must realise that such words are not only terms of endearment but also a performance of respect. Contexts differ greatly, but it would be naïve to simply assume that the continuing care and attention that older people expect (or demand) from the young is not a burden that may eventually break up the younger generation. The expression said by some older people -"I don't want to be a burden to my children" (or to society as a whole, we could add) -should be taken seriously and be understood in its specific context.
Another expression that older Dutch people sometimes say is: "I want to die, but I must wait until the 'Big Boss' (or 'the Lord') calls me." This expression brings us to religion as a mitigating factor that affects views and decisions regarding completed life euthanasia. There is a widespread assumption in the Netherlands that religious views prevent older people from voluntarily asking for euthanasia. Some people view euthanasia as not only forbidden but also unnecessary, e.g., "The Lord will take care of me; He will reward me for the suffering I go through." Completed life euthanasia, in particular, is believed to be far less acceptable to religious people than to non-believers (CIP 2019). However, religious worldviews seem to be becoming more fluid, leading to a blurred distinction between so-called religious and non-religious thoughts (cf. Fortuin, Schilderman, and Venbrux 2019). The term 'spirituality,' which embraces a wider spectrum of creeds including religious as well as humanistic ideas and nature-linked cosmologies, is also increasingly being used. Among the older Dutch adults who asserted that they should be allowed to determine for themselves if and when to receive euthanasia, research indicated that they were almost as 'religious' as others who held the opposite view (Fortuin, Schilderman, and Venbrux 2019).
How can we understand this finding? First of all, the tenets of some Christian churches are often less 'strict' than is commonly believed. Some churches, for example, may state that discontinuing lifeprolonging treatment, "is not only permitted, but might in fact even be required as an element of proper care and compassion for a seriously, irrevocably, or terminally ill patient" (Fortuin, Schilderman, and Venbrux 2019, 2-3). But, as we mentioned before, completed life euthanasia is not considered acceptable according to official declarations by many church authorities (although individual priests/ministers and church members may take a different view).
Second, if there is rationality in faith -and we believe there is (cf. Evans-Pritchard 1937) -then why should believing in a godlike creator oblige people to continue to live when they have decided that they have finished what they had to do? Why should the 'sanctity of life,' a term often used by religious authorities and ethicists (Kelly, Magill, and ten Have 2013), or 'respect for life,' a term popular among both religious believers and medical professionals, lead to the disapproval of completed life euthanasia? Why should continuing to live until 'the bitter end' be considered meaningful, while wishing to die signals a loss of meaning?
From the viewpoint of generativity, as we discussed above, it makes sense for a person to choose death if they believe their life no longer has any meaning. This sense-making is, however, double-edged. For the person making the choice, it may entail ending feelings of physical and existential fatigue, being superfluous, unneeded, and lonely. But it also implies making room for the next generation, which is the ultimate act of generativity. In a personal communication, a Catholic brother wrote to one of us, saying that he believed . . . that the world would be richer if weak [older] people are willing to make room for those who come after them. . . . Accepting suffering without complaining and thus adding a deeper value to life deserves our respect. But giving your life for others to live deserves our respect as well.
Interestingly, "giving your life for others to live" is perhaps the most Christian phrase one can imagine, as it refers to Jesus Christ giving his life for the goodness ('salvation') of humanity. In this way, the Catholic brother used one of the most fundamental ideas of the Christian faith to defend completed life euthanasia. This illustrates that acceptance of and support for the idea of euthanasia on the basis of a completed life experience may be found among highly devout people and is thus not exclusive to a secularised society.

Conclusion
This essay attempts to examine the wish for completed life euthanasia from the perspective of generativity. Namely, ending one's own life is a contribution to continuing the life of the next generation. We suggest that at a certain age, an individual may feel that their life has lost its meaning, but that this awareness is a meaningful and valuable insight in and of itself. This loss of meaning may be combined with an experience of loneliness as well as the fear of impending dependence and a slow, unpleasant, and undignified death. But such feelings do not detract from the significance of a person's realisation that generativity has stopped. It connects to reflections on why one should go on living and continue to consume personal, familial, and (perhaps scant) social resources when one could make space for others. Of course, not all older people think this way. However, if a small minority do, then this should not be trivialised and pathologised (cf. Richards 2017). Their intentions or thoughts about future generations and the realisation that their life may have become less meaningful due to decreasing generativity should be included in debates on completed life euthanasia.
We are aware that this perspective was rarely explicit in the quotations of those who explained their support for completed life euthanasia. Most of our interlocutors conveyed a strong opposition to prolonged living and drawn-out dying and pleaded for the possibility of a dignified death. As we have emphasised, however, these statements cannot be regarded as clear-cut predictions of what these people will actually decide when they approach the end of their lives -and we did not intend to suggest such a thing. Studies about the end of life have found that prospects and decisions may change as health worsens (e.g., Schwartz et al. 2004). When this happens, paradoxically, continuing life may be seen as preferable to death.
The quotations from our interlocutors were used as typical examples of the debate that is taking place in Dutch society about the idea of completed life euthanasia. The purpose of this essay was to explore a deeper dimension of the concept of 'completed life' by using generativity as a heuristic tool. The idea of (failing) generativity is certainly implied in the expression that some older people use when they pronounce that they do not want to be a 'burden' to the next generation. Furthermore, we argue that a person's conviction that their life has become meaningless is a lucid and convincing -and therefore meaningful -conclusion, particularly when analysed from the point of view of (a loss of) generativity towards the end of life.

Postscript
When we were writing this essay, the COVID-19 pandemic erupted, and we hesitated to publish our views. We wondered: Would it be appropriate to defend voluntary death while thousands of people, particularly older people, were fighting to live? Arguing for a recognition of the deeper layers of generativity with respect to euthanasia could be interpreted as an implicit pressure on older people to accept death in order to make room for younger people and to unburden medical professionals. Despite these reservations, we decided to submit this essay as a contribution to discussions about how we should live face-to-face with the pandemic.
At the same time, as the public-health crisis worsened and hospital facilities in some countries threatened to collapse under the overload of COVID-19 patients, the taboo on questioning whether older people should be given prioritised hospital access and admission seemed to diminish. Some older people even raised the issue themselves, suggesting that their medical privileges should be given to younger people. A research study among general practitioners in 2,331 of the 5,020 clinical practices in the Netherlands showed that 59% of older people with COVID-19 did not want to be referred to a hospital. The survey also indicated that their reasons for that decision were a combination of the fear of being isolated in the hospital, a potentially devastating outcome of a lengthy treatment in the intensivecare unit, and the existence of an advance end-of-life declaration (Cals, Derckx, and Blanker 2020;Weeda 2020).
Our central argument in this essay has been that recognition of meaninglessness opens the door to new meanings related to growing old. These could imply accepting -or even asking for -death. Such acceptance carries a precious lesson for the younger generation -the wisdom at old age that society needs (Baars 2017, 975). Present debates in the Dutch media about who should get first access to ICUs and vaccinations during the COVID-19 pandemic tend to focus on generational issues. For example, journalist Marianne Zwagerman called the older generation "dry wood" (dor hout) during a Dutch radio program (Zwagerman 2020). The metaphor shocked many people because Zwagerman seemed to suggest that older people's time was over and that they should be left to die -in other words, COVID-19 was a scythe to remove the dry wood. She later explained that she wanted to make it clear that you cannot sacrifice the whole economy to save a few older people. The purpose of our reflection, however, has been to discuss that older people, in their wisdom and 'of their own free will,' may find it meaningful to decide for themselves if they want to make room for the next generation, thereby contributing to younger people's future well-being.