Voluntary Assisted Dying for Grief: Medicalisation, a Proposed Autonomy—Only Approach, and Lessons From Prepubescent Gender Care

ABSTRACT

The recent addition of the diagnostic criteria for prolonged grief disorder has attracted criticism and concern about the undue medicalisation of grief and other existentially distressing yet normal life events. However, prolonged grief disorder currently forms the only pathway to VAD access for those suffering from extremely prolonged or unrelenting grief in the Netherlands, as this satisfies the requirement that the request must be due to a medical condition, and these criticisms of the disorder could jeopardise that access. A potential solution to this tension could be the currently debated autonomy—only approach to VAD, which circumvents issues of medicalisation by removing VAD from the medical domain. However, this approach raises other problems that require investigation in the context of grief specifically. In this article, I will first consider how VAD for grief is currently treated within Dutch VAD policy. This will involve an examination of prolonged grief disorder as a diagnosable condition, and how it relates to the general concern of undue medicalisation. Following this, I will consider possible ways in which persistence of a death wish due to grief can be established without the use of a medical diagnosis, as would be the case according to the autonomy‐only framework for VAD. Ultimately, I will borrow some guidelines from the field of prepubescent gender care as an area that shares many morally relevant features with the question of VAD for grief and propose what I will be calling the “watchful grief affirming waiting” model.

1. Introduction

The 2011 annual report of the regional euthanasia review committee in the Netherlands describes the case of a woman who was granted access to voluntary assisted dying (VAD) due to a diagnosis of Prolonged Grief Disorder [1]. The woman and her husband had been exceptionally close; they had decided that being in the company of anyone but each other was a waste of time and they had been living in self‐chosen isolation. When the woman's husband became seriously ill—and had requested VAD—she wished to die at the same time as him. This was not possible, and she outlived him. As she had expected, she reported to experience life without her husband as a constant hell, and no treatment had proven effective in mitigating her suffering. Ultimately, it was decided that her pathological inability to process her grief constituted a medical condition, that she was experiencing unbearable suffering with no prospect of improvement, and that this decision was voluntary and well‐considered. The regional euthanasia review committee categorised this case as having been carefully handled [1].

This case raises a host of fascinating questions regarding the parameters of the medical domain, concerns surrounding medicalisation, and the ethical implications of allowing access to VAD for increasingly existential reasons, such as grief. This is especially the case considering the current global trend within VAD discourse and legislation, where there is a shift away from concepts of alleviating suffering, and concepts of autonomy and self‐determination are more explicitly centred [2, 3]. More specifically, several jurisdictions, including the Netherlands and Germany, are considering adopting VAD regulatory frameworks which do not include a suffering requirement but base the validity of the VAD request entirely around concepts of autonomy [4, 5]. These developments raise urgent questions about how (usually) temporarily debilitating states such as grief intersect with autonomy‐only approaches to VAD. These are questions I will be examining here.

The first thing to say is that the focus in this article will be on legislation currently being discussed in the Netherlands, as this is in my view the furthest developed example of an autonomy‐only approach to VAD [6, 7]. Nonetheless, as mentioned, trends in VAD legislation and discourse are developing similarly elsewhere globally, and so while the focus here is on the Netherlands, the questions and concerns addressed in this article have international significance as these shifts develop and other jurisdictions come face to face with similar questions and sticking points.

In Section 1, I will consider how VAD for grief is currently treated within Dutch VAD policy. This will involve an examination of prolonged grief disorder as a response to the intuition that sometimes VAD is appropriate for grief, while still fulfilling the legal requirement that the suffering in question must be based in a medical condition. In Section 2, I will put forward some concerns regarding prolonged grief disorder as a diagnosis being an example of undue and potentially harmful medicalisation. Following this, I will argue that the autonomy‐only approach to VAD in many ways circumvents these issues by removing VAD from the medical domain. However, this leaves the problem of how to adequately establish whether a request based on grief can be described as persistent, which is a requirement in the proposed Dutch VAD legislation. Finally, in Section 3, I will borrow some guidelines from the field of prepubescent gender care as an area that shares many morally relevant features with the question of VAD for grief and propose what I will be calling the “watchful grief‐affirming waiting” model.

2. ‘Normal’ Grief

Before delving into a closer examination of prolonged grief disorder as a condition and my concerns about medicalisation, I want to clarify how I will be understanding grief for the purposes of this article, as there is a fascinating and ongoing body of literature considering what constitutes grief exactly. While there is certainly an emotional contingent to grief in the sense that grief is frequently characterised as a range of emotions, such as sadness, anger, anxiety, and so forth, contributors have pointed out issues with categorising grief purely as an emotion. For example, the very fact that grief usually involves a whole host of wide‐ranging emotions that are varyingly dominant at different times complicates matters in this regard. Furthermore, grief is almost by necessity much more long‐term than emotions tend to be [8, 9, 10, 11, 12, 13].

For the purposes of this article, I will be taking a similar approach to Michael Cholbi and Peter Goldie in viewing grief primarily as a process [8, 14, 15, 16]. Cholbi's (very appealing) account makes use of Korsgaard's concept of ‘practical identity’ [17]. Korsgaard defines practical identity as a description of oneself under which one values oneself and finds life worthwhile. Examples of practical identity can be to identify as a woman, a philosopher, a country music fan, a vegan, or ‘Jamie's partner’. Ratcliffe proposes to slightly widen the scope with the inclusion of ‘being the kind of person who does x’, meaning that aspects of one's practical identity may not always be immediately evident or explicitly conceptualised until one is forced to confront them in the wake of certain life events [13].

Cholbi essentially describes grief as being caused by the loss of something that one has invested part of her practical identity into. When that thing is lost, part of one's identity is in a way dislodged or disrupted. Grief is the process of recalibrating and re‐establishing one's identity—and with it, one's relationship with the world—after this identity‐affirming thing has been lost [14, 15]. This account sufficiently explains several factors about grief as a phenomenon. Firstly, it accounts for how it is possible that one might grieve a wide range of losses, from the death of a partner to the end of a political regime, as these are all things one may have invested part of their practical identity into. It also explains the wide range of emotions involved in the grief process, including sadness and anger, but also anxiety, disorientation and a sudden sense of all‐encompassing meaninglessness.

Some contributors have characterised grief as a transformative experience [10, 18, 19], which I view to be not only consistent with, but very helpfully complementary to Cholbi's account outlined above. A transformative experience is an experience that is epistemically informative in two ways. Firstly, the experience teaches the individual what it is like to have the experience; there is no amount of imagining, hypothesising or rational deliberation that can allow the individual to know what the experience is like until one goes through it. Secondly, transformative experiences teach the individual something about herself and how she relates to the world around her, something she could not have known otherwise [10]. Examples of transformative experiences are becoming a parent or embarking on a certain career.

Grief is a transformative experience in the sense that one cannot fully appreciate what grief is like until one goes through it, and it also transforms—and informs—the individual's relationship with the world. The loss of something that held some significance in terms of one's practical identity can change a person's lifeworld in numerous and infinitely indirect ways, affecting projects and areas of one's life that seemingly have nothing to do with what has been lost.

Matey explains this transformation through the distinction between focal and tacit awareness. Focal awareness is something one is actively and consciously aware of, while tacit awareness constitutes the backdrop or context for what one is focally aware of [18]. For example, if I am standing by my window, my focal awareness may be on the beautiful old oak tree in my garden that I so enjoy gazing at. However, at the same time, I am tacitly aware of the colour of the grass, of the wind in the leaves, of the heat on my palm that is radiating from the mug of tea I am holding, of the warmth of the sun coming through the window, etc. Grief has the potential to cause a shift in one's tacit awareness, to affect one's background so that things that were once the object of one's focal awareness no longer matter, or perhaps no longer matter in the same way [18].

Markovic describes this aspect of grief as a phenomenological transformation; it disrupts the taken‐for‐granted background of one's lived experience [10]. My experience of gazing at the old oak tree would be rendered significantly less enjoyable or perhaps even impossible if I suddenly became too unwell to leave my bed, or if I went blind, or if a tsunami ravaged my garden, or if I was evicted. These were all phenomenological conditions I was unaware of as necessary until they were disrupted. Ratcliffe develops this further to put forward an account of grief as ‘two‐sided’; grief is specifically and intentionally directed, while at the same time enveloping how we experience the world generally. The feelings and judgments experienced during grief are directed specifically at the thing that has been lost, while at the same affecting and implicating our relationship with how we interact with and in the world [13].

Interestingly, Cholbi's account of grief as a process has a perhaps surprisingly optimistic upshot. While those still in the throes of shock and disorientation caused by recent loss have reported a ubiquitous sense of meaninglessness, emptiness, of their entire world being shattered, Cholbi argues that the process of grief can in fact serve as an opportunity to restore and maybe even discover additional meaning in life. He refers to grief as an ‘emotional data dump’, the complexity of which will inevitably mirror the complexity of the relationship with the thing that has been lost, that has the potential to reveal a great deal about why the lost object was perceived as meaningful, how that ties into matters of identity, and how those goals, values, and norms can still be achieved and respected now that this object has been lost [14, 15].

This is closely related to the various ways in which Markovic views grief to be a transformative experience. Similarly to Cholbi, she argues that grief has the potential to teach the individual something about the normative values and frameworks she holds dear, and which make her life worthwhile and her actions worth undertaking. Additionally, though, she argues that grief can be existentially transformative in the sense that losing something very important can remind the individual of the finitude of things and thereby of their own mortality. This, too, has the potential to cause an individual to more urgently and seriously prioritise things and ensure she is living up to her own standards and ideals [10]. Returning to my earlier discussion of focal and tacit awareness, Matey explains this new‐found source of meaning that was already there but not explicitly noticed until now by loss and subsequent grief having the ability to shift objects of tacit awareness into one's focal awareness through their sudden absence, placing the meaning provided in unprecedently stark contrast [18].

An example might be helpful in explaining how grief can be both a destructive and a constructive force in terms of meaning in life. The 2023 film The Iron Claw tells the true story of the Von Erich brothers and their existence in the highly competitive and larger than life world of wrestling. Over the course of the film, Kevin Von Erich—played by Zac Efron—loses each of his three brothers until he is the only surviving Von Erich son. Towards the end of the film, he is sitting in the yard of his home, melancholy and tearful. His young sons run up to him and ask why he seems so sad. He tells them that he used to be a brother, but that he is not anymore. His children try to cheer him up by suggesting that perhaps they could be his brothers. Kevin seems to accept this on a level beyond just placating his children and making them feel better; he seems to genuinely be comforted and touched by this thought. He runs after his sons and joins the game of football they were playing, an activity him and his brothers used to enjoy together.

My suggestion here is that what Kevin is saying to his children in this scene is that being someone's brother was an important part of his practical identity, that this has been irretrievably lost, and that this loss has distorted his identity and phenomenology in a way that has robbed him of something that used to be a source of meaning. However, in grieving his brothers, Kevin was able to discover a profound and deeply felt normative commitment to values surrounding family. That if his brothers were still alive, he would want to spend as much time with them as possible and create a situation in which the entire family lived in a large house together. This later informed his choice not only to have children, but to indeed live in a very large house with his entire extended family (him, his wife Pam, their four children, and thirteen grandchildren). Grieving his brothers provided him with a transformative experience that moved something of normative significance from his tacit awareness into his focal awareness, allowing him to act in a way he perceived to meaningful and worthwhile, respecting his core values around being family‐focused in ways other than brotherhood. In a sense, his children did become his brothers, or at least ended up playing a similar role in his life.

This is how I will understand normal grief for the purposes of this article. In my view, grief constitutes a transformative experience caused by the loss of something deeply existentially meaningful on account of the individual having identified with it in a way that she deemed valuable and to make her life worthwhile in some way. Grief itself is the process of not only coming to terms with that loss, but using the newly gained epistemic information in such a way to allow the individual to recalibrate her identity and her transformed relationship with the world which she inhabits.

Ratcliffe argues that while grief can be caused by a broad range of things, there is something particular and uniquely affecting about the bereavement of a close interpersonal relationship [13]. While I do not disagree, the purposes of this article are in my view sufficiently served by a broader understanding in which grief can be caused by a wide range of things, examples of which include a relationship, employment, enjoyable activities, and a formerly strong but waning sense of identity—grief for the person one used to be.

3. Prolonged Grief Disorder

While in the vast majority of cases grief does subside and the individual is able to adapt to their new phenomenology without the object that has been lost, or at least, in which the relationship with it has changed [20], the optimistic final stage of the process that Cholbi and Matey refer to is not always reached. In some cases, the individual is never able to adapt and in some ways becomes stuck in the grieving process.

In his work on grief, Freud [21] drew a distinction between mourning and melancholia. He theorised that mourning referred to the typical or normal trajectory of processing loss, and that melancholia represented some kind of disturbance in this trajectory [21]. While the specifics have become more detailed and sophisticated, Freud's distinction ultimately developed into what is now known as prolonged grief disorder.

From clinical experience, several psychiatry and bereavement scholars noticed that patients and bereaved people were sometimes unable to perform the tasks necessary for the normal process of grieving to proceed [22]. As opposed to ‘normal’ grief, the DSM‐V provides diagnostic criteria for when grieving has become disordered or pathological, and the individual is unable to undertake the tasks necessary for processing their loss [23]. This condition is closely related to a trauma response where the individual feels extreme reluctance to engage with memories of what has been lost at all. This avoidance of anything related to the loss hinders the trajectory towards acceptance and essentially means that the patient becomes stuck in their grief [24]. To meet the criteria of prolonged grief disorder, an individual must be experiencing at least three of the following eight symptoms at least 1 year after the loss: identity disruption, disbelief about the loss, avoidance of reminders that the person is dead (or that the source of life meaning is lost), intense emotional pain related to the loss, difficulty with reintegration into life after the loss, emotional numbness as a result of the loss, feeling that life is meaningless as a result of the loss, and intense loneliness as a result of the loss [22, 23].

The inclusion of prolonged grief disorder as a diagnosis is a recent development; the condition was added in 2020 following in‐depth international testing and a public response period. Prigerson et al. provide a detailed account of the process of adding prolonged grief disorder to the DSM‐V [22]. While disordered or pathological grieving has been known for some time to mental health professionals as a possibility and a phenomenon that requires specific treatment, there are several reasons for why the condition was only acknowledged so recently by the DSM‐V, two of which are important to note here.

The first is that there was difficulty in reaching a consensus in terms of diagnostic criteria [22]. Not only had different expert work groups discovered different findings regarding indicators of prolonged grief disorder, but it was also necessary to demonstrate that this condition was sufficiently different from other disorders to merit its own entry in the manual. The second reason came mostly from the general public in the form of concern about the undue medicalisation of grief [25, 26, 27].

The authors do not elaborate on why exactly such lengths were gone to in order for prolonged grief disorder to be included in the new edition of the DSM ¹ , but an important effect of this development is that, at least in the Netherlands, grief would now constitute a valid reason to request VAD, as it is formally recognised as a medically diagnosable condition that has the potential to cause unbearable and unrelenting suffering [28]. At the same time, as illustrated by the public response to the addition of this disorder to the DSM‐V, there are severe concerns that grief is being medicalised, that a normal response to the existential ups and downs inherent to living a meaningful and interpersonally connected life is being unduly pathologized.

This concern is extensively discussed by van Wijngaarden et al. [29] In their article, the authors discuss the risks of taking an exclusively medical‐psychopathological approach to grief and other existentially meaningful or transformative life events. Their first concern is that viewing grief only through this lens will risk the medical field in some ways overstepping their area of expertise and will result in normal (albeit unpleasant or painful) aspects of life becoming pathologized in a way that is inaccurate and unreflective of the realities of life, even if a diagnosis can sometimes feel reaffirming [30]. The authors' second concern is that this approach can be overly reductive and can miss out important parts of the situation [29]. The authors argue that taking exclusively a medical‐psychopathological approach may result in the erasure of the griever's surrounding lifeworld and context, which is essential for the proper understanding of grief [31, 32, 33, 34, 35, 36]. Thirdly, the authors suggest that the medicalisation of grief may run the risk of detaching the phenomenon from its cultural and historical context. Existential life events do not happen in a vacuum, they happen in social and cultural environments [29]. The authors worry that taking an exclusively medical‐psychopathological lens, as opposed to including a broader phenomenological lens, may pay insufficient attention to the embeddedness and situatedness of such an event.

In addition to this threefold critique, I have a further concern about the medicalisation of grief. Offering a diagnosis of prolonged grief disorder according to a set of criteria that has been explicitly tested to remain constant regardless of the nature of what has been lost seems to obscure an integral element of grief as a potentially transformative existential event. By concluding that an inability to adapt to one's new reality for more than a year after the loss must necessarily be an indication of disorder within the individual, an important possibility is precluded—the possibility that what was lost was of such foundational importance to the individual's life meaning that their new reality is not perceived as worth adapting to. It is possible that Cholbi's optimistic endpoint can never be reached, because the object that has been lost was so integral to the individual's life meaning that meaning cannot be regained in other ways.

These concerns about prolonged grief disorder constituting unjustifiable and potentially damaging medicalisation of existential suffering and transformation have potential implications for the availability of VAD for complex or extended grief. As mentioned earlier, prolonged grief disorder as a diagnosis is the only pathway to being granted VAD for grief in the Netherlands, due to the requirement that the individual's suffering must be rooted in a medical condition [28]. It seems like there is at least an intuitive appeal to offering VAD for complex or particularly severe grief among practitioners, given the multiple instances where this has been performed by using the prolonged grief disorder pathway, as in the case study mentioned at the beginning of this article. The criticisms of prolonged grief disorder discussed above could jeopardise access to VAD for people who are suffering unbearably and living a life they consider to be not worth living, despite not necessarily suffering from a severe medical condition.

A potential solution to this tension is a new approach to VAD legislation and practice currently being deliberated in the Netherlands. What has become known as the completed life proposal would allow access to VAD for people who are not severely ill [6, 7]. This is one of the first real‐world examples of an autonomy‐only approach to VAD; the due care criteria would no longer include a requirement that the person is experiencing unbearable and hopeless suffering on account of a medical condition. Rather, in addition to other safeguard criteria that are fairly similar to what is enforced currently, the request would only need to be well‐considered, voluntary and persistent [6, 7]. This approach would presumably significantly broaden the scope of reasons that would render an individual eligible for receiving assistance in dying, including existential reasons such as grief. In this sense, adopting an autonomy‐only approach would allow access to VAD for those experiencing long‐term and debilitating grief without having to medicalise it in a way that misrepresents or misunderstands the phenomenon in a way that could be reductive and damaging.

However, while this approach would allow access to VAD for those who potentially need it (and for which there seems to be an intuitive appeal among at least some practitioners) while circumventing problems of medicalisation, it does raise a different problem. In most cases, grief does subside over time and usually the griever is able to return to a life that they consider to be worthwhile (according to the process outlined by Cholbi discussed earlier). This significantly complicates the requirement that the request must be persistent; this is something that will be difficult to establish in the case of grief without simply making the griever wait for a long time to see if there has been any sign of diminishment. Simply waiting for improvement and only offering support if there is no sign of it is intrinsically nonideal, as it forces the griever to go through a mandatory period of suffering or at least living a life they do not consider worth living until they can access support, but additionally, it immediately confronts us with the ethically murky task of establishing what is an appropriate timeframe to expect improvement (the very issue faced by the work group in the development of the diagnostic criteria for prolonged grief disorder). Given the extreme variability of grief responses depending on the griever and on the object that has been lost, there is a risk of imposing a restrictively rigid framework on something radically subjective.

In the next section, I will propose a possible way of establishing the persistence of a grief‐based VAD request under the autonomy‐only approach that could to some extent circumvent these issues. I will be using an analogy with offering gender care to prepubescent children to illustrate what I view to be the merits of what I will be calling ‘Watchful grief affirming waiting’.

4. Identifying Persistent Grief

In the medicalised model of grief, being diagnosed with PGD is the only pathway to being eligible for VAD [28]. A grieving individual must be experiencing severe and intense grieving symptoms for over a year, following a lengthy trajectory in which treatment options must be exhausted before VAD deliberations can begin [1]. As outlined above, while the autonomy‐only approach avoids issues surrounding medicalisation, this approach runs the risk of similarly forcing the griever to go through long waiting period before support can be accessed due to the persistence requirement. In this section, I will consider how a VAD request driven by grief can be identified as persistent in a non‐medicalised way that is more continually supportive than simply waiting at least a year before discussions can even begin.

Because non‐medicalised pathways to VAD for grief are not currently permitted, there is very limited research and literature on possible guidelines for such practices. For this reason, I am borrowing some lessons learned from the field of gender care for prepubescent children. Initially this may seem unintuitive, but the two fields share many morally relevant areas of overlap. In both cases, there is a reluctance towards treatment due to the risk of distress symptoms subsiding or desisting later. Gender care also has a history of medicalisation and pathologizing variation from a norm [37], where differences in gender expression is now widely acknowledged to constitute normal variation from gender expectations and [38, 39]. Gender is seen as a subjective and variable experience that may have many expressions [37, 40, 41, 42]. A similar case could be made for the experience of grief; variation from the norm should for this reason not automatically be interpreted as pathological. Given that the field of gender care is much further developed in terms of research and guidelines, it is a helpful place to start in terms of approaches that may also be suitable for people experiencing debilitating grief.

In the field of gender care for children, there have been three mainstream approaches to nontraditional gender expressions in prepubescent children; ‘living in your own skin’, watchful waiting, and gender affirming care [37]. I will briefly describe each approach. Then I will expand on how each of these models are relevant to how grief is currently treated, and possible next steps for considering access to VAD for persistent grief.

The ‘living in your own skin’ model is essentially viewing variations in gender identity through a medical‐pathological lens [38, 39]. Variable expressions are discouraged, and efforts are made to steer the child back to traditional gender expectations. The rationale is that during this formative time in a child's development, nontraditional expressions of gender are indicative of a burgeoning pathology, and efforts should be made to curtail the effects of this while the child is still malleable [43]. However, if the ‘symptoms’ persist, or if the child is too old when they start displaying them, that period of increased malleability is over, and this is no longer a viable pathway. In this case, other treatment options can be considered, such as social transitioning or even hormonal treatment plans [37]. A less generous way of describing this model is as a descendant of conversion therapy, which is a highly problematic and consistently ineffective treatment usually applied to homosexuality [44].

In response to this contested approach, the watchful waiting model was developed. This was based on the Groningen protocol and so is sometimes also referred to as the Dutch model [37]. According to this model, the child's gender behaviour is not necessarily pathologized, nor is it discouraged. Instead, the emphasis is on the potential lack of persistence of the gender confusion experienced by the child, on the possibility that these behaviours might desist after pubescence and into adulthood [45, 46]. In short, while the child is not necessarily discouraged from expressing their gender identity in a way that they feel comfortable with, no options for transitioning are offered until adolescence due to the risk of feelings of gender confusion desisting later.

Although this approach is generally viewed as an improvement upon the ‘living in your own skin’ model, as it makes more of an effort to respect the child's well‐being and burgeoning sense of autonomy, it has still been criticised for implicitly considering the possible subsiding of nontraditional gender expressions as the preferable option [37]. While it does not overtly pathologize the phenomenon, it has been argued that not offering any form of transition support until adolescence implies that it would be more desirable if the child could eventually adapt to the expectations set of the gender that they were born with, without needing any gender affirming interventions [47].

This finally brings us to the gender affirming care model, which is currently endorsed by the AAP [48]. In this approach, it is explicitly acknowledged that variations in gender behaviour are normal and should not be ‘cured’ or discouraged [37, 49]. Child and family are offered continual support from a gender care professional while the child's gender identity naturally unfolds. However, as opposed to the watchful waiting approach, the gender affirmative care model does endorse offering the child support and guidance on social transitioning and reversible hormonal treatments, such as puberty blockers [37, 41, 42, 50]. The emphasis in this approach is on allowing the child to explore their own gender identity while keeping all possible options open [51].

In terms of VAD for grief, the approach currently sits somewhere in between ‘living in your own skin’ and watchful waiting. It is expected that the individual's grief will manifest and express itself in a certain way, and when that is not the case, pathology is identified through the diagnosis of PGD [22, 24]. The goal is to mitigate or reduce symptoms through psycho‐medical treatments, such as CBT or anti‐depressive medication. Once symptoms persist for a certain length of time, or if treatments prove to be ineffective, only then can VAD deliberations begin. Not only does this approach force the individual to continue living with significant existential distress without adequate forms of support, but it also reduces the complex interplay of identity and environment to a pathology within the individual. By pathologizing the individual's experience in this way, it implicitly condemns the experience as invalid, disordered, or wrong, leaving no scope for the nuanced act of listening to the individual's experience and disrupted lifeworld.

While the issues of VAD for grief and gender care for prepubescent children share several morally relevant aspects, there are also some factors that make the two importantly different. The primary difference is that the treatments considered for prepubescent children are exclusively of a reversible nature, while VAD is possibly the most irreversible treatment option of all. A core aspect of gender affirming care is that all possible options for identity expression are left open until adolescence. This aspect is mutually exclusive with allowing access to VAD; death is the ultimate closer of all options. This is something that must be considered when thinking about the most appropriate approach to VAD for grief.

The second major difference is that the vast majority of people experiencing grief do eventually adjust to their new lifeworld; the percentage of grievers who go on to experience complicated grief is very small [52, 53, 54, 55]. The chances of subsistence in this way are much more contested in the context of children experiencing gender distress [37].

These differences (the inherent irreversibility of VAD and the fact that most grievers are eventually able to return to an enjoyable life) mean that an unrestricted autonomy‐only approach without additional safeguards may not be entirely appropriate for this population. The question now becomes how an autonomy‐only approach can be applied in a way that is mindful of the needs of people experiencing grief, without simply enforcing a burdensome waiting period (as is currently effectually the case).

My proposal is something in between watchful waiting and gender (or grief) affirming care. ‘Watchful grief affirming waiting’ could constitute a framework where the griever is provided with continual support while they navigate the subsequent stages of their grief. The emphasis will be on allowing the griever to navigate their new reality in a way that feels authentic to them, without necessarily attempting to mitigate or reduce grief symptoms. In this way, it will naturally become apparent if adjusting to a life that does not include what has been lost is something that the griever is interested in once the initial shock has subsided. Given that a prolonged supportive relationship is already in place, it will also not come as a surprise if the griever does decide to request VAD, and so deliberations do not need to start from scratch as the professional who will lead the consultations as well as perform the VAD procedure already has in‐depth knowledge of the griever's context and situation. In contrast to the medical‐psychopathological model, the objective is not to wait a certain amount of time to confirm the persistence of symptoms, after which point treatment is deemed necessary and appropriate; support is provided continually, and the passing of time is a by‐product of listening as an ongoing process.

A practical limitation of this approach is of course resource allocation. Grief will almost inevitably be a part of every life, and it would be impractical and unrealistic to assign a supportive professional to every single person who is experiencing grief of any kind (not just the dying of a loved one, but potentially the ending of a relationship, the passing away of a family pet, termination of employment, etc.). However, this limitation has two possible solutions.

The first is that to a certain degree, people with particularly intense or debilitating grief experiences will likely self‐identify and present themselves for more comprehensive support on their own initiative. To continue the analogy with gender care for prepubescent children, it is unlikely that children who are not experiencing any gender‐related distress will show up to a gender clinic. For many children experiencing this kind of identity confusion, their parents will notice the manifestations or expressions of this development and ideally take the initiative to consult a gender care clinic.

Naturally, this will only cover a part of the population most at risk of persistent or complicated grief. It has been found that expressions of grief are variable according to gender and ethnicity, with women and white people typically showing more noticeable grief symptoms [54]. This is not necessarily to say that other demographics experience less or less intense grief, but rather that women and white people are more outwardly explicit about their grief experience. This means there are certain groups that may not take the initiative to seek more comprehensive grief support, even if it may be required. To mitigate this possible issue, additional support could be offered to those who are identified as most at risk. There is comprehensive and robust data available of risk factors associated with the likelihood of individuals experienced persistent or complicated grief, although it should be noted that this study centres around grief caused by death of a loved one. For example, spouse and child deaths are especially indicative of complicated grief, especially when the death happens when the griever is young or middle‐aged as opposed to elderly [52, 53, 55, 56, 57] ¹ . Furthermore, the circumstances of the death are significantly associated with grief outcomes; complicated grief is more likely when the death was sudden or unexpected. These are useful indicators in terms of identifying individuals who may be at risk of experiencing difficulty in adjusting to their new lifeworld. These at‐risk individuals can be offered additional support within the ‘watchful grief affirming waiting’ model.

5. Conclusion

In this article, I have considered the possibility of allowing access to VAD for persistent grief. I have critically engaged with the medical‐psychopathological model taken now, in which the individual may be diagnosed with prolonged grief disorder if grief symptoms persist with undiminished intensity for over a year. Following diagnosis, if treatment proves to be ineffective, VAD deliberations can begin if this is something the individual is interested in and has consistently been vocal about. I expressed some concerns about this way of approaching grief as a phenomenon. Adopting an autonomy‐only approach to VAD could be a way forward that reaches similar outcomes to the current medicalised model while circumventing issues surrounding medicalisation. However, this approach raises the issue in establishing whether a VAD request driven by grief is persistent. To address this, I borrowed some approaches from the field of prepubescent gender care as a guide for how to manage caring for a phenomenon that may dissipate over time but also may not and has the potential to cause a great deal of distress if left unsupported. Although the gender affirming care model is the one that is most widely endorsed currently within the field of gender care for prepubescent children, I have argued that a more restricted approach is justified in the context of VAD for grief, given the irreversibility of VAD and also the fact that grief does largely diminish with time in the majority of cases. I have argued that adopting ‘watchful grief affirming waiting’ model will provide an adequate way of assisting people requesting VAD for grief within an autonomy‐only framework. This will offer these individuals continual support, while assessing the persistence of their request in a way that avoids problematically long waiting periods for these individuals.

Conflicts of Interest

The author declares no conflicts of interest.