Thoughts on Rational Suicide

The larger discussion of suicidal behavior has bookends—prevention of suicide on one side, rational suicide on the other. It is a discussion that has been with us for a while. Physicians, like it or not, have been drawn into this arena by the enactment in several states of laws permitting physician-assisted suicide (PAS).

Opinions within the medical community are evolving. At its Annual Meeting earlier this summer, the AMA approved the position that provisions in its Code of Medical Ethics can apply to both those in favor of or opposed to PAS (Psychiatric News). APA’s Ethics Committee has recently opined that it is unethical for a psychiatrist to participate in assisting the death of a nonterminal patient, but it has not issued any opinions on physician-assisted death in cases of terminal patients.

PAS and euthanasia occur in several European countries where the practices may be legal or where penalties against the practices are not enforced. Since 2002 Belgium has permitted this “remedy” for suffering related to psychiatric illness, including individuals with neurodevelopmental disorders and intellectual disability. Said suffering must be “unbearable or untreatable.” No hard criteria are included for arriving at this conclusion. In the July 27, 2015, BMJ Open, Lieve Thienpont and colleagues reviewed 100 consecutive applications via Belgian law for assisted suicide based on psychiatric illness; 48 were accepted, 35 carried out. Most interesting, eight of those accepted applicants rejected suicide. These patients reported that having the option gave them enough peace of mind that they chose to continue living, an extension perhaps of Friedrich Nietzsche’s famous remark that the thought of suicide gets one through many a dark night. In this study, most patients had more than one psychiatric diagnosis, and depression was the most frequent diagnosis. Given that, what should we make of certifying unbearable or untreatable symptoms of psychiatric illness? What is the definition of futility in the context of mental disorders? Anyone treating patients with severe depression has seen this dark mood descend. In the March 8, 2018, New England Journal of Medicine, Joris Vandenberghe, M.D., Ph.D., offered a thoughtful and considered opinion that declaring this state of mind permanent is a path that must be tread most carefully.

The discussion about various aspects of rational suicide is not decades old; it is eons old, and the spectrum of opinions range from “why not?” to “no way!” Albert Camus informed us, in the opening line of Myth of Sisyphus, that there is but one truly serious philosophical problem, and that is choosing suicide. Explore the issue and you will find discussions ancient and modern and culturally diverse that run the gamut: Suicide is wrong; suicide is sometimes permissible; suicide is not a moral or ethical issue; suicide is a positive response to certain conditions; suicide has intrinsic positive value. Start with Socrates and the reports of his ideas on the matter. Let the stoics weigh in. Seneca is a good source (How to Die: An Ancient Guide to the End of Life, Princeton University Press, 2018).

One might also argue that there is only one truly serious philosophical problem, and that is choosing life. Consider Montaigne and his views on life after his near-death experience (How to Live or a Life of Montaigne in One Question and 20 Attempts at an Answer, Other Press, 2010). Studies with individuals who have survived suicide attempts suggest that they immediately regret the decision—to jump from the Golden Gate Bridge, for example—and studies of advanced cancer patients who have requested assisted suicide found that they choose instead to continue on once their underlying depression or severe pain is treated.

Gear up for the debate—it’s been going on a long time.

So, what to do if called upon? First and foremost, remember that great option to “just say no.” There is no fault in declaring this to be a loaded topic about which you cannot have an objective opinion. Wise clinicians understand that premature closure on extremely high-stakes patient care decisions is dangerous and introduces risk: the direct risk to the patient and the indirect risk of making a serious and irreversible medical mistake. A second opinion should always be an option. Resist any outside forces that may be pushing you to a rushed judgment.

When you care for patients who express a desire to die, start with the imperative of looking for a spark of ambivalence. Assume that anyone you are seeing, by the very fact that you are having an encounter with that person, could be to some degree—however small—ambivalent about killing himself or herself. Evaluation, even in a situation this fraught with consequence, is potentially treatment. Look for that kernel of uncertainty; ambivalence suggests some presence of hope. Sit with people. Don’t be afraid of the patient’s pain and interior life. Be present and kind—many suicidal individuals are frightened, and they frighten others. If you can help them bear the burden of their pain and perceive that thoughts of suicide are their efforts to problem-solve their way out of their pain, you will have done much to ease their despair. Avoid as best you can yes-or-no questions. Be sure to look for underlying diagnoses or stresses that are driving the patient’s expression of suicidal thoughts. And try to nurture positive affirmation. Add that thought to your therapeutic mantra. Thoughtful but persistent optimism can be a powerful therapeutic tool. ■