Suicide and Ethical Aspects Assisted Suicide

Contemporary exploration of the ethical issues concerning suicide and assisted suicide has focused almost exclusively on a single form of suicide: physician-assisted suicide in terminal illness. Ethical issues concerning suicide in old age, independent of illness, are rarely if ever openly Controversial assisted suicide advocate Jack Kevorkian (right) speaks at a press conference held with his attorney Geoffrey Fieger. Kevorkian, a Michigan physician, claimed to have assisted in more than 130 suicides before he was convicted of second-degree murder for assisting with the suicide of Thomas Youk, 52, who suffered from Lou Gehrig’s disease. (Archive Photos, Inc.) discussed. This entry first examines the debate over physician-assisted suicide in the public arena as a preamble to its central task, and then explores the ethical issues concerning suicide and assisted suicide in old age.

The 1970s, 1980s, and 1990s saw the emergence of what is known as the right-to-die movement, a civil-rights inspired, populist social movement dedicated to enhancing the autonomy and well-being of terminally ill patients. In the wake of Elizabeth Kübler-Ross’s 1969 book On Death and Dying, this movement encouraged open discussion of dying, full disclosure of terminal prognoses, and greater attention to psychological and social aspects of fear, pain, suffering, loss, grieving, and hope in the context of dying. This movement secured legal changes, including the passage of ‘‘natural death,’’ ‘‘living will,’’ and ‘‘durable power of attorney’’ statutes intended to protect patients from unwanted treatment by giving them the right to stipulate treatment choices and to appoint surrogate decisionmakers before incompetence at the end of life sets in. This movement also lobbied for better funding of programs and facilities for the dying, including hospice; for better education of physicians in matters of dying, especially pain control; for regulations designed to require health care facilities to respect patients’ (non)treatment choices; and for greater protections of patients’ privacy and interests in specific terminal conditions, then including AIDS.

But as it pursued these issues, the right-todie movement also raised the question of what role the physician might play in directly assisting the patient’s dying and what role the dying person might play in shaping his or her own death. Public rhetoric quickly labelled the practice at issue ‘‘physician-assisted suicide,’’ although less negatively freighted labels such as ‘‘physician aid-in-dying’’ or ‘‘physician-negotiated death’’ have also been advanced as more appropriate. The label physician-assisted suicide and its linkage with terms like self-killing ensured that the policy battles concerning both social acceptance and legalization would be fought on volatile ideological turf.

Physician-assisted suicide: The philosophical argument. Proponents of legalizing physician-assisted suicide have argued in its favor on two principal grounds: 1) autonomy, the right of a dying person to make his or her own choices about matters of deepest personal importance, including how to face dying, and 2) the right of a person to avoid pain and suffering that cannot be adequately controlled. Proponents have insisted on both principled and consequentialist grounds that physician-assisted suicide is ethically acceptable—it is in accord, they argue, with basic principles of liberty and self-determination, and by allowing a dying person to satisfy his or her own values without posing serious harms to others, it satisfies the requirements of consequentialist, utilitarian moral systems.

Opponents challenge both claims, that of autonomy and that of freedom from suffering, and offer instead two principal competing claims. They insist 1) that fundamental morality prohibits killing, including self-killing, and 2) that allowing even sympathetic cases of physician assistance in suicide would lead down the ‘‘slippery slope,’’ as overworked doctors, burdened or resentful family members, and callous institutions eager to save money would manipulate or force vulnerable patients into choices of suicide that were not really their own. Pressures would be particularly severe for patients with disabilities, even those who were not terminally ill. The result, opponents insist, would be wide-scale abuse.

Compromise efforts and response to the philosophical argument. Evaluating the philosophical argument and the various components of it has been the project of many bioethicists, theologians, social policy theorists, and others; there is little resolution, however, of the competing claims of autonomist and social-consequences views both for and against. Compromise efforts, launched by figures on both sides, have focused primarily on improving pain control, including accelerated research, broader education of physicians, rejection of outdated concerns about addiction associated with opiate drugs, and recourse to terminal sedation or induced permanent unconsciousness if all else fails. These efforts typically assume that if pain in terminal illness can be alleviated, requests for assistance in suicide will no longer arise. Compromise views also hold that assistance in suicide should remain, if available at all, a last resort in only the most recalcitrant cases.

However, although proponents welcome advances in pain control, many reject this sort of compromise. It constricts the freedom of a dying person to face death in the way he or she wants, proponents say; apparent compromises like terminal sedation are both repugnant and can be abused, since full, informed consent may not actually be sought. Proponents also object on grounds of equity: it is deeply unfair, they insist, that patients dependent on life-support technology like dialysis or a respirator can achieve a comparatively easy death at a time of their own choosing by having these supports discontinued—an action fully legal—but patients not dependent on life-supports cannot die as they wish, but must wait until the inevitable end. Many opponents reject attempts at compromise as well, sometimes arguing on religious grounds that suffering is an aspect of dying that ought to be accepted, sometimes holding that patients’ wishes for self-determination ought not override the scruples of the medical profession, and sometimes objecting to any resort at all to assisted dying, even in very rare, difficult cases. Like the social arguments over abortion, there is little current resolution of the issue of physician-assisted suicide at either the level of public ferment or at the deeper level of philosophical principle, although the raising of the issue itself has meant far greater attention to issues of terminal illness.

Suicide in old age: historical views. The currently vigorous public debate over physician-assisted suicide, however, may appear to overlap very little with concerns about suicide and assisted suicide associated with aging. The debate over physician-assisted suicide has focused virtually exclusively—at least in the United States, though not in the Netherlands—on patients who are terminally ill, usually understood as expected to die within six months. In contrast, death is not seen as imminent in the same way for older persons. All older persons eventually die, but issues about suicide in the elderly typically focus on the older person’s debility and loss of function, not nearness to death, and the public debate has not directly addressed the issue of suicide in old age for reasons of age alone. Nor has it addressed the issue of suicide in a variety of other circumstances often discussed in the historical literature, including disgrace, poverty, altruistic self-sacrifice, martyrdom, symbolic protest, and the like. Yet however veiled at the moment, the issue of suicide in old age has a rich history, both in western and nonwestern cultures.

Suicide in old age: Western views. The Greek and Roman Stoics, particularly Seneca (4 B.C.–A.D. 65), Marcus Aurelius (A.D. 121–180), and Epictetus (c. A.D. 55–c. 135), praised suicide as the act of the ‘‘wise man’’ or ideal individual, a choice that could be fully voluntary, fully rational, and wholly responsible. Although, according to Stoic thought, one should seek to make oneself immune to the buffetings of fortune and the storms of the emotions (and so be less vulnerable to the kinds of reactive pathologies that can lead to suicide), one should not assign overly great importance to mere life itself. Rather, on the Stoic view, the wise man is one who achieves the disengagement and wisdom required to end his (or her) own life at the appropriate time and for the appropriate reasons. Suicide can represent a rational choice in preference to circumstances like slavery, disgrace, or a degrading and painful death; it is seen as the ultimate act of freedom.

To end one’s life at the appropriate time and for the appropriate reasons could also mean avoiding the conditions of old age, though the Stoics did not hold that old age alone always provided reason for suicide. In his essay ‘‘On Old Age,’’ Cicero (106–43 B.C.), drawing on Stoic influences, holds a generally optimistic view of old age, but says that ‘‘the old must not grasp greedily after those last few years of life, nor must they walk out on them without cause.’’ The Stoics were particularly concerned to explore the rationality of choices about suicide and the false assumptions involved in various objections to suicide. Suicide need not cut a life short, insisted Seneca, in the same way that a journey may be cut short; the journey cut short is incomplete, but the life ended by suicide can nevertheless be complete, if it is lived well. For the Stoics, it is the quality, not the quantity of life that is important. Particularly characteristic is the Stoic sensitivity to the sense of a complete life that may be attained in old age, ended not in what they saw not as depression or withdrawal, but as actively brought to a natural conclusion. In ‘‘On Old Age,’’ Cicero continues,

it seems to me that once we have had our fill of all the things that have engaged our interest, we have had our fill of life itself. There are interests that are proper to childhood: does a full-grown man regret their loss? There are interests that belong to early manhood: when we reach full maturity—what is called ‘‘middle age’’—do we look back to them with longing? Middle age itself has its special concerns; even these have lost their attraction for the old. Finally, there are interests peculiar to old age; these fall away, too, just as did those of the earlier years. When this has happened, a sense of the fullness of life tells us that it is time to die.

Christian thought utterly rejected such arguments. It saw life and death as within the power of God to bestow; it saw a personal afterlife that could reward suffering in this life, and it made faith, not simply reason, the center of its ethic. Since life was a gift from God, to commit suicide would be to reject it, to abandon one’s duty, to give up hope, to reject God. This view was held to be constant with the acceptance—indeed, the ardent embrace—of voluntary martyrdom, which—even when it involved deliberate courting of death and the voluntary performance of actions certain to result in one’s own death—was seen as an act done for the sake of God, not against God’s will. Early Christian writers disagreed about whether a virgin might kill herself to avoid sexual violation—no, intimated Tertullian (c. 160–c. 220); yes, implied Ambrose (c. 339–397)—but by the fourth century A.D., Augustine (354–430) had articulated the position that would become universal in Christianity: suicide was a sin so severe that it could not atone for any other sin. Biblical suicides like Samson (who in pulling the temple down on the Philistines killed himself as well) and Saul (who fell on his sword to avoid capture by the enemy) were to be understood, according to Augustine, as acting under a special commission from God. There could be no justification for suicide to protect virginity, since sin did not occur when consent to sex had not been given: in the words of Augustine, ‘‘lust will not pollute, if it is another’s lust.’’ By the time of Thomas Aquinas (c. 1225–1274), the Christian opposition to suicide was universal and fundamental: to take one’s one life was a sin more grievous even than to take the life of another, and Judas’ suicide after the betrayal of Jesus could only compound his sin, not atone for it. In general, however, throughout early and medieval Christian argumentation over suicide, the issue of suicide in old age is virtually never raised. Suicide is not seen as an act justified by self-respecting reasons, and, on the Christian view, whatever sufferings old age might involve should be borne with faith.

Suicide in old age: nonwestern views. In a variety of nonwestern cultures, however, considerations of age have been central. A number of traditional, oral cultures have developed elderly suicide and senicide practices, reported with varying degrees of reliability by early explorers and ethnographers. The Eskimo, for instance, are reported to have practiced socially encouraged or enforced suicide in old age ‘‘not merely to be rid of a life that is no longer a pleasure, but also to relieve their nearest relations of the trouble they give them’’ (Rasmussen, p. 144). The early Japanese are said to have taken their elderly to a mountaintop to die, a practice typically involving consent. The Vikings took violent death to be preferable to dying in bed of illness or old age. While the Hindu practice of sati could also involve young women, wives who outlived their husbands were expected to throw themselves on his funeral pyre, an expectation that particularly affected older women. Various migratory American Indian tribes abandoned their infirm members by the side of the trail, and among the Natchez of the lower Mississippi, an act like sati was practiced: when an individual belonging to the ruling group died, the widow or widower and other chosen family members would allow themselves to be strangled. And in traditional Melanesian cultures, especially in Fiji, aged parents were said to have felt a sense of duty to have themselves killed. Many other nonwestern cultures have had practices that permitted, encouraged, or required suicide of aged persons.

Suicide: twentieth century and contemporary views. In the late nineteenth and early twentieth centuries, suicide came to be seen as a function of social organization—this was the sociologist Émile Durkheim’s contribution—and of psychopathology, the contribution of Etienne Esquirol, Sigmund Freud, and many others. Suicide was increasingly seen as a socially controlled, typically reactive, pathological act, something always to be prevented if possible. Epidemiologists explored suicide rates; the law developed policies permitting involuntary hospitalization and treatment for those who were a ‘‘danger to themselves’’; psychiatry and medicine explored discursive and pharmacological ways of reducing suicidality. Efforts have focused on explaining trends in rates of suicide, including differences in male and female rates of suicide, differences in rates of suicide in different countries and cultures, and differences in the incidence of suicide and attempted suicide associated with such factors as age, alcohol use, religiosity, flexibility of coping skills, willingness to seek professional help, social support systems, use of lethal means, and failure in primary adult roles like economic success and relationship-building. Demographic findings became increasingly important, including such findings as male suicide rates increase with age; suicide rates are highest in men over seventy-five—higher than for women at any age, and higher than for male adolescents or middle-aged adult males. But although elder suicide rates are high, suicide-prevention efforts have tended to focus on the politically more appealing category of adolescents—a category that does not raise issues about the ethical acceptability of suicide. Elderly suicide is less frequently the focus of suicide-prevention efforts, and ethical issues surrounding suicide in old age, for reasons of old age, are rarely raised.

Suicide and old age: contemporary ethical issues. In general, in both historical argumentation and the very small amount of contemporary theorizing about suicide in old age, two distinct sets of reasons for suicide, are at issue, though in practice they are often intertwined:

1. Reasons of self-interest: suicide in order to avoid the sufferings, physical limitations, loss of social roles, and stigma of old age;
2. Other-regarding reasons: suicide in order to avoid becoming a burden to others, including family members, caretakers, immediate social networks, or society as a whole.

Contemporary thought, at least explicitly, entertains neither of these. With regard to self-interested reasons, modern gerontology maintains a resolutely upbeat and optimistic view of old age, insisting that it is possible to ameliorate many of the traditional burdens of old age— chronic illness, isolation, poverty, depression, and chronic pain—by providing better medical care, better family and caregiver education, and more comprehensive social programs. With regard to other-regarding reasons, including altruistic reasons, contemporary views consider it unconscionable—especially in the wealthy societies of the West—to regard elderly persons as burdens to families or to social units or to the society; nor is it thought ethical to allow or encourage elderly persons to see themselves this way. While the notion that the elderly are to be venerated is associated primarily with the traditional cultures of the East, especially China, western societies also insist (though often ineffectually in a youth-oriented culture), on respect for the aged and on enhancing long lives. Simply put, the currently prevalent assumption in the West is that there can be no good reasons for suicide in old age, even though suicide is frequent in men in old age and may be associated with many different biological, psychological, cognitive, and environmental risk factors and causes.

Some contemporary thinkers and public figures have raised issues that are closely related. For example, Daniel Callahan exposes contemporary medicine’s relentless drive for indefinite extension of life, arguing that the elderly should forgo heroic life-prolonging care and refocus their attention instead on turning matters over to the next generation. Janet Adkins, who became the first suicide assisted by the pathologist Jack Kevorkian, in effect raised the issue of whether suicide might be acceptable to avoid conditions like Alzheimer’s disease. Colorado Governor Richard Lamm’s widely misquoted remark that the terminally ill elderly have a ‘‘duty to die’’ unleashed a small storm of academic and public discussion. And C. G. Prado has raised the issue of ‘‘preemptive’’ suicide in advanced age, exploring issues of declining competence and whether the mind that is beginning to deteriorate can choose to avoid further deterioration by suicide. Prado’s is the most direct contemporary approach to issues of suicide in old age, though it is occupied more with epistemological than ethical issues; there is comparatively little other discussion. Direct focus on old age, independent of illness, as a reason for suicide has simply not become part of contemporary public thinking, despite its rich tradition in the Stoic roots of the west and in the practices of a variety of primitive nonwestern societies, and despite the vastly extended life expectancies of contemporary people in advanced industrial societies. On the contrary, public policy has in general supported not only health care and social services for the elderly, but renewed research and concern for suicide prevention, assuming that it is appropriate across the board, at all ages.

Hints of real social friction can be seen, however, over both self-interested and other-regarding and altruistic reasons for suicide in old age. Having fully legalized physician-assisted suicide and voluntary active euthanasia, the Netherlands is now considering whether to honor advance directives like living wills in which a now-competent person requests physician-aided death after the onset of Alzheimer’s disease, a condition particularly frequent among the elderly. Double-exit suicides, often of married partners in advanced age, sometimes though only one is ill, raise issues about dominance and comparative submission within a domestic relationship, and joint suicides like the 2 January 2002 deaths of Admiral Chester Nimitz and his wife Joan, at 86 and 89 respectively, though clearly the choice of both, make it still more difficult to distinguish between suicide to avoid future ill health and suicide to avoid future old age in general. Disputes over generational equity in the face of rising health care costs question whether life prolongation means merely the extension of morbidity and whether health care ought to be preferentially allocated to the young rather than the old. The issue of whether a person may ethically and reasonably refuse medical treatment in order to spare health care costs to preserve an inheritance for his or her family is already beginning to be discussed; the same issue also raises the question of suicide. And issues about suicide in old age are posed by far-reaching changes in population structure, the ‘‘graying’’ of societies in Europe and the developed world: as birthrates fall and the proportion of retirees threatens to overwhelm the number of still-working younger people, could there be any obligation, as Euripides put it in The Suppliants nearly 2,500 years ago, to ‘‘leave, and die, and make way for youth’’? No party now encourages suicide for the elderly, and indeed no party even raises the issue; but the issue of suicide as a response to self-interested avoidance of the conditions of old age and to other-interested questions about social burdens of old age cannot be very far away. Drawing as they might on both Stoic and Christian roots in the West and on nonwestern practices now coming to light, the ethical disputes over suicide in old age, independent of illness, are likely to be difficult: can suicide in old age represent, as one author puts it, the last rational act of autonomous elders, or does it represent the final defeated event in that series of little tragedies that old age often involves?