A Consideration of Rational Suicide

Let me say at the outset that I have no argument with the general view that the prevention of suicide is an admirable aim. However I would argue that it is not an absolute, because in some circumstances it is a rational act and should not be interfered with.

The general perception of suicide is of an irrational act, carried out or attempted during a period of extreme emotional and psychological distress due to circumstances which are overwhelming at the time, but with care and time may recede and disappear, allowing the resumption of normal life. There are also those with specific psychotic diagnoses who require intensive and ongoing psychiatric care because of ongoing risk. Shame, guilt and fear may lead to depression which if not recognized and counseled may lead to a suicide attempt. In most of these situations, there are circumstances which can be changed and a new view of life emerge. Looking back, the attempt will be seen as irrational, as a cry for help.

There are other situations where the circumstances which lead a person to consider ending their life cannot be altered; in fact, those circumstances are predictably going to get even worse with time. During such a person's life she will have made many decision's not to do certain things because the consequences of doing them would cause them great distress, either physical, emotional, psychological or existential. Such decisions would be considered rational if they are made after careful thought and considering all the facts (even if another person of sound mind would have made a different decision). If such profoundly distressing and unalterable circumstances exist, the decision to avoid those circumstances by ending one's life (if no acceptable alternative exists) may be a rational one.

There a number of circumstances where such a decision might be considered which may be broadly categorized as follows:

1. The terminally ill with a relatively short time frame to a predictable or actual physical disaster
   
   
2. The hopelessly ill (for example profound stroke or multiple sclerosis) with no hope of recovery and the prospect of a prolonged period of distress
   
   
3. The dislocated elderly, threatened with or actually displaced to a nursing home
   
   
4. The early dementee who views the inevitable decline into full-blown dementia as the greatest disaster which could befall him
   
   
5. The chronic psychotic whose disease has resisted all attempts at cure or adequate long-term control and whose mental anguish is greater than most of us can imagine.

Apart from the physical suffering which may be involved, these situations all have common themes of loss of control of one's life, total dependence, loss of dignity, loss of cognition and loss of personality. These are all powerful reasons for some people to consider that under these circumstances their life has little or no value. Moreover, not only is their life a burden to themselves, but they perceive that they are a burden to their family. Many parents who have dedicated their lives to the welfare of their children cannot accept that they will be a physical, emotional or financial burden to those children, and despite those children being willing to shoulder that burden, that perception cannot be annulled.

I would like to give you three brief true clinical pictures to illustrate these categories. Firstly a 79 year old man with cerebral metastases from malignant melanoma who has become hemiplegic and is dependent in palliative care. A proud, independent and active man, he decides that a slow decline in a state of total dependence over a few months is anathema, and refuses all food and fluid and with the help of sedation dies in 3 days. Secondly, a talented artist afflicted with slowly progressive multiple sclerosis finds the remaining function in her right hand arm and hand is declining so that she will be unable to paint, and she will be faced with total dependence for some years. She requests help to end her life, and a psychiatrist found that "the only symptom related to depression from which she suffers is a wish "for it all to be over", and in the circumstances of her progressive disablement, with no hope of recovery, I regard that as an appropriate emotion." Thirdly, an 80 year old woman, widowed and living alone in her own home and tending her own garden, has failing eyesight and is threatened with placement in a nursing home. As her health is otherwise good, this condition could last for years. Having a personal knowledge of conditions in nursing homes she is appalled at this prospect and requests assistance in suicide. Each of these three suicidal ideations is to me perfectly rational. They are all based on notions of unalterable physical, emotional and existential suffering.

With regard to terminal illness, Palliative Care Australia, in its position statement on Euthanasia, states that "while pain and other symptoms can be helped, complete relief of suffering is not always possible, even with optimal care", and "some people rationally and consistently request deliberate ending of life". Shah et al reported in The Lancet in 1998 the result of a large survey of senior members of the Royal College of Psychiatrists and found that 86% believed that suicide may be rational (in relation to the question of voluntary euthanasia). They said "Widespread agreement that so-called rational suicide exists is interesting since most suicides are said to occur in the context of mental illness". It is self-evident that not every request for assistance in suicide by a person with a potentially terminal illness is rational, and the possibility of treatable depression affecting the request must be very seriously considered. However, anyone who is suffering from an irreversible illness, and is to die within six months or less is in denial if they do not show some features of depressed mood. Hopelessness is not depression, and is not a mental illness; it is facing reality!

Webster's Dictionary defines suicide as a "person who deliberately takes his own life". Such acts carry a great stigma in our society, and this is applied to rational suicide, a concept which has little understanding in the community. The Committee of Enquiry of the Victorian Parliament which recommended statute protection of the right to refuse treatment even if this should cause or hasten death was at pains to argue that this did not constitute suicide or involve assisted suicide. In the case of the man I described earlier with malignant melanoma, he clearly wanted to end his life and ceased drinking, aided by sedation, in order to do so. When I reported this case to the Victorian Coroner, he found that this was not suicide! In Oregon, where assisted suicide is legal, the assisting doctor is advised not to put suicide on the death certificate but rather the underlying disease which led to the request for suicide. The reasons for this are obvious and natural - to avoid the stigma of suicide as a cause of death. The Victorian Coroner said that such cases were not reportable deaths, in clear conflict with the wording of the Coroner's Act. This stigma creates a conflict between the proper use of language and the comfort of society. We face an ongoing hypocrisy and dishonesty in relation to rational suicide by failing to recognize its reality, or we do so and redefine suicide and our laws relating to it.

I believe we need to either recognize rational suicide, or develop a new term to describe it. Given that such suicides are rational, is it not also rational to allow such patients the benefit of discussion of their dilemma without patronization, and unwanted attempts at psychiatric treatment. If their desire is rational must we deny them a rational means to accomplish their desire; the alternative is for them in desperation to use the common methods employed by the elderly such as hanging, shooting, gassing, drowning, cutting, jumping, or to be forced to suffer that which most dread without relief. If their desire is rational, how should medical practitioners deal with a request for assistance in achieving that rational suicide in a humane manner? They can ignore it, or patronize it, or try to change it (which they should do if they have any doubt that the request is rational), or they can assist by veiled means (terminal sedation) or directly by a prescription of appropriate medication, coupled with counseling and ongoing support, trying to ensure that such action is never taken before it is absolutely necessary.

A further issue is how to deal with an attempted suicide which may be rational in the light of the associated circumstances. Should the doctor intervene to prevent the suicide, or merely ensure its completion whilst palliating any adverse effects. This may be an extremely difficulty situation, but in my view, doctors should hasten slowly and seek information and advice before intervening if there is clear evidence of a terminal or hopeless illness associated with the attempt. If there is a clear advance directive in these circumstances requesting no treatment except palliation, the doctor would be in ethical and legal difficulty if he intervenes.

The extreme grief associated with a suicide which is physically traumatic and not discussed, even if rational, stands in sharp contrast with a rational suicide which has been discussed with the family who have an opportunity to say goodbye and which occurs in a peaceful manner.

Statistics on suicide are seriously distorted by a failure to recognize rational suicide. The Australian Bureau of Statistics in 1996 found 672 cases of suicide by people 75 years and older in the 5 year period 1990-1994. It is extremely likely that many of these would have been associated with hopeless or terminal illness. Personal experience tells me that there are also many rational suicides which are not recorded as suicide, the doctor who has rendered assistance recording another cause of death for obvious reasons.

In conclusion, rational suicide is a reality which needs to be given more thought by the medical profession and our lawmakers. Its recognition and careful treatment will go a long way to replacing some horrid deaths with some characterized by choice, dignity and humanity.