Suicide at the end of Life
by Rex Roman, Ph.D taken from “It Takes a Village” Ontario Association for Suicide Prevention
I recently heard an eminent professor speak at a conference about end of life situations. He claimed that physician-assisted suicide was suicide and ought to be prevented. He stated that even in situations where death was imminent, no one—especially healthcare professionals—had a right to take a life, and that we should always inspire hope in those who suffer. These statements were presented as self-evident truths, but I began to wonder whether they were as self-evident as the distinguished professor maintained. In order to substantiate the professor’s claims, one would have to maintain that suicide and physician-assisted suicide were the same in certain essential characteristics. For sure, there are similarities.
First, it is true that in both cases, death is the intended outcome. Secondly, it is also true that in each case, the person intending that death is also the person dying. I venture to guess, though, that most people in one group would not associate themselves with the other group. So what are the differences?
It is always a good idea to start with the dictionary definition. From The Concise Oxford Dictionary, we get the following definition: Suicide: The intentional killing of oneself.Although the dictionary does not provide a definition of the phrase ‘physician-assisted suicide’,there are numerous definitions to be found.The following is one of the better renditions: Physician- assisted suicide: The voluntary termination of one’s own life by administration of a lethal substance with the direct or the differences between these two types of suicide (suicide and physician-assisted suicide) are significant. indirect assistance of a physician. (MedicineNet.com)
Comparing the definitions provides a clear, and potentially significant, difference: the definition of suicide refers to one person acting alone, while in physician-assisted suicide, other people are involved. This point is surely an important difference for those healthcare workers who are asked to assist. After all, healthcare professionals have tools and skills developed to save lives. In the case of physician-assisted suicide, they are asked to do the opposite, that is, hasten death.While this is an important moral concern for the persons involved in administering physician-assisted suicide, it does not tell us whether the patient making the initial decision is wrong. From the point of view of the person intending their own death, the doctor or nurse acts as a mere tool and functions just like a noose, a bridge or a bottle of pills.
The fact that physician-assisted suicide usually requires other people in its administration underlies an important difference: in physicianassisted suicide, the person is very close to death, and therefore not physically able to take his or her own life. In stark contrast, the suicidal person is fully capable of performing the act. The ability to act independently highlights the fact that the suicidal person does not see death as an imposed reality, but rather as a choice among many. The person suffering a terminal illness is under no illusion that he or she will die; the question for this person is just when and with what amount of suffering. Is this difference a moral difference? In other words, can we say that in certain situations a person suffering from a terminal illness has a good argument to be exempted from the duty to preserve their own life? If we permit individuals in such circumstances to take their life, then we have no right to interfere. I think our first instinct is to point to the amount of time left for the patient. When a person can live a long life, maybe there is an obligation for them to pursue that life. After all, if life has any meaning, it must be to do some good in the world and to enjoy one’s life. Conversely, when someone is near death, perhaps they are no longer under the obligation to 2 It Takes a Village Suicide at the end of life contribute to life. In addition, they are suffering and are therefore no longer able to enjoy themselves. This does have the potential for being a slippery-slope argument, leaving us wondering how close to death and how much suffering a person has to have to make a distinction. Perhaps it would be useful to have some qualitative measure to help us demarcate between suicide and physician-assisted suicide. There seem to be at least two aspects which differentiate suicide from physician-assisted suicide. First, there is the fact that we can help the suicidal person by instilling hope for the future. Second, suicide is ultimately a selfish act which creates greater harm in the community. Is there a difference based on the instilling of hope? In the case of the late stages of a terminal illness, people are certain about their own death and this understanding is shared by others. No intervention will make the illness abate. Attempting to instill hope that things will get better, that together the healthcare professionals and the person can make changes to their situation, would be cruel. In the case of suicide, instilling hope is precisely what is mandated; providing hope for the person that they can make changes in their life. This is precisely the sentiment behind suicide prevention; if, through some intervention, we can get the person over the acute stage of suicidality, they may never attempt again. This is consistent with the usual medical situation where treating an illness allows people to continue their lives. With intervention, the person continues to live, leaving the illness behind. The second point focuses not only on the individual, but also on other persons involved. When a person dies by their own hand, they tend to leave a wake of sadness. This wake of sadness is the family and friends who are left with the grief, anger, sadness, and so many haunting unanswered questions. In contrast, the person who dies through physician-assisted suicide has usually discussed their prospects of death at length with their family and friends, and everyone has come to terms with what is about to happen. In this way, the person, the family, and the friends are at peace with the decision. There will still be grief and sadness, but not the torment of suicide. (Maybe, at the end of life, this is the best we can do. ) In conclusion, in both suicide and physician-assisted suicide, a person decides to take control of the time of his/her death. In this sense, I agree with the professor, that physicianassisted suicide is a type of suicide. On the other hand, the differences between these two types of suicide are significant. In the case of suicide, there is an understanding that the suicidal person’s mind can be changed by providing hope for the future; in contrast, when a person is about to die of a terminal illness, there is no corresponding hope. Perhaps most importantly, suicide is an act performed in isolation. The experience for the family and friends is devastating. Whereas, with physician-assisted suicide, there is a feeling of love, trust, and understanding that brings the family, friends, and the individual together. Rex Roman is a Board Member of OASP. He has recently finished a Fellowship with Women’s College Hospital looking at the ethical issues surrounding suicide. Rex is currently working as a consulting Ethicist