Research Paper on Suicide Issues

This sample research paper on Suicide Issues features 6200+ words (19 pages) and a bibliography with 39 sources.

Philosophical issues concerning suicide arise in a wide range of contemporary end-of-life dilemmas: the withdrawal or withholding of medical treatment; involuntary treatment; high-risk, experimental, and unconventional treatment; euthanasia, assistance, and physician assistance in suicide; requests for maximal treatment; and many others. Although suicide is often popularly understood in a narrower sense of active, pathological self-killing, traditionally abhorred, the underlying issue most broadly conceived concerns the role that individuals may play in bringing about their own deaths.

Two focal issues concerning suicide are evident in these broader dilemmas. First, should suicide be recognized as a right, and if so, under what conditions? On this first question rest the foundations for various applications of the “right to die,” as well as a variety of other issues in high-risk and self-sacrificial behavior.

Second, what should the role of other persons be toward those intending suicide? On this second question rest practical, legal, and public-policy issues in suicide prevention and suicide assistance. Both focal issues concerning suicide raise larger questions about the nature of choices to die and the relevance of mental illness, about the role of the state, about conceptual issues in determining what actions are to be counted as suicide, about the role of religious belief concerning suicide, about the possibility of an autonomous choice of suicide, and about the moral status of suicide.

The Incidence of Suicide

The United States exhibits a rate of reported suicide—10.7 per 100,000 year (year 2000 figures)—that falls approximately midway between societies in which reported suicide rates are extremely low, such as the Islamic countries, and those in which reported rates are extremely high, for example, Hungary. In the United States, there are almost 30,000 reported suicides per year and twenty-five times that many reported attempts; it is the eleventh highest cause of death for the U.S. population as a whole, ahead of homicide, the fourteenth highest. This means that, as John L. McIntosh points out, more Americans kill themselves than are killed by others.

Suicide rates are approximately equivalent across socioeconomic groups. Suicide rates are four times higher for males than females, but attempted suicide rates are four times higher for females than males. Attempt rates for whites and blacks are equivalent; rates of death by suicide are twice as high for whites. Suicide is the third leading cause of death for fifteen- to twenty-four-year-olds. For white males, suicide rates increase with age, rising to a peak of 61.7 per 100,000 in the age range eighty-four to eighty-nine; for women, suicide rates peak in midlife and decline thereafter; and elderly black women have the lowest rate of all adult groups, with those eighty-five and above showing the lowest risk (0.04 per 100,000, a rate based on such a low number of deaths that it is considered unreliable). In the United States, suicide rates declined throughout the 1990s and early 2000s— possibly due, among other factors, to the increased availability of antidepressant medications. Nevertheless, the number of deaths remains high. On average, one person commits suicide in the United States every eighteen minutes.

There are no reliable estimates of the number of unreported suicides, particularly those in medical situations involving terminal illness, the very cases that raise the most pressing current ethical issues. Suicide statistics, including those just cited, primarily reflect suicide in the narrower sense of active, pathological self-killing, whereas deaths brought about by refusal of treatment, by self-sacrifice or voluntary martyrdom, by high-risk behavior, or by self-deliverance in terminal illness are rarely described or reported as suicides. Rates of physician-assisted suicide where legal are quite low: In the Netherlands, where both voluntary active euthanasia and physician-assisted suicide are legal, the former comprises approximately 2.4 percent of the total annual mortality and the latter approximately 0.2 percent, figures fairly constant over the sixteen-year period, 1985 to 2001, for which reliable data is available. In Oregon, where physician-assisted suicide has been legal since 1997 under Measure 16, the Oregon Death with Dignity Act, 125 patients used lethal prescriptions provided legally by their physicians during the first five years of the act, representing less than 0.1 percent of the total annual deaths in the state.

Scientific Models of Suicide

Contemporary scientific understandings of the nature of suicide, primarily in the narrower sense, tend to fall into three groups: the “medical” model; the “cry-for-help,” “suicidal career,” or “strategic” model; and the “sociogenic” model.

The Medical Model

This model, heavily influential throughout most of the twentieth century, has understood suicide in terms of disease: If suicide is not itself a disease, then it is the product of disease, usually mental illness. Suicide is understood as largely involuntary and nondeliberative, the outcome of factors over which the individual has little or no control; it is something that “happens” to the victim. Studies of the incidence of mental illness in suicide often tacitly appeal to this model by attempting to show that mental illness—usually depression, less frequently other mental disorders—is always or almost always present in suicide. This invites the inference that the mental illness or depression “caused” the suicide.

More recent work presupposing the medical model has focused on biological factors associated with suicide, exploring among other findings decreases of serotonin in spinal fluid; drug challenges with fenfluramine; twin studies and other avenues of detecting heritable genetic patterns in families with multiple suicides; and environmental and disease exposures during pregnancy. While work to date remains provisional and in any case establishes correlations rather than causes, it nevertheless points to biological factors that may play a role in suicide.

The Cry-For-Help Model

A second model, developed in the pioneering work of Edwin S. Shneidman and Norman L. Farberow in the 1950s, understands suicide as a communicative strategy: It is a cry for help, an attempt to seek aid in altering one’s social environment. Thus it is primarily dyadic, making reference to some second person (or less frequently, an institution or other entity) central in the suicidal person’s life. In this view, it is the suicidal gesture that is clinically central; the completed suicide is an attempt that is (often unintentionally) fatal. While the cry for help is manipulative in character, it is also often quite effective in mobilizing family, community, or medical resources to assist in helping change the circumstances of the attempter’s life, at least temporarily. Later theorists have developed related models that also interpret suicide attempts as strategic: The concept of suicidal careers interprets an individual’s repeated suicide threats and attempts as a method of negotiating the world, though—as for the American poet Sylvia Plath (1932–1963)—an attempt in such a “career” may prove fatal.

The Sociogenic Model

Originally developed by the French sociologist Emile Durkheim (1858–1917) in his landmark work Suicide (1897), the sociogenic model sees suicide as the product of social forces varying with the type of social organization within which the individual lives. “It is not mere metaphor,” Durkheim wrote, “to say of each human society that it has a greater or lesser aptitude for suicide, … a collective inclination for the act, quite its own, and the source of all individual inclination, rather than their result” (p. 299). In societies in which individuals are very highly integrated into the society and their behavior is rigorously governed by social codes and customs, suicide tends to occur primarily when it is institutionalized and required by the society (as, for example, in the Hindu practice of sati, or voluntary widow-burning); this is termed altruistic suicide. In societies in which individuals are very loosely integrated into the society, suicide is egoistic, almost entirely self-referential. In still other societies, Durkheim claimed, individuals are neither over- nor underintegrated, but the society itself fails to provide adequate regulation of its members; this situation results in anomic suicide, typical of modern industrial society. In Western societies of this sort, institutionalized suicide has been extremely rare but not unknown, confining itself to highly structured situations: the sea captain who was expected to “go down with his ship” and the Prussian army officer who was expected to kill himself if he was unable to pay his gambling debts.

Like the medical model, the sociogenic model considers suicide to be “caused,” but it identifies the causes as social forces rather than individual psychopathology. Like the cry-for-help model, the sociogenic model sees suicide as a responsive strategy, but the responses are not so much matters of individual communication as conformity to social structures and reaction to the social roles a society creates.

Prediction and Prevention of Suicide

Two principal strategies are employed to recognize the prospective suicide before the attempt: the identification of verbal and behavioral clues and the description of social, psychological, and other variables associated with suicide. Suicide prevention includes alerting families, professionals (especially those likely to have contact with suicidal individuals, such as schoolteachers), and the public generally to the symptoms of an approaching suicide attempt. They are trained to recognize and take seriously both direct warnings (e.g., “I feel like killing myself ”) and indirect warnings (e.g., “I probably won’t be seeing you anymore”) and behavior (e.g., giving away one’s favorite possessions). They are also encouraged to be especially sensitive to these symptoms in those at highest risk, especially in males, those who are older, live alone, are alcoholic, have negative interactions with important others, are isolated, have poor or rigid coping skills, are less willing to seek professional help, have low religiosity, and have a history of previous suicide attempts— the last of these being a particularly at-risk group. Prevention strategies take a vast range of forms, from the befriending techniques developed by the Samaritans in England and the crisis hot lines widely used in the United States to involuntary commitment to a mental institution. Prevention strategies also include postvention, or post-occurrence intervention, for the survivors—spouse, parents, children, or important others—of a person whose suicide attempt was fatal, because such survivors are themselves at much higher risk of suicide, especially during the first year following the death.

These models of suicide and the associated forms of prediction and prevention are ubiquitous in contemporary medical and psychiatric practice. Yet although suicide has been treated largely as a medical or psychiatric matter, the conceptual, epistemological, and ethical problems it raises have reemerged in two central contexts: that of right-to-die issues in terminal illness and that of political phenomena such as self-sacrifice and suicide terrorism.

Conceptual Issues

The term suicide carries extremely negative connotations. There is little agreement, however, on a formal definition. Some authors count all cases of voluntary, intentional self-killing as suicide; others include only cases in which the individual’s primary intention is to end his or her life. Still others recognize that much of what is usually termed suicide neither is wholly voluntary nor involves a genuine intention to die, such as suicides associated with depression or other mental illness. Many writers exclude cases of self-inflicted death that, while voluntary and intentional, appear aimed to benefit others or to serve some purpose or principle— for instance, the Greek philosopher Socrates (c. 470–399 B.C.E.), who drank the hemlock; Captain Lawrence Oates (1880–1912), thean English explorer who, after falling ill during the return trip from an expedition to the South Pole, deliberately walked out into a blizzard to allow his fellow explorers to continue without him; or the Buddhist monk Thich Quang Duc, who immolated himself in the streets of Saigon in June 1963 to protest the Diem regime during the Vietnam war. These cases are usually not called suicide, but self-sacrifice or martyrdom, terms with strongly positive connotations.

However, attempts to differentiate these positive cases from negative ones often seem to reflect moral judgments, not genuine conceptual differences. Conceptual and linguistic framing of a practice plays a substantial role in social policies; for example, supporters of physician-assisted suicide often use the term aid-in-dying as well as earlier euphemisms such as self-deliverance to avoid the negative connotations of suicide, while opponents insist on the more negative term suicide. The term suicide is not used in Oregon’s Death with Dignity Act to describe the practice it makes legal, and indeed the statute stipulates: “Actions taken in accordance with this Act shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law” (Section 3.14). In contrast, the U.S. Supreme Court cases Washington v. Glucksberg and Vacco v. Quill (decided jointly in 1997) expressly considered the issue as one involving “suicide.” Similarly, Palestinian militants attacking Israeli civilians have been called suicide bombers by their targets and by the Western press, but they are called martyrs by their supporters and those who recruit them for this role.

Cases of death from self-caused accident, self-neglect, chronic self-destructive behavior, victim-precipitated homicide, high-risk adventure, refusal of lifesaving medical treatment, and self-administered euthanasia—all of which share many features with suicide but are not usually termed such—cause still further conceptual difficulty. Consequently, some authors claim that it is not possible to reach a rigorous formal definition of suicide, and prefer a criterial or operational approach to characterizing the term, noting its varied, shifting, and often inconsistent range of uses. Nevertheless, conceptual issues surrounding the definition of suicide are of considerable practical importance in policy formation, affecting, for instance, coroners’ practices in identifying causes of death, insurance disclaimers, psychiatric protocols, religious prohibitions, codes of medical ethics, and laws prohibiting or permitting assistance in suicide.

Suicide in the Western Tradition

Much of the extremely diverse discussion of suicide in the history of Western thought has been directed to ethical issues. The Greek philosopher Plato (c. 428–c. 348 B.C.E.) acknowledged Athenian burial restrictions—the suicide was to be buried apart from other citizens, with the hand severed and buried separately—and in the Phaedo, he also reported the Pythagorean view that suicide is categorically wrong. But Plato also accepted suicide under various conditions, including shame, extreme distress, poverty, unavoidable misfortune, and “external compulsions” of the sort that had been imposed on his teacher Socrates by the Athenian court when it condemned him to drink the hemlock. In the Republic and the Laws, respectively, Plato obliquely insisted that the person suffering from chronic, incapacitating illness or uncontrollable criminal impulses ought to allow his life to end or cause it to do so. Plato’s pupil, the Greek philosopher Aristotle (384–322 B.C.E.) held more generally that suicide is wrong, claiming that it is “cowardly” and “treats the state unjustly.” The Greek and Roman Stoics, in contrast, recommended suicide as the responsible, appropriate act of the wise man, not to be undertaken in emotional distress, but as an expression of principle, duty, or responsible control of the end of one’s own life, as exemplified by Cato the Younger (95–46 B.C.E.), Lucretia (sixth century B.C.E.), and Seneca (c. 4 B.C.E.–65 C.E.).

Although Old Testament texts describe individual cases of suicide (Abimilech, Samson, Saul and his armor-bearer, Ahithophel, and Zimri), nowhere do they express general disapproval of suicide. The Greek-influenced Jewish general Josephus (c. 37–c. 100 C.E.), however, rejected it as an option for his defeated army, and clear prohibitions of suicide appear in Judaism by the time of the Talmud during the first several centuries C.E., often appealing to Genesis 9:5, “For your lifeblood I will demand satisfaction.” The New Testament does not specifically condemn suicide, and mentions only one case: the self-hanging of Judas Iscariot after the betrayal of Jesus. There is evident disagreement among the early church fathers about the permissibility of suicide, especially in one specific circumstance: Eusebius of Caesarea (c. 260–c. 339), Ambrose (339–397), Jerome (c. 347–c. 419), and others all considered whether a virgin may kill herself in order to avoid violation.

While Christian values clearly include patience, endurance, hope, and submission to the sovereignty of God, values that militate against suicide, they also stress willingness to sacrifice one’s life, especially in martyrdom, and absence of the fear of death. Some early Christians (e.g., the Circumcellions, a subsect of the rigorist Donatists) apparently practiced suicide as an act of religious zeal. Suicide committed immediately after confession and absolution, they believed, permitted earlier entrance to heaven. Rejecting such reasoning, Augustine (354–430) asserted that suicide violates the commandment “Thou shalt not kill” and is a greater sin than any that could be avoided by suicide. Whether he was simply clarifying earlier elements of Christian faith or articulating a new position remains a matter of contemporary dispute. In any case, it is clear that with this assertion the Christian opposition to suicide became unanimous and absolute.

This view of suicide as morally and religiously wrong intensified during the Christian Middle Ages. Thomas Aquinas (c. 1225–1274) argued that suicide is contrary to the natural law of self-preservation, injures the community, and usurps God’s judgment “over the passage from this life to a more blessed one” (Summa theologiae 2a 2ae q64 a5). By the High Middle Ages the suicide of Judas, often viewed earlier as appropriate atonement for the betrayal of Jesus, was seen as a sin worse than the betrayal itself. Enlightenment writers began to question these views. The English statesman Thomas More (1478–1535) incorporated euthanatic suicide in his Utopia (1516). In his Biathanatos (1608, published posthumously in 1647), the English poet John Donne (1572–1631) treated suicide as morally praiseworthy when done for the glory of God—as he claimed was the case for Christ. The Scottish philosopher and historian David Hume (1711–1776) mocked the medieval arguments, justifying suicide on autonomist, consequentialist, and beneficent grounds.

Later thinkers such as the French writer Madame de Stael (Anne-Louise-Germaine, nee Necker, the baroness Stael-Holstein, 1766–1817) and the German philosopher Arthur Schopenhauer (1788–1860) construed suicide as a matter of human right—although Mme. De Stae subsequently reversed her position. Throughout this period, other thinkers insisted that suicide was morally, legally, and religiously wrong: Among them, the English evangelist and founder of methodism John Wesley (1703–1791) said that suicide attempters should be hanged, and the English jurist William Blackstone (1723–1780) described suicide as an offense against both God and the King. The German philosopher Immanuel Kant (1724–1804) used the wrongness of suicide as a specimen of the moral conclusions the categorical imperative could demonstrate. In contrast, the Romantics tended to glorify suicide, and the German philosopher Friedrich Nietzsche (1844–1900) insisted that “suicide is man’s right and privilege” (Nietzsche, p. 210).

Although religious moralists have continued to assert that divine commandment categorically prohibits suicide, that suicide repudiates God’s gift of life, that suicide ruptures covenantal relationships with other persons, and that suicide defeats the believer’s obligation to endure suffering in the image of Christ, the volatile discussion of the moral issues in suicide among more secular thinkers ended fairly abruptly at the close of the nineteenth century. This was due in part to Emile Durkheim’s insistence (1897) that suicide is a function of social organization, and also to the views of psychological and psychiatric theorists, developing from the French physician Jean Esquirol (1772–1840) to the Austrian neurologist Sigmund Freud (1856–1939), that suicide is a product of mental illness. These new “scientific” views reinterpreted suicide as the product of involuntary conditions for which the individual could not be held morally responsible. The ethical issues, which presuppose choice, reemerged only in the later part of the twentieth century, stimulated primarily by discussions in bioethics of terminal illness and other dilemmas at the end of life.

Suicide and Martyrdom in Religious Traditions

The major monotheisms, Judaism, Christianity, and Islam, all repudiate suicide, though in each martyrdom is recognized and venerated. Judaism rejects suicide but venerates the suicides at Masada, where in May of the year 73 C.E. some 960 Jews trapped in a fortress built on a high rock plateau killed themselves rather than be taken prisoner by the Romans, and accepts kiddush hashem, self-destruction to avoid spiritual defilement. At least since the time of Augustine, Christianity has clearly rejected suicide but accepts and venerates martyrdom to avoid apostasy and to testify to one’s faith. Islam also categorically prohibits suicide but at the same time defends and expects martyrdom to defend the faith. Yet whether the distinction between suicide and martyrdom falls in the same place for Judaism, Christianity, and Islam is not clear. Judaism appears to accept self-killing to avoid defilement or apostasy; Christianity teaches passive submission to death when the faith is threatened but also celebrates the voluntary embrace of death in such circumstances; some Islamic fundamentalists support the political use of suicide bombing, viewing it as consistent with Islam and its teachings of jihad, or holy war, though others view this as a corruption of Islamic doctrine. Thus while all three traditions revere those who die for the faith as martyrs and all three traditions formally repudiate suicide, at least by that name, the practices they accept may be quite different: Christians would not accept the mass suicide at Masada; Jews do not use the suicide-bombing techniques of their Islamic neighbors in Palestine; and Muslims do not extol the passive submission to death of the Christian martyrs, appealing on Koranic grounds to a more active self-sacrificial defense of the faith.

Non-Western Religious and Cultural Views of Suicide

Many other world religions hold the view that suicide is prima facie wrong, but that there are certain exceptions. Still others encourage or require suicide in specific circumstances. Known as institutionalized suicide, such practices have included the sati of a Hindu widow, who was expected to immolate herself on her husband’s funeral pyre; the seppuku or hara-kiri (suicide by disembowelment) of traditional Japanese nobility out of loyalty to a leader or because of infractions of honor; and, in traditional cultures from South America to Africa to China, the apparently voluntary submission to sacrifice by a king’s retainers at the time of his funeral in order to accompany him into the next world. Eskimo, Native American, and some traditional Japanese cultures have practiced voluntary abandonment of the elderly, a practice closely related to suicide, in which the elderly are left to die, with their consent, on ice floes, on mountaintops, or beside trails.

In addition, some religious cultures have held comparatively positive views of suicide, at least in certain circumstances. The Vikings recognized violent death, including suicide, as guaranteeing entrance to Valhalla (the central hall of the afterlife). Some Pacific Islands cultures regarded suicide as favorably as death in battle and preferable to death by other means. The Jains, and perhaps other groups within traditional Hinduism, honored deliberate self-starvation as the ultimate asceticism and also recognized religiously motivated suicide by throwing oneself off a cliff. On Mangareva, members of a traditional Pacific Islands culture also practiced suicide by throwing themselves from a cliff, but in this culture not only was the practice largely restricted to women, but a special location on the cliff was reserved for noble women and a different location assigned to commoners. The Maya held that a special place in heaven was reserved for those who killed themselves by hanging (though other methods of suicide were considered disgraceful), and they recognized a goddess of suicide, Ixtab. Many other pre- Columbian peoples in the western hemisphere engaged in apparently voluntary ritual self-sacrifice, notably the Aztec practice of heart sacrifice, which was generally characterized at least during some historical periods by enhanced status and social approval. The view that suicide is intrinsically and without exception wrong is associated most strongly with post-Augustinian Christianity of the medieval period, surviving into the present; this absolutist view is not by and large characteristic of other cultures.

Contemporary Ethical Issues

Is suicide morally wrong? Both historical and contemporary discussions in the Western tradition exhibit certain central features. Consequentialist arguments tend to focus on the damaging effects a person’s suicide can have on family, friends, coworkers, or society as a whole. But, as a few earlier thinkers saw, such consequentialist views would also recommend or require suicide when the interests of the individual or others would be served by suicide. Deontological theorists in the Western tradition have tended to treat suicide as intrinsically wrong, but, except for Kant, are typically unable to produce support for such claims that is independent of religious assumptions. Contemporary ethical argument has focused on such issues as whether hedonic calculus of self-interest— weighing pleasures and pains, or benefits against harms—in which others are not affected, provides an adequate basis for an individual’s choice about suicide; whether life has intrinsic value sufficient to preclude choices of suicide; and whether any ethical theory can show that it would be wrong, rather than merely imprudent, for the ordinary, nonsuicidal person, not driven by circumstances or acting on principle, to end her life.

Epistemological Issues

Closely tied to conceptual issues, the central epistemological issues raised by suicide involve the kinds of knowledge available to those who contemplate killing themselves. The issue of what, if anything, can be known to occur after death has, in the West, generally been regarded as a religious issue, answerable only as a matter of faith; few philosophical writers have discussed it directly, despite its clear relation to theory of mind. Some writers have argued that because we cannot have antecedent knowledge of what death involves, we cannot knowingly and voluntarily choose our own deaths; suicide is therefore always irrational. Others, rejecting this argument, instead attempt to establish conditions for the rationality of suicide. Others consider whether death is always an evil for the person involved, and whether death is appropriately conceptualized as the cessation of life. Still other writers examine psychological and situational constraints on decision making concerning suicide. For instance, the depressed, suicidal individual is described as seeing only a narrowed range of possible future outcomes in the current dilemma, the victim of a kind of tunnel vision constricted by depression. The possibility of preemptive suicide in the face of deteriorative mental conditions such as Alzheimer’s disease is characterized as a problem of having to use the very mind that may already be deteriorating to decide whether to bear deterioration or die to avoid it.

Public-Policy Issues

It is often, though uncritically, assumed that if a person’s suicide is rational, it ought not to be interfered with or prohibited. This assumption, however, raises policy issues about the role of the state and other institutions in the prevention of suicide.

Rights and the Prevention of Suicide

In the West, both church and state have historically assumed roles in the control of suicide. In most European countries, ecclesiastical and civil law imposed burial restrictions on the suicide as well as additional penalties, including forfeiture of property, on the suicide’s family. European attitudes and legal sanctions concerning suicide were translated into colonial societies as well, for example in India, Africa, and various Pacific Islands. In England, suicide remained a felony until 1961, and in Canada until 1971. Suicide has been decriminalized in most of the United States and in England, primarily to facilitate psychiatric treatment of suicide attempters and to mitigate the impact on surviving family members; in most U.S. states, however, assisting another person’s suicide is a violation of statutory law, case law, or recognized common law. In Germany assisting a suicide is not illegal, provided the person whose death it will be is competent and acting voluntarily; in the Netherlands, physician-assisted suicide is legal under the same guidelines as voluntary active euthanasia: In Switzerland, assisted suicide is legal if it is done without self-interest on the part of the assister; and in Belgium, physician-performed voluntary active euthanasia is legal but physician-assisted suicide is not. Ongoing ferment characterizes the legal status of physician-assisted suicide in many countries.

Building on Shneidman and Farberow’s early work, suicide-prevention strategies have been enhanced by considerable advances in the epidemiological study of suicide, in the identification of risk factors, and in forms of clinical treatment. Suicide-prevention professionals welcome increased funding for education and prevention measures targeted at youth and other populations at high risk of suicide. Nevertheless, philosophers are increasingly alert to the more general theoretical issues these strategies raise, for example, the effect of high false-positive rates on the right to avoid unjustified coercion. Restrictions to prevent suicide— such as involuntary incarceration in a mental hospital or suicide precautions in an institutional setting—typically limit liberty, but because the predictive measures of suicide risk that are available are neither perfectly reliable nor perfectly sensitive, they identify some fraction of persons as potential suicides who would not in fact kill themselves and fail to identify others who actually will. There are two distinct issues here. First, how great an infringement of the liberty of those erroneously identified is to be permitted in the interests of preventing suicide by those correctly identified? Second and more generally, can restrictive measures for preventing suicide be justified at all, even for those who will actually go on to commit suicide? Civil rights theorists are generally disturbed by the first of these problems, libertarians by the second.

Although U.S. law does not prohibit suicide, suicide has not been recognized as a right. There has been considerable pressure from right-to-die groups in favor of recognizing a broad right to self-determination in terminal illness not only by refusal of life-prolonging treatment but also by bringing about one’s own death. In the Washington v. Glucksberg and Vacco v. Quill cases, the U.S. Supreme Court ruled unanimously that there was no constitutional right to assisted suicide, though the Court’s ruling did not prohibit states from establishing laws that would legalize it. Cases such as these, however, tend to conflate the notion of a negative right to assistance in suicide, which would prohibit interference when a willing physician wished to provide assistance to a patient, with the far more controversial notion of a positive right to assistance in suicide—something that would give patients a claim to be provided with help from physicians when they sought it.

Other rights issues raised by suicide include, for example, freedom of expression. When Hemlock Society president Derek Humphry’s Final Exit—a book addressed to the terminally ill that provided explicit instructions on how to commit suicide, including lethal drug dosages—was published in the United States in 1991 and sold over half a million copies, its publication was protected on the grounds of freedom of expression; yet in several other countries, including France and Australia, Final Exit was banned. More recent controversy surrounds web sites that provide explicit how-to information about suicide, including how to do so using readily available materials, and internet chat rooms that encourage or dare visitors to kill themselves.

Physician-Assisted Suicide

Although issues of the permissibility of suicide generally have been the focus of sustained historical discussion, contemporary public-policy debate tends to focus on a narrower, specific issue: that of physician-assisted suicide, usually coupled with the question of voluntary active euthanasia. There are two principal arguments advanced for the legalization of these practices. First, claims about autonomy appeal to a conception of individuals as entitled to control as much as possible the course of their own dying. To restrict the right to die to the mere right to refuse unwanted medical treatment and so be allowed to die, this argument holds, is an indefensible truncation of the more basic right to choose one’s death in accordance with one’s own values. Thus, advance directives, such as living wills and durable powers of attorney, “do not resuscitate” (DNR) orders, and other mechanisms for withholding or withdrawing treatment, are inadequate to protect fundamental rights. Second, arguments for the legalization of physician-assisted suicide, usually together with arguments for voluntary euthanasia, involve an appeal to what is variously understood as mercy or nonmaleficence. Because not all terminal pain can be controlled and because suffering encompasses an even broader, less controllable range than pain, it is argued, it is defensible for a person who is in irremediable pain or suffering to choose death if there is no other way to avoid it.

Two principal arguments form the basis of the opposition to legalization of these practices. The first is that killing (in both suicide and euthanasia) is simply morally wrong, and hence wrong for doctors to facilitate or perform. The second argument is that legalization would invite a “slippery slope” leading to involuntary killing. The slippery slope argument contends, among other things, that permitting assistance in suicide or the performance of euthanasia would make killing “too easy,” so that doctors would turn to it for reasons of bias, greed, impatience, or frustration with a patient who was not doing well; that it would set a dangerous model for disturbed younger persons who were not terminally ill; and that, in a society marked by prejudice against the elderly, the disabled, racial minorities, and many others, and motivated by cost considerations in a system that does not guarantee equitable care, “choices” of death that were not really voluntary would be imposed on vulnerable persons. Suicide in these circumstances would become a matter of social expectation or imperative. The counterargument for legalization replies that more open attitudes toward suicide would reduce psychopathology by allowing more effective counseling, and that by bringing practices that have always gone on in secrecy out into the open—and hence under adequate control—legalization would provide the most substantial protection for genuine patient choice.

Data from the Netherlands, where physician-assisted suicide and voluntary active euthanasia have been legally tolerated since the mid-1980s and are now legal, and from Oregon, where physician-assisted suicide became legal in 1997, do not support claims about a slippery slope, though full legalization is comparatively recent in both. In both only a very small fraction of patients who die actually die with physician assistance. Most are patients with cancer: 75 percent in the Netherlands, 79 percent in Oregon. Even so, of patients with cancer, the vast majority of those who die in either the Netherlands or Oregon do not die with this form of assistance. There is no evidence of disparate impact on groups of patients understood as vulnerable—the elderly, the poor, people with disabilities or with developmental delays, and others, although prior to the development of the protease inhibitors, was high for people with AIDS. Pain has not been the central issue; rather, most patients who have elected physician assistance in dying have done so, according to family members, physicians, and hospice caregivers, to avoid deterioration and loss of control over their circumstances. In Oregon, for example, the most frequently reported concerns by patients who died in 2001 included loss of autonomy (94%), decreasing ability to participate in activities that make life enjoyable (76%), and loss of control of bodily functions (53%); inadequate pain control and the financial implications of treatment were mentioned by just 6 percent each.

Particularly relevant to public-policy discussions is the contention of some contemporary writers that suicide will become “the preferred way of death” because it allows control over the time, place, and circumstances of dying. Others claim that as pain control in terminal illness improves, interest in physician-assisted euthanatic suicide will disappear. These may seem to be mere predictive claims. But in the technologically developed nations, where the epidemiologic transition in causes of death now means that the majority of the population will not die of parasitic and infectious disease, as was the case in all societies until the middle of the nineteenth century and is still the case in many less developed nations, but will die of late-life degenerative diseases with prolonged downhill courses, these claims may seem to harbor quite different normative visions of the roles people may—and should—play in their own deaths. One now faces a death that is comparatively predictable and prolonged, often perceived as burdensome to oneself and to those one loves.

Several particularly contentious issues have been raised in view of these facts. One concerns the question of whether a person can have a “duty to die.” Some theorists have argued that as the burdens and costs of terminal care increase, both to the patient and to the family, a person becomes obligated to end his life; other commentators find this claim repugnant, an example of the kind of thinking that would fuel a slide down the slippery slope. Resolution of this issue rests on whether an individual’s preferences and personal sense of concern for and obligation to family or others can be disentangled from social expectations about costs and savings.

Another issue of growing philosophical concern is that of suicide in old age, for reasons of old age alone rather than illness that accompanies old age. Despite extensive discussion among the Stoics of this matter—they held it to be a reasonable choice—and despite the prospects of vastly extended life expectancies of people in advanced industrial societies, such matters as preemptive suicide to avoid the deterioration of old age have been very little discussed.

Nor has the issue of altruistic suicide, not only in order to spare healthcare costs or other burdens for family members or others, but also in situations such as political protest and military strategy, received adequate philosophical analysis. In situations in which individuals committing suicide believe themselves to be acting for the common good, even at extreme personal sacrifice, is suicide—though it might be labeled with such euphemisms as martyrdom or heroism— morally acceptable or even praiseworthy? Such issues will form the basis for some of the many ethical challenges concerning suicide to be faced in future years.

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