Let death be my dominion

Medical advances have thrown open the debate about voluntary euthanasia for the terminally ill. This, in turn, will challenge attitudes to suicide in general

MoreoverOct 14th 1999 edition

BILL WHITE had had enough. Paralysed in a gymnastics accident in 1967, he had spent the past 32 years as a quadriplegic hooked up to a respirator, longer than almost anyone else in the United States. He needed 24-hour care and rarely left the hospital. Despite this, Mr White's life was not empty. He had many friends. He was known for his vitality, generosity and sense of humour. He raised money for charity. Computers offered him a window to the outside world. Nevertheless, earlier this year he decided that he wanted to die, and demanded that his ventilator be turned off.

Friends, family, local Catholic priests and the staff at Strong Memorial Hospital in Rochester, New York, where he had lived for three decades, spent weeks trying to make him change his mind. A disability-rights group even went to court to try to stop the hospital from fulfilling his request. All these efforts failed. This summer Mr White got his way. His ventilator was turned off, and he died. Michael McBride, a friend of 25 years, was bitter. “Why his life should not be worth living I'll never know,” he said. “He was a great guy and I miss him already.”

In one way Mr White's case is not that remarkable—life-saving treatment is withdrawn every day in hospitals around the world. But what did make it notable was that, after failing to persuade him to continue living, the hospital's staff felt duty-bound to comply with his demand—and his family to acquiesce to it—and so to help him, in effect, to commit suicide. Although his health had begun to deteriorate, the same could be said of many 50-year-olds. Unlike most people whose machines are switched off, he was not terminally ill, and he had learned to live with his condition over many years. Yet his decision to die was reported sympathetically, though sorrowfully, even in Rochester's local Catholic newspaper.

Disapproval of Mr White's choice was far more muted than might have been expected in most western societies a generation ago. Over the past few decades, ageing populations and advances in medical technology have put a growing number of people in Mr White's position—attached to a machine but wanting to die. Even for those who escape this fate, medical treatment has often made death more prolonged and more painful. These developments have sparked complex and emotive debates about how to handle the final stages of life.

The Dutch parliament is currently considering a bill which would make permanent a 15-year experiment in allowing doctor-assisted suicide by codifying in law regulations which have governed such practices. Backers of the bill originally wanted to extend the right to die to children as young as 12 years old. That provision was too much even for the Dutch, and it has been dropped. But it shows how far the boundaries have moved. The Dutch experiment has been closely watched by other countries. Switzerland and the American state of Oregon have also passed laws which allow some forms of physician-assisted suicide, a practice which goes on everywhere whatever the law says. Like it or not, the idea that people have a “right to die” is no longer considered outlandish. Indeed, it is gaining support.

So far this “right” is usually discussed in a single, strictly limited context: terminal illness. And yet, if this right exists, what about suicide in general? Why should the right to die be confined only to the terminally ill or those in great pain? Does not everyone, including the hale and hearty, have the right to choose the timing and manner of their own death? And if they do, what right do the rest of us have to disapprove of suicide, or to try to stop it?

These are uncomfortable and disturbing questions. Most of those advocating legalised voluntary euthanasia would be horrified by the suggestion that their arguments could ever lead to a greater tolerance, or even endorsement, of suicide in general. The taboo against suicide in western culture remains strong. Although suicide is no longer a crime in most countries, and suicides are no longer buried, as they once were, at a crossroads with a stake through their hearts, severe disapproval of suicide survives in a different form.

Today it is widely perceived as a medical problem, almost exclusively the result of mental or emotional instability. Groups dedicated to suicide prevention have sprung up around the world, and the study of suicide and the treatment of those who attempt it have become major branches of psychology. Suicide has become less a sin, more a modern disease.

The growing debate about euthanasia has barely dented this consensus that suicide in other contexts can never be the choice of a healthy mind. Questions of when voluntary euthanasia can be permitted, the nature of consent and the role of doctors and families are regularly explored in both the popular media and professional journals. But most discussion has steered clear of the basic issue of whether suicide itself is right or wrong, or can ever be rationally chosen.

“Our society has not evolved a measured, considered set of moral rules, laws, and customs concerning suicide,” observes Margaret Pabst Battin, author of “The Death Debate” (Prentice Hall; $24.95), a lucid survey of the ethical issues suicide raises. Given that 70-80% of people in the developed world now die under some kind of medical care, she finds this a “cause for philosophic and practical alarm.”

It is difficult to believe this reticence can continue indefinitely. If voluntary euthanasia at the end of life becomes more widely accepted, it is likely that society's disapproval of suicide in general will come under greater scrutiny, if only because the dividing line between suicide in the case of the terminally ill and other kinds of suicide will become more blurred. The ensuing debate could make the current disagreements over euthanasia look tame.

Nor are public attitudes to suicide merely academic. Despite the strong social disapproval of suicide, many people choose it. Official figures indicate that worldwide more than 750,000 people kill themselves every year. The true number is probably much higher. And the number of people who attempt suicide, researchers estimate, is about ten times the number who succeed. In almost every country not torn by war or political conflict, more people kill themselves than are murdered—even in the United States, where the murder rate is higher than in other rich countries. Suicide is among the leading causes of death in people aged 15 to 24 in scores of countries, and in many the suicide rate for young people has risen in the past decade according to statistics collected by the World Health Organisation. Disapproval, reticence and treating suicide solely as a symptom of mental illness have not actually done much to curb it.

If a public debate about the morality of suicide were to develop out of the euthanasia debate, how might it proceed? That is difficult to predict, because current attitudes towards suicide are such an incoherent medley of views inherited from the past. Nevertheless, both sides of any such debate would have a rich fund of arguments to draw upon. Although there has been little public discussion of the morality of suicide, philosophers have always been fascinated by the subject. As is the way with philosophers, many have often come to diametrically opposite conclusions. Aristotle condemned it. David Hume defended it. Jean-Jacques Rousseau called the right to suicide a “clear and self-evident principle”. For Ludwig Wittgenstein it was an “elementary sin”, a challenge to any moral system. “If suicide is allowed, then everything is allowed. If anything is not allowed, then suicide is not allowed,” he concluded.

However, even in this secular age, any such debate would probably have to begin by examining the religious objections to suicide which, at least in Judeo-Christian cultures, have been the most persistent and are still widespread. The most basic of these is that suicide is forbidden by the Bible. In fact, there are no explicit biblical injunctions against suicide, only prohibitions of killing which are better interpreted as forbidding the unlawful killing of others. This was pointed out as long ago as the 17th century by John Donne, an English poet and divine, who wrote an entire book on suicide. Moreover, the suicides that do occur in the Bible—Samson, Saul and Judas among others—are not described in a disapproving manner.

The gift of life

In any case, both the Jewish and Christian disapproval of suicide dates from the fourth century AD, late in the development of both religions, and does not derive directly from scripture. Ironically, the Christian Church, encouraged by the arguments of St Augustine, adopted a strict prohibition against suicide precisely because it had become so popular among Christians. A vogue for martyrdom, and even collective suicide, had by then begun to threaten the Church. Any religion which preaches that life on earth is a vale of tears, a mere prelude to a better after-life, would seem to be inviting its adherents to kill themselves, unless it can offer a good reason for them to delay their departure for paradise. Declaring suicide a mortal sin was the Church's solution. Islam took the same path, forbidding it outright. Other religions, such as Buddhism and Hinduism, are less condemnatory.

Scriptural or clerical injunctions do not weigh very heavily with the secular-minded or the occasional church-goer. But a range of other religious arguments hold greater sway. Life is said to be a gift from God, one that therefore should not be destroyed. Similar analogies based on property or personal relations—man is made in the image of God; the body is the “temple” of God; human beings are the servants or sentinels of God on earth—are often expressed.

All these notions aim to say that God has entrusted us with our lives, and that we have no right to repudiate that trust. But all are vulnerable to the objection that God has also supposedly given man free will, and if the “gift” of life has become so onerous, if it is one of excruciating pain and unending misery, for example, is the recipient really obliged to be so grateful? Who is morally culpable in this case, the person who wants to return this poisoned chalice, or the omnipotent and omniscient God who has chosen to impose it on the hapless recipient?

A more sophisticated religious argument, promulgated in the 18th century and still heard frequently today, is that suicide is “unnatural”, that it violates the natural order of the universe. God has created the world and its physical laws, and placed man in it. Suicide frustrates the divine scheme. In a celebrated essay on suicide, Hume, a great Scottish philosopher, thoroughly demolished this view.

He pointed out that almost any human action alters the natural order. “If I turn aside a stone which is falling upon my head, I disturb the course of nature, and I invade the peculiar province of the Almighty by lengthening out my life beyond the period which by the natural laws of matter and motion He had assigned it, ” he wrote. “It would be no crime in me to divert the Nile or Danube from its course, were I able to effect such purposes. Where then is the crime of turning a few ounces of blood from their natural channel?” To the argument that human life is a special exception, Hume's reply was blunt: “the life of man is of no greater importance to the universe than that of an oyster.” If one accepts the deist view of God as a “watch maker” who sets the world ticking and then does not intervene, Hume's conclusion seems irrefutable.

A second category of arguments against suicide is secular and involves, in one form or another, claims that we owe it to other people—family, friends or society as a whole—not to kill ourselves. In this view, suicide is always a supremely selfish act in that it ignores genuine obligations that all human beings have towards others. It is undeniable that most suicides have a devastating impact on family and friends. “Suicide kills two people,” Arthur Miller wrote famously in “After the Fall.” “That's what it's for!”

The anguish of survivors can be terrible. “The grieving process is much more difficult,” explains Stephanie Weber, the executive director of Suicide Prevention Services in Batavia, Illinois. “Not only do survivors have to cope with a sudden death, but one which has been intentionally inflicted by someone they love.” Survivors are often overwhelmed by guilt and anger at the same time—guilt that they were not able to prevent the suicide, and anger at the person for killing themselves. Their anger is frequently misdirected at police, medical staff and friends. “Eventually the anger does have to be directed at the person who died, and it can stay with you forever,” says Ms Weber. She speaks from personal as well as professional experience. She became a suicide counsellor after her own mother killed herself in 1979.

Given the high cost to survivors, any moral evaluation of many specific cases of suicide would condemn them on this score alone. And claims that many suicides are reneging on wider social obligations—by depriving the society which nurtured them of their talents and labour—might also be accepted as a good reason to condemn the suicide of some individuals. But arguments based on social obligations are curiously double-edged. For every case in which a suicide is opposed or condemned on grounds that it repudiates an obligation to others, a contrasting situation can be conjured in which suicide might actually fulfill such obligations.

The frail, old or seriously ill person whose care is a prolonged financial and emotional burden on others might, if social obligation is the primary yardstick, feel not only justified in killing themselves, but required to do so. In the past, many subsistence societies have in fact adopted this view, expecting old people to retreat to the wilderness to die when they can no longer contribute to the communal welfare. If similar standards were adopted by developed societies, prisoners, the disabled, drug addicts, the mentally ill, even the long-term unemployed—anyone, in short, who is dependent on others or can be described as a burden—might find themselves in a similar situation. Social obligation is a poor basis for a general condemnation of suicide because it can just as easily be used to justify, and even promote, suicide in certain circumstances.

This problem is avoided by another class of arguments against suicide based on the axiom that there is an intrinsic value to all human life, and that suicide is therefore wrong. This is a frequently voiced view and initially seems quite attractive. It is often expressed in religious terms, as the “sanctity” or “sacredness” of life, but does not necessarily require religious sanction to command respect. Immanuel Kant relied on man's rationality and capacity for moral choice to argue that it is wrong to treat any human being, even ourselves, as a means to some other end, and therefore wrong to kill ourselves to avoid pain or misery.

The value of gifts

Some such concept of the value of life itself is deeply engrained in western culture, and lies behind many contemporary public policies which are emphatically not utilitarian. Compulsory euthanasia of the severely disabled or the mentally impaired would be anathema to most people, whether or not those concerned are burdens on society as a whole or could ever lead meaningful lives. Medical care is given to the terminally ill, and expensive efforts are made to extend their lives. Long-term prisoners are not used for scientific experiments or the harvesting of transplant organs, although it could be argued that this would benefit society as a whole. Similarly, to commit suicide is wrong, goes this argument, because it rejects the intrinsic value of human life. Life is more than merely a utilitarian means to certain benefits. If these benefits become unattainable, life cannot be simply thrown away, even for the convenience of the person who holds it. A society which values life, therefore, should also condemn suicide.

But in practice the value of human life is not observed so absolutely. Few people are total pacificists, for example. Most societies sanction killing in war, for self-defence and, until recently, capital punishment. The rationale in all three cases is the saving of other lives. This also justifies the approval of heroic self-sacrifices such as the pilot who crashlands his plane to avoid a congested residential area or someone who gives up their place in a lifeboat to others. Although rarely described as such, these are a type of suicide.

Once sacrifice, or self-sacrifice, is conceded as a morally acceptable exception to the intrinsic value of human life, the principle collapses as an effective objection to suicide in general. Many suicidal people might, if they were disposed to argue their case, claim that they were, indeed, sacrificing themselves to save others, if not from imminent death, at least from a life blighted by the need to care for them. Moreover, if life is intrinsically valuable, the question arises: valuable to whom? The value of human life must consist in more than mere biological existence. If the holder of any individual life finds it no longer of value, then surely objections to that person's suicide based solely on the value of life carry little weight?

So there are problems with most of the common arguments used to justify a blanket disapproval of suicide. But those who would advocate a more tolerant attitude towards suicide in any future debate will also face obstacles. Their case must, in some sense, be based on the idea that a decision to commit suicide can be rational. Establishing this is more difficult than it appears.

The current medical model of suicide, which has spawned such a great increase in suicide-prevention and intervention efforts, denies absolutely that suicide, except for the terminally ill, can ever be a rational choice, and claims that society has an obligation to stop someone with an unbalanced mind from destroying themselves just as it would try to stop them from doing other harmful acts. The fact that suicide is utterly irrevocable just adds to the obligation to intervene.

There is a great deal of evidence for this view. Most people who fail at suicide, or who are rescued after an attempt, do not try to kill themselves again. Anti-depressant medication and counselling have helped many people banish suicidal thoughts. And yet the terminally ill also often have great difficulty in coming to a rational decision about whether they want to live or die. A study of 168 terminal-cancer sufferers published last month in the Lancet by researchers at the University of Manitoba in Canada found that their desire to go on living fluctuated greatly, depending largely on their experience of distressing symptoms. Given this, should not society reinforce the taboo against suicide and resist even a relaxation of laws against euthanasia?

There is also something peculiar about the very notion of “rational” suicide. Because no one really knows what comes after death, the idea that a rational weighing of costs and benefits can be ever be made seems nonsensical. Whatever comes after death, even if it is nothingness, may be worse than continuing to live even with the most excruciating pain; on the other hand, it may be better than anything that life has to offer even to the healthy and successful. No one this side of death really knows.

A successful defence of rational suicide lies in a more subtle argument often used by those advocating voluntary euthanasia and doctor-assisted suicide for the terminally ill. Prolonged, agonising deaths in which a patient's personality and sense of self-worth disintegrate can be degrading. Without these, life can seem meaningless. No one should be forced to continue suffering if they find their plight humiliating, their sense of selfhood destroyed. There are human values which trump even continued life.

Questions of dignity

This is a powerful argument, one which is widely recognised in other contexts, such as heroic self-sacrifice. Many people would choose death rather than kill their own children or take an active part in genocide, for example, or at least they like to think that they would make this choice. On a more mundane level, many people, while healthy and of sound mind, choose to sign “living wills” saying that they do not want to be kept alive with extraordinary medical measures. One reason may be the prospect of the pain involved. But another is clearly that many people are revolted by the image of themselves as helpless objects of pity.

A loss of the dignity and self-worth which gives life meaning also lies behind many suicides by physically healthy people. Does this make them rational? If retaining a sense of dignity or personal integrity can be a deciding factor for those who are terminally ill, it is difficult to see why it should not also apply to others as well. Those tormented by permanent mental illness, for example, often try to kill themselves. Perhaps, despite their mental illness, theirs is a rational choice. If they persist in it, even after repeated attempts to persuade them otherwise, why should not their desire to die command as much respect as that of someone with terminal cancer?

Extending the same reasoning to everyone, healthy or ill, would recreate in contemporary society an approach to suicide reminiscent of the Roman stoics, the Japanese samurai or the French Montagnards. They believed suicide was an honourable and perfectly rational option for anyone who found that they could no longer pursue a life that was meaningful to them or consistent with their self-respect. A few contemporary authors have even speculated that suicide could become the preferred end to life, because it permits individuals the maximum amount of choice over the timing, manner and painfulness of death. Such a shift in attitudes would represent a revolution, and would be bitterly resisted by many.

Another concept increasingly deployed by advocates of euthanasia and doctor-assisted suicide is that the terminally ill have a “right to die”—that is, not only a right to refuse treatment, but a right to obtain help in committing suicide. In 1997 the American Supreme Court found that there is no constitutional right to assisted suicide. But the court's ruling did not bar states from passing laws explicitly creating such a right if they chose to do so. If a right to die does eventually win legal recognition in more jurisdictions, as it has in the Netherlands, then once again it raises the question of why such a right should be confined to the terminally ill—a subject rarely explored by those advocating it. The rationale usually cited in their case is that patients facing imminent death should have control over their own fate, and that a society which respects individual autonomy, as liberal democracies claim to do, should respect this most intimate and personal of decisions. On the face of it, this seems justifiable.

But, in fact, the right to die is an idea with disturbing implications. Terminally ill patients are not the only people facing death. We all are. And if someone decides that life is no longer worth living—because of physical or mental pain, rejection by others, humiliation, despair or, for that matter, boredom—then autonomy will mean little if they have to wait until they are in the grip of terminal illness to claim a “right” as basic as the right to die. If Mr White, the Rochester quadriplegic, had not required a respirator, should he have been forced to continue living, or to resort to the extreme of self-starvation?

But what is the nature of this right? Is it a “negative” or “liberty” right, such as the freedom of speech or religion, requiring that others should not interfere with someone exercising it as long as that person is not injuring others? Or is it a “positive” right, such as the right to health care, education or a minimum standard of living, requiring that others, usually via the government, assist anyone exercising it? Many voluntary euthanasia campaigners believe that the right to die should be a positive right, requiring doctors to assist those who want to die.

Extending either kind of right to those who are not terminally ill would challenge many of today's settled attitudes. A “negative” right to die would limit suicide prevention efforts to those cases where some other factor—obvious mental illness or obligations to immediate family—could be cited to override it, and even then perhaps only until the person concerned had time to reflect on his or her decision. A “positive” right to die would require not just doctors, but the rest of us, to help suicides kill themselves.

Although this seems a preposterous suggestion, it does follow from many of the arguments put forward by those advocating euthanasia and physician-assisted suicide. They want to confine the right to die to the terminally ill. This will probably be the desire of most people. So why are euthanasia advocates required to make the case for doing this? Does it really matter that there are few good arguments for limiting the discussion in this way? Is a troubling debate about the wider issue of suicide inevitable?

Not inevitable perhaps, but likely. In liberal democracies, which rely on open and free debate to function, the logical implications of any public-policy argument are a power to be reckoned with. The values and choices of liberal societies sometimes defy logic, of course, but they are always open to challenge on rational grounds.

In their efforts to achieve a more humane end to life, euthanasia advocates have always recognised that they had to refute one “slippery slope” argument—that allowing euthanasia and assisted suicide could lead to coercion of the old and ill and a hastening of their death to suit the living. But they also face another “slippery slope” which few have yet recognised—that the arguments for euthanasia could lead to calls for the acceptance of suicide as morally valid not just for the terminally ill, but for many others as well. If the old taboo crumbles, what will replace it?

This article appeared in the Moreover section of the print edition under the headline "Let death be my dominion"

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