Suicide as a Moral Issue

Who Should Control When and How We Die?

“Suicide is an event that is a part of human nature. However much may have been said and done about it in the past, every person must confront it for himself anew, and every age must come to its own terms with it.”

—Johann Wolfgang von Goethe (1749–1832)

Behind Goethe’s simple statement lies a profound truth: dying voluntarily is a choice intrinsic to human existence. It is our ultimate, fatal freedom. That is not how the right-thinking person today sees voluntary death: he believes that no one in his right mind kills himself, that suicide is a mental health problem. Behind that belief lies a transparent evasion: relying on physicians to prevent suicide as well as to provide suicide—and thus avoid the subject of suicide—is an evasion of personal responsibility fatal to freedom.

Not long ago the right-thinking person believed that masturbation, oral sex, homosexuality, and other “unnatural acts” were medical problems whose solution was delegated to doctors. It took us a surprisingly long time to take these behaviors back from physicians, accept them comfortably, and speak about them calmly. Perhaps the time is ripe to rethink our attitude toward suicide and its relation to the medical profession, accept suicide comfortably, and speak about it calmly. To accomplish this, we must de-medicalize and destigmatize voluntary death and accept it as a behavior that has always been and will always be a part of the human condition. Wanting to die or killing oneself is sometimes blameworthy, sometimes praiseworthy, and sometimes neither; it is not a disease; it cannot be a bona fide medical treatment; and it can never justify deprivation of liberty.

Death Transformed

Increasing life expectancy, advances in medical technology, and radical changes in the regulation of drug use and the economics of health care have transformed how we die. Formerly, most people died at home. Today, most people die in a hospital. Formerly, patients who could not breathe or whose kidneys or livers or hearts failed to function died. Now, they can be kept alive by machines, transplanted organs, and immunosuppressive drugs. These developments have created choices not only about whether to live or die but also about when and how to die.

Birth and death are unique phenomena. Absent celibacy or infertility, practicing birth control—that is, procreating voluntarily—is a personal decision. Absent accidental or sudden death, practicing death control—that is, dying voluntarily—is also a personal decision. The state and the medical profession no longer interfere with birth control. They ought to stop interfering with death control.

As individuals, we can choose to die actively or passively, practicing death control or dying of disease or old age. As a society, we can choose to let people die on their own terms or force them to die on terms decreed by the dominant ethic. Camus maintained that suicide is the only “truly serious philosophical problem.” It would be more accurate to say that suicide is our foremost moral and political problem, logically anterior to such closely related problems as the right to reject treatment or the right to physician-assisted suicide.

Faced with a particular personal conduct, we can approve, facilitate, and reward it; disapprove, hinder, and penalize it; or accept, tolerate, and ignore it. Over time, social attitudes toward many behaviors have changed. Suicide began as a sin, became a crime, then became a mental illness, and now some people propose transferring it into the category called “treatment,” provided the cure is under the control of doctors.

Crucial Questions

Is killing oneself a voluntary act or the product of mental illness? Should physicians be permitted to use force to prevent suicide? Should they be authorized to prescribe a lethal dose of a drug for the purpose of suicide? Personal careers, professional identities, multibillion-dollar industries, legal doctrines, judicial procedures, and the life and liberty of every American hang on how we answer these questions. Answering such questions requires no specialized knowledge of medicine or law. It requires only a willingness to open our eyes and look life—and death—in the eye. Evading that challenge is tantamount to denying that we are just as responsible for how we die as we are for how we live.

The person who kills himself sees suicide as a solution. If the observer views it as a problem, he precludes understanding the suicide just as surely as he would preclude understanding a Japanese speaker if he assumed that he is hearing garbled English. For the person who kills himself or plans to kill himself, suicide is, eo ipso, an action. Psychiatrists, however, maintain that suicide is a happening, the result of a disease. Against this mindset, the view that, a priori, suicide has nothing to do with illness or medicine, which is my view, risks being dismissed as an act of intellectual know-nothingness, akin to asserting that cancer has nothing to do with illness or medicine.

We are proud that suicide is no longer a crime, yet it is plainly not legal; if it were, it would be illegal to use force to prevent suicide and it would be legal to help a person kill himself. Instead, coercive suicide prevention is considered a life-saving treatment and helping a person kill himself is (in most jurisdictions) a felony.

Supporters and opponents of policies concerning troubling social issues—such as slavery, pornography, abortion—have always invoked a sacred authority or creed to justify the policies they favored. Formerly, God, the Bible, the Church; now, the Constitution, Law, Medicine. It is an unpersuasive tactic: too many deplorable social policies have been justified by appeals to Scriptural, Constitutional, and Medical sanctions.

The question of who should control when and how we die is one of the most troubling issues we face today. The debate is in full swing. Once again, the participants invoke the authority of the Bible, the Constitution, and Medicine to cast the decisive ballot in favor of their particular program. It is a spineless gambit: persons who promote particular social policies do so because they believe that their policies are superior to the policies of their adversaries. Accordingly, they ought to defend their position on the grounds of their own moral vision, instead of trying to disarm opponents by appealing to a sanctified authority.

For a long time, suicide was the business of the Church and the priest. Now it is the business of the State and the doctor. Eventually we will make it our own business, regardless of what the Bible or the Constitution or Medicine supposedly tells us about it.