Category Archives: Physician Assisted Suicide

(1938 – )

What Counts as Suicide? It’s Not So Easy to Say


Peter Y. Windt, formerly associate professor of philosophy at the University of Utah and former chairman of the department, has worked on many problems in bioethics, especially the ethics of (re)designing human nature; philosophical method and problems of informal logic; and problems in epistemic justification.

Windt’s analysis of the concept of suicide suggests that disagreement over the definition of “suicide” leads to confused thinking and thus to confused social policy. Arguing that the concept of suicide is “open-textured,” he provides a Wittgensteinian analysis of the concept “suicide” in terms of criteria, characteristics in virtue of which an event is a suicide, but which are neither necessary nor sufficient conditions. Thus, to suppose that the term ‘suicide’ always has a core, clearly definable meaning,  or that deaths can be clearly classified as suicide or not, is mistaken. Prof. Windt was influential in the genesis of this collection of historical sources.

Peter Y. Windt, adapted from “The Concept of Suicide,” in M. Pabst Battin and David J. Mayo, eds., Suicide: The Philosophical Issues, New York: St. Martin’s Press, 1980, pp. 39–47.



What counts as suicide? In many disputes over social practices, opponents call the act suicide; proponents call it something else, for example, self-sacrifice, self-caused accident, martyrdom, heroism, self-deliverance, self-defense, aided dying, and so on. This is because the very term ‘suicide’ often has strongly negative connotations, while alternative terms may have comparatively positive associations. If we are to make moral claims about the ethics of suicide, we need to have some idea of what counts as suicide; but this is a harder problem than it may seem.

Consider, then, what must be the case in order for an act to count as suicide. It might be thought that death must occur in all cases of suicide. But where an attempt at suicide (say, by shooting) results in enough brain damage to destroy the personality, or where abuse of alcohol or other drugs produces radical destruction of memory and character, we sometimes are tempted to speak of suicide, even though the body survives. If calling such cases suicides is not mere metaphor or exaggeration, then death of the organism will not be a necessary condition of suicide (however, we might then make a case for death of the person as a necessary condition). To sidestep the debate about the nature of persons and the definition of death, let us suppose, tentatively, that death, either of the person or of the organism, is a necessary condition of suicide.

If we concede that death is a necessary condition of suicide, then we also may want to concede that another necessary condition is the applicability of some reflexive description of the death. One such description would be that one has killed oneself. In other cases it is more appropriate to say one has gotten oneself killed; and in still other cases that one has let oneself be killed. For example, one may commit suicide by shooting oneself deliberately and with premeditation (killing oneself). Or one may commit suicide by ordering a servant to do the job (getting oneself killed). Or, on falling into a river, one may opt for suicide and refuse to swim (letting oneself be killed). One might even kill oneself by deliberately starting a fight, offering little resistance, and thereby letting oneself by killed (as intended), getting oneself killed, and committing suicide—all at once. Thus, while some cases of suicide might involve the deceased being killed by someone else or someone else’s getting him killed or letting him be killed, the deceased must also kill himself or get himself killed or let himself be killed.

But the applicability of one or more of these descriptions is not a sufficient condition of suicide. One who drives into a rock wall, mistaking a late-evening shadow for a tunnel entrance, has killed himself. It is less natural to say he has gotten himself killed, and wrong to say he has let himself be killed. One who comes between a grizzly bear sow and her cubs while trying to photograph them may get himself killed, but not kill himself (the bear does that) nor let himself be killed (he puts up a good fight, under the circumstances). A prisoner may let himself be killed, rather than give information, but does not thereby get himself killed, nor kill himself. None of these cases should be counted as suicide.

Then what other features distinguish suicide from other kinds of death? The literature on suicide mentions several factors: that death was caused by the actions or behavior of the deceased; that the deceased wanted, desired, or wished death; that the deceased intended, chose, decided, or willed to die; that the deceased knew that death would result from his behavior; that the deceased was responsible for his death. My contention is that all these factors are criteria of suicide, rather than necessary or sufficient conditions.

To analyze the concept of suicide in this way is to approach the question of what is suicide as the philosopher Ludwig Wittgenstein [q.v.] would, by offering an account that is open-textured. This means that characteristics of cases of suicide may be found which are definitional, in the sense that they really are the characteristics by virtue of which an event is a suicide, but which are neither necessary nor sufficient conditions for an event’s being a case of suicide—that is, for each such characteristic, cases of suicide may be found which do not have the characteristic, and cases may be found of events which have the characteristic but are not cases of suicide. Such characteristics are criteria of suicide. If the concept of suicide is open-textured, then, it must involve some criteria. This is not to deny that some definitional characteristics of suicide may be necessary conditions, nor is it to deny that some complex combination of characteristics of suicide may constitute a sufficient condition. It is to deny that there is some nuclear set of characteristics which is to be found in all cases of suicide—some core, indispensible characteristics–and in no other cases.

The claim that a concept is open-textured need not indicate that it is arbitrary, vague, or inconsistent. While different criteria may be involved in different cases, we should expect to find similarities among the whole family of cases which justify their assimilation under a single concept. Such similarities will be the result of different combinations of criteria (and any necessary conditions) under different circumstances. And, because similarity is capable of degrees and variations, we might expect to find that some cases of suicide are paradigms, while others, though still genuine cases of suicide, exhibit various atypical characteristics. And we can expect to encounter borderline cases which are similar to typical cases of suicide in some respects, dissimilar in others, so that we simply do not know whether to count them as suicides or not.

How do open-textured accounts work? Let us suppose, for example, that a man has gone hiking along a primitive trail which at one point employs a slender log as a bridge, crossing a very swift stream. At this point on the trail, he ventures out onto the log, falls into the stream, and drowns. What kinds of details about this case would determine that it was a case of suicide, and what kinds of details would determine that it was not?

We should note that if he is in high spirits, generally satisfied with his lot, cheerfully thinking of his plans for the evening, loses his balance because the log shifts under his feet, and tries valiantly to swim to safety, then there will be no question of suicide and the death will be accidental. Or, if he is in despair, wants to die, has planned to do so at that spot by drowning, deliberately leaps from the log and makes no effort to swim, we will have no hesitation in calling his death a suicide. The cases which need careful consideration are those in between, in which only some of the factors in question are present.

Suppose our victim suffers from depression and wants to die, although he has formed no plans for his death. Accidentally, he slips on the log and falls in. But then he refuses to swim and lets himself drown. Here we have a suicide, but no significant causation by the deceased. On the other hand, suppose that he has no depression or inclination to die, but believes falsely that he can swim the stream safely. He leaps in to cool off and is drowned. Here his actions do cause his death, but it is not a suicide. The difference between these two cases rests on the presence or absence of the desire to die and the decision to do so.

But now suppose that our victim has been suffering for some time from a recurring compulsion to commit suicide. He fears this compulsion, desires not to succumb to it, has sought aid in combatting it, but it grows in him as he hikes this day, and at the bridge it drives him into the water and to his death. Although this counts as a case of suicide, the very nature of the compulsion and his struggle with it indicates that he did not desire to die nor intend to do so. In fact, the compulsion operated against his will. Thus, wanting, willing, intending, or deciding to die are not necessary conditions of suicide. In this case we should note that the operant criteria seem to be that his actions did cause his death and that he knew that death would result from them. (We should distinguish this case from one in which he has a compulsion to jump without regard to consequences, in which he would have jumped compulsively but died accidentally as a result. Compulsive suicide requires knowledge of the fatal consequences likely to result from the compulsive behavior.)

If our victim has the intention or desire to die sometime that day but has not decided yet how it should happen, or has decided that it should happen, say, by poison, later on, then he might slip, fall off the log and drown by accident. But what if he specifically wants to or intends to die by jumping off the log and drowning? Suppose that, as he is poised to jump, composing himself and gathering his willpower, a fierce gust of wind upsets him and he falls (not jumps) into the stream. Confused by the unexpected shock of the cold water, he swims as strongly as he can for shore, but drowns anyway. Although he has died as he intended, his death is accidental. Here the absence of fatal causation by the deceased is significant.

In these cases, whether or not a death due to compulsive behavior was suicide depended upon whether the deceased knew that the result of the compulsive behavior would be fatal. But such knowledge is not a necessary condition of suicide. Suppose that our victim is moody, depressed, and decides to leap from the log and try to swim the stream. He is not sure that he will survive, and not sure that he won’t. If he does, he is prepared to take it as a good omen and thinks he will return to his normal life with renewed vigor. If he dies, he supposes that it will be just as well. He is leaving his fate up to chance, the gods, or whatever. Here he cannot be said to have known that he would die; nevertheless, we will count his death as a suicide. But, of course, the kind of knowledge in question is not sufficient to determine that a death is suicide: our victim may know perfectly well that falling into the stream would be fatal for him, fall accidentally, and not have committed suicide.

Finally, what of responsibility? Before considering examples, we should realize that the claim that a person is responsible for an event can mean many different things. It sometimes means that the person has caused the event for which he is responsible. Sometimes to say that a person is responsible is also to say that he is rational, has an adequate grasp of reality, understands his situation, acts within acceptable parameters, and so on. Our victim might have been clearly not responsible in this sense (he may have been suffering from a variety of neuroses or incapacities) and still could have committed suicide by throwing himself from the log. Or, on the other hand, he could have been fully responsible in this sense and have died accidentally by falling from the log. Still, this sort of responsibility is not totally irrelevant to questions about suicide. For example, if our victim thought he could breathe water as easily as air, his killing himself by leaping into the stream would not be a case of suicide. But the significance of this kind of diminished capacity may be only that it reveals lack of knowledge or intention, and, thus, no new criterion is found here.

Again, we might consider whether a person is morally responsible, that is, morally liable for an action. If he were careless or negligent in attempting to cross the stream, then, our victim would be morally responsible for his accidental death. But he would not be morally responsible for the compulsive suicidal death already described. Since the question of one’s moral liability often is a question of one’s intentions, actions, and motives with respect to some behavior, and since intentions, causality, and motives are criterial for suicide, there will be a close connection between the determination of moral responsibility for some deaths and the determination that they are suicides.

It may be felt that there is still some other sense of responsibility in which it must be true of all suicides that the deceased is responsible for his own death. But I think this will turn out to amount to nothing more than a necessary condition already admitted tentatively, namely, that some reflexive description of the death be true. To say that the deceased killed himself, got himself killed, or let himself be killed, perhaps, is to attribute to him some minimal sort of responsibility for his death.

If the concept of suicide is open-textured, as I have argued, can anything be said generally about the similarities which knit the cases of suicide into a single family? It is tempting to reply that what all suicides have in common is just that they are suicides, and that the account of criteria, and the circumstances in which they are significant, is the account of the similarities which connect the various cases. That account, of course, should consider many more situations and circumstances than those given here, and, indeed, the account may be open-ended, so that some further elucidation of significant details always may be possible. But perhaps one useful, if somewhat vague, remark can be made about the similarities cases of suicide bear to one another.

In suicide we find a peculiar negation of the value of life. Of all persons, we should expect he whose life it is to be most sensitive to the value of a life; but in suicide, it is that very person who allows the value of his life to be overridden by other factors. The overriding of the value of the lives of others found in homicide is, somehow, less puzzling, perhaps even less awesome. To understand the suicide, we must understand how this negation of the value of one’s own life is possible. But, of course, while this may say something about the way in which suicides are similar, it does not take us very far. The negation of the value of life occurs in too many ways. In some cases a life really may not be worth living further; in others delusion and irrationality may only make it seem so; in still others something of greater worth may be achieved by sacrificing life; and so on. The sense of negation of the value of life thus invoked is itself open-textured.

Failure to appreciate the open texture of the concept of suicide will result in distortion of our views as to what is and what is not suicide. Definition of the concept in terms of some nuclear set of characteristics may err in excluding some genuine cases of suicide from our consideration, or including cases which are not suicides, or distorting our conception of the nuclear features themselves, so that we may seem to find them just where our strong intuitions about what suicide is tell us they may be.

Consider, as just one among many possible instances of error, the following speculative scenario: Suppose we became convinced that suicide could be defined, say, as self-caused death, where there is a wish to die on the part of the victim. Such a conviction would lead us to ignore the importance of intention or choice. In that case, we would refuse to count as suicides cases in which persons have no wish to die but intentionally do let themselves die, e.g., persons who refuse lifesaving medical treatment because they find the conditions of continued existence (impairment, suffering, etc.) worse than death itself. Such persons intend to die but need not wish to do so—they may find death the least undesirable of the choices available to them. Or, again, we might be led to count as cases of suicide cases of accidental death, e.g., a person who desires to die and unintentionally causes his own death by driving carelessly—the crucial error here being the supposition that there must be some causal connection between the desire and the death.

Or, what is ultimately most dangerous, we might begin to distort our conception of wishing or desiring, incorporating into it aspects of intention and causality. Thus, we might presume that intention to die always reveals a wish to die—in some cases so thoroughly suppressed that it can be detected in no other way save through the intentional self-destructive act. And we might attribute the wish to die an exaggerated causal efficacy, so that where it is present and death occurs, we presume that it must have been the cause of death. But this distortion of what it is to wish to die, combined with the view that all suicides involve this wish, might tend to seduce us into regarding suicide as a medical or behavioral problem, its victims suffering from a desire with which they cannot cope and which will cause their destruction unless some intervention is successful. At this point suicidal behavior would be regarded as a symptom of an illness, and the questions simply would not be raised whether it is intentional or not, rational or not. And so we would not hesitate to intervene, to treat, to commit; for we would see ourselves as rescuing victims rather than as interfering with deliberate, intentional actions. And at this point we would have not only theoretical error but a risk of unjust treatment of persons.

Now this scenario is far too speculative and simple to be an adequate account of any widely held theories or practices regarding suicide. It merely indicates ways in which an incorrect definitional stance on suicide can tend to contribute to error in such theories and policies. But the scenario is not sheer fantasy, either, for such tendencies have played a part in the development of some views of suicide which treat it as such, e.g., always having its origin in a death wish, or in depression, or even as always involving failure of the individual to cope with his situation. But we claim, on the contrary, that in some situations death is the best method of coping, as proponents of aid-in-dying may claim: when suffering in terminal illness leaves no alternative that the person views as acceptable, “suicide” is a method of coping that ought to be honored by the medical profession and by others in general. It may be a full-fledged choice even when it is not an actual wish to die.

Of course, recognition of the open-textured character of the concept of suicide will not, by itself, insure accurate assessment and just treatment of suicides and suicidal individuals or of individuals whose lives end in ways that might be labeled “suicide” but not appropriately so. But it is one step in the right direction.

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Filed under Americas, Physician Assisted Suicide, Selections, The Modern Era, Windt, Peter Y.

(1930– )

from Reason, Self-determination, and Physician-Assisted Suicide


Educated at Yale, Georgetown, and Harvard, Daniel Callahan was a cofounder of The Hastings Center, the first institute for bioethics, in 1969, and served as its president from 1969–1996. Callahan’s interests in bioethics range from the beginning to the end of life, and in later years have focused on health policy and research policy with an increasing concern for global issues. He is the author or editor of some 40 books. Particularly influential has been Setting Limits: Medical Goals in an Aging Society, which launched an extensive discussion of intergenerational justice and the appropriate limits of health care for the elderly.

In the article excerpted here, Callahan responds to the claims of those supporting legalization of physician-assisted suicide in terminal illness. Callahan argues against this view on three grounds: that euthanasia and assisted suicide are evil, or more accurately, “morally mistaken”; that while physical pain and psychological suffering in the terminally ill are to be alleviated, assisted dying is not the way to do it; and that allowing physician-assisted suicide will risk wider killing based on “private standards of a life worth living”—the slippery slope argument. These are among the most prominent arguments in the case against legalization of assisted dying.

Daniel Callahan, “Reason, Self-determination, and Physician-Assisted Suicide,” in Kathleen Foley and Herbert Hendin, eds., The Case against Assisted Suicide: For the Right to End-of-Life Care. Baltimore and London: Johns Hopkins University Press, 2002, pp. 52–68. Biographical material in the introductory passage from The Hastings Center.



Claiming the right to control our bodies and our lives is characteristically American. “Give me liberty or give me death” is a part of our history. It could thus well be said that the physician-assisted suicide movement represents the last, definitive step in gaining full individual self-determination: “Give me liberty and, if I want it, give me death.” As a movement, physician-assisted suicide seeks to reassure us that we can die as we choose and, with a physician’s expert help, be certain that we will die in the most technically expeditious fashion.

However mistaken in its direction and emphasis (as I will argue it is), a turn to physician-assisted suicide is a perfectly understandable response to the increased difficulty of dying a peaceful death, a dying ever more ensnared in technological and moral traps. First, there are all the cultural and medical obstacles now thrown in the way of simply allowing people to die from disease. Medicine tends to conflate the value of the sanctity of life and the technological imperative, rendering an acceptance of death morally suspect. Moreover, by increasingly judging all deaths to be events for which humans can and should take responsibility, we are blurring the distinction between killing and allowing to die; there is now every incentive to seek final and decisive control over the process of dying. Physician-assisted suicide seems to present the perfect way to do just that.

The physician-assisted suicide movement rests on two basic claims, secondarily supported by other considerations as well. Those claims are our right to self-determination and the obligation we all owe to each other to relieve suffering, but especially the obligation of the physician to do so. The movement’s deepest point might simply be understood as this: If we cannot trust disease to take our lives quickly or peacefully, and we cannot rely on doctors to know with great precision how or when to stop treatment to allow that to happen, then we have a right to turn to more direct means. In the name of mercy, physicians should be allowed to end our lives at our voluntary request, or, alternatively, be permitted to put into our hands those means that will allow us to commit suicide. We will then be assured a peaceful death, one that we have fashioned for ourselves. For the peaceful death no longer (and never assuredly and perfectly) given us by nature, we must shape, by our choice, a death of our own making.

This is a dangerous direction to go in the search for a peaceful death. This path to peaceful dying rests on the illusion that a society can safely put in the hands of physicians the power directly and deliberately to take life, euthanasia, or to assist patients in taking their own life, physician-assisted suicide. (I see no moral difference between them—just as the law in most places would see no difference between my shooting someone and my giving a gun to another so he or she can do it.) It threatens to add still another sad chapter to an already sorry human history of giving one person the liberty to take the life of another. It perpetuates and pushes to an extreme the very ideology of control—the goal of mastering life and death—that created the problems of modern medicine in the first place. Instead of changing the medicine that generates the problem of an intolerable death (which, in almost all cases, good palliative medicine could do), allowing physicians to kill or provide the means to take one’s own life simply treats the symptoms, all the while reinforcing, and driving us more deeply into, an ideology of control.

The suffering that leads people to embrace physician-assisted suicide can seem compelling: prolonged agony; a sense of utter futility; pain that can be relieved only at the price of oblivion; a desperate gasping for breath that, if relieved, will be followed again and again by the same gasping; or the prospect of months or years in a nursing home, or dependent on a trapped, overburdened family member. The possibilities of suffering, physical and psychological, should not be minimized, and I do not want to rest my resistance to physician-assisted suicide on any slighting of that kind. I can well imagine situations that could drive me to want such relief or feel driven to want it for others. The movement to legalize euthanasia and assisted suicide is a strong and, seemingly, historically inevitable response to that fear. It draws part of its strength from the failure of modern medicine to reassure us that it can manage our dying with dignity and comfort. It draws another part from the desire to be masters of our fate. Why must we endure that which need not be endured? If medicine cannot always bring us the kind of death we might like through its technical skills, why can it not use them to give us a quick and merciful release?

The Relief of Suffering: Virtues and Duties 

No moral impulse seems more deeply ingrained than the need to relieve human suffering. It is a basic tenet of the great religions of the world. It has become a foundation stone for the practice of medicine, and it is at the core of the social and welfare programs of all civilized nations. Unless we have been brutalized, our feelings numbed by cruelty or systematic indifference, we cannot stand to see another person suffer. The tears of another, even a total stranger, can bring tears to our own eyes. At the heart of the virtue of compassion is the capacity to feel with, and for, another. With those closest to us, that virtue often leads us to feel the pain of another as if it were our own. And sometimes it is stronger than that: it is a source of intensified anguish that we cannot lift from another the pain we would, if we could, make our own. A parent feels that way about the suffering of a child, and a spouse or friend about the suffering of a loved one who is trapped by pain that cannot be moved from one body to another.

Yet for all the depth of our common response to suffering, and our general agreement as a civilized society that it should be relieved, the scope and depth of that moral duty are not clear, especially for physicians. The problem of physician-assisted suicide forces us to answer a hard question: Ought the general duty of the physician to relieve suffering encompass the right to assist a patient to take his or her own life if that is desired and seems necessary? The question can be put from the patient’s side as well: Is it a legitimate moral request for a patient to ask a doctor for assistance in committing suicide?

But there is an even more fundamental question that must be explored before turning to those questions: What should be done in response to such suffering? Is it simply a nice thing to relieve suffering if we can, a gesture of charity or kindness worthy of praise? We might say that our impulse of compassion is a good to be cultivated and expressed—that we will all be better off if we entertain that as an ideal in our lives together. Or is there more to it than that? Might it be that the relief of suffering is a moral duty, not just a noble ideal, to which we are obliged even if our sense of compassion is faint, even if what is asked of us might cause some suffering on our own part? How far and in what way, that is, does our duty extend in the relief of suffering, and just what kind of suffering is encompassed within such a duty?

One common answer to such questions is that we are, at the least, obliged to relieve the suffering of others when we can do so at no high cost to ourselves, and that we should do so when the suffering at stake is unnecessary. But that does not tell us much that is helpful, though it is surely important to repeatedly remind ourselves and others of such obligations. The hard cases are those in which the demands on us may be morally or psychologically stressful, and in which there is uncertainty about the significance of the suffering.

It is useful to distinguish two kinds of burdens. In one, the demand on us is to act, to do something specifically to relieve the suffering. That may mean giving our already overcrowded time just to be with someone in pain, someone whose first need is for companionship, for closeness; or providing otherwise needed money to improve the nursing care of a dying parent; or taking the trouble to find a better doctor, or hospital, for a spouse receiving poor care. Demands of that kind can be heavy, pressing our sense of duty to the limit; sometimes it can be unclear just where the limit is.

The other burden is subtler: the need to discern when suffering cannot, or should not, be wholly overcome, when our duty may be to accept the suffering of another, just as the person whose suffering it is must accept it. Many legitimate moral demands, for instance, will carry with them the possibility of suffering, and they should not for that reason be shirked. To take an unpopular position, to stand up for one’s rights, to remain true to one’s promises and commitments can all entail unavoidable suffering. A parent’s commitment to the good of a child may require, and probably will at times require, that for the sake of the child’s development the parent accept the need for the child to bear the penalties of his or her own choices and mistakes, and thereby to suffer as a parent is watching that happen. The same can be said of many other human relationships—those with friends, lovers, husbands, and wives. As bystanders to the suffering, we have to accept its unavoidability for the sufferer. We cannot relieve that suffering. The demand in some cases is to accept the suffering that another must endure, not run from it. Patience, loyalty, steadfastness, and fortitude are called for in accompanying the persons who must suffer, to help and allow them to do and be what they must, however heavy the burden on them and others. We are called on to suffer with the other, to be a supportive presence.

For just those reasons it cannot be fully correct to say that our highest moral duty to each other is the relief of suffering. More precisely, our duty is to enhance one another’s good and welfare, and the relief of suffering will ordinarily be an important way to accomplish that. But not always. What we need to know is whether the suffering exists because without it some other human good cannot be attained; and that is exactly the case with the suffering caused by living out one’s moral duties or ideals for a life.

Therein lies the ambiguity of the term “unnecessary suffering,” frequently invoked as the kind of suffering physician-assisted suicide can obviate. Suffering will surely be “unnecessary” when it serves no purpose, when it is not an inextricable part of achieving important human goals. Unavoidable necessary suffering, by contrast, is that which is the essential means, or accompaniment, of valuable human ends, and not all suffering is. Yet the real problem here is in deciding on our goals, and the hardest choice will be in deciding whether, and how, to pursue goals that may entail suffering. If we make the avoidance or relief of suffering itself the highest goal, we run the severe risk of sacrificing, or minimizing, other human purposes. Life would then be focused on avoiding pain, minimizing risk, and craftily eying all possible life projects and goals in light of their likelihood of producing suffering.

If that is hardly desirable in the living of our individual lives, it is no less problematic in devising social policy. A society ought, so far as it can, to work for the relief of pain and suffering; and that is to state a simple moral principle. But a more complex principle is needed: A society should work to relieve only suffering that is not an unavoidable part of living out its other values and aspirations. That means it must ask, on the one hand, what those values are or should be and, on the other, what policies for the relief of suffering might subvert society’s general values.

The most profound question we must then ask is this: If the suffering of illness and dying comes from the profound assault on our sense of integrity and self-direction, what is the best way we can—as those who give care, who want to do right by a person—honor that integrity? The claim of proponents of physician-assisted suicide is that the assault of terminal illness on the self is legitimately relieved, even mercifully and honorably so, by recognizing the right to self-determination to end that life.

Yet notice what we have accepted here. It is the idea that our integrity can be served only by the self-determination that brings death, by the direct implication of another in our death, and by accepting the implicit assumption that the suffering is “unnecessary”—meaningless, avoidable. To accept that comes close to declaiming that life can have meaning only if marked by self-determination, a strange notion indeed, flying directly in the face of human experience. That experience shows that a noble and heroic life can be achieved by those who have little or no control over the external conditions of their lives, but have the wisdom and dignity necessary to fashion a meaningful life without it. We would also be declaring that a life not marked by self-mastery, self-determination, is a meaningless one once burdened with unwanted suffering. It is not for nothing perhaps that modern medicine in its quest for cure has itself contributed to the harmful idea that all suffering is pointless, representing not life and its natural condition but the failure of medicine to overcome, or relieve, that suffering.

Is Self-empowerment Socially Neutral? 

But might it not be said, in response, that permitting physician-assisted suicide would not involve taking a general position on the meaning of life, death, and suffering, but only empowering each individual and his or her physician-accomplice to make that determination? Would it not be, in that sense, socially neutral? Not at all. To establish physician-assisted suicide as social policy is, first, to side with those who say that some suffering is meaningless and unnecessary, to be relieved as decisively as possible, and that only individuals can determine what such suffering is; and, second, to say that such a highly variable, highly subjective matter is best left to the irrevocable judgment of doctor and patient. That is not a neutral policy at all, but one that makes a final judgment about what constitutes an appropriate, socially acceptable response to dying (the mutually agreed-on deliberate death of a person) and about social policy (the legitimation of physician-assisted suicide as a response to perceived threats of suffering and loss of self-integrity).

A great hazard of this approach is that it declares some forms of human suffering—but only those forms determined by private, variable responses—to be so beyond human help and caring that they are open only to death as a solution. It is, moreover, a striking break with both the medical and moral traditions of medicine to treat the desires and wishes of patients as if they alone legitimate a doctor’s skills. It is to make doctors artisans in the fashioning of a patient’s life (and in this case death), a role well beyond the traditional role of medicine, which has been to restore and maintain health.

There is little disagreement about the duty of the physician to relieve physical pain, even though there are some significant disputes about how far that effort should go. Of more pertinence to my concern here, however, is the extent of the duty of the physician to relieve suffering, that is, to try to relieve the psychological or spiritual condition of a person who as a result of illness suffers (whether in pain or not). I contend that the duty is important but limited.

Two levels of suffering can be distinguished. At one level, the principal problem is that of the fear, uncertainty, dread, or anguish of the sick person in coping with the illness and its meaning for the continuation of life and intact personhood—what might be called the psychological penumbra of illness. At a deeper level, the problem touches on the meaning of suffering for the meaning of life itself. The question here is more fundamental: What does my suffering tell me about the point or purpose or end of human existence, most notable my own? The questions here are no longer just psychological but encompass fundamental philosophical and religious matters.

The physician should do all in his or her power to respond, as physician, to the first level, but it is inappropriate, I contend, to attempt to solve by lethal means the problems that arise at the second level. What would that distinction mean in practice? It means that the doctor should, through counseling, pain relief, and cooperative efforts with family and friends, do everything possible to reduce the sense of dread and anxiety, of disintegration of self, in the face of a threatened death. The doctor should provide care, comfort, and compassion. But when the patient says to the doctor that life no longer has meaning, or that the suffering cannot be borne because of its perceived pointlessness, or that a loss of control is experienced as an intolerable insult to a patient’s sense of self—at that point the doctor must draw a line. Those problems cannot properly be solved by medicine, and it is a mistake for medicine even to attempt to solve them.

The purpose of medicine is not to relieve all the problems of human mortality, the most central and difficult of which is why we have to die at all or die in ways that seem pointless to us. The purpose of medicine is not to give us control over our human destiny, or to help us devise a life to our private specifications—and especially the specification most desired these days, that of complete control of death and its circumstances. That is not the role of medicine because medicine has no competence to manage the meaning of life and death, only the physical and psychological manifestations of those problems.

Medicine’s role must be limited to what it can appropriately do, and it has neither the expertise nor the wisdom necessary to respond to the deepest and oldest human questions. What it can do is relieve pain and bring comfort to those who psychologically suffer because of illness. That is all, and that is enough. When physicians would use medical knowledge, designed to help with that task, to directly cause death as a way of solving a patient’s problems with life and mortality itself, they go too far, exceeding their own professional and moral rights. There has been a longstanding, historical resistance to giving physicians the power to assist in suicide precisely because of the skill they could bring to that task. Their technical power to help death along must not be matched by a moral or legal authority to engage in physician-assisted suicide; that would open the way for a corruption of their vocation.

I do not claim that a sharp and precise line can always be found between the two levels of suffering, but only that some limits can be feasibly set to enable us to say when the physician has strayed too far into the thickets of the second level. For ordinary purposes, it remains appropriate to speak of the duty of the physician to “relieve pain and suffering,” but only as long as it is understood that this can be done to relieve only the problems of illness, not the problems of life itself. What life itself may give us, at its end, is a death that seems, in the suffering it brings, to make no sense. That is a terrible problem, but it is the patient’s problem, not the doctor’s. The doctor can, at that point, relieve pain, make the patient as comfortable as possible, and be another human presence. Beyond that, the patient must be on his or her own. Patients have no resource left but themselves at that point.

Suffering and Subjectivity 

There is also another side to the issue. When physician-assisted suicide is requested, the doctor is being asked to act on the subjective suffering of another—variable from person to person, externally unverifiable, and always in principle reversible—with an action that will be objective and irreversible. As the human response to evil and suffering suggests, there is nothing in a particular burden of life, or in the nature of suffering itself, that necessarily and inevitably leads to a desire to be dead, much less a will to bring that about. That will and must always be a function of the patient’s values and the way those values are either legitimated or rejected by the culture of which that patient is a part. Suffering in and of itself is not a good clinical predictor of a desire to be dead, which is why depression or a history of previous mental health problems is a far better predictor of a serious desire for suicide than illness, pain, or old age is. Thus we face a complex double challenge: to determine if, under those ambiguous circumstances, we should empower one person to help another to kill him- or herself; and if so, what the moral standard should be for the one who is to do the helping.

Physician-assisted suicide is mistakenly understood as only a personal matter of self-determination, the control of our own bodies, not to be forbidden since it is only a small step beyond our no longer forbidding suicide. But unlike unassisted suicide, an act carried out solely by the person, physician-assisted suicide should be understood as a social act. It requires the assistance of someone else. Legalizing physician-assisted suicide would also provide an important social sanction for suicide, tacitly legitimating it, and affecting many aspects of our society beyond the immediate relief of individual suffering. It would in effect say that suicide is a legitimate and reasonable way of coping with suffering, acceptable to the law and sanctioned by medicine. Suicide is now understood to be a tragic situation, no longer forbidden by the law but hardly anywhere understood as the ideal outcome of a life filled with suffering. That delicate balance would be lost and a new message delivered: Suicide is morally, medically, legally, and socially acceptable.

All civilized societies have developed laws to reduce the number of situations in which one person is allowed to kill another. Most have resisted the notion that private agreements can be reached allowing one person to help another take his or her life. Traditionally, three circumstances have primarily been acceptable for the taking of life: killing in self-defense or to protect another life, killing in the course of a just war, and killing in the case of capital punishment. Killing in war and killing by capital punishment have been opposed by some, more successfully in the case of capital punishment, which is now banned in many countries, most notably in western Europe.

The proposal to legalize physician-assisted suicide is nothing less than a proposal to add a new category of acceptable killing to those already socially legitimated. To do so would be to reverse the long-developing trend to limit the occasions of legally sanctioned killing (most notable in the campaigns to abolish capital punishment and to limit access to handguns). Civilized societies have slowly come to understand how virtually impossible it is to control even legally sanctioned killing. Even with carefully fashioned safeguards, having legally sanctioned killing invites abuse and corruption.

Does it not make a difference that the absolute power is given, not to subjugate another (as in slavery), but as an act of mercy, to bring relief from suffering? No. Although the motive may be more benign than in the case of slavery as usually understood, that motive is beside the point. The aim in prohibiting physician-assisted suicide is to avoid introducing into society the inherent corruption of legitimated private killing. “All power corrupts,” Lord Acton wrote, “and absolute power corrupts absolutely.” It is that profound insight—a reflection on human despotism, usually justified initially out of good, empathetic motives—that should be kept in mind when we would give one person the right to kill another.

We come here to a striking pitfall of the common arguments for physician-assisted suicide. Once the key premises of that argument are accepted, there will remain no logical way in the future to (1) for long hold the line against euthanasia, to take care of those physically or psychologically unable to take their own lives; (2) deny euthanasia to any competent person who requests it for whatever reason, terminal illness or not; and (3) deny euthanasia and physician-assisted suicide to those who suffer but are incompetent, even if they do not request it. I am not saying that such a scenario will in fact take place, but only that the arguments given in favor of euthanasia logically entail the possibility. We can erect legal safeguards and specify required procedures to keep that scenario from coming to pass, but over time they will provide poor protection if the logic of the moral premises on which they are based is fatally flawed. The safeguards will appear arbitrary and flimsy and will invite covert evasion or outright rejection.

The Logic of the Arguments 

Where are the flaws in these arguments? Recall that there are two classical arguments in favor of euthanasia and assisted suicide: our right of self-determination, and our claim on the mercy of others to relieve our suffering if they can do so, especially our claim on doctors. These two arguments are typically spliced together and presented as a single contention. Yet if they are considered independently—and there is no inherent reason they must be linked—they display serious problems. Consider first the argument for our right of self-determination. It is said that a competent adult ought to have a right to physician-assisted suicide for the relief of suffering. But why must the person be suffering? Does not that stipulation already compromise the right of self-determination? How can self-determination have any limits? Why are not the person’s desires or motives, whatever they be, sufficient? How can we justify this arbitrary limitation of self-determination? The standard arguments for physician-assisted suicide offer no answers to those questions.

Consider next the person who is suffering but not competent, perhaps demented or mentally retarded. The standard argument would deny euthanasia and physician-assisted suicide to that person. But why? If a person is suffering but not competent, then it would seem grossly unfair to deny that person relief simply because he or she lacked competence. Are the incompetent less entitled to relief from suffering than the competent? Will it only be affluent, middle-class people, mentally fit and able, who can qualify? Will those who are incompetent but suffering be denied that which those who are intellectually and emotionally better off can have? Would that be fair? Do they suffer less for being incompetent? The standard argument about our duty to relieve suffering offers no response to those questions either.

Is it, however, fair to euthanasia advocates to do what I have done, to separate and treat individually the two customary arguments in favor of a legal right to euthanasia and physician-assisted suicide? The implicit reason for joining them is no doubt the desire to avoid abuse. By requiring a showing of suffering and terminal illness, the aim is to exclude perfectly healthy people from demanding that, in the name of self-determination and for their own private reasons, another person can be called on to kill them or assist them in suicide. By requiring a show of mental competence to effect self-determination, the aim is to exclude the nonvoluntary or involuntary killing of those who are depressed, retarded, or demented.

My contention is that the joining of those two requirements is perfectly arbitrary, a jerry-rigged combination if ever there was one. Each has its own logic, and each could be used to justify euthanasia and physician-assisted suicide. But that logic, it seems evident, offers little resistance to denying any competent person the right to be killed, sick or not, and little resistance to killing those who are not competent, so long as there is good reason to believe they are suffering, There is no principled reason to reject that logic, and no reason to think it could long remain suppressed by the expedient of an arbitrary legal stipulation that both features, suffering and competence, be present. In fact, in its statutes on physician-assisted suicide, the state of Oregon requires a terminal illness only, not a condition of suffering also. The result, of course, has been to remove a potential barrier to physician-assisted suicide.

There is a related problem worth considering. If the act of physician-assisted suicide, conventionally understood, requires the uncoerced request and consent of the patient, it no less requires that the person to do the assisting have his or her own independent moral standards for acceding to the request. The doctor must act with integrity. How can a doctor who voluntarily brings about, or is instrumental in, the death of another legitimately justify that act? Would the mere claim of self-determination on the part of someone be sufficient? “It is my body, doctor, and I request that you help me kill myself.” There is historical resistance to that kind of claim, and doctors quite rightly have never been willing to do what patients want solely because they want it. To do so would reduce doctors to automatons, subordinating their integrity to patient wishes or demands. There is surely a legitimate fear, moreover, that if such claim were sanctioned, there would be no reason to forbid any two competent persons from entering into an agreement for one to kill the other, a form of consenting-adult killing. Perhaps the resistance also arises out of a reluctance to put doctors in the role of taking life simply as a means of advancing patient self-determination, quite apart from any medical reasons for doing so.

Physician Integrity 

The most likely reason for resistance to a pure self-determination standard is that our culture has, traditionally, defined a physician as someone whose duty is to promote and restore health. It has thus been customary, even among those pressing for euthanasia and physician-assisted suicide, to hang on to some part of the physician’s traditional role. That is why a mere claim of self-determination, which requires no reference to health at all, is not enough. A doctor will not cut off my healthy arm simply because I decide my autonomy and well-being would thereby be enhanced.

What may we conclude from these still-viable traditions? To justify committing an act of physician-assisted suicide and still maintain professional and personal integrity, the doctor must have his or her own independent moral standards. What should those standards be? The doctor will not be able to use a medical standard. A decision for physician-assisted suicide is not a medical but a moral decision. Faced with a patient reporting great suffering, a doctor cannot, therefore, justify physician-assisted suicide on purely medical grounds. The doctor must believe that a life of subjectively experienced intense suffering is not worth living in order to feel justified in taking the decisive and ultimate step of killing the patient. It must be the doctor’s moral reason to act, not the patient’s reason (even though their reasons may coincide). But if the doctor believes that a life of some form of suffering is not worth living, then how can the doctor deny the same relief to a person who cannot request it, or who requests it but whose competence is in doubt? There is no self-evident reason why the supposed duty to relieve suffering must be limited to competent patients claiming self-determination—or why patients who claim death as their right under self-determination must be either suffering or dying.

There is, moreover, the possibility that what begins as a right of doctors to engage in physician-assisted suicide under specified conditions will soon become a duty to offer it up front to patients. On what grounds could a doctor deny a request by a competent person for physician-assisted suicide? It is not sufficient just to stipulate that no doctor should be required to do that which violates his or her conscience. As commonly articulated, the arguments about why a doctor has a right to assist in suicide—the dual duty to respect patient self-determination and to relieve suffering—are said to be central to the vocation of being a doctor. Why should duties as weighty as those be set aside on the grounds of “conscience” or “personal values”?

These puzzles make clear that the moral situation is radically changed once our self-determination requires the participation and assistance of a doctor. Executing our will is no longer a solitary act but a social act requiring two people. It is then that doctor’s moral life, that doctor’s integrity, that is also and no less encompassed in the act of physician-assisted suicide. What, we might then ask, should be the appropriate moral standards for a person asked to assist in a suicide? What are the appropriate virtues and sensitivities of such a person? How should that person think of his or her own life and find, within that life, a place for physician-assisted suicide?

Now I could imagine someone granting the weight of the considerations against euthanasia I have advanced and yet having this response: Is not our duty to relieve suffering sufficiently strong to justify running some risks? Why should we be intimidated by the dangers in decisive relief of suffering? Is not the present situation, where death can be slow, painful, and full of suffering, already a clear and present danger?

Our duty to relieve suffering—by no means unlimited in any case—cannot justify the introduction of new evils into society. The risk of doing just that in the legalization of physician-assisted suicide is too great, particularly since the number of people whose pain and suffering could not be otherwise relieved would never be large (as even most physician-assisted suicide advocates recognize). It is too great because it would take a disproportionate social change to bring it about, one whose implications extend far beyond those who are sick and dying, reaching into the practice of medicine and into the sphere of socially sanctioned killing. It is too great because, as the history of the twentieth century should demonstrate, killing is a contagious disease, not easy to stop once unleashed in society. It is too great a risk because it would offer medicine too convenient a way out of its hardest cases, those in which there is ample room for further, more benign reforms. We are far from exhausting the known remedies for the relief of pain (frequently, even routinely, underused) and a long way from providing decent psychological support for those who, not necessarily in pain, nonetheless suffer because of despair and a sense of futility in continuing life.

Reason, Rationality, and Physician-Assisted Suicide

Could it not be said, however, in those cases in which physicians cannot relieve the suffering of a patient, that suicide would be a rational act for that patient? “Rational suicide,” as it has sometimes been called, surely has a kind of initial plausibility. Death is a definitive way to rid oneself of suffering and, if life with the suffering seems not worth living, then it would seem rational to be rid of that life.

In trying to evaluate this line of thought, some distinctions are necessary. The first is the need to distinguish between the rational and the reasonable. In its most minimal sense, an act can be said to be “rational” if it is consistent with the premises behind it. It does not matter what the premises are as long as the conclusion logically follows. In that sense, if it is believed that life is not worth living, then it is rational to end that life. It was no less rational for the Nazis, operating on the premise that inferior groups stood in the way of some imagined superior race, to conclude that it would be best to eliminate them. This form of rationality might be called instrumental rationality: it is indifferent to the quality of the premises and is interested only in coming up with deductions or conclusions consistent with them. Given consistent deductions or conclusions, the criterion of “rational” has been met.

The notion of what is “reasonable,” however, is meant to deal with the failings of instrumental rationality. Good, reasonable premises can stand up to careful scrutiny. Being “rational” in the sense specified above is the easy part. Knowing what is a justifiable premise is the hard part. The history of moral and political debates has shown that rational errors, displaying bad and inconsistent reasoning, are possible but that far more common is disagreement about premises.

Hence, the important question is not whether suicide can be rational—it surely can be in the narrow instrumental sense—but whether it is a reasonable way for human beings to deal with suffering. There are good reasons to doubt this. One of them is the simple fact, which any physician (or even layperson) can readily verify, that there seems to be no correlation whatever between the suffering a person may undergo and a decision to commit suicide. Put another way, if suicide is seen as a rational way to handle suffering, why is suffering a poor predictor of suicide (and thus—one might speculate in the absence of any clear data on this point—of physician-assisted suicide as well)? Both the Dutch experience and the early evidence from Oregon suggest that suicide is most attractive to those who fear a loss of control—and that, as a general rule, the majority of people who commit suicide have some history of mental illness. That history hardly proves suicide to be irrational in any and all cases, but it does give credence to the view that suffering at the end of life is rarely a predictor of suicide—and one test of rationality is whether there is some general and observable consistency between the fact of suffering and the choice of suicide. There simply is no such consistency.

Why is that? I surmise that since life in general—and not just the end of life—can be filled with tragedy and suffering, it is generally judged unreasonable to use suicide as a way of coping with tragedy and suffering. On the contrary, whether it is death from cancer, or the loss of a beloved spouse, or a broken romance, or an economic failure, in almost every culture suicide has not been considered an appropriate response.

There are two likely reasons for this. One of them is that since suffering is likely to be part of every life at one or more stages, life should not end when it occurs. The other reason (and here I speculate) is that there is a kind of perceived or felt duty to bear suffering as a form of mutual human support. The kind of despair that suicide represents is a temptation for all of us when life is miserable. But my ability to put up with it, to show it can be endured, is helpful to my neighbor when he or she is miserable. We all suffer at one point or other, and we all need the witness of each other that we can get through it. If we are essentially social creatures, not simply isolated individuals, then our life with other people will affect the way we look at life; we will learn from them just as they will learn from us. Suicide is, in that sense, not a private act at all. Families have to live with its aftermath, even as do those who only collect the bodies of those who have committed suicide. We are all models for each other’s lives, even if we are not aware of it. A society that accepted suicide as a way of life would be creating a set of models: those who chose to reject the earlier tradition of solidarity in favor of a more contemporary tradition of self-determination and the evasion of suffering.

It is probably some such insight that lies behind the traditional religious rejection of suicide and not, as more commonly thought, the belief that God is the author of life and thus has the final say over its disposal. In any event, I judge it to be reasonable to resist suicide as a way to manage suffering and unreasonable to think about it solely in instrumental terms, that is, that it ends our lives and thus releases us from misery.

Curing One Evil with Another 

Physical pain and psychological suffering among those who are critically ill and dying are great evils. The attempt to relieve them by the introduction of euthanasia and assisted suicide is an even greater evil, or to speak more accurately, is even more gravely morally mistaken, a softer notion that does not presuppose malicious motives. Those practices threaten the future security of the living. They no less threaten the dying themselves. Once a society allows one person to take the life of another based on their mutual private standards of a life worth living, there can be no safe or sure way to contain the deadly virus thus introduced. It will go where it will thereafter. The belief that physician-assisted suicide can be safely regulated is a myth—the confidentiality of the doctor-patient relationship makes it impossible to provide adequate oversight. Since we cannot know what goes on in the privacy of the doctor-patient encounter, we can never know whether, and to what extent, laws regulating physician-assisted suicide (and euthanasia as well) will be violated or ignored. The lack of any correlation between suffering and a desire for suicide means, of necessity, that physicians will have enormous discretion in assisting in suicide—but no way of knowing how to make a definitive evaluation of the extent of, or the legitimacy of, the suffering the patient reports.

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Filed under Americas, Callahan, Daniel, Physician Assisted Suicide, Selections, The Modern Era

(1926– )

from Apologia for Suicide


Born in London and educated at Oxford, Mary Rose Barrington became a lawyer and charity administrator, combining law practice with assisting in the management of a large group of almshouses for the aged. Her principal interests include voluntary euthanasia, animal protection, and psychical research. She is a past chairman of the London-based Voluntary Euthanasia Society (re-named EXIT, The Society for the Right to Die with Dignity, and renamed again Dignity in Dying). She has also been honorary secretary of the Animal Rights Group and is a vice -president of the Society for Psychical Research.

Barrington, an advocate of rational suicide and the notion of “planned death,” argues that humane and advanced societies must embrace this notion—much as traditional pride in extensive procreation has given way to the concept of planned birth—in a world that is increasingly crowded, and increasingly populated by those who are old and no longer have a great desire to live. She argues in detail for the psychological comfort that the notion of planned death would give to the elderly, who might foresee and welcome their own deaths rather than waiting to be “passively suppressed.”

Mary Rose Barrington, “Apologia for Suicide,” from Euthanasia and the Right to Death, ed. A. B. Downing. London: Peter Owen, 1969. Material in introduction and abridgement from M. Pabst Battin and David J. Mayo, Suicide: The Philosophical Issues, New York: St. Martin’s Press, 1980, pp. 90–103.



Of the many disagreeable features inherent in the human condition, none is more unpalatable than mortality. Many people declare that they find the concept of survival and immortal life both inconceivable and preposterous; but they will usually admit to a minimal pang at the thought of being snuffed out in due course and playing no further part in the aeons to come. That aeons have already passed before they were born is a matter that few people take to heart, and they tend on the whole to be rather glad not to have experienced the hardships of life before the era of the Public Health Acts and pain-killing drugs. To cease from being after having once existed seems altogether different and altogether terrible. This is an odd conclusion, bearing in mind that whereas before birth one must be reckoned to have had no effect on the course of events at all, the very act of birth and the shortest of lives may produce incalculable and possibly cataclysmic effects by indirect causation. Viewed in this light we might all be filled with satisfaction to think that our every move will send ripples of effects cascading down time. In fact, speculations of this kind do little if anything to satisfy the immortal longings, and even though being remembered kindly by others is generally felt to be something of a comfort, absolute death remains absolutely appalling. Many people who have no religious convictions save themselves from despair by filing away in their minds some small outside chance that they might, after all, survive, perhaps as some semi-anonymous cog in a universal system; many others resolutely refuse to give any thought to death at all.

If human convictions and behavior were a direct function of logical thinking, one would expect that the more firmly a person believed in the survival of his soul in an existence unhampered by the frequently ailing body, the more ready he would be to leave this world and pass on to the next. Nothing of the sort appears to be the case, at least for those whose religion is based on the Old Testament. Self-preservation is presented in such religions as a duty, though one that is limited by some inconsistent provisos. Thus a person may sacrifice his life to save others in war, or he may die a martyr’s death in a just cause; but if he were to reason that there was not enough food in the family to go round, and therefore killed himself to save the others from starvation (a fate, like many others, considerably worse than death), this would be regarded as the sin, and erstwhile crime, of suicide. Whether performed for his own benefit or to benefit others, the act of suicide would be condemned as equivalent to breaking out from prison before the expiry of the term fixed, a term for which there can be no remission.

The old notions about suicide, with an influence still lingering on, are well summarized by Sir William Blackstone in his famous Commentaries on the Laws of England (1765–9): “The suicide is guilty of a double offence: one spiritual, in invading the prerogative of the Almighty and rushing into his immediate presence uncalled for; the other temporal, against the King, who hath an interest in the preservation of all his subjects.”

Religious opposition to suicide is of decreasing importance as people become ever more detached from dogmas and revelationary teachings about right and wrong. The important matter to be considered is that while the humanist, the agnostic or the adherent of liberal religion seldom condemns suicide as a moral obliquity, he appears on the whole to find it as depressing and horrifying as the religious believer for whom it is sinful. There are many reasons for this, some good, and some regrettable.

Indoctrination against suicide is regrettably to be found at all levels. In itself the tendentious expression “to commit suicide” is calculated to poison the unsuspecting mind with its false semantic overtones, for, apart from the dangerous practice of committing oneself to an opinion most other things committed are, as suicide once was, criminal offenses. People are further influenced by the unhappy shadow cast over the image of suicide by the wide press coverage given to reports of suicide by students who are worried about their examinations, or girls who are upset over a love affair, or middle-aged people living alone in bed-sitting-rooms who kill themselves out of depression―troubles that might all have been surmounted, given time. In pathetic cases such as these, it is not, as it seems to me, the act of suicide that is horrifying, but the extreme unhappiness that must be presumed to have induced it. Death from despair is the thing that ought to make us shudder, but the shudder is often extended to revulsion against the act of suicide that terminates the despair, an act that may be undertaken in very different circumstances.

The root cause of the widespread aversion to suicide is almost certainly death itself rather than dislike of the means by which death is brought about. The leaf turns a mindless face to the sun for one summer before falling for ever into the mud; death, however it comes to pass, rubs our clever faces in the same mud, where we too join the leaves. The inconceivability of this transformation in status is partly shot through with an indirect illumination, due to the death of others. Yet bereavement is not death. Here to mourn, we are still here, and the imagination boggles at the notion that things could ever be otherwise. Not only does the imagination boggle, as to some extent it must, but the mind unfortunately averts. The averted mind acknowledges, in a theoretical way, that death does indeed happen to people here and there and now and then, but to some extent the attitude to death resembles the attitude of the heavy smoker to lung cancer; he reckons that if he is lucky it will not happen to him, at least not yet, and perhaps not ever. This confused sort of faith in the immortality of the body must underlie many a triumphal call from the hospital ward or theatre, that the patient’s life has been saved―and he will therefore die next week instead of this week, and in rather greater discomfort. People who insist that life must always be better than death often sound as if they are choosing eternal life in contrast to eternal death, when the fact is that they have no choice in the matter; it is death now, or death later. Once this fact is fully grasped it is possible for the question to arise as to whether death now would not be preferable.

Opponents of suicide will sometimes throw dust in the eyes of the uncommitted by asking at some point why one should ever choose to go on living if one once questions the value of life; for as we all know, adversity is usually round the corner, if not at our heels. Here, it seems to me, a special case must be made out for people suffering from the sort of adversity with which the proponents of euthanasia are concerned: namely, an apparently irremediable state of physical debility that makes life unbearable to the sufferer. Some adversities come and go; in the words of the Anglo-Saxon poet reviewing all the disasters known to Norse mythology, “That passed away, so may this.” Some things that do not pass away include inoperable cancers in the region of the throat that choke their victims slowly to death. Not only do they not pass away, but like many extremely unpleasant conditions they cannot be alleviated by pain-killing drugs. Pain itself can be controlled, provided the doctor in charge is prepared to put the relief of pain before the prolongation of life; but analgesics will not help a patient to live with total incontinence, reduced to the status of a helpless baby after a life of independent adulthood. And for the person who manages to avoid these grave afflictions there remains the spectre of senile decay, a physical and mental crumbling into a travesty of the normal person. Could anything be more reasonable than for a person faced with these living deaths to weigh up the pros and cons of living out his life until his heart finally fails, and going instead to meet death half-way?

It is true, of course, that, all things beings equal, people do want to go on living. If we are enjoying life, there seems no obvious reason to stop doing so and be mourned by our families and forgotten by our friends. If we are not enjoying it, then it seems a miserable end to die in a trough of depression, and better to wait for things to become more favorable. Most people, moreover, have a moral obligation to continue living, owed to their parents while they are still alive, their children while they are dependent, and their spouses all the time. Trained professional workers may even feel that they have a duty to society to continue giving their services. Whatever the grounds, it is both natural and reasonable that without some special cause nobody ever wants to die yet. But must these truisms be taken to embody the whole truth about the attitude of thinking people to life and death? A psychiatrist has been quoted as saying: “I don’t think you can consider anyone normal who tries to take his own life.” The abnormality of the suicide is taken for granted, and the possibility that he might have been doing something sensible (for him) is not presented to the mind for even momentary consideration. It might as well be argued that no one can be considered normal who does not want to procreate as many children as possible, and this was no doubt urged by the wise men of yesterday; today the tune is very different, and in this essay we are concerned with what they may be singing tomorrow.

There is an obvious connection between attitudes to birth and to death, since both are the fundamentals of life. The experience of this century has shown that what may have appeared to be ineradicably basic instincts can in fact be modified in an advanced society, and modified not merely by external pressures, but by a corresponding feedback movement from within. Primitive people in general take pride in generating large families, apparently feeling in some deep-seated way that motherhood proves the femaleness of the female, and that fatherhood proves the maleness of the male, and that the position in either case is worth proving very amply. This simple pride is not unknown in advanced countries, although public applause for feats of childbearing is at last beginning to freeze on the fingertips, and a faint rumble of social disapproval may be heard by an ear kept close to the ground. The interesting thing is that it is not purely financial considerations that have forced people into limiting their progeny, and least of all is it the public weal; people have actually come to prefer it. Women want to lead lives otherwise than as mothers; men no longer feel themselves obliged to assert their virility by pointing to numerous living tokens around them; and most parents prefer to concentrate attention and affection upon a couple rather than a pack. The modification in this apparently basic drive to large-scale procreation is now embraced not with reluctance, but with enthusiasm. My thesis is that humane and advanced societies are ripe for a similar and in many ways equivalent swing away from the ideal of longevity to the concept of a planned death.

It may be worth pausing here to consider whether the words “natural end,” in the sense usually ascribed to the term, have much bearing on reality. Very little is “natural” about our present-day existence, and least natural of all is the prolonged period of dying that is suffered by so many incurable patients solicitously kept alive to be killed by their disease. The sufferings of animals (other than man) are heart-rending enough, but a dying process spread over weeks, months or years seems to be one form of suffering that animals are normally spared. When severe illness strikes them they tend to stop eating, sleep and die. The whole weight of Western society forces attention on the natural right to live, but throws a blanket of silence over the natural right to die. If I seem to be suggesting that in a civilized society suicide ought to be considered a quite proper way for a well-brought-up person to end his life (unless he has the good luck to die suddenly and without warning), that is indeed the tenor of my argument; if it is received with astonishment and incredulity, the reader is referred to the reception of recommendations made earlier in the century that birth control should be practiced and encouraged. The idea is no more extraordinary, and would be equally calculated to diminish the sum total of suffering among humankind.

This will probably be taken as, or distorted into, a demand for the infliction of the death penalty on retirement. And yet the bell tolls for me no less than for others. Apart from the possibility that he may actually have some sympathy for the aged, no one casting a fearful eye forward into the future is likely to advocate treatment of the old that he would not care to see applied to himself, lest he be hoist with his own petard. It cannot be said too many times that so long as people are blessed with reasonable health, reasonable independence and reasonable enjoyment of life, they have no more reason to contemplate suicide than people who are half their age, and frequently half as sprightly as many in their seventies and eighties today. Attention is here being drawn to people who unfortunately have good reason to question whether or not they want to exercise their right to live; the minor infirmities of age, and relative weakness, and a slight degree of dependence on younger people who regard the giving of a helping hand as a natural part of the life-cycle, do not give rise to any such question. The question arises when life becomes a burden rather than a pleasure.

Many middle-aged people are heard to express the fervent wish that they will not live to be pain-ridden cripples, deaf, dim-sighted or feeble-minded solitaries, such that they may become little else than a burden to themselves and to others. They say they hope they will die before any of these fates descend upon them, but they seldom affirm that they intend to die before that time; and when the time comes, it may barely cross their minds that they could, had they then the determination, take the matter into their own hands. The facile retort will often be that this merely goes to show that people do not really mean what they say and that like all normal, sensible folk, they really want to live on for as long as is physically possible. But this, I would suggest, is a false conclusion. They mean exactly what they say, but the conditions and conditioning of society make it impossible for them to act in accordance with their wishes. To face the dark reality that the future holds nothing further in the way of joy or meaningful experience, and to face the fact without making some desperate and false reservation, to take the ultimate decision and act upon it knowing that it is a gesture that can never be repeated, such clear-sightedness and resolution demand a high degree of moral strength that cannot but be undermined by the knowledge that this final act of self-discipline would be the subject of head-shakings, moralizings and general tut-tutting.

How different it would be if a person could talk over the future with his family, friends and doctors, make arrangements, say farewells, take stock of his life, and know that his decision about when and how to end his life was a matter that could be the subject of constructive and sympathetic conference, and even that he could have his chosen ones around him at the last. As things are at present, he would always be met with well-meant cries of “No, no, you mustn’t talk like that,” and indeed anyone taking a different line might feel willy-nilly that his complicity must appear unnatural and lacking in affection. We feel that we ought to become irrational at the idea that someone we care for is contemplating ending his own life, and only the immediate spectacle of intense suffering can shock us out of a conditioned response to this situation. The melancholy result is that a decision that cries out for moral support has to be taken in cheerless isolation, and if taken at all is usually deferred until the victim is in an advanced state of misery.

But supposing the person contemplating suicide is not in fact undergoing or expecting to undergo severe suffering, but is merely an elderly relation, probably a mother, in fragile health, or partially disabled, and though not acutely ill is in need of constant care and attention. It would be unrealistic to deny the oppressive burden that is very often cast on the shoulders of a young to middle-aged person, probably a daughter, by the existence of an ailing parent, who may take her from her career when she is a young woman in her thirties of forties, and leave her, perhaps a quarter of a century later, an elderly, exhausted woman, demoralized over the years by frequently having had to choke back the wish that her mother would release her by dying. Even in a case such as this, human feeling does demand, I would think, that the younger person must still respond to intimations of suicide with a genuinely felt, “No, no.”

But what of the older person’s own attitude? Here we arrive at the kernel of the violent and almost panic-stricken reaction of many people to the idea of questioning whether it is better, in any given situation, to be or not to be. For if there is no alternative to continued living, then no choice arises, and hence there can be no possibility of an older person, who is a burden to a younger person, feeling a sense of obligation to release the captive attendant from willing or unwilling bondage, no questioning of the inevitability of the older person’s living out her full term. But what if there were a real choice? What if a time came when, no longer able to look after oneself, the decision to live on for the maximum number of years were considered a mark of heedless egoism? What if it were to be thought that dulce et decorum est pro familia mori? This is a possibility that makes many people shrink from the subject, because they find the prospect too frightful to contemplate. Is it (to be charitable) because they always think themselves into the position of the younger person, so that “No, no” rises naturally to their lips, or is it (to be uncharitable) because they cannot imagine themselves making a free sacrifice of this sort?

This very controversial issue is, it may be remarked, outside the scope of voluntary euthanasia, which is concerned exclusively with cases where a patient is a burden to himself, and whether or not he is a burden to others plays no part whatever. The essence of voluntary euthanasia is the co-operation of the doctor in making crucial decisions; the “burden to others,” on the contrary, must make all decisions and take all responsibility himself for any actions he might take. The issue cannot, however, be ignored, because the preoccupation of many opponents of voluntary euthanasia with its supposed implications, suggests that few people have any serious objection to the voluntary termination of a gravely afflicted life. This principal theme is usually brushed aside with surprising haste, and opponents pass swiftly on to the supposed evils that would flow from making twilight existence optional rather than obligatory. It is frequently said that hard-hearted people would be encouraged to make their elderly relatives feel that they had outlived their welcome and ought to remove themselves, even if they happened to be enjoying life. No one can say categorically that nothing of the sort would happen, but the sensibility of even hard-hearted people to the possible consequences of their own unkindness seems just as likely. A relation who had stood down from life in a spirit of magnanimity and family affection would, after an inevitable period of heart-searching and self-recrimination, leave behind a pleasant memory; a victim of callous treatment hanging like an accusing albatross around the neck of the living would suggest another and rather ugly story. Needless to say, whoever was responsible would not in any event be the sort of person to show consideration to an aged person in decline.

Whether or not some undesirable fringe results would stem from a free acceptance of suicide in our society, the problem of three or four contemporaneous generations peopling a world that hitherto has had to support only two or three is with us here and now, and will be neither generated nor exacerbated by a fresh attitude to life and death. The disabled, aged parent, loved or unloved, abnegating or demanding, is placed in one of the tragic dilemmas inherent in human existence, and one that becomes more acute as standards of living rise. One more in the mud-hut is not a problem in the same way as one more in a small, overcrowded urban dwelling; and the British temperament demands a privacy incompatible with the more sociable Mediterranean custom of packing a grandmother and an aunt or two in the attic. Mere existence presents a mild problem; disabled existence presents a chronic problem. The old person may have no talent for being a patient, and the young one may find it intolerable to be a nurse. A physical decline threatens to be accompanied by an inevitable decline in the quality of important human relationships―human relationships, it is worth repeating, not superhuman ones. Given superhuman love, patience, fortitude and all other sweet-natured qualities in a plenitude not normally present in ordinary people, there would be no problem. But the problem is there, and voluntary termination of life offers a possible solution that may be better than none at all. The young have been urged from time immemorial to have valiant hearts, to lay down their lives for their loved ones when their lives have hardly started; it may be that in time to come the disabled aged will be glad to live in a society that approves an honorable death met willingly, perhaps in the company of another “old soldier” of the same generation, and with justifiable pride. Death taken in one’s own time, and with a sense of purpose, may in fact be far more bearable than the process of waiting to be arbitrarily extinguished. A patient near the end of his life who arranged his death so as, for example, to permit an immediate transfer of a vital organ to a younger person, might well feel that he was converting his death into a creative act instead of waiting passively to be suppressed.

A lot of kindly people may feel that this is lacking in respect for the honorable estate of old age; but to insist on the obligation of old people to live through a period of decline and helplessness seems to me to be lacking in a feeling for the demands of human self-respect. They may reply that this shows a false notion of what constitutes self-respect, and that great spiritual qualities may be brought out by dependence and infirmity, and the response to such a state. It is tempting in a world dominated by suffering to find all misery purposeful, and indeed in some situations the “cross-to-bear” and the willing bearer may feel that they are contributing a poignant note to some cosmic symphony that is richer for their patience and self-sacrifice. Since we are talking of options and not of compulsions, people who felt like this would no doubt continue to play their chosen parts; but what a truly ruthless thing to impose those parts on people who feel that they are meaningless and discordant, and better written out.

What should be clear is that with so many men and so many opinions there is no room here for rules of life, or ready-made solutions by formula, least of all by the blanket injunction that, rather than allow any of these questions to be faced, life must be lived out to the bitter end, in sickness and in health, for better of for worse, until death brings release. It is true that the embargo on suicide relieves the ailing dependent of a choice, and some would no doubt be glad of the relief, having no mind for self-sacrifice. But in order to protect the mildly disabled from the burden of choice, the severely sick and suffering patient who urgently wants to die is subjected to the same compulsion to live. The willingness of many people to accept this sheltering of the stronger at the expense of the crying needs of the incomparably weaker may be because the slightly ailing are more visible and therefore make a more immediate claim on sympathy. Everyone knows aged and dependent people who might find themselves morally bound to consider the advisability of continuing to live if an option were truly available; the seriously afflicted lie hidden behind hospital windows, or secluded from sight on the upper floors of private houses. They are threatened not with delicate moral considerations, but with the harder realities of pain, disease and degeneration. Not only are they largely invisible, but their guardians are much given to the issuing of soothing reports about, for example, the hundred thousand or more patients who die of cancer every year, reports in which words like “happiness” and “dignity” are used liberally, and words like “pain” and “humiliation” tactfully suppressed. Let us not be misled by the reassuring face so often assumed by doctors who would have us believe that terminal suffering is just a bad fairy tale put out by alarmist bogey-men. One can only hope that the pathetic human wrecks who lie vomiting and gasping out their lives are as sanguine and cheerful about their lamentable condition as the smiling doctor who on their behalf assures us that no one (including members of the Euthanasia Society) really wants euthanasia. . . .

Here again it must be made clear that what is needed is the fostering of a new attitude to death that should ultimately grow from within, and not be imposed from without upon people psychologically unable to rethink their ingrained views. The suffering and dying patients of today have been brought up to feel that it is natural and inevitable, and even some sort of a duty, to live out their terminal period, and it would do them no service to try to persuade them into adopting an attitude that to most of them would seem oppressive, as aimed against them rather than for their benefit. If people have an ineradicable instinct, or fundamental conviction, that binds them to cling to life when their bodies are anticipating death by falling into a state of irrevocable decay, they clearly must be given treatment and encouragement consistent with their emotional and spiritual needs, and kindness for them will consist of assurances that not only is their suffering a matter of the greatest concern, but that so also is their continued existence. It is future generations, faced perhaps with a lifespan of eighty or ninety years, of which nearly half will have to be dependent on the earning power of the other half, who will have to decide how much of their useful, active life is to be devoted to supporting themselves through a terminal period “sans everything,” prolonged into a dreaded ordeal by ever-increasing medical skill directed to the preservation of life. It may well be that, as in the case of family planning, economic reality will open up a spring, the waters of which will filter down to deeper levels, and that then the new way of death will take root. The opponents of euthanasia conjure up a favorite vision of a nightmare future in which anxious patients will be obsessed with the fear that their relatives and doctors may make surreptitious plans to kill them; the anxiety of the twenty-first century patient may, on the contrary, be that they are neglecting to make such plans . . . focusing attention on practical steps, how is this to be brought about? Should schoolchildren be asked to write essays on “How I Would Feel if I Had to Die at Midnight” or compositions envisaging why and in what circumstances they propose to end their lives? The answer may well be that they should. An annual visit to a geriatric ward might also be in order. The usual argument against facing up to such reality is that life is long and death is short, and that dwelling on an unfortunate aspect is morbid and best shunned. . . . But instant death is granted to few, and the others would be well advised to expect to be an unconscionable time a-dying, and partly a-dying, and be prepared to meet the challenge not only of death, but of the unconscionable time preceding it. I would contend that the true end of education should be to prepare the pupil to learn in the course of life to orientate all knowledge and experience within the framework of a life bounded by decline and death, and to regard a timely and possibly useful death as the summation of the art of living. Pending the comfort of a death-conditioned society, a recommended exercise for the individual who is minded to reconcile himself to dying is a constant making and remaking of wills. An evening spent distributing largesse, followed by the clearing of the desk, the answering of letters and the paying of accounts, has the effect of a direct invitation to the Almighty to take you while you are in the mood to add your final touch to the day’s work.

It is, of course, all too easy to make light of death when it seems far from imminent, and all too easy for someone who has had a satisfying life to say that other people, who may have had very little happiness, must learn to accept that their one and (ostensibly) only life must now cease. It may well turn out that we who insist on the right to come to terms with death before life becomes a burden may, when the time comes, be found to fail in our resolute purpose, and may end our lives by way of punishment in one of the appalling institutions provided by the state for the care of the aged. The failure may be due to physical helplessness coupled with the refusal of others to give the necessary help, or it may be due to a moral failure ascribable to personal weakness and the pressures of society, pressures that sometimes take a form too oblique to be recognized as twisters of the mind. Ending with a further complaint about linguistic misdirection, my final objection to tainted words is that a patient ending his own life, or a doctor assisting him to end it, is said to “take life,” just as a thief “takes” property with the intention of depriving the owner of something he values. Whatever it is that is taken from a dying patient, it is nothing he wants to keep, and the act is one of giving rather than taking. The gift is death, a gift we shall all have to receive in due course, and if we can bring ourselves to choose our time for acceptance, so much the better for us, for our family, for our friends and for society.

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Filed under Barrington, Mary Rose, Europe, Physician Assisted Suicide, Selections, The Modern Era