EXAMINING THE ETHICS OF SUICIDE

From philosophers and religious leaders to the annals of medical science, suicide has been debated due to its complex nature and numerous gray areas. There are no black and white definitions or viewpoints when it comes to suicide or physician-assisted suicide. Many ponder the morality of killing one's self when all hope has been lost whether it be a physical or emotional loss of quality in one's life. Others ask if there is such a thing as a good death or a rational suicide. Utilizing philosophy and religion, this paper examines the critical issues related to the ethics of suicide and value for the states of both a quality life and a peaceful death.

Suicide and Assisted Suicide

Those who struggle with their lives and those who take care of them struggle with the idea of whether or not there is such a thing as a good death. That is when thoughts turn to contemplating suicide. This may come up especially with a person “who is debilitated or terminally ill” and see “suicide as an escape from life or from an otherwise slow, lingering wait for death with pain and suffering.” There continues to be a belief that suicide may be less about ethics and more about emotional or mental illness because people cannot handle their life, thereby making it not morally wrong. Human beings can only take so much bodily pain or mental suffering before they want to be better, so they turn to the idea that perhaps what happens after this life might be better than what they are currently experiencing.

Active and passive euthanasia.

Further complicating the ethical issues around assisted suicide, many have divided the action into passive and active euthanasia, so that those who were morally set against doctors who stopped life support functions directly might find it acceptable if the doctor decided to just not act at all so that life could end more quickly without the question of overdosing the patient or taking any other action that might be deemed murderous. Passive euthanasia could include the refusal of treatment and include “voluntary stopping of eating and drinking.” Those that support this practice claim that they do it on the basis that “all persons have a moral right to choose freely what they will do with their lives as long as they inflict no harm on others. This right of free choice includes the right to end one's life when we choose.” Many physicians believe that rational suicide is acceptable when people are being kept alive by “artificial means, may be in chronic pain, may have no reasonable quality of life, and may have no hope for a dignified death.”

Reasons for the Ethical Dilemma

Goethe made an interesting statement about by saying that it is part of human nature and while there has been a lot said and done about it, “every person must confront it for himself anew, and every age must come to its own terms with it.” Camus called suicide the only “truly serious philosophical problem.” This is because, like other situations where there is no clear-cut answer of right and wrong attached to it, suicide and assisted suicide invoke more questions than answers. This is because it is considered an act what has both “a good and evil effect.”

The problem is that suicide invokes this “moral conflict” because of “deep, long-held values and ideals about life and relationships.” Suicide has been prohibited due to religion and viewed as socially unacceptable or criminally wrong when connected to the medical community. This is because the ethical dilemma revolves around the question of “who should control when and how we die” and whether those who “invoke the authority of the Bible, the Constitution, and Medicine” really are those upholding the highest ethics in regards to the decision on suicide.

The entire nature of dying and living has changed due to technology and advancements in science. The overall quality of life has improved and people are living longer. More importantly, it is the nature of death that has experienced the most radical transformation. While people used to die at home, now most experience the end of their life in an “institutional setting such as a convalescent home or hospital” where they receive various types of medicines and procedures that can prolong life by months and even years. While some may appreciate the extension of life, many “feel a profound lack of control” with the majority feeling like they “would like to be allowed to end their lives before incurable and painful disease finally kill them.”

The Quality of Life Debate

Those who believe euthanasia is ethical rely on the line of reasoning that focuses on the quality of life issue to prove it is a morally acceptable action to take. It was Socrates who first said that it made sense to take one's life sooner than later in order to avoid the effects of the life getting any worse, so he drank the hemlock “as an escape from the inevitability of death.”

What is problematic with this ethical stance is where to draw the line on what is considered a loss in the quality of life and the question of a person's motives who decides that it is time to end that person's life. Suicide has become more of a medical issue because of the very fact that advances in technology - machines to sustain life and organ transplants - as well as the use of drugs has “transformed how we die.” Going beyond the idea that it can improve chances for life, these “developments” have also altered “when and how to die.”

The differences in opinion on the ethics of suicide seem to boil down to a philosophy based on what life means to that person who is arguing for or against the ethics of suicide. There are those who put God as the central aspect of their existence, which provides a greater meaning for the idea of life and also a moral basis that helps define one's purpose. Because there is the view that God created life, it is not up to human beings to decide if life should be taken away, so therefore would be morally wrong whether one decided to take one's own life or help someone take their own because they did not want to exist any more. On the opposite end of the spectrum are those that have a soul-centred approach to life that seeks meaning in doing. In referencing Tolstoy, he made the point that “life is meaningless if nothing is worth doing and that nothing is worth doing if nothing one does will make a permanent difference to the world.” Therefore, this leaves the door open to justify the decision to purposely leave life that has no more meaning whether it is from physical or emotional illness.

Another concept tied to the ethics of suicide and the value of life has to do with the concept of what is called a “worthwhile life” where it is a “function of how much good it includes added up against how much bad.” It is interesting that this idea could easily be inserted into the debate on if a life is not worthwhile because of severe pain or terminal illness, might it be better to no longer existing within a life that seemed to have more bad than good.

Whatever the case, the argument remains that those in the position to do so in the medical profession should feel obligated “to relieve the suffering of our fellow human beings and to respect their dignity.”

Philosophical Approaches to Suicide

The Stoics, including Socrates, embraced suicide as a way to continue control over their own path and situation because it was “morally honourable to choose the manner of one's death when it was imminent and inevitable.” Two 19th and 20th century philosophers presented varying ethical viewpoints on the subject of suicide:

    Schopenhauer stated that, although suicide may be regarded as a moral and
    metaphysical error because it results from the frustrations of life, it is the final act of
    self-determination, an act of ultimate dignity, in this immoral world. Schopenhauer
    proposed that individuals had a fundamental right to end their lives, whereas
    Wittgenstein asserted that suicide was an elementary sin, and suggested that it was an
    act of self-annihilation and the ultimate act of disrespect and violence.

Pliny said, “Life is not so desirable a thing as to be protracted at any cost. Whoever you are, you are sure to die, even though your life has been full ob abomination and crime. The chief of all remedies for a troubled mind is the feeling that among the blessings which Nature gives to man there is none greater than an opportune death.” Suicide, to the philosophers, became a noble action to take because “as soon as the terrors of life reach the point at which they outweigh the terrors of death, a man will put an end to his own life.”

If one was applying the Kantian viewpoint on the ethics of suicide, the conclusion would be that assisted suicide is an act of murder. Since the purpose of assisted suicide is to help a person stop their suffering, it does not meet Kantian ethics because “a Kantian does things for the sake of doing things, not because it leads to a certain consequence.” Therefore, there is no situation where killing a person could be determined as a “universalized” situation so it would be morally wrong in any case.

Now, the idea of suicide has become more socially accepted due to the effect of stress, pressure, and anxiety as normal life instead of being connected to only those with mental problems. Ethical concerns still exist, however, for the medical community and its participation in the care of terminal patients.

Religious Viewpoints on Suicide

Unlike many philosophers, religion took a decidedly different viewpoint on the ethics of suicide. St. Augustine and St. Thomas Aquinas believed that the act of suicide “opposed the natural law and violated a person's duty to God, oneself and the community.” Today's ethical debate over suicide has moved away from the religious aspect as more people believe that it has less to do with human morality as it does with medical ethics in terms of treating conditions and diseases. In order to gain a well-rounded understanding of the ethical complexity of suicide, it is important to examine a variety of perspectives.

The Buddhist perspective. The Buddhists place a very high value on life and believes that every individual needs to accept the life that has been given us even if that includes sickness and old age. Killing is not acceptable whether it is someone else or one's self.

The Jewish tradition and Christian viewpoint. The Jewish religion looks at suicide as a crime even though the Bible did not condemn it as the philosopher Schopenhauer pointed out. Preservation of life is vital to the Jewish tradition. Similarly, those with a Christian background contend that life is holy and that “God alone must decide when and how life must begin and end.”

The Perilous Line Walked by Physicians

The primary concern for physicians is to ensure that they make ethical decisions on what is best for the patient in terms over adequate care and comfort when they are in a terminal state or have a malignant condition that is compromising the quality of their life. The main ethical issue involves patient autonomy versus paternalistic intervention on the part of the physician or nurse. This relationship creates issues when a rational person who can no longer live with the limited state of existence they have left due to pain or disability wants to end their own or when they want the physician to help them end it.38 Many ethicists are stating that this autonomy, or right to decide by the patient, supersedes that of the focus on providing health care that sustains life.39 Others refer to this state of an individual as “self-determination. The problem exists when “a client's self-determined wishes and his or her well-being are in conflict with each other, and this conflict makes it difficult.” The issue is further complicated when a patient is incapacitated and may not be able to clearly state their self-determined wish.

Additionally, patients and society have always viewed physicians as “protectors of life,” so there is a real dilemma of changing that role to one that “takes lie even in the name of relieving suffering.” After all, physicians have “sworn to protect life not end it” but those suffering also have the right to decide if they no longer want to exist that way.

Technology has complicated the issue by sustaining the lives of those with illnesses while some people would refer to this as prolonging death because those on the machines may have “physical and mental capabilities that cannot be restored, whose degenerating conditions cannot be reversed, and whose pain cannot be eliminated.” In some places in the world, assisted suicide is considered a crime, so physicians have to be worried that any of their actions might fall into this category regardless of whether they are trying to make a patient more comfortable. Other physicians may feel that their rights are violated if they are expected to “cooperate in a patient's suicide when it goes “against their own deeply held convictions.”

Invoking the “double effect” principle. Some in the medical community who advocate the use of physician-assisted suicide turn to the double effect principle to say that it is morally right for a doctor to provide a patient with a medicine that can both treat the pain and cause death. However, for those against euthanasia, the point is that there are five conditions that must be met in order to invoke the double effect. These conditions state that:

The act itself must be morally good or at least indifferent. The good effect is directly
    intended, while the evil effect is foreseen but unintended. The good effect must not be
    produced by means of the evil effect. The good effect must be proportionate to the
    evil effect. There must be a grave reason for permitting the evil effect.

The conclusion reached by applying this to euthanasia is that the good effect of the medicine stopping the pain only comes from achieving death, which is considered an evil effect, so therefore this principle cannot be applied as moral justification.

The slippery slope argument. Many who argue that assisted suicide is unethical point to the concern that a slippery slope will have physicians and nurses helping end more people's lives for less justifiable reasons or for questionable reasons brought forth by a patient's relatives.51 The concern is that crossing a morally questionable line can lead to questionable behaviour in the long run. The other worry is that physicians will become indifferent to their patients and be insensitive, losing touch with the human aspect of life and health. For example, “euthanasia would corrupt the character of doctors, and encourage them to view some patients as lacking inherent worth.”

Those who also question assisted suicide point to other ethical questions, such as “What will keep the inconvenienced relatives of a patient from persuading him or her to ‘voluntarily' ask for death? What will become of people who, once having signed a request to die, later change their minds, but, because of their conditions, are unable to make their wishes known?”

The organ donor factor. The other ethical concern tied to assisted suicide is the need for good organs from brain dead people to use in those who would be able to survive once they received transplants. This raises the concern that some may be hurried along into death to harvest organs yet the other side of the argument contends that euthanasia is then helping end one person's suffering while giving others the gift of life through organ transplant.56 Again, suicide and euthanasia are complex issues with no easy answers.

Finding the Ethical Medium

Physicians and nurses agree that it is a difficult topic to reach a straightforward conclusion on without stopping to consider many of the critical ethical issues mentioned in this paper. However, many feel that there is credence in considering rational suicide if it is “supported foremost by a respect for patients' autonomous rights and then by a consideration of their perception of quality of life and the principle of proportionality.” Many agree that on the issue of the quality of life, it should be up to the person actually living that life to determine the level of actual quality because a doctor or someone else is not really experiencing that pain or condition like the patient.

Suicide and assisted suicide continues to be an issue that is “morally ambiguous” because there are no clear ethical answers to the quality of life or a person's rights to decide when and if life is not worth living. As a complex issue, suicide and assisted suicide are influenced by a mix of social, philosophical, medical, and religious ideals that provide more questions about ethics than resolutions. As these types of issues have taken on a larger role within the medical profession, a new type of philosophy has emerged known as bioethics, which focuses on “areas of morality in the context of health care and biotechnology. Interestingly enough, these bioethicists are trying to define the status of human beings set against these moral issues to determine the ethics behind the dilemma. As such, they have concluded that “what counts morally is not being ‘human' but being a ‘person,' a status earned by possessing identifiable mental capabilities such as being self-aware or having the ability to engage in rational behaviour.”

Conclusions

Suicide and assisted suicide is a difficult issue to reach conclusions on. As an ethical dilemma, it touches on deep-seated moral values based on religious, philosophical, and ethnic backgrounds as well as has far-reaching legal, social, and medical implications. Physicians and nurses face difficult decisions between caring for their patients through extending their lives but also trying to be sympathetic to the level of quality that patient has in terms of their rights and dignity to not choose to live with extreme pain in a terminal condition. Equally challenging is that no situation is exactly the same and while some may seem justifiable due to the nature of the patient's condition, another might be completely questionable. The other dilemma is concluding whether or not it is right to play “God” by taking life even if that is what the person wants. These ethical issues will continue to be debated as patient and physician relationships evolve and medical science progresses.

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