It’s time to look beneath the stigma and see a socially-accepted role for suicide in a nation where our lives are our own.
I will die. You will die. Death is not a question of if; it is only a question of when and how. Modern medicine has doubled American life expectancy over the past two centuries. At forty, we have not yet entered middle age, while at the dawn of the nineteenth century that would have been our life expectancy. Every blessing has its cost, however, and longevity is no exception. The longer we live, the more we age. Even before forty, that slow but steady physical and mental decline is making itself at home in our hair, our skin, our eyes, our joints, and, yes, our brains. Medical technologies are impressive at keeping these limitations at bay, but time marches on. Though increasing levels of debilitation are shifted later and later in life, they will come, and we, as individuals and as a society, are remarkably ill-prepared to handle that eventuality. We seem to be in collective denial that there is a point at which our current tools are inadequate to preserve an acceptable quality of life, howsoever we define that for ourselves.
In denying that this point exists, we fail to plan for it, both practically and emotionally, and the price of our failure is that some of us are continuing to live when we no longer want to. For some of us, there is a period of suffering or indignity at the end of our lives: an unhappy twig that if we could stand back and cultivate our lives like a gardener, we would trim off to shape our lifetimes to our own priorities and values. In single-mindedly pursuing the preservation of life as the holy grail of medicine and considering quality only within that framework, we lose sight of the human experience in each life; we cease to care for the person and instead care for the body.
Be it denial or simply discomfort, our willful blindness to the reality of death (our own and that of others) leaves us exposed, unprepared to actively shape this important and inevitable transition from our lives. Having visited both my grandparents’ and now my parents’ generations in nursing homes, living as they would not have wanted to live, it has become clear that avoiding these kinds of endings is not easy. Without conscious, assertive preparation, and action, individuals whose quality of life ends before their life does will simply be moved, mindlessly, through the standard stages of care. Those with chronic or terminal conditions face a similar situation.
Those who do not choose will have society choose for them, and society’s default is to preserve life regardless of its quality. This is not unreasonable. Where individuals haven’t made explicit what they want, caregivers and medical personnel need a default framework from which to operate. That said, the decades-long struggle of the death-with-dignity movement is clear evidence that even when individuals are explicit about what they want, society and the medical community have been largely unwilling to loosen their grip on that default framework and empower individuals to more actively shape when and how their lives end.
There is a need to rehabilitate the concept of “suicide.” Suicide means to intentionally end one’s own life. Period. The word itself carries no judgment. It provides no information about the reason(s); life-expectancy; physical, mental, or emotional state; morality; legality; or anything else one might want to layer on top of this beleaguered word. The act of suicide is as diverse as the people who choose it. From the emotionally distraught who cannot see past their current situation to samurai who have brought dishonor upon their station, from sufferers of psychosis whose inner voices drive them to destruction to those elderly who have reached the extent of the limitations they wish to live with, from the condemned who take the blade rather than have another do the deed to those suffering from chronic pain, from widows whose society calls on them to die upon their husbands’ funeral pyres to Antarctic explorers who wish to give their comrades a better chance of survival, from toppled monarchs with no safe path to exile to individuals facing a terminal illness … all these are faces of suicide.
That people commit suicide tells us nothing about their choices. Specifically, it tells us nothing about how the choice was made. Was it a carefully considered suicide or was it rash? Did the individual feel in control or powerless? Was the choice based in self-respect, self-care, and self-love, or was it based in fear, despair, or anger? There is a world of difference between a distraught teenager bullied into suicide and an individual with a chronic or terminal illness who, after careful deliberation, decides to die rather than suffer through what the future most likely holds.
I fear that our society has lost sight of the rational and compassionate reasons for suicide. Suicides that are tragic or brutal make lurid headlines, but there are numerous non-newsworthy suicides that take place privately, peacefully, and sometimes in the presence of loved ones; I have been privileged to be present at a few of them. The beauty and dignity of these endings—these suicides—have taught me a great deal about what is possible. They are a reminder that, while we cannot stop the end from coming, for those ready to meet it we can, sometimes, gently shape when and how it comes.
We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.
Right to Life = Right to Death
On July 4, 1776, the signers of the U.S. Declaration of Independence gave voice to the ideal that all people should be valued on the basis of their shared humanity. Inherent in this were the individual’s rights to life, liberty, and the pursuit of happiness. In the two hundred years that followed, while still falling far short of that vision, our society has taken great strides toward it. Also in those intervening centuries, advancements in medical science and technology have dramatically changed how long we live, how we spend the last years of our lives, and how we die.
In exploring the value of more consciously incorporating our own inevitable deaths into our approach to life, the above statement from the Declaration of Independence offers a philosophical anchor from which to approach the complex, messy, and painful reality of our mortality. In this country, few would question the assertion that one should have the right to one’s own life. The assertion that one should have the right to one’s own death, however, is not so readily embraced. Understandably so. Life seems like a happy thing while death seems like a sad thing, and understanding them to be the same thing requires an intellectual reconciliation that lays bare our own transience.
Life is as much a part of death as death is of life. Our lives, though we experience them as ongoing, are ultimately a single, finite whole: a lifetime. Remove the concept of death, and you remove the concept of life. Suggesting that one has the right to one’s life but not to one’s death is akin to suggesting that one has the right to breathe but not to exhale, to look but not to see, to love but not to care. It’s nonsense.
Even if life and death were not inextricable parts of the same tapestry, it is illogical to argue that one has the right to one’s life but not to one’s death. A “right” implies an option, something that one can choose to exercise or not. You have the right to pursue happiness, but you are not obliged to do so. To have the right to life but not death would be like having the “right” to light but not being allowed to turn it off. You must sleep in the light, relax in the light, make love in the light. Yes, you have light, but if you cannot have dark, you don’t have the right to light, you just have light, and that’s a very different concept.
Freedom Comes at a Cost
Rights are powerful, but like fire, they can burn. Freedom of speech means you are free to speak. It also means that one whose views are abhorrent to you is free to speak. It means that one whose words sow hatred, fear, and bigotry is free to speak. Freedom of speech comes at a cost; I am willing to pay it, but am under no illusion that it is a benign blessing. The right to one’s own life—the right to live or die, as one so chooses—is no less hot a flame.
If your life is truly yours, then it is yours to end. If this is true for you, then it is true for your neighbor, your parent, your spouse, your sibling, and your child. In recognizing every individual’s right to his or her own life, we must accept that this right will sometimes be exercised for reasons that we do not understand or agree with. Liberty, however, does not demand that we understand; it demands that we respect. If we are to hold sacred every individual’s right to his or her own life, then we must pay the price that liberty exacts. People will choose to die. People we love may choose to die.
I will now spend the rest of this article tempering the position that I just staked, but I want to start here, in this uncomfortable place, because death and suicide are not topics that lend themselves to easy answers, only painful trade-offs. The more latitude society gives people in choosing their own deaths, the more we will be faced with difficult decisions—our own and those of others—and with losses to which we are not reconciled. The more restrictions society places around people’s ability to choose their own deaths, the greater society’s interference in the individual’s right to self-determination. At one end of the spectrum is a society in which anyone having a bad day could head to the corner store for a lethal dose. At the other is a society in which our lives belong to the state.
There is an emotional chasm between believing we have the right to our own lives and being comfortable when someone exercises that right. This chasm is plainly visible in that, while suicide is not illegal in any U.S. state, if you sit with a loved one as he or she transitions from this life, you could be falsely accused of assisting and charged with a serious crime. As a society, as individuals, we are nothing if not conflicted, and that is understandable. Death—and self-chosen death in particular—is a rite of passage with which we will always have to strive to make our peace.
Shifting the Perspective
In seeking a more open and respectful societal approach toward end-of-life choices, it is important to acknowledge where we currently are. For most of human history, living long enough to suffer from cancer, dementia, or crippling old age was an issue few people faced. Medical technology and its impact on our lives have developed dramatically over the past century, but medicine’s role in society has not modernized as rapidly. As a result, modern American society approaches end-of-life choices from the our-lives-belong-to-the-state end of the regulatory spectrum. While I realize that most wouldn’t use those words to describe the current regulatory approach to suicide, the practical ramifications of our current policies are that our lives are only very rarely ours to comfortably and freely end.
It is helpful to think about suicide from the perspective at the other end of the regulatory spectrum, the perspective under which society deems personal liberty paramount and holds that restrictions should be added only as needed. First, our founding principles demand that we grant all individuals the right to their own lives. Second, in spinning our perspective, it quickly becomes clear that despite all the contentious debate and hard-won legal advances, our society is nowhere near striking a reasonable balance between protecting the individual’s right to self-determination and protecting the individual’s interests and safety.
The Question for Society
From the perspective that individuals have the right to their own lives, the issue becomes whether or not it is appropriate to regulate, or interfere with, the exercise of that right. Assuming most of us agree that selling lethal medications at the corner store is not in the individual’s best interest, what regulatory role should society play? What criteria should be used to determine when it is appropriate for society to prevent, delay, allow, or facilitate individuals’ exercising their right to their own lives? The question for society is how to adequately protect our citizens without excessively curtailing individual liberty.
Legislators face this kind of question regularly: Which intoxicants should be illegal? Should we tax to support those who get injured or who are in retirement? In making these decisions, society must balance the ideal that individuals should be able to make their own choices with the reality that the human brain operates in an uneasy balance between unconscious drives, outside influences, and conscious choices.
The question for an individual considering suicide is whether or not, by his or her own estimation, future pleasures are likely to outweigh future pains. This is a complex and deeply personal reckoning, and society has no role in it. Interfering with an individual’s ability to consider what is best are factors such as the immediate intensity of physical or mental suffering, social pressure not to be a burden, fear of cost, social pressure imposing a religious doctrine, and fear that care or pain treatment will be inadequate. These are the kinds of issues society should consider in deciding how best to balance protecting the individual’s ability to choose wisely with protecting the individual’s ability to choose.
Where society can allay fears without curtailing the individual’s right to self-determination should be a priority, most notably in managing cost and ensuring adequate care and pain treatment. Far thornier will be deciding when to shield the individual from short-term influences and outside pressures. For example, when are social pressures great enough to warrant societal interference? In those circumstances, how can adequate protection be provided in a way that least restricts personal choice? Society’s role should be in process not in outcome. It is not society’s place to choose either life or death for its citizens. Instead, society can create an environment that protects the individual’s ability to freely decide what is in his or her own long-term best interest, and it can provide a more supportive medical establishment for both those who choose to carry-on and those who choose to hasten their deaths.
Pain, Suffering, Values, and Dignity
It is dangerously easy to take another’s apparent circumstances and presume that it feels like what we would feel if we were in that situation. It doesn’t. We don’t have those nerve cells or those values or that history or that approach to dignity. It is impossible for one person to feel what another is experiencing. If we are to fully respect every human’s individuality and personhood, then we have to accept what someone tells us about his or her quality of life and his or her values, no matter how uncomfortable it might make us. We might make different choices for ourselves, were we in another’s circumstances, but we certainly don’t want another making choices for us in such circumstances.
Quality vs. Quantity
It is easy enough to celebrate increased life expectancy, but when I sit with my elderly aunt who suffers from dementia, and in her more lucid moments repeatedly observes that “we wouldn’t let a beloved cat or dog live like this,” it is clear that length of life is not the entire story. Many a refrigerator magnet quotes Emerson’s “it is not length of life, but depth …” as we remind ourselves that a well-lived life comes from quality not quantity.
Where one can enjoy quantity with quality, great, but there are times when one must choose between them. In over-emphasizing the preservation of life, we sometimes degrade people’s overall quality of life. Extending someone’s life is not necessarily improving it, and it could be making it worse. My aunt, for one. If there were a numeric way to measure her overall lifetime ratio of joy to suffering, that value would be steadily dropping year by year. It is not what she wanted before dementia took hold, and it is not what she wants now, as she struggles to control her fear that she can’t remember where she lives.
We need to remind ourselves that the literal contracting heart muscle is of secondary concern to the figurative heart, which holds the character and dignity of a person. If society wishes to maximize the quality of people’s lives, it must recognize that quantity sometimes does the opposite.
Learning to Value Absence
Our brains seem to find it far easier to intuit the value of something than to intuit the value of absence-of-something. Our closets, garages, and storage units are testament to our propensity to gravitate toward the price value of an object (should we ever want to use it again) at the expense of the abstract value of the space created by not having that object (though we will pay considerably for additional square footage).
It is all too easy, in thinking about another’s suicide deliberation, to overvalue additional days of life, which we can see in the physical presence of a living person, while discounting the value of avoided pain and suffering or the value of protected dignity, which are abstract and intangible. In considering another’s suicide deliberation, we should guard ourselves against undervaluing what we cannot see. We do ourselves and others a grave disservice in clinging to visible, quantifiable metrics and undervaluing the abstract, experienced ones. In some cases, there can be enormous value in the absence of life, a value that lies in the avoidance of pain and the preservation of dignity.
Primum Non Nocere
In thinking of how society and medicine might best approach end-of-life choices, including suicide, I am often reminded of the medical mantra first do no harm. On the surface it seems simple and clear, but good intentions without wisdom can produce ugly results. Harm is sometimes easy to see, but it often isn’t.
Keeping an individual alive who does not want to be causes harm. Prolonging pain, suffering, or indignity, no matter how well-intentioned the actions, causes harm. Denying an individual the right to self-determination causes harm. Burdening another with one’s own values or judgments causes harm. Death may be easy to recognize, but it is not always the greater harm.
In explaining their seemingly radical decision to secede, the signers of the Declaration of Independence stated: “… accordingly all experience hath shewn, that mankind are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed.”
While speaking of governments, this statement includes a far more general observation of human nature. Our lives are all we know. One’s consciousness has never experienced anything but life, and turning from life through suicide is not an easy choice. Those who oppose death-with-dignity laws often warn of a slippery slope whereby the ease of obtaining a lethal prescription will encourage any who are ill or elderly to trivially cast off the life that ails them. Neither I nor the signers of the Declaration of Independence have seen anything to suggest that this is the case.
Consider the example set by Oregon’s Death with Dignity Act (DWDA), which was enacted late in 1997. The Oregon Death with Dignity Act: 2016 Data Summary shows that, from 1998 through 2016, fewer than two-thirds of the terminally ill who went through the not-insignificant DWDA process to obtain a lethal prescription actually used it. The Oregon Health Authority does not track the number of patients who would have been eligible but did not get a prescription. However, comparing total cancer deaths from the 2016 Oregon Vital Statistics Annual Report with 2016 DWDA cancer deaths is telling. In 2016, only 1.3 percent of the cancer deaths in Oregon were DWDA deaths. (For tracking purposes, DWDA deaths are not counted as suicides but as deaths due to the DWDA-qualifying terminal illness.) Clearly, a more open-minded approach to suicide has not, even for those who face increasing debilitation and death within the next six months, caused a stampede of individuals eager to shuffle off this mortal coil.
Suicide has many facets, and we should remember that it can be a wise, gentle, carefully weighed choice. Increasingly, people are realizing that the overall quality of their lifetimes might be better if they did not conclude with a period, sometimes a long period, of physical or mental suffering. For those facing such a future, it is enormously comforting to know that a gentle option is available and that they are in control. Add the respect, understanding, and support of those around them, and a scary future suddenly has far fewer fangs.
It is also possible that a more open, respectful approach to suicide might actually decrease the number of rash, poorly considered suicides. Individuals suffering from intense emotional or physical pain are unlikely to turn to a medical system that will put them in lock-down, psychiatrically stigmatize them, and disrespectfully presume that their consideration of suicide is wrong. They would likely feel safer exploring their options with loved ones or medical personnel, knowing that the community is there not to stop them but to ensure that they are safe to consider their choices and that they take adequate time to do so.
My hope is for a society in which individuals are empowered, if they so choose, to take more control over how and when their lives end and in which all those who choose to end their lives do so only after careful consideration and for reasons based in self-love, self-care, and self-respect.