Progressive Dying: Meaningful Acts of Euthanasia and Assisted Suicide

In this paper I use William James's understanding of “significance” in life to show that for certain patients euthanasia and assisted suicide can be importantly meaningful acts that family, friends, and health care professionals must acknowledge and even, at times, aid in bringing to fruition. Dying with meaning is transformative. It reshapes the lives of others that are left behind, giving to their lives new groundings by engaging them in the meaning of dying for us. For the patient, dying with meaning takes the seemingly formless void in the abyss of death and gives it a significant purpose in the last stages of life itself; it turns potential nothingness into actual significance. To the extent that we outsiders do not help the dying, we condemn terminally ill patients to a meaningless existence until they die.     

Suicide in the Subway: Psychodynamic Aspects*

ABSTRACT: Fifty-one cases of suicide attempts in the subway have been investigated to examine the question of whether the method used has psychodynamic significance or is merely adventitious. We found that no single characteristic distinguished subway suicide from all other suicide modalities, although as a group the subway cases had a higher proportion of psychotic and previously suicidal patients than other series quoted in the literature. However, there were important differences between subway suicide cases seeking a “traumatic” death (jumping in front of a train; lying across the track awaiting destruction) and those seeking a “nontraumatic” death (electrocution on the live “third rail”). The traumatic group had histories of exposure to violence, other traumatic suicide attempts, hostile or destructive delusions, and many “destroy” words on psychological test protocols. The smaller nontraumatic group had no such history of exposure to violence; their previous suicide attempts were nontraumatic; delusions, when present, were not menacing; and the psychological tests showed more “escape” words than “destroy” words.     

Mental Illness,Natural Death,and Non-Voluntary Passive Euthanasia

When it is considered to be in their best interests, withholding and withdrawing life-supporting treatment from non-competent physically ill or injured patients – non-voluntary passive euthanasia, as it has been called – is generally accepted. A central reason in support of the procedures relates to the perceived manner of death they involve: in non-voluntary passive euthanasia death is seen to come about naturally. When a non-competent psychiatric patient attempts to kill herself, the mental health care providers treating her are obligated to try to stop her. Yet it has been suggested that death by suicide can be a part of the natural course of a severe mental illness. Accordingly, if the perceived naturalness of the deaths occurring in connection with non-voluntary passive euthanasia speaks for their moral permissibility, it could be taken that a similar reason can support the moral acceptability of the suicidal deaths of non-competent psychiatric patients. In this article, I consider whether the suicidal death of a non-competent psychiatric patient would necessarily be less natural than those of physically ill or injured patients who die as a result of non-voluntary passive euthanasia. I argue that it would not.     

Stress,Coping, and Suicide Risk in Psychiatric Inpatients

The present study investigated the relationship between interpersonal problems, coping styles, and suicide risk. Seventy-one adult psychiatric inpatients completed a suicide risk scale, a measure of interpersonal problems, and a coping scale designed to measure eight coping styles. Patients admitted with a history of suicidal attempts were compared with patients admitted for other reasons. Interpersonal problems were found to be significantly and positively related to suicide risk. The coping style of “suppression” (tendency to avoid threatening or uncomfortable situations) was found to be significantly and positively related to suicide risk [F(2, 68) = 4.54, p < .01]. Several other coping styles were found to be significantly related to suicide risk. These findings are congruent with a “two-stage model of countervailing forces” and have both research and clinical implications.     

The Opinions of GP's Patients About Suicide,Assisted Suicide,Euthanasia, and Suicide Prevention: An Italian Survey

A survey about opinions on end‐of‐life issues of a population represented by 1,171 people in the waiting room of general practitioners' surgeries was conducted in a province of northern Italy. Most subjects did not consider suicide as a reasonable option even in cases of a serious and incurable disease. Moreover, subjects did not consider euthanasia as a possible option either; however, they did express an opposite attitude when considering euthanasia in a third‐person perspective. People with a personal history of suicidal behavior appear to present as a different population, overall expressing more open attitudes.     

Rational Suicide: An Impoverished Self-Transformation

ABSTRACT: The normal human condition is such that even with the best that life can offer suicide is understandable. Life is short, often painful, unpredictable, and lonely. In addition the lives of some individuals are in effect “suicidal careers” in that the harshness of normal life is combined for them with extra suicidal catalysts. Suicide makes sense. Minimally suicide resolves the life problem for the suicide. At the same time suicide is an impoverished self-transformation. Life, as trying and despairing as it can be, is still all we have. The suicide resolves the life problem by obliterating life itself, rather than by transforming self, history, and society. The suicide gives his or her life back inappropriately. In this sense no suicide is ever rational.     

Suicide Behavior

ABSTRACT: A survey of community attitudes and beliefs concerning suicidal behavior is reported, in which women from two suburbs differing widely in their rates of hospital treated self-poisoning and self-injury were interviewed. Sympathetic attitudes to suicidal behavior and to those who engage in it were significantly more prevalent in the low-risk area. Community beliefs regarding lethality, etiology, and ability to distinguish suicide and “attempted suicide” are reported, and the relationship of these beliefs to attitudes is discussed.     

Empirically Based Criteria for Rational Suicide: A Survey of Psychotherapists

This qualitative study was designed to develop a set of empirically based criteria for rational suicide by asking psychotherapists to define “rational suicide.” Data analysis revealed three components of a rational suicide: (1) the presence of an unremittingly hopeless condition (eight examples provided), (2) a suicidal decision made as a free choice, and (3) the presence of an informed decision-making process (five elements listed). It is suggested that the criteria may possibly be used in assessing the rationality of suicidal clients.     

Suicide and euthanasia--special types of partner relationships

Euthanasia is a controversial and important issue in West Germany, especially given the Nazis' killing of minorities during World War II. This paper concentrates on the joint issues of suicide and euthanasia in the context of the doctor-patient relationship. A new evaluation of suicide prevention and euthanasia, especially as they relate to the training of medical students and doctors, is advocated.     

Near-Death Experiences and Attempted Suicide

ABSTRACT: Attempted suicide is correlated with an increase subsequent risk of committed suicide. However, preliminary data and psychodynamic hypotheses suggest that serious suicide attempts followed by transcendental near-death experiences (NDEs) may decrease rather than increase subsequent overt suicide risk, despite the NDEs’ apparent “romanticization” of death. Studies of NDEs and of their influence on suicidal ideation are proposed which may yield greater understanding of self-destructive urges and new strategies of suicide prevention.     

Assisted Suicide,Suffering and the Meaning of a Life

The ethical problems surrounding voluntary assisted suicide remain formidable, and are unlikely to be resolved in pluralist societies. An examination of historical attitudes to suicide suggests that modernity has inherited a formidable complex of religious and moral attitudes to suicide, whether assisted or not. Advocates usually invoke the ending of intolerable suffering as one justification for euthanasia of this kind. This does not provide an adequate justification by itself, because there are (at least theoretically) methods which would relieve suffering without causing the physical death of the suffering person. Carried to extremes, these methods would finish the life worth living, but leave a being which was technically alive. Such acts, however, would provide no moral escape, since they would create beings without meaning. Arguments seeking to justify ending the lives of others need some grounding in concepts of the meaning of a life. The euthanasia discourse therefore needs to take at least some account of the meaning we construct for our lives and the lives of others.     

Problem Solving,Stress, and Coping in Adolescent Suicide Attempts

Twenty adolescents who had made suicide attempts were compared with 20 nonpsychiatric control subjects on measures of problem solving, stress, and coping. The suicidal group did not show evidence of “rigid” thinking or of deficits in the ability to generate solutions to standardized interpersonal problems. However, they did report recent histories of more severe life stress and had inaccurate appraisal of the extent to which stressful events could be controlled. Although suicidal patients were able to generate as many adaptive strategies as control subjects for coping with their own most severe recent real-life stressor, they actually used fewer. They were also more likely to identify maladaptive behaviors as ways of coping. These findings support a transactional model of adolescent suicidal behavior, whereby inaccuracies in the appraisal aspects of problem solving (but not in the solution-generation aspects) in the face of high life stress lead to a reduction in the use of adaptive efforts to cope.     

Would we rather lose our life than lose our self? Lessons from the Dutch debate on euthanasia for patients with dementia

This article reviews the Dutch societal debate on euthanasia/assisted suicide in dementia cases, specifically Alzheimer's disease. It discusses the ethical and practical dilemmas created by euthanasia requests in advance directives and the related inconsistencies in the Dutch legal regulations regarding euthanasia/assisted suicide. After an initial focus on euthanasia in advanced dementia, the actual debate concentrates on making euthanasia/assisted suicide possible in the very early stages of dementia. A review of the few known cases of assisted suicide of people with so-called early dementia raises the question why requests for euthanasia/assisted suicide from patients in the early stage of (late onset) Alzheimer's disease are virtually non-existent. In response to this question two explanations are offered. It is concluded that, in addition to a moral discussion on the limits of anticipatory choices, there is an urgent need to develop research into the patient's perspective with regard to medical treatment and care-giving in dementia, including end-of-life care.     

Youth Suicide: The Knowledge and Attitudes of Australian Teachers and Clergy

This is the first study of the suicide-related knowledge and attitudes of teachers and clergy in Australia. These professional groups have been identified as “gatekeepers” who might serve as a first line of assistance for distressed young people. Such gatekeepers, along with medical and mental health professionals, have a vital role to play in the prevention of youth suicide, of which Australia has the highest rates in the world. This research confirmed that high numbers of teachers and clergy have been approached by suicidal young persons. However, their gatekeeping role may be compromised by a low level of knowledge about signs of suicide risk, which was found even among those who had taken courses in suicide or death and dying or who had personally known someone who suicided. Suicidal behavior was found to be generally regarded as unacceptable, especially by those with a high religious commitment. Further educational efforts about suicide risk identification and prevention seem to be needed for both teachers and clergy; it will be important for such education to take into account attitudinal issues and how these might affect communication with young suicidal people.     

The Moral Foundations of Equipoise and Its Role in International Research

This article reviews the Dutch societal debate on euthanasia/assisted suicide in dementia cases, specifically Alzheimer's disease. It discusses the ethical and practical dilemmas created by euthanasia requests in advance directives and the related inconsistencies in the Dutch legal regulations regarding euthanasia/assisted suicide. After an initial focus on euthanasia in advanced dementia, the actual debate concentrates on making euthanasia/assisted suicide possible in the very early stages of dementia. A review of the few known cases of assisted suicide of people with so-called early dementia raises the question why requests for euthanasia/assisted suicide from patients in the early stage of (late onset) Alzheimer's disease are virtually non-existent. In response to this question two explanations are offered. It is concluded that, in addition to a moral discussion on the limits of anticipatory choices, there is an urgent need to develop research into the patient's perspective with regard to medical treatment and care-giving in dementia, including end-of-life care.     

Consistent Liberalism does not Require Active Euthanasia

I argue that ‘classical liberalism’ does not sanction any easy permissiveness about suicide and active euthanasia. I will use liberal arguments to argue that the distinction between active and passive euthanasia is real and that assisted suicide is, at the very least, deeply troubling when viewed from an authentic liberal perspective. The usual argument for active euthanasia is a utilitarian, not a liberal argument, as recent calls to eliminate the conscientious objection rights of doctors who refuse participation in such procedures plainly demonstrate. The paper focuses on arguments in the public sphere (such as those articulated by James Rachels).     

Risk Factors,Warning Signs,and Drivers of Suicide: What Are They,How Do They Differ,and Why Does It Matter?

Research investigating suicide attempts and deaths by suicide has yielded many specific risk factors and warning signs for future suicidal behaviors. Yet, even though these variables are each valuable for suicide prevention efforts, they may be limited in their applicability to clinical practice. The differences among risk factors, warning signs, and “drivers,” which are person‐specific variables that lead individuals to desire death by suicide, are highlighted. The scarce evidence on drivers is described and specific recommendations for conducting future drivers‐focused research and targeting them in clinical practice are suggested.     

Suicide and the military justice system.

The United States military is sensitive to suicide. There are military policies that direct the formation of active suicide prevention programs. The U.S. military emphasizes a humanitarian approach. Modern military law, however, may view suicidal behavior as deviant. The prosecution of this behavior, although theoretically possible, has never occurred until recently. The U.S. military has now convicted soldiers for attempted suicide and assisted suicide. This article reviews these recent court decisions and suggests revisions in the military law.     

Perturbation and Lethality as Precursors of Suicide in a Gifted Group

ABSTRACT: Thirty cases, for whom longitudinal personality data were available from 1921 to 1960, were analyzed. All the cases were Caucasian males with high I.Q.'s. Five individuals had committed suicide (all by gunshot), 10 (matched) individuals had died natural deaths from cancer or heart disease, and 15 were still living. A blind clinical analysis was conducted primarily in terms of two guiding concepts, perturbation and lethality, by means of a Meyerian “life chart” and a “psychological autopsy,” respectively. The results indicated that four of the five cases deemed to be most suicidal had, in fact, committed suicide—a chance probability of 1 out of 1,131. The prodromal clues—instability, trauma, and personality controls—are discussed. The role of the “significant other” and the “burning-out” of affect seem to be paramount. Suicide is seen as a discernible part of a life style and as a predictable outcome, in a person of 50, by the time that individual is 30 years old.     

Is attempted suicide an offense?

The English poet William Ernest Henley wrote: “I am the master of my fate, I am the captain of my soul.” However, Hamlet's dilemma of “to be or not to be” faces many a soul in times of distress, agony and suffering, when the question asked is “to die or not to die”. If the decision were to die and the same is implemented to its fructification resulting in death that is the end of the matter, the dead is relieved of the agony, pain and suffering and no evil consequences known to our law follow. But if the person concerned were unfortunate to survive, the attempt to commit suicide becomes punishable with imprisonment and fine under Section 309 of the Indian Penal Code (IPC). Petitions have assailed the validity of Section 309 IPC praying time and again to declare the section void. On the other hand, euthanasia and physician assisted suicide have become prominent public issues in many countries over the past few years. Several countries or regions of countries have debated legislation on euthanasia and/or physician assisted suicide. Although there is growing public acceptance of physician-assisted deaths all over the world, many professional organizations remain opposed to it. Most of the debates on the issue are usually framed as issues of morality while many basic empirical questions remain unanswered. This paper attempts to examine the causes and consequences of attempted and completed suicide.