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In 1917, perhaps still troubled by the suicides of two of his brothers and of a close friend, Ludwig Wittgenstein wrote:
If suicide is allowed then everything is allowed.
If anything is not allowed, then suicide is not allowed.
This throws a light on the nature of ethics, for suicide is, so to speak, the elementary sin …
In contrast, in 1961 the Nobel physicist Percy Bridgman, then almost 80 years old and suﬀering from terminal cancer, shot himself, leaving a ﬁnal note:
It isn’t decent for society to make a man do this thing himself. Probably this is the last day I will be able to do it myself.
These views frame the scope of the contemporary debates over the ethics of suicide. At one extreme, some hold the view that suicide is, as Wittgenstein put it (though he questioned even this view), ‘the elementary sin,’ the act most clearly ‘not allowed.’ At the opposite extreme, others hold that control over one’s own life is a matter of right, and ending that life something for which, at least in circumstances like painful terminal illness, a person ought to receive assistance and social support.
These debates are both ancient and new. In the West, prior to the beginning of the twentieth century, suicide had often been viewed as a moral question; at the beginning of the twentieth century, however, ‘scientiﬁc’ views of suicide as the product of social forces or of individual psychopathology worked to remove suicide from ethical scrutiny. Suicidality came to be seen largely as a clinical matter for prevention and treatment. Not until the emergence of the right-to-die movement in the latter part of the twentieth century did ethical issues about physician-assisted suicide and hence about suicide itself begin to re-emerge as a matter for philosophical reﬂection and for public debate.
1. Conceptual Issues
In popular discourse, the term ‘suicide’ carries extremely negative connotations. However, there is little agreement on a formal deﬁnition. Some authors count all cases of voluntary, intentional self-killing as suicide. Others include only cases in which the individual’s primary intention is to end his or her life. Still others recognize that much of what is usually termed ‘suicide’ is neither wholly voluntary nor involves a genuine intention to die, including many of the cases usually labeled ‘suicide’—especially those associated with depression or other mental illness. Many writers exclude cases of self-inﬂicted death which, while voluntary and intentional, appear aimed to beneﬁt others or to serve some purpose or principle: for instance, Socrates’ drinking the hemlock, Captain Oates’ walking out into the Antarctic blizzard to allow his fellow explorers to continue without him, or the self-immolation of war protesters. These cases are usually not called ‘suicide’ but ‘self-sacriﬁce,’ ‘martyrdom,’ ‘heroism,’ or other terms with strongly positive connotations. However, attempts to diﬀerentiate these positive cases often seem to reﬂect moral judgments, not genuine conceptual diﬀerences.
Nonwestern traditional cultures oﬀer many additional conceptual puzzles. Is the label ‘suicide’ appropriate for wives and royal retainers who allow themselves to be buried alive at the death of the king? For widows who, responding to strong social expectation, commit sati by throwing themselves on their husband’s funeral pyre? For jihad or religiously motivated holy-war acts certain to cause one’s own death? For kamikaze missions undertaken by volunteers who know they will not return but who are seen as making a supremely heroic sacriﬁce for the good of the nation? In all cultures, cases of death from self-caused accident, self-neglect, chronic self-destructive behavior, victim-precipitated homicide, high-risk adventure, and self-administered euthanasia—which all share many features with suicide but are not usually termed such—cause still further conceptual diﬃculty. Consequently, some authors claim that it is not possible to reach a rigorous formal deﬁnition of suicide, and that only a criterial or operational approach to characterizing uses of the term can be successful. Nevertheless, conceptual issues surrounding the deﬁnition of suicide are of considerable practical importance in policy formation, as for instance in coroners’ practices in identifying causes of death, psychiatric protocols, insurance disclaimers, religious prohibitions, and laws either prohibiting or permitting aiding suicide in situations such as terminal illness.
2. Traditional And Contemporary Ethical Arguments Concerning Suicide
Because recent scientiﬁc views of suicide have tended to presuppose that suicide is not a voluntary act, much of the most signiﬁcant argumentation concerning the moral status of suicide is to be found in the historical tradition. Traditional discussions of suicide employ a wide range of types of arguments, including principle based, consequentialist, and virtue-based arguments. In each of these categories, some arguments are directed toward the conclusion that suicide is immoral and/or should be prohibited; others lead to the conclusion that suicide is morally permissible and/or should be permitted; a few lead to the conclusion that suicide is morally obligatory in certain sorts of circumstances.
2.1 Principle-Based Arguments
Many thinkers in Western philosophical and religious traditions which employ principle-based, duty-based, or other deontological forms of moral reasoning have argued that suicide is intrinsically wrong, and, hence, that it is prohibited. Conversely, others argue that because suicide is prohibited (by God), it is known to be intrinsically wrong. For example, traditional Judaism cites the Biblical passage at Genesis 9:5, ‘For your lifeblood I will surely require a reckoning,’ as the basis of the principle that suicide is wrong; the only exceptions involve self-killing to avoid spiritual deﬁlement, a practice known as Kiddush Hashem (as in the mass suicide at Masada), and temporary insanity. In classical Greece, Socrates, as portrayed in Plato’s Phaedo, cites the secret, ‘whispered’ Orphic principle that man is a ‘prisoner’ or ‘possession’ of the gods and ought not run away; thus suicide would violate the wishes of the gods. Early Christian thinkers implied or asserted that suicide is wrong per se, since, as Augustine argued, it is to reject God’s gift of life and runs counter to the will of God. In exceptional cases like those of Samson pulling down the temple on the Philistines—and himself—, and Saul falling on his sword, Augustine insists, suicide must have been commanded by God, but such cases are very, very rare and do not excuse ordinary persons.
In the high Middle Ages, Thomas Aquinas deﬁnitively established Christianity’s opposition to suicide with a set of ﬁve arguments. Central among these is the principled claim that suicide is unnatural: ‘everything naturally seeks to keep itself in being.’ From this principle, Thomas drew the conclusion that ‘… suicide is, therefore, always a mortal sin in so far as it stultiﬁes the law of nature …’ Still later, philosopher Immanuel Kant argued that suicide can be shown to be intrinsically wrong by application of the Categorical Imperative: one cannot will without contradiction that it be universal law. Many other moralists have held that, as a matter of basic ethical principle, suicide is intrinsically wrong.
At the same time, however, other thinkers employing deontological or principle-based reasoning have argued that suicide can be morally permissible or even praiseworthy. Typically, these thinkers assert that the principle of autonomy is fundamental, claiming that unless the person is not acting voluntarily or does not have adequate information, or unless serious harm to others will follow, a person’s choice of suicide is to be respected. Defenses of suicide by Seneca, by Rousseau’s character St. Preux in the novel Heloise, by Schopenhauer, and by Mme. de Stael (though she later argued against suicide) are of this form: they assert that as a matter of principle, suicide is not intrinsically wrong and that suicide can be a morally acceptable, sometimes praiseworthy thing to do.
Although the language of moral rights is not available to the earlier thinkers, some have elevated the principle of autonomy into the basis of a fundamental right to suicide. For example, Schopenhauer and Nietzsche see suicide as a matter of the basic right of the individual to choose whether to continue to exist in the world. As Nietzsche put it, ‘suicide is man’s right and privilege.’
2.2 Consequentialist Arguments
Other thinkers have argued that suicide is morally permissible in certain situations, though not in others. Typically, these arguments are consequentialist or utilitarian in character—outcome-oriented, so to speak—assessing the permissibility of suicide in terms of its impact on the suicidal person, on family members, on friends and associates, and on the larger society. Aristotle, for example, says that suicide is wrong because it ‘treats the state unjustly’; he is concerned about its impact on society. Christian and Islamic thinkers often argue not only that suicide is wrong in itself but that it will mean damnation for the victim. Blackstone argued that the suicide is an ‘oﬀense against the king,’ who has an interest in the preservation of all his subjects. Samuel Pepys, recounting in his diary his eﬀorts to intervene on behalf of the widow of a man who has just drowned himself, points to the disastrous impact suicide could have on family members, inasmuch as the English legal system made a suicide’s property forfeit to the Crown.
Using similarly consequentialist arguments, many contemporary authors also point to the consequences suicide can have for family members (especially children) and other close associates. They particularly emphasize the sense of guilt and shame that may be aggravated in survivors. Suicide, on these consequentialist arguments, damages its victim, damages family members, and can damage the society of which they are part.
However, not all consequentialist arguments speak against the morality of suicide. Greek and Roman Stoics, defending suicide in principle, also point to the beneﬁcial consequences suicides like that of Cato might have in protecting the freedoms of society. Both traditional and contemporary authors acknowledge that the suicide of an aggressive or abusive person may have positive consequences for others by removing a threat, that the suicide of a person suﬀering an extended, expensive illness may relieve burdens on an overwrought family, and that suicides of self-sacriﬁce and principle can have substantial beneﬁts for society. Because these arguments appear to favor or even encourage suicide in many sorts of circumstances, they are currently viewed as extremely controversial. They are rarely openly discussed, though they play an inﬂuential role in the background of concerns about ‘slippery slope’ pressures on vulnerable persons.
2.3 Virtue-Based Arguments
Still other thinkers treat suicide as an index of character. For example, Aristotle asserts that suicide is ‘cowardly’—that is, that it is evidence of a defect of character, a failure to act virtuously by exhibiting insuﬃcient courage in facing a diﬃcult situation. Many later thinkers, including Augustine and Thomas Aquinas, have adopted the view that suicide is ‘cowardly.’ These and other Christian writers also celebrate the willing acceptance of suﬀering, particularly in emulating the sacriﬁce made by Christ. As Mme. de Stael put it in her second essay on suicide opposing the libertarian stance of her ﬁrst, ‘Suﬀering is a blessing … it is a privilege to be able to suﬀer.’
In contrast, Greek and Roman Stoics favoring suicide, as well as many later authors, also employ virtue criteria, but argue to the opposite conclusion. The Stoics held that real cowardice held in fearing death, and that committing suicide itself requires courage. Examples cited in this tradition include the heroic suicides of Cato, Lucretia, and Seneca, respectively involving commitment to an ideal of political liberty, sexual virtue, and personal courage in the face of an untrustworthy emperor. For some virtue theorists, suicide can involve other virtues as well: fortitude, loyalty, civic responsibility, and many others. Thus, on a virtue-based analysis, too, arguments may be made both against and for the ethical permissibility of suicide.
3. Social Correlates, Biochemical Findings, And Markers Of Suicide Risk
The question of whether suicide is wrong—whether in principle, or because of its consequences, or as a fault of character—seems to presuppose that the act is at least to some degree under the agent’s voluntary control. Traditional accounts of the morality of suicide, both those which allow it in some or all circumstances—including Plato, the Stoics, Hume, Nietzsche, and others—and those which oppose it in all or virtually all circumstances—Aristotle, Augustine, Thomas Aquinas, Kant, and others—agree in assuming that the act is suﬃciently voluntary that the person whose death it will be can appropriately be blamed (or praised) for so acting—after all, he or she could have refrained from suicide and kept on living.
Scientiﬁc views of suicide, introduced by Durkheim and Freud at the beginning of the twentieth century, have challenged this assumption. Durkheim’s anomie theory held that suicide is a function of the degree of integration of the social body: suicide can be altruistic, where suicide practices are highly institutionalized; it can be egoistic, where individuals do not respond to social expectations and regulations; or it can be anomic, where society does not provide adequate regulation of its members, as, Durkheim believed, in modern industrial society. In contast, Freud insisted that suicide was the product of mental illness. For much of the twentieth century, whether suicide was understood as the product of social forces or as the consequence of underlying depression or other mental disorder, in either case it has been seen as largely beyond the voluntary control of its victim.
Suicide prevention, pioneered by Edwin Shneidman in the mid-twentieth century and continued by many later suicidologists, works in part to identify risk factors associated with elevated rates of suicide: risk is greater for males (especially older white males), for alcohol abusers, for those with low religiosity, for those with poor or rigid coping skills, for those less willing to seek professional help and more likely to ignore the warning signs of suicide, for those with poorer support systems, for those with access to more lethal technology such as guns, and for those for whom failure is more obvious in the primary adult role (deﬁned for males as economic success; for women, as success in relationships). Also at heightened risk are teens who listen to heavy-metal music and white males who listen to country music, though these factors are not causes but proxies for other variables, like alcohol or drug use or divorce. Copycat eﬀects following celebrity suicides, holiday dips and post-holiday peaks, and seasonal variations in suicide have all been explored in the search for explanations, as has the concept of suicidal ‘careers’ as a form of coping mechanism.
At the same time, new ﬁndings in psychiatry, biochemistry, epidemiology, and genetics are beginning to erode assumptions about voluntariness as they reveal biological correlates of suicidal behavior. Depression, it has long been known, is strongly associated with suicide (some studies suggest that it is present in as many as 80–90 percent of cases, though in other studies the rate is lower). Levels of 5-HT, or serotonin, a neurotransmitter, and its metabolite 5-HIAA are decreased, as measured in CNS spinal ﬂuid. Fenﬂuramine used as a challenge agent evokes an impaired response in people who have made serious suicide attempts. Prolactin release is stimulated by serotonin; it too is decreased in suicidal persons. There is some evidence of heritable genetic patterns in families with multiple suicides: adoption studies show that adoptees with suicide in their biological families are at greater risk for suicide than other adoptees, and there is some evidence of signiﬁcant association between genetic variation in the gene for tryptophan hydroxylase (TPH) and violent suicide attempts. It may even be the case that depression and suicidality are associated with second-trimester exposure during pregnancy to winter ﬂu.
Such ﬁndings suggest that suicide, as well as suicidal ideation and suicidal and parasuicidal behavior, along with aggressive behavior generally, may be to some degree biologically determined, either directly or in conjunction with social and environmental factors. If so, suicidality would thus be less a focus for moral blame or praise than for clinical treatment and concern. It may even be possible to develop a biological test—for example, a blood test, a saliva assay, or a urine analysis—that would screen for CNS neurotransmitter abnormalities associated with suicidal behavior. While work to date establishes correlations rather than causes, it nevertheless points to psychological and situational factors that may play a causal role in suicide.
Some theorists have assumed that such research will eclipse ethical issues in suicide altogether. However, this research faces two challenges: ﬁrst, the deﬁnitional issue of who counts as a ‘suicide’ (as distinct from martyr, hero, self-sacriﬁcer, or terminally ill patient seeking an easier death), and second, the prudential issue of whether suicide can ever serve the interests of the person who commits it. Deﬁnitional challenges to research programs are numerous: should research on completed ‘suicides’ include among its cases, for example, self-sacriﬁcing parents who put themselves in harm’s way to protect their children, or social protesters who immolate themselves for political causes, or the sea captain who elects, as tradition has required him, to go down with the ship? The prudential challenge asks whether there can be ‘good reason’ for suicide in some cases, such as painful terminal illness or extreme old age, and hence whether research is misguided if it focuses primarily on negatively valued cases; that is, those called ‘suicides’ in ordinary parlance.
Some theorists suggest that there are two basic groups of suicides: on the one hand, people with neurotransmitter abnormalities or other biological defects who suﬀer from mental illness, depression, or extreme emotional stress, people who cannot consider their best alternatives, and on the other hand biologically normal people who can make such considerations but who ﬁnd themselves caught in situations in which suicide appears to be the most reasonable choice, a way out of their diﬃculties. These groups are sometimes distinguished as ‘irrational’ or mentally ill, and ‘rational’ suicides. A clear diﬀerentiation is not adequately supported by current ﬁndings, primarily because research on ‘suicide’ typically includes just those attempts and completed cases conventionally labeled suicide, overlooking cases not usually identiﬁed as suicides where the motivation is viewed as understandable or heroic, as in, for example, cases of political protest or of hastened dying in terminal illness. By some estimates, 95 percent of suicide cases are ‘irrational’ and ﬁve percent ‘rational,’ though this estimate is itself challenged by conceptual concerns about what counts as ‘suicide’ in the ﬁrst place.
Nevertheless, this distinction inﬂuences much of contemporary discussion about ethical issues in suicide. ‘Irrational’ suicides are assumed not to pose moral issues concerning the agent, since they are assumed not to be voluntary in a robust sense, though of course second parties like family members and physicians may face moral questions about whether and how to intervene. ‘Rational’ suicides, on the other hand, are assumed to be appropriately considered in ethical terms: these are people who make a choice to end their own lives, and the moral issue is whether it can ever be right to choose as they do.
4. The Contemporary Debate Over Physician-Assisted Suicide
Beginning in the latter part of the twentieth century, the so-called ‘right-to-die’ movement began to challenge life-prolongation practices in the treatment of the terminally ill. Patients, it argued, should have the right to control the care given them as they are dying, whether by refusing treatment like respirators or antibiotics or by discontinuing treatment already in progress—even if this means they will die. By giving a central role to patients’ autonomous decisions about medical care at the end of life, the right-to-die movement also raised the issue of whether the terminally ill patient may deliberately and directly end his or her own life—and receive help from his or her physician in doing so. As of the year 2001, physician-assisted suicide had become legal only in the Netherlands and the US state of Oregon, and had brieﬂy been so in the Northwest Territory of Australia, but the issue was being widely debated in many countries, especially in the USA, Canada, the UK, Belgium, Australia, Colombia, and several Scandinavian countries.
Four principal ethical arguments, all to be found in earlier, historical discussions of the ethics of suicide, contribute to this broadly international public debate over whether physician-assisted suicide (and, in some countries, voluntary active euthanasia) should be regarded as morally acceptable and legally permitted. The two principal arguments on the pro side are (a) the argument from autonomy, that the autonomous choice of a competent person is to be respected, and (b) the argument from mercy, an argument for freedom from suﬀering, that the dying patient has the right to try to avoid pain and suﬀering as much as possible, including by means of a deliberately undertaken earlier death if that is the only eﬀective way to avoid them. At least on some views, both conditions are necessary and neither suﬃcient in itself: a person must both choose autonomously and have no realistic alternative in seeking freedom from suﬀering in the process of dying to underwrite an adequate case for physician-assisted suicide. Neither voluntary choice alone in the absence of terminal suﬀering nor terminal suﬀering without genuine choice would be suﬃcient to make such a case.
On the opposing side, two principal arguments against moral recognition or legal acceptance of physician-assisted suicide also inform the current debates, (a) the argument from the intrinsic wrongness of killing—that killing, and hence self-killing, is in itself wrong, and (b), that permitting assisted suicide would risk the ‘slippery slope’: it would invite pressures on patients by overwrought or greedy families, unscrupulous physicians, or cost-conscious institutions, all of which might force a vulnerable patient to ‘choose’ suicide when they did not really wish to die.
Each of these arguments is open to rebuttal. For instance, the claim that killing is not morally permissible can be countered by the objection that killing in self-defense, in war, and in capital punishment are regarded as permissible. The claim that death may be the only way to avoid pain and suﬀering is countered with the possibility of deep sedation. Such counterarguments are themselves open to rebuttal: for example, that it is only the killing of innocents that is prohibited, or that deep, irreversible sedation is tantamount to causing death, in that it permanently ends the possibility of human experience. These counter-counter-arguments are in turn open to still further reply. In practice, the disputes over physician-assisted suicide are hugely extended and extremely complex, simmering in many disciplinary areas— philosophy, law, medicine, psychology, sociology, political theory, theology, social anthropology, economics, and public policy—in many countries around the world.
These disputes have had a focusing eﬀect, redirecting the larger normative debate about suicide, quiescent since Durkheim, Freud, and the beginning of the twentieth century, toward a speciﬁc type of case, terminal illness. Contemporary disputes about the ethical issues in suicide no longer address the larger range of cases in which suicide had been considered permissible or impermissible by various cultures at various times: in shame or dishonor, in chronic illness, in old age, in extreme poverty, for blindness or other disability, on being widowed, for social protest or the defense of principle or religious belief, to avoid degrading labor or coercion in unacceptable activities, and many other reasons. The debate over right-to-die issues and physician-assisted dying that has emerged in the latter part of the twentieth century is indeed a debate about the ethics of suicide, but it is a highly speciﬁc, highly focused debate, raised virtually exclusively with regard to physical suﬀering in the context of terminal illness; it does not yet address whether and when suicide is morally impermissible, permissible, or obligatory in any of a much wider range of situations.
While the right-to-die debates over the ethics of physician-assisted suicide in terminal illness continue to ferment, primarily in the developed nations, work is re-intensifying in suicide prevention, focused especially on teens and on some groups of persons at higher identiﬁed risk, and on improvement in the care of dying patients, particularly on more eﬀective pain control. Some believe that these measures will be able to reduce both the incidence of suicide and the call for physician-assisted suicide in the future.
5. The Future
In 1975, Henry Van Dusen, former president of Union Theological Seminary, and his wife Elizabeth—both leaders in American theological life—committed suicide together by taking overdoses. Mr. Van Dusen was 77 and had had a disabling stroke ﬁve years earlier; Mrs. Van Dusen was 80, blind, and suﬀering from serious arthritis. They left a letter saying that ‘We still feel this is the best way and the right way to go,’ predicting that it would become more frequent and more publicly accepted. It is not yet possible to say whether they were right; some observers argue that the ethical issues in suicide will recede again out of public view as modern medicine becomes more and more capable of alleviating pain and suﬀering now feared by the dying, while others think the ethical issues will become more and more broadly explored, as patients seek greater and greater autonomy in the matter of their own dying. And some think that these ethical issues will be central in the moral life of many societies for the foreseeable future, as life expectancies increase and the likelihood of dying from late-life degenerative disease grows. If so, ethical scrutiny in the matter of suicide will turn to two sorts of issues: the morality of approaching terminal illness and unavoidable death by ‘designing’ one’s own dying, and the risks of social encouragement and pressures that could develop as it becomes a normal, socially tolerated, expected thing to do. Whether such trends will in fact develop is impossible to predict, but it is possible to predict what ethical issues such trends would raise.
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