Part I: Suicide and Mental Illness
Under the banners of compassion and autonomy, some are calling for legal recognition of a “right to suicide” and societal acceptance of “physician-assisted suicide.” Suicide proponents evoke the image of someone facing unendurable suffering who calmly and rationally decides death is better than life in such a state. They argue that society should respect and defer to the freedom of choice such people exercise in asking to be killed. However, the consequences of accepting this perspective need to be carefully examined.
Accepting a “right to suicide” would create a legal presumption of sanity, preventing appropriate mental health treatment.
If suicide and physician-assisted suicide become legal rights, the presumption that people attempting suicide are deranged and in need of psychological help, borne out by many studies and years of experience, would be reversed. Those seeking suicide would be legally entitled to be left alone 1 to do something irremediable, based on a distorted assessment of their circumstances, without genuine help.
An attempt at suicide, some psychologists say, is often a challenge to see if anyone really cares about the person seeking help.2 Indeed, seeking physician assistance in a suicide, rather than just acting to kill oneself, may well be a manifestation, however subconscious, of precisely that challenge. If society creates a “right to suicide” and legalizes “physician-assisted suicide,” the message perceived by a suicide attempter is not likely to be, “We respect your wishes,” but rather, “We don’t care if you live or die; your life does not matter.”
Almost all who commit suicide have mental health problems.
Few people, if any, simply make a cool, rational decision to commit suicide. In fact, studies have indicated that 93 – 94% of those committing suicide suffer from some identifiable mental disorder.3 In one such study of suicides in St. Louis , Missouri , Dr. Eli Robbins found that 47% of those committing suicide were diagnosed with either schizophrenic panic disorders or affective disorders such as depression, dysthymic disorder, or bipolar disorder. An additional 25% suffered from alcoholism while another 15% had some recognizable but undiagnosed psychiatric disorder. 4% were found to have organic brain syndrome, 2% were schizophrenic, and 1% were drug addicts.4 The total of those with diagnosable mental disorders was 94%. An independent British study yielded a remarkably similar total figure, finding that 93% of those who commit suicide suffer from a diagnosable mental disorder.5
Persons with mental disorders make distorted judgments.
Suicide is often a desperate plea by individuals who consider their problems intractable and hopeless. Experts in psychology recognize that these individuals make flawed evaluations of their personal situations.
The suicidal person suffering from depression typically undergoes severe emotional and physical strain.6 Such physical and emotional exhaustion impairs basic cognition 7, creates unwarranted self-blame, and generally lowers overall self esteem 8, all of which foster distorted judgments.9 These effects also feed the sense of hopelessness that is the primary trigger of most suicidal behavior.10
Studies have shown that during the period of their obsession with the idea of killing themselves, suicidal individuals tend to think in a very rigid, dichotomous way, seeing everything in “all or nothing” terms; they are unable to conceptualize or even acknowledge any range of genuine alternatives.11 Many are locked into automatic thoughts and responses, rather than accurately understanding and responding to their environment.12 Suicide attempters also tend to exaggerate their problems, minimize their achievements, and generally ignore the larger context of their situations.13 They sometimes have inordinately unrealistic expectations of themselves.14 During the period of their disorders, these individuals usually see life as overly traumatic and view temporary minor setbacks as major permanent ones.15
Most of those attempting suicide are ambivalent; often, the attempt is a cry for help.
Studies and descriptions of suicide attempters whose attempts were thwarted by outside intervention (or in some cases, because the means used in the attempt did not take complete effect) demonstrate that most suicidal individuals have neither an unequivocal nor an irreversible determination to die. For example, one study conducted by two psychiatrists in Seattle , Washington , found that 75% of the 96 suicide attempters studied were actually quite ambivalent about their intention to die.16 They are not actually driven to die, but rather to accomplish something by the attempt. Suicide is their means, not their end.
Often, suicide attempters are apparently seeking to establish some means of communication with significant people in their lives 17 or to test the affection of their loved ones.18 Psychologists have concluded that other motives for attempting suicide include retaliatory abandonment (responding to a perceived abandonment by others with a revengeful “abandonment” of them through death), 19 aggression turned inward, 20 a search for control, 21 manipulative guilt, 22 punishment, 23 escapism, 24 frustration, 25 or an attempt to influence someone else.26 Communication of these feelings–rather than death–is the true aim of the suicide attempter, which explains why, paradoxically but truthfully, many admit after an obvious attempt that they really did not want to kill themselves.27 Psychiatrists have long advanced the opinion that underlying a suicidal person’s ostensible wish to die is actually a wish to be rescued.28 A suicide attempt may quite accurately be described, not as a wish to “leave it all behind,” but as a “cry for help.”29 To allow or assist in a suicide, therefore, is not truly fully respecting a person’s “autonomy” or honoring an individual’s real wishes.30
The disorders leading many to attempt suicide are treatable.
Depression can be treated. Alcoholism can be overcome. The difficult situations and circumstances of life that, at the moment, seem permanent and pervasive, often dissolve or resolve in time. The emotional and cognitive patterns of thought clouding the suicide attempter’s judgment and causing feelings of utter despair and hopelessness can be re-channeled in more rational, positive ways with proper psychiatric care.31
Crucial to such turnarounds are timely interventions. Encouraging or validating the disturbed individual’s feelings or misperceptions makes the individual less likely to seek the help he needs and subconsciously probably wants.
Few of those rescued from suicide attempts try again.
The fact that so few, once rescued and treated, ever actually go on to commit suicide lends credence to the theory that most individuals attempting suicide are ambivalent, temporarily depressed, and suffering from treatable disorders. In one American study, less than 4% of 886 suicide attempters actually went on to kill themselves in the 5 years following their initial attempt.32 A 1977 Swedish study of individuals who attempted suicide at some time between 1933 and 1942 found that only 10.9% of those eventually killed themselves in the subsequent 35 years.33 These findings suggest that intervention is actually the course most likely to honor that individuals true wishes or to respect the person’s “autonomy” and value of his life.
Part II: Pain Control
Proponents of euthanasia argue that “mercy-killing” is necessary because patients, particularly those with terminal illness, experience uncontrollable pain. They argue that the only way to alleviate the pain is to eliminate the patient.
The better response to patients in pain is not to kill them, but to ensure that their pain is managed and controlled. According to the 1992 manual produced by the Washington Medical Association, Pain Management and Care of the Terminal Patient, “adequate interventions exist to control pain in 90 to 99% of patients.”34 The problem is that not all medical personnel employ current methods and medical technology for pain control and management.
Doctor Kathleen Foley, Chief of Pain Services at the Memorial Sloan-Kettering Cancer Center in New York , explained in the July 1991 Journal of Pain and Symptom Management how proper pain management has mitigated patient wishes for assisted suicide:
We frequently see patients referred to our Pain Clinic who request physician-assisted suicide because of uncontrolled pain. We commonly see such ideation and requests dissolve with adequate control of pain and other symptoms, using combinations of pharmacologic, neurosurgical, anesthetic, or psychological approaches.35
Approaches to Effective Pain Management
Treating “Total Pain”36
The social and mental pain suffered by terminally ill patients exacerbates their physical pain.37 Dr. Matthew Conolly noted, “[F]ailure to remember this complexity is one of the most common reasons why patients fail to achieve adequate symptomatic relief.”38 Therefore, effective “total pain” control requires a cooperative effort of doctors, nurses, psychiatrists, and counselors.
Proper administration of an opioid, particularly morphine, has been proven to provide effective pain management in the majority of patients with severe pain. A February 1993 article in Anesthesiology noted, “In the setting of widespread cancer, although more than half of patients will experience pain, their pain is manageable by oral administration of opioids alone in 70-80% of cases.”39
Many methods other than opioids are available. Some patients may benefit from radiation therapy, nerve blocks (including even spino-thalamic tractotomy in selected cases), non-steroidal anti-inflammatory drugs, and non-pharmacological methods, which include distraction and relaxation.40 Transcutaneous electrical nerve stimulation and direct spinal cord (dorsal column) stimulation may be valuable.41
Technological advances have greatly increased the available options in administering opioids. One of these, Patient Controlled Analgesia (PCA) (a pump which can deliver a continuous infusion of a drug such as morphine, as well as allow patient-activated doses for breakthrough pain), eliminates any delays in pain relief.42 Studies have shown that PCA may actually lower the amount of medicine administered to patients, while providing them with a safe and effective way to have more control over their treatment.43, 44
Another technological advance is the 72-hour patch made by Alza Corporation that releases controlled amounts of the opioid fentanyl through the skin. This patch allows patients to sleep through the night, avoiding sleep interrupted to take more medicine.45 The development of time released morphine provides this same benefit. There is increasing interest in infusing opiates directly into the spinal column, sometimes using an implanted pump. This allows effective pain relief with a much lower total dose with fewer systemic side effects.46
Barriers to Effective Pain Control
Despite our ability to control pain through medicine and technology, there are some patients who needlessly suffer due to beliefs and practices that disrupt proper pain management. Poor pain assessment by physicians, patient reluctance to report pain, and patient hesitance to take and physician reluctance to prescribe appropriate medication, are some barriers that prevent proper pain management.
These barriers are caused by several myths related to addiction, tolerance, and side effects. Some doctors do not prescribe adequate opioid medication because they fear their patients will become addicted. However, r esearch shows that only 0.04% of patients treated with morphine become addicted.47 Side effects associated with opioids, such as constipation, nausea, and vomiting, can be effectively managed by other medication and careful opiate titration. While a patient may develop a degree of tolerance to morphine over time, such tolerance rarely becomes total addiction, and, therefore, increased doses of the opioid continue to provide relief.
Efforts to Educate Doctors and the Public
In an effort to counter beliefs and practices that disrupt proper pain management, health care professionals in 27 states are promoting cancer pain initiatives.48 These initiatives provide education for doctors, patients, and the general public about effective pain management, especially in terminal patients. The U.S. Department of Health and Human Services has produced a series of Clinical Practice Guidelines for Acute Pain Management and is now working on additional guidelines specifically for cancer pain.
Adequate technology and medicine are available to effectively control pain. While some barriers to the implementation do exist, efforts are being made to remove those barriers. Instead of trying to legalize the killing of patients in pain, the public should be making sure that doctors are taught and willing to use effective pain management, and patients should be demanding creative palliative care while familiarizing themselves with pain control procedures and options.
Part III: What about the Terminally Ill?
Proponents of physician-assisted suicide frequently begin by advocating legalization for those who are terminally ill; however, their advocacy efforts have expanded beyond “helping” the terminally ill. Yet as noted, most of the conditions leading one to feel an urgency to die can be treated, especially pain, depression, and respiratory conditions.
|Treatable depression, rather than the terminal illness itself, usually accounts for such a patient’s expression of a wish to die.|
|After a diagnosis of terminal illness, a person normally goes through a series of stages of coming to terms with impending death. The process of resolving unfinished business in his or her life can be therapeutic and valuable–a value which is lost by acceding to a depression-induced request for assistance in suicide.|
|Given growing pressures to contain medical costs and misguided social attitudes, if assisting suicide is legalized, many terminally ill patients will feel they are burdens and have a duty to die, rather than seek appropriate medical attention.|
A study of terminally ill patients published in The American Journal of Psychiatry in 1986 confirmed that most terminal patients seek suicide not because they are ill, but because they are depressed.
The striking feature of [our]results is that all of the patients who had either desired premature death or contemplated suicide were judged to be suffering from clinical depressive illness; that is, none of those patients who did not have clinical depression had thoughts of suicide or wished that death would come early.49
USA Today has reported that among older people suffering from terminal illnesses who attempt suicide, the number suffering from depression reaches almost 90%.50
Even Jack Kevorkian, the notorious suicide doctor, said at a court appearance that he considers anyone with a disabling disease who is not depressed “abnormal.”51 Kevorkian and others who argue in favor of physician-assisted suicide still ignore that the depression of these terminally ill patients is treatable, even though the disease itself may not be. The depression triggers the suicidal tendencies, not the terminal illness.
Suicidologist Dr. David C. Clark emphasized that depressive episodes in the seriously ill “are no less responsive to medication”52 than depression in others. Additionally, psychologist Joseph Richman, former President of the American Association of Suicidology, confirmed, “[E]ffective psychotherapeutic treatment is possible with the terminally ill, and only irrational prejudices prevent the greater resort to such measures.”53 Indeed, the suicide rate in persons with terminal illness is only between 2% and 4%.54 Competent and compassionate counseling, coupled with appropriate medical and psychological care, are the caring and appropriate responses to people with terminal illness expressing a wish to die.
The dying process should not be circumvented, especially not by those who are terminally ill.
In 1969, psychiatrist Elisabeth Kubler-Ross outlined the 5 stages of the dying process – denial, anger, bargaining, depression, and acceptance. Since that time, Dr. Kubler-Ross has worked with thousands of dying patients and their families, counseling them during the dying process. In a recent interview, she indicated that her experience over the past 20 years tells her that suicide is wrong for patients with terminal illness.
Lots of my dying patients say they grow in bounds and leaps, and finish all the unfinished business. [But assisting a suicide is] cheating them of these lessons, like taking a student out of school before final exams. That’s not love, it’s projecting your own unfinished business.55
This “unfinished business” of contemplating the meaning of life, resolving old disputes, mending relationships, reaching a final recognition, and appreciating all the good that has been a part of one’s life, are all short-circuited by those who, overcome by depression, yield to their depression and kill themselves. Despite their compassionate motives, those healthy bystanders who encourage or even assist in these suicides are in fact abetting the loss of the precious moments of these patients’ lives.
Many consider suicide primarily because they are convinced they are burdens on their families or society.
The principal reason people in a 1991 Boston Globe survey said they would consider some option to end their lives if they had “an incurable illness with a great deal of physical pain” was not the pain, not the “restricted lifestyle,” and not the fear of being “dependent on machines,” but rather that they “don’t want to be a burden” to their families.56 Family members who support the suicide of a terminally ill patient often unwittingly reinforce the notion that the ill family member’s life has lost all meaning and value and is nothing but a “burden.” Many patients with terminal or incurable diseases learn to manage their health care and live for years. Assisting with their suicide removes all possibility of these ill-patients influencing others or simply blessing the lives of those around them in their last years.
In an era of concern over escalating medical costs, “unproductive” consumers of medical services are increasingly made to see themselves as drains on society and the economy. When suicide is promoted as a socially acceptable “option,” the pressure to avail oneself of it is immense. To snuff the life of an ill person is to place a value on every other human life, a value that does not respect or acknowledge the inherent dignity of every human, but a value that is calculated and strictly material.
Thus, if assisting suicide for those with terminal illness is legalized, the so-called “right to die” is very likely in practice to become a “duty to die.” Many consider the law to be the teacher of what is right and proper, and such a codification would be manipulated by the health care industry and by those who regard human life as worthless if the person is not fully productive, engaging, and interacting within society.
Part I by Burke J. Balch, J.D., and Randall K. O’Bannon, M.A.
Part II by Burke J. Balch, J.D., and David Waters
Part III by Burke J. Balch, J.D., and Randall K. O’Bannon, M.A.
- A. Sullivan, Voluntary Active Euthanasia for the Terminally Ill and the Constitutional Right to Privacy, 69 CORNELL L. REV. 363 (1984).
- Stengel, SUICIDE AND ATTEMPTED SUICIDE 113 (1964).
- Barraclough, Bunch, Nelson, & Salisbury , A Hundred Cases of Suicide: Clinical Aspects, 125 BRIT. J. PSYCHIATRY 355, 356 (1976) and E. Robins, THE FINAL MONTHS 12 (1981).
- E. Robins, supra note 3.
- Barraclough, et al, supra note 3.
- American Psychiatric Association, DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS III 210-211; 214-15; 223, 364 (3d ed. 1980); See also H. Kaplan & B. Saddock, MODERN SYNOPSIS OF COMPREHENSIVE TEXTBOOK OF PSYCHIATRY IV 367, 369, 373 (1983); S. Dubovsky & M. Weissberg CLINICAL PSYCHIATRY AND PRIMARY CARE 25 (1983); Klerman, Affective Disorders HARV. GUIDE TO MOD. PSYCHIATRY 253, 255 (1979); Baker, Dorzab, Winokur & Cadoret, Depressive Disease: Classification and Clinical Characteristics, 12 COMPREHENSIVE PSYCHIATRY 354 (1971); Woodruff, Murphy & Herjank, The Natural History of Affective Disorder — I: Symptoms of 72 Patients At The Time of Index Hosp. Admission, 5 J. PSYCHIATRIC RESEARCH 255 (1967).
- Beck, Thinking and Depression, 9 ARCHIVES GEN. PSYCHIATRY 324, 326 (1963).
- Id. at 321.
- Id. at 327.
- Minkoff, Bergman, Beck & Beck, Hopelessness, Depression and Attempted Suicide, 130 AM. J. PSYCHIATRY 455 (1973).
- Neuringer, Dichotomous Evaluations in Suicidal Individuals, 25 J. OF CONSULTING PSYCHOLOGY 445, 445 (1961).
- Beck, supra note 7.
- Id. at 328.
- Neuringer, supra note 12; A. Alvarez, THE SAVAGE GOD 199 (1972) cites the case of the suicide of 17th century poet Thomas Chatterton as an example, according to some critics, of an individual possibly overrating his talent and possessing unrealistically high expectations for immediate success.
- Larremore, Suicide and the Law, 17 HARV. L. REV. 331, 333 (1904); Marzen, O’Dowd, Crone & Balch, Suicide: A Constitutional Right?, 24 DUQUESNE L. REV. 1, 127 (1985).
- Dorpat & Boswell, An Evaluation of Suicidal Intent in Suicide Attempts, 4 COMPREHENSIVE PSYCHIATRY 117 (1964).
- Rubinstein, Meses & Lidz, On Attempted Suicide, 79 A.M.A. ARCHIVES NEUROLOGY AND PSYCHIATRY 103, 111 (1958).
- Stengel, supra note 2.
- Jensen & Petty, The Fantasy of Being Rescued, 27 PSYCHOANALYTIC Q. 327, 336 (1958).
- H. Hendin, SUICIDE IN AMERICA 223 (1982).
- Peretz, The Illusion of Rational Suicide.
- Marzen, et al, supra note 15, at 125.
- K. Menninger, MAN AGAINST HIMSELF 50 (1938).
- Marzen, et al, supra note 15, at 125-26.
- Stengel, supra note 2.
- Id, at 113-14.
- Jensen & Petty, supra note 19.
- Rubinstein, supra note 17, at 109.
- Stengel, supra note 2, at 73.
- Silverman, Silverman & Eardley, Do Maladaptive Attitudes Cause Depression? 41 ARCHIVES GEN. PSYCHIATRY 28, 29 (1984).
- Rosen, The Serious Suicide Attempt: Five Year Follow Up Study of 886 Patients, 235 J.A.M.A. 2105, 2105 (1976).
- Dahlgren, Attempted Suicides 35 Years Afterward, 7 SUICIDE AND LIFE-THREATENING BEHAVIOR 75, 76, 78 (1977).
- Albert Einstein, “Overview of Cancer Pain Management,” in Judy Kornell, ed., Pain Management and Care of the Terminal Patient (Washington: Washington State Medical Association, 1992), p. 4.
- Kathleen M. Foley, “The Relationship of Pain and Symptom Management to Patient Requests for Physician-Assisted Suicide,” Journal of Pain and Symptom Management v. 6 (July 1991): p. 290.
- “Total pain” is a concept developed by Dr. Saunders. See, Cicely Saunders, The Management of Terminal Malignant Disease, (1984), p. 232.
- C. Richard Chapman, “The Psychology of Cancer Pain,” Supra Note 1, p. 21.
- Matthew Conolly, “Alternative to Euthanasia: Pain Management,” Issues in Law and Medicine v. 4 (Spring 1989): p. 499.
- Robert Truog and Charles Berde, “Pain, Euthanasia, and Anesthesiologists,” Anesthesiology v. 78 (Feb. 1993): p. 357.
- American Cancer Society in Association with the National Cancer Institute, “Questions and Answers about Pain Control,” (1992), pp. 43-51.
- Matthew Conolly, M.D., letter to author, August 2, 1993 .
- Louis Saeger, “Patient Controlled Analgesia (PCA) in Caner Pain Management,” Supra Note 1, pp. 149-53.
- Chuck Michelini, “Patients Put in Control of Their Pain Medication,” Medical Tribune (October 29, 1986): p. 46.
- Gene Bylinsky, “New Gains in the Fight against Pain,” Fortune (March 22, 1993): p. 116.
- Matthew Conolly, M.D., letter to author, August 2, 1993 .
- Jane M. Anderson, “Pain Management: Challenging the Myths,” Medical World News (April 1992): p. 20.
- David E. Weissman, June L. Dahl, and John W. Beasley, “The Caner Pain Role Model Program of the Wisconsin Cancer Pain Initiative”, Journal of Pain and Symptom Management v. 8 (January 1993): p. 29.
- James H. Brown, Paul Henteleff, Samia Barakat, and Cheryl J. Rowe, “Is It Normal for Terminally Ill Patients to Desire Death?” American Journal of Psychiatry. Vol. 143, No. 2 (February 1986), p. 210.
- USA Today , August 9, 1993 , 2nd Editorial Page.
- People v. Kevorkian Transcript p.93-94, 90-390963-AZ, Motion for Preliminary Injunction (Oakland Co. Cir. Ct., June 8, 1990)
- Floria Johnson Skelly, “Don’t dismiss depression, physicians say,” American Medical News, September 7, 1992 , p.28.
- Joseph Rchman, Letter to the Editor, “The Case against Rational Suicide,” Suicide and Life-Threatening Behavior, Vol. 18, No. 3 (Fall 1988), p. 288.
- Skelly, supra note 4.
- Leslie Miller, “Kubler-Ross, Loving Life, Easing Death,” USA Today, Monday, November 30, 1992 , p.6D
- Richard A. Knox, “Poll: Americans favor mercy killing,” Boston Sunday Globe, November 3, 1991, p. 22, as well as Robert J. Blendon, Ulrike S. Szalay, and Richard A. Knox, “Should Physicians Aid Their Patients in Dying?” Journal of the American Medical Association, vol. 267, No. 19 (May 20, 1992), p. 2660.