What role may a person play in the end of his or her own life? Is suicide wrong, always wrong, profoundly morally wrong? Or is it almost always wrong, but excusable in a few cases? Or is it sometimes morally permissible? Is it not intrinsically wrong at all though perhaps often imprudent? Is it sick? Is it a matter of mental illness?
Is it a private or a social act? Is it something the family, community, or society could ever expect of a person? Or is it solely a personal matter, perhaps a matter of right, based in individual liberties, or even a fundamental human right?
What role a person may play in the end of his or her own life is the central ethical issue in suicide around which a set of related issues also form: What should the role of other persons be towards those intending suicide? What should the role of medical and psychiatric clinicians be toward a patient who intends suicide since it is they who are said to be charged with protecting human life?
|the ethics of suicide|
What intervention may the state make to interfere with a person’s intention to end his or her own life? What responsibility do others—both immediate others such as family and friends or more distant or generalized others such as employers or institutions or society as a whole— bear when a person commits suicide?
This spectrum of views about the ethics of suicide— from the view that suicide is profoundly morally wrong to the view that it is a matter of basic human right, and from the view that it is primarily a private matter to the view that it is largely a social one—lies at the root of contemporary practical controversies over suicide. These practical controversies include at least three specific matters of high contemporary saliency:
- Physician-assisted suicide in terminal illness, the focus of intense debate in parts of the world with people who have long life expectancies and with high-tech medical systems, particularly the Netherlands, the United States, the United Kingdom, Canada, Switzerland, Belgium, Germany, and Australia;
- Hunger strikes and suicides of social protest, as in Turkey, Northern Ireland, and wartime Vietnam;
- Suicide bombings and related forms of self-destruction employed as military, guerilla, or terrorist tactics in ongoing political friction, including kamikaze attacks by wartime Japan; suicide missions by groups from Tamil separatists to al-Qaeda, and suicide bombings in the conflicts in Israel, Palestine, Iraq, and elsewhere.
Ethical issues have occupied the center of attention in the philosophical discussion of suicide, but conceptual and epistemological ones also play a role, as do a broad range of further issues raised within world historical, religious, and cultural traditions.
Conceptual and Linguistic Issues
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 neither is wholly voluntary nor involves a genuine intention to die, such as suicides associated with depression or other mental illness.
|Conceptual and Linguistic Issues|
Many writers exclude cases of self-inflicted death that, while voluntary and intentional, appear aimed to benefit others or to serve some purpose or principle—for instance, Socrates drinking the hemlock, Captain Lawrence Oates’s (1890–1912) 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 or martyrdom, terms with strongly positive connotations.
Attempts to differentiate these positive cases from negative ones often seem to reflect moral judgments, not genuine conceptual differences, and the linguistic framing of a practice plays a substantial role in social policies about suicide.
For example, supporters of physician-assisted suicide often use the term aid-in-dying as well as earlier euphemisms such as self-deliverance to avoid the negative connotations of suicide while opponents insist on the more negative term suicide. Islamic militants attacking civilians are called martyrs by their supporters and those who recruit them but suicide bombers by their targets and by the Western press.
Differences among languages also play a role in the conceptualization of suicide. While for example English, French, Spanish, and many other languages have just a single, primary word for suicide, German has four: Selbstmord (self-murder), Selbsttötung (self-killing), Suizid (the Latinate term), and Freitod (free death).
This latter German term has comparatively positive, even somewhat heroic, connotations, making it possible for Germanspeakers to think about the deliberate termination of their lives in a linguistic way not easily available to speakers of English or other languages that rely on a single, principal term with strongly negative connotations.
Linguistic issues also arise in attempts to refer to the performance of the act of suicide. The expression to “commit” suicide has been common, echoing the phrase to commit a crime; contemporary suicidologists typically use a variety of less-stigmatizing alternatives, including suicided, completed suicide, and died by suicide.
|the act of suicide|
Some authors claim that it is not possible to reach a rigorous formal definition of suicide and prefer a criterial or operational approach to characterizing the term, noting its varied, shifting, and often inconsistent range of uses. Translation from one language to another may also prove difficult since there is sometimes little way to preserve comparatively positive connotations of some terms.
Cases of death from self-caused accident, self-neglect, chronic self-destructive behavior, victim-precipitated homicide, high-risk adventure, refusal of life-saving medical treatment, and self-administered euthanasia—all of which share many features with suicide but are not usually termed such—cause still further conceptual difficulty.
Nevertheless, conceptual and linguistic issues concerning suicide are of considerable practical importance in policy formation, affecting, for instance, coroners’ practices in identifying causes of death, insurance disclaimers, psychiatric protocols, religious prohibitions, codes of medical ethics, laws prohibiting or permitting assistance in suicide, social stigma and respect, and public response to international and political issues such as suicide bombing and protest suicide.
Closely tied to conceptual issues, the central epistemological issues raised by suicide involve the kinds of knowledge available to those who contemplate killing themselves.
The issue of what, if anything, can be known to occur after death has generally been regarded as a religious issue answerable only as a matter of faith; few philosophical writers have discussed it directly, despite its clear relation to theory of mind.
Some writers have argued that since we cannot have antecedent knowledge of what death involves, we cannot knowingly and voluntarily choose our own deaths; suicide is therefore always irrational.
Others, rejecting this argument, instead attempt to establish conditions for the rationality of suicide. Others consider whether death is always an evil for the person involved and whether death is appropriately conceptualized as the cessation of life.
Still other writers examine psychological and situational constraints on decision making concerning suicide. For instance, the depressed, suicidal individual is described as seeing only a narrowed range of possible future outcomes in the current dilemma, the victim of a kind of tunnel vision constricted by depression.
The possibility of preemptive suicide in the face of deteriorative mental conditions such as Alzheimer disease is characterized as a problem of having to use that very mind which may already be deteriorating to decide whether to bear deterioration or die to avoid it.
Still others suggest that suicide would be the most straightforward expression of normative skepticism, expressing the view that life has no meaning and nothing is of value.
Suicide in World Historical Traditions: the West
Much of the extremely diverse discussion of suicide in the history of Western thought has been directed to ethical issues. Plato acknowledges Athenian burial restrictions— the suicide was to be buried apart from other citizens with the hand severed and buried separately—and in the Phaedo, he also reports the Pythagorean view that suicide is categorically wrong.
But Plato also accepts suicide under various conditions, including shame, extreme distress, poverty, unavoidable misfortune, and external compulsions of the sort imposed on Socrates by the Athenian court: Socrates was condemned to drink the hemlock.
|Suicide in World Historical Traditions: the West|
In the Republic and the Laws, respectively, Plato obliquely insists that the person suffering from chronic, incapacitating illness or uncontrollable criminal impulses ought to allow his life to end or cause it to do so. Aristotle held more generally that suicide is wrong, claiming in the Nichomachean Ethics that it is cowardly and treats the state unjustly.
The Greek and Roman Stoics, in contrast, recommended suicide as the responsible, appropriate act of the wise man, not to be undertaken in emotional distress but as an expression of principle, duty, or responsible control of the end of one’s own life, as exemplified by Marcus Porcius Cato Uticencis (Cato the Younger) (95 BCE–46 BCE), Lucretia (sixth century BCE), and Lucius Annaeus Seneca.
Although Old Testament texts describe individual cases of suicide (Abimilech, Samson, Saul and his armorbearer, Ahithophel, and Zimri), nowhere do they express general disapproval of suicide.
However, the Greekinfluenced Jewish soldier and historian Flavius Josephus (37 CE–100 CE) rejects it as an option for his defeated army, and clear prohibitions of suicide appear in Judaism by the time of the Talmud during the first several centuries CE, often appealing to the Biblical text Genesis 9:5: “For your lifeblood I will demand satisfaction.” New Testament does not specifically condemn suicide, and mentions only one case: the self-hanging of Judas Iscariot after the betrayal of Jesus.
There is evident disagreement among the early Church Fathers about the permissibility of suicide, especially in one specific circumstance: among others, Eusebius Pamphilus (c. 264–340), Ambrose (c. 340–397), and Jerome (c. 342–420) all considered whether a virgin may kill herself in order to avoid violation.
While Christian values clearly include patience, endurance, hope, and submission to the sovereignty of God, values that militate against suicide, they also stress willingness to sacrifice one’s life, especially in martyrdom, and absence of the fear of death.
Some early Christians (e.g., the Circumcellions, a subsect of the rigorist Donatists) apparently practiced suicide as an act of religious zeal. Suicide committed immediately after confession and absolution, they believed, permitted earlier entrance to heaven.
Rejecting such reasoning, St. Augustine asserted that suicide violates the commandment Thou shalt not kill and is a greater sin than any that could be avoided by suicide.
Whether he was simply clarifying earlier elements of Christian faith or articulating a new position remains a matter of contemporary dispute. In any case, it is clear that with this assertion, the Christian opposition to suicide became unanimous and absolute.
This view of suicide as morally and religiously wrong intensified during the Christian Middle Ages. St. Thomas Aquinas argued that suicide is contrary to the natural law of self-preservation, injures the community, and usurps God’s judgment “over the passage from this life to a more blessed one” (Summa theologiae 2a 2ae q64 a5).
By the High Middle Ages the suicide of Judas, often viewed earlier as appropriate atonement for the betrayal of Jesus, was seen as a sin worse than the betrayal itself. Enlightenment writers began to question these views.
Thomas More incorporated euthanatic suicide in his Utopia.In Biathanatos, John Donne (c. 1572–1631) treated suicide as morally praiseworthy when done for the glory of God—as, he claimed, was the case for Christ; David Hume mocked the medieval arguments, justifying suicide on autonomist, consequentialist, and beneficent grounds.
Later thinkers such as Mme. de Staël (Anne Louise Germaine, née Necker, the baroness Staël-Holstein)— although she subsequently reversed her position—and Arthur Schopenhauer construed suicide as a matter of human right.
Throughout this period, other thinkers insisted that suicide was morally, legally, and religiously wrong: among them, John Wesley (1703–1791) said that suicide attempters should be hanged, and Sir William Blackstone (1723–1780) described suicide as an offense against both God and the king.
Immanuel Kant used the wrongness of suicide as a specimen of the moral conclusions the categorical imperative could demonstrate. In contrast, the Romantics tended to glorify suicide, and Friedrich Nietzsche insisted that “suicide is man’s right and privilege.”
Although religious moralists have continued to assert that divine commandment categorically prohibits suicide, that suicide repudiates God’s gift of life, that suicide ruptures covenantal relationships with other persons, and that suicide defeats the believer’s obligation to endure suffering in the image of Christ, the volatile discussion of the moral issues in suicide among more secular thinkers ended fairly abruptly at the close of the nineteenth century.
This was due in part to Émile Durkheim’s insistence that suicide is a function of social organization, and also to the views of psychological and psychiatric theorists, developing from Jean Esquirol (1772–1840) to Sigmund Freud, that suicide is a product of mental illness.
These new scientific views reinterpreted suicide as the product of involuntary conditions for which the individual could not be held morally responsible. The ethical issues, which presuppose choice, reemerged only in the later part of the twentieth century, stimulated primarily by discussions in bioethics of terminal illness and other dilemmas at the end of life.
Suicide and Martyrdom in Monotheist Religious Traditions
|Suicide and Martyrdom in Monotheist Religious Traditions|
The major monotheisms, Judaism, Christianity, and Islam, all repudiate suicide though in each, martyrdom is recognized and venerated. Judaism rejects suicide but venerates the suicides at Masada and accepts Kiddush Hashem, self-destruction to avoid spiritual defilement.
At least since the time of Augustine, Christianity has clearly rejected suicide but accepts and venerates martyrdom to avoid apostasy and to testify to one’s faith. Islam also categorically prohibits suicide but at the same time defends and expects martyrdom to defend the faith. Yet whether the distinction between suicide and martyrdom falls in the same place for Judaism, Christianity, and Islam is not clear.
Judaism appears to accept self-killing to avoid defilement or apostasy; Christianity teaches submission to death where the faith is threatened but also celebrates the voluntary embrace of death in such circumstances; some Islamic fundamentalists support the political use of suicide bombing, viewing it as consistent with Islam and its teachings of jihad, or holy war to defend the faith, though others view this as a corruption of Islamic doctrine.
|Sir William Blackstone|
Thus, while all three traditions revere those who die for the faith as martyrs and all three traditions formally repudiate suicide, at least by that name, the practices they accept may be quite different: Christians would not accept the mass suicide at Masada; Jews do not use the suicide-bombing techniques of their Islamic neighbors in Palestine; and Muslims do not extol the passive submission to death of the Christian martyrs, appealing on Quranic grounds to a more active self-sacrificial defense of the faith.
Other Religious and Cultural Views of Suicide
Many other world religions hold the view that suicide is prima facie wrong but that there are certain exceptions. Still others encourage or require suicide in specific circumstances.
Known as institutionalized suicide,such practices in the past have included the sati of a Hindu widow who was expected to immolate herself on her husband’s funeral pyre; the seppuku or hara-kiri of traditional Japanese nobility out of loyalty to a leader or because of infractions of honor; and, in traditional cultures from South America to Africa to China, the apparently voluntary submission to sacrifice by a king’s retainers at the time of his funeral in order to accompany him into the next world.
|Other Religious and Cultural Views of Suicide|
Inuit, Native American, and some traditional Japanese cultures have practiced voluntary abandonment of the elderly, a practice closely related to suicide, in which the elderly are left to die, with their consent, on ice floes, on mountaintops, or beside trails.
In addition, some religious cultures have held comparatively positive views of suicide, at least in certain circumstances. The Vikings recognized violent death, including suicide, as guaranteeing entrance to Valhalla.
Some Pacific Island cultures regarded suicide as favorably as death in battle and preferable to death by other means. The Jains, and perhaps other groups within traditional Hinduism, honored deliberate self-starvation as the ultimate asceticism and also recognized religiously motivated suicide by throwing oneself off a cliff.
On Mangareva, members of a traditional Pacific Islands culture also practiced suicide by throwing themselves from a cliff, but in this culture not only was the practice largely restricted to women, but a special location on the cliff was reserved for noble women and a different location assigned to commoners.
The Maya held that a special place in heaven was reserved for those who killed themselves by hanging (though other methods of suicide were considered disgraceful), and, though the claim is disputed, may have recognized a goddess of suicide, Ixtab.
Many other preColumbian peoples in the Western hemisphere engaged in apparently voluntary or semi-voluntary ritual self-sacrifice, notably the Aztec practice of heart sacrifice, which was generally characterized at least at some historical periods by enhanced status and social approval.
The view that suicide is intrinsically and without exception wrong is associated most strongly with post-Augustinian Christianity of the medieval period, surviving into the present; this absolutist view is not by and large characteristic of other cultures.
Ethical Issues in Contemporary Application: Physician-assisted Suicide
The right to die movement emerging in the 1970s, 1980s, and 1990s, counting among its achievements the passage of natural death, living will, and durable power of attorney statues that gave patients greater control in decision making about their end-of-life medical care, also raised the question of what role the dying person might play in shaping his or her own death and what role the physician might play in directly assisting the patient’s dying.
These notions have often appealed to the concept of death with dignity, though the coherence of that notion is sometimes challenged. Public rhetoric quickly labeled the practice at issue physician-assisted suicide although less negatively freighted labels such as physician-aid-in-dying or physician-negotiated death have also been advanced as more appropriate.
|Ethical Issues in Contemporary Application: Physician-assisted Suicide|
Proponents of legalizing the practice have argued in its favor on two principal grounds:
- autonomy, the right of a dying person to make his or her own choices about matters of deepest personal importance, including how to face dying, and
- the right of a person to avoid pain and suffering that cannot be adequately controlled.
- that fundamental moral principle prohibits killing, including self-killing, and
- that allowing even sympathetic cases of physician assistance in suicide would lead down the slippery slope, as overworked doctors, burdened or resentful family members, and callous institutions eager to save money would manipulate or force vulnerable patients into choices of suicide that were not really their own. Pressures would be particularly severe for patients with disabilities, even those who were not terminally ill, and the result would be widespread abuse.
Compromise efforts, launched by bioethicists, physicians, legal theorists, and others on both sides, have focused primarily on the mercy argument from avoiding pain: It is claimed that improving pain control in terminal illness, including accelerated research, broader education of physicians, rejection of outdated concerns about addiction associated with opioid drugs, and recourse to terminal sedation or induced permanent unconsciousness if all else fails will serve to decrease requests for physician assistance in suicide. These compromise views also hold that assistance in suicide should remain, if available at all, a last resort in only the most recalcitrant cases.
However, although proponents of physician-assisted suicide welcome advances in pain control, many reject this sort of compromise arguing that it restricts the freedom of a person who is dying to face death in the way he or she wants.
They point out that other apparent compromises, such as the use of terminal sedation, are both repugnant and can be abused, since full, informed consent may not actually be sought.
Proponents also object on grounds of equity: It is deeply unfair, they insist, that patients dependent on life-support technology such as dialysis or a respirator can achieve a comparatively easy death at a time of their own choosing by having these supports discontinued—an action fully legal—but patients not dependent on life supports cannot die as they wish but must wait until the inevitable end when the disease finally kills them.
Many opponents of physician-assisted suicide reject attempts at compromise as well, sometimes arguing on religious grounds that suffering is an aspect of dying that ought to be accepted, sometimes holding that patients’ wishes for self-determination ought not override the scruples of the medical profession, and sometimes objecting to any resort at all to assisted dying, even in very rare, difficult cases.
And some who accept the claim that death is sometimes a benefit to which a person can be morally entitled still object that placing this choice in the hands of patient would make him or her worse off by obliging him or her to choose at all, even if the choice is against.
There is little resolution, however, of the competing claims of autonomist and mercy claims on the one hand and wrongness-of-killing and social-consequences views on the other.
Like the social arguments over abortion, disagreement continues both at the level of public ferment and at the deeper level of philosophical principle although the raising of the issue itself has meant far greater attention to issues about death and dying.
Ethical Issues in Contemporary Application: Suicide in Old Age
While comparatively rarely discussed in contemporary moral theory, the more difficult applied question concerns suicide in old age for reasons of old age alone though this is said to be an issue that will increasingly confront an aging society.
|Ethical Issues in Contemporary Application: Suicide in Old Age|
In both historical argumentation and the very small amount of contemporary theorizing, the fundamental issues of suicide in old age concern two distinct sets of reasons for suicide, in practice often intertwined:
- Reasons of self-interest: suicide in order to avoid the sufferings, physical limitations, loss of social roles, and stigma of old age;
- Other-regarding reasons: suicide in order to avoid becoming a burden to others, including family members, caretakers, immediate social networks, or society as a whole.
With respect to other-regarding reasons, including altruistic reasons, contemporary views consider it unconscionable—especially in the wealthy societies of the developed world—to regard elderly persons as burdens to families or to social units or to the society; nor is it thought ethically permissible to allow or encourage elderly persons to see themselves this way.
While the notion that the elderly are to be venerated is associated primarily with the traditional cultures of the Asia, especially China, Western societies also insist, though sometimes ineffectually in a youth-oriented culture, on respect for the aged and on enhancing long lives.
Simply put, the prevalent assumption in the Western cultures in the twenty-first century is that there can be no good reasons for suicide in old age even though suicide is frequent, especially in men in old age.
Daniel Callahan (1930–), although opposing suicide in old age, points to contemporary medicine’s relentless drive for indefinite extension of life, arguing that the elderly should forgo heroic life-prolonging care and refocus their attention instead on turning matters over to the next generation.
Carlos Prado (1937–), exploring issues of declining competence, raises the issue of preemptive suicide in advanced age. Colorado Governor Richard Lamm’s widely (mis)quoted remark that the elderly have a “duty to die,” unleashed a small storm of academic and public discussion concerning suicide in terminal illness and in old age (Hardwig 1997).
Hints of real social friction can be seen over both self-interested and other-regarding and altruistic reasons for suicide in old age. Having fully legalized physicianassisted suicide and voluntary active euthanasia, the Netherlands is now considering whether to honor advance directives such as living wills in which a now-competent person requests physician-aided death after the onset of Alzheimer disease, a condition particularly frequent among the elderly.
Double-exit suicides, often of married partners in advanced age even though only one is ill, startle public awareness. Disputes over generational equity in the face of rising health care costs question whether life prolongation means merely the extension of morbidity and whether health care ought to be preferentially allocated to the young rather than the old.
The issue of whether a person may ethically and reasonably refuse medical treatment in order to spare health care costs to preserve an inheritance for his or her family is already beginning to be discussed; the same issue also raises the question of suicide.
And issues about suicide in old age are posed by far-reaching changes in population structure, the graying of societies in Europe and the developed world: As birthrates fall and the proportion of retirees threatens to overwhelm the number of still-working younger people, could there be any obligation, as Euripides (c. 480–406 BCE) put it in The Suppliants nearly 2,500 years ago, go “hence, and die, and make way for the young”?
No party now encourages suicide for the elderly, and, indeed, no party even raises the issue; but the issue of suicide as a response to self-interested avoidance of the conditions of old age and to other-interested questions about social burdens of old age cannot be very far away.
Drawing as they might on both Stoic and Christian roots in the West and on non-Western practices now coming to light, the ethical disputes over suicide in old age, independent of illness, are likely to intensify the currently vigorous debate over suicide in terminal illness: Can suicide in old age represent, as one author puts it, the last rational act of autonomous elders, or does it represent the final defeated event in a series of little tragedies of all kinds?