On logical suicide

I was at an internal medicine grand rounds talk one day when a colleague started speaking about “logical suicide”; as in suicide that does not seem like the irrational choice we all have come to believe it is. Experience, philosophy, or science, have taught us that a human being’s overriding desire in life is to live. If we deviate from this, if a person wants not to live, then that human being must be ill or evil. But are there ever situations when suicide can actually be thought of as logical? It takes a little bit of tearing down of our usual norms to even contemplate this, but I was curious to explore this further.

A life worth living

In medical ethics circles you’ll often hear the terms “a life worth living” and “quality of life” banded around. What is a life worth living? Most of our lives. We have our basic physiological needs met; we have freedom to think, decide, and act accordingly; and we have (most of us, I mean) the physical capabilities to transform our desires into acts. But, then, just what is a life not worth living? You could say that it is a life that lacks those things we spoke about before, but that’s not true. You may lack any, a few, a lot, most, or all of your physical abilities and yet still consider your life worth living. The important thing is that decision on the ‘worthiness’ of your life is made by you, the owner of that life and body.

A life not worth living

The medical profession and some societal groups, though, have decided on certain broad aspects of a human being’s existence which, if lacking, deem that person’s life a “life not worth living”.  Things like if a person’s brain lacks measurable electrophysiological activity, or if the person requires constant support in their nutrition, hydration, breathing, etc. Of course, the problem with a third party deciding which life is worthy and which not worthy of living is a very fearful one. The Nazis, for example, conceived a concept of “a lifeunworthy of life”. Initially, they considered it a socially useful tact to destroy peoples who were brain dead, brain impaired, mentally retarded, or psychiatrically ill to the extent that they could not survive without the assistance of others. It was considered that these people weren’t worthy of life and in fact were unaware of what life meant, therefore, eliminating them from society (by purposely killing them) was totally acceptable. We are now all very aware that the Nazis’ category of “life unworthy of life” eventually extended to some very broad groups of people and resulted in mass killings without a logical rationale. I, am, however, now digressing…

Suicide

Why do people suicide? That is a question psychologists, scientists, doctors, religious people, and a lot of us ask every day! What do people who suicide tell us (in their last writings or after a “near miss”)? That they did it to end to the pain, that they could see no other options in their life, that they no longer wanted the mundanity of life, that they had failed beyond what they considered remediable, that they had succeeded enough that anything further would be a downhill decline which they didn’t want to face, that they had nothing left to live for, that they had more to gain in death and the afterlife, that they didn’t want to be a burden on others around them that supported them in their existence, etc., etc. People’s reasons for dying are as complex as those we live for. And yet, for most of us, living just seems like the right thing to do. Most of us don’t even question it. And when we become ill or our life is threatened in any other way, our instinct is to try to preserve it. Then what is wrong with people who want to die? People will often quote you that up to 95% of people who commit suicide have a mental illness, for example, depression. But I’ve always wondered about the other 5%. OK, OK, 4% didn’t have a diagnosed mental illness but were intoxicated with drugs or alcohol, acted impulsively after a sudden change in life circumstance, or suicided “accidentally”. But what about the remaining 1%?

Logical Suicide

I’ll start by acknowledging that I’m playing devil’s advocate here just to explore this question further. My colleague who spoke of logical suicide was in fact speaking of one of our patients. It’s not that he disliked this patient and wanted him to die, he was just saying that if this patient decided to suicide, it wouldn’t be considered a totally irrational thing to do. Of course, there were a gasps of disbelief in the room and a few chuckles thinking he was purposely trying to bring up a taboo for a few laughs. How could he speak such preposterous ideas? Because he knew the patient was very aware of his own conditions. The patient did not suffer an intellectual impairment and he knew what he had been through with his condition and that it was only going to get much worse for him. He was in constant pain and discomfort. He was still physically able to act so as to procure his own death and he was not depressed or suffering any other mental illness. Would he want to face further suffering and physical deterioration? If he didn’t, would his opinion be irrational? If he suicided, could you consider his decision illogical? What happened in that room with our colleague having raised this, is that the conversation quickly changed topic. It is still taboo to speak of these things, apparently.

Now, consider a person who, like most of us, has set an agenda for his life, something he would like to achieve and this is what motivates him day to day to keep living. For some of us this is doing a particular job, helping others, marrying the person you love, competing in a sporting race, raising your children, making music, self-expression, visiting a particular place on earth, caring for your parents, etc. These are things worth living for, for you, at least. Now, let’s consider, for example, a person whose sole motivating thing in life is to get married and have children. He wants that more than anything else in life, and that would make his life happy and complete. He is not unhappy without it, however, but he is just existing with the purpose of achieving his dream. What if he was born with a physical impairment that meant he was completely dependent on someone else to care for him and as a result wasn’t able to meet any women to have potentially fall in love with him, marry him, or have his children? He reaches 20 and hasn’t met anyone yet, online or in person. He reaches 30 and he is still in the same predicament. He reaches 40 and his parents, who are his only source of real meaningful love (but not of romantic love, which he desires), are becoming elderly and still his predicament hasn’t changed or improved. He isn’t any more likely now to a) become free of his illness, b) prevent his own physical deterioration, c) find a new overwhelming desire/purpose for his life, or d) fulfil his own self-designated mission in life. What is he living for? How does he answer that question to himself if he isn’t a religious man? Is he living to wait for his death one day?... Well, if this man suicides thinking he has nothing of value to him to live for, could you honestly say his suicide was not logical?

Living

When someone speaks of suicide, of contemplating it, we often see ourselves come up in defence of “life”. We tell the person that they should seek treatment for a mental illness, or we “remind” them how wonderful life is, or we tell them how missed they will be and how many people love and care for them, or we say that perhaps soon medical science will come up with a solution to what discourages them from life, or we tell them to think of how much they will hurt others if they go through with what they’re contemplating… We’re actually pretty good advocates for life! However, perhaps what we should be doing instead of telling others how to feel or what to think, is ask some questions of how they’ve reached their conclusions. The person most likely to convince you of something, even living, is yourself. And hearing back your own arguments for life vs. death is perhaps the only way to have a person change their minds on suicide.

Until recently we still spoke a lot on suicide prevention, but that lead to a lot of people (family, friends, religious ministers, health professionals, etc.) feeling guilty. They were feeling guilty because suicide was being discussed as purely “preventable”, which mainly implied that it could and should be prevented, and if a person succeeded in suiciding then it meant that someone (or everyone) had failed this person. The emphasis is now shifting to raising ‘suicide awareness’, to be able to recognise those at risk of suicide. Most of these people can be helped. The others we may not be able to prevent from suiciding, but we can equally help while they’re living. You don’t need to be anyone special or especially-trained to do this, all you have to do is be a human being and engage the attention of another human being. Who knows, they may just help you too.