Suicide, assisted suicide, and physician-assisted suicide

Something like one million people each year in the United States try to kill themselves (with various levels of determination) and about four percent of them succeed. That makes suicide the 10th-leading cause of death: way ahead of homicide, and about on a par with auto accidents. About half of those attempts involve people with alcohol, tranquilizers, or opiates on board, raising the question of whether the person involved would make the same choice sober. (The answer might be “yes”: someone could decide in cold blood to kill himself and have a drink or three to steel himself to do it, or someone in chronic pain and taking opiates for it could decide that the pain is more than she wants to handle for years to come.)

In many cases, the impulse is transient; of those who survive suicide attempts, fewer than 10% eventually finish the job. Even people who, seemingly by chance, survive suicide attempts using methods that kill 95% or more of the people who try them (e.g. jumping from tall buildings or bridges, gunshots to the head) mostly don’t try it again. That suggests that most of those who succeed in taking themselves off were not acting on a steady, settled decision that life wasn’t worth living.

That being the case, preventing someone from committing suicide seems as straightforward a public-health objective and medical responsibility as preventing any other sort of sudden death.

Suicidal thoughts are even more widespread than suicide attempts. Physicians and other service providers know something – not as much as they would like, but something – about how to keep those thoughts from turning into attempts, and how to reduce the lethality of the attempts that are made. (Keeping guns out of the hands of those who might use them on themselves ranks high, since guns are especially effective means of ending one’s own life.)

Much of the burden of this work falls on psychiatrists. Those I know are proud of their many successes and intensely distressed by their occasional failures. So it doesn’t surprise me to find my friend Keith Humphreys, who teaches psychiatry, strongly opposed to having physicians – and psychiatrists above all – involved in helping people kill themselves. And published descriptions of Belgium’s legal Kevorkians are not encouraging in terms of how much care they use to avoid helping to end the lives of people who would, if they survived, be happy about it.

With all that said, I still think that people who have formed and held the view that their lives would be better shorter ought to be allowed to act on that view. The fact that much suicide is impulsive doesn’t mean that all suicide is impulsive. The fact that some people might change their minds later, either spontaneously or as the result of a medical breakthrough, doesn’t – in my view – justify the state in requiring someone who doesn’t want to go on living to do so anyway.

And the right to die ought logically to include the right to seek help in dying from a willing helper. There’s not much that can be done to prevent suicide by someone sufficiently determined and capable (physically and psychologically) of acting without help; but when someone asks for help that creates the opportunity, by surrounding the act of helping with appropriate rules, to try to screen out the cases where the intention is impulsive.

Where I agree with Keith is in thinking that the helper should not be a physician (with some exceptions I’ll get to). Physicians have the social role of protecting life and health; getting them involved in killing those who aren’t dying creates too much role tension, given that in the vast majority of cases the goal ought to be prevention.

But the real reason not to get docs involved in assisted suicide is that their professional knowledge and skill are almost completely irrelevant to the task. A physician can provide (probabilistic) information about the subject’s current and likely future health status, including mental health. “Is my depression going to get any better?” is a question a psychiatrist can try to answer. But “Would I be better off dead?” isn’t a medical question, and therefore a medical professional has no qualification for offering an opinion.

Nor is a physician needed to provide technical help, except where the laws get in the way. A breathing mask or plastic bag plus a tank of nitrogen will kill someone reliably and painlessly, and a plumber is more likely than a physician to be able to provide the requisite equipment and aid in its use. “Physician-assisted suicide” is an artifact of a world in which suicide is illegal, and some of its more reliable means (opiates and barbiturates, for example) available only with medical approval. In the special case of death by intravenous injection, skilled help is necessary simply because most of us don’t know how to mainline, even if we had the equipment and the nerve. That makes the physician the natural helper for someone who is already dying and in intense physical pain; a lethal dose of morphine or its equivalent can be given without anyone explicitly asking for a lethal dose when nothing less than a lethal dose will stop the pain.

But in the cases Keith addresses – physically healthy people who want to die because they can’t see any end to the suffering from their life situations or their somatic or mental illnesses – I’d want to keep the doctors far away. Someone in that situation ought to be allowed to register his or her decision to stop living, and – after some waiting period and approval by an actual “death panel” based on the panel’s conclusion (perhaps having taken psychiatric or other medical advice) that the subject’s intention is serious and not merely impulsive, is not made under pressure from others, and that the reasons the subject offers for the decision are not likely to materially change in the near future – be allowed access to carry out his or her intention without interference, and with help from willing helpers.

Of course this is personal. I’m now at an age where I’m going through the deaths of older relatives and friends, and every year my age gets closer to theirs. Some live well to the very end, but by no means all. I can think, without pausing, of five people close to me whose lives would have been improved by a fatal stoke months or years before the Man with the Sickle eventually showed up. I’ve spent enough endless hours in nursing homes to be absolutely certain I want to die before I land in one.

Yes, I’m worried that permission to die could evolve into social pressure to die. (See Tom Schelling’s “Strategic Relationships in Dying.”) And of course your mileage may vary. If your moral or religious principles forbid suicide, no one should try to change your mind, and you shouldn’t have to be involved in helping anyone else. But none of that seems to me an adequate reason to force continued life on those who are tired of it.

Footnote I note that Arthur Caplan, whose exquisite ethical sensibility requires that people who want to live die instead unless they can get replacement kidneys in ways that Caplan finds acceptable, also holds that people who want to die should be required to live until Caplan is satisfied there’s no “slippery slope” nearby. Seventeen people will die today in the United States waiting for kidneys, but Caplan and friends have made sure that potential living donors (you can get along just fine on one kidney) can’t be compensated for donating, so the waiting lists just keep getting longer.

In the good old days, the people who told you that innovations to alleviate human suffering (vaccination, anaesthetic-assisted childbirth, contraception, IVF) were e-e-e-e-villll and must be forbidden by law were called “bishops.” Now they’re called “bioethicists.” This represents dis-improvement in two important ways: (1) Bishops had more impressive costumes; (2) The separation of church and state doesn’t work to keep the bioethicists from imposing their professionally hyperactive consciences on the rest of us, whether we agree with them or not.