Is Suicide Prevention an Absolute?
2018; Hogrefe Verlag; Volume: 39; Issue: 5 Linguagem: Inglês
10.1027/0227-5910/a000568
ISSN2151-2396
AutoresBrian L. Mishara, David N. Weisstub,
Tópico(s)Grief, Bereavement, and Mental Health
ResumoFree AccessIs Suicide Prevention an Absolute?Considerations When Medical Assistance in Dying Is an OptionBrian L. Mishara and David N. WeisstubBrian L. MisharaCentre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices and Psychology Department, Université du Québec à Montréal, Canada and David N. WeisstubInternational Academy of Law and Mental Health, Montréal, CanadaPublished Online:October 25, 2018https://doi.org/10.1027/0227-5910/a000568PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreSuicide prevention services do their utmost to prevent suicides with all persons, regardless of the suicidal individual's characteristics and reasons given for wanting to die. Their assumptions are that doing otherwise constitutes discrimination and that they would venture into an ethical morass if they attempt to determine whether some lives are more worthy of saving than others. At least, this is how it is supposed to work in principle. Doctors are meant to work equally hard to save the life of a wounded murderer as they do with the victim of a homicide attempt. The suicidal 90-year-old patient who has cancer should obtain the same quality of suicide prevention services as the 16-year-old whose girlfriend abandoned him. Today, an increasing number of countries permit or are considering legalizing euthanasia ("termination of life upon request") and assisted suicide, together referred to as medical assistance in dying (MAID). In this context, should we continue to strive to prevent all suicides, or are there some circumstances where we should abstain from preventing a death by suicide or even encourage people to seek MAID?Suicide Prevention in Theory and in Practice We live in a post-Kantian universe, with many societies dominated by the paradigms of secular humanism and modern-day versions of relativism. We tend to embrace human reason and increasingly reject religious dogma and absolutes as the basis of morality and decision-making. Those who persist in claiming that suicide prevention is a moral obligation that is an absolute have been pressured to concede that there might be exceptions that should be given credence. A wide variety of justifications support the view that there are competing interests that have to be attended to depending on the context. Some have described the current ethical state of affairs by using the philosophical vocabulary of quasi absolutes, which on the face of it sounds like a contradiction, as if to say that when there are moral compromises, a concept so to speak is half pregnant. Exceptions indeed are exceptions, and in the matter of suicide, because death is absolute and irreversible, great care must be taken to find a connection between our competing values and the outcomes that we deem necessary to maintain an acceptable level of either social or individual conscience.In most situations, people working in suicide prevention are comfortable with the policies of their mandate to prevent suicide without differentiation based on personal characteristics or the reasons people give to decide to end their lives. Nevertheless, it is a reasonable assumption that differentiations are sometimes made, particularly when resources are limited, and sometimes individual sentiments can compromise official policies. When compromises bring into question the moral judgment of the protectors, it can be challenging to come up with explicit rationales for suicide prevention. The practical reality is that whether it is the absolute value of human life that is the ultimate reference, or the fact that people after suicide prevention are more often than not thankful, there remains a matter of conscience about what to do when there is an articulated assertion in favor of or against anyone's life. In jurisdictions where MAID is legal, not only is there no interference with the desire to hasten death, but there are direct interventions to terminate life in some circumstances. Mishara and Weisstub have written a series of articles on the ethical basis of suicide prevention policies of official organizations and governmental agencies (2005, 2007, 2008, 2010a, b, 2013a, b, 2015, 2016). Mainly, however, such policies refer to prevention rather than how to react to difficult cases. An interesting example is the Samaritans of the United Kingdom and Wales, whose explicit position grants a strong level of respect for a person's right to make the decision on whether to remain alive. The Samaritans' commitment is to require the assent of a caller before sending an ambulance. Although they usually succeed in convincing callers to receive help, they ultimately have a policy of respecting the caller's decision to live or die without rescue against their will, which is not the case in American centers (see Mishara & Weisstub 2006 for a detailed comparison). In practice, suicide prevention workers may face moral dilemmas in conforming to the mandate of helping everyone despite the circumstances. In a silent monitoring study, where Mishara and colleagues (2007) listened to 2,611 calls to US helplines, there were a very small number of calls (four) where helpers actually encouraged the caller to proceed with their suicide attempt. These were extreme situations. For example, one caller standing on a bridge told how he was unsuccessful in desisting from raping his 6-year-old daughter and, since he was unable to arrest this practice through therapy, decided to end his life. After having explored all the treatments and options and after deciding that the person was in fact incorrigible, the helpline worker expressed the view that it was a logical conclusion to jump. Although this went against the ethical standards of the helpline in question, it does point out the common-sense observation that even in the suicide prevention universe there can be an outlook, prejudicial or not, that there are persons deserving of death.The Advent of Medical Assistance in Dying After decades of volatile debate, the trend internationally is to create exceptions to the historically stated absolute mandate to prevent death. We are witnessing a push toward the legalization of MAID. Some US states, Colombia, Germany, and Switzerland now allow medically assisted suicide, where lethal medications are provided and are administered by the individuals themselves. In addition, the Australian state of Victoria has legalized assisted suicide as of 2019. In Albania, Belgium, Canada, Luxembourg, and The Netherlands, both euthanasia and assisted suicide are permitted. These practices also take place in Japan, with mixed reactions by the judiciary. In Belgium, The Netherlands, and Switzerland, MAID is also available to persons who experience extreme suffering from a mental disorder, but whose suffering is not associated with any life-threatening or untreatable physical illness. This legal provision of death for some has opened up a public dialogue about having categories of wanting to die, which veers away from having a firm set of criteria toward a spirit of progressive liberalism in expanding access. There are heated debates where well-honed arguments about obligations to protect vulnerable populations are presented (e.g., Cohen-Almagor, 2009; Lerner & Caplan, 2015).Are There Justified Distinctions Between How to Respond to People Requesting MAID and Suicidal Individuals? In earlier decades, when the legalization of euthanasia and assisted suicide was first introduced to the public forum, the slippery-slope issue was widely debated. It was feared that once the door was opened, MAID would be expanded and made available to persons who were not experiencing intolerable suffering from an irreversible terminal illness. Today, this narrative is much less evident in the public eye. An autonomy-based mantra now dominates the discourse in Western countries. Nevertheless, there is a critical literature that is tantamount to the slippery-slope critique, where authors have expressed serious trepidation about misguided applications, their perception being that legalized euthanasia and assisted suicide have resulted in the miscarriage of justice. For example, in Switzerland, Belgium, and The Netherlands, MAID, which was initially available only to persons who were already dying or at an advanced stage of a severe degenerative physical illness, is now practiced with persons whose suffering is solely from mental health problems. In The Netherlands, there is currently a proposal before the parliament to allow MAID for any person who is elderly and tired of living, without any requirement that the person have mental or physical problems, or that intolerable suffering be a part of the request.Is There a Difference Between MAID and Suicide? Several organizations have proposed that there is a clear distinction between suicide and MAID. The American Association of Suicidology (2017) has stated that there are 15 ways in which suicide and MAID differ. They take as a basis for their proposed distinctions the nature of MAID as it is practiced in the US states where assisted suicide has been legalized for persons who are terminally ill. Their distinctions describe how the practice and implications of MAID differ from the practice of ending one's life. They note that with MAID, the patient is mainly surrounded by family at the time of death, whereas suicides normally occur in isolation. In fact, it is illegal for others to be present and thus encourage, help, or assist a person to end their life in most countries, including all countries where MAID is permitted (see Mishara & Weisstub, 2016). Another distinction points to the interminable suffering component in MAID, but experiencing suffering as interminable is also a characteristic of suicides. Despite the aforementioned range of distinctions that describe the respective nature of the practices of MAID and suicide, there are in fact no viable research findings to date that indicate that one can reliably distinguish between persons who are appropriate candidates for MAID and suicidal individuals who would benefit from suicide prevention interventions. If the experience of great suffering does not allow us to successfully distinguish between people who die by suicide and persons who seek or receive MAID, is there another avenue to distinguish them? If MAID is limited to persons who are already dying or where death is foreseeable, then it can be argued that MAID is truly distinguishable from suicide based on the fact that in MAID, people choose to alter the manner and timing of a foreseeable death, while in the case of suicide, a person chooses to die when death is not already going to occur in the near future. We might theoretically postulate that there is less ambivalence about changing the manner and timing of death, when compared with ending the life of a physically healthy person. However, the reality is, as with most human decisions, that people seeking medically assisted death are not consistently making clear choices without ambivalence. There are a host of influences that confuse the decision-making process. For example, treatable side effects of medications used to treat physical illnesses are often accompanied by depression and its associated feelings of hopelessness (e.g., chemotherapy for cancer, Parkinson's disease medications). In the absence of empirical data allowing us to determine when the desire to die by MAID can or cannot be alleviated, one may contend that there is a moral imperative to always provide help and intervene before a request to die by MAID is granted.When Is Suicide Rational and Without Ambivalence? We propose that the distinction between a rational and irrational suicide is a fuzzy notion to apply successfully in clinical and intervention settings. Rational assessment of facts is not a prime component in many of the critical decisions that are part and parcel of a person's life. Whether it be a marriage or the purchase of an automobile, major life decisions are fraught with a bundle of emotional and nonrational determinants. Human suffering, by its very definition, accentuates the presence of nonrational and emotionally charged elements (Apkarian et al., 2004). When people say that suicide is rational, what they often mean is that the explanation given for the suicide has been articulated in a manner that is understandable to them (Mishara, 2003). However, the ability to provide an understandable rationale for a decision does not negate the influence of emotion and conflictual thinking that stand behind the decision in question.Defenders of MAID sometime insist that in this category of decision-making, it can be demonstrated that there is little or no ambivalence about the choice. However, those who specialize in suicide prevention work insist that ambivalence is an omnipresent feature of the desire to die. The question of whether or not such ambivalence is present among MAID candidates should be clarified by empirical data. The example of Oregon is instructive, where among all terminally ill persons who convinced two doctors that their suffering was intolerable and were granted their request for assisted suicide, 36% obtained the lethal medication but never took it (Oregon Public Health Division, 2012). Is the Concept of Autonomy an Exaggerated Icon? It is unquestionably a worthy value to enhance the conditions for the autonomous choices of citizens despite the handicaps that exist around them. The freedom to choose has been the cri de coeur of societies that have resisted the paternalism of preceding centuries. Autonomy has been an emancipatory flag for marriage rights, life choices with respect to living arrangements, medical interventions, and a multitude of decisions affecting the quality of life, both materially and affectively. We have come to admit the right to make poor choices and, as a society, we agree to allow individuals to suffer the consequences of misguided behaviors. Smoking is allowed and interventions against a person's will are frequently regarded as morally offensive. How then do we rationalize suicide prevention interventions?Feelings of hopelessness are seminal to suicide and MAID choices. In the case of MAID, it is assumed that the feeling of hopelessness reflects the reality of the circumstances: There is no way of relieving the person's suffering. When that suffering is associated with the imminence of death and the symptoms of an incapacitating terminal illness, the lack of hope is generally justified by the lack of cure for the illness, assuming that the suffering is an inevitable consequence of the medical condition and its effects. However, people who work in hospices and in palliative care contend that in most cases, the suffering of terminally ill persons can be alleviated or substantially diminished, so that the desire to die prematurely is averted (e.g., Canadian Cancer Society, 2016; Richmond, 2005). Similarly, the ethos of suicide prevention is in its essence connected to the goal of diminishing hopelessness and embracing the possibility of regaining a desire for sustaining life. In the absence of empirical data indicating reliably who can and cannot regain the will to continue living, providing help is the only way to determine whether hope can be increased and the desire to die significantly diminished. Suicide Prevention and the Liberal Zeitgeist Without reliable criteria to distinguish between suicides and MAID requests, what are the parameters for suicide prevention that can be guidelines for best practice? What are the limits of an individual's own fundamental ethical commitments? Should suicide prevention groups persist in their universal interventions owing to the overriding value of saving lives whenever possible? Where should suicide prevention policymakers draw the limits of interventions in a manner helpful in day-to-day practices? Given the lack of empirical evidence on the critical issue of the range and types of ambivalence that occur in real-life situations in MAID, it is probable that suicide prevention groups will continue to maintain their policy of offering interventions in almost every case owing to the belief that saving lives, despite recent trends, is a mandate that has stood the test of time.In the past, Thomas Szasz (1986) argued that suicide prevention activities should be abandoned in favor of an absolute respect for individual autonomy. His arguments have been generally ignored by the suicide prevention community, based on their belief that respecting autonomy does not preclude offering and actively providing help to suicidal individuals. Also, it is believed that the ability to make autonomous decisions without undue influence is often already compromised, for example, in the case of a person with schizophrenia who experiences hallucinations of a voice telling him or her to kill themselves, a person with untreated clinical depression who feels hopeless even in hopeful circumstances, a person whose reasoning is compromised by being inebriated, or someone whose decision-making is influenced by fears about the progression of their illness.Current trends in the legalization of MAID increasingly support individual autonomy in life and death decisions, even when their decision-making may be based on erroneous premises. Mishara and Kerkhof (2018) point out that in The Netherlands, before having access to death by MAID, both the patient and the doctor must concur that the patient has tried all other available treatments that could reasonably be believed to be able to diminish the suffering. In 45% of all requests in The Netherlands (Onwuteaka-Philipsen et al., 2017), the request did not lead to euthanasia, often because the physician believed that other forms of help were available and should be tried first. Patients who are refused access to MAID rarely persist with a request for MAID when they receive appropriate medical, mental health, or psychosocial interventions. However, when MAID was legalized in Canada in 2016, the law did not allow a doctor to refuse a request for MAID when it was believed that there were available treatments to alleviate the patient's suffering. In Canada, the patient alone decides whether the suggested treatments are acceptable. Even if the doctor believes that the physical or mental suffering can be sufficiently diminished by available treatments, he or she is obligated to approve access to MAID if the other criteria are met. The Canadian approach constitutes an extreme example of the trend toward not only respecting self-determination, but making the state complicit in providing death to some people who could have changed their mind about wanting to die had appropriate treatments or help been provided. To deprive people who meet the criteria for MAID of the opportunity to receive suicide prevention interventions by putting them in a category apart has no empirical or clinically reliable justification. Providing help to all without discrimination is not incompatible with respect for autonomous decision-making. Offering suicide prevention interventions to all provides an opportunity for some people who otherwise would have died prematurely to regain the will to live, regardless of their circumstances. Brian Mishara is Director of the Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices (CRISE) and Psychology Professor at the Université du Québec à Montréal, Canada. 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P. 8888, Succ Centre-ville, Montréal, Quebec H3C 3P8, Canada, mishara.brian@uqam.caFiguresReferencesRelatedDetailsCited byBeihilfe zum Suizid oder ärztliche Sterbehilfe?2 November 2020 | Psychiatrische Praxis, Vol. 47, No. 08The Experience of Adults Bereaved by the Suicide of a Close Elderly Relative: A Qualitative Pilot Study14 September 2020 | Frontiers in Psychology, Vol. 11Is suicidality a mental disorder? Applying DSM-5 guidelines for new diagnoses7 October 2019 | Death Studies, Vol. 56 Volume 39Issue 5September 2018ISSN: 0227-5910eISSN: 2151-2396 Published onlineOctober 25, 2018 InformationCrisis (2018), 39, pp. 313-317 https://doi.org/10.1027/0227-5910/a000568.© 2018Hogrefe PublishingPDF download
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