Suicide, Strictly Speaking

by Gerald Dworkin

The Death of Socrates, by Jacques-Louis David (1787), depicting Socrates prepared to drink hemlock, following his conviction for corrupting the youth of Athens.

In 1998 I was a co-author of a book called Euthanasia and Physician-assisted Suicide: For and Against. I was for; Sissela Bok was against. The point to note here is that the title used the concepts of euthanasia and assisted suicide. Euthanasia is no longer invoked by proponents of medically-assisted dying (hereafter abbreviated as AD) as all such measures explicitly prohibit the physician from administering the drug which causes death. Assisted-suicide is currently banned from their vocabulary by all groups advocating for AD.  

I have been an advocate, and an activist, for passing legislation implementing AD in California (successful) and Illinois (on the political agenda). But I have some problems with the idea that AD should be excluded from the category of suicide. This is my topic today.

Advocates of AD have two reasons for their  linguistic avoidance. 

The first is a purely tactical matter. We are trying to get a social policy enacted and many people who might be won over have personal and religious objections to the very idea of suicide. They may believe that our lives belong to God. They may believe that there is a social stigma attached to suicide no matter how justified, in some cases, it may be. They may feel that the many cases in which suicide is committed by persons who are clearly psychologically disturbed and not capable of making rational decisions will be , mistakenly, extended to what they think are reasonable cases. They may fear that the idea that all suicides are sinful or irrational or cowardly will be applied to their loved ones if they commit suicide.

Since all these, in my view mistaken, attitudes will make it harder to get political support for legalising AD, I see this linguistic choice as a reasonable tactical proposal.

But, as a philosopher, I feel an obligation to point out that as a conceptual matter there is nothing inaccurate or false about stating that a person who takes a drug, knowing that it will cause her death,  and takes it because it will cause her death, is committing suicide on any reasonable conceptual analysis of what suicide is.  

It is not an easy matter to actually pin down what our conception is. It is best to begin by considering clear cases and then to consider more puzzling ones.  Insofar as it is possible we should not allow our moral views about suicide to influence our conception of suicide. We should not try and settle the definition by excluding cases we do not think justified.

John Donne, argued—contrary to the entire Christian tradition—that Christ was a suicide, albeit a quintessentially admirable one, done for the glory of God. Whether it was a suicide or not depends on what we believe about Christ’s intentions and actions not on whether what he did was admirable or not.

The World Health Organization has a definition  they use for gathering statistics about the incidence of suicide. It has the virtue of simplicity. Suicide is the act of deliberately killing oneself.  But all the complexity emerges when one looks closer at the idea of “deliberately.” It has the virtue of excluding accidental or unforeseen deaths. But there are complexities concealed in the idea of deliberate killing  oneself.

Does someone who continues to smoke knowing it is likely to result in an earlier death kill himself deliberately? Does the driver who swerves into a tree to avoid killing a child wandering into the road kill himself deliberately? Does the patient who asks to be taken off the breathing machine because it is  intrusive and painful kill himself deliberately?

Did the Antarctic explorer, Oates, whose weakened condition was hindering his fellow explorers ability to make it through the expedition, and walked out of the tent into a blizzard, deliberately kill himself? What about the Captain who goes down with his ship?

It is clear that we need a more refined and complex analysis. I propose the following definition of A commits suicide.

  1. A  does P which he believes will result in his immediate death.
  2. He does P because he intends to die.
  3. P causes A’s death.

Many philosophers will not be satisfied with this definition. They will present examples which are not clearly satisfied. Consider the soldier who throws himself on a live grenade to save his fellow soldier’s life. 1) and 3) above are clearly satisfied. 2 is not. He may believe he is going to die but he does not intend to die. If he wakes up badly wounded he will not say “Damn!” A similar case is the driver who steers into the tree. 

They will point out that one can commit suicide by failing to do something as in failing to take the pills that will enable one to live.

Exercise for the reader. The above definition classifies “Suicide by cop” correctly.  Does it also include the case where I pay you to kill me? Should it?

Searching more deeply for counter-examples will turn up bizarre examples.

A intends to die. He believes that his shooting himself in the foot while walking in a forest will result in his death. He fires his gun. A passing hunter believes that A is trying to kill him, fires his gun at A, and kills him. All three conditions of the proposed definition are met.

But A has not commited suicide because the causal path from his firing his gun to his death is mistaken, and the actual cause is not the one he mistakenly envisaged.

Still,  I consider the above definition good enough for the set of deaths that we are talking about.  The question I am posing now is are there non-tactical reasons for opposing classifying those who avail themselves of AD as having committed suicide.

Here are the considerations which are favorable to the view that we ought to exlclude deaths due to AD from the category of suicide.

They are all considerations which single out features that make deaths from AD different from  other cases of suicide. And, further, these differences are thought to justify our wanting to exclude them from the class of suicides.

The most important feature is that  people who intend to use AD are going to die in a relatively short time no matter what they do. They are not simply dying, i.e. going to die–we all are in that situation–but they have reason to believe that death  will be within a relatively close period of time. They no longer have the option of a normal life span.

The reason this is important is that what they are losing by causing their own death now is a span of life that is quite short compared to that expected by others who take their own life. So the cost to them of cutting off their life is much less that other suicides. (An interesting case to consider is to be found here. Assume that, instead of euthanasia, AD was available.)

The second consideration is that the life they are losing is one, usually, of great suffering. There is pain, of course, but that can in many cases be controlled.  What cannot be reduced is their loss of autonomy. They may be unable to move. They may be unable to speak. They may be unable  to breathe without machines. They may be unable to think straight. 

So the defining feature of those who take their own life in MAD is the prospect of fairly imminent death and the period of time between now and death is expected to be intolerable.  

The claim is that these are such special self-caused deaths that they should be distinguished from all other suicides. Our attitudes towards those who die this way, or those who help them, should reflect the special character of these deaths and the best way to do that is to deny the application of the same term to characterize them.

It is also interesting to note that the American Society of Suicidology has recently excluded such cases from those that are relevant to their work. Here is their statement:

The American Association of Suicidology recognizes that the practice of physician aid in dying, also called physician assisted suicide, Death with Dignity, and medical aid in dying, is distinct from the behavior that has been traditionally and ordinarily described as “suicide,”the tragic event our organization works so hard to prevent. Although there may be overlap between the two categories, legal physician assisted deaths should not be considered to be cases of suicide and are therefore a matter outside the central focus of the AAS.

Having given the best account I can of why deaths from AD are importantly different from  other cases of suicide the question remains should we redefine the concept in order to mark this difference.  The alternative would be to keep the definition but to mark the difference by using terms such as “rational”, “justified”, “warranted” , “admirable”.  This is what we do with terms such as “lying.”  If I tell the Nazi at the door that there are no Jews inside we don’t say I didn’t lie.

We say the lie was a good thing to do. It was justified, the right thing to do, admirable.

Here is one reason for preferring to keep the definition. Consider the people who jumped from the World Trade Tower on 9/11.  They have all the features which we have considered as possible reasons for not calling their deaths suicide. They had a very short prospect of continued life. They faced an unpleasant death. They made a rational decision to end their life. Are we to classify them as suicides or not?

Or consider the spy captured in wartime.  He knows that the enemy intend to torture him to learn about his fellow spies. They will then execute him. Fortunately he has his arsenic capsule handy. He takes it. 

Here is the Wiki definition of a suicide pill:

A suicide pill (also known as the cyanide pill, kill-pill, lethal pill, death-pill, or L-pill) is a pill, capsule, ampoule, or tablet containing a fatally poisonous substance that one ingests deliberately in order to quickly commit suicide. Military and espionage organizations have provided their agents in danger of being captured by the enemy with suicide pills and devices which can be used in order to avoid an imminent and far more unpleasant death (such as through torture), and/or to ensure that they cannot be interrogated and forced to disclose secret information. As a result, lethal pills have important psychological value to persons carrying out missions with a high risk of capture and interrogation.

It is interesting to note that this discussion includes all the parallels with MAD including the psychological value to the person of knowing he can avoid a terrible death.

Again we are faced with the choice of whether to keep the standard definition and classify  these cases as suicide. Or to deny the application of the term because of the special features involved.

Most advocates of AD have made the choice to deny the application of the standard definition of suicide because of the ways in which AD differs from other cases of suicide.  I prefer to keep the standard definition but to emphasize the many important differences between standard cases and those of assisted-dying including the rationality of the decision-making, the fact that death is very near, the importance of being able to determine for oneself what kind of life is worthwhile, the important benefit of having a way out (which they may never choose to use).  By doing so we can defend some cases of suicide against hostile and mis-informed beliefs about it. 

I understand, as does the AMA which recently issued a report about nomenclature stating that AD should always be referred to as “ physician-assisted suicide”, the tactical efficacy issue.  It is an empirical question as to which strategy– conceptual re-definition or direct tackling of the important differences among different kinds of suicide– will be more effective. It would be nice if conceptual rigor would make  desirable social reform more likely; but it might produce rigor mortis instead.

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