Dear Sir
Dr Takimoto's reflection on suicide in cancer patients challenged me (Takimoto, Reference Takimoto2021).
First and foremost, it recalls Albert Camus’ well-known assertion: “There is but one truly serious philosophical problem and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy” (Camus, Reference Camus1942).
This is a focussed piece of advice. It forces one to consider ones set of values. If I think I should kill myself over such-and-such an issue and I do — good and well. I have made a point, even if it is my last one and even if it might be judged foolish.
If, however, I decide that the issue is worth dying for, but I do not to kill myself then I have to ask myself — why not? What do I believe? Who am I? Am I a Hero or Coward? And — how much do I believe this versus that? Hence, a hierarchy of values is built.
There is an alternative way of asking Camus’ question: Is there anything worth dying for? This approach similarly builds ones value system although in a less solipsistic and melodramatic framework. It suggests a more pragmatic and altruistic philosophy.
I appreciate the way Takimoto reduced the question to a dichotomy: impulsive suicide (a temporary emotional imbalance; possible mental ill-health) and rational suicide.
However, I think the concept of “rational” is problematic. Do we mean logical? In which case thinking of suicide might follow a well-reasoned algorithm, although its veracity depends on the original premise. For example, it makes sense to kill oneself because the doctor said I will soon become bed-bound. But what if the doctor is wrong?
Alternatively, does “rational” refer to autonomy?
Autonomous decision-making can only pass medical muster if there is no mental illness. That is the person has competency and capacity.
Interestingly, the main religions in the world say suicide is wrong not because of autonomy or mental health or logic — but because my life (i.e., the soul) belongs to God. Therefore, I cannot do with my life as I please. This is a theological dogma. However, practically every religion acknowledges autonomy as a given. (What choice do they have?) Each of us has free will and the final choice. The clergy nevertheless will pontificate that whatever one does or decides the final redress for the immortal soul will be in the world to come.
I believe that Autonomy (based on free-will and consciousness) is sacrosanct and hence filled with Godliness. In this case, Autonomy assumes full responsibility for any and all decisions.
Impulsive thoughts of suicide happen early in the diagnosis of cancer owing to despair, hopelessness, lack of information about treatment options, and insufficient contemplation about death. During this fragile early stage, support by oncologists and psycho-oncologists is important. The impulsive suicidal pattern of thinking may return during the ups and downs of disease relapse and new treatments.
--
Thinking about suicide and the shortening of life, I am reminded of the death sentence God handed to Adam and Eve. It was a two-fold punishment.
Adam and Eve were never immortal. The original plan according to the Jewish tradition was they were to live naked and pure for 1000 years. However, after eating of the fruit of the tree of knowledge of good and evil they were sentenced to death. Tradition states that Adam's death sentence shortened his life by 70 years. Adam died age 930. (There is no tradition for how long Eve lived.)
Similarly, a death today — let us say by execution or suicide or euthanasia — is not strictly speaking creating death. It is a shortening of life or merely bringing forwards the inevitable. Likewise, saving a life is merely postponing death. A little semantics I acknowledge but of value heuristically.
The second punishment was the introduction of consciousness. By the same token that Adam and Eve knew they were Naked, they now understood Death. Angst, the fear of death, had entered the world. Possibly more terrifying than living only 930 years and not a 1000 was the daily knowledge of mortality, previously non-existent. This was (and is still) our beastly burden to bear.
Awareness of death takes on greater import when the end of life is near. Let us say there are a few months left. And let us say that the quality of life is poor for all sorts of reasons and the person is suffering. At this point, the thought of suicide is less a Defense mechanism (such as at diagnosis or relapse) and more an Escape mechanism.
Worldwide there are many countries which have introduced variations of the theme of physician-assisted dying (PAD) (Quill et al., Reference Quill, Battin and Pope2021). PAD may be defined as “the practice where a physician provides a terminally ill patient, at their explicit request, with a prescription for a lethal medication that they can take on their own.”
In some countries [USA (PAD), Canada (Medical Assistance in Dying), and Australia (Voluntary-Assisted Dying)], an effort is made to distinguish between a medically prescribed self-administered lethal dose of medications and de novo suicide, because the word “suicide” is associated with mental illness, irrationality, and “self-destruction”. In Europe, however, authorities are less anxious and sentimental about the expressions “assisted suicide” or “euthanasia”, and in that way more honest.
Most patients who enquire about the possibility of PAD do not follow through with a formal request. Contemplation alone appears to be enough to act as a release valve and to return a sense of control.
If someone with one week left to live wants to commit suicide, and has competency and capacity, we would be hard pressed to say this is not rational and autonomous. And what if he had 1 month to live or 6 months? And if he took a lethal dose of narcotics would it be correct for the doctor to inject naloxone to reverse the opioids? The moral and ethical conundrum of course is — how can we be certain there is only two weeks left to live? And can we be certain there is not a cure around the corner?
There is a Jewish story: An elderly woman came to synagogue every day to pray. She had done so all her adult life. However, in the past two years, she had been struck with crippling rheumatoid arthritis. She was hunched, crippled, in constant pain but dragged herself to daily prayers. She asked the rabbi: what value is my suffering? He had no answer for this pious lady. One day he advised her not to come to the synagogue for 3 days — to take a break. She died on the third day.
Theoretically, we value the value of life absolutely. We know aught else.
We must, however, in the same breath understand the significance of suffering without meaning.
