“Framing” the right-to-die for the United States

Recently, Derek Humphry wrote about the words we use to discuss end-of-life concerns in the US, focusing on the appropriateness of the term “suicide.”  He did so, in part, to stimulate a discussion about the words we use.  Like Humphry, I have no personal problem with the use of the term suicide–it accurately describes death by our own hand–but I resist it for several reasons.

For me, the term suicide should be reserved for those people with unsuccessfully treated mental illness, despair, and depression who end their own lives.  The term, deservedly or not, has always connoted shame, opprobrium, weakness, dishonor, derision, reproach, and even immorality–”it is against God’s laws.”  I would see it as a perfectly appropriate word were it not for the social and cultural context that has built up around it over millennia.

For similar reasons, I resist the word euthanasia, which literally means “good death,” something that everyone I have ever talked to about the subject wants.  But euthanasia may be voluntary or involuntary, active or passive, ambiguities that create imprecise meanings beyond the derivation of the word.  Difficulties with the term resemble the problem with suicide, and it carries further opprobrium related to the Nazi euthanasia program, which targeted people for death because of disability, religion, or personal characteristics deemed unacceptable by the German government of that era.

George Lakoff, Emeritus Professor of Cognitive Science and Linguistics at the University of California at Berkeley, suggests that the language we use should reflect not only our values, but shared values, especially ones cherished by those who disagree with us; otherwise we will not successfully get our messages across to shape the public discourse.  Opponents of the right to die on our own terms understand this point and try to shape the public discourse with their own framing.

Because I have tried to learn the lessons of framing issues as taught by Lakoff, I have resisted using either of these terms to argue for the voluntary, autonomous right to die.  The distinction between suicide driven by mental health issues and the voluntary decision of a dying person to peacefully hasten death to end or avoid suffering is crucial.  

The American Association of Suicidology (AAS) recognizes that the practice of physician aid-in-dying is distinct from the behavior that has been traditionally and commonly described as suicide.  AAS finds many characteristics of death by suicide that do not apply to aid-in-dying or, I would suggest, to the right-to-die (RTD) in general.  A full discussion of the AAS position can be found here. 

The AAS analysis of suicide compared with aid-in-dying or, I suggest, a hastened death by someone who is already dying, can be summarized by looking at the distinctions suggested by AAS, which I have reformulated below:

1.  In suicide, a life that could have continued with quality for a much longer time is cut short;

2.  Suicide, even when marked by ambivalence, typically stems from seemingly unrelenting psychological pain and despair;

3.  In suicide, the person can neither enjoy life nor see that things can change positively in the future;

4.  In suicide, the individual typically suffers from a sense of isolation, loneliness, and loss of meaning;

5.  The term “suicide” may seem to imply “self-destruction”;

6.  Suicide in the conventional sense often involves physical self-violence, as in gunshot wounding, self-hanging, jumping from great heights, self-cutting, self-drowning, and the intentional ingestion of substances or compounds that may cause a painful death;

7.  While suicide in the conventional sense may involve sustained suicidal thinking and prior planning, during periods of acute stress, suicide decisions-to-act are sometimes reached impulsively;

8.  In suicide, the person often “sees no way out” of their desperate situation, whereas hastening a death involves acceptance that the person is dying and wants to avoid continuing or expected suffering;

9.  Suicide in the ordinary, traditional sense is much more common among those with mental illness, often a complex byproduct influenced by anhedonia [inability to feel pleasure], impaired thinking, cognitive distortion and constriction, impaired problem-solving, anxiety, perseveration, agitation, personality disorders, and/or helplessness and hopelessness;

10. The conventionally suicidal person may be unable to assess his or her situation clearly or objectively;

11. Suicide leaves those bereaved by suicide deaths with higher rates of complicated grief and PTSD, and they may be at higher risk for suicide themselves than is the general population;

12. Death by suicide is often associated with substantial social stigma, often a considerable burden for bereaved families or other persons involved, including, for example, treating physicians and psychotherapists;

13. Risk factors considered significant in some strategies of suicide prevention, like childhood trauma, addiction, recent divorce, access to firearms, or other factors that may contribute to emotional pain or capability of suicide, do not typically apply to those choosing aid-in-dying or hastened death;

14. In suicide, the person typically dies alone and in despair, rather than with emotional support by friends or relatives.

I suggest that these differences make the term suicide inappropriate, if not self-defeating, as we try to convince others that the RTD should be an unalienable right in a free society founded on personal liberty and autonomy.  It seems that it is to the RTD movement’s advantage to leave the word suicide for describing those whose acts fit the traditional view of suicide.

The most recent figures from 2017 reveal that about 47,000 people died by their own hand, an increase of about one-third over the 18-year period between 1999 and 2017.  A crucial characteristic that sets most suicides apart from rational decisions to hasten one’s death because of irremediable suffering that is leading to death is that at least 99% of suicides are by violent or painful means, such as by guns, falls, poisoning, fire, or hanging.

In contrast, the Final Exit Network (FEN) has always stood for peaceful, planned deaths for those dying with irremediable suffering for whom the quality of theirs lives has deteriorated to an unacceptable level, or soon will, as determined by each such individual.  Hastening one’s death voluntarily because of such suffering, using a peaceful, effective method is about as far from a conventional death by suicide as is driving a car from Boston to San Francisco and riding on a plane to get from the one city to the other.  Both methods will get a person to the same destination, but the modes of transport are exceedingly different, a difference that cannot be conveyed by saying, “I travelled from Boston to San Francisco.”  Likewise, “death by suicide” in no way conveys the differences between a thoughtful, planned, peaceful death and a violent, often impulsive death.

If we choose words like suicide, assisted suicide, and euthanasia, the connotations those words carry automatically prejudice the way the issues will be perceived.  If Lakoff is correct in the assertion that framing influences reasoning, then how we talk about the ending of a life can affect how we and others think about aid in dying.

I agree with those who favor honesty in our discussions and in the use of words.  But I question whether certain words are merely honest, or are also misleading because of our conscious and unconscious negative associations with them.  It is in the self-interest of the RTD movement to use terms that both are accurate and do not diminish the differences between traditional suicide and voluntary, autonomous hastened death by those who are suffering and dying.  I suggest that it is not euphemistic to use precise language that conveys moral values that are widely shared and not tarnished by unsavory associations.

All rational people know that our life journey will come to an end.  If that end can come without pain and suffering, not only for them, but for their families and friends, we may achieve an important part of a “good death.”

Most of those who fear death may be fearing a bad death–one with unwanted pain and suffering.  If that pain and suffering can be avoided by receiving aid in death or peacefully achieving death by our own hand, who has the right to deny each of us that choice?  We should all have the freedom to make that decision on our own, without coercion or compulsion by others, no matter how well-meaning those others may be.

Free, autonomous people take charge of their own lives and their own deaths to the extent it is possible to do so.  The words we use in describing that process and its outcome should reflect what we do accurately and without the opprobrium associated with a word like suicide.