(The author has a graduate certificate in bioethics from Florida State University. This is Part 1 of a 2-part post.)
The word “suicide” is commonly found in contemporary discussions of hastening one’s death at the end-of-life. Sometimes the word is used unmodified, but often it shows up in modified form, such as assisted suicide, accompanied suicide, physician-assisted suicide, pre-emptive suicide, and rational suicide. This can be seen in recent popular works by Amy Bloom, Katie Englehart and Lewis Mitchel Cohen, and in the authoritative subject manuals “Final Exit 2020” and “The Peaceful Pill Handbook”; or look no further than the Frontline documentary about Craig Ewert’s trip to Dignitas, titled “The Suicide Tourist.” But is it appropriate to use the word “suicide” in this context?
The word has three entries in the Oxford English Dictionary. Readers are encouraged to look in any dictionary because the definitions found there will be virtually the same. As a verb, its unambiguous definition is “to take one’s own life.” As a noun or adjective things get complicated because it not only means “the action or an act of taking one’s own life,” but also, “a course of action which is disastrously damaging to oneself or one’s interests.”
This has relevance because you almost never see the word used as a verb. Its usage is virtually always as a noun or an adjective. Thus, we see a litany of modifiers whose job is to ameliorate the negative aspect of the word “suicide” and make clear that this is a “good” suicide, which is a little like saying, “he chose a course of action which was disastrously damaging to himself and his interests, but he did it in a good way.”
Along a similar line, consider that the suicidal person is typically seen as a troubled person who feels hopeless and unable to see past their current circumstances to the full potential of the life ahead of them. According to the Centers for Disease Control and Prevention (CDC), suicide is a serious public health problem (CDC n.d.). Rightly or wrongly, suicide is commonly understood as an irrational act that society wishes to discourage and prevent. Thus, if we describe a death as a “rational suicide,” this is akin to saying it was “an irrational act that we wish to discourage and prevent but was done in a rational way.”
But more important than the technical definitions are the stark and vast incongruities in the ideas represented by the suicides of healthy people versus the ideas represented by the hastened deaths of dying people. Already this year there have been at least three widely reported suicides of prominent college athletes (Newberry, 2022), and the New Yorker has published a feature article about child suicide titled “The Unthinkable: Why is youth suicide on the rise?” (Solomon, 2022). Or consider the case of sexagenarian Donald Antrim, who last year published his story in a New Yorker feature titled “Finding a Way Back From Suicide” (Antrim, 2021a) and more fully as a book titled “One Friday in April: A Story of Suicide and Survival.” (Antrim, 2021b).
Contrast that set of stories with the stories of people who are at the end of their lives. These are people who recognize and acknowledge that they are on a definite path to an imminent death. They have evaluated their circumstances and their remaining potential in the context of their life’s values, goals, and accomplishments, and in terms of, as Dworkin (1993, 201) puts it, their “critical interests.” These people now seek a measure of autonomy and a sense of personally-defined dignity in closing out their life when its loss is foreseen in the next days, weeks, months, or in the case of something like dementia, years. They are suffering at the end of their life and have reached the point where they welcome death.
The differing concepts represented by these two different sets of people cry out for different vocabularies. The distress and pain that surrounds the suicide of a healthy person is different in kind and in degree from the distress and pain of the hastened death of a dying person. The idea that repeatedly using the word “suicide” in the end-of-life context will eventually erode its negative connotations is unlikely. The CDC reports that in 2019, suicide was the second-leading cause of death in the United States for age group 10 – 24, and the third-leading cause for age group 25 – 44 (CDC, 2021). The agony and costs of suicide far outweigh the attention generated by the right-to-die movement. Attempts to modify the word “suicide”, or to rehabilitate its meaning, are misguided.
One difference that these vocabularies need to account for is the difference between a killing and a death. The suicide of a healthy person is more about that person’s decision to kill themselves, an unnatural event, than it is about their death. Though that person is now dead, they were not in a state where they were dying or at the end of their life. The suicide is generally viewed as someone who we expected to be a part of our lives for some time to come. We struggle to make sense of the event and sometimes never recover from it.
Conversely, the hastened death of a person at the end of their life is about their death, a natural event, and not about a killing. Dying is an inevitable part of life. It is completely within our intellectual domain to recognize and understand when we are dying, and it is eminently reasonable to desire a sense of autonomy over the event such that we accomplish it in a manner that brings us peace and dignity. The claim that such a person is “killing themselves” is true only in the most base and trivial sense. That claim distorts the meaning and purpose of the event. The claim’s objective is to denigrate the choice and sway public opinion against it. To improve our understanding of the event and our ability to communicate with others, we must drop references to “killing” and “suicide,” and embrace references to “caring” and “death.”
Consider also that the American Association of Suicidology (AAS) says there are 25 suicide attempts for every death by suicide (AAS 2022). This raises an interesting question: how many of those failed attempts are by people hastening their death at the end of their life? Because we fail to recognize these hastened deaths as something different from “suicide”, particularly in jurisdictions lacking legislated Death with Dignity or MAiD, we don’t know and can’t say. But we can guess the answer is far closer to zero than it is to 25, which would further suggest that seeking a death with dignity is a different thing than suicide. But the AAS already told us this years ago in their 2017 statement “’Suicide’ is not the same as ‘Physician Aid in Dying’”, where they delineate 15 differences between the two concepts (AAS, 2017). And this is a position taken even earlier by the American College of Legal Medicine in their 2008 “ACLM Policy on Aid in Dying,” where they say:
the ACLM is the first such organization to publicly advocate elimination of the word ‘suicide’ from the lexicon created by a mentally competent, though terminally ill, person who wishes to be aided in dying (Zaremski, 2008).
For substantial reasons then, “suicide” is not appropriate for the end-of-life context. But if this word is not available to us, what do we replace it with? This is a question that has been asked before and a great deal of effort has been expended on it without a resolution. We will explore this part of the problem in next week’s post.
Yes! We need a new way of expressing the decision to end our lives that does not imply depression or, as the Vital Statistics reports call it, “self- harm.” Consider it Self-affirmation, with a capital S. My friend Debora Shapiro left a note for the coroner: “Please don’t call it suicide. Call it a voluntary death.” My friend Adrienne Germain wrote about her choice to die peacefully. But today I found that her Wikipedia biography has been updated with the notation that “Germain committed suicide on May 19, 2011.” I can hear her yelling “Eeek!” Next week’s post cannot come too soon. Thank you Doug Wussler!
A “voluntary death” can mean a number of things.
One of my husband’s aunts developed a form of leukemia at age 89. Her expected life span with treatment was nine to twelve months and six to nine months without treatment. She was a practicing Catholic and in consultation with her priest decided that it didn’t conflict with her faith to decline treatment. That could be considered a “voluntary death” in that she chose to shorten her life.
People with an expected life span of six months or less to live often choose hospice care. The stated goal of hospice is neither to prolong life or hasten death. Choosing hospice care could be considered a “voluntary death” in that people with an expected life span of six months or less often outlive that prognosis if they choose to treat their underlying illness.
Getting approval for an DNR or DNI order could be seen as a “voluntary death” (as long is it is the patient’s choice and not signed under coercion or a surrogate is coerced into signing it) because declining resuscitation or intubation could be a death sentence when these interventions could save a person’s life. Would it be a quality of life acceptable to the person? No one knows what would happen as a result of these interventions and it’s up to the patient to decide whether the potential worst-case scenario is acceptable. Some people would say no, others maybe, and others yes.
Thank you Doug Wussler for re-iterating the eternal conundrum about the word “suicide”. Good article. But at the end you carelessly used another problematic word-“terminal”. Yes hastening a looming death should not be mixed with a young physically healthy life-taking. But neither should “terminal” be the dividing line for when hastening a death is “rational”. Cancer patients can pretty clearly be predicted to die in 6 months or less. People with degenerative neurological diseases like Lou Gehrig’s or MS cannot, but it is terribly cruel to force them to become totally
paralyzed first. Now please speak to that.
Excellent, Doug, and I too look forward to reading next week’s installment. I’ve tended to think, “oh, it’s just semantics” and not worry about the terminology used. However, you and many others are absolutely correct that we do need a new term now because of the prevalence of public freakouts over the suicides of young people.
Ellen –
My argument is that the word “suicide” is not appropriate for the end-of-life context. It not only fails to accurately communicate what one is doing when one hastens one’s death in that context, it mischaracterizes the act. You seem to be making a different point, i.e., that a hastened death can be rational even if the person’s condition is not terminal. I agree with you. I did not use the word “terminal,” that word was in the ACLM’s statement, which also advocates that the word “suicide” should not be used in the end-of-life context. What you seem to object to is that they happen to define the end-of-life context more narrowly than we do, as does the AAS, whose statement refers to “Physician Aid in Dying.” How to define that context is an argument for another day. What I am trying to do at this point is show that there is more agreement than people realize for abandoning the word “suicide” in the end-of-life context. Finding a new and appropriate word for the end-of-life context is the first step to broadening everyone’s understanding of who deserves to be included in that context. Our cause needs appropriate language so that we can effectively communicate with others.
Thanks for correcting me on who wrote what I objected to. I GET what you argue about removing the word “suicide” from end of life
issues entirely, and I totally agree or I would have argued that too. And you can’t determine what other people say once your thoughts are out there. But “terminal” also desperately needs to be totally removed from the end of life equation.
Why not say a person died by choice.
We don’t say a person died of a type of cancer…we say they died of cancer.
To consider the state of mind of a person who dies by choice would be like considering the state of their body when they die of cancer.
A great article which looks at a very important issue. Patients who choose an assisted death are already dying, they do not have the option of life or death. They are left with the choice of the continuation of unbearable suffering, that is unable to be ameliorated, or the cessation of their suffering that only death can achieve. Those who ‘suicide’ do have a choice between life and death. Their deaths are tragic, no one can ever deny this. No matter how dire their circumstances, they still are afforded the option of life, no matter how difficult it is. The desire that terminally ill individuals have to live is enormous. Most have attempted numerous medical therapies that have failed to cure them. Their bodies are dying and the process cannot be reversed. An assisted death is dignified and is often described as a ‘beautiful death’. It is not suicide.
I enjoyed reading your comments but what struck me most was that there are 25 attempted suicides for everyone that succeeds. I am a disabled lady half past 80, who has left a nursing home against medical advice four times since 1989, and now am trying to find a way to die because lifts hurt my osteropersis broken bones, but the condition of young people who attempted suicides concerns me much more, and those injured by others definitely should have the right to die.
Why oppose free will, the right to choose a happy ending? If suicide was halfway legal, then the depressed could get counseling first, and the ill and elderly like myself could have a going away party. Death can be such a blessing that it should be celebrated when it is chosen.
If you are looking for a term to use in an obituary or death notice why not just say that So-&-So “completed life” on such-&-such a date? It has the connotation of a last act freely chosen without the negative associations of suicide. And it is neutrally factual.
My late husband “completed life”, too. He had lived with frontotemporal degeneration for over 11 years, the last six year and four months as a private-pay long-term care resident. I was his health care and financial power of attorney. Knowing that he was pro-life and didn’t want to end his life prematurely due to lack of medical treatment due to his disability when he could no longer speak for himself. He entered hospice care when there was nothing left that could prolong his life. So he also “completed” his life, albeit naturally.