Some days are simply rich with ideas. This post is based on an article by Meera Balasubramaniam, MD, MPH, that has just appeared in the Journal of the American Geriatrics Society, entitled, “Rational Suicide in Elderly Adults: A Clinician’s Perspective.”(1) Dr. Balasubramaniam implicitly frames a question: can a person in the absence of any diagnosible mental illness or terminal disease rationally decide to commit suicide? Can suicide be a rational choice?
It’s a complex question on a number of levels. Perceptions of suicide are shrouded in religion and superstition, and even that shrouding is full of contradictions. While Christian and Jewish religions view suicide as inherent proof of mental illness and as a violation of God’s law, no one accuses Samson or the victims of Masada of mental illness.(2) For them, it was considered a rational choice, just not for anyone else. Implicitly, that position says “it’s OK to commit suicide for religion, but not for any more practical reason.” In the blink of an eye Christian and Jewish scripture appears to justify Islamic suicide bombers.
Everyone should have a problem with that. There’s a difference between taking your own life and killing someone else. No scripture justifies murder.
Part of the complexity is uncertainty. Younger people talk about suicide; older people actually carry it out. When someone mentions it, is it an appeal for status, reaffirmation or help? Or just as casual comment about something that has crossed the mind? If someone mentions it, why are they doing so? It’s not easy to know.
Six US states and the District of Columbia recognize that people with terminal illness are allowed “death with dignity.” However, persons who enter dementia or Alzheimer’s, or have some other kind of horrible disease that is not clearly terminal, are denied that option. Why should that be? Caring for the “living dead” is very lucrative for nursing homes, but does nothing for the patient and tortures the family. And there’s no sign that nursing homes use that windfall to subsidize those they can help. Why is someone spending $100,000 per year to keep a body alive after the brain has stopped functioning? And most of the time, that $100,000 is coming from taxpayers — you — after family assets are exhausted. Medicare doesn’t pay for the long term care that these patients require.
For the rest of the country, the only options for death with dignity are extreme sedation or highly illegal suicide before illness becomes extreme. It’s this lack of recourse to death with dignity that justifies rational suicide.
By the way, nursing homes and doctors have tried to override living wills to keep patients alive. Often, courts have sided with them. It takes a strong advocate for the patient to make sure the patient’s instructions are carried out, when the patient cannot advocate for themselves. A living will in itself is no guarantee. That become another justification for acting in advance of that need.
Ray Bradbury argued many years ago in The Martian Chronicles that for everything there is a time, including a proper time for dying. Going past that can simply be agony.
How will you go?
Personally, I believe that suicide can be a rational decision, and that people have a right to make that decision without fear of reprisal against anyone still living. We should offer counseling to help people think through the decision without value judgment.
- After a lengthy siege, the population of a fortress commits mass suicide by jumping off a cliff rather than be taken prisoner and enslaved.