Source: Washington Post
Date: 2 March 2004

A Calculated Departure
For Someone in Good Health, Can Suicide Ever Be a Rational Choice?

By Barron H. Lerner

Carolyn G. Heilbrun's suicide this past October could not have come as a great surprise to her family and friends. After all, the 77-year-old former Columbia University literature professor and mystery author had written for years about her plans to kill herself.

Heilbrun was suffering from none of the conditions commonly associated with suicide when she evidently took an overdose of pills and put a plastic bag over her head. She was neither terminally ill, in severe pain nor, apparently, depressed. Instead, she committed what some have called "rational suicide" -- ending one's life out of a conviction that one has lived long enough, that the likely future holds more pain than joy.

Rational suicide, a coinage dating back nearly a century, has also been called balance-sheet suicide, suggesting that sane individuals can objectively weigh the pros and cons of continued life, and then decide in favor of death.

Even if one countenances euthanasia or some type of expedited death for suffering or dying individuals, rational suicide pushes the envelope further. It raises a provocative question: Can it ever be rational -- or defensible -- for a sane and healthy person to kill himself or herself? Medical ethicists, clinicians and experts in suicide find themselves at odds on the matter.

Margaret P. Battin, professor of philosophy at the University of Utah, is a defender of the idea -- one she calls, given the aging of the population, "an issue for the coming century." Rational suicide, says Battin, "represents one of the fullest forms of expression of one's autonomy. It is the right of people to shape the ends of their lives."

Daniel P. Sulmasy, philosopher and ethicist at New York Medical College and St. Vincent's, a Catholic hospital in New York, couldn't disagree more. "Anyone who is not mentally ill and chooses the irrationality of committing suicide has done something morally wrong." says Sulmasy. Many other Christian denominations take a like stance.

Nor do those two positions represent the whole spectrum of opinion. There are also those who view any rational suicide as a failure of a medical system that should have identified a patient calling for help. "Most suicidal persons desperately want to live," states the Web site of the American Association of Suicidology, a group devoted to the understanding and prevention of suicide.

This concern is what makes Heilbrun's decision such a disturbing one, says suicide expert John L. McIntosh, chairman of the psychology department at Indiana University South Bend. Even someone making what appears to be a thoroughly rational case for suicide, McIntosh says, can be suffering from depression or cognitive rigidity, an unwillingness to consider other options. Health professionals, he stresses, should be diagnosing and then treating such individuals.

And always lurking in the shadows of the debate is one other concern: the so-called slippery slope. That is, once a society condones suicide, for whatever reason, what's to stop it from one day promoting the act? An individual's right to die, then, might become his duty to do so.

No Safeguards

Suicide has been in the news often in recent years. In 1997, the U.S. Supreme Court reviewed state laws passed in Washington and New York that prohibited physicians from prescribing medications to end the lives of terminally ill patients. The high court upheld the laws, ruling that there was no constitutional right to such "physician-assisted suicide." Individual states, however, were free to pass such legislation. One, Oregon, did so in 1997.

Any more active involvement of doctors in patients' final acts has raised consistent objections. In 1999 Michigan physician Jack Kevorkian was convicted of second-degree murder for causing the death of Thomas Youk, a man with end-stage Lou Gehrig's disease. Unlike in previous cases, where Kevorkian had counseled patients on how to end their lives, in Youk's case, he actually injected the lethal medications himself.

Kevorkian had for decades advocated physician participation in ending the lives of patients who sought help in dying. This process, known as euthanasia, has been practiced for decades in the Netherlands.

But these recent discussions about physician-assisted suicide and euthanasia have dealt with individuals who are extremely ill and dying. The Oregon law, for example, has safeguards to ensure that candidates for assisted suicide indeed have less than six months to live. No such legal safeguards or parameters exist for rational suicide.

Among young adults or adolescents, suicidal thoughts usually indicate an underlying mental illness, such as depression. There is no question among health professionals that such individuals should receive aggressive psychiatric treatment.

But what about the elderly? Can old people convincingly argue they have completed their lives and want to check out before experiencing a stroke or other debilitating illness? Is this type of rational suicide, often called elder suicide, ever justified? Here, the debate becomes more complicated.

Science Out of Fiction

Fiction writers have long worried about societies that tolerate -- or even advocate -- premature death among the elderly. In his 1882 novel "The Fixed Period," the British satirist Anthony Trollope mocked an imaginary country that admitted its 67-year-old members into a so-called college for a year of contemplation before euthanizing them.

In his 1954 short story "The Test," Richard Matheson described a society similar to Trollope's: Because of concerns about overpopulation, people aged 65 or older had to pass a test every five years. Those who failed were labeled inadequate and killed. In the story, the 80-year-old protagonist, Tom Parker, commits suicide rather than go through the humiliation of testing.

Despite such cautionary tales, some prominent figures have argued that there may be a point after which life loses its value. In a 1905 speech, legendary Johns Hopkins University physician William Osler, then in his mid-fifties, mused approvingly about Trollope's scenario. Given the "uselessness of men above sixty years of age," he announced at a lecture, "incalculable benefits might follow from such a scheme." Osler quickly backtracked after he was attacked in the newspapers. He died in 1919 at the age of seventy.

But debate about assisted death and its permutations continued.

In the 1970s "the right to choose" became a mantra in American medicine, from abortion to the treatment of breast cancer. Wasn't there also be a right for elderly people to die as they saw fit?

A person who helped bring this idea to the public was British journalist Derek Humphry, founder of the Hemlock Society, which endorsed facilitating death among terminally ill patients. The society took its name from the poison taken by Socrates when faced with an unjust death sentence.

Now known as End-of-Life Choices, the group supports state legislation to permit physician-assisted suicide.

In 1991 Humphry published "Final Exit," which provided readers with explicit information about how to commit suicide, including the proper doses of medications and other tips, such as placing a plastic bag over one's head. The book sold more than 500,000 copies and topped the list of hardcover advice books in the New York Times for 18 weeks. A third edition of "Final Exit" was published in late 2003.

Humphry stated in the book that he was opposed to rational or elder suicide, arguing that laws that helped very sick patients to die would actually obviate the need for healthy people to preemptively end their lives. The inclusion of this type of information led to concerns that Humphry was encouraging a slippery slope: The suicide cocktails described in "Final Exit" might be used by those who merely lacked health insurance or saw themselves as a burden.

In 1993 the New England Journal of Medicine published a study suggesting that such behavior might be occurring. The authors of the study found that the number of asphyxiations using plastic bags in New York had increased from eight to 33 in the year after publication of the book. More worrisome was that 16 of the 33 people had no known medical illness. In nine of the cases, copies of "Final Exit" were found at the scene of the suicide.

But more recent data, Battin says, don't bear out the idea that broader public knowledge of options fuels a rise in suicide incidence among vulnerable individuals. Since the passage of the Oregon's Death with Dignity act, the number of deaths due to physician-assisted rose from sixteen in 1998 to thirty-eight in 2002. This is hardly a surge of inappropriate deaths, she states. And, according to 2003 article in the British Medical Journal, the number of requests for euthanasia or physician-assisted suicide in the Netherlands has remained stable -- at roughly 5,000 per year -- over the past decade. Three-quarters of these patients had cancer.

A Legacy of Questions

It is hard to say how many people commit rational suicide. As Douglas Harwood and his colleagues at the University of Oxford reported in the Journal of Affective Disorders in 2002, the surviving relatives of a person who commit suicide feel shameful and rejected, which may lead them not to discuss the event. The Heilbrun family declined to be interviewed for this article. Information about Heilbrun's death was obtained from obituaries and tributes that appeared in newspapers and New York magazine.

Sometimes the subject draws attention when a failed suicide attempt leads to a hospital admission. For example, Columbia University Medical Center recently held an ethics conference on a woman with a nonfatal neurological disease who, having contemplated ending her life for years, finally attempted it -- unsuccessfully.

Nor, given the aging of the population, is the topic of rational suicide likely to disappear.

Heilbrun was a highly respected feminist scholar and expert in modern British literature known for her independent thinking. Among her achievements was being the first woman to receive tenure at Columbia University.

Heilbrun, who also wrote popular mystery novels under the pseudonym Amanda Cross, had been especially open about her plans. In her 1997 book, "The Last Gift of Time," she described life after age 70 as "dangerous, lest we live past both the right point and our chance to die."

Two concerns that Heilbrun mentioned were her "inevitable decline" and becoming a burden on others. Her motto, she said, was, "Quit while you're ahead."

But though she was then 71 years old, Heilbrun chose not to act -- not yet.

Her sixties, to her surprise, had been a source of astonishing pleasure. She wanted to keep writing, enjoy her family and friends, spend time in a new home and keep certain "promises."

In the July 2003 issue of the Women's Review of Books, however, Heilbrun wrote that she feared "living with certainty that there was no further work demanding to be done." She had consented to life, she stated, "only on the terms of borrowed time."

On Oct. 9, 2003, Heilbrun was found dead in her New York apartment, having committed suicide. A nearby note read "The journey is over. Love to all."•

Barron H. Lerner, Angelica Berrie-Gold Foundation Associate Professor of Medicine at Columbia University, is working on a book on how physicians and patients reach medical decisions.

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