An ethical examination of suicide

In general, ethical considerations of suicide need to be divided into two categories. The first category refers to the rationality of suicide, so to speak, whether suicide is so rational that it would be better to expire because of the severity of the illness. The second relates to the morality of suicide, which governs whether suicide is morally acceptable. The rationality of suicide can also be distinguished by addressing whether such a situation is possible and by assessing the reliability of patients’ lucid and predictive judgments in such situations.

Rationality of suicide

Let us assume the following scenario: A person is in constant and unbearable pain, and there is nothing that can be done except for enduring the pain, which cannot be remedied by current medical treatments. Would such a life be deemed salvable and or is it better to perish?

We usually judge whether life itself is worthwhile by gauging the amount of well-being elicited in the time that passes. Accordingly, very little well-being is gained by critically ill patients. Yet, many people recognize the value of life despite all the pain. In such a case, if the value of life itself outweighs the negative value of the pain, then a lifetime of enduring pain is worth living. However, if the value of life does not outweigh the negative value of the pain that one incurs by continuing to live, then the situation becomes so unbearable that it would be better to choose death.

This way of thinking assumes that people can objectively evaluate their situation and thus correctly foresee the life they will lead if they opt to live. However, it is usually difficult to imagine that a lucid evaluative judgment can be made in a situation characterized by constant unbearable pain, as in the previous example.

Hence, while acknowledging that the rationality of suicide is theoretically possible, is rational suicide practically impossible because such an individual's judgment is unreliable? Let us return to the principle of informed consent. Consider the case of a patient with constant and unbearable pain who consents to surgery. The principle of informed consent leaves no reason to question the patient's predictive judgment and it would be in the caregivers’ interest to treat the patient if this patient can make decisions soundly. If so, the predictive judgments of critically ill patients concerning the rationality of suicide should be treated in the same way, provided they can decide logically.

In summary, a theoretical basis exists for the benefits of rational suicide, and there is room for critically ill patients’ assessment to be accepted as reliable under certain conditions.

Morality of suicide

Even if rational suicide is possible, the question of morality (i.e., whether suicide is acceptable) is another matter.

Thomas Aquinas (Reference Aquinas1947) and Kant (Brassington, Reference Brassington2006) consider any form of suicide to be ethically unacceptable, but Hume (Reference Hume2011) suggests that suicide must be self-determined in accordance with God's providence and is not a violation of duty. Likewise, Locke states that suicide should be self-determined as the patients hold ownership of the body (Kihara, Reference Kihara2015). Particularly in psychology and theology, the ethical permissibility of suicide has been questioned for a long time both in the East and the West. Therefore, from a moral perspective, it is not possible to make a uniform decision on how to deal with suicide among cancer patients.

Ethical responsibilities for preventing suicide in cancer care

Autonomous and rational suicide can exist in real life, and purposely opting for death is known as a deliberative suicide. Notably, the viability of suicides by deliberation exists via utilitarianism and self-determination.

Similar to deliberative suicides, is there room for suicides to be self-determined in cancer care? Do medical professionals have an ethical responsibility to prevent suicide in cancer care?

Apart from philosophical ideas regarding suicide, various studies in the field of psychology, such as psychological autopsies, have denoted that suicide is caused by social and biological factors. According to data published by the WHO, 96.8% of suicide victims had some kind of mental disorder, among which the most common were mood disorders (Bertolote and Fleischmann, Reference Bertolote and Fleischmann2002). This statistic is also true for cancer patients: 95% of the cancer patients who committed suicide in Finland were reported to have some kind of mental illness, and nearly half of them suffered from depression (Henriksson et al., Reference Henriksson, Isometsa and Hietanen1995). This finding suggests that patients are more likely to choose suicide under the influence of a mental illness. Specifically, in depression, suicide is more likely to be chosen as a symptom, since rarefaction is a symptom itself. Although we are doubtful due to the scarcity of large-scale studies, it is not difficult to imagine that depressive symptoms are present at a higher rate than usual among patients who commit suicide. In other words, psychiatric symptoms, such as depression, have an impact on suicide in oncology.

Suicide among cancer patients can be caused by temporary external factors, such as shock due to cancer notification, or as a symptom of mental illness. Under these circumstances, even if a person decides that suicide will promote well-being, the reliability of the rationality of that decision is infinitely low. Therefore, suicide among cancer patients is a common occurrence. Additionally, suicide among cancer patients is not a free decision made by the patient after much deliberation but is rather an incautious choice. This type of suicide is called impulsive suicide wherein the rationality of suicide is not established in terms of the reliability of the decision. At this point, the individual has temporarily lost autonomy. Since impulsive suicidal behavior influenced by mental illness cannot be considered autonomous, even if the patient has the capacity to make decisions, the suicide attempt should be prevented based on the presumption that the patient's interest lies in the protection of life.

Some may argue that contemplative suicide is also possible in cancer patients. In fact, impulsive suicide and deliberate suicide exist on a spectrum that may be considered a mosaic, especially in the middle. Thus, it is certainly impossible to make a clear distinction between impulsive and deliberate suicide. Consequently, all suicidal behaviors of patients should be treated as impulsive suicide in oncology practice. In the field of medical treatment, doctors have an ethical responsibility to do good, and the most important of these good deeds is to protect and preserve life. For this reason, physicians have an ethical responsibility to uniformly prevent suicide from the standpoint of “if in doubt, act for the benefit of life” in relation to the field of oncology, where it is difficult to distinguish between thoughtful and impulsive suicide.

Furthermore, from the perspective of the impact on medical practice, physicians have an ethical responsibility to prevent suicide. The fear of the phenomenon of suicide is a problem in medical practice. When a suicide occurs in a medical setting, the phenomenon can cause fear among surrounding patients, especially those undergoing treatment. This fear may destabilize the patient's condition and may cause harm to others. Physicians are, therefore, responsible for preventing suicide from the perspective of preventing harm to other patients as well.

Conflict of interest

The authors declare no conflicts of interest associated with this manuscript.