Assisted dying, the duty of preventive care and patient autonomy

A slight breach in this long-established opinion has occurred with the increasingly more open debate on euthanasia or assisted dying. For example, in Reference Tallis2012 Raymond Tallis, chair of Healthcare Professionals for Assisted Dying (HPAD), made a convincing case for the belief that healthcare professional bodies such as the British Medical Association (BMA) and the medical Royal Colleges ought to adopt a position of neutrality with regard to assisted dying (Tallis Reference Tallis2012). Nevertheless, the topic of non-assisted suicide remains shrouded in controversy: in 2017 a House of Commons report on suicide prevention still stated that the government commends a ‘zero suicide policy’, encouraging ‘any approach which acknowledges that suicide is not inevitable and seeks to prevent all suicide’ (House of Commons Health Committee 2017: p. 11). Accordingly, the role of the psychiatric clinician is often considered to be to take suicidal ideation as indicative of mental illness and to prevent suicide at all times.

The problematics of this duty of preventive care and the patient's rights of autonomy have been discussed most thoroughly by Hewitt (Reference Hewitt2013), Onkay (Reference Onkay2014) and Hatherley (Reference Hatherley2019). Onkay focuses on the conflict between patient autonomy and the clinician's duty of care, stating that clinicians must allow for the possibility of suicide made under free will and beware of infringing on the patient's autonomy. Hewitt discusses the issue particularly with regard to mental disorders, where the patient is automatically considered irrational and non-autonomous, and has pointed out both the importance of equalling psychological suffering to physical suffering and the capability of (some) psychiatric patients to make rational choices regarding suicide. More precisely, ‘rational suicide’ can be defined as suicide ‘on the basis of realistic beliefs [about one's circumstances] and in light of the fundamental interests which incorporate the agent's “real” – that is, his long-term – values’ (Mayo Reference Mayo1986: p. 154). Hatherley goes one step further and argues that, in certain cases, psychiatric patients should have access to assisted suicide.

Is suicide always negative?

To establish whether rational suicide should be permitted or supported by the medical field, and whether psychiatric patients must be excluded from this debate entirely, we must first discuss the original premise, still widely upheld, that suicide is at all times negative. This premise can be approached not just from a clinical perspective, but also from a theological, philosophical or legal perspective. These perspectives have evolved over a long history of scholarship, founded more than two millennia ago by the renowned Athenian philosopher Plato. The complexity of the problems discussed above is reflected by a potential incongruity within the writings of Plato, who seeks to reconcile the various perspectives, represented in three of his works, into a wider theory on suicide and the value of human life. The perceived incongruity within this theory, which at one point opposes and at another supports suicide, offers an opportunity for the modern reader to consider different perspectives on suicide within the same author, and observe how they develop and unfold differently according to the context in which they are discussed.

Plato's opinion on suicide should nevertheless not be taken as representative of Greek popular opinion, but as independent thought. The more general history of, and attitudes towards, suicide in Ancient Greece have been elaborately discussed by Anton van Hooff (van Hooff Reference van Hooff1990) and Elise Garrison (Garrison Reference Garrison1991). In fact, at the time of writing, Plato's views were innovative and revolutionary, and we may learn from them still. The purpose of such a historical and philosophical approach, and this article, is not to allege the existence of direct comparisons with issues in modern psychiatry, but rather to increase our awareness of the prejudices and alternate motivations behind our own, modern views on suicide.

The structure of this discussion

This article begins with a brief discussion of the clinical definition of suicide and its application to the death of Socrates. Subsequently, it discusses the theological–philosophical perspective on suicide in Phaedo, the medical–utilitarian perspective in Republic and the legal–utilitarian perspective in Laws. Through discussion of these fundamental historical works the article aims to demonstrate a potential need both to mollify the persisting concept of suicide as necessarily irrational, especially among people with mental illness, and to raise questions about the role of psychiatric care in relation to suicide.

The untreatable body

Plato praises a carpenter who declines medical treatment, at the risk of death, because ‘he has no time to be ill and it does not benefit him to live in this way, being occupied with this illness, and neglecting the work in front of him’ (406d–e; cf. 407a). We would not immediately associate the refusal of treatment with suicide, but the carpenter's case may be comparable to the conundrum of a person with advanced cancer refusing chemotherapy, when the balance between benefits and risk is unclear: in a situation where treatment is declined despite favourable chances at recovery, a psychiatrist is often involved and the term ‘suicide’ might be mentioned. Nevertheless, regardless of whether we consider the carpenter's death a suicide, Plato's message is clear: not all lives must be continued. Moreover, he even thinks that doctors should take the initiative to refuse treatment: ‘If someone is by nature sickly and intemperate, his life is of no use to himself or others, and the art [of medicine] does not exist for these people’ (my emphasis) ( 408b, cf. 407d–e).

Here it seems that the reason one should die or stay alive is a sense of duty to the community, which contrasts with Plato's view in Phaedo that one should remain alive because it is in one's own interest to practise philosophy until sufficiently prepared for death. Of course, it is natural that Plato alters his perspective to fit the context, and the passages above show that he does not necessarily oppose benefit to the individual to benefit to the community. Indeed, Socrates preferred death to escaping or going into exile because, as he expresses in both the Apology and Phaedo, he would no longer be able to do his ‘work’, namely teaching philosophy, and so contribute to the improvement of his soul and the city. This implies that Plato includes a kind of duty to the state in the practice of philosophy and assumes that an individual who is unable to contribute to the community must therefore live an unhappy, unphilosophical life and himself desire to die. Thus, Plato ultimately focuses on the interest of the individual, as he did in Phaedo.

The incurable soul

One passage in Republic discusses disease of the soul: ‘[the arts of medicine] will treat those of your citizens who are well-natured both in body and soul, but those who are not, who are diseased in their bodies, they will allow to die, and those who are ill-natured in their souls and incurable they will themselves kill’ (409e–410a). Ironically, this is the direct opposite of our modern approach to mental illnesses. However, before rejecting Plato's recommendation as unnecessarily cruel and inhumane, we should consider it more closely. First, ‘ill-natured in their souls’ most likely refers only to those whose mental illness has led them to depraved and criminal behaviour. Therefore, the line between medical treatment and punitive measure is blurred, as it often is even nowadays although capital punishment has all but disappeared in most Western societies. Second, the word ‘incurable’ (ἀνιάτους) is key here and brings to mind the previous comparison to a patient with advanced cancer. At this point, where Republic traverses beyond its utilitarian perspective and mentions the well-being of the soul, Plato bluntly assesses the situation according to his theory on what constitutes a ‘life worth living’: the patient's soul is corrupted and cannot be purified; therefore a philosophical life and subsequent happy afterlife are no longer possible; therefore death is the rational option for the sake of both the state and the patient himself. Admittedly this guideline is vague – how can we know that some corruption of the soul is incurable? – but it indicates that Plato still has in mind Phaedo, and the purification of the soul through philosophy.

‘Rational’ death in Plato

Plato's view, then, as derived from Republic, appears to be that death (through suicide or otherwise) is advisable in two cases: when one can no longer live a philosophical life because one is unable to be of use to the state, and when one can no longer live a philosophical life because one's soul is incurably corrupted. To the modern reader this reasoning may appear unconvincing, for the obvious reason that we have a different idea of when life is worth living. From a medical point of view especially the threshold is quite low, and a psychiatrist must certainly discourage anyone from taking their own life on account of some inability to be of use to the state. Nor do we typically believe in the incurable, or curable for that matter, corruption of souls. But let us briefly consider the latter as a metaphor for some chronic psychiatric disorder: if someone suffering from schizophrenia were to take their own life, in the hypothetical situation that one could determine this decision was reached after careful consideration of their present hardship and lack of future prospects, can such a suicide be termed ‘rational’? The current consensus appears to be that it cannot. But to what extent does that consensus derive from an objective assessment of the patient's situation and ability to make autonomous decisions, or from our own prejudiced ideas that death is always negative and suicide always irrational? We may disagree with Plato's approach to the ‘art of medicine’, but in disagreeing we may also begin to take a closer look at the reasoning behind our own approach.

Plato's four exceptions to the ban on suicide

A first exception to the ban on suicide appears in Book 9 (at 854c), where Plato has presented several ways in which temple-robbers might suppress their desire for crime, and states: ‘if by doing these things you abate your disease, good: but if not, consider death the better option and free yourself from life’. The term ‘free yourself’ (ἀπαλλάττου) indicates that death is some sort of release (and thus positive) for the immoral individual. A similar idea is conveyed by the comparison of criminal urges to a disease, which seems to suggest that the temple-robbers are victims and should be put out of their misery. We recall the recommendation in Republic (at 410a) that doctors ‘kill those who are ill-natured in their souls and incurable’. Here Plato applied the same reasoning as in Republic, namely that when it is no longer possible to live a philosophical life and thereby obtain a blessed afterlife, one might as well quit life straightaway and end a miserable existence.

Another three exceptions to the ban on suicide are presented in the following passage:

Exception 2 confirms that being ordered by the state to kill oneself, as Socrates was, is considered suicide (Garrison Reference Garrison1991: p. 9). Notably, the phrase ‘robbing himself of his appointed fate’ reminds us of Socrates’ statement in Phaedo that we are assigned to life by the gods and we should not try to escape. The word for ‘fate’, μοῖρα (literally ‘divine fate’), has religious associations, and Novak has pointed out that the divine decree of fate is here equalled to the decree of the city, bringing together the different (theological and utilitarian) approaches to suicide which Plato has shown in Phaedo and Republic (Novak Reference Novak1975: p. 26).

Exception 3 is, again, somewhat problematic: in Phaedo Plato explains that a happy afterlife awaits the philosopher, and yet the philosopher should never end his life in order to achieve this happiness. Surely, then, ending one's life to avoid some extreme misfortune and improve one's happiness in that way is not allowed either, nor would it lead to a happy afterlife since one is not fully purified yet. However, ‘inescapable’ (ἄφυκτος) carries the same meaning as ‘incurable’ (ἀνιάτος) did above, namely that the situation cannot be repaired and the circumstances that keep the individual from practising philosophy cannot be changed. We also sense a degree of empathy: Plato acknowledges that sometimes someone experiences a misfortune so great that the pain is simply unbearable. In this case suicide, not on account of some sudden flood of emotions but on account of a lack of future prospects, can be rational.

The final exception, suicide as a result of ‘sharing in some unmanageable and unendurable shame’, similarly resembles a mercy killing, but again Plato's point is not so much that the person should hurry to death out of misery, but rather that there is no reason to stay alive when circumstances no longer permit the individual, who is overwhelmed by misfortune or shame, the opportunity to successfully purify themselves through philosophy.

Plato emphasises that outside of the aforementioned exceptions those who ‘inflict on [themselves] this unjust penalty because of laziness and cowardice’ (873c–d) are reproachable. This statement is noteworthy because one could easily argue that people who end their lives ‘compelled by an exceedingly painful and inescapable turn of fate’ or ‘sharing in some unmanageable and unendurable shame’ are in fact also showing laziness and cowardice: the line between inescapable/unmanageable and escapable/manageable is surely very thin. Thus, Plato's reasoning in Laws allows him to argue in favour of or against essentially any case of suicide one may present. This has everything to do with the legalistic purpose of the text: ‘punishments for crimes must vary according to their motive and circumstance’ (Garrison Reference Garrison1991: p. 17). Therefore, it is clear that Plato did not think that all suicides are equally bad, but rather that each case is individual and may be judged as permissible according to circumstances.

A harmonisation of thoughts

Laws, Plato's final work, has brought together aspects of Phaedo, such as Socrates’ suicide as ordered by the state and the idea of life as a gift or task from the divine, with aspects of Republic, such as the individual's relation with the state and the utilitarian view on life. Perhaps Plato in his old age was now seeking, as Carrick aptly described, to ‘harmonize in some condensed fashion his earlier thoughts on the topic of suicide’ (Carrick Reference Carrick2001: p. 160; see also pp. 155, 166).