Choosing death: the moral status of suicide*

Our moral conception of suicide is examined. It is argued that a neutral definition of suicide is difficult to achieve and that how we treat the question of suicide shows what value we place on the sanctity of life or on life as a means to other ends. The case is made that autonomy, the principle of self-governance, has acquired special importance in the modem world to the detriment of other ethical principles such as beneficence. problem that is

"There is but one truly serious philosophical problem and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy." Camus. 1942 There are at present opposing tensions in the way in which we conceive suicide. The government's White Paper Health of the Nation (HMSO, 1992} sets a target of 15% reduction In overall suicide rates, Including suicide and open verdicts, by the year 20OO. This policy has an implicit moral position which is that suicide is morally bad and should be prevented If possible. There are other views which are in opposition to this. For example, the Michigan Commission's report on death and dying allows for a doctor to help adults to commit suicide if they are suffering from terminal conditions likely to result in death within six months. Furthermore, a US district judge has recently ruled that "like the abortion decision, the decision of a terminally ill person to end his or her life involves the most intimate and personal choices a person can make in a lifetime and constitutes a choice central to personal dignity and autonomy" (Roberts, 1994). These views which articulate the belief that suicide is a personal and legitimate choice are becoming prominent and widely discussed by the medical profession and laity (Anon, 1994o,b) and in the US there are at present attempts, in several states, to enact laws on euthanasia and assisted suicide (Charatan. 1994;Anon, 1994c). The implication of these views for the practice of psychiatry needs to be carefully examined. The aim of this paper is to explore our moral conception of suicide. It will argue that a neutral definition of suicide is difficult to achieve because suicide is a deeply moral question and as such its dÃ©finitionalso stands as a signifier of society's judgement of suicide. It will also argue that how we treat the question of suicide demonstrates what value we place on life as such, or on life as a means to other ends. It will show that autonomy, the principle of self-governance, has acquired special significance in modern society such that the value of life itself has become of secondary importance in relation to it. Thus, the main thrust of the paper concerns the philosophical and ethical debate about suicide. There is, of course, a recognition that much of the ethical debate is conducted with the assumption that suicide occurs in the setting of autonomous action. Whereas, in the clinical context, the assumption is that suicide occurs in the context of mental illness and temporarily impaired ability for autonomous action.

What is suicide?
Suicide can be defined as the killing of oneself. However, this simple statement, in practice, is difficult to apply with certainty and confidence to particular cases. This is because there is implicit in the definition the notion of intention. Suicide may be said to occur, if and only if, there is intentional termination of one's life. Deaths resulting from accidental events are excluded from suicide by this definition. The effect of this definition is to emphasise the importance of intention and thereby of responsibility for the act. The notion of responsibility, of culpability in this sense, is linked to the idea of answering for or, of being judged and perhaps condemned for, a particular act. Thus, in assigning a particular death to the category of suicide, a judgement of the victim's responsibility for the act is also being made, even though no significant civil or criminal consequence depends on this judgement.
Text of guest lecture delivered to Psychiatry Section, Birmingham Medical Institute on 4 October 1994 Psychiatric Bulletin (1996), 20, 85-89 It is possible to have a wider definition of suicide in which the term suicide is applied to all cases of death resulting directly or indirectly from a positive or negative action of the victim himself, which he knows will produce this result but in which suicide was not the intention. This definition broadens the scope of suicide beyond cases where death is directly intended by the subject to include deaths in which foreknowledge of the likelihood of death can be demonstrated but is not the primary intention of the subject. In this definition, Captain Oates' death will count as suicide. Yet, because we may not want to disvalue Captain Oates' conduct, we may feel inclined not to refer to his death as suicide. This position may be justified on the ground that suicide was not his primary intention but rather that his desire was to save his companions' lives and death was an indirect consequence of that desire. This kind of example underlines the fact that since suicide is regarded as morally wrong, our definition of it seeks to exclude some acts which we admire, i.e. value, from within the purview of such a description.
A neutral, relatively value-free definition of suicide would be more akin to an instrumental definition in which intentions whether oblique or direct, and the influence of accidental events, would not materially alter what counts as suicide. Although we may very well end up with terms such as 'accidental suicide' or 'intentional sui cide'. The advantage of such a definition would be that it will not seek to demarcate particular forms of dying by one's own hand from other forms, simply on the basis of the demonstration of intention. In this way suicide will become less value-laden; it cannot of course become totally value-free. Our recognition of it as distinct from other forms of dying such as homicide, natural death, already commits us to a value judgement of sorts. Even if an entirely value-free definition was possible, it could be argued that this is not desirable, precisely because we may still wish to communicate in some way our moral view of the act, albeit in an implicit manner.

Suicide is always and in itself wrong
The rule forbidding the act of killing oneself has a long history in Western thought. It appears in several different guises in the writings of Aristotle, Augustine, Aquinas, Kant and Spinoza. It as sumes the force of law in Aquinas' (1918) Summa Theologica, written in 1269, wherein he sum marises his reasoning in the following way: (a) "because everything naturally loves itself, the result being that everything naturally keeps itself in being and resists corruptions so far as it can. Wherefore suicide is contrary to the inclination of nature..."; (b) "because every man is part of the community and so, as such, he belongs to the community. Hence by killing himself he injures the community... "; (c) "because life is God's gift to man, and is subject to his power, Who kills and makes to live. Hence whoever takes his own life, sins against God... For it belongs to God alone to pronounce sentence of death and life..." For Aquinas, it would be wrong to kill oneself on "account of... having committed a sin... because one deprives oneself of the time needful for repentance" and likewise it would be wrong for a woman to kill herself "lest she be violated, because she ought not to commit on herself the very great sin of suicide to avoid the lesser sin of another. For she commits no sin in being violated by force, provided she does not consent". Aqui nas' writing makes plain his conviction that suicide is always and in itself wrong and furthermore that the wrongness of suicide is not mitigated by the circumstances or purposes of those committing the act. This duty not to kill oneself received re-inforcement in Blackstone's (1979) Commentaries on the Laws of England (1765-69). This stipulation not to kill oneself is justified on grounds which echo Aquinas' Summo: "that no man hath a power to destroy life, but by commission from God, the author of it". But, Blackstone recognised mitigating circumstances, for he says "the party must be of years of discretion, and in his senses, else it is no crime". He is quick to add "this excuse ought not to be strained to that length... that the act of suicide is an evidence of insanity; as if every man who acts contrary to reason, had no reason at all".
This idea, that life is the natural state and death an evil which all living things flee, which Aquinas expressed in his Summa is central to several other philosophical approaches. Thus, Augustine (4th C;1993) claimed that "every living thing flees from death" and Spinoza (1989) in the 17th century that "the basis of virtue is the endeavour to preserve one's being". However, Kant (18th C;1948) goes further by attempting to locate his argument against suicide within the framework of his general principles of morality. For Kant, we should act as if the maxim of our actions were to become through our wills "a universal law of nature". Thus, a man who feeling sick of life takes his own life would be acting according to a maxim which said "from self-love I make it my principle to shorten my life if its continuance threatens more evil than it promises pleasure". Kant concludes that if this was a universal law of nature the very system of nature whose function is to stimulate the furtherance of life "would actually destroy life and would thereby contradict itself'. In addition, suicide would also contradict Kant's second maxim which says "act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always the same time as an end". For Kant, a man who "does away with himself In order to escape from a painful situation" is making use "of a person merely as a means to maintain a tolerable state of affairs till the end of his life". But, for Kant, "a man is not a thing" to be used simply as a means in this way for he is an end in himself.
These views express a categorical disapproval of suicide and by implication emphasise the pri macy of life as life, not simply as a property or means which allows us to have other ends or projects in sight; a position which can easily seem oppressive and inflexible in the modern era. It leaves little room for the autonomy of the individual to make his or her own choices and turns life, whatever the quality of it, into a sacred possession. The propensity in our own time is to assert that the value of life, whether it is worth living or not, is open to the judgement of each individual subject. This view is in direct opposi tion to the belief that suicide is expressly contrary to nature.

Where is the crime?
I have shown that the most consistent argument against suicide has been that it is contrary to nature. This argument rests on the assumption that human conduct should take as its model behaviour which is natural, although it is never clear what 'natural' means or is, in this context. It could simply mean behaviour which has been observed in the natural world or which is prevalent in society or canonised by custom. A fairly robust rebuttal of this kind of argument was given by Hume (1986) in 1784 in his posthumous essay 'Of suicide'. In it, Hume sought to under mine superstition and authority as the basis of belief. He showed that all human conduct which alters the world in any way was "equally innocent, or equally criminal". He did not see any moral difference between the preservation of life or its destruction, for as he argues "were the disposal of human life the peculiar province of the Almighty that it were an encroachment on his right, for men to dispose of their own lives; it would be equally criminal to act for the preservation of life as for its destruction". He continues, "if it would be no crime in me to divert the Nile or the Danube from its course... Where then is the crime of turning a few ounces of blood from their natural channel"? He concluded that "suicide may often be consistent with our interest and with our duty to ourselves". The essence of Hume's case is that the morality of a particular conduct is not inherent in the conduct, but rather, is ascribed to it by human beings. In other words how we come to value suicide or homicide is no different from how we come to ascribe particular value to an African sunset or an English countryside; the value is imposed by us and not granted by a deity. This description of morality frees it from super stition and renders it a peculiarly human project which human beings have to be responsible for. Moreover, Hume's analysis of suicide indicated that the act receives some of its colouring from the circumstances, characters and purposes of those committing it, and indeed from the con sequences of their act. For him, it could be in our interest to take our own life.

The meaning of life
This paper has shown that suicide can be conceived of as morally wrong in and of itself or that its moral value can be determined only when one knows more about the circumstances of it. In other words that its value is not categorically bad. Once this position is taken seriously, life as an end in itself, as an irreducible good, ceases to have compelling authority. The sanctity of life becomes a relative matter. Some would argue that life now becomes a means to other goods and its value can be derived solely from these goods. The question, then, is under what circumstances would it be right to commit suicide. Existentialist philosophers like Camus and Sartre were parti cularly interested in exploring the nature of our freedom, as we experience it in the real world. In his philosophical work The Myth of Sisyphus (1942) Camus argued that even in the face of the meaninglessness of life, and of life's absurd ity, we human beings have to assert our freedom and dignity and this by "accepting such a universe" and drawing from it "strength". Camus was particularly aware that he did not "know whether this world has a meaning that trans cends it" but for him man gives his own meaning to the world by his actions and it was "essential to die unreconciled (to the absurdity of the world) and not of one's own free will". To die of one's own free will, for Camus, would be a repudiation of one's responsibility to oneself.
Sartre regarded death as something that deprives us of the capacity or opportunity to be authors of the meaning of our own life. Unlike Heidegger (1927) and Ortega y Gasset (1933) he did not believe that it is the finality of death which renders life, as we live it, meaningful. Sartre (1943) wrote that "death is never that which gives life its meaning" but that on the contrary it is "that which on principle removes all meaning from life". For Sartre, suicide is morally wrong and an act of bad faith since it would bring about death, the end of life; for to "be dead is to be a prey for the living" and "to exist only through the Other, and to owe to him one's meaning".
The existentialist opposition to suicide accepts the legacy of Hume, in that it recognises the authority of individual persons to make their own morality, but In accepting this gift of autonomy it refutes the notion that suicide could be a good thing in any circumstances. The freedom which human beings have is delimited in the existenti alists' world by the need to act responsibly and always in good faith. And, suicide in this schema would be "an absurdity which causes my life to be submerged in the absurd" {Sartre, 1943).

Dying is an art
Once autonomy assumes authority as a principle which determines how moral issues will be resolved, the human will to control one's destiny takes into its ambit both the control of life's projects and the place and timing of one's death. As Campbell & Collinson (1988) put it "a person who endeavours to live well, to achieve moral sensitivity and develop virtues of character and action will also wish to die well". In this way "choosing how one shall die may be regarded as a peak of achievement in self-determination and personal autonomy" (Campbell & Collinson, 1988). This desire to rein in death within the province of human agency such that its timing and manner ceases to be arbitrary, has echoes of the Stoic attitude towards death and suicide. Cicero (45 BC),in De Finibus says "when the bulk of a man's circumstances are in accord with nature, it is appropriate for him to remain in life; when the balance is on the other side, or seems likely to be so, it is appropriate for such a man to quit life". The emphasis, here, is that "it is not a blessing to live, but to live well", but also that what "applies to living also applies to taking leave of life, because it is not a question of dying earlier or later but of dying well or ill" (Seneca. 56 AD). Thus, within this scheme, in our consideration of suicide we are obliged to examine the possibility of an autonomous suicide, and in doing that we are implicitly invited to accept that no moral authority except that of the protagonist exists to judge the rightness or otherwise of the act. Autonomy becomes for us the pre-eminent moral principle. Following from this suzerainty of autonomy, it is prudent to ask whether this heightened position of autonomy cannot some times stand to obscure rational and proper debate about the rightness or wrongness of actions. There are moral philosophers like Mur ray (1994) who argue, cogently, that autonomy has become transmuted into a rallying cry for those who elevate certain kinds of moral commit ments -those chosen voluntarily and compe tently -over all other moral concerns and values. He argues that "when autonomy is the answer; the question is largely limited to asking whether the person decided freely". Autonomy "counsels us not to ask if the decision was wise, or even good".

Conclusion
Suicide is the result of the action of an individual but nonetheless it has profound effects upon the immediate families of the subject and indeed, upon the wider society in which the subject lived. In contemporary society, the case is being made, by some, for the legal right to have doctors assist in suicide, when at the same time, others are demanding that doctors prevent suicide. The one position emphasises autonomy and the rights of the individual whereas the other takes a wider perspective of our responsibilities to others, deriving its moral force from the principle of beneficence. There is certainly a case for arguing that the use to which the principle of autonomy can be put, can ignore the complex web of relationships, the duties and responsibilities we have for one another, such that the need to act as a community can be restrained. There must remain space for heteronomy, the governance of our individual conduct by others, within the framework of contemporary ethics. So that all human conduct, even when competently and freely chosen, must take into account the effects upon others of any conduct and must allow for the imposition of the will and interest of others wherever appropriate. This view is a revision of Aquinas' recognition that suicide "injures the community".