Getting cancer changed my feelings about people who smoke. I remember hearing a fellow philosopher expound, with a wave of his cigarette, on his right to choose whether to live and die smoking, or to quit and merely survive. I was just beginning a year of chemotherapy, and mere survival sounded pretty good to me. But I was the visiting speaker, and my hosts were unaware of my diagnosis. Several of them lit up after dinner as we listened to their colleague’s disquisition—they with amused familiarity, I with an outrage that surprised even me and would have baffled them, if I had dared to express it. That I didn’t dare is a cause for regret even now, ten years after the fact.

A Right of Self-Termination?

In this article, I shall present three arguments for the permissibility of physician-assisted suicide (PAS), and then examine several objections of a ‘‘Kantian’’ and non-Kantian nature against them. These are really objections against certain types of suicide. I shall focus on active PAS (e.g., when a patient takes a lethal drug given by a physician, in which case both the physician and patient are active). I shall assume the patient is a competent, responsible, rational agent, who gives his being in physical discomfort (pain, nausea, etc.) as the reason for intending his death. I am assuming, therefore, the pain while a source of suffering does not undermine his rational agency in a way that threatens responsibility for choice.1 Current legal proposals for permitting PAS focus on procedures

Physician-assisted suicide, the doctrine of double effect, and the ground of value.

In nine lively essays, bioethicist J. David Velleman challenges the prevailing consensus about assisted suicide and reproductive technology, articulating an original approach to the ethics of creating and ending human lives.

Beyond Price: Essays on Birth and Death

Each year, on average, almost 5000 people die of suicide in England and Wales. The 1992 Health of the Nation aimed to reduce the suicide rate by 15% by 2000. The 1999 Department of Health National Service Framework sought to cut the suicide risk by a further fifth from this target.1 There has been significant pressure on mental health services to improve risk assessment in order to reduce the suicide rate. This implies that suicide is mainly seen as a medical or psychiatric issue – a mental illness.

Decisions regarding end of life are encountered more frequently than before. Recently there have been debates and disputes over physician-assisted suicide and euthanasia. The debate has become more intense following the Assisted Suicide Bill. The number of British people who have visited Dignitas in Switzerland for assisted suicide has doubled from 2005 to 2006.2 Two high profile cases brought the issue of physician-assisted suicide back into public discourse. First, 45 year old multiple sclerosis sufferer Debbie Purdy took her case to court in order to protect her husband from prosecution when assisting her to end her own life. Then Daniel James, a 23 year old rugby player who had become paralysed in an accident, ended his life in Switzerland. These cases challenge the idea that suicide necessarily arises from a mental illness.

Physician-assisted suicide highlights this challenging question – is ‘intent to commit suicide prima facie evidence for a disease of the mind?’3

Burgess and Hawton highlight the difficulties psychiatry encounters when facing suicide.4 They claim that not all who commit suicide are mentally ill, and also that mental illness is often not clearly distinguishable from normal distress. Moreover considering the difficulties in treating mental illnesses the authors suggest ‘there seems to be no a priori reason why psychiatrists should always find themselves bound to try to prevent suicide’. The case of Dr Chabot provides some insight into this problem. Dr Chabot helped a 50 year old social worker to commit suicide. The case was taken to the Netherlands Supreme Court. The court did not question the rationality. The Dutch Society of Psychiatrists’ committee, following the Chabot case, took the position that suicide should not be considered as an a priori psychopathological phenomenon.5

The extent to which someone is expressing their free will and is capable of being responsible for their actions is important to establish when deciding whether suicide indicates a psychopathological state of mind. The principle of autonomy, integral to a free society, requires that a person's decisions regarding their own life should be respected wherever possible.4 According to UK law every adult is assumed to have capacity until proven otherwise.

The idea of rationality of suicide has seemed ‘abhorrent’ and ‘close to eugenics’ to some professionals.6 This belief may be rooted in fear of malpractice rather than a strong philosophical or ethical argument, for it is clear that psychiatrists from time to time face cases in which suicide is a rational option. Ong and Carter reported a holocaust survivor who was detained under the Mental Health Act because of being suicidal. The patient accused the psychiatric team of acting like Nazis by wanting to exert control over who should live or die.7 As Loefler put it: ‘suicide is not necessarily a matter of insanity, irrationality or despair, and it is not primarily of medical concern’.8 To call all suicides mentally ill downgrades their individual responsibilities.9

Suicide is indeed a complex issue encompassing philosophical, ethical, legal and practical dilemmas. It needs open debate with due consideration to different aspects and points of view. Lack of precise measures to detect mental illness is not a sufficient reason to assume all suicides are due to abnormal mental states. It must be a drive towards developing measures that enable us to detect and exclude mental illnesses with more confidence and certainty.

Does suicide always indicate a mental illness

‘Right to die’ movements are on the political agenda across the globe. The World Federation of Right to Die Societies lists 51 member organizations in 28 different countries. Many of these are campaigning for legislation like that in Oregon where physician-assisted dying has been legal since 1997, subject to various safeguards, including that: the request for death must be made by a competent adult with no more than six months left to live (as assessed by two independent doctors); the request is followed by a mandatory waiting period before it is granted; and the lethal substance provided is self-administered. Feminist psychologist Sandra Bem, who killed herself in 2014, would not have been eligible for an assisted death under the Oregon model, even if there had been comparable legislation in the state where she lived. This is because she was not terminally ill. Diagnosed some years earlier with Alzheimer’s, she had said from the outset that she would end her life while she still could, because she did not want to live to become someone unrecognizable to herself and her loved ones. She researched ways of dying and killed herself (alone, to avoid implicating others) two days after a farewell service held by her family (Ove, 2014). An obituary appeared in The Psychologist (Golden, 2014) in the same issue as a slew of correspondence about the proposed British legislation on assisted dying. Sandra Bem’s choice to die as she did prompts us to consider, as feminists and as psychologists, how we engage with, and contribute to, the current controversies relating to the ‘right to die’.

I. Feminism and the ‘right to die’: Editorial introduction to the Special Feature

The right to choose death.

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The right to choose death.