Psychosomatics 45:452-454, October 2004
© 2004 The Academy of Psychosomatic Medicine
Fatal Freedom: The Ethics and Politics of Suicide • Seduced by Death: Doctors, Patients, and the Dutch Cure
By Thomas Szasz, Syracuse, N.Y., Syracuse University Press, 2002, 200 pages, $19.95, ISBN 0-8156-0755-5 • By Herbert Hendin, New York, W.W. Norton & Company, 1996, 256 pages, $27.50, ISBN 0-3930-4003-8
Lewis M. Cohen, M.D.
When was the last time you read a psychiatry book for pleasure? As someone who admittedly cannot recall when I picked up anything other than a required text or journal, these two books combine intellectual stimulation with total enjoyment. Both authors are passionate and erudite in their attempts at illuminating the modern phenomenon of suicide. As American medicine has advanced to the point that it can prolong the lives of literally millions of individuals, psychiatry is challenged to understand what constitutes suicide and how to conceptualize and manage people's wishes when they are dying.
Before I go on much further with this review, I should acknowledge my connections to the authors. Although I have met neither, their writings have actively influenced my thinking as I conduct research and try to make sense of patients who discontinue the life-support treatment of dialysis. Dr. Hendin is the Executive Director of the American Foundation for the Prevention of Suicide, an organization that has provided me with a grant to study suicide in renal disease. In a section on the termination of dialysis in Fatal Freedom, Dr. Szasz quotes and gently chides me for having written, "When I determine that a dialysis cessation request is motivated by depression or other forms of psychopathology, I have not hesitated to institute vigorous psychiatric treatment, including hospital commitment."1 Frankly, I feel complimented to be the object of Dr. Szasz' critique. (Incidentally, in the couple of cases where I involuntarily hospitalized a psychiatric patient who wished to stop dialysis, this usually involved bipolar affective disorder. My experience has consistently been that the patient's judgment and delusions invariably improved with treatment, and it was possible to rapidly resume maintenance dialysis.)
Dr. Szasz, a true iconoclastic psychiatrist, has published more than 600 articles and 24 books in which he regularly lambasted the psychiatric establishment for being a tool of society/government and especially for the use of coercive forms of treatment. I recall reading his The Myth of Mental Illness (1961) during residency and being inspired but not entirely convinced by the strongly worded opinions. Now a professor emeritus at the State University of New York Health Science Center in Syracuse, his current thinking about suicide resonates more with that of my own. Even where we disagree, it is a pleasure to follow his thought processes and absorb the anecdotes drawn from history, philosophy, and theology.
Dr. Szasz subtitles the first chapter, "Our Self-Mutilated Vocabulary," and quickly makes the point that, "For killing others, we have a richly nuanced vocabulary; for killing ourselves, we have only a single word, which we hate to utter." He underscores that our linguistic self-paralysis results in the word, suicide, expressing two very different meanings—the mode of death and a simultaneous denunciation and condemnation of the act as being sinful, criminal, and irrational. Like matricide and patricide, use of the suffix "cide" implies that suicide is a wrongful act.
On the other hand, our society approves or even applauds certain types of homicide—acts that cause the death of other human beings. For example, killing in self-defense or in combat are considered to be meritorious, and not criminal offenses. When the judiciary does get involved, it distinguishes between various degrees of murder, manslaughter, involuntary manslaughter, etc., each depending on the motivation and circumstances.
Dr. Szasz defines suicide as being "any behavior motivated by a preference for death over life that leads directly (perhaps only after the lapse of several days) to the cessation of one's life." He points out that suicide, self-killing, or autohomicide—interchangeable terms throughout the book—was recognized by the Greeks and Romans to be courageous or cowardly and legitimate or illegitimate depending on the circumstances. Different societies, including that of our own, have lauded self-sacrifice for great causes. Judaism and Christianity have had contradictory and changing views on suicide. Each religion has interpreted the Biblical commandment of "Thou shalt not kill" to also include suicide. Both theologies have celebrated their martyrs, while they have also punished those who kill themselves by denying burial in holy ground. Both have found a way in modern times to excuse the prohibition of suicide: by employing a psychiatric defense. Burial in Jewish and Christian cemeteries of suicides is now commonplace, as theologians explain that the individual was mentally ill and accordingly not responsible for the behavior. Dr. Szasz is incensed at this intellectual solution and use/misuse of psychiatry.
The shift in thinking and practice also represents an interesting application of the principle of double effect. This was eloquently articulated by St. Thomas Aquinas (1225–1274), who wrote in a chapter titled, "Whether it is lawful to kill a man in self-defense?" the following:
Nothing hinders one act from having two effects, only one of which is intended, while the other is beside the intention. Now moral acts take their species according to what is intended, and not according to what is beside the intention. Accordingly, the act of self-defense may have two effects, one is the saving of one's life, the other is the slaying of the aggressor. Therefore this act, since one's intention is to save one's own life, is not unlawful.2
The same principle is invariably cited in bioethical discussions of all medical acts that serve to accelerate dying, whether it is intermittent use of opiates for symptom management in catastrophically ill patients, terminal sedation, or cessation of life-support treatments. Dr. Szasz suggests that by changing a few words the formula equally applies to and justifies the killing of oneself.
Advocates of physician-assisted suicide have justified the practice by also quoting the principle of double effect, an approach which Dr. Szasz strongly disputes. He argues vociferously that joining the words "assisted" and "suicide" is "cognitively misleading and politically mischievous," and that it results in a euphemism that is as misleading as "pro-choice" for advocating abortion and "right to life" for prohibiting abortion. He would not only reject the term physician-assisted suicide but also the social policy. This last opinion is one of the reasons that I chose to link these two books in a review: although Drs. Szasz and Hendin would likely square off like heavyweight boxing contenders on most matters, they agree that legalization of physician-assisted suicide is a problematic solution to our wish to help patients receive compassionate end-of-life care.
Before shifting to Seduced by Death, I would be neglectful if I did not underscore Dr. Szasz's central theme, if for no other reason than it runs entirely counter to how most of us have been trained to think about suicide. In Fatal Freedom, he writes that "we cannot decide whether killing oneself is right or wrong, an element of our inalienable personal liberty, or an offense of some sort that ought to be prohibited and perhaps punished. We are too uptight about suicide to recognize that sometimes killing oneself is the right thing to do and sometimes the wrong thing to do." Dr. Szasz firmly believes that suicide, or what he also occasionally calls "death control," should be a personal choice and responsibility and neither hindered or facilitated by law and medical practice. By way of contrast, until recently the field of psychiatry has largely held the view expressed by Dr. Hendin and the late Dr. Klerman that "95% of those who kill themselves have been shown to have a diagnosable psychiatric illness in the months preceding suicide. ... Our efforts should concentrate on providing treatment ... and, in the case of terminal illness, helping the individual come to terms with death."3
In the wonderfully titled Seduced by Death, Dr. Hendin vividly presents his view of society's difficulty in navigating between "the Scylla of either excessive or neglectful medical care and the Charybdis of euthanasia." When he assumed the helm 15 years ago of what was then called the American Suicide Foundation, the organization was concerned with neither assisted suicide nor euthanasia. Dr. Hendin was witness to the wave of interest in the United States that manifested itself in publication of Final Exit, a book that laid out specific recommendations and a prescription for ending one's life, and the referendum and legalization of physician-assisted suicide in Oregon. Concerned about the direction medicine was moving, Dr. Hendin traveled to the Netherlands in order to examine the Dutch experience.
In the Netherlands, de facto legalization of euthanasia and physician-assisted suicide had already existed for two decades. Over half of Dutch physicians admit to practicing euthanasia, and Dr. Hendin states that euthanasia estimates range from 5,000 to 20,000 of the 130,000 annual deaths. However, in the next paragraph, he cites the 1991 Remmelink Report that found only 2% (i.e., 2,300) of the deaths were caused by frank euthanasia. Dr. Hendin later argues that official numbers underestimate the true prevalence.
Of greater interest to me was another finding of the Remmelink Report: 49,000 of the yearly deaths involve a medical decision at the end of life. Ninety-five percent of these are evenly split between those that follow withholding or discontinuing life-support treatments and those involving administration of analgesic medication for pain that secondarily hastens dying. Although these deaths are of less direct interest to Dr. Hendin, according to Dr. Szasz many of them would also qualify as being suicides.
Most of the publicity surrounding Seduced by Death centers on Dr. Hendin's discussion of "involuntary" or "nonvoluntary" euthanasia—what the Remmelink Report calls "termination of the patient without explicit request." This refers to euthanasia performed without consent on competent, partially competent, and incompetent patients. The capacity to participate in life-and-death decisions is of obvious interest to psychiatrists, and our field has not sufficiently investigated, defined, or made recommendations about this issue. Certainly when it comes to discontinuation of life-support treatment in the United States, the majority of cases in our intensive care units involve patients who cannot meaningfully participate in the discussion because of dementia, delirium, medication effects, encephalopathy, or reliance on ventilatory support. Among patients stopping dialysis, one-third of the decisions are made by families and staff on their behalf (I actually think this number is an underestimate).
These issues directly lead to the intriguing chapter, "Who Should Decide? Coma and Dementia." The discussion presages this year's highly publicized case of Terri Schiavo, whose family feud attracted the attention of a strange coalition of conservative politicians, the religious right, antiabortion groups, and disability organizations. The chapter is, however, most notable for Dr. Hendin's moving account of his own decisions to provide "aggressive" medical treatment for his mother, who had previously resided for 9 years in a nursing home with progressive dementia. He openly questions the subjectivity of his judgments and the capability of any loving family member to make a rapid series of decisions regarding hospitalization, transfer to intensive care, ventilation, tracheostomy, gastrostomy, and intravenous hydration.
I do not know if this is apocryphal, but colleagues have told me that in order to better comprehend the situation in the Netherlands, Dr. Hendin learned Dutch. If so, it explains the wealth of details and interviews that fill this book. It is also a clue as to the single-minded devotion and scholarship that he brought to the quest of illuminating this subject.
Neither of the books that I chose to review was written to provide a balanced perspective of the subject. Dr. Hendin's chapter, "Selling Suicide" is an inspired polemic of the "take-no-prisoners" flavor, and Dr. Szasz has long railed against psychiatric commitment and the curtailment of freedom and liberty. However, both authors have staked out positions that need to be seriously considered as the field of medicine struggles to reach a consensus regarding end-of-life care. When I entered medicine the goal was to preserve and extend life at any cost. That is no longer the medical imperative, and our specialty now desperately needs to debate the legitimacy of allowing or even helping people to die—what Dr. Szasz would broadly include in his definition of suicide. Both of these books are daring and gutsy in staking out positions on the question of just who should control when and how we die. Both books should provide the reader with an intellectually stimulating alternative to plowing through the latest issue of The American Journal of Psychiatry.
FOOTNOTES
Dr. Cohen is Medical Director, the Renal Palliative Care Initiative, and Staff Psychiatrist, Consultation Psychiatry Service, Baystate Medical Center, Springfield, Mass.
REFERENCES
- Cohen LM: Suicide, hastening death, and psychiatry, Arch Intern Med 1998; 158:1973–1976[Free Full Text]
- Aquinas T: The Summa Theologica of St. Thomas Aquinas. Translated by Fathers of the English Dominican Province. London, RT Washbourne, 1918, p 209
- Hendin H, Klerman G: Physician-assisted suicide: the dangers of legalization. Am J Psychiatry 1993; 150:143–145[Abstract/Free Full Text]
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