Choosing The Time To Die

ed. R. Fox, Internat. Assn. For Suicide Prevention, Vienna, 1970

 Special evening meeting, Royal Society of Medicine, Sept. 25th 1969

Considering that we all of us have to die one day, it is truly remarkable that we should not wishto choose for ourselves the most suitable and convenient time to do so, but instead put that moment off for as long as possible, no matter what the penalties. Both the patient on the one hand and his medical attendant on the other agree about this, though from different points of view. Even when the continuance of life has become almost wholly disagreeable, the sufferer would rather die tomorrow than today. The relics of an obsolescent Christian tradition, the fear of the unknown, the fear of the process of dying, even the fear of an afterlife, have led this way in the past. But things are changing, and thoughtful people are beginning to take a very different attitude. To them the fears of dying and of death have become less dreadful than the fear of what doctors can and will do to them in an intensive care unit; and what may be their ultimate end when, mindless and incontinent, their vegetable life is still being maintained in a geriatric ward. Those who have contemplated this prospect have not hesitated to express a preference for a short and easy passage, conducted with the decency and dignity which is possible when one is in one's right senses, and sees and assents to one's fate. The death of Socrates is the ideal on which they would wish to model their leave‑taking.

Doctors have come to the present consensus along a different road. We believe that it is our duty to save life, wherever possible, even when, as it may seem, this is against the express wish of those who have opted for death. It has been shown very convincingly that in perhaps as many as six out of every seven cases, the attempted suicide is calling for help with his problems of this life, rather than wanting above all things to dies The seventh case we confine, if we can, to the range of the pathological. Such is the strength of the normal wish to survive that when this urge fails there must be illness. If a man really does not wish to live, then we think he must be insane, and unfit therefore to decide his own fate. It becomes our duty to save him willy nilly, first to save his life and then to cure his melancholy.

This simpleminded, view was perhaps a fair one in times gone by; but even now there are cases in which it is dangerously irrelevant, and more and more it calls for reconsideration. We must become sensitive to the predicament of those human beings who come to a settled and firm. conviction that.they want no more of this life and would prefer to end it. This is, especially the case when such a decision has been reached on sound principles, when.all a man's most obvious obligations to himself, his family and to society have been discharged, and full consideration has been given to the feelings of others. If a man then proposes to die, it is an impertinence on the part of his medical attendant to offer to intervene.

Yet what can the sufferer do to attain his end? There exists for him no automated Euthanasia Institute; and he cannot call on his doctor or his family or his friends to murder him. He has only the recourse of suicide; but if he tries to emulate Socrates he is only too likely to find the cup of hemlock dashed from his lips. The passing of the Suicide Act of 1961 has brought new hope to uch a than. Killing one­self is no longer an unlawful act, and a man has a right to do anything with his own person that is not unlawful. In the Euthanasia Society we have considered the problem of the would‑be suicide who. finds hi mseift threatened on all sides by those who would frustrate his wishes. In such circumstances it is up to him to declare his intentions, and give good warning of what he proposes to do. Those who might interfere should be told in plain terms that they have no right to do so. The Societyts legal adviser offers the following form of notice:

 TO WHOM IT MAY CONCERN

    I have decided, for reasons of health and age,' to exercise my 'lawful right to bring my life to its end, and I hope that my last wish will be treated with proper respect.

    I absolutely forbid anyone to lay hands on me or interfere with me in any way while I remain alive (except for the purpose of removing organs, for transplantation when my death is certain) and I warn anyone who is minded to disregard this notice that treating or even touching a person against his will is in law both a criminal and civil offence. I thereby instruct my personal representatives to initiate proceedings against any person who attempts unsuccessfully to resuscitate me, and if the attempt is successful I shall take action myself.

    I am of sound and contented mind, and having now made my peace with life and death in my own way I ask to be allowed to die in my own time.

    Signed

    Dated

 So much for the situation of the man who wishes to end his life on grounds whose validity would be recognised by all not warned back by their religious convictions. But what of the man whose grounds are not reasonable in this sense? Does he not have, the same personal right as a last recourse? And who are weto say his reasons are not cogent if they are cogent to him? Speaking person­ally, I would maintain that the right to die transcends the claim of family or society. A man's life is his own, and if we say it is not, we are saying that he is a slave and not a free man. Slavery is. still slavery, even when it is near and dear ones who are the slavemasters.

What ‑ to take the argument to its logical extreme ‑ are the humane considerations we should bear in mind in treating the irretrievably psychotic patient who has repeatedly shown his determination to die? An account of such a patient has been given by Watkins, Gilbert and Bass in the American Journal of Psychiatry only a few months ago. This man made eight separate and desperate attempts at suicide by slashing himself, jumping from a height and running with his head full tilt against a wall. The authors refer to other such patients, and comment that as supervision and control are increased, more and more ingenious methods of evading them are used, such as aspirating torn up paper tissues and tearing the blood vessels with the fingers. They say, “It is, only by constant alertness on the part of the staff that the determined patient may be prevented from killing himself.” What this means is that the invasion of his privacy must be complete. The patient must be stripped down to the state in which there is absolutely nothing of him, not one of his bodily or mental functions, which can be his to call his own. I ask you, what right do we have to debase and degrade. both the patient and his custodians to this level? What harm would be done if, by the accident of a blind eye, the patient did make away with himself?

In preventing suicide, we are only attacking a symptom. We are doing die patient no service, perhaps a disservice, if we cannot influence permanently for the better the, state of mind that led him to his attempt. What is the value of saving the life, say, even of a suicidal recurrent depressive, if it is only to force him, to face again, in a few weeks or months, the same predicament? How can we be sure that the impulsive psychopath, who has opted for death, is not really doing his best, both for himself and everyone else?

Nor should we forget the welfare of society. If a chronic­ally sick man dies, he ceases to be a burden on himself, on his family, on the health services and on the community. If we can do nothing to get a patient better, but do our best to retard the process of dying ‑ extend it perhaps over months and years ‑ we are adding to the totality of ill health and incapacity. To take an obvious example, transplant surgery, in providing a spare set for people who have run through one pair of kidneys, one liver or heart, increases the number of people in the community who at any one time are suffering from diseases of the kidneys, liver and heart. There is, of course, absolutely no limit to the burdens we can go on piling up, by trying to keep badly damaged individ­uals alive. Improving techniques and increasing effort in such diret­ions make the very words "Health Service" a misnomer.

Professional optimism must not blinker us from reality. There are processes that lead through physical or mental illness, through accum­ulating incapacities or senescence, to conditions which doctors cannot mitigate, but can only try to render tolerable. A stage is reached at last, which to psychiatrists needs no description, to which death would certainly be preferable, but one which could have easily been avoided. Flow, then, has the patient been allowed to get so far? Has there been no mistake along the way? No failure of courage? Surely, in nearly all these cases there was a turningpbint, when the doctors knew that there was nothing effective to be done, when the patient could have seen, could have been shown, the road ahead, and could have decided how much further lie wanted to go?

These difficult problems derive in part from the confusion of our standards of value. Since death is inevitable, it is pathetic that in fac­ing it we should be full of fear. The fact that we can look forward with certainty to an end at some time should be a source of consolationand serenity. Death is not the least enviable of all states, and is to be preferred to living and suffering misery and degradation. Long illness is only to be endured if there is hope of eventual recovery; it should not be endured when there is no such hope.

In combating death, when we are not able to combat the causes that are leading to death, we are fighting against nature instead of using natural forces to help us. We are beginning to realise, in a hundred different fields, that we cannot do this without paying a price: whether or not the ultimate end is attained and is worthwhile, along the way there will have been immense efforts spent to no avail, and the disagreeable surprises of unexpected and unwanted consequences.

Death is the natural cure of all incurable suffering. Those of our patients who would welcome such a cure must be met with respect and understanding. Should we not look forward to a future when we exercise more than our present control both of our exits and our entrances? Would it not be a noble world in which no child would be born that was not a wanted child, and those who died, died of their own volition? The biological role of death is not only inescapable, but of inestimable value. We must appreciate the part that death plays in the promotion of health. Death is an equal partner with birth in the renewal of life, for human societies, for human kind, and indeed for the entire world of living things.