Each victim of suicide gives his act a personal stamp
which expresses his temperament, the special conditions
in which he is involved, and which, consequently, cannot be
explained by the social and general causes of the phenomenon
—Émile Durkheim in Le suicide (1897)
§
For many, making a distinction between euthanasia (literally, "the good death" or a "dignified death", cf. Kalish, 1981) and suicide is a fruitless exercise in semantic minutiae. Whatever we may call it, many say, the end result is the same—a person has decided to end his life. How one chooses to carry out the act is merely a semantic or legal distinction and carries more import for society itself (e.g., for purposes of record-keeping or telling loved ones "how" and "why") than for the dying person himself. Unfortunately, failing to consider this distinction carefully has tremendous implications for the way in which we provide the dying person with emotional and spiritual care—if any at all. If the distinction is merely one of method of dying, then we are basically to treat all dying people the same—as people who have made their choice and are "ready to go".
This convenient, pragmatic manoeuvre relieves us of any responsibility for looking after anything beyond the dying person's most immediate needs, namely assistance with legal and financial "loose ends" and with physical comfort. Issues of psychological distress and mental wellbeing are not actively considered when our deepest understanding of these two modes of dying involve semantic and legal distinctions. Mental health workers end up restricting themselves to dealing with the emotional issues of the living, not the dying—presumably because the former is a more reliable source of income and the latter is a reminder of the mortal limits of modern mental health care.
This paper will attempt to make some concrete distinctions (if "concrete" distinctions even exist in the first place) between euthanasia and suicide, in an explicit effort to better understand the potential mental health needs of those whose motives we may profoundly—if not recklessly—misunderstand. The paper will not "argue" the different "sides" of the euthanasia debate but will, rather, try to develop a sense of empathy for the human being who wants to die and/or says she is ready to die. Implications and recommendations will be discussed.
Before we go on to define, compare, and distinguish euthanasia and suicide, we should ask "Why bother in the first place?" As intimated above, the reasons primarily concern the mental health of the person who wants to die. Death, in any form, is a scary thing because for many people it is the epitome of mystery and "the unknown". That which is unknown can be intensely frightful (Cicirelli, 2001, 1999; Fullerton et al., 1992; Graham & Gaffan, 1997; Grinberg & Grinberg, 1984). A common response to this fear is avoidance. A convenient way to avoid the topic of death is to refrain from spending much time thinking about different ways in which people can end their lives. Thus, we willingly gloss over the morbid distinctions between euthanasia and suicide, resorting to simplistic, categorical definitions and not considering their deeper implications.
Yet a consideration of this issue is critical if we are to appreciate and improve the emotional well-being of people before, during, and after euthanasia or suicide. If, for instance, either of these acts is intimately associated with an episode of depression or other distressed state of mind, then it is our responsibility to make a more concerted effort to ask the person why he wants to die. Doing so could save his life. If a decision is, ultimately, made to die, we must look at how the person chooses to die, for this may provide many clues as to his state of mind and level of distress. Finally, if the person does end up dying, the distinction between euthanasia and suicide carries significant consequences for surviving family members who must somehow come to terms with the death. At all three stages of the process (for lack of a better term), insistence that euthanasia and suicide are merely legal differences lets us "off the hook" and provides justification for our fear of dealing with the dying person's overwhelming emotions. Clearly, this is unacceptable.
Traditional definitions of suicide often draw directly from the dictionary or from the law books. According to the well-known Cambridge International Dictionary of English (2001), euthanasia is "the act of painlessly killing someone who is very ill or old, especially to reduce their suffering". The Cambridge Dictionary of American English (1999) defines suicide as "the act of killing yourself intentionally". Canada's National Advisory Council on Aging (Date N/A) makes a further distinction between passive euthanasia ("withholding or ceasing treatment of someone who is ill or injured and not expected to recover), active euthanasia ("intervening actively to end a person's life"), and assisted suicide ("providing the means for someone to commit suicide") (p. 2). The Criminal Code of Canada (1985) makes ominous reference to euthanasia in two of its section:
(14.) No person is entitled to consent to have death inflicted on him, and such consent does not affect the criminal responsibility of any person by whom death may be inflicted on the person by whom consent is given.
(241.) Everyone who counsels a person to commit suicide or aids or abets a person to commit suicide, whether suicide ensues or not, is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years.
No legal reference is made to suicide per se, as it is not considered illegal in Canada.
These definitions are simple and elegant, but from a clinical point of view they provide little helpful information. Most notably, they make little or no reference to the state of mind of the individual considering ending her life. Without such information, we cannot effectively care for those who are contemplating these two distinct phenomena. Let us turn, therefore, to four broad distinctions which may be more fruitful.
Euthanasia and suicide differ in the sense that the former is often a response to chronic physical illness, pain, or discomfort. Whether committed by someone else (euthanasia proper) or by the person himself (which for purposes of this paper I will include under the "euthanasia" category1), the primary motivation is physical—to end physical suffering, however the individual may interpret and experience it. Suicide, on the other hand, differs in two major respects. First, it is often in response to emotional or spiritual distress and not so much to physical pain or disability. Suicide is in response to what Edwin Shneidman (1993) very perceptively describes as "psychache"2:
Psychache refers to the hurt, anguish, soreness, aching, psychological pain in the psyche, the mind. It is intrinsically psychological—the pain of excessively felt shame, or guilt, or humiliation, or loneliness, or fear, or angst, or dread of growing old or of dying badly, or whatever. When it occurs, its reality is introspectively undeniable. Suicide occurs when the psychache is deemed by that person to be unbearable. This means that suicide also has to do with different individual thresholds for enduring psychological pain.
All our past efforts to relate or to correlate suicide with simplistic nonpsychological variables, such as sex, age, race, socioeconomic level, case history items (no matter how dire), psychiatric categories (including depression), etc., were (an are) doomed to miss the mark precisely because they ignore the one variable that centrally relates to suicide, namely, intolerable psychological pain; in a word, psychache (p. 147).
Second, the emotional state of psychache is usually acute—unlike the chronic course of discomfort we see in the person contemplating euthanasia. In the former, the emotional distress has reached an apex—it is at this moment that it has become positively unbearable and must end in any way. Whereas one may reasonably surmise that chronic physical pain will probably never cease, a person in the throes of acute emotional distress is temporarily clouded in her judgment. Although the emotional distress is often continuous, during its over all course it is usually not as severe as to warrant contemplation of a suicide attempt.The implications here are crucial. It is, of course, debatable whether the person contemplating euthanasia truly wants to die (D. Jackson, 2000, personal communication, but we shall leave that debate for another paper), but on balance I argue that it is the acutely suicidal person who is in desperate and more immediate need of emotional and spiritual support. If, as will be discussed shortly, suicide is seen as a cry for emotional help, then we are obligated to attend to the person's unique psychache and not merely his outward actions.
A distinction can also be made in terms of the degree of planning involved in both modes of ending life. In euthanasia, we see a more deliberate, rational, and linear progression of events. One "decides" to die, plans the method, carefully arranges his affairs, consults extensively with family members, and then dies in a relatively calm and controlled environment, often under medical "supervision". In suicide, the decision to die is often a "snap" one—something has happened to "break the camel's back" and it is so severe that emotion reigns over reason. One may plan this type of death, but not to the degree we see with the person who wishes to be euthanised. The suicidal person may, indeed, put her affairs in order, but often quite hastily and in such a fashion that she concomitantly cries out for help from loved ones. For instance, she may redraw her will to make adequate provisions for her spouse, but at the same time may attach a codicil to the will that reads more like a painful suicide note than a legal document (see Elmer, 2001; see also Brevard & Lester, 1991; Heim & Lester, 1991).
Further, the suicide process is anything but "linear". It is emotionally tumultuous and chaotic because it is governed by a flurry of contradictory emotions (I want to live, but not like this; I want to live, but I just can't do it; I hate my life but I want to live). The mere presence of this tumultuousness is a siren call for some sort of crisis intervention and not merely a resigned acceptance of the fact that the person has "obviously decided to go".
As intimated earlier, the circumstances surrounding the death are also crucial to consider. More than in suicide, the person who wishes to be euthanised will try to be surrounded by friends and family at the time of the planned death The death is perceived (whether honestly or not) as another stage in the person's life history—something to be shared with loved ones. In suicide, the circumstances are often gut-wrenching and pitiful. A sense of shame, perhaps even failure, permeates the event. One person I spoke with says this of her suicide attempt: "I felt like I was losing my mind. It was the loneliest I'd ever been. I didn't want anyone to see me like this" (J. Dawes, personal communication, October 2002). Friends and relatives are absent, only to be informed of the suicide after the fact—often through a painful suicide note. The body is not properly disposed of, but, rather, is left to decay on the bed, in the bathroom, or in the car. Especially if the victim is male, the death is often violent (e..g. gunshot) (see McIntosh, 1994 and also Kaplan, 1996).
The lethality of the weapon and the grim surroundings at the time of the suicide almost echo the complete absence of peace that the euthanised person expects. The violent, lonely death seems to signal—to both victim and loved ones—the continued, relentless emotional torture that may continue well after death. In this sense, we ought to become even more suspicious that the death is unwanted, that as health providers we have failed someone who either reached out for help and was rebuffed, or who did not know how to reach out.
All of these distinctions can be distilled into one central issue: Does the person really want to die? It can be argued that in the case of euthanasia nobody technically "wants" to die. In the absence of physical and emotional pain, most of us would prefer to be alive than to be dead or to have never existed. Most of us recognise something wonderful in life that we just do not want to give up. Here, the distinction between euthanasia and suicide becomes irrelevant. We are forced to move beyond legalistic definitions and those which attempt to deal with the messy issue of suicide by superficially inferring people's states of mind. If it is the case that the person who "wants" to die would prefer to stay alive (either if circumstances were better or if they had more support), then in all cases we must do our best to attend to our clients' emotional and spiritual needs.
The issue of the difference between euthanasia and suicide came to a head in a gerontology course I had the pleasure (misfortune?) of taking a few years ago. During the course, I was obliged to listen to two social workers talk about the relationship between depression and suicide. Having found the presentation to be overly clinical and limited in scope, I played devil's advocate and asked both the presenters and the professor whether people who may not necessarily meet DSM criteria for depression—such as those contemplating euthanasia—could also be considered "suicidal" in the sense described in this paper (i.e., in the sense of feeling intense psychache). My query was met with a quick and resounding response: "Euthanasia has nothing to do with suicide. It is a purely legal concept."
My professor remained silent. I was quite upset upon hearing this, because it sent the message that today's clinicians are afraid to abandon traditional, seemingly clear-cut definitions of suicide and euthanasia. The consequences of this can be devastating. No matter how we define these two different phenomena (clearly, my own definitions are debatable), we must refrain from treating people, their behaviours, and their emotions as neatly classifiable, diagnosable entities. Doing so only reinforces the growing contemporary view that people are nothing more than machines and that their deaths are nothing more than cool, calculated decisions to turn those machines off. This risks alienating even more distressed and vulnerable individuals.
When many of today's older people are still
reluctant to discuss emotions with healthcare providers (Katz, 1997), we must do
everything in our power to break down barriers. This includes giving up our technical
manuals and definitions and starting to view people as human beings, each with their own
unique perceptions and reactions.
[1] Namely because I want to make a distinction between what a dying person may consider a "merciful" or "dignified" intentional killing of herself for purposes of alleviating physical pain, and a more emotionally-charged, rash "suicide" for purposes of alleviating emotional discomfort. The two are not, of course, mutually exclusive, but they differ enough that I would like to consider them as separate phenomenon.
[2] The concept of psychache is particularly important because it disarms another elegant, but simplistic, way of looking at suicide. To the credit of modern mental health professionals, we recognise that those who commit suicide are usually depressed (see, for example, McIntosh et al., 1994). However, in our efforts to avoid dealing with unpalatable emotional issues such as suicide, we often cling excessively to psychiatric definitions of states of mind (e.g., American Psychiatric Association, 1994). This practice, unfortunately, often excludes from consideration those suicidal individuals who may not meet diagnostic criteria for depression or related conditions but are, nonetheless, in deep emotional pain.
[3] Pseudonym.
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Copyright © 2002, by Eddy M. Elmer
Permanent URL: http://www.eddyelmer.com/articles/suisfu.htm