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Department
Philosophy
Course Code
PHL 302
Professor
Glen Hoffmann

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PHILOSOPHICAL AND ETHICAL ISSUES
Rational suicide: uncertain moral ground
Karen L. Rich PhD (c) RN
Doctoral Candidate, School of Nursing, The University of Southern Mississippi, Hattiesburg, Mississippi, USA
Janie B. Butts DSN RN
Associate Professor, School of Nursing, The University of Southern Mississippi, Hattiesburg, Mississippi, USA
Submitted for publication 25 April 2003
Accepted for publication 22 October 2003
Correspondence:
Karen Rich,
School of Nursing,
The University of Southern Mississippi,
Hattiesburg,
2701 Hardy Street,
MS 39406,
USA.
E-mail: [email protected]tt.net
RICH K.L.&BUTTS J.B. (2004)RICH K.L.&BUTTS J.B. (2004)
Journal of Advanced Nursing 46(3), 270–283
Rational suicide: uncertain moral ground
Background. The ambiguities involving end-of-life issues, such as physician-assisted
suicide and voluntary stopping of eating and drinking, have caused ablurring of the
definition of rational suicide and have prompted rich dialogue with moral deliber-
ations that seem to be on disparate paths among bioethicists and other health care
professionals. With the evolution of advanced medical technology extending life
expectancy in older, disabled, and terminally ill people, rational suicide has become
acritical issue of debate.
Aim. The purpose of this article is to address the ethical positions supporting and
opposing rational suicide and to consider whether coherence can be achieved
through an ethic of care.
Findings. Attitudes towards suicide have been controversial, varying from accept-
ance to non-acceptance depending on social, political and religious influences.
Nursing attitudes are no different from general societal attitudes and, consequently,
nurses are treading on uncertain moral ground.
Conclusion. Nurses who have not reflected on the moral issues involved with
rational suicide may be unprepared psychologically and professionally when
working with patients who may be contemplating such actions.
Keywords:rational suicide, physician-assisted suicide, end of life, nursing care,
autonomy, ethic of care
As if every passion didn’t contain its quantum of reason!
(Nietzsche1968)
Introduction
‘A vast public health crisis that makes us so uncomfortable
that we divert our eyes from it’ was astatement made by
Solomon (2001, p. 248) about suicide, and it has become a
stark reminder to society about the woes of suicide. In the
United States, approximately 30 000 suicides are certified
each year, with one million people dying of suicide each year
worldwide (Johnstone 1999, Beauchamp &Childress 2001).
Questions of moral conflict, such as deep, long-held values
and ideals about life and relationships, have surfaced from
the hot debates and moral deliberations of bioethicists and
other health care professionals about rational suicide. With
the continual progression of technological advancements in
medicine, however, many people are asking the question,
‘What is agood death?’ Thoughts about trying to experience
agood death have gained relevance in the last decade. The
act, or one may say the consolation, of suicide is one way that
some believe that they might ensure agood death. Aperson
who is debilitated or terminally ill may sometimes view
suicide as an escape from life or from an otherwise slow,
lingering wait for death with pain and suffering.
Analysis of what is meant by rational suicide and its
implications is not as explicit as one might anticipate. For
example, questions must be considered about what qualifies
270 2004 Blackwell Publishing Ltd
www.notesolution.com
as rational, whether or not physician-assisted suicide (PAS)
should be considered within the definition of rational suicide,
and whether the refusal of life-sustaining treatment and
withdrawal of life support are actually rational suicide,
including voluntary stopping of eating and drinking (VSED).
The motivation for this paper came from the experiences of one
of the authors, who was caught psychologically unprepared
when apatient dying from acquired immune deficiency
syndrome (AIDS) requested information about the Hemlock
Society (a voluntary organization in the United States of
America which campaigns for the legalization of euthanasia).
Many implications of rational suicide are too broad to be
covered adequately in this article. However, some of the basic
ethical issues will be addressed, including an exploration of
positions supporting and opposing rational suicide and
consideration of an ethic of care approach in providing
coherence among these views.
Historical background
Suicide has long been controversial. Through the years, it has
varied from being socially accepted, religiously prohibited,
secularly criminalized, medicalized, and back again to some-
times being considered an acceptable choice (Johnstone
1999). The autonomous taking of one’s life has figured
prominently in literature since ancient Greece. In Plato’s
Phaedo (Jowett trans. 1871/1999), Socrates explained to
Crito why he saw no benefit in delaying drinking the
hemlock. Socrates stated, ‘I am right in not doing thus
[delaying], for Ido not think that Ishould gain anything by
drinking the poison alittle later; Ishould be sparing and
saving alife which is already gone; Icould only laugh at
myself for this’ (p. 675). Socrates’ reasons for his decision to
commit arational act of suicide sooner rather than later may
be similar to those of people today who view rational suicide
as an escape from the inevitability of death from terminal
illness.
Gottlieb (2000, p. 313) discussed the Stoics’ belief that ‘the
way to cope with fate is to travel light’ [and to] ‘regard
anything you might lose as more or less gone already and you
will be protected against the worse blows that fate can deal’.
As in the case of Socrates, it seems that the Stoics, as early as
65 AD, believed that it was morally honourable to choose the
manner of one’s death when it was imminent and inevitable.
When the Stoic Seneca thought that there was no escaping
death or exile from the hand of aparanoid Nero, he chose to
open his veins in ahot bath (Marinoff 1999). Seneca’s choice
was not asurprise, considering the history of his obsession
with death and frequent talk of suicide (Gottlieb 2000). He
was quoted as stating that ‘just as Ishall select my ship when
Iamabout to go on avoyage, or my house when Ipropose to
take aresidence, so Ishall choose my death when Iamabout
to depart from life’ (Andrews 1990, p. 290). And so he did.
Ideas about suicide appeared permissive among the early
Christians, from the 5th to 10th centuries AD; however, a
strong Christian prohibition of suicide on moral grounds was
also evident. St Augustine and St Thomas Aquinas were
influential in opposing suicide. The latter objected to it
because he believed that it opposed the natural law and
violated aperson’s duty to God, oneself, and the community
(Johnstone 1999). Many religious condemnations related to
suicide are less apparent today because of society’s shift in
thinking that suicide is no longer amoral condition but a
medically treatable or preventable condition. However,
suicide still seems taboo and continues to remain contrary
to natural law according to the majority of Christian
religions.
Suicide was secularized and considered to be acriminal act
that prompted harsh prejudices and penalties for suicidal acts
from about the 11th to the 14th century. Rather than receive
any type of probation sentence, people attempting suicide
were sent straight to prison, and, ironically, could be
sentenced to death for attempting to commit suicide. It was
during the 18th century that suicide began to be viewed as
resulting from emotional or mental illness.
Two philosophers of the 19th and 20th centuries, Scho-
penhauer and Wittgenstein, respectively, had dissimilar moral
views on the issue of suicide. In linking his views on
pessimism, Schopenhauer (trans. 1940) stated that, although
suicide may be regarded as amoral and metaphysical error
because it results from the frustrations of life, it is the final act
of self-determination, an act of ultimate dignity, in this
immoral world. Schopenhauer proposed that individuals had
afundamental right to end their lives, whereas Wittgenstein
(1979, 1916 Eng. trans. von Wright &Anscombe) asserted
that suicide was an elementary sin, and suggested that it was
an act of self-annihilation and the ultimate act of disrespect
and violence. From the 18th century to the present, decrim-
inalization and emphasis on medical treatment and preven-
tion, rather than suicide being amoral condition, have
ushered in agradual socio-cultural acceptance and legitimi-
zation of suicide in some cases (Johnstone 1999).
What is rational suicide and what is the dilemma?
Suicide is taken from the Latin term sui,ofoneself, and
cidium,meaning aslaying or to kill. The word did not
become part of the English language until 1651 (Johnstone
1999). Rational denotes something that is characterized by
reason or is intelligible, sensible, or can be understood
Philosophical and ethical issues Rationalsuicide
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing,46(3), 270–283 271
www.notesolution.com
(Angeles 1992). From these definitions, one can surmise that
rational suicide involves self-slaying that is characterized by
reason or makes sense to others. The defining characteristics
of rational suicide suggested by Siegel (1986) include suicidal
persons having arealistic assessment of their life circum-
stances, being free from psychological and severe emotional
distress, and having amotivation that would be understand-
able to most uninvolved observers within the suicidal
person’s community. Two additional characteristics provided
by Werth (1995) include decision-making that has been
deliberated over aperiod of time and involvement of the
suicidal person’s significant others when possible.
Many professionals are discussing the controversial
instances of suicide under the category of rational suicide.
Allowing any suicide seems contradictory to good practice,
when mental health professionals are accustomed to
intervening when aperson acts in away that poses a
danger to self. However, in Werth and Cobia’s (1995)
qualitative and quantitative study of psychotherapists’
attitudes, they asked ‘Do you believe in the idea of
rational suicide? Why or why not?’ Eighty-eight per cent
of respondents indicated that they believed in the concept
and described their beliefs about the term, which consisted
of approving of the act when: (a) people contemplate
suicide when there is an unyielding hopelessness in their
condition according to their perception, (b) they are not
coerced and they make afree choice about suicide and
(c) they exercise sound decision-making in the process.
These beliefs were consistent with those described by Siegel
(1986) and Werth (1995).
Acritical question that arises about rational suicide that is
not answered clearly in the literature is whether rational
suicide includes only those suicides autonomously accom-
plished by rational persons, such as self-slaying, or whether it
also includes PAS undertaken with arational state of mind.
Further, there remains aquestion of whether or not the
refusal of life-sustaining treatment or withdrawal of life
support should be classified as rational suicide. These cases
have been discussed ambiguously in the literature in relation
to rational suicide. Some ethicists have attempted to draw
distinctions between rational suicide, PAS, and refusal or
withdrawal of treatment. However, the distinctions remain
weak because clear guidelines have not been provided
(Ahronheim et al. 2000, Beauchamp &Childress 2001,
Bandman &Bandman 2002, Fontana 2002, Jonsen et al.
2002). These ambiguous distinctions leave unanswered
questions and further complicate decisions about when and
in what situations a‘right to die’ will be applied, and whether
suicide should be viewed as aright. To that end, an important
ethical uncertainty for nurses and other health care profes-
sionals is whether intervention is obligatory when patients
plan arational suicide (Batten 1995).
Nurses and the conflict in principles
The physician and philosopher William James was quoted as
saying, ‘I take it that no man (sic) is educated who has never
dallied with the thought of suicide’ (Andrews 1990, p. 290).
The 30, 000 suicides that are certified each year in the United
States do not include those classified as accidental deaths
(Beauchamp &Childress 2001). Also not included in these
numbers are the rational suicides or PASs that are not
officially certified as such but may often be certified as being
due to terminal illness.
In addition to the obvious impact of suicide based on the
numbers of lives involved (both those who commit suicide
and their significant others), the issue of rational suicide is
particularly relevant to nurses and health care professionals
because of its association with people who are terminally ill,
permanently disabled, and older people facing problems
associated with ageing. Ahronheim et al. (2000) reported that
according to surveys most patients with cancer, amyotrophic
lateral sclerosis (ALS) and AIDS would approve of having the
option of PAS. The highest risk of suicide occurs with older
men, particularly those with chronic disease.
At the most basic level, it seems that patient autonomy is at
stake vs. paternalistic intervention based on the moral,
religious, or legal decisions of others. Pellegrino and
Thomasma (1996, p. 121) described autonomy as ‘a capacity
for self-rule, aquality inherent in rational beings that enables
them to make reasoned choices and actions based on a
personal assessment of future possibilities evaluated in terms
of their own value systems’. According to Pellegrino and
Thomasma, when individuals exercise autonomy they are
able to make responsible judgements about what they believe
to be good. They further stated that there ‘is amoral claim on
others to act towards us in such away that capacity for
self-governance can function as fully as circumstances permit’
(1996, p. 121). Therefore, do the limits of autonomy include
rational persons having the right to end their own lives,
especially if help from others is not solicited or needed? This
question leads to another question of consciousness and
orientation to life (Finnerty 1987). Are people guided by
some general obligation, such as their belief of ahigher
power, to preserve their own life for any reason? Unfortu-
nately, there are no clear answers because people, including
health care professionals, either see rational suicide as an
autonomous right or as aparadox (Cotton 1993).
Some ethicists argue that autonomy has superseded bene-
ficence as the first principle of medical ethics over the last
K.L. Rich and J.B. Butts
272 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing,46(3), 270–283
www.notesolution.com

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Description
PHILOSOPHICAL AND ETHICAL ISSUES Rational suicide: uncertain moral ground Karen L. Rich PhD (c) RN Doctoral Candidate, School of Nursing, The University of Southern Mississippi, Hattiesburg, Mississippi, USA Janie B. Butts DSN RN Associate Professor, School of Nursing, The University of Southern Mississippi, Hattiesburg, Mississippi, USA Submitted for publication 25 April 2003 Accepted for publication 22 October 2003 Correspondence: RICHH K..L & BBUTTTSS JB.. 2004 )) Journal of Advanced Nursing 46(3), 270283 Karen Rich, Rational suicide: uncertain moral ground School of Nursing, Background. The ambiguities involving end-of-life issues, such as physician-assisted The University of Southern Mississippi, suicide and voluntary stopping of eating and drinking, have caused a blurring of the Hattiesburg, 2701 Hardy Street, denition of rational suicide and have prompted rich dialogue with moral deliber- ations that seem to be on disparate paths among bioethicists and other health care MS 39406, USA. professionals. With the evolution of advanced medical technology extending life E-mail: [email protected] expectancy in older, disabled, and terminally ill people, rational suicide has become a critical issue of debate. Aim. The purpose of this article is to address the ethical positions supporting and opposing rational suicide and to consider whether coherence can be achieved through an ethic of care. Findings. Attitudes towards suicide have been controversial, varying from accept- ance to non-acceptance depending on social, political and religious inuences. Nursing attitudes are no different from general societal attitudes and, consequently, nurses are treading on uncertain moral ground. Conclusion. Nurses who have not reected on the moral issues involved with rational suicide may be unprepared psychologically and professionally when working with patients who may be contemplating such actions. Keywords: rational suicide, physician-assisted suicide, end of life, nursing care, autonomy, ethic of care As if every passion didnt contain its quantum of reason! the hot debates and moral deliberations of bioethicists and (Nietzsche 1968) other health care professionals about rational suicide. With the continual progression of technological advancements in medicine, however, many people are asking the question, Introduction What is a good death? Thoughts about trying to experience A vast public health crisis that makes us so uncomfortable a good death have gained relevance in the last decade. The that we divert our eyes from it was a statement made by act, or one may say the consolation, of suicide is one way that Solomon (2001, p. 248) about suicide, and it has become a some believe that they might ensure a good death. A person stark reminder to society about the woes of suicide. In the who is debilitated or terminally ill may sometimes view United States, approximately 30 000 suicides are certied suicide as an escape from life or from an otherwise slow, each year, with one million people dying of suicide each year lingering wait for death with pain and suffering. worldwide (Johnstone 1999, Beauchamp & Childress 2001). Analysis of what is meant by rational suicide and its Questions of moral conict, such as deep, long-held values implications is not as explicit as one might anticipate. For and ideals about life and relationships, have surfaced from example, questions must be considered about what qualies 270 2004 Blackwell Publishing Ltd www.notesolution.com
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