Rational Exits

I first wrote about Old Age Rational Suicide (OARS) a year ago in reviewing a book of essays by European writers, many from England–I’ll See Myself Out, Thank You.  The issue has recently been discussed from a clinical perspective by Meera Balasubramaniam in the Journal of the American Geriatrics Society, and in comments by others.

While Balasubramaniam took no position on the question of whether suicide can ever be rational, several commentators seemed alarmed by the idea.  An editorial in the Journal, responding to the article, made these arguments:

“Acceptance of the idea of rational suicide in older adults is in itself ageist.  It implicitly endorses a view that losses associated with aging result in a life that is not worth living. The debates about PAD [physician-assisted dying/death] must also recognize and consider rational suicide in older adults as a slippery slope, an ethical challenge that is already happening.”

The World Health Organization (WHO) defines ageism as “stereotyping, prejudice, and discrimination against people on the basis of their age.”  This definition generally follows the ideas of Robert Neil Butler, a physician, gerontologist, and psychiatrist who in 1969 coined the term ageism, which he defined as a combination of three connected elements:   prejudicial attitudes toward older people, old age, and the aging process; discriminatory practices against older people; and institutional practices and policies that perpetuate stereotypes about elderly people.

In my view, it is ageist to believe that older people cannot be autonomous individuals with the cognitive or intellectual capacity to decide matters of life and death for themselves when they are not mentally ill.  To compel or pressure the elderly to end their lives because of the “losses associated with aging” would be an inexcusable ethical lapse, but to claim that an elderly person cannot freely choose that option is condescending, normalizing the very stereotype the editorial condemns.

Many older people decide for themselves that they don’t want to be wholly dependent on others, and they don’t want to be remembered as someone in that circumstance.  Others do not want to be an increasing burden on their family, a decision that is theirs, irrespective of whether the family feels that they are a burden.  Such old and increasingly infirm individuals may get little, if any, pleasure from living with myriad physical dysfunctions, and all that such health problems entail. They are the ones who should decide whether their lives are any longer worth living.

Although deciding that one’s life is not worth continuing can be a product of social pressures or discriminatory attitudes by society, we cannot justifiably reach that conclusion in the abstract, as the Journal‘s editorial does.  Many elderly people, for example, fear the loss of mental capacity, quite apart from any social pressure.  This fear seems particularly personal and individualized.  Each case should be judged on its own merits.  

Rational suicide likely has been around at least since homo sapiens first walked the earth, but because this was a pre-literate time, we don’t have writings to prove this.  For the period beginning around 3,000 years ago, however, we know a bit more about attitudes toward suicide.  A brief history of suicide, including the rational kind, can be found here:

In ANCIENT GREECE, suicide was generally regarded as not wrong in itself, but there had to be a justification for it. Although Plato was considered to be often opposed to suicide, he made three important exceptions: when “legally ordered by the State” (as in the case of Socrates); for painful and incurable illness; and when one is “compelled to it by the occurrence of some intolerable misfortune”.

Two other Greek philosophers, Democritus and Speusippus, both committed suicide because of health problems when they were very elderly (the former died at the age of 90). Then, the Epicureans generally felt that when life became unbearable, suicide was justified. And, the Stoics also believed that suicide was permissible, especially if one had an incurable illness.

In ANCIENT ROME, there was usually no prohibition of suicide for citizens. However, suicide was forbidden for slaves and soldiers: the former for economic considerations, and the latter for patriotic reasons. Because life was not considered as a gift of the gods, most leading Romans supported the idea of suicide for specific situations, such as individuals preferring death to dishonour, or those who wished to avoid the decrepitude of old age. Seneca, the philosopher and statesman, strongly believed that if being elderly “begins to unseat my reason and pull it piecemeal, if it leaves me not life but mere animation, I shall be out of my crumbling, tumble-down tenement at a bound.”

Apparently, the ancients did not worry much about ideas like ageism, preferring rational analysis to categorizing our lives into negatory memes, in part perhaps because they did not have any supreme religious leaders directing their views.

Among my personal acquaintances, I have heard expressed on many occasions that they do not want to live the last months or years of their lives in a nursing home.  While such ends were common, and perhaps accepted as inevitable, for people of my parents’ generation, my mother had a different view for herself.  At age 87, she was unwilling to tolerate even a brief stay at a nursing home for rehabilitation, in spite of my efforts to make her stay more tolerable.  I did not blame her because I understood her distress, and I share it still.

It is difficult for me to understand how supporting elderly persons’ autonomy to decide how their lives will end based on objective, rational reasons is prejudice or discrimination against the elderly.  In fact, not accepting their autonomy to do so seems like prejudice or discrimination. 

In Oregon, where people must be terminally ill to choose to participate in the PAD law, the median age of those who did so in 2017 was 74.  Only 19.6% were under age 65.  Age stereotypes seem irrelevant in such decisions.  If the Oregon data are representative of the other states with PAD laws, participants are mostly elderly people with terminal illnesses, notwithstanding that there are occasional inaccuracies with medical opinions about how long a person may have to live.

“Rational suicide” (what I prefer to term “rational exit”) can be defined as a decision to hasten one’s death in the absence of clinically-defined mental illness.  This is, in fact, the circumstance of those who use PAD laws.  

Christine Hartmann, a healthcare researcher and policy analyst, writing in response to criticism of the concept points out, “Rational suicide in older adults may be . . . no different from rational suicide in individuals with terminal illnesses.  Death is inevitable because of an eventual failure of the physical body to sustain life; suicide is the hastening of that event.”

One of the problems with the term suicide, and a reason I and others prefer different ways to talk about ending one’s life before it ends by some disease process, is that, as Balasubramaniam explains, “Suicide has historically been considered pathological, preventable, and within the purview of psychiatry.”  But when there is no mental illness (or treatable mental illness), the matter is not within the purview of psychiatry and should carry no opprobrium, yet the term suicide will forever be burdened by undeserved ignominy.  

In such cases, deciding to exit one’s life falls into the realm of personal decision-making, philosophical examination, ethical evaluation, and social considerations.  Among those social considerations may be the views of one’s family.  I suggest that the views of one’s family are worthy of consideration when those relationships are built on mutual respect, demonstrated concern for the individual’s welfare, and acceptance of the idea that we are all autonomous, with no one having veto power over another’s wishes about her own life.

The late American legal philosopher Ronald Dworkin succinctly explained this concept of autonomy: “Making someone die in a way that others approve, but he believes a horrifying contradiction of his life, is a devastating, odious form of tyranny.”