Journal ofMedical Ethics 1999;25:457-462

Autonomy, rationality and the wish to dieDavid M Clarke Monash University, Melbourne, Australia

AbstractAlthough suicide has traditionally carried a negativesanction in Western societies, this is now beingchallenged, and while there remains substantial publicconcern surrounding youth and elder suicide, there isa paradoxical push to relax the prohibition undercertain circumstances. Central to the argumentsbehind this are the principles of respect for autonomyand the importance of rationality. It is argued herethat the concepts of rationality and autonomy, whilevaluable, are not strong enough to substantiate acategorical "right to suicide" and that the concepts of"understandability" and "respect" are more usefuland able to provide the foundation for responding toa person expressing a wish to die. Roman suicide,sometimes held as an example of "rational suicide",illustrates the effects of culture, tradition and valueson the attitudes to, and the practice of, suicide.(7ournal ofMedical Ethics 1999;25:457-462)Keywords: Suicide; euthanasia

IntroductionAlthough suicide has always occurred, and overthe centuries been a topic of interest forphilosophers and others, in Western societies ithas generally carried a negative sanction. Histori-cally, this sanction has been religious, viewing sui-cide as a rejection of God's gift of life, and civil,where it was considered a failure to accept one'sobligation to the state. More recently the socialsanction has been institutionalised within medi-cine and psychiatry, and the suicidal person hasbeen seen as mentally disturbed, a danger to him-or herself, and an appropriate object of "care".About 20 in 100,000 males and 10 in 100,000females die by suicide each year in the UnitedStates and other Western countries, and this rate isincreasing.'- Of particular community concernare the higher than average rates in the elderly,4and the increasing rate in young people.5 6

In the midst of this, however, is a seeminglyparadoxical push to relax the moral prohibition onsuicide, and to see suicides occurring in the face ofadversity as "rational". This is particularly dis-cussed in the context of euthanasia, physicalillness and aging. The arguments come mainly intwo forms; one emphasising the respect forindividual autonomy, and the other the rational

assessment of utility. Suicide as practised andwritten about by the Greek and Roman philoso-phers has been held up as an example of "rationalsuicide". This paper offers an analysis of theseideas in relation to the clinical and ethical aspectsof suicide.

The psychiatric view of suicideAs described above, a very influential perspectiveof suicide in contemporary Western society is thatprovided by the concept of mental illness, definedbroadly as a disturbance of the mind affectingthinking, mood, motivation and behaviour. Exactfigures vary depending on how the presence of"mental illness" is determined, but studies gener-ally indicate that most people who commit suicidehave a disturbance of mental functioning.3 7-12 Themost common diagnoses given are depression,personality disorder and alcohol dependence orabuse, and these often are present in combination.Phenomena commonly observed in suicidal pa-tients are feelings of hopelessness, helplessness,ambivalence, hostility and loss of control, togetherwith various cognitive distortions.'3- 6 The latterinclude a pessimistic view of the future, a limitedconsideration of possible options and impairedproblem-solving ability. A further common co-occurrence is the presence of disrupted socialrelations. The decision to end one's life is usuallytaken in the context of exhausted individual, fam-ily and social network resources.'7 This pattern ofhopelessness, pessimism, a reduced ability to con-sider possible solutions, and perceived reducedsocial support is seen in both the young and theold.'8 '9 Furthermore, people who proceed to sui-cide have usually had suicidal thoughts for sometime.20The importance of these observations does not

lie in concluding that psychiatric illness "causes"suicide, but in noting that suicide rarely occurs inthe absence of some persistent disturbance ofmental functioning. Surprisingly perhaps, this iscounter to public perception which often viewssuicide as an acute response to a life stress.2'Studies also show that only a small fraction ofpeople who commit suicide have a terminal physi-cal illness, although this group becomes more sig-nificant in the older age group. In a study of

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458 Autonomy, rationality and the wish to die

suicides over the age of 65 years, it was found that14% had a terminal illness.22 Most patients withterminal illness do not wish an early death, and ofthose who do express the wish to die, almost allare found to have a depressive illness affectingjudgment and decision making.23 The tragedy forthe elderly is that when depressed and physicallyill, the suicidal ideation is rarely identified orappropriately treated.4 24Hence, we may conclude that suicide and the

desire to die usually occur in the presence ofaltered mental states - that is, mental states thatimpair a person's ability to think rationally and toconsider options fully. Nevertheless, there aretimes when people express the wish to die in theabsence of depression or other state which mightimpair mental function, and the concept of"rational" suicide needs further consideration.

Rational suicideTo claim that any action, suicide in this case, isrational is to claim that there are good reasons forit - "that it is sensible, appropriate, in keeping withone's fundamental interests, and perhaps evenadmirable".25 It is to say that the action is takenafter informed deliberation and not impetuouslyor directed too much by emotion. Motto defines arational decision as having two characteristics:being realistic and having minimal ambivalence.26The first criterion addresses the importance ofgaining full knowledge of the options andconsequences, the second the potential problemof transient desires being inconsistent with a per-son's more longstanding and fundamental values.The first task is, therefore, to weigh up the risks

and benefits, the utility if you like, of each option.This requires mental competency, itself not a sim-ple matter to be sure about.27 28 However, leavingthat aside, this task involves gaining all possiblefacts and "imagining" all possible consequences.In the situation of writing advance directives, thehypothetical determination of "what if . . ." hasbeen shown to be difficult.29 In the considerationof life or death this would seem to be impossible.How can a person consider rationally the options"to be or not to be"? The phrase "I would be bet-ter off dead" is nonsensical in that there is noknown sense of "being" after death. Even forpeople who hold the view that there is life afterdeath, it is essentially of an unknown quality anda matter of faith rather than rational thought. Ifthe state of death is considered to be a "nothing-ness", then even though life might be experiencedas intolerable, no rational consideration of alter-natives can be made. There are some, however,who wish to argue that death is knowable, and asMayo puts it, "fully known. If it is annihilation,

what else could one want to know about it"?3.Despite the attractive simplicity of this idea, itremains difficult to conceive how one can, eithercognitively or experientially, know "nothingness".Although one may imagine that death will be likedreamless sleep or being under an anaesthetic, it isan assumption or at best a guess. Nobody knows.

It can, however, be argued that the question insuicide (if not always, sometimes) is not "to be ornot to be", but "whether to die now or later".When considered in this way, the nature of exist-ence or non-existence after death is still importantin a rational assessment of the relative quality ofexistence. Technically, the comparison cannot bemade because of the presence of the unknown.

If we were to focus on another question, that isthe "good" that is to be gained for oneself by sui-cide, let us say freedom from pain or suffering;such things can only be "good" when consideredin the context of a human life. They are "good"when attained in life, but have no meaning outsideof it. Indeed, the irony in suicide is that in order toovercome some adversity of life, life itself isobliterated.The above discussion may sound a bit like split-

ting hairs, but is important when one considersthe decision at stake. It indicates that the decisionwhether or not to commit suicide is usually madeoutside the realm of logical thought. That is not tosay that it is irrational, though there are timeswhen it patently is. Rather it is arational. (Perhapsthe truly altruistic suicide is an exception, wherethere is another life for which the "good" can beconsidered.) In most situations, the considerationto end one's life because of persistent physical ormental pain cannot be made on rational grounds.It is therefore highly sensitive to cognitive andaffective dispositions - to despair, pessimism andcognitive distortions posited earlier. One commitssuicide because one "no longer wants to relate tothis particular existence".3" In other words, it is amatter of feelings, emotions and intuitions asmuch as cognitions.

This is an important issue because there is atrend to speak less of the "morality" of suicide,with its presumed overtones of religious judgmen-talism, and to speak more of the "rationality" ofsuicide as if rationality replaces morality in decid-ing whether or when suicide is right or wrong,good or bad, and that it is objectively or reliablydetermined. I am arguing here that it is neitherobjectively determined, nor indicative of goodnessor rightness. When the stakes are high, as in theirreversible decision to commit suicide, therequirement for "rationality" needs to be high.Not only must the act be logically derived fromthe beliefs and values taken as premises, but the

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premises must be strongly supported. Withrespect to suicide, and perhaps with most majorlife decisions, these conditions cannot be met. Inany case, the components of "rationality" - reasonand premise - are culturally determined and soone would have to ask: "which rationality"?32Although suicide may be understandable in anyparticular circumstance, it is not technicallyrational. Furthermore, if something is under-standable (or rational in the looser sense of theword), that does not mean it is for the best, allthings considered, and in that sense moral. Theremay be more than one understandable (or"rational") view. Hence the need for deliberation.On the other hand, if something is not under-standable (and seemingly irrational) to us, thatdoes not mean it might not be understandable orseemingly rational to someone else. Understand-ability occurs only as we are able to identify andempathise with another person's situation and hisor her feelings and values. It is therefore affectedby our own situation, feelings and values. Wood33points out that suicides frequently have both aninstrumental and an expressive component. Fre-quently suicide arises out of, and expresses, a per-son's feelings of anger, meaninglessness, rejectionor desire for revenge. What may not seem under-standable or rational instrumentally, may, in fact,be quite understandable when the expressivenature is revealed. However, the ability to under-stand a person's wish to die still does not meanthat suicide is for the best.The point of these remarks is to illustrate that to

come to a conclusion that an act of, or decisionregarding, suicide is reasonable is not straightfor-ward. The requirements for "rationality" cannotbe formally met. "Understandability" is all thatcan be hoped for and that does not automaticallydirect us to the best decision, particularly in thelight of the cognitive and affective distortions usu-ally present. Such judgments in the end involvenot only intellectual considerations, but a synthe-sis of the affective, empathic, intuitive, cognitiveand interpersonal. The rejection of an absoluteclaim to rationality with respect to suicide,however, does not diminish the imperative torespect a person's autonomy, to whatever extentthat itself is not impaired.

AutonomyThe term "autonomy" has its origins in referenceto the self-rule or self-governance of the Greekcity-states. This original meaning was thenapplied to individuals, and given moral status, byKant.34 In common usage, it implies "being one'sown person or being able to act according to one'sbeliefs or desires without interference".35 It thus

requires the capacity to think rationally and tomake a reasoned decision consistent with one'svalues, and the ability to think and act freely,without undue influence from others. Autonomycan be frustrated either by external forces (loss ofliberty) or by one's own capacities (agency). Therespect for autonomy means acknowledging andhonouring a person's right to hold views, to makechoices and to take actions based on his or herpersonal values and beliefs. This idea wasexpressed by Kant as a respect for persons; to vio-late a person's autonomy is to treat that person asa "means" rather than as an "end-in-themselves".

In its extreme form autonomy is presented as anindividual right - in the present context, the "rightto die".36 This is usually stated as being a functionof one's freedom to choose (a liberty-right),provided that one's choice does not harm orviolate the rights of another person. Battin,however, goes further and argues that the right tocommit suicide is so strongly related to humandignity that it is a "fundamental" human right, notto be overridden by utilitarian concerns.37 Respectfor an individual's view is also incorporated intoutilitarianism under the concept of "interests" and"preferences",38 39 although because utilitarianismconsiders the views of all "stakeholders", in theend it may clash with respect for individualautonomy.Few people would not agree that respecting

persons' autonomy is important. However, weneed to understand what it is we are respecting.We are respecting persons' rights to exercise theirability to make independent decisions governingtheir life. An autonomous act will be madewithout coercion, on the basis of reason and con-sideration, and consistent with personal values ormoral code. In an ideal model of autonomy, suchpersonal values would also be autonomously orindependently derived. This last requirement isclearly not possible. People develop and matureover many years in the midst of a variety of socialinstitutions in which they are heavily influencedby parents, peers, culture and experience. As aresult of identifications and dis-identificationsthey develop their own moral structure40 whichincludes a range of values, some of which mayconflict. By the time people are adults, they willhave values that they are able to express andaffirm, as in a code, and other less well articulatedvalues that will be held only as "intuitions". Inaddition, as a result of experience, a person willhave developed a number of psychological andsocial needs which themselves may contradictdeeply held values. The result is psychic conflictand ambivalence. Most people who commit orattempt suicide express ambivalence about their

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460 Autonomy, rationality and the wish to die

decision.20 Whether a person does or does notcommit suicide is influenced by the thoughts,impulses and desires most prominent at the time.Such desires and impulses come out of his currentpredicament, interpreted in the context of hisemotional needs and fears, social environmentand overarching values and beliefs. In the light ofthis ambivalence in values and thought, and theimpossibility of autonomy in the acquisition ofprinciples and values, our concept of autonomy inthe sense ofindependence ofthought and action isconsiderably weakened. In the situation of a lifecrisis, or mental or physical illness, it is readilyapparent that autonomy is even further impaired.Returning, therefore, to the notion of "respect forautonomy", we need also to be cognisant andrespectful of the ways in which individualautonomy is limited in any situation. When a per-son expresses a wish to die, ambivalence ispresent. Actually, he would rather live, if he couldonly find a better solution. Demoralisation and arestricted view of options limit autonomy.

Roman suicideAlthough it is not known how much suicide waspractised in ancient Greece and Rome, it was cer-tainly written about in the literature and practisedby some. However, it is Stoicism that is creditedwith making suicide not just acceptable, butesteemed.4' One of the classic cases was that ofSeneca, who in AD 65 was accused ofinvolvementin a conspiracy to overthrow Nero. After beinggiven the death sentence, Seneca, together withhis wife and in the company of friends, cut hisveins, then discussed philosophy and gave dicta-tion to his secretaries, before finally drinking poi-son in a rather dramatic re-enactment of the deathof Socrates. This apparently became the model forothers. Roman suicides have been described asbeing theatrical and social events, marked withcalm and philosophical overtones.42

Stoicism developed in a period of significantsocial demoralisation following the collapse of theGreek city-states and the Alexandrian empire. Itbuilt on the Cynic idea of separation of oneselffrom worldly matters and emphasised personalindifference to things around. This was a state ofmind, whereby, through the mental indifferenceattained, adverse events would exert no power.The indifferent person was free. This was linkedwith a belief in predestination - that there was adivinely arranged course of events which a personwas powerless to alter. A person became free whenhe accepted what was ordained and gave up hisown desires and wishes. Unlike the Cynics, wholived simply, the Stoics retained the Epicureanpreference for pleasure and material success. They

believed renunciation of such was unnecessary aslong as they remained indifferent to them! Philos-ophy itself, at least for the philosophers, was con-sidered to be a way of cultivating a mind that madeone indifferent.The Stoics did not fear death but, in a

philosophical way, attempted to practise the sameindifference towards it as to life. They wereintrigued by the idea of dying nobly and contem-plated the deaths of their mentors. "Dying well"became as important as "living well". It has beensuggested that one explanation for this emphasislay in their restricted access to the traditionalopportunities for acquiring glory through militaryor civic fame.43 Consequently, although notcondoning it generally, the Stoics did considersuicide acceptable in some circumstances,namely: in service to others (altruism); to avoidbeing forced to commit some evil; impoverish-ment; chronic physical illness, and mentalinfirmity.44 It also became a privileged form ofcapital punishment for the upper class, andfollowing the glorified example of Socrates theredeveloped a tradition of suicide. The Stoicattitude to suicide is summed up in the words ofSeneca:

"The best thing which eternal law ever ordainedwas that it allowed to us one entrance into life, butmany exits. Must I await the cruelty either ofdisease or of man, when I can depart through themidst of torture, and shake off my troubles? Thisis the one reason why we cannot complain of life:it keeps no one against his will."45

It is difficult for us to interpret or understandRoman suicide because of the cultural distancebetween us and them, and because of thepossibility of literary distortion in the accounts.43There are apparent contradictions in the stance ofthe Stoics that are difficult to explain. First, is thebelief in divine control of nature, alongside theirinsistence to take control over dying. Second, istheir emphasis on developing an indifference tolife's adversities whilst being willing to give up lifebecause of sickness or poverty. Third, the ideal ofindifference seems betrayed by their accumulationof wealth - Seneca himself had become verywealthy, with extensive property andinvestments.46 While the Stoics were able todiscuss death and suicide in an apparently calmand reasoned way, the rather dramatic descrip-tions of fearless philosophising in front of an audi-ence, the clear role-modelling that occurred andthe contradictions in thought and practice betrayprofound ambivalences.The Stoics are put forward as an example of

rational, autonomous suicide - suicide which is

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reasonably considered with little emotion, andwithout fear. What seems paramount in theexample of the Romans is their desire to be incontrol of their death and to face it nobly. This canbe understood in the context of their previousprivileged status and their frustrated feelings ofentitlement and power. However, rather thanbeing a rational suicide, it seems more to be a"rationalisation" of suicide that attempted to dullthe pain or shame of life with a glorification ofmental superiority and control over life and death.When there is little substantial dignity, death pro-vides the final opportunity for its expression. Thedenial of an emotional context and expression,and the contradiction in their philosophy andpractice, would seem to make Roman suicide apoor example of a healthy approach to life'sadversities.The Roman example also indicates to us the

influence that social context and shared valueshave on people's attitude to suicide. There arecontemporary examples of this phenomenon. InHungary, the exceptionally high rates of suicidefound in the south-east regions have been under-stood as part of a traditional acceptance ofself-destruction in times of trouble.47 Conversely,the New Zealand Maori men and women havehad substantially lower rates of suicide than thePakeha (New Zealanders of European origin),and this has been attributed to the security andesteem gained from active involvement in the tra-ditional Maori culture.48 This, and otherevidence,49 50 supports the idea put forward byDurkheim that suicide is very much related tosociocultural factors; particularly the level of inte-gration in family, religious, political and economiclife.

ConclusionDiscussions about the moral status of suicide arebeing fuelled by the more specific debate concern-ing euthanasia - that is, in the presence of pain orsuffering or other irremedial circumstance, shouldpeople be allowed intentionally to end their livesand to receive professional help to do so. Thearguments for this usually come as a plea for therespect for individual autonomy, and by way ofconceptualising a "rational" suicide - the latterargument stating that, although life is generally tobe affirmed, there are times or situations where itis rational to do otherwise.The assertion of this paper is that the concepts

of both autonomy and rationality alone areinadequate arguments for euthanasia or suicidebecause neither is present in such an ideal or pureform as to allow such a categorical defence. Ratherthan being rational, the strongly affective and

evaluative aspects of the decision making need tobe acknowledged. Consideration of personal andinterpersonal aspects and values cannot be donein a purely unemotional manner, and this is thedeficiency of Roman suicide as an ideal. In placeof rationality, the concept of "understandability"is more meaningful and useful, though it isacknowledged that it may not appear to carry thesame moral force. Similarly, where autonomycannot be recognised, at least without consider-able weakening of the concept, the Kantianconcepts of dignity and respect for persons stillremain.

In summary, while it is accepted that there areimportant principles carried behind the banners ofautonomy and rationality, neither exist as ideal andcategorical phenomena. They therefore cannot beused as blanket justifications for the permission ofsuicide. To consider the meaning of an expressedwish to die or a request to be allowed to die, theprinciples of respect for autonomy and rationalityneed to be taken into account, together with anevaluation of their degree of limitation. It is impor-tant to ask why a request is being made, to examinefor cognitive distortions and impairments ofcoping, to try to understand the expressive natureof the wish, and to consider these in the person'ssituational and developmental context. Even in theelderly and the sick there are developmental stagesto be passed and crises that can be met in ways thatgive meaning and affirm life.5' Many elderly sickexperience loneliness and desertion, and an ex-pressed wish to die in these circumstances shouldnot be presumed to be autonomous. Rather,depression, pessimism, fear and social isolation canall be met and addressed in authentic ways thatgives respect to the person.52One of the great advantages of the notions of

autonomy and rationality is their force in moralargument. Terms such as "understandability" or"respect for the person" may seem, at first, not ashelpful because they seem to carry less moralweight and direct us less obviously to a particularconclusion. This is not a reason for abandoningthem in favour of apparently more useful but lessvalid concepts. An exaggerated emphasis onautonomy can lead to an avoidance of listening to,and understanding, the patient. Where rationalityis overemphasised, the expressive and emotionalmeaning of a wish to die will be overlooked. Aclinical approach to a person expressing a wish todie must seek to understand all these aspects anddevelop a coherent understanding of the person,including his or her thoughts, desires, values andrelationships.

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462 Autonomy, rationality and the wish to die

AcknowledgmentsThis paper was written during a period of studyundertaken in the Bioethics Research Centre atthe University of Otago. I am grateful to ProfessorGrant Gillett and Professor Bela Blasszauer forhelpful comments.

David M Clarke MBBS, MPM, PhD, FRACGPJFRANZCR, is Associate Professor in the Departmentof Psychological Medicine, Monash University, Mel-bourne, Australia. Correspondence to: Dr DMClarke, Departnment of Psychological Medicine,Monash Medical Cenitre, 246 Clayton Road, Clay-ton, Vic 3168, AUSTRALIA. e-nmail: david. clarke(aUnmed. monash. edu. au

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