(National Post) - Can suicide ever be a rational choice?
More than two-thirds of all suicides are driven by a mentally disordered mind, experts say. But a provocative new article published this week in the Canadian Journal of Psychiatry asks can suicide ever be rational — a decision made under free will, in the absence of any diagnosable mental illness and with full appreciation for the potential consequences?
“Designating suicide as an undesirable event that should never occur raises the debate of who is responsible for one’s life and runs the risk of erroneously attributing blame for suicide,” University of Toronto psychiatry resident Dr. Angela Ho writes.
In cases where people are of full mind and mental capacity, “there is much debate about whether suicide can ever be rational,” Ho writes.
Society’s “overarching desire” is to prevent death by suicide, she said.
But the view that death is “the greatest of harms” potentially overlooks the possibility that intolerable psychological suffering may be equally harmful, she said.
No one can predict with any certainty someone will commit suicide, Ho said. Still, the responsibility for preventing suicide tends to fall on the treating doctor, she said. Patient suicides are among the most frequent malpractice claims against psychiatrists.
“Physicians are often expected to predict and prevent suicide, and then if it occurs, they may be blamed,” Ho said.
But that attitude ignores the complexity of suicide, she said.
Most guidelines for managing people with suicidal thoughts are based on the premise that depression, substance abuse or other forms of mental illness drive suicide.
Little is said about the concept of rational suicide — managing cases of suicidal thinking in people without mental illness and with mental capacity, and who therefore should be able to make rational decisions, Ho writes.
“People may have difficulties coping with life,” Ho said in an interview. “Maybe they don’t have a lot of support or healthy ways of dealing with their emotions. Sometimes people feel overwhelmed and feel like suicide is the only answer.”
“The person says they want to end their life, but their thought process isn’t necessarily disordered because of depression or psychosis,” Ho said.
Clearer guidance for doctors is needed on how best to approach these cases, she said.
It’s an issue that raises tension between individual rights and a doctor’s human instincts and ethical duty to protect life, she said.
That tension is being played out in the euthanasia debate.
Quebec’s Parti Quebecois is pledging to pass its controversial bill on doctor-assisted dying if re-elected. Bill 52 would allow terminally ill patients who are capable of giving consent the right to request a doctor-hastened death to avoid “constant and unbearable” suffering.
Ho said there is growing interest whether unbearable suffering from psychological pain may be the same as suffering associated with terminal illness.
“How do we interpret that kind of distress, and is the harm from unendurable suffering any less legitimate?”
That’s where the controversy lies, she said. “It’s not clear whether it really is possible that people can have thoughts of suicide that are not driven by some underlying mental illness.”
Some would argue that profound psychological distress is, in and of itself, mental illness, she said.
Her hope is that her paper “will open up the discussion on the topic of suicide, which is sensitive and stigmatized.”
Research shows that the vast majority of people who die by suicide were struggling with some form of mental disorder at the time, says clinical psychologist Dr. Marnin Heisel, an associate professor in the department of psychiatry, epidemiology and biostatistics at the University of Western Ontario in London.
Losing a loved one to suicide “changes one’s life for the rest of one’s life and the pain it can cause, and the damage it can cause can be irreparable,” he said.
It would be irrational to hospitalize everyone “who raises the question of mortality, or what it might mean,” Heisel said.
“But on the flip side, we should not say that, if somebody says, ‘I want to hasten death,’ and they don’t suffer from a diagnosable mental disorder, we have no right to intervene.
“That’s exactly when we need to intervene — not punitively and not restrictively, but out of caring, out of support and out of help.”