Journal of Social Issues, Vol. 52, No. 2 , 1996, pp. 51-62

Psychological Issues in Euthanasia, Suicide, and Assisted Suicide

David Lester Center for the Study of Suicide Blackwood, New Jersey

This paper reviews various life-ending techniques such as euthanasia, suicide, and assisted suicide in order to better address the psychological issues related to these actions. Specific attention is paid to investigating when a death is deemed to be appropriate and the role that the level of appropriateness should play in the decisions of individuals to terminate a life. In addition, a number of additional psychological concepts such as Locus of control and subjective norms are exam- ined in terms of their importance for decisions regarding euthanasia and suicide.

Although most of the debate about euthanasia, suicide, and assisted suicide has focused on various moral and legal issues, there are also important psycho- logical issues involved. Since death is inevitable, the critical decision we all face is how to die. This paper will discuss the appropriateness of these various life- ending techniques, and explore the reasons why people may choose assisted suicide over self-inflicted suicide. In addition, this paper will examine a number of psychologically relevant issues that play a significant role in people’s decision to terminate their existence.

Euthanasia

There have been many recent changes in guidelines and practices involving euthanasia. In the United States and other nations, it has become legitimate to refuse life-prolonging treatment in cases of severe injury or disease. Individuals can sign do-not-resuscitate orders, draw up living-wills, and give power-of- attorney to others (West, 1993). There are also mechanisms established for

Correspondence regarding this article should be addressed to David Lester, Center for the Study of Suicide, RR41, 5 Stonegate Court, Blackwood, NJ 08012.

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00224537/96/0600-0051503.00/1 0 1996 The Society for lhe Rychological Study of Social Issues

52 Lester

guiding others who must make decisions in cases of terminally ill people as to whether to withhold or withdraw life-sustaining procedures (Miles & Gomez, 1988). Along with these changes, it is also acknowledged that people have the legal right to kill themselves. Killing oneself is no longer illegal in any of the American states (Victoroff, 1983) and has been decriminalized in most devel- oped nations including, for example, Canada (Lester, 1992) and New Zealand (Lester, 1993a).

Although allowing people to die (i.e., passive euthanasia) is legally pro- tected in America, there is no legal provision for actively causing death (i.e., active euthanasia). In Germany, however, the law contains an interesting paradox (Battin, 1993). While killing on request (including voluntary euthanasia) is pro- hibited, assisting suicide is not. For example, a private organization known as the German Society for Humane Dying provides information on how to commit suicide. To receive the instructions, a person must be a member for at least a year, be terminally ill, must not have received treatment for a psychiatric disor- der for the previous two years, must keep the instructions to him- or herself, and must arrange to have the instructions returned to the society after death. In difficult circumstances, the society can arrange for someone to obtain the neces- sary medications and can provide a companion during the dying process.

In The Netherlands euthanasia is protected by a series of court decisions that have established a set of procedures that involve the individual meeting several criteria (e.g., the person’s request must be voluntary and the suffering intoler- able) and having two independent physicians approve the actions (Battin, 1993). A recent survey indicated that 1.8% of deaths in the Netherlands involved eutha- nasia at the request of the patient with some physician involvement, including 0.3% unambiguous physician-assisted suicides (van der Maas, van Delden, Pij- nenburg, & Looman, 1991). Furthermore, public support for a liberal euthanasia policy in the Netherlands is about 81% (Borst-Eilers, 1991).

Differences in policies between and within nations, as well as differences between sanctioned and actual practices, suggest that we consider the issues involved in euthanasia more closely as they pertain to current practices in the United States. Given that physicians in America have been assisting patients to die for many years without publicity (Quill, 1993), it may be argued that the issue is no longer should we permit euthanasia? but should we regulate eutha- nasia? There is much to be said for permitting and regulating a behavior. Simply making a behavior illegal is not an adequate solution since this drives the behav- ior underground, often with disastrous consequences for the society (as illus- trated by the banning of alcohol and the restrictions on abortion earlier in this century).

It has been argued that psychologists and psychiatrists in the United States have too often supported the status quo rather than agitating for social change based on their understanding of human behavior (Halleck, 1971). From this

Psychological Issues 53

perspective, it is important that physicians who have been practicing some form of euthanasia in the past without publicity have come forward to inform us that this practice has been occurring whether society approves or not and whether society regulates it or not.

As an indication of this trend, Humphry (1991), founder of the Hemlock Society, recently published a “how-to” book on suicide which quickly rose to the top of the best-seller lists. More recently, Jack Kevorkian has built devices which enable people to kill themselves, and he has been present and assisted them when they in fact made their fatal suicidal action. Kevorkian (1988) believes that physicians should go so far as to establish medical clinics where terminally ill patients could opt for death under controlled circumstances. Such an idea is not new. Indeed, Alfred Nobel, founder of the Nobel Prizes, suggested this many years ago (Sohlman, 1962). In addition, public opinion surveys by both Lou Harris and the Roper Organization have found that a majority of the general public supports physician-assisted suicide (West, 1993).

Suicide and Assisted Suicide

Although it has been argued that suicide prevention is not always appropri- ate (Szasz, 1986), others argue that suicide should be consistently prevented (Pretzel, 1968). These beliefs regarding suicide and its prevention have tradi- tionally been based on issues of morality and rationality; however, it may be argued that one should also consider the quality of life issue. These issues are reviewed below.

Suicide and Morality

The moral issue, to begin with, generally revolves around elements related to the deontological and utilitarian positions (Beauchamp & Childress, 1979). The deontological position is represented by a basic belief in absolute principles such as thou shalt not kill and is generally illustrated by opposition to capital punishment, abortion, and suicide. In some cases, however, absolute principles may compete with one another or people may be forced to act against them. For example, those firmly opposed to abortion and capital punishment often go to war quite willingly. In addition, some individuals advocating this principle often do not wony about killing nonhuman organisms and as such their application of the principle seems arbitrary (Soifer, this issue).

In contrast to the absolute principle that thou shalt not kill is the principle of autonomy. Although autonomous individuals are viewed as possessing the right to behave in any noncriminal way they choose, the difficulty lies in agreeing upon who is autonomous. This label is typically not granted to the psychiatrically disturbed, the retarded, children, or those suffering from extreme stress. Federal

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courts, for example, typically grant adults the right to refuse blood transfusions and surgery on religious grounds, but will authorize such treatment for their children.

An alternative to the deontological position is the utilitarian position. Ac- cording to this position, among the various criteria proposed for morality is the goal of maximizing good and minimizing harm. The best options with regard to suicide, therefore, are those that achieve this goal. The problems with this position, however, are twofold. First, judgments of good and harm are subjective and different people weight them differently. Second, one must consider whom we are maximizing for. When suicide is discussed, people often worry about the harm caused to others by an individual’s suicide, and in some societies the potential harm to the society has been used to argue against the acceptability of suicide. It is interesting to note that this issue is rarely raised, and certainly never applied, for other personal decisions such as marriage or having children.

Suicide and Rationality

The concept of rationality, as it relates to suicide and assisted suicide, includes two issues. First, one must determine whether the reasoning of the suicidal individual is logical. Although it has argued that these individuals are quite logical decision makers (Lester, 1993b), a related issue concerns the ratio- nality of the premises upon which these individuals make their decisions. Cogni- tive therapists, for example, argue that patients often hold irrational beliefs such as the idea that we should be thoroughly competent, adequate, and achieving in all possible respects in order to consider ourselves worthwhile (see e.g., Ellis, 1973).

Given the belief that the majority of suicidal individuals do reason logically, it has been suggested that we ought to grant them autonomy to view their situation within their own cognitive framework, as indeed we do in all noncrimi- nal decisions that people make (Lester, 1993b). The growing tendency to view people as responsible for their behaviors, as in Reality Therapy (Glasser, 1965), and in choosing their psychiatric lifestyles, as in Direct Decision Therapy (Greenwald, 1973), could lead us to view the choice of suicidal behavior by people as more rational and autonomous than hitherto believed. Greenwald, for example, believes people choose to be depressed and that the decision may seem quite appropriate once we determine the context in which the decision was made. Thus, suicidal actions by depressed people do not necessarily mean that they are not autonomous individuals.

Suicide and Quality Of Life

As suggested earlier, some practitioners have asserted that it is important to prevent all suicides. Whatever the circumstances of the case, they assert that

Psychological Issues 55

everyone ought, in an ideal world, to be prevented from committing suicide. In an ideal world, everyone would be able to receive and benefit from good psycho- therapy and appropriate medication. In addition, therapy would be effective, there would be no incompetent therapists, there would be no side effects from medication, and there would adequate insurance coverage for therapy.

Of course, the world is not ideal. Therapy often does not work, therapists are sometimes incompetent (see e.g., Middlebrook, 1991), medication does have side effects, and insurance coverage for therapy is being reduced in current health plans. Thus, it may be argued that suicidal clients have little reason to expect a better life if they do not commit suicide. They may be quite rational in expecting things to continue to be bad or to worsen.

Given the above, the question of whether suicide can be rational cannot be answered based solely on the issues of rationality and morality. The question must also take into account the alternatives open to the person regarding issues of quality of life (e.g., suicide vs. psychiatric hospitalization, or suicide vs. a lingering death from cancer). For example, until the development of new anti- nausea medications, the best medication for patients undergoing chemotherapy for cancer was marihuana, but the American government judged their “war on drugs” to be more important than the pain of cancer patients. Perhaps patients would reevaluate their quality of life decisions if alternatives such as the use of marihuana were included in treatment plans (see, e.g., Rollin, 1985).

Psychological Issues Related to Euthanasia, Suicide, and Assisted Suicide

The issues surrounding euthanasia, suicide, and assisted suicide involve, among other things, decisions about the way in which a person dies. Lawmakers may decide which ways are legal and philosophers may argue about which ways are moral, but the way in which we die is also an issue that psychologists and psychiatrists should consider. For example, as psychologists, we have to ask what makes a death psychologically appropriate? Since this concept should be instrumental in decisions regarding euthanasia and assisted suicide, let us exam- ine some of the possibilities for an appropriate death as well as other psycho- logically relevant issues.

The Concept of an Appropriate Death

The concept of an appropriate death was not introduced until recently in the writings of psychologists and psychiatrists, though concern with the notion ex- tends far back in history. Although the disciplines of philosophy (see, e.g., Soifer, this issue) and literature (see, e.g., Garrison, 1995) have long recognized the importance of investigating the issue of the appropriateness of death, the concept has only recently begun to appear in the writings of psychologists and psychiatrists (Lester, 1970; Weisman & Hackett, 1961).

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Weisman and Hackett (1961), for example, brought psychiatric attention to the concept by specifying the conditions that they felt constituted an appropriate death. These authors described patients with whom they had come into contact who correctly anticipated their own death and did so without depression, suicidal ideation, or panic. These patients were not demoralized, debilitated, or resigned to death. They did not act like those hexed into death by suggestion. On the contrary, they had the conviction that death was inevitable and that it was desir- able. Death was confronted with peace, calm, and lack of apparent concern.

Based on the above observations, Weisman and Hackett (1961) formulated a number of criteria for judging a particular death to be appropriate. First, death must be seen as reducing conflict for the individual or as a solution to abiding problems. Second, death must be seen as being compatible with superego de- mands. Third, there must be a continuity of important relationships as death approaches or a prospect of their being restored (as in typical reunion fantasies). Lastly, death must fulfill a wish for the patient. In this respect, the death of Antigone in Sophocles’ play of the same name can be seen as appropriate (Lester, 1987).

Although Weisman and Hackett did not think that suicide could be an appropriate death using these criteria, they presented no cases that argued for or against their position on this. It has been argued, however, that it is possible to formulate alternative criteria for an appropriate death, some of which would cover suicide within the five following possibilities (Lester, 1970).

1. The role of an individual in his own death. Some writers judge a death to be appropriate insofar as the person played a role in his or her own death. A person struck down by chance factors, such as lightning, therefore, does not die an appropriate death. In contrast, it may be argued that a person committing suicide plays the maximum role in his or her own death.

2. Bodily integrity in death. Some perceive a “natural” death as positive because in a natural death the body retains its integrity. An act of suicide, in contrast, destroys the body’s integrity and as such may be perceived as inap- propriate. From this point of view, any life that is prolonged by the use of transplants and medical intrusions into the body cannot be appropriate. A death from natural causes without medical intrusion alone is appropriate. As such, assisted suicide could be appropriate under this criterion if an acceptable method is used.

3. Consistency in lifestyle. If you ask people how they expect to die, they can often give you an answer. Perhaps they have thought about this and decided between preferred alternatives. Their choice will reflect something about them- selves, their personality, and their fears, but it may also reflect their lifestyle. A passive person may choose to die from a disease or at the hands of another. An aggressive person may choose to die in a fight or in war. A self-destructive person may commit suicide. An appropriate death can, therefore, be defined as

Psychological Issues 57

one consistent with the person’s lifestyle. For example, Ernest Hemingway’s suicide by firearm in the face of growing medical and psychiatric illness was consistent with the death-defying lifestyle he had cultivated during his lifetime. Again, assisted suicide could be viewed as appropriate using this criterion.

4. The time of death. Shneidman (1967) suggested that the timing of a person’s death was a relevant factor. Specifically, it was argued that one could sometimes discern an inner consistency in an individual’s acts and ambitions so that, after a given point, any further life would be a defeat or a pointless repeti- tion. Within a person’s life, there may be specific points or crests when death would be appropriate and would give a self-consistent tone to the lifestyle of the person. Such a death can even heighten an individual’s impact by making his memory more treasured. Assisted suicide could be consistent with this criterion.

5. The kinds of death. Kalish (1966) distinguished between four primary types of death. When the organism ceases to function and the organs of the individual cease to function, there is physical death. Individuals are psycho- logically dead when they cease to be aware of their own self and of their own existence. The individuals know neither who they are or even that they exist. Social death is when the individual accepts the notion that for all practical purposes he or she is dead, as in cases of voodoo death in which the hexed individual may refuse nourishment and lay down to die (Lester, 1972b). Social death may also be defined from the point of view of the significant others, such as when the people who know the person act as if he or she no longer exists (e.g., the elderly relative who is placed in a home and forgotten). The final kind of death is anthropological death in which the individual is cut off from the commu- nity and treated as if he or she no longer existed (e.g., the Orthodox Jew who marries a Gentile is anthropologically dead to the Orthodox community).

These four kinds of death can occur at different times in an individual’s life. Psychological death may occur before physical death, as in those who lie in comatose states for long periods before they die without ever recovering con- sciousness. It has been suggested that a death could be considered appropriate when all four of these different kinds of death coincide in time (Lester, 1970). A person who falls into coma (psychological death) and physically dies much later has had an inappropriate death. The person placed in a nursing home and forgot- ten about (social death) does not die an appropriate death. Using this criterion, assisted suicide could be viewed as an appropriate death.

The concept of an appropriate death, therefore, is an important one for a number of reasons. For example, it may be argued that it is the responsibility of counselors, psychotherapists, and doctors to ensure that a patient dies an appro- priate death. In order to meet this responsibility, one must first be aware of the alternative concepts for an appropriate death. If death for a patient is more appropriate in one particular manner then perhaps it is our duty to allow, and perhaps to facilitate, the patient to die in that way. Lester (1995), for example,

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has discussed the techniques that counselors might use in helping patients decide upon the way in which they want to die, including suicide and assisted suicide. It is argued that, just as it is wrong for a marriage counselor to insist always on divorce for clients or to insist always on continuing the marriage, it may be wrong for a psychotherapist to insist on a particular attitude toward and choice for the mode of death. As such, it may be argued that psychotherapeutic inter- vention should be based on a patient’s psychological well-being rather than on moral or legal issues.

Psychological Intervention

If the right to commit suicide exists, what is the justification for suicide intervention? Macks (1971) argued that the goal of suicide prevention centers should not be to prevent suicide but rather to help clients find alternatives. As such, suicide prevention is suitable only if the client is ambivalent, and clients must have the right to informed consent over any actions taken with them as the target.

Although Szasz (197 1) noted that labeling clients as psychiatrically dis- turbed is sometimes used simply to justify forcible intervention into their lives, if a client voluntarily seeks advice and help, then not responding would be unethi- cal. However, since almost all suicide prevention centers are passive, waiting for clients to contact them, then their responding may be interpreted as ethical. In addition, it has been suggested that psychotherapy may be particularly effective for the suicidal elderly (Richman, 1992b). Although research suggests that the elderly can come to enjoy life, there is concern that the emphasis on suicide and assisted suicide, especially in connection with old age and chronic illnesses, will deter nursing home staff, social workers, and psychotherapists from working with the suicidal elderly to improve the conditions of their life and their enjoy- ment of living.

More active suicide prevention, however, may run the risk of being oppres- sive. To force counseling on those who do not request it is demeaning and can be life-threatening. Ernest Hemingway, for example, committed suicide partly to avoid ever having to return to the Mayo Clinic for further treatment (Lester, 1987; Szasz, 1971). In addition, the practice of labeling people as psychiatrically disturbed has been shown to be affected by the sex, social class and ethnicity of the psychiatrist (Loring & Powell, 1988). Subsequent decisions as to whether suicidal people are psychiatrically disturbed are clearly affected by the opinion of the psychiatrist as to the rationality of suicide (Lester, 1972a). There are some psychiatrists who view almost all suicides as psychiatrically disturbed while others find only 5% to be psychiatrically disturbed (Temoche, Pugh, & Mac- Mahon, 1964).

Based on the above, Lester (1990) formulated a labeling theory of suicide

Psychological Issues 59

and cautioned that labeling people as suicidal may, on occasion, actually increase the risk of future suicide. An interesting case was recently reported in which putting a suicidal client on “suicide watch” in the hospital increased her self-destructive behavior and so was deemed counterproductive (Pauker & Cooper, 1990).

Locus of Control

There are issues involved in euthanasia, suicide, and assisted suicide that go beyond the basic moral dilemma of whether it is “right” or “wrong.” For exam- ple, although about 30,000 people in the United States kill themselves each year without help from others, an increasing number of individuals are opting for some form of assisted suicide. This raises the psychodynamic question of why some people want others to participate in their suicide. Even Freud, a physician who could easily have injected himself with morphine, wanted his physician to do it for him (Gay, 1988; Lester, 1991).

One possible explanation for the increase in assisted suicide may be found in the concept of locus of control. Psychologists have published a great deal of research on the personality dimension of external vs. internal locus of control. Some people believe what happens to them is a result of powerful others or fate, while other people believe they themselves are responsible for what happens to them. Psychologists consider an internal locus of control to be psychologically healthier than an external locus of control (Rogers, 1959). Individuals who choose to commit suicide by themselves may have an internal locus of control; those who want others to assist them may want to avoid responsibility for their own death. This decision may be consistent with having an external locus of control or may be made in order to minimize the self-perceived sinfulness of the act of suicide.

It has been noted that people are more willing to accept responsibility for good deeds than for bad deeds, for successes rather than failures (Mullen & Riordan, 1988; Plous, 1993), and for joint outcomes than for outcomes produced by oneself (Ross & Sicoly, 1979; Plous, 1993). Since suicide is seen as morally wrong by most major religions, some potential suicides may see the participation of others, especially physicians, as making them less morally at fault themselves. Indeed, Jacobs (1967) reported that the major theme in suicide notes was justi- fication by suicidal individuals for their violation of the sacred trust of life. Often the notes ask God for forgiveness and request significant others to pray for the deceased.

Subjective Norms

The role of subjective norms may also be a crucial factor in any discussion concerning euthanasia and assisted suicide. In their theory of reasoned action,

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Ajzen and Fishbein (1980) have hypothesized that behavioral intentions are affected by attitudes (i.e., our evaluative feelings about a behavior) and subjec- tive norms (i.e., our beliefs about the ways in which significant others wish us to behave). The publicity about physician-assisted suicide, and the legal acceptance of such a choice in The Netherlands and in some states of America (such as Oregon) may make this choice more morally acceptable by affecting our subjec- tive norms.

Those who object to assisted suicide often refer to the slippery slope argu- ment. For example, if society permits voluntary active euthanasia, then society may slip into permitting less-than-voluntary active euthanasia and finally invol- untary active euthanasia. The latter situation, most recently practiced in Nazi Germany, may lead to the decision by “experts” or “authorities” to terminate the life of those who are elderly, chronically ill, handicapped, or retarded. If we permit assisted suicide, perhaps eventually some people (especially the elderly) may be forced by others to commit suicide when they do not wish to die.

Although the slippery slope argument is commonly advanced to argue against changes in social policies, such as gun control and abortion, a more likely danger is that the societal approval of assisted suicide may lead people to expect the elderly and terminally ill to choose this option. In days of limited health care resources, the care of the elderly, especially those who are ill, consumes time, effort, and money that could deployed elsewhere. If society expects the elderly to choose suicide in order to free up resources for the rest of society, the elderly may well internalize this demand. This is especially likely if the elderly feel they are a burden (both interpersonal and financial) on their children or other relatives. 0. H. Mowrer, former President of the American Psychological Association, for example, committed suicide in part because of the burden he might be to his children and because his lingering might deprive them of any inheritance (Hunt, 1984).

The likelihood of this societal attitude is illustrated by the comments of Governor Richard Lamm of Colorado, who recommended that the government stop providing medical care to the elderly who have lived beyond their natural span, presumably somewhere in their 70s (Richman, 1992a). The role of social conformity in influencing decisions has been well documented (Plous, 1993), and we should be wary of setting up customs that may appear to be implicit demands on others.

Conclusion

The aim of this paper has not been to argue for or against euthanasia or assisted suicide, but rather to raise psychological issues that are pertinent to the decision. It would be of great interest to collect information on the psychological state of those requesting assisted suicide so that we can assess the psycho-

Psychological Issues 61

dynamics of the request better and perhaps decide whether such requests are rational or merit psychotherapy.

However, focusing on psychological issues does sometimes bias the presen- tation against the individual, in the same way that growth of the discipline of victimology seemed to place the blame for criminal behavior on the victim. Discussion of the motives of the individual who chooses assisted suicide, and raising the possibility that the motives may not be completely rational is not meant to imply that such behavior should be discouraged. After all, many, if not most, of our choices in life are motivated in part by irrational considerations. Why should our choices involving death be less so?

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DAVID LESTER has PhD.’s in psychology from Brandeis University and in social and political science from Cambridge University. He has written exten- sively on issues in thanatology, and is Past-President of the International Asso- ciation for Suicide Prevention. He is Executive Director of the Center for the Study of Suicide in Blackwood, New Jersey.