Suffering, Relief, Suicide: Can Mental Suffering Justify Ending One\'s Life?

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Biomedical Ethics Gareth McNamara

Suffering, Relief, Suicide: Can Mental Suffering Justify Ending One's Life? Introduction In contemporary biomedical ethics, many of the scholars who argue for the moral permissibility of suicide, physician-assisted suicide and/or euthanasia rely upon a common argumentative framework. This framework, reduced to its most basic and general form, can be stated as follows: P1. Generally, life itself does not constitute an unbearable or unreasonable burden. P2. Persons ought not be subject to unbearable or unreasonable burdens, and should be permitted relief from such burdens wherever possible. P3. Under certain conditions (such as prolonged and unresolvable suffering) life itself may come to constitute an unbearable or unreasonable burden. P4. In cases where life itself constitutes such a burden, death may constitute a relief of that burden. C. Under conditions where life itself constitutes an unbearable or unreasonable burden, it may be morally permissible/preferable/correct to end one's life. Though the relative strength or weakness of the conclusion drawn from this line of argumentation varies between scholars (as does the related matter of whether or not it extends beyond unassisted suicide to also include physician-assisted suicide and voluntary euthanasia), the general framing of the problem in terms of relief from undue suffering remains relatively static.1 I refer to arguments taking this form as Suffering/Relief arguments. In this paper, I will argue that scholars have tended to apply Suffering/Relief arguments exclusively to cases of physical disease, disability and degradation, and do not pay adequate

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A notable exception to this are pure libertarian arguments for the moral permissibility of suicide. Libertarian scholars, rather than being concerned primarily with the negation or alleviation of suffering, argue that a right to suicide logically follows from the autonomy we accord to moral agents. As such arguments are not the primary focus of this paper, I will not address them in-depth here.

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Biomedical Ethics Gareth McNamara attention to their implications in cases of mental illness and suffering. I will provide a brief explanation of what might motivate us to differentiate between cases of physical and mental suffering when considering the moral status of suicide, and assess whether or not we should be persuaded by this. I will conclude by contending that, in order to be consistent, Suffering/Relief arguments in favour of suicide must apply to cases of both physical and mental suffering, and discussing whether or not the implications of this should trouble us. Importantly, for the purposes of this paper I will be concerned only with Suffering/Relief arguments for the voluntary termination of life. In the interest of tackling all the philosophically relevant issues concisely, I will not devote time here to discussing the implications that assenting to a Suffering/Relief argument permitting paternalistic, involuntary euthanasia might have for cases of psychological suffering.

The Physical/Psychological Divide The cases typically employed to illustrate and reinforce Suffering/Relief arguments are overwhelmingly cases involving physical disease, disability and/or degeneration. Without belabouring this point, some of the conditions most frequently invoked in order to satisfy the P3 conditions in Suffering/Relief arguments include motor-neurone disease2, HIV/AIDS3, multiple forms of cancer in their advanced stages and so forth. Certain characteristics are common to all of these conditions. They are all in some sense chronic or incurable; regardless of the best efforts of medical professionals, they can be expected to continue to afflict the individual in question until their death. They all can be said to have a significant negative impact on the afflicted's quality of life, and to give rise to substantial pain and suffering. Perhaps most importantly, they are all

Chetwynd, S.B. “Right to Life, Right to Die and Assisted Suicide”. Journal of Applied Philosophy. Vol 21, No. 2. 2002. Battin, Margaret Pabst. “Going Early, Going Late: The Rationality of Decisions about Physician Assisted Suicde in Aids”. In Ending Life: Ethics and the Way We Die. Oxford University Press: Oxford. 2005.

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Biomedical Ethics Gareth McNamara explicitly physical ailments. Although having a degenerative nerve disease, or a chronic autoimmune disorder, or a terminal form of cancer undoubtedly has an impact on one's mental wellbeing, the majority of Suffering/Relief arguments are concerned exclusively with the physical suffering such conditions give rise to. Significantly less attention has been paid to whether the Suffering/Relief argument might also apply in certain instances of mental suffering, with some authors implying that such suffering can not justify assisted and unassisted suicide or euthanasia as certain forms of physical suffering can. I see two primary issues which might motivate drawing such a distinction. First is the issue of whether there is a notable difference in kind between mental and physical suffering. Second, there is a question regarding patients' competence in cases of mental suffering that is not ordinarily cause for concern in cases of physical suffering. I will address each of these issues in turn.

Mental Suffering and Physical Suffering: A Difference In Kind? It is important at this point to acknowledge the murkiness of the divide between physical and mental suffering. To some extent, all suffering has both physiological and psychological aspects; all suffering involves both the observable and quantifiable stimulation of the nervous system and certain regions of the brain associated with the perception of pain and the individual, subjective experience of the person who is suffering.4 However, this is not to say that there are not significant differences between physical and mental suffering. Though a patient's experiencing mental suffering may cause observable changes or stimulation in her nervous system and/or brain, the suffering she is experience cannot be

Raus, Kasper and Sterckx, Sigrid. “Euthanasia for Mental Suffering” in New Directions in the Ethics of Assisted Suicide and Euthanasia. Cholbi, M. and Varielius, J. (eds.). Springer International: Switzerland. 2015. pp. 87.

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Biomedical Ethics Gareth McNamara reduced merely to these physical effects. As per Raus and Sterckx, mental suffering, unlike physical suffering, “cannot clearly be described in terms of tissue damage” 5. Furthermore, the role of pain differs between cases of physical and mental suffering. In instances of physical suffering, an individual's experiencing pain is symptomatic of an underlying condition. The same may be true to some extent in cases of mental suffering arising from a documented psychological illness, where the pain experienced by the individual arises from an identifiable cause. However, there remain many instances of mental suffering that can not be attributed to a pathological psychological condition. In such “non-psychological” cases, the pain experienced by the individual in question is not merely an indicator of the problem, it “actually is the problem”6. These factors suggest that it is correct to make a distinction of kind between mental and physical suffering. However, this distinction and our reasons for making it alone do not seem to justify a blanket prohibition on suicide for individuals suffering from the former whilst continuing to permit suicide in certain cases of the latter. After all, it seems possible that a case of mental suffering (as we have conceived it above) could be so severe as to satisfy the P3 conditions of the Suffering/Relief framework. Therefore (assuming we accept that unassisted and assisted suicide and euthanasia are sometimes permissible in cases of physical suffering) the mere existence of a difference in kind between mental and physical suffering should not persuade us that they are never permissible in cases of mental suffering.

The Question of Competence Imagine you are walking along a street in the city when you notice a man on the side of a high

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Raus and Stercx, pp. 88 Ibid.

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Biomedical Ethics Gareth McNamara bridge. You recognize that the man intends to jump, and that in doing so he will surely kill himself. In this instance, you would in all likelihood feel compelled to intervene in some way to stop the man from jumping. Perhaps you would call out and try to reason with him, or contact the emergency services. Perhaps you would take more direct and decisive action, physically restraining him to prevent him from jumping. What is important here is your instinct to prevent the man from jumping, and what that reveals to us about our underlying views with respect to suicide. With the exception of the types of cases normally advanced under the Suffering/Relief framework, we tend to think that suicide ought be prevented, thereby implying that it constitutes a significant moral harm. This is evidenced in the massive bloc of the psychiatric industry dedicated to suicide prevention, in suicide-prevention hotlines and other resources provided by governmental, faith-based and other voluntary organizations and in our own gut reaction in the case of the man on the roof above. Not only is the act of suicide thought of as morally harmful, the reasoning process which leads a person to end their own life is (again, with the exception of cases normally advanced under the Suffering/Relief framework) is deemed to be flawed in some way. There is a general sense that it is irrational, in one respect or another, to desire and/or seek to bring about the end of one's own life. An action's being irrational is not ordinarily enough in itself to justify prohibition of that action, nor our interference with an autonomous agent's engaging in it. Even actions which are both irrational and severely detrimental to our physical health are not necessarily prohibited, nor do they justify us in preventing another from choosing them. For example, as a smoker wellversed in the harmful effects of tobacco, I must acknowledge that cigarettes are detrimental to my health and, given the high likelihood of disease or other significant harm resulting from my habit, it is irrational for me to continue to smoke. And yet I do, and would strongly resist any forceful

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Biomedical Ethics Gareth McNamara attempt by another to stop me doing so7. Though the probability of the man's jump from the bridge causing him significant harm is even greater than that of a smoking habit, both are ultimately actions which will in all likelihood have a severe negative impact. To willingly expose oneself to unnecessary and grave harm in this way appears prima facie to be irrational; yet, at least in my case, it seems that the autonomy afforded to me as a moral agent bars others from engaging in any kind of extreme coercive or invasive action to prevent me from smoking. This is not to say that autonomy trumps in all cases. If that were so, there would be no need for us to justify suicide and euthanasia using the Suffering/Relief framework: the autonomy of the agent seeking suicide or euthanasia would be sufficient alone. I do not believe that this is the case. For instance, if the government passes legislation banning smoking in, say, nursery schools and oncology wards, this does not constitute an unjust infringement on smokers' autonomy. On the other hand, if I am smoking a cigarette in an acceptable setting and a passer-by (who deems my behaviour self-harmful and irrational) snatches it from my hand and crushes it beneath her shoe, it seems that she has overstepped a boundary with respect to my autonomy. To return to the parallel of the man on the bridge, it would seem that the mere existence of various anti-suicide resources, hotlines etc does not unjustly infringe on his autonomy. It also does not seem that you would infringe on his autonomy by speaking to him and trying to persuade him not to jump. However, should you physically restrain him to prevent him from jumping, or request that the emergency services do so for you, your actions might start to resemble those of the cigarette-snatching passer-by above. So too might the actions of psychiatrists and other mental health professionals who sometimes pursue highly coercive and invasive actions (including but not limited to physical restraint, drug treatment and electro-

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At least within a context where smoking could not be regarded as impacting negatively on the health of others who have not assented to such, such as in a public building or other enclosed space.

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Biomedical Ethics Gareth McNamara convulsive therapy) to prevent their patients from committing or desiring to commit suicide. The standard response to this worry is that the desire to end one's life is inherently irrational, and an individual's having such a desire indicates a more global irrationality on their part. If one's thinking is irrational in this way, one actually lacks autonomy. Therefore, even coercive or invasive measures are permissible when undertaken to prevent an individual from ending their own life; we ought not worry about violating the suicidal individual's autonomy, as their being suicidal precludes them from being autonomous. Let us address some of the underlying assumptions in this response. Firstly, the notion that ending one's life is inherently irrational. The Suffering/Relief framework demonstrates that this need not be true in all cases. However, we could concede that perhaps, in the absence of the sort of conditions required by P3 of the framework, the desire to end one's life is irrational. In the interest of upholding the principle of generosity, and in not taking assisted and unassisted suicide and euthanasia off the table wholesale, let us assent to this modified version of the claim. Secondly, let us turn to the claim that having an irrational desire is indicative of an individual's global irrationality. This seems highly over-broad. Many people have irrational desires and act upon them. Even in cases where these irrational desires and acts are also harmful to the individual in question, we do not as a rule assume this means that these individuals are globally irrational. It would not be philosophically serious, for example, to suggest that my smoking habit indicates that I am globally irrational, and thus lack autonomy. We could modify this claim by narrowing it specifically to the irrational desire to end one's own life, in the absence of conditions satisfying P3 of the Suffering/Relief framework. The claim that a desire to end one's own life without having what we would normally take be good reasons for doing so indicates a global irrationality at least seems defensible. Even with these concessions to the standard response, I still contend that we have

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Biomedical Ethics Gareth McNamara compelling reasons to reject it. As we explored in the previous section, it seems plausible that mental suffering might sometimes be sufficient to meet the requirements of P3, even if it comes in the absence of associated physical suffering or a definite, diagnosable psychological illness. We need not be able to attribute suffering to a definite medical cause for it to satisfy P3. Regardless of what causes the suffering in question, all we need demonstrate is that it is severe enough as to constitute an unbearable or unreasonable burden. Given this, an individual who experiences such mental suffering and who desires to end their own life to relieve themselves from this suffering is not behaving irrationally, nor can we attribute to them a global irrationality. Therefore, they retain their autonomy, and we cannot seek to prevent them from ending their own life through coercive, invasive means. Furthermore, mental suffering is primarily a subjective phenomenon experienced by the individual themselves and is not amenable to systematic and definite external evaluation as suffering arising from physical or psychological illnesses or ailments. Thus, it may very well be the case that the only person who can determine whether or not a particular individual's suffering satisfies the requirements of P3 is the individual themselves.

Conclusion These findings raise a number of troubling issues. Because of its nature, the Suffering/Relief framework must admit mental suffering in the absence of a defined medical condition as a possible justifier of suicide alongside suffering arising from physical and psychological illness. This broadens the scope of the framework far beyond that which it is normally used to justify. We may deem this unproblematic, in which case we must hold that mental suffering can justify ending one's own life, even in the absence of a defined psychological condition. This also means that any coercive or invasive measures taken to prevent people from committing suicide- in

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Biomedical Ethics Gareth McNamara particular, those undertaken en masse by the psychiatric industry -must be subject to greater scrutiny, and may in fact be in mass violation of individuals' autonomy. Of the two directions that this line of argumentation points us in, this is the one I find to be more compelling, though also significantly more disturbing. Alternatively, we may choose to reject these implications, and instead take this line of reasoning as a reductio ad absurdum on the Suffering/Relief framework, which highlights problems in the way the framework is constructed, and provides us tools with which to improve it. The most obvious amendment one could make to the framework to protect against the criticisms raised in this paper would be to stipulate that in order for suffering to satisfy P3, it must be the result of a defined medical condition. This move is not without its problems. As our understanding of human physiology and psychology is ultimately limited and in a constant state of development, there is the potential for all mental suffering to be explainable in terms of medical conditions in the future. Additionally, medicine is an imperfect discipline with a margin for human error. In the case that a doctor misdiagnoses or fails to diagnose an underlying condition that gives rise to intense suffering, it does not seem right that this should preclude their patient from seeking relief from this suffering under the Suffering/Relief framework. Finally, this move risks creating a de facto “hierarchy of misery”, in which certain medical conditions are privileged above others with respect to the framework. Under such a hierarchy, two individuals could experience similarly high levels of suffering as the result of two different medical conditions (say, for instance, advanced-stage cancer which we normally think of as meeting the P3 conditions and arthritis which we normally do not), yet only one of them would be permitted to relieve their suffering through suicide. This seems confused, at best.