By definition, suicide is (intention) to kill oneself voluntarily and with purpose. Interpretation is needed to determine whether it is justified as this depends on ones’ own moral views. The Catholic Rule Of Double Effect (RDE) states an act that has good and bad consequences is justified if the intent is solely the good consequence(s), not the unavoidable bad consequence(s), e.g. a doctor increasing the morphine drip in order to decrease pain, yet knowing it will lead to death in a few days. The RDE is used as a normative principle to evaluate actions, and also to shape how suicide is defined. The intent, not the outcome, defines the rightness or wrongness of the action and there is a distinction between the intended and/or direct consequence and unintended (foreseen) or direct consequences.

Beauchamp and Childress (2001) suggest the following conditions for RDE:

• Nature of the act – good and/or morally neutral (independent of consequences)
• Agent’s intention – only good effect, bad effect can be foreseen, tolerated and/or permitted, but not intended
• Distinction between means and effect – the bad effect must not be means to a good effect as then the agent intends the bad effect in pursuing the good effect
• Proportionality between good and bad effect – the good effect must outweigh the bad effect

For example if a pregnant women develops cancer of the uterus, removal of the uterus is permissible to save the mother’s life, but abortion cannot be induced if there is the possibility of heart failure due to the stress of the pregnancy.

Is suicide morally permissible?

Kant believed suicide is never justified because it violates self-respect, whereas Hill (a contemporary of Kant) distinguishes seven types of suicide:
Where individuals fail to properly value themselves and violate respect for themselves as rational person: impulsive (brief/intense emotion); apathetic (depression) self-abasing (self-loathing/ self-contempt/punishment); hedonistic calculated (future holds more pain than pleasure);
Where it manifests rather than violates, self-respect:prevent sub-human life (survival as physically alive but mentally destroyed);end severe irremediable suffering (severe pain uncontrolled by medication) morally principled (help/preserve integrity of others, e.g. POWs with military secrets or if being ill on an expedition will endanger others)

Should assisted suicide be legalised?

A few decades ago, most people strongly opposed assisted suicide, but today there has been a marked shift in attitude and great public interest. Some courts have followed suit but in most countries it is still illegal. The opposing liberal and conservative view remains. There is also the fear that legalising assisted suicide would lead to abuse (as has happened in the Netherlands) – a wrong diagnosis/prognosis could lead to a suicide decision; MCOs could exert pressure to terminate health care; greedy relatives, dishonest doctors, etc. Some advocate rather turning a blind eye to it happening behind closed doors.

On the other hand, some might argue that there is a “duty to die” to prevent the catastrophic consequences for families when terminally ill people pursues prolongation of life at all cost- this often exhausts family/ caregivers and all funds because families are bound by ties of care and affection, destroy their future- “stealing the future of loved ones to buy a little time”. Most people will argue that this kind of care is admirable but certainly not a duty.

There is also a fear that legalising assisted suicide would change the traditional role of the doctor/health professional from that of a healer to that of expediter of death! It is strongly felt that such acts should not violate moral convictions but legislation could do exactly that. Proponents of legalising assisted suicide propose that stringent legislation could limit abuse, bring comfort to those living with terminal disease and possible suffering, whilst opponents feel the risks are too great and that it would increase dehumanisation and callousness of life.

Should assisted suicide be a legal option for those patients who choose it, regardless of their medical condition? The argument is often made when patients are terminally ill and face a future of increasing dependence and pain, but what about those patients who are not in physical pain, are not terminally ill, for example those who suffer from locked-in syndrome?

In this episode of the Square Brackets podcast, the hosts talk about the power of myth in relation to the perceived value of life, and whether the right to die is open to abuse for personal [or State] gain.

Read: Death becomes him

Over the past decade, Ludwig Minelli has helped more than 1,000 people kill themselves and has turned Zurich into the undisputed world capital of assisted suicide. Minelli sees himself as a crusader for what he calls “the last human right”—and he believes that helping more and more people to die advances his cause. Even if you believe in an absolute right to die on your own terms, how far is too far in the quest to secure that right?

Read: Tony Nicklinson: ‘I have a fear of living like this when I am old and frail’

After a stroke in 2005 left him almost completely paralysed, Tony Nicklinson has been fighting for the right to end his own life. Here, ahead of a high court ruling, he is interviewed via Twitter by Observer readers and Elizabeth Day, who meets his family and supporters – along with opponents of euthanasia.

Assisted suicide and euthanasia

This is a very controversial topic, including terminology. If one believes that suicide is morally permissible, one is still not obliged to assist.

Know the difference between suicide and euthanasia:

• Suicide: the intentional taking of one’s own life
• Euthanasia: the intentional taking of another’s life

Euthanasia is derived from Greek and means “good health”. There are several different “types”:

• Involuntary euthanasia – the patient was not consulted or refused the offer of euthanasia
• Non-voluntary euthanasia – the person has no capacity for an informed decision
• Voluntary passive euthanasia – withholding or withdrawing treatment at the person’s request
• Voluntary active euthanasia – active administration of an agent leading to death

Broadly speaking, most people equate euthanasia with assisted suicide, leading to a merciful death, whereas medical associations tend to use euthanasia to mean voluntary active euthanasia and call passive euthanasia “letting die”, but these distinctions are blurred, e.g. turning off a respirator is still an act. Further, the distinction between suicide, euthanasia and assisted suicide is also becoming increasingly blurred. All of this concerns mainly doctors, but other health professionals may also be involved.

Euthanasia involves the intentional termination of a person’s life for the sake of that person (e.g., to relieve intolerable suffering in the face of an incurable disease). The two main questions concern whether euthanasia is ever morally permissible and if so in what instances it is permissible. Two important distinctions are frequently brought to bear on the debate. First is that between voluntary, non-voluntary, and involuntary euthanasia (respectively whether the person has chosen, is incapable of choosing, or has not chosen euthanasia). Most proponents of euthanasia restrict themselves to a defence of voluntary and sometimes non-voluntary euthanasia. The other distinction concerns that between active and passive euthanasia. This latter distinction connects up with the status of acts versus omissions and the doctrine of the double effect (see above). Those who argue in favour of euthanasia do so on the grounds that it respects the wishes of the agent and/or prevents human suffering. Those who argue against it do so on the grounds that human life is sacred and/or that to allow euthanasia would devalue human life and possibly create a slippery slope leading to unjustifiable abuses.

Questions to guide your thinking on the topic. Note that you don’t have to try and answer these questions, they are simply meant to stimulate your thinking:

• Do you believe that people should have control over their own bodies, including when and how they die?
• What gives rise to this belief?
• If your role in the healthcare system is to improve the quality of life for your patients, can you rationally support the idea of assisted suicide? Under what conditions would it be socially acceptable?

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References and suggested reading

• Beauchamp, T.L. & Childress, J.F. (2001). Principles of biomedical ethics. Oxford University Press.
• Costeloe, K. (2007). Euthanasia in neonates. British Medical Journal, 334:912-913

Professional Ethics in Physiotherapy by the University of the Western Cape is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.