In ANCIENT GREECE, suicide was generally regarded as not wrong in itself, but there had to be a justification for it. Although Plato was considered to be often opposed to suicide, he made three important exceptions: when “legally ordered by the State” (as in the case of Socrates); for painful and incurable illness; and when one is “compelled to it by the occurrence of some intolerable misfortune”.
Two other Greek philosophers, Democritus and Speusippus, both committed suicide because of health problems when they were very elderly (the former died at the age of 90). Then, the Epicureans generally felt that when life became unbearable, suicide was justified. And, the Stoics also believed that suicide was permissible, especially if one had an incurable illness.
In ANCIENT ROME, there was usually no prohibition of suicide for citizens. However, suicide was forbidden for slaves and soldiers: the former for economic considerations, and the latter for patriotic reasons. Because life was not considered as a gift of the gods, most leading Romans supported the idea of suicide for specific situations, such as individuals preferring death to dishonour, or those who wished to avoid the decrepitude of old age. Seneca, the philosopher and statesman, strongly believed that if being elderly “begins to unseat my reason and pull it piecemeal, if it leaves me not life but mere animation, I shall be out of my crumbling, tumble-down tenement at a bound”.
There are eight suicides mentioned in the Old Testament, two in the Apocrypha, and one in the New Testament. But, none of the passages in the Bible, describing these suicides, makes any adverse comments on the morality of these acts. There are no explicit biblical condemnations against suicide - only prohibitions of killing which really apply to the unlawful slaughter of others. Throughout the New Testament, there are frequent reminders to the faithful that earthly life is of little importance (for example, “I put no value on my life”, Paul tells us in Acts 20.24). Unfortunately, a religion which preaches that life on this planet is a vale of tears, a prelude to a better afterlife, would seem to be inviting its adherents to kill themselves. In fact, suicide among the early Christians became increasingly popular and began to threaten the very existence of the Christian Church. Therefore, in the fourth century AD, persuaded by the arguments of Augustine, a strict prohibition of suicide was adopted - and, it became a mortal sin.
In the MIDDLE AGES, suicide was often regarded as the result of diabolical temptation, induced by despair or madness. Savage penalties were inflicted on the dead body - such as dragging it through the streets where the deceased had lived, and hanging it. The estates of these persons were confiscated, and Christian burial was forbidden. Sometimes, the corpse of a suicide was buried at a busy crossroads (in order to confuse the spirit), pinned down by a wooden stake through the chest - thus preventing, it was hoped, the spirit emerging to bother the living.
Attitudes towards suicide began to change slowly during the RENAISSANCE, although for many religious people, this act was still regarded as diabolical. For example, Thomas More, writing in Utopia in 1516, notes that someone with a distressing, incurable disease can “free himself from this bitter life…since by death he will put an end not to enjoyment but to torture...it will be a pious and holy action”. Later, Michel de Montaigne, in his Essays, observed that “unendurable pain and fear of a worse death seem the most excusable motives for suicide”.
In 1777, David Hume, in his Essays on Suicide and the Immortality of the Soul, argued that suicide did not contradict one’s obligation to God, to fellow humans, or to oneself: in particular, he asked, “Why should I prolong a miserable existence, because of some frivolous advantage which the public may perhaps receive from me?” And, The Times of February 27, 1786 announced a debate on “Is suicide an act of courage?” - it cost sixpence to attend, a high price in those days. Three years later, the same newspaper stated that suicide was “now a general subject of conversation among all ranks of people”.
In the 19th CENTURY, in England, coroners’ juries began bringing in verdicts of “non compos mentis”, indicating that an individual was only insane at the actual moment of suicide. And, among the aristocracy, some suicides were attributed more to accidents than to madness - thus, the suicide of an Earl of Bath, Charles Grenville, was reported as being due to “the casual going off of a pistol”. In 1839,Bentley’s Miscellany contained a satirical section describing the “London Suicide Company” whose three directors were Graves, Knell and Gravesend. Gilbert and Sullivan’s Mikado, in 1885, satirized the idea that a death sentence should be given for an attempted suicide by hanging Nanki-Poo for trying to take his own life. Such satires indicated a growing ambivalence towards suicide. In this century, the religious penalties for suicide were finally abandoned.
Across Europe, suicide was slowly decriminalized, although it was not until 1961 that the Suicide Act was finally adopted in England and Wales which removed the penalties which had been in place for this deed (this Act was not applicable to Scotland, where suicide had never officially been considered as a crime). However, assisting someone to commit suicide, in the United Kingdom, remains a crime to this day - it is strange to think that helping someone now in a ‘non-crime’ is still a crime.
Since the 1930s, there have been thousands of research studies and books on suicide, and many conferences have been held, especially in the United States and Western Europe. In England, the first right-to-die organization in the world, the Voluntary Euthanasia Society, was formed in 1935, by a group of senior doctors, such as Lord Moynihan, and clergy, including Canon Dick Shepherd. Since the mid-1970s, there is the World Federation of Right-to-Die Societies, now an umbrella group for 52 national organizations in 25 countries.
There are basically four ways in which a doctor may help someone to die. The first, once called “passive euthanasia”, involves the withholding or withdrawing of medical treatment which is perhaps required to keep someone alive. This is completely legal because it is everybody’s right to refuse medical treatment: and, when death results, it should never be considered as a suicide because this death is due to the underlying pre-existing disease or cause.
If someone is conscious, and is mentally competent, refusing treatment is straightforward. However, it is very important for all competent adults to complete a LIVING WILL (also known today as an ADVANCE DECISION), in which they can state the type of medical care they would wish to receive if they should become so ill or severely disabled that they cannot speak for themselves. Today, such documents are sometimes called “pro-choice” because they can allow individuals either to refuse further treatment, which would prolong their lives, or to request being kept alive for as long as possible, subject to medical consent.
Advance decisions offer an important layer of protection, legally documenting (since 2000, in Scotland, due to the Adults with Incapacity Act; and since 2007, in England and Wales, because of the Mental Capacity Act) an individual’s choices, and sometimes tipping the scales when there is debate or confusion about what to do. Thus, they can be of considerable benefit to one’s family - relieving them of the burden of responsibility about what a relative wants (possibly avoiding potential family disagreements) - as well as to the doctors involved at the end of a person’s life. In addition, in an advance decision, an adult can name a health care proxy (a relative or very close friend) who can explain someone’s wishes and expectations if these are unclear in the advance decision.
Living wills or advance decisions allow us to take responsibility for our medical care right up to the end. Furthermore, it is important to stress that these documents are fully supported by the British Medical Association, the General Medical Council (which issued further guidelines in 2009 stressing again that doctors must respect their patients’ last wishes regarding final medical treatment), the Royal College of Nursing, and the Law Society. In the UK, the main organizations providing advance decision documents are Compassion in Dying, in London, and Friends At The End, in Glasgow (for further information, please see the “Useful Links” section of this website).
The second way in which a doctor can assist someone to die is through a procedure, once known as the "double effect", but, more recently in the UK, progressively called "terminal sedation", "continuous deep sedation" and then, the "Liverpool Care Pathway". In reality, SOARS considers that these terms are essentially variations of "SLOW EUTHANASIA". When someone is suffering from the effects of a terminal illness, a doctor can use sedatives and painkillers (like diamorphine) to “lessen the pain and/or distress”. Officially, a palliative care doctor will prescribe these drugs in dosages which are necessary to keep the patient symptom-free. But, a more compassionate doctor can give increasing amounts of such drugs, privately knowing that the intention is to shorten the patient’s life.
A good example of double effect was demonstrated in the High Court case (in London) of Annie Lindsell in 1997. She had motor neuron disease, and had written a living will refusing tube feeding, if this became necessary to keep her alive. In 1997, she sought a court declaration that her GP could administer enough diamorphine to render her unconscious when her ability to swallow food normally became affected. In the High Court, her doctor stated that “I believe in the forthright and unhesitating relief of distress and pain, with no half measures…I am going to treat Annie when she develops symptoms which prevent her from eating and drinking. This will allow her to sleep. There will be no eating and drinking. The decline into death is quite predictable”. The High Court confirmed this approach.
Thirdly, a doctor can help a terminally-ill patient, or someone suffering unbearably from a severe chronic illness, with an ASSISTED SUICIDE. The doctor can either write a prescription for a lethal substance or perhaps even provide the actual drug. The patient can take this whenever he or she wishes to do so. This possibility is illegal in the UK. But, it is legal in the USA - in Montana, Oregon, Vermont and Washington State - and also in Luxembourg, The Netherlands and Switzerland. In these places, there are strict guidelines, and the system works well, without any abuse, supported by the local populations and a majority of doctors. Also, it is generally agreed that doctor-assisted suicide legislation does not compromise the development or easy access to palliative care, or the important patient-doctor relationship.
Finally, the fourth way for a doctor to end a patient’s life is by EUTHANASIA when a lethal drug is injected: this can be either non-voluntary or voluntary (in the latter situation, the patient has given permission for this procedure to happen). This is illegal in the UK. The best example of non-voluntary euthanasia in this country is the death of King George V in 1936. The king was dying slowly and he was semi-conscious on his last day. Without his knowledge, his doctor, Lord Dawson, consulted Queen Mary and her sons before he injected morphine and cocaine into the royal jugular vein. Later that year, in a debate in the House of Lords regarding a possible bill to legalize euthanasia, Lord Dawson stated that there was “no need to change the law as all good doctors do it”. Voluntary euthanasia today is legal in Belgium, Luxembourg and The Netherlands. As with doctor-assisted suicide, there are strict guidelines to be followed. Governmental reports on what is happening are regularly issued. About three per cent of all deaths in The Netherlands (where voluntary euthanasia has been possible since 1981) occur this way.
It is generally believed that British doctors would prefer a law allowing doctor-assisted suicide to one permitting voluntary euthanasia. There are two main reasons for believing this: firstly, as the patient is actively involved, in having to actually swallow the lethal substance, this reduces any concerns that it is not what the individual wants; and secondly, doctors are not directly ending a life, but merely providing someone with the opportunity to do so.
Until a 2004 survey was made by Professor Clive Seale, of London University, no one knew how often doctor-assisted dying occurred in the UK. Reporting in the January 2006 issue of Palliative Medicine, he estimated that one-sixth of all the deaths in this country were actually hastened by the intended, compassionate use of the “double effect”. But, rather surprisingly, he believed that there were also one thousand cases of voluntary euthanasia and two thousand deaths, due to non-voluntary euthanasia, occurring annually. Similar results were also obtained by Professor Seale in a follow-up study he made in 2007-08 which was reported in Palliative Medicine in 2009: then, he noted that “continuous deep sedation is relatively common in UK medical practice, particularly in hospitals and home care settings”.
In the UK, there have been ten attempts since 1936 in Parliament (at Westminster and in Edinburgh) to change the law to legalize either voluntary euthanasia or doctor-assisted suicide: unfortunately, in spite of popular support now in the region of 75 per cent, these efforts have been unsuccessful. It is vital that what is possible in Europe and in the United States today is carefully and impartially regularly reviewed. Then, we should ask ourselves, if legalized doctor-assisted suicide and voluntary euthanasia can work well in these places, why not in the UK? Are we, in this country, so different from the Belgians, the Dutch, the Luxembourgers, the Swiss, or those who live in Oregon or Washington State?
General medical opinion has been divided on the need for legislation for doctor-assisted dying. Back in 1996, a BMA News Review survey of 750 doctors revealed a 50/50 split. At the BMA annual conference in 2005, a neutral position was officially adopted, only to be reversed to the previous negative stance in 2006 after a vigorous campaign led by the Christian Medical Fellowship. In 2009, the Royal College of Nursing also decided to be neutral on this issue.
Today, in the Western world, everyone lives much longer than previously - an increase in prosperity, and many good developments in the medical sciences have made this possible. In the early stages of old age, most people can cope, perhaps setting new goals and meeting challenges as they arise. But, for so many individuals, as they move into their late 80s and 90s, there is a gradual decline, both physical and psychological.
Many very elderly people may still not suffer from a serious specific illness, but instead, from numerous, increasingly annoying health problems. When the unrelenting burdens of living, at a very advanced age, exceed the joys of being alive, competent individuals can finally reach the tipping point in wanting to die. Surely that final decision should be theirs, not made by anyone else. They know that they do not want to see themselves draining away still further before they are a completely empty self. They have become tired of the difficult and unpleasant symptoms of old age. They have to consider if they should die now or wait, thereby causing themselves and perhaps their families to suffer still more, and then die. It is surely their right when they are old and ailing to decide when is the best time to die, for themselves and for all those around them.
People are generally very frightened by the idea of suicide. Perhaps this is because it is painful to imagine that those we love might choose to die, to leave us permanently. However, if someone is suffering unbearably from the effects of old age, suicide gives that individual release from further suffering. This rational, or “balance-sheet” suicide makes excellent sense because the reasoning used can conform to normal logic.
In the UK, the main objective of the Voluntary Euthanasia Society (the first right-to-die society in the world, originally founded in 1935) was "to make it legal for a competent adult, who is suffering unbearably from an incurable illness, to receive medical help to die at their own considered and persistent request" - thus, including the possibility of doctor-assisted suicide for severely disabled individuals as well as endorsing the concept of "old age rational suicide". However, when the VES was re-structured in 2005, becoming Dignity in Dying, its main objective was limited to changing the law to provide doctor-assisted dying only for the terminally-ill (that is, those who are expected to die within six months). SOARS considers this change most unfortunate as disabled people and the very elderly can suffer much longer and more severely than the terminally-ill.
Today, it is very reassuring that in four European countries (Belgium, Luxembourg, The Netherlands and Switzerland) there is increasing support for old age rational suicide.
The Netherlands adopted adequate safeguards to permit both doctor-assisted suicide and voluntary euthanasia in 1981 - for those who had a terminal illness or suffered severely from an incurable disease. Then, in 2001, in order to examine the physical and psychological problems faced by many elderly people in that country, the Dijkhuis Commission was established (Dr Jos Dijkhuis was an emeritus professor of clinical psychology and psychotherapy). In its 2004 final report, this Commission noted that for elderly individuals who “had a hopeless outlook on their future...euthanasia legislation can indeed apply”.
Today, the main Dutch right-to-die society, Right to Die - NL ("NVVE"), has over 140,000 members (the national population is about 16,500,000). In 2008, this organization noted, regarding very elderly people, that “The total dependence on others, the loss of control over their personal life…(means) that every new day is experienced as an unbearable task…they are longing for death…they have become too old in their experience and wish to be released from their lives”. This Dutch society is undertaking further research and conferences on this important problem.
In 2010, a citizens' initiative, known as "Uit Vrije Wil" (or "One's Own Free Will") was started, seeking the legal possibility for elderly Dutch nationals to be able to have a doctor-assisted suicide if this is their competent decision. Over 120,000 signatures were quickly collected in favour of such legislation - with former parliamentarians, and many legal scholars and doctors giving their support. A draft bill has been prepared for parliamentary discussion. And, the Royal Dutch Medical Association (KNMG), in 2011, produced a supportive position paper, with its chairman noting that, among the very elderly, a "constellation of factors" could produce "unbearable and lasting suffering", when "euthanasia should be allowed".
In 2002, the European Court of Human Rights, in Strasbourg, noted (regarding the appeal made to it by Diane Pretty, who suffered from motor neuron disease) that “without in any way negating the principle of sanctity of life protected under the Convention, the Court considers that it is under Article 8 that notions of the quality of life take on significance. In an era of growing medical sophistication, combined with longer life expectancies, many people are concerned that they should not be forced to linger on in old age or in states of advanced physical or mental decrepitude which conflict with strongly held ideas of self and personal identity”.
In Switzerland, doctor-assisted suicide has been possible for several decades both for those who are terminally-ill as well as those severely disabled. In 2008, EXIT Deutsche Schweiz, the right-to die society in the German-speaking part of this country, held a conference on also providing similar assistance to Swiss citizens who are very elderly - in particular, it noted that, "it is about their own subjective and individual perception of their own dignity". And, in 2011, EXIT Deutsche Schweiz amended its statutes to reduce the "unnecessary hurdles placed in the way of the aged who are of sound mind and wish to die".
In April 2014, the General Assembly of EXIT Suisse Romande (the right-to-die society in the French-speaking area of Switzerland) officially broadened the scope of who it can help to include its elderly members who are suffering severely but were not terminally ill "since forcing them to continue living can be torture". Then, in the following month, EXIT Deutsche Schweiz, at its AGM, also agreed to widen its services so that its members who are suffering "from ailments linked to old age" can have the option of a doctor-assisted suicide.
There are three Swiss organizations - Dignitas (in Zurich), EX International (in Bern), and Lifecircle (near Basle) - which are willing to help foreigners to have a doctor-assisted suicide if they are terminally-ill, severely disabled, or elderly with medical problems, Fortunately, in May 2011, voters in the canton of Zurich rejected (by 78% to 22%) an attempt to prevent foreigners travelling there for a doctor-assisted suicide.
By 2014, at least 250 Britons have died in Switzerland with the help of one of these three Swiss organizations, and several of these individuals were excellent examples of "old age rational suicide".
SOARS is in regular contact with the leaders of the right-to-die societies in Belgium, Luxembourg, The Netherlands and Switzerland regarding their involvement in the procedures which are available for old age rational suicide in their countries.