COMMENTARY

Suicide and Communal Values: Ethical Implications for Psychiatrists

Ronald W. Pies, MD

Disclosures

January 27, 2014

In This Article

Self-chosen Dying

Yet, I do not want to convey the view that "all suicides are created equal" insofar as their ethical or moral status is concerned. In my view as a psychiatrist and bioethicist, the momentous issue of self-chosen dying must be carefully examined in the context of the patient's circumstances, motivations, clinical status, and "provisions" for friends and loved ones. I will give just 2 very condensed examples.

Mr. Jones. Mr. Jones, aged 75 years, is in the final stages of pancreatic cancer and has made a decision to end his own life. He is in moderate pain, despite optimal medical management and substantial pain medication.

Mr. Jones has explained his decision to his family and closest friends. According to both his internist and a consultant psychiatrist, Mr. Jones has no psychiatric history of significant mood disorder, is not clinically depressed, remains mentally alert and lucid, and has no psychotic ideation or major cognitive distortions. He has made adequate and thorough provisions for the care of his family, including taking care of the necessary financial and legal issues. Mr. Jones's family, while understandably heartbroken, are supportive of his decision and plan for his final days at home, with experienced hospice nurses available for palliative care and treatment of his pain.

Mr. Jones, in a lucid state of mind, voluntarily elects to decline further food and drink. The hospice nurses provide support and education to his family about this method of ending one's life, known as "voluntarily stopping eating and drinking" (VSED).[2] After drifting into unconsciousness, Mr. Jones dies without evident distress, surrounded by family, within 8 days.

Mr. Smith. Mr. Smith, aged 23 years, has a history of recurrent major depressive episodes and impulsive suicide attempts. Three weeks ago, he experienced a painful break-up of his long-standing romantic relationship of 3 years, after his girlfriend left him for another man. Mr. Smith is angry, embittered, and outraged that this has happened.

For the past 2 weeks, he has slept poorly, lost interest in nearly all of his usual activities, lost 8 pounds, and feels that "there is just no point" in life anymore. He sees no reason to talk to his friends or family about the situation. Instead, he impulsively buys a handgun, checks into a motel, and fatally shoots himself. He made no provisions for any of his legal or financial affairs, left no will, and died with a credit card debt of more than $15,000. His mother, the joint account holder, was saddled with the debt.

Mr. Smith leaves behind grieving and perplexed parents, 2 siblings, and many friends who say, "We didn't see this coming -- he never talked to us about how the break-up affected him. Did we miss something we should have seen? What did we do to deserve this?"

Clearly, there are important clinical and psychiatric differences between these patients. Moreover, from the standpoint of communal values -- that is, one's ethical obligations to friends, family, and community -- I believe that we can view the cases of Mr. Jones and Mr. Smith quite differently. Indeed, I believe that most psychiatrists would have approached each case with different clinical and ethical goals in mind, had they been asked to intervene early in the course of events.

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