Suicide as a Moral Issue; R. Szasz

The Therapeutic State Suicide as a Moral Issue by Thomas Szasz "Suicide is an event that is a part of human nature. However much may have been said and done about it in the past, every person must confront it for himself anew, and every age must come to its own terms with it." -JOHANN WOLFGANG VON GOETHE (1749-1832) B ehind Goethe's simple statement lies a profound truth: dying voluntarily is a choice intrinsic to human existence. It is our ultimate, fatal freedom. That is not how the right-thinking person today sees voluntary death: he believes that no one in his right mind kills himself, that suicide is a mental health problem. Behind that belief lies a trans parent evasion: relying on physicians to pre vent suicide as well as to provide suicide and thus avoid the subject of suicide-is an evasion of personal responsibility fatal to freedom. Not long ago the right-thinking person believed that masturbation, oral sex, homo sexuality, and other "unnatural acts" were medical problems whose solution was dele gated to doctors. It took us a surprisingly long time to take these behaviors back from physi cians, accept them comfortably, and speak about them calmly. Perhaps the time is ripe to rethink our attitude toward suicide and its relation to the medical profession, accept sui cide comfortably, and speak about it calmly.

Thomas Szasz, MD., professor ofpsychiatry emeritus at SUNY Health Science Center in Syracuse, New York, is the author of Fatal Freedom (forthcoming from Praeger), from which this article is adapted. 41 To accomplish this, we must de-medicalize and destigmatize voluntary death and accept it as a behavior that has always been and will always be a part of the human condition. Wanting to die or killing oneself is sometimes blameworthy, sometimes praiseworthy, and sometimes neither; it is not a disease; it can not be a bona fide medical treatment; and it can never justify deprivation of liberty. Death Transformed Increasing life expectancy, advances in medical technology, and radical changes in the regulation of drug use and the economics of health care have transformed how we die. Formerly, most people died at home. Today, most people die in a hospital. Formerly, patients who could not breathe or whose kid neys or livers or hearts failed to function died.

Now, they can be kept alive by machines, transplanted organs, and immunosuppressive drugs. These developments have created choices not only about whether to live or die but also about when and how to die. Birth and death are unique phenomena. Absent celibacy or infertility, practicing birth control-that is, procreating voluntarily-is a 42 THE FREEMAN/IDEAS ON LIBERTY. JULY 1999 personal decision. Absent accidental or sud den death, practicing death control-that is, dying voluntarily-is also a personal deci sion. The state and the medical profession no longer interfere with birth control. They ought to stop interfering with death control. As individuals, we can choose to die active ly or passively, practicing death control or dying of disease or old age. As a society, we can choose to let people die on their own terms or force them to die on terms decreed by the dominant ethic. Camus maintained that suicide is the only "truly serious philosophi cal problem." It would be more accurate to say that suicide is our foremost moral and political problem, logically anterior to such closely related problems as the right to reject treatment or the right to physician-assisted suicide.

Faced with a particular personal conduct, we can approve, facilitate, and reward it; dis approve, hinder, and penalize it; or accept, tolerate, and ignore it. Over time, social atti tudes toward many behaviors have changed. Suicide began as a sin, became a crime, then became a mental illness, and now some peo ple propose transferring it into the category called "treatment," provided the cure is under the control of doctors. Crucial Questions Is killing oneself a voluntary act or the product of mental illness? Should physicians be permitted to use force to prevent suicide? Should they be authorized to prescribe a lethal dose of a drug for the purpose of sui cide? Personal careers, professional identities, multibillion-dollar industries, legal doctrines, judicial procedures, and the life and liberty of every American hang on how we answer these questions. Answering such questions requires no specialized knowledge of medicine or law.

It requires only a willingness to open our eyes and look life-and death-in the eye. Evad ing that challenge is tantamount to denying that we are just as responsible for how we die as we are for how we live. The person who kills himself sees suicide as a solution. If the observer views it as a problem, he precludes understanding the suicide just as surely as he would preclude understanding a Japanese speaker if he assumed that he is hearing garbled English. For the person who kills himself or plans to kill himself, suicide is, eo ipso, an action. Psychiatrists, however, maintain that suicide is a happening, the result of a disease. Against this mindset, the view that, a priori, suicide has nothing to do with illness or medicine, which is my view, risks being dismissed as an act of intellectual know-nothingness, akin to asserting that cancer has nothing to do with illness or medicine. We are proud that suicide is no longer a crime, yet it is plainly not legal; if it were, it would be illegal to use force to prevent sui cide and it would be legal to help a person kill himself. Instead, coercive suicide prevention is considered a life-saving treatment and help ing a person kill himself is (in most jurisdic tions) a felony.