The ethics of suicide — assisted or not

(Hippocrates of Kos, Wikipedia)

“A friend of mine decided, for no proper reason, to starve himself to death. I heard of this when he was already in that third day of his fast, and went and asked him what had happened. ‘I’ve decided to take this course,’ he said. Yes, but all the same, what was it that moved you to do so? If your decision is justified, look, here we are at your side and ready to help you on your way; but if your decision is unreasonable, you ought to change it. —‘We ought to hold to our decisions.’—What are you up to, man? Not to every decision, but to those that are justified.” (Epictetus, Discourses, II.15.4-7)

This passage from Epictetus encapsulates, I think, pretty much all there is to say about the ethics of suicide, assisted or not. I do not wish to oversimplify an issue that is keeping philosophers, politicians, doctors, and patients involved in endless discussions. An issue, moreover, that carries huge societal and personal implications. And yet there it is. Epictetus is saying three things in this brief excerpt from the Discourses: (i) suicide is admissible; (ii) it is a duty of one’s friends or caretakers to be of assistance to the person who has decided to commit suicide; but (iii) that person has a duty to carry out due diligence, specifically making sure — as far as it is humanly possible — that she has properly considered and evaluated the reasons for taking such an extraordinary step.

Of an entirely different opinion is Aaron Kheriaty, M.D., an associate professor of psychiatry and human behavior and director of the Medical Ethics Program at the University of California Irvine School of Medicine. He has recently penned a lengthy condemnation of the whole idea of physician assisted suicide in New Atlantis. He goes after individual doctors, medical organizations, and even countries (Canada, the Netherlands) who have supported the notion.

Of course, such procedures ought to be carried out in a regulated fashion, to make sure that this is what the patient wants, that they know what they are doing and why, and that there is no undue pressure or foul play. All sides agree to this sort of standards.

So why does Kheriaty object to the whole idea? So far as I can see, his main argument is that doctors have taken the Hippocratic oath, and that to help a patient to commit suicide violates such oath. End of story.

The Hippocratic oath dates from the 5th-3rd century BCE, and it was allegedly (but unlikely) written down by Hippocrates of Kos (460-370 BCE). The earliest surviving version dates from a few centuries later, in 275 CE. Here it is:

“I swear by Apollo Physician, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.
To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician’s oath, but to nobody else.
I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein.
Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.
Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I break it and forswear myself, may the opposite befall me.” 
(Full text in Greek and English here.)

Notice that the oath begins with a prayer to a select number of Olympian gods, contains a prohibition against abortion, an injunction to share financial resources with one’s teacher, one to teach others for free, and another not to use “the knife,” meaning no surgery allowed. Most modern doctors are in obvious violation of pretty much all these clauses (with the partial exception of abortion, of course).

Also notice that the oft-cited phrase “first do no harm” appears nowhere in the original oath. The Latin version, primum non nocere, doesn’t show up until the 17th century.

The Hippocratic oath has, of course, been modified a number of times, most recently in 2019. The current version widens the focus of care from the individual to the community, and even to the ecosystem — a reflection of contemporary concerns about the increasingly dire state of the environment.

Interestingly, different medical schools use different versions of the oath, which means that it is disingenuous — as Kheriaty does — to talk about the oath. A 1994 article by R. Crawshaw (full text here), entitled “The Hippocratic oath is alive and well in North America,” reports that of 126 US medical schools surveyed, 67 use a modified Hippocratic Oath, 33 use the Declaration of Geneva (dating from 1948), eight use another oath, four use the so-called Oath of Maimonides, three use the original oath, two do not use any kind of oath, one uses a covenant, and another one use an unknown oath.

In other words, there is no such thing as the Hippocratic oath, and the original document has been modified a number of times to adapt to the times. Which makes any dogmatic appeal to it meaningless.

Moreover, let’s talk about that famous “do no harm” thing. There is only one place in the original where “harm” is mentioned: “I will abstain from all intentional wrong-doing and harm.” But “harm” can — and has been — interpreted in a number of ways. Kheriaty would want us to believe that assisting someone who has thoughtfully decided to end his life is doing “harm.” But this is rather patronizing, as well as narrow minded. Suppose I suffer from a degenerative neurological disorder that will soon leave me a shell of my previous self, and cause suffering to my loved ones who will not be able to recognize the person I was. How on earth is allowing that, against my express wish to the contrary, a form of “harm”?

Kheriaty makes a big deal throughout his article of medical associations that decide to take a neutral stance on the issue — basically allowing their members the freedom of conscience to decide one way or the other. That seems to me an eminently sensible stance, because the issue is indeed a delicate one, and one can easily see how individual doctors may reasonably decide one way or the other. But Kheriaty says that “a closer look at the recent rash of legalization of assisted suicide in several states and countries shows that doctors’ own medical associations actively helped to pave the way, all while ducking behind a disingenuous guise of merely staying neutral. The story is a growing scandal to the profession of medicine.”

Well, The Canadian Medical Association (CMA), for one, disagrees with Kheriaty, stating that it “supports the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying.”

Kheriaty’s logic is more than a bit faulty, as I hope it will be clear from the following: “A neutral position is not truly possible on the legal question about whether assisted suicide should be permitted. To take a position that says that doctors can perform it if they want while others may choose to abstain is to take a position in favor of permitting the practice. It is analogous to a position that says that some people can choose to steal if they want, while others who find it objectionable need not steal. Translated, this means stealing is permissible.” First off, the CMA, for instance, explicitly adds the clause “within the bounds of existing legislation.” I’m not aware of any state in which stealing is permissible according to the law. Second, the two cases are very different: nobody defends the right to steal, not even criminals, who usually object when someone else steals from them. But assisted suicide is an issue on which society has not yet settled, so a neutral stance is actually very wise.

Later on Kheriaty tries two more questionable analogies for assisted suicide: with prisoners’ executions and with torture. The American Medical Association is rightly opposed to its physicians participating in either scenario, regardless of whether those practices are legal or not. But nobody in his right mind could possibly construe execution or torture as not harmful to the subject, unlike the case of assisted suicide, provided the caveats listed above hold. Undaunted, Kheriaty claims that assisted suicide makes “the physician into a killer” — notice the explicitly inflammatory language, which has little to do with reasoned arguments.

Indeed, Kheriaty escalates his rhetoric even further: “when assisted-suicide debates began surfacing in the United States, my father quipped, ‘Why not truck driver–assisted suicide?’ Behind this seemingly flippant remark is a morally serious point. When we put the matter this starkly, assisted suicide and euthanasia appear to be simply what they are: the killing, or the facilitation of killing, of one human being by a fellow human being. This is an inherently repugnant reality.” This is quasi-religious talk, the sort of self-righteous “this is repugnant to me, therefore it is objectively abominable” stance taken by people who are short on rational arguments.

On my part, I go back to Epictetus and his famous “open door” policy:

“Remember that the door is open. Don’t be more cowardly than children, but just as they say, when the game is no longer fun for them, ‘I won’t play any more,’ you too, when things seem that way to you, say, ‘I won’t play any more,’ and leave, but if you remain, don’t complain.” (Discourses I.24.20)

And:

“Has someone made smoke in the house? If it is moderate, I’ll stay. If too much, I exit. For you must always remember and hold fast to this, that the door is open.” (Discourses I.25.18)

The notion here is, as always with Epictetus, simple, clear, and powerful: we are masters of our own decisions and judgments (and of little else). If we decide that things are truly unbearable, then we have a right to exit. But if we stay, we have a duty to do our best with whatever situation is at hand. It is hard to imagine a more frank and liberating attitude about suicide: the decision is up to me, because the responsibility is mine — whether I stay or leave.

By becoming a patron, you'll instantly unlock access to 12 exclusive posts
12
Writings
By becoming a patron, you'll instantly unlock access to 12 exclusive posts
12
Writings