Handling suicidal ideation is not as easy as determining a mental illness.
It’s 3 a.m. and you’re on your fourth overnight in a row. The track-board still says there are several patients waiting to be seen. You have managed to clear the sickest of the bunch, but you notice the chief complaint of “suicidal ideation.” You enter the room and introduce yourself and are greeted by a frail, but well dressed, coherent, well-spoken gentleman. He tells you that he was a professor of law and was recently told he has stage IV pancreatic cancer. After discussing with several oncologists he has decided to forego chemotherapy and/or radiation and wants to just end his life. Despite this recent diagnosis he denies any prior history of depression or suicidality, and currently has no symptoms of depression.
According to your checklist, he has full medical decision making capacity. However, he is unapologetically clear on his intent to kill himself. If not for his ex-wife overhearing his plans to kill himself and calling 911, he had every intention of taking the bottle of narcotics he obtained. He sought the assistance of his physicians, but unfortunately he lives in New York State where Physician Aid-in-Dying laws have still not been passed. He asks you, “So what are you going to do with me doc? Medically clear me for psych and have them commit me? Or let me go home, to die peacefully at my own hands, before this cancer causes me more pain?”
Introduction and Background
In contemporary western medicine respect for individual liberties, patients’ bills of rights, and respect for self-determination and autonomy, are key practice principles that have entered clinical medicine. Although, autonomy and the resultant rights patients have been afforded have been criticized by some, they have been generally upheld by many more in the legal, ethical and even medical communities. According to Wolpe and others, the respect for an individual autonomy is here to stay in some form in the U.S. [2,3] Rhodes and Holzman state “Physicians are obliged, by law and by ethics, to respect the treatment refusals of a competent patient even when the consequences will be dire and even when the physician disagrees with the choice and does not share the patient’s values.” Respect for autonomy and autonomous decisions, is heralded as one of the most important principles in bioethics.  Bennett and Harris state that “People are said to be autonomous to the extent to which they are able to control their lives, and to some extent their destiny, by the exercise of their own faculties”. In other words, from several different vantage points, respect for an individual’s autonomy is integral to western medicine.
Despite a general movement in the West to respect an individual’s autonomy, it is still held that people brought to the attention of healthcare and/or legal authorities with suicidality are usually deemed to lack medical decision-making capacity or competence. [3, 7-13] This is despite many of these patients later demonstrating that they possess the “mental ability to make a rational decision, which includes the ability to perceive, to appreciate all relevant facts, and to reach a rational judgment upon such facts.” 
Hence, a blanket statement or fixed treatment decision committing all who attempt or contemplate suicide to mental treatment against their will seems at odds with the respect for a patient’s autonomy and self-determination that has become the hallmark for ethical medical care in most developed nations.
What this assumption that suicidal individuals are mentally incompetent misses is that suicide is a complex and often, misunderstood act, which tends to leave more questions than provide answers. Suicide is defined as the intentional termination of a person’s own life.  Here are some examples of suicide, or what might be considered suicide:
- A young woman, having just broken up with her partner, drinks a bottle of alcohol and jumps off a skyscraper.
- An elderly man takes an overdose of barbiturates, leaving a note stating he has just had enough. He has enjoyed his life, has no more family or friends, and no longer enjoys life.
- An Army officer is captured during war, and tortured to reveal potentially damaging secrets. In order to avoid the betrayal of her fellow soldiers, she hangs herself.
- A cancer patient, riddled with pain despite high dose opioid analgesics, decides he has suffered long enough, and swallows a three-month supply of painkillers.
- A peace activist against the innocent killing and raping of a minority tribe in a SE Asian nation, goes on a hunger strike for 120 days without eating or drinking, and eventually succumbs.
- An end-stage-renal-disease patient on dialysis, is tired of the imposition on loved ones and tri-weekly inconvenience, and decides to stop receiving dialysis. He has never had a history of depression, and his physician determines he has medical decision-making capacity. He is allowed to refuse all further treatments, and dies 10 days later.
All of these involve the intentional termination of a person’s own life, and hence are suicides by definition, but are they all the same? All have reasons for their actions, but are some more acceptable and/or less wrong than others? Is it still suicide if one refuses life-saving treatment vs. puts a gun to one’s head? Like Robert Veatch, I would argue that active or passive ending of one’s own life is still suicide by the above provided definition, and hence subject to the same analysis of motivation and state of mind.
Suicide as a Mental Illness
It is presumed, both customarily and legally, that most people in a modern society possess decision-making capacity, and hence should be respected as such. [9,10,16,17] Although many patients who are suicidal may in fact lack medical-decision making capacity and be irrational, and hence should be treated under appropriate psychiatric care, I will focus my argument on those who are without any cognitive disabilities or mental maladies.
Psychiatrist Thomas Szasz criticized psychiatry for medicalizing suicide as a mental illness or disease. He described psychiatrists as coercively gaining control over suicidal patients by taking responsibility for their lives and using suicidality to justify their involuntary hospitalization and treatment. He also disapproved of the language used to describe “self-killing,” because this language casts committing suicide as an act of “badness or madness, akin to a crime.” [7,8]
Appelbaum states that only 20-25% of patients admitted for depression related to suicide were found to have impairment of their capacity, as compared to patients admitted for an acute exacerbation of schizophrenia (50%). Thus by his analysis, up to 80% of patients admitted for major depression still possess medical decision-making capacity. It is only the few whose impairment places them at the lower end on the “performance curve” of rational performance that should be considered to be incompetent. 
To reiterate the above point, Canadian psychiatrist, Dr. Angela Onkay Ho summarized her views on being rational yet desiring to take one’s own life as follows:
People without psychiatric illness can freely desire suicide or a hastened death based on carefully contemplated, logical decision-making processes… Assuming that the decision is uninfluenced by the coercion of others, the desire for hastened death is considered a rational decision to avoid the unbearable suffering associated with terminal illness. 
Although Ho focuses her argument on terminal illnesses, rationality can be determined by those who possess a pattern of rational decision-making in their life, and are free from a mental malady. 
A case that garnered a lot of international media attention was the death of Kerrie Wooltorton in Norfolk, England. In 2007, she consumed several glasses of antifreeze in a suicide attempt and called an ambulance. She carried a letter with her informing doctors that she knew the consequences of her actions, wanted no life-saving treatment, and had come to the hospital only to be made comfortable, because she did not want to die alone.
To whom this may concern, if I come into hospital regarding taking an overdose or any attempt of my life, I would like for NO lifesaving treatment to be given. I would appreciate if you could continue to give medicines to help relieve my discomfort, painkillers, oxygen etc. I would hope these wishes will be carried out without loads of questioning.
Please be assured that I am 100% aware of the consequences of this and the probable outcome of drinking anti-freeze, e.g. death in 95-99% of cases and if I survive then kidney failure, I understand and accept them and will take 100% responsibility for this decision.
I am aware that you may think that because I call the ambulance I therefore want treatment. THIS IS NOT THE CASE! I do however want to be comfortable as nobody want to die alone and scared and without going into details there are loads of reasons I do not want to die at home which I realise that you will not understand and I apologise for this.
Please understand that I definitely don’t want any form of Ventilation, resuscitation or dialysis, these are my wishes, please respect and carry them out. 
One of the takeaways from reading this letter, besides her seemingly clear rationality and capacity, is her addressing a common misconception that those who call Emergency Medical Services (EMS) are “subconsciously” reaching out for help. Although, she did not want to go into the details as to why she did not want to die alone, it seems clear she was aware of all of the repercussions of her actions. Her physicians determined that she was competent after much deliberation and legal consultation, and allowed her to die in the hospital two days later. Two years later, a legal inquest and autopsy performed by the Norfolk coroner exonerated the physicians and endorsed the physicians’ decision to allow her to die comfortably. 
Rational suicide is a subset of suicidality by people who possess medical decision making capacity, usually confirmed in courts of law to be competent and rational. Those presenting in this fashion, are not the mentally distraught and oftentimes intoxicated persons who might be reacting to a recent or series of stressors in their lives.
This is not the impetuous patient who may be “acting emotional” and/or “seeking attention” after a recent break up from their significant other. Nor is it a person who suffers from a truly volitional or cognitive disorder. Sadly, these tend to be people who have acted in competent and rational manners up until the point where they decided to end their lives. They may be suffering from an incurable ailment or have emotional and/or physical pain that no medication can control, or they may just feel that they have lived long enough and feel it is time to end their lives. These difficult decisions are hard to understand at times, but our lack of understanding should not impact on a rational and competent individual’s right to self-determination, and yes, suicide.
1.Giwa A. The Right To Die; An Analysis on the Current Laws Banning Physician Aid in Dying Statutes in New York State. Medicine and Law Journal. 2018 Sept; 37:3: 387-398.
2. Wolpe, PR. The triumph of autonomy in American medical ethics: A sociological view in DeVries R. and Subedi J. (Eds.) Bioethics and Society: Sociological Investigations of the Enterprise of Bioethics, Prentice Hall, New York. 1998.
3. Mackenzie, C. Autonomy. The Routledge Companion to Bioethics. Routledge. 2015.
4. Rhodes, R and Holzman, IR. The Not Unreasonable Standard for Assessment of Surrogates and Surrogate Decisions. Theoretical Medicine 25:367-385. Kluwer Academic Publishers. 2004.
5.Bennett, R and Harris, J. Reproductive Choice. The Blackwell Guide to Medical Ethics. Blackwell Publishing, LTD. 2007.
6.Harris, J. The Value of Life: An Introduction to Medical Ethics. Routledge and Kegan Paul. 1985.
7. Ho, A O. Suicide: Rationality and Responsibility for Life. Can J Psychiatry. 2014 Mar; 59(3): 141–147.
8. Szasz T. Fatal freedom: the ethics and politics of suicide.Westport (CT): Praeger; 1999.
9. Jerry Menikoff. The Constitution and the Right to Die. Law and Bioethics, an introduction. Georgetown University Press. 2008.
10. Beauchamp, T L and Childress, J F. Principles of Biomedical Ethics. 7th Edition. Oxford University Press. 2013.
11. Clarke, DM. Autonomy, rationality and the wish to die. Journal of Medical Ethics 1999;25:457-462
12. Degrazia, D et al. Biomedical Ethics. 7th Edition. McGraw-Hill. 2011.
13. Brandt, RB. The Morality and Rationality of Suicide. A Handbook for the Study of Suicide. Oxford University Press, Inc. 1975.
14. STATE of Tennessee, DEPARTMENT OF HUMAN SERVICES, v. Mary C. NORTHERN. 563 S.W.2d 197 (1978)
15. Veatch, RM. The Basics of Bioethics. 3rd Edition. Routledge. 2013.
16. Appelbaum, P S. Assessment of Patients’ Competence to Consent to Treatment. N Engl J Med 2007; 357:1834-1840
17. Gert, B et al. Bioethics: A Return to Fundamentals. 1st edition. Oxford University Press. 1997.
18. Callaghan, S and Ryan, C J. Refusing medical treatment after attempted suicide: Rethinking capacity and coercive treatment in light of the Kerrie Wooltorton case. Journal of Law and Medicine. (2011): 811-819
19. Szawarski, P. Classic cases revisited: The suicide of Kerrie Wooltorton. Journal of the Intensive Care Society (JICS). 2013 July; 14 (3): 211-214.