Friday, 31 August 2018

A Debate Over ‘Rational Suicide’


On a March morning in 1989, Robert Shoots was found dead in his garage in Weir, Kan.

He had run a tube from the tailpipe of his beloved old Chrysler to the front seat, where he sat with a bottle of untamed Turkey. He was 80.

His daughter wishes he had mentioned this plan once they spoke by phone the night before because she didn’t get to mention a satisfying goodbye. But she wouldn't have tried to dissuade him from suicide.

Years earlier, he had told her of his intentions.

“It wasn’t an enormous surprise,” she said of his death.

“I knew what he was getting to do and the way he was getting to roll in the hay .”

(Wary of harassment in her conservative upstate NY town, she has asked me to withhold her name.)

Mr. Shoots, a retired painter, was happily remarried and enjoyed healthiness.

He still went fishing and played golf, showing no signs of depression or other mental the illness that afflicts most of the people who take their own lives.

Nevertheless, he had explained why he someday planned to require his life.

“All the people he knew were dying in hospitals, filled with tubes, lying there for weeks, and he was just horrified by it,” his daughter said. He decided to avoid that sort of death.

Is suicide by older adults ever a rational choice? It’s a subject many older people discuss among themselves, quietly or loudly — and one that physicians increasingly encounter, too.

Yet most have scant training or experience in the way to respond, said Dr. Meera Balasubramaniam, a geriatric psychiatrist at the NY University School of drugs.

“I found myself seeing individuals who were very old, doing well, and shared that they wanted to finish their lives at some point,” said Dr. Balasubramaniam.

“So many of our patients are confronting this in their heads.”

She has not taken an edge on whether suicide is often rational — her views are “evolving,” she said.

But hoping to get more medical discussion, she and a co-editor explored the difficulty during a 2017 anthology, “Rational Suicide within the Elderly,” and she or he revisited it recently in a piece of writing within the Journal of the American Geriatrics Society.

The Hastings Center, the ethics institute in Garrison, N.Y., also devoted much of its latest Hastings Center report back to a debate over “voluntary death” to forestall dementia.

Every a part of this concept, including the very phrase “rational suicide,” remains intensely controversial.

(Let’s leave aside the related but separate issue of physician aid in dying, currently legal in seven states and therefore the District of Columbia, which applies only to mentally competent people likely to die of a terminal illness within six months.)

“The suicidal state isn't fixed. It’s a teeter-totter.”

Dr. Yeates Conwell Suicide has already become a pressing public health concern for older adults, more than 8,200 of whom took their lives in 2016, consistent with the Centers for Disease Control and Prevention.

“Older people generally, and older men specifically, have the very best rates” said Dr. Yeates Conwell, a geriatric psychiatrist at the University of Rochester School of drugs and a longtime suicide researcher.

That’s true albeit research consistently shows older adults feeling happier than younger ones, with an improved psychological state.

A complex web of conditions contributes to late-life suicide, including physical illness and functional decline, personality traits, and coping styles, and social disconnection.

But the overwhelming majority of older people that kill themselves even have a diagnosable mental illness, primarily depression, Dr. Conwell acknowledged.

Suicide often also involves impulsivity, instead of careful consideration.

That doesn’t fit anybody’s definition of a rational act.

“The suicidal state isn't fixed,” Dr. Conwell said. “It’s a teeter-totter. There’s a will to measure and a will to die, and it goes back and forth.”

When health care providers aggressively treat seniors’ depression and work to enhance their health, function and relationships, he said, “it can change the equation.”

Failing to require action to stop suicide, some ethicists and clinicians argue, reflects an ageist assumption — one older people themselves aren’t resistant to — that the lives of old or disabled people lack value.

A tolerant approach also overlooks the very fact that folks often change their minds, declaring certain conditions unendurable within the abstract but choosing to measure if when the worst actually happens.

Slippery-slope arguments factor into the talk, too.

“We worry that we could shift from a right to die to a requirement to die if we make suicide seem desirable or justifiable,” Dr. Balasubramaniam said.

But the dimensions of the boomer cohort, with the drive for the autonomy that has characterized its members, means doctors expect more of their older patients to contemplate controlling the time and manner of their deaths.

Not all of them are depressed or otherwise impaired in judgment.

“Perhaps you are feeling your life is on a downhill course,” said Dena Davis, a bioethicist at Lehigh University who has written about what she calls “pre-emptive suicide.”

“You’ve completed the items you wanted to try to to. You see life’s satisfactions getting smaller and therefore the burdens getting larger — that’s true for tons folks as our bodies start breaking down.”

At that time, “it could be rational to finish your life,” Dr. Davis continued.

“Unfortunately, in the world, we currently sleep in, if you don’t take hold of life’s end, it’s likely to travel in ways that are inimical to your wishes.”

Dr. Davis cared for her mother as she slowly succumbed to Alzheimer’s disease. She intends to avoid an identical death, a choice she has discussed together with her son, her friends and her doctor.

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