On December 2, 1982, 62-year-old Barney Clark became the first human to receive a permanent artificial heart. In addition he was given a key that could be used to turn off his compressor, if he wanted to die. One of the physicians, Dr. Willem Kolff, justified the key by stating that if Clark suffered and felt that life was not enjoyable or worth enduring anymore, he had the right to end his life. Clark never used the key. He died 15 weeks after the operation. This case illustrates the growing importance of ethical reflection regarding suicide. Today it is the 10th leading cause of death in the general population, and the suicide rate is on the rise in groups ranging from teenagers to the elderly. The purpose of this article is to clarify important issues and options involved in the ethical aspects of suicide. It is crucial that pastors and other Christian leaders understand how these issues are being argued, apart from reference to the biblical text. This will enable the Christian community to argue in a pluralistic culture for positions consistent with the Bible and to understand how others are framing the debate. This article focuses on three issues: the definition of suicide, the moral justifiability of suicide, and moral problems involved in paternalist state intervention to prevent people coercively from committing suicide.
The Definition of Suicide
Before discussing the morality of suicide, two preliminary issues must be examined. First is whether the term “suicide” should be used purely conceptual, descriptive manner or in normative, evaluative manner. Second is the need to define suicide to show how suicidal acts differ from other selfdestructive acts.
IS SUICIDE A DESCRIPTIVE OR AN EVALUATIVE TERM?
Should suicide be defined in a purely conceptual, descriptive manner or in normative, evaluative terms? Suppose one person said suicide is sometimes morally permissible and another said suicide is always wrong. It would be possible for these two people to agree over substantive moral issues regarding suicide and differ merely in their definition of what counts as suicide. For example two people could agree that a Jehovah’s Witness who refuses a blood transfusion (see case six discussed below) was morally justified in his action, one arguing that it was a morally justifiable suicide, the other that it was not a suicide at all but a case of martyrdom. Thus definitions are important in clarifying where agreement and disagreement lie in a moral discussion.
Beauchamp and Childress have argued that one should opt for a stipulative definition of suicide, which is conceptual, descriptive, and nonevaluative.1 The definition they propose is this: An act is a suicide if and only if one intentionally terminates one’s own life, no matter what the conditions or precise nature of the intention or the causal route to death. Their argument for this stipulative definition is that an ordinary language definition is evaluative and carries with it an attitude of disapproval. If an act is a suicide, many say, then it is wrong. But, according to Beauchamp and Childress, this prejudices one’s understanding of suicide and removes objectivity from the conceptualizing of the term. If an act of selfcaused death is morally appropriate, one should hesitate to label it a suicide because of the evaluative nature of the term.
Hauerwas has argued against Beauchamp and Childress, claiming that the evaluative use of moral terms is preferable to mere stipulative descriptive uses.2 Hauerwas points out that the idea of a normatively “uncorrupted” definition of suicide distorts the very grammar of the term. He agrees that the definition of suicide itself cannot settle how and why suicide applies to certain kinds of behavior and not to others. But this is because the use of moral terms of appraisal like suicide derives from broad world view considerations of the culture in question. Within ones world view a person finds the factual and moral beliefs that are necessary to make judgments about when a range of lifeending behavior is morally inappropriate. So the way one understands “suicide’ already incorporates moral judgments and factual beliefs about the world in general.
In this writer’s judgment, Hauerwas is right. By their nature, moral terms are evaluative, they are intended to guide behavior, and the normative component of a moral term derives its applicability from world view considerations of the community that uses the term to praise or blame behavior. Thus an “uncorrupted” definition fails to weight properly the evaluative component of the term “suicide,” and it would be revisionary in nature and could therefore effect the way the morality of specific behaviors is perceived.
WHAT IS SUICIDE?
When an ethical term is being defined, a proposed definition should explain the ordinary language intuitions of people of good will regarding clear and borderline cases of what to count as acts of suicide. Thus cases are important guides in defining ethical terms.
Examination of cases. The following cases may be noted:
- An elderly man, despairing of life, leaves a note behind and jumps off a bridge.
- A soldier captured in war takes a capsule in order to avoid a torturous death and to hide secrets from the enemy.
- A truck driver, foreseeing his own death, drives off a bridge in order to avoid hitting children playing in the road.
- A hospitalized cancer patient with six months to live shoots himself in order to save his family from unneeded psychological and financial suffering.
- A terminally ill patient, realizing death is imminent, requests that she not be resuscitated again if another heart failure occurs.
- A Jehovah’s Witness refuses a simple blood transfusion for religious reasons and subsequently dies for lack of blood.
Case one above (the elderly man jumping off the bridge) is clearly a case of suicide. Suicide clearly involves at least a person’s death and that persons involvement in his or her own death. In a suicide, a person must willingly bring about his or her own death. This insight is expressed in what might be called the standard definition of suicide: a suicidal act involves the intentional termination of one’s own life. But this definition needs clarification in light of the other cases listed.
Consider first the matter of intention. Some understand intention to be the notion that a person has the power to avoid a foreseen death, and yet willingly and knowingly chooses not to do so. On this view, all six cases above would be suicides. But most people would not agree with this usage, e.g., cases two, three, and five do not appear to be suicides at all.
A different understanding of intention defines it in terms of what someone is trying to do. The intent of an act specifies what the act itself is, and an intent can be clarified by the reasons or motives for doing the act. For example in the truck driver case above, the ultimate intent of the act seems to be the sacrificial preservation of the life of others. In this case the truck driver did not desire to die, but permitted his own death to accomplish an act of lifesaving. This second sense of “intent” seems more in keeping with the common usage of “suicide,” so it is to be preferred to the first sense.
Case two raises the issue of coercion. The soldier terminated his own life because he knew he would be killed by means of prolonged torture and because he did not wish to reveal his country’s secrets. Some have argued that this is not an example of suicide because it involves (a) coercion and (b) other-directed and not self-directed motivation. If the soldier were not under coercion but terminated his life anyway, this would most likely be classified as a suicide. Thus if an act is coerced, it probably does not count as a suicide.
What about self-destructive acts for the sake of others such as cases two and three? Some hold that these are not suicides because they involve other-directed and not self-directed motivation. These are sacrificial acts, not suicides. Here death is not desired, but one’s own life is taken for the sake of others.
Some philosophers add the stipulation that other-directed acts are suicidal if they are done for animals or nonpersonal states of affairs (e.g., wealth). Thus case four is an act of self-destruction for others (a cancer patient shoots himself to save others economic and psychological distress) and should be classified as a suicide because it is not done to save the lives of others, but to realize a nonpersonal state of affairs
The Jehovah’s Witness case could be treated similarly. If God does command that no blood be taken and if a blood transfusion violates this command, then refusing a blood transfusion would be not a suicide but a sacrificial act of martyrdom. An important issue in this case is whether the Jehovah’s Witness interpretation of Scripture is accurate. Most biblical scholars do not think so and thus would have a factual problem with case six.
What about a Buddhist monk who sets fire to himself in protest of a war? Some would argue that this is not a suicide because it is selfsacrifice for the lives of others. Beauchamp disagrees and believes that such an act is suicidal because the monk himself directly and intentionally causes the lifethreatening condition (the fire) that brings on the death.3 According to Beauchamp, most people would judge such an act as suicidal and this shows that usage turns on the fact that the agent creates the conditions for death, not on the notions of sacrifice or martyrdom.
But even if one grants that the monk’s act is a suicide, all that follows is that there are different ways an act counts as suicidal, and in addition to the issue of self versus othermotivation, there is also the issue of direct causation of death. It would seem then that all things being equal, an act of martyrdom or sacrifice for the lives of others is not a suicide.
However, Beauchamp’s point does raise the issue of direct causation and active means used by the individual. This writer considers case four a suicide but not case five. If a sick but nonterminal person died as a result of refusing to eat or take medication, that would be considered a suicide. These insights indicate that a selfdestructive act is a suicide if the person is nonterminal and death is intentionally and directly caused as a means to some other end. In case five death is foreseen, but not directly and intentionally caused. Thus this is an example of passive euthanasia. In case four, however, death is directly and intentionally caused by a gunshot, and this is what makes the act a suicide.
A definition of suicide. From these deliberations about the cases listed above, fundamental intuitions about suicide, embedded in ordinary language, become clearer. On the basis of these deliberations the following definition of suicide can be formulated: An act is a suicide if and only if a person intentionally and/or directly causes his or her own death as an ultimate end in itself or as a means to another end (e.g., pain relief), through acting (e.g., taking a pill) or refraining from acting (e.g., refusing to eat) when that act is not coerced and is not done sacrificially for the lives of other persons or in obedience to God.4
This attempt to define suicide does not mean that all nonsuicidal acts of selfdestruction are considered morally permissible. For example a daredevil, foolishly performing an unnecessarily risky stunt for money or fame, jumps to his death. Such acts can be wrong for several reasons: they harm others (e.g., loved ones left behind) by removing a member of the community, they manifest a disrespect for human life, they can contribute to similar acts, and so on.
Is Suicide Moral?
Before discussing different views regarding the morality of suicide, two preliminary points should be made. First, this discussion of the morality of suicide focuses on the morality of a suicidal act done by a rational, competent decisionmaker. Such a person can effectively deliberate about and understand different courses of action and the ends they accomplish, as well as different means to accomplish those ends.
Second, some ethicists argue that the subjective and objective aspects of the morality of suicide should be distinguished. The former refers to the guilt incurred by the person who commits suicide, the latter refers to the morality of suicide considered objectively as an act in itself. The idea behind this distinction is that some persons may commit suicide who are in such a state of distress (e.g., they are severely depressed, acting on false information, etc.) that their act may be objectively wrong but the individuals themselves may not be blameworthy. The act may be called a serious mistake, but excusable.
However, this distinction is a questionable one, since in such cases it could be claimed that the person was not acting rationally and since it is not clear how an act can be at once morally wrong but not blameworthy. Perhaps the act is not blameworthy in the weak sense that one can easily understand and empathize with it. But the act would still be morally blameworthy if it is a morally wrong act, and it is the moral sense of blameworthy that is of chief interest in ethics. In any case the focus here is on the ‘objective” side of the morality of suicide: Can a suicidal act as such be morally justifiable when it is done by a rational, competent decisionmaker?
THE LIBERAL VIEW: SUICIDE AS SUCH CAN BE MORALLY JUSTIFIABLE
The first view is a liberal approach to suicide. Advocates of this approach hold that an act of suicide may be morally justifiable even if that act does some harm to others, provided that the act does not do substantial damage to others and that it is in keeping with the individual liberty of the agent. Even if a person has some duty to others, say, family members, the suicide can still be morally acceptable provided the distress to others caused by the suicide does not outweigh the distress to the person who refrains from committing suicide. No person is obligated to undergo extreme distress in order to save others from a smaller amount of distress.
There are two major approaches to the morality of suicide within the liberal camp: the utilitarian approach and the autonomy approach. These views are not necessarily mutually exclusive.
The liberal utilitarian position. Richard Brandt defines suicide as the intentional termination of ones own life and argues against the view that suicide is always immoral.5 It may be appropriate, he says, to take ones own life to avoid catastrophic hospital expenses in a terminal illness and thus meet one’s obligation to ones family. It may also be the case that a person may maximize his or her longrange welfare by bringing about death.
A person who is contemplating suicide is making a choice between “world courses” — a world-course that includes his immediate suicide and several possible world-courses that contain his death at a later point. These alternatives are to be understood as world-courses, Brandt says, not as future life-courses which refer only to the alternatives for the individual alone. This is because one’s suicide or failure to commit suicide impacts the rest of the world, and the morality of suicide must take into account the welfare of all relevant parties, not just the welfare of the person contemplating suicide.
A prospective suicidal person must attempt to take into account all the relevant information, including all his own shortterm and longterm desires. Brandt argues that though one can never be certain of all these factors, he must not let this fact stand in his way. A prospective suicidal person should compare the worldcourse containing his suicide with the best alternative. If the former worldcourse maximizes utility, all things being considered, then it would be rational and morally justifiable to commit suicide.
Among the problems regarded as good and sufficient reasons for suicide are these: painful, terminal illness; some event that has made a person feel ashamed or lose his prestige and status; reduction from affluence to poverty; the loss of a limb or of physical beauty; the loss of sexual capacity; some event that makes it seem impossible to achieve things deemed important; loss of a loved one; disappointment in love; and the infirmities of increasing age. If a person experiences these or other serious blows to his prospect for happiness, he may be justified in suicide if such an act maximizes the net amount of utility compared to alternative acts. In cases of morally justifiable suicide, others are morally obligated to assist in executing the decision, says Brandt, if the person needs help.
The liberal autonomy position. A second liberal approach to the morality of suicide is the autonomy position. Major advocates of this view are Tom L. Beauchamp and James F. Childress.6 They state that persons should be allowed to be selfdetermining agents who make their own evaluations and choices when their own interests are at stake. If a person is a competent, rational decisionmaker, he has a right to determine his own destiny even if others believe that a course of action would be harmful to the individual.
The principle of beneficence states that a person should seek to benefit others and himself, and the principle of nonmaleficence expresses the duty to not harm others or oneself. In a case of rational suicide, there may be a conflict of duties between autonomy on the one hand, and beneficence and nonmaleficence on the other hand. In such cases autonomy should take precedence over other moral considerations. Disrespect is shown to individuals and the principle of autonomy is violated if the right to commit suicide is denied when, in their considered judgment, they ought to do so and no serious adverse consequences for others would result (such consequences do not necessarily present overriding grounds for opposing suicide).
The autonomy view is consistent with both a utilitarian ethic and a deontological ethic. If the autonomy view is utilitarian, then the principle of autonomy is justified on the grounds that accepting this principle maximizes utility compared to rejecting autonomy and acting on alternative rules. In this case the autonomy view becomes a way of expressing a utilitarian approach to the question of suicide.
If the autonomy view is deontological, then it becomes an alternative to the utilitarian approach. Here autonomy is seen as an expression of an intrinsic duty to respect persons and the priority of autonomy vis á vis beneficence and nonmaleficence becomes an attempt to emphasize individual liberty and qualityoflife considerations regarding suicide.
THE CONSERVATIVE VIEW: SUICIDE AS SUCH IS NOT MORALLY JUSTIFIABLE
The conservative view holds that suicide as such is not morally justifiable. A number of reasons have been offered for this view: It violates one’s sanctityoflife duty to respect oneself as an end and not a means, it violates a natural law principle that man’s very nature is such that he has an inclination to continue in existence and he has a moral duty to act in keeping with that nature, it violates man’s duty to God as the Giver and ultimate Owner of life, it violates one’s duty to one’s community by injuring that community in some way.
According to Hauerwas, an ethics of autonomy (where the principle of autonomy overrides all other moral considerations) implies that suicide is not only rational, but also that it is a moral right.7 This shows, Hauerwas says, how inadequate a minimalistic ethic of autonomy and a nonnaturalistic view of rationality really is as an overall approach to morality, suicide included. An ethics of autonomy has an insufficient view of the good lifethe life of the virtuous person and community that each person ought to seek. As a result an ethics of autonomy fails to explain why anyone should decide to keep on living in the face of difficulties.
First, Hauerwas argues that the basic reason suicide is wrong is that life is a gift bestowed by a gracious Creator. While there are other reasons against suicide, any account of suicide must consider the rational support given for the factual belief that human lives are gifts from Cod. Because life is a gift, man is obligated to his Creator to live. Living is an obligation in that man is to go on living even when he is far from figuring out why things happen as they do. This obligation expresses the rational belief that Cod gives purpose to life in the midst of hardships.
Second, Hauerwas states man should not commit suicide because of his duty to others in the community. People should not be viewed as atomistic individuals who are loosely connected to others. Rather, people live in systems. A persons existence depends on his and other’s lives in community. Their willingness to live in the face of pain, boredom, and suffering is (a) a moral service to one another; (b) a sign that life can be endured; (c) an opportunity to teach others how to die, how to face life, how to live well, and how a wise person understands the connection between happiness and evil (e.g., one does not obtain joy or live a good life only when he avoids hardship, but when he learns to live with it); and (d) a way of refusing to give the community a morally unhelpful memory of the person who committed suicide, which could hurt those left behind in their attempt to live well as individuals and in community with others. An act of suicide signals the failure of the community to be present to care for the suicidal person in his time of need, and it signals the person’s lack of care for the community.
Third, Hauerwas argues that suicide is inconsistent with the very nature of medicine, especially the authority of medicine. Medicine is not to be defined merely as a technological field. The authority of medicine is not just that of a technologically skilled group of people. It is the authority of a virtuous profession wherein people in a community signal the virtue of being present for one another in time of need. The medical professional expresses his or her commitment to be present to heal or to care for the weak and sick when care cannot be reciprocated. The sick person signals his or her desire to place trust in the community’s representative, the medical personnel, and allow the community to care for that person in time of need. Suicide signals a break in this value to be present for one another in time of need, and thus suicide is inconsistent with the presuppositions that make medicine itself intelligible.
ASSESSMENT OF THE VIEWS
Broad world view considerations. The debate about suicide clearly surfaces two fundamentally different sets of presuppositions about how to approach broad issues such as the purpose of life, the nature of morality, community, medicine, and persons, and the ultimate ownership of life. Thus the debate about suicide is difficult to separate from broad world view considerations. What is the good life, what is the point of life, and how does one’s answer to these questions inform one’s perspective about the nature and purpose of suffering? Is life sacred? Should life be treated as a gift? Is utilitarianism a better approach to ethics or is a deontological view a better approach? Is a quality of life or a sanctity of life approach to suicide preferable? Should persons be ultimately viewed atomistically, as individuals, or should they equally and irreducibly be seen as members of a community to which they are responsible? Is medicine to be understood along the traditional lines as presented by Hauerwas, or should it be seen as a contractual arrangement between patient and physician wherein medical goods and services are obtained so long as the patient wishes to have them?
The liberal and conservative views tend to answer these questions differently. Their competing views on the morality of suicide express deep differences on these basic, world view questions. It is beyond the scope of this article to attempt a broad analysis and evaluation of these different outlooks, apart from some brief, specific considerations to be offered shortly. One’s view about the morality of suicide is an expression of one’s general world view. It is here that a JudeoChristian world view becomes especially precious and relevant.
The statements of the liberal and conservative views above have already presented some of the specific arguments relevant to assessing these positions. Further, the arguments against the liberal views function as arguments for the conservative view. Therefore the following pages focus directly on criticisms of the liberal position. These criticisms show that the liberal view is morally inadequate and the conservative view is to be preferred.
Criticisms of the liberal utilitarian view. First, the liberal, utilitarian view is problematic because of the difficulties inherent in utilitarianism in general (e.g., the failure to treat people as ends in themselves and the failure to recognize the fact that some moral rules are intrinsically right). Further, if a utilitarian justification is offered for a specific act of suicide, then that justification proves too much; it does not merely make the act of suicide permissible, it makes it morally obligatory. Why? Because one is morally obligated to maximize utility, and if an act of suicide maximizes utility, then it would be morally obligatory. But any view which makes a suicide obligatory is wrong.
Utilitarians respond to this argument in two ways. First, they argue that under certain circumstances, a rule requiring suicide would not be morally wrong. Deontological ethicists argue that this rule would dehumanize persons by treating them as a means to an end and by elevating a qualityoflife standard above a sanctityoflife standard. It should be clear that ones evaluation of this debate will turn on ones opinion regarding the relative merits of utilitarianism versus deontological ethics and quality of life versus sanctity of life.
Second, utilitarians argue that a rule requiring suicide in certain circumstances might turn out to be wrong because adopting such a rule may itself fail to maximize utility. Deontologists respond by pointing out that utilitarians cannot rule out the possibility that such a rule may maximize utility and in any case the moral impermissibility of a rule requiring suicide is not grounded in utility considerations but in the moral inappropriateness of requiring someone to treat himself or herself as a means to an end.
Criticisms of the liberal autonomy view. Other criticisms can be raised against the autonomy model which apply to the utilitarian model as well. For one thing, the liberal view in both forms violates a person’s duty to himself or herself. This has been expressed in several ways:
- To take ones own life is to deny its intrinsic value and dignity. It is to assume wrongly that man is the originator and therefore the controller of his life.
- Some have offered a natural law argument to the effect that everything, human nature in particular, is naturally inclined to perpetuate itself in existence. In response, it has been pointed out that suicidal persons do not have this inclination to continue existing. But this response fails to recognize that the notion of inclination used in natural law arguments is not to be understood as a psychological preference for life, but as a normative, natural urge grounded in ones nature as a human being.
- Suicide is wrong because it involves the direct, intentional killing of human life. Such an act treats persons, who have intrinsic value, as means to ends.
- Suicide is also a self-refuting act, for it is an act of freedom that destroys future acts of freedom; it is an affirmation of being that negates being; it serves a human good (e.g., a painless state) by violating other, more basic human goods (e.g., life itself) as a means to that end; it is an act of morality that gives up on all other moral responsibilities and rejects the moral way of life.8
- Suicide runs the risk of being an inappropriate way of entering life after death. Even if one does not believe in life after death, such a state is possible and perhaps reasonable in light of arguments that can be raised in support of it. Either way, it is unwise to risk entering life after death in a morally improper way.
As Hauerwas has pointed out, the autonomy model fails to capture the importance of community, the traditional understanding of medicine as a morally authoritative vocational expression of the community’s respect for life, and a virtuous understanding of the good life and suffering. Suicide fails to explain adequately why anyone should continue to live when he no longer wishes to, and thus it is inappropriate from a moral point of view.
Paternalism and Suicide Intervention
GENERAL STATEMENT OF THE VIEWS
Is it justifiable for some agent of the state coercively to prevent a suicide or to compel a competent adult to take life-saving medical treatment? Opinions differ on these questions. The libertarian view opposes such paternalistic interventions because they are considered a violation of individual liberty, patient autonomy, and the respect for persons that presents an obligation to respect the wishes and desires of competent, adult decisionmakers (provided of course that no overriding harm is done to others). In this view people have a right to commit suicide.
The second view, the beneficence model, is generally in favor of such interventions to keep the person from serious and irrevocable harm. Society has a duty to prevent people from harming themselves in acts of suicide.
Paternalism is the refusal to accept and go along with a person’s wishes, choices, and actions for that person’s own benefit. Paternalism is rooted in the idea that the community as represented, say, in a physician, has better insight into what is good for a patient than does the patient, and thus can do what is medically good for the patient even if it is not judged good by the patient’s own value system.
Strong paternalism involves overriding the competent, rational wishes, choices, and actions of another. Individual liberty is overridden because of benefit to the person, even though that person is not impaired as a decisionmaker. Weak paternalism involves acting in the best interests of a person who is impaired as an actor or as a decisionmaker. There is little disagreement that weak paternalism is morally justifiable. In fact most ethicists do not see it as paternalism at all, because it involves acting or deciding for a person who is incapable of doing so. Often such interventions eventually restore patient autonomy and liberty.9
The principle of respect for persons requires that persons be treated as ends in themselves and never as a means only. Respect is shown for the intrinsic worth and dignity of a person. The principle of autonomy requires that individuals should respect the selfdetermination of others by not doing for them what they would not want done to themselves and doing for others what they would wish done to themselves. The principle of beneficence says that people have a duty to benefit others and to act in their best interests. Beneficence comes in degrees: one ought not inflict harm on others, one ought to prevent harm, one ought to remove harm, and one ought to do good.
EXPOSITION AND EVALUATION OF THE VIEWS
The libertarian view. According to Engelhardt, in the present secular society moral pluralism must prevail.10 Individual communities may share a substantive vision of the good life (and the good death), but a peaceable secular state must remain pluralistic and must respect rights that preserve individual liberty. Peace is maintained only by respecting the principle of autonomy as the supreme moral principle. Autonomy prevails in every situation, provided of course, that autonomous actions do not do overriding harm to others. Beneficence is important, says Engelhardt, in that it gives content to different individual or community visions of the good life. Thus beneficence preserves autonomy.
Regarding suicide, a rational, competent decision-maker has the autonomous right to refuse life-saving treatment or to commit suicide without interference. Further, such individuals have a right to be assisted in suicide by others. In a peaceable, secular state, it is wrong to interfere with the moral authority expressed in free choices of individuals or those who assist them in refusing treatment or in committing suicide. In such a state autonomy reigns supreme and paternalistic interventions are unjustifiable.11
Several strengths have been claimed for the libertarian view. First, it is important to respect the principle of autonomy, individual rights, and the privacy of individuals, and the libertarian view attempts to express this respect. Second, respecting the autonomy of a person can be part of what is needed to cure that person, so violations of patient autonomy can do harm. However, when it comes to suicide, this point is not applicable. Third, the libertarian view is a reaction to class dominance, and in a pluralistic society, legal moralism (liberty is limited to prevent a person from acting immorally) can easily be an oppressive tool in the hands of an elite. Forcing someone to live against his or her own will can be oppressive and fails to respect persons, so the argument goes, by failing to honor his selfdetermination.
In spite of these strengths, a number of weaknesses in the libertarian view have been surfaced. First, this view easily degenerates into an inordinate individualism that fosters, under the guise of respect for autonomy, disinterest in the plight of others and premature abandonment of a patient in time of need. Honoring autonomy is not always the best way to respect a person, especially when he is autonomously choosing to disrespect himself in a serious way. Suicide is a serious act of disrespect for oneself, even when chosen autonomously, and so honoring a suicide disrespects a person. Freedom is not a bare, formal principle. People are free to do what they ought to do, they are not entitled to do anything they want to do, and suicide violates the sanctity of life.
Second, the libertarian view fails to recognize that decisionmaking is an interpersonal process. The physicianpatient relationship, the familyindividual relationship, and other important relational systems (e.g., friendships) should be part of decisionmaking. Usually when a person is contemplating suicide, the others in that person’s system will argue against it out of respect for the sanctity of life and the desire not to lose the suicidal person. Admittedly this may not be true in all cases. But the libertarian model does seem to individualize decisionmaking inordinately and fails to guard adequately against hasty decisions that may not be morally justifiable.
A third, related point is that the libertarian view, in its retreat to private morality, treats people as atomistic individuals. Thus it fails to come to grips with the common good, the nature of community and how community constitutes part of what it is to be a person, and the community’s interests in preserving the sanctity of life.
This atomistic view of individuals also distorts the patient-physician relationship by viewing it as an autonomous contractual agreement for the exchange of services that both parties enter freely. But the patient-physician relationship is a commitment between unequal parties (the patient needs healing) which must be present in order to heal. This involves altruistic, but authoritative beneficence on the part of the physician, and trust on the part of the patient. This model can be abused, but it does seem to capture the real nature of the patient-physician relationship. The physician is committed to healing, and suicide is an act against that commitment.
Fourth, as Callahan has pointed out, the libertarian view expresses a minimalistic ethic (one may morally act in any way he chooses if he does not harm others).12 The libertarian view, as a minimalistic ethic, has a number of features that make it barren and inadequate as a social ethic. It confuses a useful principle for government regulation with the broader requirements of the moral life; it inappropriately draws a sharp line between the public and private spheres with different standards for each; it has a shriveled notion of publicprivate morality in its reduction of interpersonal, moral obligations to a simple honoring of those agreements people have freely and voluntarily entered; it fails to account for the moral importance of communal life, the common good, and shared values; and it tends to view all interventions into autonomous adult decisionmaking in a negative light.13
Fifth, the libertarian view utilizes the wrong notion of rationality. On this view, rationality is nonnormative rationality: the ability to competently understand options and their consequences, formulate means to ends, and so on. Such a view of rationality in morality tends to reduce substantive ethics to procedural ethics: one arrives at a morally correct outcome if he uses the correct procedure in reaching that outcome. In the case of suicide, if a rational procedure was followed in the deliberation process, the choice of suicide is correct.
A more adequate view of rationality is a normative one: One is morally rational if one has the ability (perhaps through the cultivation of virtue) to gain insight into what is morally true and good. This view of rationality emphasizes the substantive aspects of ethics. It is true that men of good will frequently differ over what is in fact morally true and good. But the solution to this is an emphasis on argumentation and virtue, not a retreat to nonnormative rationality and procedural ethics. The libertarian view does the latter and for that reason is inadequate.
The beneficence view. Advocates of the beneficence view are more sympathetic to the legitimacy of limiting individual liberty, including the right to commit suicide, in order to (a) benefit the individual and prevent him or her from serious and irrevocable harm, (b) preserve the common good and the community’s interest in the sanctity of life, and (c) preserve the beneficent, healing, covenantal model of medicine.
It may be best to view the libertarianbeneficence debate as a continuum, with the former emphasizing quality of life, individual autonomy, and nonnormative rationality, and the latter emphasizing sanctity of life, beneficence, the common good, and normative rationality. Not all advocates of the libertarian view would sanction every act of rational suicide and not all advocates of the beneficence model would hold that a line is never crossed where a person should be permitted to commit suicide. Some advocates of the beneficence model hold that all acts of suicide require intervention, while others would severely limit the permissibility of suicide but agree that in some rare and extreme cases it may be allowed.
Two main advocates of the beneficence model are Edmund Pellegrino and David Thomasma.14 They argue that autonomy should not always win in medical conflicts and that in general, beneficence should be ranked higher than autonomy. This ranking is grounded in a virtue approach to ethics, which involves respecting the sanctity of life, the traditional view of the physician as a beneficent healer, and the common good.
Pellegrino and Thomasma express their views about suicide in the context of the Elizabeth Bouvia case. In 1983 Elizabeth Bouvia, a 26-year-old who was virtually quadriplegic, dependent on others for her bodily functions, and suffering from intense pain, entered a California hospital and stated that she wanted to starve to death. A lower court rejected her petition and authorized involuntary tube feedings. In April 1986 the California Supreme Court granted removal of a nasogastric feeding tube from Bouvia on the grounds that she was a rational, competent decision-maker and that her request was in keeping with patient autonomy and privacy.
Pellegrino and Thomasma agree that a competent person has a moral right to refuse life-sustaining systems, but assisted suicide is clearly wrong and once a feeding tube was given Bouvia, its removal was wrong because it involved a clear intent to bring about death. By contrast other advocates of the beneficence model would not agree that Bouvia had a moral right to refuse life-sustaining treatment. Thus advocates of this view are more conservative than those of the libertarian view, but differ over the right to refuse life-sustaining treatment for a nondying patient.
The morality of suicide clearly surfaces how broad world view considerations are important for understanding and evaluating different moral positions. In the final analysis one’s approach to suicide is determined largely by the world view one brings to the issue. Christian leaders should study the general arguments involved in suicide and other ethical issues of broad cultural concern. When they do, they will be in a better position to discuss the issues while being sensitive to the secular, pluralistic nature of the culture. Also they will have excellent opportunities to present the gospel of Christ at intellectually appropriate places in the discussion.
1 Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 2d ed. (New York: Oxford University Press, 1983). pp. 93-95.
2 Stanley Hauerwas, Suffering Presence: Theological Reflections on Medicine, the Mentally Handicapped, and the Church (Notre Dame: University of Notre Dame Press, 1986), pp. 10-35.
3 Tom L. Beauchamp, “Suicide,” in Matters of Life and Death, ed. Tom Regan (Philadelphia: Temple University Press, 1980), pp. 75-77.
4 Some add the qualification that death must occur fairly quickly after the action or omission. See Life-Sustaining Technology and the Elderly (Washington, DC: U.S. Government Printing Office, 1987), p. 150. But the time factor is extremely controversial and an act could be suicidal even if death did not occur for some time.
5 Richard B. Brandt, “The Morality and Rationality of Suicide,” reprinted in Biomedical Ethics, ed. Thomas A, Mappes and Jane S. Zembaty, 2d ed. (New York: McGrawHill Book Co., 1986), pp. 337-43. See also, Beauchamp, “Suicide,” pp. 78-96.
6 Beauchamp and Childress, Principles of Biomedical Ethics, pp. 93-101.
7 Hauerwas, Suffering Presence: Theological Reflections on Medicine, the Mentally Handicapped, and the Church, pp. 100-13.
8 This type of argument is offered by Albert Camus, “An Absurd Reasoning,” in The Myth of Sisyphus and Other Essays (New York: Vintage Books, 1955), pp. 3-48.
9 For further distinctions regarding paternalism, see James Childress, Who Should Decide? Paternalism in Health Care (New York: Oxford University Press, 1982), pp. 12-21.
10 H. Tristram Engelhardt, Jr., The Foundations of Bioethics (New York: Oxford University Press, 1986), esp. chaps. 13 and pp. 301-20.
11 A less extreme libertarian view is expressed by Childress, Who Should Decide? esp. pp. 28-76, 157-85. Childress grounds his argument against paternalism not in the principle of autonomy, but in the principle of respect for persons. Thus respect for a person may require nonintervention if that honors a person’s wishes, choices, and actions Childress holds that paternalism is altruistic beneficence and generally ranks beneficence below autonomy because the latter may more clearly express respect for persons. However, it could be argued that in an act of suicide, a person actually disrespects himself or herself, and while allowing a suicide may in one sense respect a person, yet because of the finality of suicide, such an act shows overriding disrespect for the individual. Thus it shows more respect for persons to interfere with an autonomous suicide than to allow it.
12 Daniel Callahan, “Minimalistic Ethics,” Hastings Center Report 11 (October 1983):19-25.
13 Ibid. For more on the contrast between liberal and conservative approaches to abortion, infanticide, euthanasia, war, and capital punishment, see J. P. Moreland and Norman Geisler, The Life and Death Debate: Moral Issues of Our Time (Westport, CT; Praeger Books, 1990).
14 Edmund D. Pellegrino and David C. Thomasma, For The Patients Good: The Restoration of Beneficence in Health Care (New York: Oxford University Press, 1988).