| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ALL ISSUES | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Book Reviews |
Lucy Davidson, M.D., Ed.S.
Key Words: Book Reviews • Suicide • End-of-Life Issues
Suicide bridges many domains—health, mental health, philosophy, ethics, jurisprudence, sociology, neurobiology, and theology—to name a few. Approaching the understanding of suicide exclusively from within one's own discipline is like looking close-up at one shade of dots in a pointillist canvas. Geriatric psychiatrists reading James Werth's book Contemporary Perspectives on Rational Suicide, in Brunner/Mazel's Series in Death, Dying, and Bereavement will get the picture.
Contributors to the book were asked to consider the following criteria for rational suicide:
• The person considering suicide has an unremitting, hopeless condition.
• The decision is made as a free choice.
• The decision-making process is sound, including 1) consultation with a mental health professional; 2) non-impulsive consideration of all alternatives; 3) congruence with personal values; 4) consideration of the impact on significant others; and 5) consultation with significant others and other professionals.
Although the book examines the broader concept of rational suicide and specifically chooses not to entertain discussion of the subsidiary issue, physician-assisted suicide, it's easy to see that many healthcare professionals might be engaged in a patient's consideration of rational suicide. Those working with geriatric populations are even more likely to come in contact with individuals who may pursue some consideration of hastening death. Although clinicians may have strong beliefs against providing the means of death to someone in their care, how will the clinician participate in or ignore the patient's examination of alternatives? If the clinician seeks to restrict consideration of suicide or to affirm alternatives that preclude chosen death, on what bases will these perspectives be conveyed to the patient? Persons from a range of moral, ethical, and professional viewpoints will find this book disturbing and helpful.
The overall impact of Contemporary Perspectives on Rational Suicide derives from its structure. Werth has alternated the paired Pro- and Con- essays of significant thinkers, practitioners, and advocates from diverse groups affected by the issue of rational suicide. Two essential things were asked of authors: 1) that they write from the perspective of their own group, and 2) that they not read manuscripts coming from the author of the paired opposing viewpoint. The first editorial prerogative gives the reader a thoughtful look through other eyes at territory that the insularity of one's own discipline might have obscured. Shared territory begins to show new features when the orienting landmarks are examined from other directions. At times, the authors' struggles to interpret definitional criteria for rational suicide highlight greater distinctions among disciplinary perspectives than differences between the Pro and Con positions. Making this multidisciplinary lens observable is a wonderful gift to clinicians who provide care in multidisciplinary teams.
The second editorial mandate creates a book that is dialogue instead of debate. It averts the usual thrust-and-parry of authors with opposing viewpoints. The reader gains a deeper understanding of what each author has to say and how that position is developed and supported. The book's structure goes a long way toward securing the idea that adversarial confrontation squanders the passion and compassion evoked by medical situations raising the question of rational suicide.
Some authors approached their discussion inductively, considering particular situations and whether Werth's criteria for rational suicide would fit. They either supported rational suicide by examining case histories that fulfilled the operational definitions or brought forth instances at odds with the criteria to demonstrate opposition. Some incisive authors also examined the implicit assumptions underlying Werth's criteria for rational suicide. Autonomy, in our present culture, is often accorded greater moral preeminence than values supporting community and social integration.
Both Daniel Callahan, in his chapter from the philosopher's perspective, and Jay Callahan, as social worker, ground their opposition to rational suicide in its destructiveness of the common good. Werth's criteria for rational suicide elevate self-determination, individual rights, control, and autonomy, to the exclusion of social well-being, community support, and the common good. Consideration of "significant others" restricts the understanding of those affected by suicide to an immediate and intimate circle.
Daniel Callahan opens by considering that the rationality of an act does not determine whether it is right or wrong. Those who begin consideration of rational suicide from the decision-points of competence and rationality regarding the individual who wants to die, forgo essential aspects of moral reasoning that should bear on such a precious decision. If primum non nocere is the physician's first responsibility, understanding the types of harm that an act may cause is prerequisite to inquiry with the individual.
Examining underlying assumptions leads to other questions. What are hopeless conditions or hopeless diseases that make them a criterion for rational suicide? Werth defines them as including, but not limited to, "terminal illnesses, severe physical or psychological pain, physically or mentally debilitating or deteriorating conditions, or a quality of life no longer acceptable to the individual." "Unacceptable quality of life" provides no guidance for rational suicide because all nonpsychotic people with suicidal intent find their quality of life intolerable. Other than hopelessness as a symptom of depression, the hopelessness of a condition may depend mostly on what one was hoping for. Hoping not to have to die after all? Hoping to exercise perpetual control over bodily functions and unassailable authority over family and subordinates? Hoping for death without dying or at least without decline? Sorting through one's hopes may be critical work at the end of life—work that would be a privilege to share with a patient. The psychiatrist who limits his task to certifying that the patient is competent, nonpsychotic, and not depressed hasn't really offered the benefit of his abilities and acumen to the person considering suicide.
Clearly, elderly persons are in the age-group most likely to have terminal illnesses and functional decline and to be viewed as particular candidates for rational suicide. They are also this country's population group with the highest suicide rates (leaving aside the issue of how rational or irrational any deaths recorded as suicides are).
Elderly individuals are more likely than younger persons to have visited a healthcare provider shortly before suicide and, thereby, they represent a considerable opportunity for intervention. However, the chapters contributed by gerontologists are some of the book's least illuminating. Each author in this Pro-and-Con pairing seems to have approached his chapter as a brief literature survey, with greater emphasis on citation than exposition. Because many of the writers cited are contributors to the book, readers especially interested in elderly patients might derive more from the section on geriatric groups by not leapfrogging ahead to those chapters. The context and substance provided by earlier offerings will make the gerontology chapters more accessible.
ACKNOWLEDGMENTS
Dr. Davidson is Clinical Associate Professor of Psychiatry at the Emory University School of Medicine.
| ||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ALL ISSUES | SEARCH | TABLE OF CONTENTS |
