Major support for The Suicide Plan is provided by the John and Wauna Harman Foundation.

The “S”-Word: Suicide and the Right-to-Die Movement

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The question of how to describe the act of choosing to end your life is so controversial that even advocates disagree about how to define it and what to call it.

For some involved in the right-to-die movement, assisted suicide is a term laden with the stigma associated with mental illness. To them, the word “suicide” is so pejorative they refer to it as the “s-word.”

For others, it’s simply the definition of death by choice.

FRONTLINE producers Karen O’Connor and Miri Navasky spoke with two leaders on both sides about their approach to the question. Selections from their conversations are below:

BARBARA COOMBS LEE: President, Compassion & Choices

A longtime advocate of aid-in-dying, Coombs Lee leads one of the major nonprofit groups dedicated to protecting and expanding the rights of the terminally ill.

I think that people who see no distinction, no difference between suicide and aid in dying have probably not had very much experience with either, because experientially, they’re diametrically opposed. They’re not just a little bit different. They are diametrically opposite experiences. And I have had experience with both.

When someone whom I cared about committed suicide, it [felt] like a violation. The feelings that come up are not only shock and disbelief and anger and guilt and shame, and “What could I have done more? Clearly she was mentally imbalanced. Clearly we weren’t all there for her in some crucial way.” And it takes years to work through how that mental illness could have been managed better so that her self-destructive impulses weren’t realized — because that’s what they were. She was mentally ill, and she had disordered thinking and self-destructive impulses.

In aid in dying, the people are left with, well, sadness of course — “Dad isn’t here with us anymore,” grief, a sense of loss, “He’s gone,” — but such an overwhelming affirmation of who he was, and what I meant to him, and what he meant to me, and that I was privileged to be part of it. And the respect and the affirmation of the life, that Dad cared so much about the meaning of his life and the meaning of his death, and how that would be carried forward in our family, that this is [he] shaped the experience for us. I don’t feel anger or guilt or shame. I feel love and I feel privilege.

Is that determined by the method use, or the intent?

No, It’s determined by whether [laugh] it’s suicide or aid in dying. It has to do with whether it was self-destructive of personhood — “I don’t want to be in this world; I’m going to destroy myself” — versus “My life has been beautiful. My time on this earth has been well spent. My meaning is complete. My joy is unimaginable. It is at an end.”

Between those two extremes, is there a continuum? There are rational suicides.

I don’t know if I would agree with that. I think that if the impulse is toward self-destruction, destruction of the life, that that is indicative of disordered thinking because the will to live is so very strong. I think that is the definition of the difference between suicide and aid in dying. …

I’m having trouble thinking of too many examples along that continuum, because as I said, the will to live is so great that the impulse to self-destruction is a pathological impulse, which can usually be treated effectively with psychiatric care and medications.

I’m thinking of John Welles, Hunt Williams’ friend. He chose to take his own life with a gun. It represented absolute control to him. Is that a suicide?

My sense is John Welles wouldn’t have chosen that if he’d had better options. He was terminally ill. He was dying of cancer. He was at the point where he was starting that very steep decline, and he wouldn’t have been able to have the wherewithal to kill himself if he’d waited too much longer.

Society let him down. We let John Welles down, because we didn’t offer him an aid-in-dying option, and he was forced to use the violent means in what should have been a peaceful end. …

… So there’s a philosophical belief that this is not suicide, but it’s also critical in terms of that legal issue.

The difference between aid in dying and suicide is not a semantic issue. It’s not a linguistic nicety. It’s a legal distinction. It’s a legal distinction in Oregon, and it is an error to call the practice, as it is practiced in Oregon, suicide. Assisted sui– physician-assisted, all those things are illegal in Oregon, and so if you call it that, you’re essentially still accusing people of a felony. There is a felony in Oregon, it is enforced, it has been strengthened, and it’s got nothing to do with aid in dying.

In Oregon, what would be an assisted suicide?

An assisted suicide would be aiding and abetting a mentally ill, imbalanced person to act on their self-destructive fantasies, their self-destructive ideation. …

So assisted suicide in Oregon always implies mental illness?

Assisted suicide in Oregon always implies something quite out of the medical practice. It is not a medical practice. It is not engaged in with the kind of diligence and evaluation and care and end-of-life concern that aid in dying is.

Do you hope that aid-in-dying will some day be extended to those who aren’t terminally ill?

I don’t think that aid in dying — that is, the access to life-ending medication — is appropriate for either the chronically ill or the mentally ill. I think that it’s appropriate for the terminally ill. For people who are not deciding, “Should I live or should I die?” but for people for whom that decision has been taken away from them. They are dying. And the only choice they have is how. What might the circumstances be like?

I think the aid in dying … is properly reserved to people who are terminally ill and mentally competent. That’s really what it’s all about. And I don’t see it extending to people who are mentally ill or chronically ill. I don’t think that the American people would support that kind of extension, and I personally would not support that kind of extension.

DEREK HUMPRHY: Advocate and Author, Final Exit

As the founder of the Hemlock Society and author of Final Exit, a book that explains how to take your own life, Humphry is often considered the father of the right-to-die movement in the U.S.

There’s been a shift in language. Compassion & Choices objects to “assisted suicide” and prefers “aid in dying.”

I find that hypocritical. I mean, “aid in dying” is perfectly good English, but it could be just giving the person love and comfort and an aspirin, and it doesn’t actually say what you mean. But “assisted suicide” says what you mean. You’re not beating about the bush.

Why the euphemisms? Are they strategic decisions? Why the indirectness?

The indirectness is other people’s choices. I’ve never stopped using the word “assisted suicide.” But “assisted suicide” says what it means. And I think the general public now has come to understand that the phrase “physician-assisted suicide” is help to die. I’m not in with those who want euphemisms. …

Did you have concerns that [your book Final Exit] could be used under the wrong circumstances?

That, I knew, was a possibility. Remarkably few people, mentally ill, commit suicide. When you look at the actual figures, it’s very small. In America, 2.5 million people die in the normal course of events at the end of their life; 30,000 commit suicide for unknown, varied reasons. So the comparison is very small.

Then I look at another [fact]. Guns are sold all over America. I can walk in any shop and buy a gun, as a decent citizen. Guns are meant for hunting or self-protection. Most American men who commit suicide use a gun. The makers of guns don’t mean them for suicide, but they’re misused. A mere knife to cut up your meat or your bread is not meant for suicide, but many people use it to slash their wrists. Anything can be misused. And my book is sometimes misused, but I think the greater use and the greater service of Final Exit is to the intelligent people who have reached the end of their life and are dying, [who] want a quicker escape. …

Legalization efforts are specifically for the terminally ill. Some believe it should be extended to those with irreversible and chronic illnesses. Where are you on that?

Perhaps I’m a stick in the mud, but I’ve always argued that assisted medical dying should be for the terminally ill and the hopelessly ill with degenerative diseases. I have said, and it’s on record, that assistance for the mentally ill might come in many years’ time, when we understand mental illness better and there’s a more tolerant society, but that’s something in the future. And the right-to-die movement as I try to influence it stays away.

Now, mental illness is great suffering. I don’t diminish it at all. And people tell me that their suffering is as great as somebody with advanced cancer, and so forth. And at least somebody with a terminal illness knows that it’s going to end, one way or another. People with mental illness, unless they commit suicide, live on and on with their suffering. But that’s another subject. I don’t think it’s one that I or we can solve at present. I don’t think society’s ready to tackle that side of it. … And there are ways to alleviate with drugs a good deal of mental illness.

The thing that worries me is that because of the success of the right-to-die movement, with diminishing the taboo and getting some laws passed, people with mental illness problems are more and more coming to us and saying, “Well, what’s the difference? Why not help me?” And we have to say, “You know, we’re not in a position to help you. We’re finding it hard enough to help the terminally ill, meeting a lot of resistance, mainly from the churches, on this issue. We cannot offer you help.”

I personally, my very person, is that I don’t think we — as a society, all of us — have mastered mental illness at all. I think, OK, there are drugs which will alleviate the symptoms of mental illness, but I don’t think we’ve got very far in understanding it and dealing with it. I think mankind’s got a lot of work to do to master that form of suffering.

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