Waiting Around to Die

They were among my father’s last words, uttered a few days before he died. I sat in one of the kitchen chairs next to the hospice bed set up in the den where the television normally stood. Dad’s emaciated frame was racked with cancer; he couldn’t have weighed more than eighty pounds. With visible effort, he lifted his head off the pillow and gazed into middle distance above my right shoulder.

“Isn’t it awful strange?” he said. He’d left Belfast more than thirty years earlier, but he’d never lost his Shankhill brogue.

“What’s that, Dad?” I asked him.

He gestured feebly with one hand, as if to take in the bed, the pill bottles, the emesis basins—the whole bleak scenario of the last few months. “This,” he said. “Just waiting around to die.” At the risk of minimizing my father’s physical pain and mental torment, those months of waiting around were an agony for all of us.

The opiate tablets we were to give Dad for his breakthrough pain had a red-printed warning on the packaging of each dose: chewing the pill would lead to a rapid and fatal absorption of morphine. The warning struck me as having a kind of subtext—all my father had to do was chew, and his ordeal would be over.

I knew he wouldn’t chew the pill. A deeply religious man, my father had long embraced an austere Protestantism held over from his Ulster upbringing. Though we seldom ever spoke about suicide, I knew he considered it to be a grave sin—a transgression that swept the offender beyond any opportunity to repent of it. I knew better than to argue—his beliefs were marrow deep—but I wondered why an immortal soul would never, in all of eternity, find a chance of contrition for something done in this life.

The idea that suicide is a sin was introduced to Western culture about fifteen centuries ago. “No suicide described in the Bible is spoken of in terms of condemnation,” David J. Mayo writes in the Journal of Personal & Interpersonal Loss.

[T]he historian Gibbon (1947) notes that some early sects of Christians, convinced that martyrs would be gathered under the throne of God, sought martyrdom by taunting Romans until they were executed. This disturbed St. Augustine, who responded in the 5th century with biblical and other religious arguments to the effect that suicide was contrary to God’s will. Augustine’s condemnation of suicide became church doctrine at the Councils of Orleans, Braga, and Toledo in the 6th century and eventually found its way into law throughout Europe and the United States. As recently as a century ago, attempting suicide was not only illegal in Great Britain but was a capital offense.

Those vestiges of dogma continue to haunt our contemporary discussions of suicide. Much of the modern ethical writings about the taking of one’s life focus only on end-of-life decisions and medical assistance—the so-called “rational suicides.” These are suicides where the person in question is capable of weighing the pros and cons of ending his or her life. Terms like “terminally ill,” “agony,” and “humiliation” appear again and again in the literature. The discussion less often addresses those in good physical health.

In each of the three U.S. states where physician-assisted suicide is now legal—Washington, Oregon and Vermont—patients must meet a number of criteria before the physician can act with criminal impunity. All three states require a few common benchmarks, most notably that patients must be mentally competent to make such an irrevocable decision, and they must have a medically verified life expectancy of less than six months.

These criteria at first seem reasonable to me, maybe even virtuous. Of course we would want this kind of end-of-life decision to be a rational and deliberated choice. Of course such an extreme option should be limited to those who have no hope of recovery and can only look forward to pain and degradation. But what if terminal illness isn’t really a preeminent factor in actual cases of elder suicide? What if some sort of mental illness was more often present? How would that change the tone of my musing?

Edwin Schneidman, the father of modern suicidology and the cofounder of the Los Angeles Suicide Prevention Center, coined the term “psychological autopsy” to mean a rigorous investigation of all the antecedents to a suicide. It’s a painstaking reconstruction of what a person did and said and seemed to feel in the days leading up to his or her death. It also incorporates police reports and medical records and the testimony of friends and family.

The journal Aging and Mental Health recently published a study that performed psychological autopsies on ninety-five suicides among the elderly. As a sort of control group, the authors also performed psychological autopsies on ninety-five deaths by natural causes from the same years and the same population. In this way the situations of those who took their own lives could be compared, in a statistically rigorous way, with similar people whose deaths were not due to suicide. In all 190 cases, the last six months of life were studied.

While debate about the ethics of elder suicide tends to revolve around terminal illnesses and loss of autonomy, those end-of-life issues didn’t turn out to be the common causes of real-life suicides among the elderly. The study found that those who took their own lives actually had less impairment of “functional autonomy” in their final months of life. Those who took their own lives also had fewer chronic health problems than those who died naturally. “In our study,” the report observes, “suicide cases were found to have a lower risk of having cancer, emphysema, and cardiovascular disease at the time of death.”

Now, one could posit that these elderly people had decided to end their lives precisely because they were still able to and because they anticipated imminent impairment. Significantly, however, the study found that mental health, most notably depression, was a variable that showed up much more frequently in the suicide cases than in the control cases. Based on the psychological autopsies, “the suicide cases were ten times more likely to present a current psychiatric disorder during the six months preceding death than the controls.”

All of which complicates how we think about elder suicide. It might be another vestige of dogma, but why am I more inclined to privilege physical pain and external circumstances when I consider the ethics of suicide? Why does internal pain, in the form of mental illness and chemical imbalance, strike me as a less acceptable reason? And isn’t this why physicians’ opinions are part of the law—because we want to limit suicide to those who are unarguably rational?

Valica Boudry, a journalism professor at the University of Wisconsin, compared newspaper coverage of suicides in 1993 and 2003. This was an attempt “to see how suicide was ‘framed,’ or placed in a social context.” In other words, what narrative do we, as a culture, use when we talk about suicide? Boudry examined a total of 442 articles about those who had taken their own lives and tallied the reasons given in the reports.

Many articles offered no reasons; they just reported a death as a suicide. But, in 1993, eighteen articles mentioned mental illness as the cause, while 140 blamed the suicide on personal problems like custody battles or financial ruin. The articles from 2003 were similarly disproportionate: mental health was mentioned only twenty times, while 107 suicides were attributed to situational problems.

“Americans are in part still blaming individuals for suicide, instead of accepting the role of mental illness,” Boudry concludes. “Culturally, Americans seek to understand why someone would commit suicide instead of accepting mental illness as the likely culprit. The illness is generally the why.”

So is the cultural stigma that haunts our idea of suicide really a stigma about mental illness? And could this be another cultural vestige of dogma? Am I still in some way conflating mind with soul? In other words, do I still tacitly deem mental illness a kind of “soul-sickness” rather than a chemical imbalance or a neurological disorder?

Edwin Schneidman also coined the term “psychache.” It was a word he used as a label for a kind of unremitting psychological pain. The agony of “excessively felt shame or guilt, or humiliation, or loneliness, or loss, or sadness, or dread of growing old, or of dying badly.” It is, in a sense, the psychological equivalent of a painful disease that does not respond to therapy and severely affects one’s quality of life.

But Schneidman’s two ideas—psychache and psychological autopsy—seem at odds to me. Can any post hoc gathering of information ever let us understand the psychache that leads to suicide if we have never felt it ourselves? Do I have any grounds for assuming that my father’s physical suffering was qualitatively different than the mental pain that leads a physically healthy man or woman to suicide?

In her 1979 essay collection, The White Album, Joan Didion talks about our need to fashion our lives into some kind of narrative we can make sense of. The alternative—senselessness—is simply too bleak an option. “We tell ourselves stories in order to live,” Didion writes. “We look for the sermon in suicide, for the social or moral lesson in the murder of five.”

The need to find a kind of sermon in suicide is understandable. We want the stories of our lives to make sense. We prefer the rational over the irrational. When it comes to suicide perhaps we also want a comforting narrative that will explain why we are not like them.

I wish my father had had a much briefer and less painful death, and I would have wholeheartedly supported his decision if he had chosen to chew the morphine pill and avoid those last few weeks of senseless torment. But I have no idea why I demur from allowing the same option to those whose unremitting pain is “merely” mental, who are physically capable of living on for years but do not want to do so. Ultimately, I suppose, the way we talk about suicide, even elder suicide, reflects the bigger, supremely complicated question of how we think about humanity—what it means to be in pain, what it means to be rational, which choices should be collective, and which should be autonomous.