Rational Suicide in the Elderly: the US perspective

A recent article in the Washington Post describes a group of residents of a retirement community in Philadelphia who hold clandestine meetings to discuss their desires for a rational end of life when they feel the time is right for them. Avoiding end stage dementia is cited as one of their particular concerns. The article is of interest as its theme is close to the heart of MDMD’s campaign. The notion of “Rational Suicide in the Elderly” is emerging as a topic for academic research – see MDMD’s review of a book on this topic published in 2017.

The article quotes Yeates Conwell, a psychiatrist specializing in geriatrics at the University of Rochester and a leading expert in elderly suicide. “The concern that I have at a social level is if we all agree that killing yourself is an acceptable, appropriate way to go, then there becomes a social norm around that, and it becomes easier to do, more common.” Prof Conwell believes that promoting rational suicide “creates the risk of a sense of obligation for older people to use that method rather than advocate for better care that addresses their concerns in other ways.” He believes that this is particularly dangerous with older adults because of widespread ageist attitudes and that as a society, we have a responsibility to care for people as they age.

MDMD agrees with Prof. Conwell that there is a responsibility to care for people (elderly and others) who need care… but only when that care is the “care” wanted by the individual. Similarly, MDMD welcomes improved palliative care for those who find that they can be adequately helped by it. Prof Conwell seems to believe that those wishing a peaceful exit from life, for good reason, and after careful consideration of all other options, should not be helped. To MDMD that is denying them the “care” that they need, forcing them to suffer against their will instead – surely not what a compassionate society would want.

MDMD also agrees that there should be no “obligation” for anyone to feel they “should” chose an assisted death if that is not their wish. However, we should not confuse “obligation” with a well-informed and carefully considered choice of something which becomes socially more available and acceptable. Married people who are unhappy with their partners are not “obliged” to divorce, however many are grateful to be able to choose this option, after careful consideration, now that it is considered socially acceptable, freeing them from the constraints of an unhappy marriage.

MDMD believes that the issue is not about “age” but about unacceptable quality of life due to incurable illness. The MDMD view is that the issues relate to likely future health, quality of life, and the individual’s ability and wish to adapt to their changing situation. These are discussed in our piece on When is a Life Complete?.

The Washington Post article cites a paper on suicide risk in long-term care facilities which reviews the academic literature. The paper concludes “Existing research on suicide risk in long-term care facilities is limited, but suggests that this is an important issue for clinicians and medical directors to be aware of and address. Research is needed on suicide risk in assisted living and other non-nursing home residential settings, as well as the potential role of organizational characteristics on emotional well-being for residents.” In the UK “rational suicide in the elderly” (or better, in the incurably ill who feel that they have unacceptably low quality of life), seems under researched. Work done by Dignity in Dying suggests that 7% of suicides were by people who were “terminally ill”. The percentage of suicides which could be considered to be rational suicides of those whose quality of life is intolerable due to incurable health conditions, is likely to be significantly larger.

MDMD agrees that much more research is needed in this area. It is something that needs to be tracked over time. Informally some people say things like “I don’t want to end up like my mother did” or “I don’t want to end up in a nursing home”, echoing the opinions of the group in Philadelphia. Such statements are very common among MDMD supporters. What will these people do in practice when they reach that stage? Will the aging baby-boomer generation take a different approach to their parents in reality if the law hasn’t changed to make it easier to end one’s life at the time of chosing? Will people just leave it too late?

Understanding and tracking trends is one thing, deciding how society should help such people have a good death is another. MDMD campaigns for carefully controlled legal access to peaceful and reliable means to end life, ideally with the help and counciling of medical professionals, to enable a good death. The current options of refusing life-preserving treatment,  DIY suicides without professional guidance, or one-way journeys to Switzerland are woefully inadequate. We need a better solution which goes hand-in-hand with better palliative care.