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THE COUNSELING PSYCHOLOGIST / July 2000Silverman / RATIONAL SUICIDE

REACTIONS

Rational Suicide, Hastened Death,and Self-Destructive Behaviors

Morton M. Silverman

University of Chicago

One of the 15 major recommendations from

The Surgeon General’s CalltoActiontoPreventSuicide

(U.S.PublicHeathService,1999)wasto“insti-tutetrainingforallhealth,mentalhealth,substanceabuse,andhumanserviceprofessionals (including clergy, teachers, correctional workers, and socialworkers) concerning suicide risk assessment and recognition, treatment,management,andaftercareinterventions.”Therefore,Icommendtheeditorsofthisjournalforpresentingthisspecialsetofarticlesdevotedtothetopicsof suicideassessment,intervention,andprevention,aswellastheroleofmentalhealth professionals in deliberations concerning rational suicide and has-tened death. These major contributions may well serve as the template forotherprofessionaljournalstoeducatetheirreadershipsaboutcurrentcontro-versies,challenges,andopportunitiesformentalhealthprofessionalsastheyengage in clinical encounters related to death and dying, dying with dignity,andtheassessment,treatment,andpreventionofsuicideandself-destructivebehaviors.In this response article I will elaborate on some of the more controversialissues raised by Werth and Holdwick (2000 [this issue]), as well as byWestefeld et al. (2000 [this issue]). Both articles are rich in ideas, concepts,andscientificdata.Iwillcommentontheimplicationsoftheseoverviewsforthe training and clinical practice opportunities of counseling psychologists.Mygoalsaretocriticallyanalyzecertainaspectsofthestateoftheartinthesefields to stimulate and challenge thinking about working with patients whochoose to end their lives. My own training, experience, and expertise aremorefocusedinthefieldsofsuicidologyandthepreventionofmentaldisor-ders than in the areas of death and dying. Therefore I will direct more of myresponses and reactions to these areas.Probablythemostcontroversialareawithinthefieldofsuicidologytodayrelates to the appropriate role for mental health professionals in decisionsaboutdeathanddying.Specifically,Irefertotheconceptsof

rationalsuicide

and

hastened death

, and the meanings and connotations that these termsengender. Many professional organizations have prepared statements and

540

guidelines in response to the need to clarify terms, concepts, professionalroles,andlegal/ethicalresponsibilities.Amongothers,theAmericanAssoci-ationofSuicidologycommissionedaworkgrouptomakerecommendationsto its membership regarding how to respond to this topic (Maltsberger et al.,1996). As with many other consensus statements by professional organiza-tions(Farberman,1997),thiscommitteemaintainedaneutralstancependingmore research, clinical experience, political action, and legal decisions.The use of the term

rational suicide

to describe a rational decision andactiontoendone’sownlifestandsinjuxtapositiontotheassumptionthatallotherlethalformsofself-destructivebehaviorareirrational.Untiltherewasanationaldebateaboutwhohadcontrolandlegalresponsibilityforadecisionto terminate life, it was generally accepted that almost all suicides were theresult of irrational thinking and behaviors (Mayo, 1998). After all, con-sciouslydecidingtoendone’slifeisarejectionofJudeo-Christianteachings,except in exceptionally rare circumstances. Hence, I have difficulty with themerging of the two terms to describe a lethal behavior that is not necessarilyrational (Rogers & Britton, 1994).Interestingly,theconceptofrationalsuicidemainlyhasbeendiscussedinthecontextofchronicorterminalillness(i.e.,inresponsetothepresenceofadefinable and measurable physical disorder or dysfunction). It is often thecase that these physical illnesses have altered an individual’s self-image,self-concept,orabilitytoliveanormallife.Someofthebetterknownchronicand debilitating illnesses that result in a shortened life span include, but arenot limited to, Huntington’s Disease, Alzheimer’s disease, amyotropic lat-eral sclerosis (Lou Gehrig’s disease), AIDS, multiple sclerosis, and certainforms of cancer. Of note is that many of these chronic, debilitating diseasesaffectthecentralnervoussystemandhencecaninterferewithrationalthink-ing, reality testing, decision-making processes, problem solving abilities,and cognition. It therefore may not be so surprising that these diseases andtheireffectsonthetotalindividual’sself-conceptseemtobemostoftenasso-ciated with decisions regarding rational suicide and hastened death. Deter-miningrationalthinkinginapotentiallycognitivelycompromisedindividualconsidering a rational suicide remains a challenge and a responsibility thatrequires many checks and balances in the evaluative process (Rogers &Britton, 1994).The concept of rational suicide evolved in parallel with the incredibletechnological advances within the field of medicine in the past two decades.Inshort,ifitwerenotformajoradvancesinbiotechnology,treatmentmodali-ties,interventionsthatprolonglife,anddiagnosticapproaches,wewouldnotbe saving or preserving as many lives as is now routine and expected by thegeneralpopulation.Asmorepeoplelivelongerandareabletomanagebetterwith their chronic and sometimes even debilitating illnesses, we have

Silverman / RATIONAL SUICIDE 541

engaged new concepts and new emphases such as ensuring the “quality of life.” As many of these formerly acutely devastating illnesses have becomemanageable, and as more individuals have taken back “ownership” of theirown health and well-being, the healing professions have been challenged toredefine their roles and responsibilities regarding the care and protection of patients. Not only have the challenges come from within the doctor-patientrelationship,theneedtoredefineroleshasbeenstimulatedaswellbyrapidlyevolving technologies and scientific advancements.We have entered an era of bioengineering, genetics, and biotechnologythathasrevolutionizedourunderstandingofsusceptibilitytoillness,diseaseprogression,andourabilitytoeffecttreatmentresponsiveness,effectiveness,andefficacy.Inpartduetoanemphasisonqualityoflifeandendoflifedeci-sions,therehasbeenrenewedattentionpaidtotheuseofmedicationtoallevi-atepainandthemanagementofchronicpainsyndromes.Asadirectresultof individuals living longer with their illnesses and becoming more articulateabouttheirlong-termneedsinrelationshiptotheirillnesses,thefieldofmed-icine has broadened its traditional boundaries by incorporating approachesaimed at better understanding the relationship between mind and body, therole of spirituality in the healing process, and the use of alternative forms of Western medicine.Hence it is something of a paradox that as a result of major advances inextending life, society is now preoccupied with ensuring that individualsmaintainfullautonomyandcontroloverdecisionsaboutprematurelyendingtheirlives.Ofnoteisthattheconceptofrationalsuicideimpliesthatthedeci-sion and action of self-inflicted death is a rational attempt to gain or perhapsregain autonomy and control over one’s life. Are our attitudes toward deathanddyingchanging?(Stillion&Stillion,1998-1999).If,infact,wearerede-fining our concepts of what constitutes life and what is the interrelationshipbetweenlife,living,anddying,thenwemayneedanewvocabulary,classifi-cation system, and nomenclature to talk with our patients and to talk witheachotherabouthowtoassessandtreatourclients(O’Carrolletal.,1996).Werth and Holdwick (2000) present suggestive survey data from manydifferent sources (suicidologists, clinical psychologists, professional coun-selors, psychiatrists) that support their position that there is a “70% to 80%acceptability rate for rational suicide and physician aid-in-dying” (p. 518).As a clinician-scientist approaching this new challenge to traditional meth-ods of caring for patients, I want to know how many individuals are activelycontemplatinghasteneddeath.Inotherwords,Iwanttoknowhowprevalentthe problem is and for whom the problem exists. Some studies suggest thatmost individuals with terminal illnesses do not choose hastened deaths(Lokhandwala & Westefeld, 1998; Marzuk et al., 1988).

542 THE COUNSELING PSYCHOLOGIST / July 2000