Article

OMEGA—Journal of Death and Dying

0(0) 1–17
Wish to Die: Suicide ! The Author(s) 2019
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DOI: 10.1177/0030222819871182
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Inês Costa-Maia1, S
ılvia Marina2 ,

and Miguel Ricou2

Abstract
This article analyzes suicidal behavior and how its inherent processes of death ide-
ation can overlap with those seeking euthanasia. We present a literature review of
three main events in suicide (suicidal ideation, suicide attempt, and suicide) in dif-
ferent populations and evaluate implications for health-care practice and risk assess-
ment taking into account the context of euthanasia. We ponder upon the motives
behind suicide and its link with wish to die requests to hasten death. We discuss
the possibility of the reversal of a wish to die as well as a potential process of
differentiating between individuals who would maintain their wish and benefit from
termination of life and others who would later change their minds.

Keywords
suicide, euthanasia, autonomy, wish to die, hastened death

Suicide and suicidal behavior are an important global burden for society cur-
rently and a cause for widespread concern. Suicide can be said to take place
when a person’s individual threshold for what he can bear in terms of emotional
pain is exceeded (Shneidman, 1993). Nonetheless, suicide can also be motivated

1
Faculty of Medicine, Porto University, Portugal
2
Faculty of Medicine, CINTESIS - Center for Health Technology and Services Research, Porto
University, Portugal
Corresponding Author:
Miguel Ricou, Department of Community Medicine, Information and Health Decision Sciences of the
Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-519 Porto, Portugal.
Email: mricou@med.up.pt
2 OMEGA—Journal of Death and Dying 0(0)

by social concerns, as illustrated by Durkheim’s classification. He distinguishes

fatalistic, egoistic, anomic suicide from altruistic suicide (Jones, 1986).
In 2013, in the United States, suicide was the 10th leading cause of death for
all ages, and it results in medical and work loss costs up to 51 billion dollars
(National Center for Injury Prevention and Control & Centers for Disease
Control and Prevention, 2011/2013). Nonfatal suicidal behavior is also highly
prevalent with an estimated 9.3 million adults reporting suicidal thoughts in the
2014 in the United States (SAMHSA, 2014). In Portugal, the 2010 suicide rate
was of 10.3 per 100,000 population, a rate higher than other violent deaths such
as car accidents and work-related deaths, but these figures appear to be an
underestimation (Carvalho et al., 2013). Such numbers unsurprisingly support
the need to further examine and understand the phenomenon of suicide and
especially the events leading up to it.
To perfect risk evaluation in suicide, some authors have tried to decide
whether death ideation can be said to be a limited state in a person’s existence
or whether certain individuals display an inherent propensity to death ideation
(therefore making it a trait, such as anxiety). It appears reasonable to classify
these ideations and attempts as limited to a certain moment in time: Suicidal
ideation is in general an infrequent and limited experience in a person’s lifetime,
just as the majority of individuals who attempt suicide do not attempt it a
second time (Klonsky, May, & Saffer, 2016). For these reasons, it seems impru-
dent and also discriminatory to attribute these events to some personality fea-
ture of an individual. Nonetheless, when assessing future clinical risk, it can be
useful to concede a trait-like variable because, for example, future suicide
attempts are strongly predicted by previous ones (Klonsky et al., 2016), regard-
less of the fact that the majority of individuals who attempt suicide do not
engage in such an attempt a second time. The same can be said in the context
of ideation, as some individuals who display suicidal ideation at one point in
their biography will engage in thoughts of suicide throughout their lives.
Death ideation can arise from several circumstances, as it has been commonly
self-reported by patients, such as a response to suffering, to a feeling of loss of
self, or arise from the desire to live only under certain specified conditions, or as
a mean to exert control over life and escape from suffering (Branigan, 2015). It is
important to clarify that the concept of response to suffering has a wider range of
meanings, comprising various possible courses of action such as searching for
ways to adapt just as death ideation. An escape from suffering is itself a response
to suffering, showing the individual’s inability or unwillingness to have a dif-
ferent and more adaptive approach.
Understanding the role of suffering is crucial for this discussion. Suffering
originates as a natural adaptive response to a modification in circumstances
which is experienced as unwelcome. Suffering is critical in view of forcing the
individual to adapt to his or her new context, thereby hopefully being able to
suppress the repercussions of the original disturbing situation. However, this
Costa-Maia et al. 3

adaptation might not be achieved by individuals, which for various personal

reasons do not possess the ability to adjust. A person’s inability to adjust can be
inherently behind both his or her turning to suicide and euthanasia. It is this
inability which should be at the center of discussions about the social accept-
ability of these events. Generally speaking, a suicide that was motivated by a
person’s core values and beliefs (i.e., altruistic suicide) tends to be more easily
accepted, whereas self-caused deaths motivated by an inability to adjust, as in
the majority of suicides and euthanasia cases, are generally viewed in a negative
light. In a similar manner, orthothanasia is also more widely accepted, as the
individual here does not desire to die per se, but instead desires do avoid possible
repercussions of a particular inescapable treatment or therapeutic course he
would have to endure. Views on this matter commonly base themselves on
the debater’s past experiences and on a consideration of personal values of
various orders. That explains the difficulty in personally identifying with and
accepting the choice individuals unable to adapt to new life circumstances con-
sider, making them view euthanasia or physician-assisted suicide as a somewhat
remote possibility, while accepting concepts such as orthothanasia effortlessly.
Taking into account the aforementioned, the discussion about the link
between suicide and euthanasia is crucial, both are conceptually similar and
can arise from common motivators. In euthanasia and physician-assisted sui-
cide, the main motivators for a wish to die found by Ricou and Wainwright
(2018) were a diagnosis of depression, the reduced functional status, the pain,
the lower levels of social support, and the perception of loss of dignity. Either
way, it can be said that the suicide act is the ultimate result of an intrinsic
inability to adapt to a new and hostile life circumstance or context in which
suffering is ever-present. In euthanasia and physician-assisted suicide, on the
other hand, the motives quoted by patients also seem to reflect failure to adjust
and an inability to find meaning for life beyond the constraints of their ailment,
whether because of the effects of their medical condition, their loss of the sense
of self and control, and their fears about the future (Pearlman et al., 2005).
Today, more than ever, the controversy surrounding euthanasia and
physician-assisted suicide and its ethical implications is a topic of heated
debate in the health-care community. It also presents a matter of public interest.
In Portugal, renewed interest has been triggered by the publication of a mani-
festo signed by approximately 300 persons, many of whom prominent members
of Portuguese society: Here, the depenalization and regulation of assisted death
practices is advocated (Vasconcelos et al., 2016). In such matters, it is vital to
consider the impact any new legal decision might have in view of physician’s
traditional professional responsibility to provide the best possible care for the
patient while also honoring the latter’s autonomy and freedom of choice (Gillett
& Chamberlain, 2013). With that in mind, it becomes necessary to carefully
ponder upon the patient’s wish to die and its consistency as well as the likeli-
hood of its mutability both in the context of assisted death practices and suicide.
4 OMEGA—Journal of Death and Dying 0(0)

The termination of life is not and should not be permissible simply because a
patient requests to die (Stoyles & Costreie, 2013). In these cases, an understand-
ing of the motivators involved in this decision is need. The involvement of
health-care professionals in the decision-making process is of highest impor-
tance in aiding the patient come to his or her own resolution, keeping in
mind that the principle of autonomy is not absolute. In the context of reversible
decisions, it does not pose a major problem. However, when the decision results
in an irreversible and fatal outcome, the difficulty for health-care professionals is
significantly superior, as it is necessary to reconcile a professional obligation to
preserve well-being with the prospect of termination of life and uncertainty
about its benefit for the patient. Among these health professionals, psychologists
can be the most qualified professionals who can contribute with practical knowl-
edge in this field (Galbraith & Dobson, 2000), although very little is known
about the role of psychologists in requests of hasten death (Marina,
Wainwright, & Ricou, 2019). Nevertheless, if psychologists have skills to inter-
vene with people with suicidal behavior (McCabe, Garside, Backhouse, &
Xanthopoulou, 2018), they will be able to intervene with people who request
to die.
The aim of this literature review is to provide an overview of three main
events in the study of suicide (suicidal ideation, suicide attempt, and suicide)
in different populations regarding their incidence and progression and to discuss
the link between euthanasia and suicide through its underlying process, named
wish to die. Such approach will make it possible to evaluate possible ethical
implications for health-care professionals’ practice in view of the public debates
about hastened death practices.

Method
To understand the main events in suicide, we conducted a literature review,
seeking to incorporate the highest number possible of studies. We extended
our search to cover the period from the year 1985 to 2016. The research was
performed by two researchers independently using the PubMed and Google
Scholar electronic databases. Disagreements were resolved by discussion
between the researchers and through reference to the full article. The combined
key words used were suicidal ideation, suicide attempt, completed suicide, sui-
cide, prospective, and prospective study. The literature review was carried out
according to the following inclusion criteria: (a) the study was published in or
after the year of 1985; (b) it was a longitudinal or prospective follow-up study;
(c) the study included at least one of the following suicidal outcomes: ideation,
attempt, or suicide; (d) the study was original research; (e) it was written in the
English language; and (f) it was available in full-text.
Costa-Maia et al. 5

Figure 1. Flow diagram of the literature search.

Studies were excluded if they were insufficiently focused on the topic and if
noncompliance with the inclusion criteria. A flowchart of the literature search is
presented in figure 1.

Results
Seventeen articles were included in the content analyses. The articles were ini-
tially coded and analyzed according to the outcomes previously stablished (sui-
cidal ideation, attempts, and suicide; Table 1). Three main themes emerge from
the content analyses: the first one was designated risk factors and predictors of
suicidal behavior and suicide; the second one, differentiators of suicide ideators,
attempters, and individuals who commit suicide; and the third one, time line and
risk of suicidal activity.
6 OMEGA—Journal of Death and Dying 0(0)

Table 1. Characteristics of the Studies Included in the Review.

Reference paper Sample Study design Outcome

Suokas, Suominen, Suicide attempters (n ¼ 1,018); Prospective follow- Suicide

Isometsa, 540 women, 478 men up 14 years
Ostamo, and
Lonnqvist (2001)
Kuo, Gallo, and Community sample (n ¼ 1,920); Prospective follow- Suicidal ideation,
Eaton (2004) 1,213 women, 707 men; ini- up 13 years suicide attempt,
tial sample (n ¼ 3,481) suicide
Suominen, Isometsa, Suicide attempters (n ¼ 224); Prospective follow- Suicide
Ostamo, and 125 women, 99 men up 12 years
Lonnqvist (2004)
Wenzel et al. (2011) Hospitalized patients (n ¼ 706); Prospective follow- Suicide
207 suicide ideation and 499 up 30 years
recent suicide attempts
Borges, Angst, Nationally representative U.S. Prospective follow- Suicidal ideation,
Nock, Ruscio, and sample (n ¼ 5,001) up 10 years suicide attempt
Kessler (2008)
Maser et al. (2002) Affectively ill patients (n ¼ 955) Prospective follow- Suicide
up 14 years attempt, suicide
Goldston Psychiatric unit hospitalized Prospective follow- Suicide
et al. (1999) adolescents (n ¼ 180); up 5 years attempt, suicide
attempters (n ¼ 75)
Fergusson and Birth cohort (n ¼ 954) Prospective Suicidal ideation,
Lynskey (1995) follow-up 16 years suicide attempt
Oquendo Patients with DSM-III-R major Prospective Suicide
et al. (2007) depression or bipolar disor- follow-up 2 years attempt, suicide
der seeking treatment for a
major depressive episode
(n ¼ 314); 184 women and
130 men
Beck and Hospitalized suicide attempters Prospective follow- Suicide
Steer (1989) (n ¼ 413); 239 women and up 5 to 10 years
174 men
Beck, Brown, Psychiatric outpatients Prospective follow- Suicide
Berchick, Stewart, (n ¼ 1,958); 1,135 women up 10 months to
and Steer (1990) and 823 men 7 years
Noell and Homeless adolescents Prospective follow- Suicidal ideation,
Ochs (2001) (n ¼ 422); 180 women and up 6 months suicide attempt
242 men
Fawcett et al. (1990) Major affective disorder Prospective follow- Suicide
patients (n ¼ 954) up 10 years
Phillips and Individuals with body dysmor- Prospective follow- Suicidal ideation,
Menard (2006) phic disorder (n ¼ 185); 180 up 1 to 4 years suicide attempt,
women and 242 men suicide
(continued)
Costa-Maia et al. 7

Table 1. Continued.
Reference paper Sample Study design Outcome

Brown, Beck, Steer, Psychiatric outpa- Prospective follow- Suicide

and tients (n ¼ 6,891) up 20 years
Grisham (2000)
Beck, Steer, Kovacs, Patients hospitalized for suicid- Prospective follow- Suicide
and al ideation (n ¼ 207); 111 up 5 to 10 years
Garrison (1985) women; 96 men; with previ-
ous suicide attemp-
ters (n ¼ 60)
Kaplan, Harrow, and Hospitalized patients (n ¼ 297); Prospective follow- Suicidal ideation,
Clews (2016) 97 schizophrenia; 45 schizo- up 20 years suicide
affective disorders; 102 uni- attempts, suicide
polar nonpsychotic
depression and 53 bipo-
lar disorder

Suicidal Ideation, Attempts, and Suicide

The definitions initially developed by O’Carroll et al. in 1996 and revised in 2007
by Silverman, Berman, Sanddal, O’Carroll and Joiner were used. Suicidal ideation
is defined as any self-reported thought of engaging in suicide-related behavior.
Suicide attempt refers to a self-inflicted act undertaken the intent to end one’s
life. It must be distinguished from self-harm or other suicide-related behavior.
Suicide is classified as a self-inflicted death with evidence, either explicit or
implicit, of intent to die.
A primary analysis of the data gathered indicates a steady decrease in abso-
lute figures of incidence according to the severity of the outcome, with suicidal
ideation registering the majority of occurrences followed by suicide attempts
and in a far smaller proportion, suicides. This tendency is verified across all
studies and samples.
Suicidal ideation incidence ranged from 5% to 56%, with a higher percentage
being registered in high risk samples of psychiatric patients and homeless ado-
lescents (Kaplan et al., 2016; Noell & Ochs, 2001). Community and nationally
representative samples registered a lower percentage (5%–10%), followed by a
birth cohort of adolescents (15%; Borges et al., 2008; Fergusson & Lynskey,
1995; Kuo et al., 2004).
A fall in incidence is registered in the outcome of suicide attempts which
ranged between 2% and 21%. Once again, the lowest figures were documented
in population representative samples (2%–3%), with a cohort of 16-year-old
adolescents registering a similar incidence of 3% although the same group had
previously registered higher incidence of suicidal ideation (Borges et al., 2008;
Fergusson & Lynskey, 1995; Kuo et al., 2004). High risk samples of psychiatric
8 OMEGA—Journal of Death and Dying 0(0)

hospitalized patients and outpatients presented a significantly greater percentage

of suicide attempts (13%–21%) when compared with the samples discussed
previously (Goldston et al., 1999; Kaplan et al., 2016; Maser et al., 2002;
Oquendo et al., 2007; Phillips & Menard, 2006) as well as homeless adolescents
(21%; Noell & Ochs, 2001).
Suicide incidence ranged from 0% to 10%, with a percentage of 0.4% in an
U.S. community sample and an absence of suicide events in a population of
hospitalized psychiatric adolescent patients after a follow-up of 5 years
(Goldston et al., 1999; Kuo et al., 2004). Psychiatric at risk samples registered
an incidence percentage from 1% to 10%, with a group of hospitalized patients
with severe mental illness displaying a suicide incidence of 9.8%, a fact partially
explained by a presence of individuals with psychotic disorders, which register a
higher number of suicides when compared, for example, with depressive patients
(Kaplan et al., 2016). Samples of hospitalized suicide attempters and ideators
likewise listed elevated percentages of suicide (5%–8%; Beck & Steer, 1989;
Beck et al., 1985; Suokas et al., 2001; Suominen et al., 2004; Wenzel et al.,
2011). Psychiatric outpatients had an analogous suicide incidence of 1% when
compared with a community sample (Beck et al., 1990; Brown et al., 2000).
Affectively ill patients, patients in treatment for major depressive disorder and
patients with body dysmorphic disorder had suicide incidence ranging from 1%
to 4% in the considered studies (Fawcett et al., 1990; Maser et al., 2002;
Oquendo et al., 2007; Phillips & Menard, 2006).

Risk Factors and Predictors of Suicidal Behavior and Suicide

Several risk factors and predictors were found to be noteworthy and useful in
the context of identifying individuals prone to suicidal thoughts and behaviors
and ultimately suicide (Table 2).

Time Line and Risk of Suicidal Activity

Risk of suicide over a course of time varies across different samples and studies
but appears to be highest during the first 12 months to 2 years and generally
declines during follow-up and most considerably after a decade (Table 3).

Discussion
The results suggest that there are differences in the incidence rates of suicidal
ideation, suicide attempts, and suicide which ensues a reflection upon the fact.
While suicidal ideation is highly incidental in both high risk and community
samples, it does not translate itself into equivalent frequency rates in suicide
attempts and suicides. The same phenomenon can be observed in suicide
attempts and suicides. This fact can indicate that the majority of individuals
who present suicidal ideation and commit a suicide attempt may not die by
Costa-Maia et al. 9

Table 2. Risk Factors and Predictors of Suicidal Behavior and Suicide Identified on Each Study.

Reference paper Predictors/risk factors

Suokas et al. (2001) Male sex, previous suicide attempt, somatic disease, wish to die as
motive for index suicide attempt, previous psychiatric treatment.
Kuo et al. (2004) Hopelessness positively associated with suicide, suicidal ideation, and
suicide attempt.
Suominen High scores on Beck’s SIS in index attempt seemed to be a more
et al. (2004) powerful predictor of eventual suicide than previous attempts or
hopelessness.
Wenzel Diagnosis of a psychotic disorder, taking active precautions to prevent
et al. (2011) discovery during the attempt, suicidal thoughts and wishes were
associated with an increased risk of suicide.
Borges et al. (2008) Ages 15 to 24 years at baseline more likely to have new onset idea-
tion; older population more likely to have persistence of ideation.
Ideation predicted positively or negatively by other employment
status, Black race, previously married or parent of young child
status. Prior suicide attempt is significantly related to future sui-
cide attempts.
Maser et al. (2002) Males 1.7 times more likely to commit suicide, especially in youngest
age-group. Females 1.7 times more likely to attempt suicide. More
chronic course of illness in attempters.Impulsivity and assertiveness
traits found to be prospective predictors of suicide.
Goldston Number of prior attempts was the strongest predictor of postho-
et al. (1999) spitalization attempts. Severity of depressive symptoms and anxiety
as personality trait also predicted attempts.
Fergusson and Suicidal tendencies varied with the extent of met criteria for psychi-
Lynskey (1995) atric disorder, adjustment problems, and exposure to adverse
family circumstances.
Oquendo Family history of suicidal acts, drug use, smoking, BPD, and early
et al. (2007) parental separation were risk factors for suicidal behavior in men,
whereas prior suicide attempters, suicidal ideation, lethality of past
attempts, hostility, depressive symptoms, fewer reasons for living,
BPD, and smoking where risk factors in women.
Beck and Risk of suicide in alcoholics was over 5 times greater than that of the
Steer (1989) nonalcoholics. SIS Precautions subscale was also found to predict
eventual suicide.
Beck et al. (1990) Beck Hopelessness Scale significantly related to eventual suicide
(cutoff score of 9 or above identified 94.2% suicides).
Noell and Gay, lesbian, bisexual, and unsure status was associated with recent
Ochs (2001) suicidal ideation.
Fawcett Panic attacks, severe psychic anxiety, diminished concentration, global
et al. (1990) insomnia, moderate alcohol abuse, and severe loss of interest or
pleasure (anhedonia) were associated with suicide in the first year.
Severe hopelessness, suicidal ideation, and history of previous
(continued)
10 OMEGA—Journal of Death and Dying 0(0)

Table 2. Continued.
Reference paper Predictors/risk factors

suicide attempts were associated with suicide occurring after the

first year.
Phillips and Individuals with body dysmorphic disorder have a high rate of suicidal
Menard (2006) ideation and attempts.
Brown et al. (2000) Significant risk factors for suicide in univariate survival analyses:
severity of depression, hopelessness, and suicide ideation.
Beck et al. (1985) Beck Hopelessness Scale score of 10 or more identified 91% of the
eventual suicides.
Kaplan et al. (2016) Males’ suicidal activity seems more triggered by psychotic symptoms
and potential chronic disability, while females’ suicidal activity
seems more triggered by affective symptoms.
Note. SIS ¼ Suicidal Intention Scale; BPD ¼ borderline personality disorder.

suicide. This can suggest that the possibility of reversing the wish to die can be a
recurrent event. The importance of such possibility is capital for clinical practice
and gains new significance in situations where wish to die are present (e.g.,
assisted death practices and euthanasia). In fact, taking uniquely into consider-
ation raw numbers of incidence, it could be defended that a patient expressed
desire to die should always be faced with a skeptical attitude on the grounds of
the improbability of its certainty. The previous statement presents an erroneous
oversimplification of a complex matter, failing to take into consideration the
individuals who truly wish to die and probably will resort to suicide or hastened
death. A related dilemma arises and we are faced with the question of how to
differentiate those who in fact want to die and maintain their resolution from
those who only state they want to at a certain moment in time. The literature
review carried out did not offer an answer to this problem but nonetheless
offered insight to help differentiate the two groups of individuals mentioned
earlier. Certain scales used to measure risk factors like hopelessness and wish
to die appear to have discriminative power when evaluating individuals at risk
for suicide. It is crucial to understand that artificial scales and instruments
cannot predict with complete precision a fatal outcome and have varying
degrees of sensitivity and specificity. There is no way to declare, without any
doubt, that a certain individual with death ideation will maintain this wish in the
future and therefore should be allowed to do so. An extensive evaluation of an
individual with death ideation is indispensable and cannot be neglected in order
to safeguard both patient’s best interests and certainty of decision. From psy-
chology, it is known that a decision made in certain conditions cannot reflect the
persons best interest (Mather & Lighthall, 2012).
If death ideation is commonly self-reported by patients as a response to
suffering (Branigan, 2015), the same issue can be closely connected with those
Costa-Maia et al. 11

Table 3. Time Line and Risk of Suicidal Activity.

Reference paper Chronological incidence

Suokas et al. (2001) Fifty percent of suicides occurred during the 2 following years;
frequency of suicide increases during follow-up.
Wenzel et al. (2011) Suicide rate is elevated but declines heavily after the first 10 years
(20% suicides occurred in the first year).
Borges et al. (2008) More than 33% of respondents with a baseline history of suicide
ideation continued to have suicide ideation at some time over
the intervening decade.
Maser et al. (2002) Risk of suicide within 1-year greatest in older individuals or with
significant anxiety, panic attacks, emotional turmoil, and psy-
chotic symptoms. Suicide within a year predicted by clinical but
not personality variables and beyond a year by temperament
factors not clinical variables.
Goldston et al. (1999) The first 6 months to 1 year after discharge were the period of
highest risk for suicide attempt.
Fawcett et al. (1990) Panic attacks, severe psychic anxiety, diminished concentration,
global insomnia, moderate alcohol abuse, and severe loss of
interest or pleasure (anhedonia) were associated with suicide in
the first year. Severe hopelessness, suicidal ideation, and history
of previous suicide attempts were associated with suicide
occurring after the first year.
Brown et al. (2000) Mean length of time from the intake to suicide: 4.07 years; range
from 2 weeks to 12 years.
Kaplan et al. (2016) Maximum suicidal activity generally declines over the three time
periods (early, middle, and late follow-ups) following discharge
for both males and females across categories with the excep-
tion of female schizophrenia and bipolar patients.

about the requests to hasten death. According to the results obtained in the
literature review carried out by Ricou and Wainwright (2018), the main moti-
vators of a wish to die are connected with patient suffering (e.g., pain) and the
perception that patients have about the suffering they believe they cause
others. The authors also identified important psychological dimensions that
seem to be associated to the wish to die and argue about a possible role for the
mental health professionals on this subject. The present work shows that
individuals prone to suicidal behavior can be, at least to a degree, identified
using predictors such as hopelessness (considered to be especially helpful) and
dissatisfaction with life. The evaluation of the individual’s personality and
psychiatric history is highly important, and traits such as high impulsivity and
assertiveness were found to be predictors of suicide, especially in the
long term.
12 OMEGA—Journal of Death and Dying 0(0)

Another problem frequently identified has to do with establishing a satisfac-

tory temporal interval upon which to rely on for assessing will to die. Taking
into consideration the psychological motivators identified in the wish to die
(Ricou & Wainwright, 2018), this issue assumes particular relevance. The deter-
mination of said interval, even though in an estimated form, is an important
complement to individual scale and marker evaluation as it could contribute to a
more accurate assessment of wish to die and the likelihood of its endurance over
time. Wish to die remains elevated in the short term after an index episode of
suicidal activity and a period of at least a year is required to register a decline in
the number of suicides. It can be argued that the evaluation of an individual’s
wish to die would inevitably need to be performed for a considerable period of
time to avoid misjudgment of the clinical situation and probably over the course
of years instead of months.
This statement has several implications. While some people subjected to
chronic suffering, may it be emotional or physical, are expected to continue
living or having the ability to withstand suffering long enough to perform
such a prolonged evaluation, there are others who are not. These people
could not possibly be evaluated using the same approach, posing the problem
of a higher level of uncertainty in their resolution and on their ability to adapt to
changes brought on by new life conditions and circumstances. Once again, this
argument reinforces the idea that there is not a universal approach to patient
assessment that can guarantee the best course of action to every individual. This
is a complex matter, and it is very important to stress that meeting requirements
produced from a previously agreed on method of assessment does not guarantee
that the best possible outcome for a particular person is achieved. A standard
positive evaluation should in no way minimize the importance of clinical judg-
ment of health-care professionals and therapeutic alliance, which can prove to
be deciding factors in instances of uncertainty and reservations. The nature of
this relationship allows for a certain degree of intuition concerning patient’s
desires, although the subjective element of experience is very difficult, or even
impossible, to quantify and categorize scientifically. Nonetheless, its absence
from a process of assisted death practices is unimaginable and greatly damaging
to patients who might suffer grave harm from a purely legal application of
procedures in a matter that transcends simple rules and regulations. In fact,
this privileged relationship can gain prominence in the context of terminal
patients in which the time available to evaluate the wish to die is scarce and
may be very limited.
In the present work, suicidal behavior and its integral death ideation was
analyzed and paralleled with a similar wish to die in the context of euthanasia.
However, there are differences between the two, even though both phenomena
can be linked by an underlying process of suffering. Euthanasia requests are
many times associated with terminal diseases which will inevitably lead to death,
while suicide is viewed as an act of an individual with a normal life expectancy
Costa-Maia et al. 13

and therefore highly unconceivable for the general public. Nevertheless, we must
also remember that even in the context of euthanasia, there are conditions that
produce unbearable physical or mental suffering that do not constitute terminal
disorders such as paraplegia, blindness, and mental illness. Euthanasia and
assisted death practices in patients without somatic terminal illnesses are con-
troversial. The problem lies in the fact that individuals are euthanized prema-
turely, when there may be possibility of quality living beyond the time of their
decision (Cohen-Almagor, 2016). In chronic illnesses, that possibility is closely
related to a potential adaptation to the patient’s new circumstances. In fact,
even in the context of terminal illness in which the patient will inevitably suc-
cumb to their condition, and despite the fact that desire to die is common, it can
decrease over time (Chochinov et al., 1995). Therefore, and as previously stated,
a significant temporal interval is necessary to truly evaluate patient’s wish to die
and a subsequent request to die. However, in the Netherlands, it has been
reported that 65% of deaths by euthanasia occur within a period of only 2
weeks since the first request (Chochinov et al., 1995), a problematic trend. All
in all, fostering hope in patients is imperative, nonetheless when all treatment
options are exhausted and individual suffering reaches a limit, death ideation,
and patient’s requests to die deserve to be carefully considered (Berghmans,
Widdershoven, & Widdershoven-Heerding, 2013).

Conclusions
The main conclusion that can be drawn from this literature review is that iden-
tifying individuals who wish to die without any doubt, and if that wish is main-
tained over the time is an impossibility. This does not mean, however, that there
are not valid and applicable methods that can be used to minimize the possibility
of injustice and disservice. Such methods must be explored and evaluated as
potential procedures for screening of individuals especially in the context of ter-
ritories which are discussing the legalization and regulation of physician-assisted
suicide and euthanasia. Standardization of this process is necessary in an attempt
to provide a solution acceptable to a majority of individuals in this situation. We
strongly believe that, even though this is a situation that generally excites pas-
sionate views and opinions, it must allow room for an evidence-based approach
from several areas of knowledge (e.g., Medicine, Psychology). It is imperative to
develop research on the matter of hastened death in a way that could provide a
better understanding of hastened death predictors and the temporal evolution of a
wish to die. The experiences of psychologists in this context should be very impor-
tant and must be taken into account.
All in all, the possibility of accepting death in those with a wish to die must be
the object of careful consideration so as to provide the best possible care and
protect individual’s interests while respecting their autonomy. There are new
movements on the rise advocating for the liberalization of these practices.
14 OMEGA—Journal of Death and Dying 0(0)

The proposition of legalization of assisted death for people over 75years old in the
Netherlands who no longer wish to live despite having no illness (DutchNews,
2016) is a good example. It becomes more evident that there is a need to make
efforts to protect patients, especially in vulnerable populations, therefore prevent-
ing the perilous banalization of death. It is also important to remember that other
options must be made available for terminal and nonterminal patients with incur-
able diseases, such as palliative care and specialized medical, psychological and
social assistance, so that death is not viewed as the only route to a life with
dignity. We strongly believe that the legislation on euthanasia and physician-
assisted suicide should consider different procedures that must be followed in
requests to hasten death according different dimensions. For example, the proto-
col procedures should differ in case of a terminal illness from the cases of an
incurable but not terminal illness should be two separate entities.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

ORCID iD
S
ılvia Marina https://orcid.org/0000-0003-4808-9000

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Author Biographies
Inês Costa-Maia, medical doctor, graduate by the Faculty of Medicine of Porto
University, Portugal. Member of the European Platform Wish to Die.

S
ılvia Marina, psychologist, researcher at CINTESIS – Center for Health

Technology and Services Research. PhD Student at Faculty of Medicine of
Porto University, Portugal. Member of the European Platform Wish to Die.

Miguel Ricou, psychologist, president of the Ethics Committee of the Order of

Portuguese Psychologists. Member of the Board of Ethics of EFPA –
Portuguese Representative. Professor at Faculty of Medicine of Porto
University, Portugal. Associated member of CINTESIS – Center for Health
Technology and Services Research. Coordinator of the European Platform
Wish to Die.