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”Autonomy, rationality and the wish to die”

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(Extracted conclusion formulated by David M Clarke in The Journal of Medical Ethics)

Discussions about the moral status of suicide are being fuelled by the more specific debate concerning euthanasia – that is, in the presence of pain or suffering or other irremedial circumstance, should people be allowed intentionally to end their lives and to receive professional help to do so. The arguments for this usually come as a plea for the respect for individual autonomy, and by way of conceptualising a ”rational” suicide – the latter argument stating that, although life is generally to be affirmed, there are times or situations where it is rational to do otherwise.

The assertion of this paper is that the concepts of both autonomy and rationality alone are inadequate arguments for euthanasia or suicide because neither is present in such an ideal or pure form as to allow such a categorical defence. Rather than being rational, the strongly affective and evaluative aspects of the decision making need to be acknowledged. Consideration of personal and interpersonal aspects and values cannot be done in a purely unemotional manner, and this is the deficiency of Roman suicide as an ideal. In place of rationality, the concept of ”understandability” is more meaningful and useful, though it is acknowledged that it may not appear to carry the same moral force. Similarly, where autonomy cannot be recognised, at least without considerable weakening of the concept, the Kantian concepts of dignity and respect for persons still remain.

In summary, while it is accepted that there are important principles carried behind the banners of autonomy and rationality, neither exist as ideal and categorical phenomena. They therefore cannot be used as blanket justifications for the permission of suicide. To consider the meaning of an expressed wish to die or a request to be allowed to die, the principles of respect for autonomy and rationality need to be taken into account, together with an evaluation of their degree of limitation. It is important to ask why a request is being made, to examine for cognitive distortions and impairments of coping, to try to understand the expressive nature of the wish, and to consider these in the person’s situational and developmental context. Even in the elderly and the sick there are developmental stages to be passed and crises that can be met in ways that give meaning and affirm life. Many elderly sick experience loneliness and desertion, and an expressed wish to die in these circumstances should not be presumed to be autonomous. Rather, depression, pessimism, fear and social isolation can all be met and addressed in authentic ways that gives respect to the person.

One of the great advantages of the notions of autonomy and rationality is their force in moral argument. Terms such as ”understandability” or ”respect for the person” may seem, at first, not as helpful because they seem to carry less moral weight and direct us less obviously to a particular conclusion. This is not a reason for abandoning them in favour of apparently more useful but less valid concepts. An exaggerated emphasis on autonomy can lead to an avoidance of listening to, and understanding, the patient. Where rationality is overemphasised, the expressive and emotional meaning of a wish to die will be overlooked. A clinical approach to a person expressing a wish to die must seek to understand all these aspects and develop a coherent understanding of the person, including his or her thoughts, desires, values and relationships.

– David M Clarke, Monash University, Melbourne, Australia
Professor i medicinsk psykologi

The full article and its references can be read in Journal of Medical Ethics 1999, 25:457-462

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