JMS Pearce
Hull, England

Preservation of life is often an unwritten axiom of medical practice. Sections on therapeutics in medical books and papers usually assume the obvious: aim to preserve or extend life. They rarely discuss the alternative harm or good that results from allowing nature to take its course unhampered. There are elements in humans of all generations, of all cultures, of a self-destructive force, silent and invisible. This recognition is important if we are to understand the varied behavior of both the healthy and the sick. Doctors have regard for the quality of life, but sometimes they do not confront the subjective, underlying circumstantial and personal issues of patients. The complex variations between individual cases and the definitions of free will are dangerous ground for artless generalizations.

Physicians have always been aware of the apparently careless, self-harming disregard for medical advice that is shown by many patients. It can be seen as evidence of self-harming or self-destructive behavior. Familiar examples include those who abuse drugs; the bronchitic who continues to smoke; the alcoholic who continues to drink; the obese or diabetic who continues to overeat; the stressed, self-driven businessman who continues to overwork; the many patients who fail to comply with a prescribed course of medication. Consideration of suicide,¹ the most serious consequence of the self-destructive urge, may shed light on the subconscious urge to self-harm.

Suicide

In the Classics, the instinct of Eros (to preserve life) battles against the instinct of Thanatos (death). The powerful force of self-­preservation was described as the will to live by the German philosopher Arthur Schopenhauer (1788–1860). The Dutch philosopher Baruch Spinoza (1632–1677) (whom Bertrand Russell regarded as the noblest and most lovable of the great philosophers) appraised suicide in Part III of his Ethics, where he defined the principle of conatus as that striving by which each thing strives to persevere in its own being is nothing but the actual essence of the thing. [my italics]² He asserted that human essence was necessarily self-affirming, and therefore it was impossible willfully to commit suicide rationally or freely: “No one, therefore, unless he is overcome by external causes, and those contrary to his nature, neglects to see what is useful to him, i.e. to preserve his being.” Spinoza believed that in suicide an essential factor was being overcome by external factors, which we would call mental stress or physical illness. Nothing was good or bad independently of human desires and beliefs.

Immauel Kant (1724–1804) similarly argued that the suicidal agent placed the release from painful circumstances—his happiness—above the rational autonomy, which was the source of all values. For Kant, suicide was irrational, motivated by misfortune and founded on self-love, which was to aim at life. The act of suicide, therefore, contradicts the purpose of life.³

Conversely, a recent paper about suicide suggests “an etiological continuum of self-destruction from subintentional to intentional.”⁴ However, based on epidemiology, it fails to explore the causes of the self-destructive urge.

Albert Einstein wrote in the 1930s to Freud to ask how the imminent threat of war might be prevented, to which Freud replied: “Thanatos is at work in every living creature and is striving to bring it to ruin and to reduce life to its original condition of inanimate matter.” He referred to it as a death instinct that might cause self-destruction. The death instinct, usually subconscious, is an integral part of the human condition, though a part that varies in both degree and expression.

Some refer this subconscious force to the indefinable human soul or spirit. The erudite novelist Taylor Caldwell in her story The Sound of Thunder wrote that the human spirit was not a mathematical equation; it could not be measured by scientific instruments. Man was beyond science; only his body was the field of the biologist. She asserts no man has the identical emotions, loves, and desires that another man has. It is nonsensical to make prescriptive judgments of his choices.

Judgments of society

The dilemma for society is not new. For the ancients following Plato, Socrates, and Aristotle, suicide was conceived as an act against God, linked with murder, an affront to the State: “to die to escape from poverty or love or anything painful is not the mark of a brave man, but rather of a coward” (Aristotle, (Nicomachean Ethics).

In 1654, Richard Whitlock MD showed the abhorrence of society: “No man is Master of his own Body, and therefore selfe-destroyers have not common burial and are after Death thereby disgraced…”⁵ Daniel Defoe was similarly disparaging when he said that self-destruction was the effect of cowardice in the highest extreme. Self-destructive behavior nonetheless continued.

Yet the Greek and Roman philosophers allowed that under certain circumstances suicide was acceptable, as in the well-known instance of Socrates, who chose to ingest hemlock when condemned to death for practices subsequently deemed honorable, though contrary to prevailing Athenian law. The robust heroism of the Greeks and Romans dominated the ideas of early generations. Suicide could be thought of as an honorable solution to intolerable situations, illustrated in the deaths of both Cassius and Brutus as related in Shakespeare’s Julius Caesar.

The recent Lancet Commission indicated that “dying is understood to be a relational and spiritual process rather than simply a physiological event; networks of care lead support for people dying, … and [notably] death is recognized as having value.”⁶

Despair and suffering

Early writers must have been aware of intolerable suffering as a cause of suicide. Milton appreciated that self-destruction could be a consequence of unhappiness when in Paradise Lost (1667; Book 10; 1016) he wrote:

But self-destruction therefore saught, refutes
That excellence thought in thee, and implies,
Not thy contempt, but anguish and regret
For loss of life and pleasure overlov’d.

Indian culture had a traditionally socially acceptable form of the voluntary ending of life. In Jainism it was called santara or sallekhana and in Hinduism prayopavesham or samadhi marana. In principle, this entailed a person coming to the realization that they had no remaining responsibilities or desires.

In medieval and Victorian times, the prevalent poverty, sickness, and childhood deaths caused grievous unhappiness and despair; but even when such a gross act as suicide was attempted, the underlying cause often was incapable of remedy or was ignored.

Environmental destruction

The deliberate ravaging of the environment is also plainly self-destructive, although if mankind perishes the planet undoubtedly will survive and regenerate. If we look at our present failure to provide safe drinking water; beaches safe to bathe in; at our destruction of oceanic life, trees, and green spaces; and at our industrial and domestic chemical and plastic detritus and carbon emissions, it is hard to escape the idea that homo sapiens is hell-bent on destroying not only his environment but in that process, destroying himself.

Patients’ choice

All this gives pause for medical reflection. Our patients, particularly those of rural communities who are accustomed in their farm animals to illness, accidents, and death, often display a natural understanding of the quality of life and its limitations in adverse circumstances. This is evident in their expectations of the natural history of illness and in their choices of if and when to seek and to heed advice.

There are times when the flypaper of conventional orthodoxy holds down the free spirit. Doctors and their professional bodies not only advise, but often besiege people with stern, authoritarian instruction, telling them what to eat, what to drink, how much exercise to take. And they appear oblivious to the rank contradictions in such advice from one year to the next. The approved limits for saturated fatty acids, the desirable “safe” weekly intake of alcohol have been subject to wild variation in recent years. There are many other examples.

Not content to give the best advice we can muster to individual patients, and to warn them plainly about harmful practices and products, our Colleges and Associations extend their legitimate role with bans and bureaucratic incursions into the fields of advertising of many products, a far cry from our professional duty to the individuality, choices, and privacy of the patient in front of us. Perhaps it is no surprise that patients so often disregard these tainted, politically correct proscriptions of medical authorities. In offering advice, we should be conscious that authoritarian bans destroy the fundamental right of free choice.⁷ Should we not respect patients’ personal assessments of the limitations as well as their values of life, health, and enjoyment? Let me give two hypothetical examples.

A sixty-five-year-old man whose mother and grandmother died in their seventies of a dementing illness may understandably not wish to curtail his intake of alcohol, food, or tobacco. He may or may not be right in seeing his family history as a predictor of his own fate, but the choice, with its implications for his wife and grown-up children, is his.

A woman who has labored for thirty years, locked into an unhappy marriage, whose children have grown up and flown from the nest, may have a different and more pessimistic view of her future than a woman blessed with a more fulfilled life. If she harbors a latent self-destructive urge, the result of her unhappiness and perhaps driven by feelings of guilt and inadequacy, she may choose to ignore medical advice about diet and medications. We may be tempted to label her as depressed and add to her burden by prescribing antidepressant drugs; experience shows she may not take them.

Not everyone who is miserable or unhappy is clinically depressed. We have all had colleagues and friends who have great difficulty in filling their lives satisfactorily when left isolated or in retirement. Some have been widows or widowers, lonely and remote from their surviving families. They often neglect their health, exercise, and diet, and some take solace in alcohol or cigarettes.

Medicine has neither easy nor simple answers to these problems. If a sense of futility and a self-destructive lifestyle emerge under duress, we may sometimes be able do more by offering friendship and companionship than by rigidly prescribing counseling that dictates how someone should or should not lead their own lives. Over-simplified orthodox medical counsel may fall short of constructive understanding and sympathy. There are grounds for optimism. We could be more useful allies to our patients if we recognized the self-destructive urge, which is present to some degree in all of us, and may lead to “undesirable” lifestyles and responses to medical advice. The values of life are theirs. The choices are theirs. We should offer help and advice but not hinder their right to make their own decisions.

References

1. Shneidman E. The definition of suicide. Northvale, NJ: Jason Aronson, 1995.
2. Spinoza, Ethics. 1677. (translated by A Boyle, revisited by GHR Parkinson), JM Dent & Sons Ltd, London,1989.
3. Kant I, Foundations of Metaphysics of Ethics. Longmans, London, 1969.
4. Neeleman J et al. Predictors of suicide, accidental death, and premature natural death in a general-population birth cohort. Lancet. Jan 1998 10;351(9096):93-7.
5. Whitlock R. Ζωοτομι’α, or, observations on the present manners of the English: Briefly anatomizing the living by the dead. London, Tho. Roycroft, 1654.
6. Sallnow L et al. Report of the Lancet Commission on the Value of Death: bringing death back into life. Lancet. 26 February-4 March 2022; 399(10327): 837–884.
7. Rodríguez-­Prat A et al. Understanding patients’ experiences of the wish to hasten death: an updated and expanded systematic review and meta­ethnography. British Medical Journal Open 2017; 7: e016659.