Suicide’s Euphemisms

 As physician-assisted suicide makes legal and cultural strides in the west, its broadest victory has been linguistic. When Oregon became the first U.S. state to legalize assisted suicide in 1994, no mention of suicide was made in the law except to insist that any actions taken in accordance with “death with dignity”—the preferred euphemism at the time—shall not, for any purpose, constitute suicide.

Especially in the last 10 years, “death with dignity” has waned in favor of the euphemism “aid in dying,” which has had a meteoric rise across the media, higher education, and professional medical contexts. In 2017, the largest U.S. professional organization that works for suicide prevention adopted a statement titled “‘Suicide’ Is Not the Same as ‘Physician Aid in Dying.’” It’s common now for news outlets covering “aid in dying” to exclude the term “suicide” entirely.

Yet, patients who die by knowingly ingesting fatal drugs are, both conceptually and empirically, clear instances of suicide. Start with the concept of suicide. Suicide is intentional self-killing. This is how suicide is defined by most dictionaries, philosophers, and suicidologists. It is not part of the concept of suicide that the self-killing be tragic, irrational, or morally wrong.

The purpose of ingesting a fatal dose of drugs prescribed by a physician is to die. If the patient takes the drugs and survives, she has failed at what she was trying to do. Assisted suicide statutes require that terminally ill patients who seek lethal drugs must be of sound mind and understand what they are doing. Ironically, then, any attempt to gerrymander intention around intending death is procedurally ruled out by the way that advocates of the practice have made it publicly available.

Assisted suicide laws in the U.S. limit participation to those with a terminal illness. Advocates insist that because terminally ill patients are already dying, they are not choosing their deaths, only the timing and manner of an inevitable and imminent death. But, of course, just because a person will die soon does not mean she does not choose her death if she takes her life sooner. I might be scheduled to give blood next week, but if I give blood today, I still choose (and intend) to give blood. Nor would we hesitate to use the term “suicide” to describe a man who hangs himself the day before his scheduled execution.

Diagnosis of a terminal illness does not cause us to recategorize other events that will happen to the dying person. We do not think that the homicide of a terminally ill person or a prisoner on death row is not homicide. We do not think terminally ill people who marry are not truly participating in marriage (because the stakes are different) compared to people who marry when they have an indeterminate amount of life left.

Some advocates for “aid in dying” language insist that the issues facing the suicidal among the general population are empirically different from those facing the terminally ill who seek to end their lives. But here, too, a fair and careful examination reveals that physician-assisted suicide does not stray far from other acts of suicide.

The most influential theory of suicide is that of the late suicidologist Edwin Shneidman. Shneidman says that suicide fundamentally is a product of what he calls “psychache” or psychological pain. Suicide occurs in individuals who are overwhelmed by psychological distress stemming from unmet psychological need.

How well does this psychology described in Shneidman’s theory apply to suicide among the terminally ill? According to data from Oregon, only 27% of patients who used assisted suicide in the last quarter century listed physical pain as one of their motivations. Instead, they usually name psychological and existential concerns, such as the loss of autonomy and being a burden on others. These are concerns that map well onto the psychological pain that Shneidman identifies in suicidal individuals. Other empirical work commonly supports the idea that patients who choose assisted suicide experience significant psychosocial suffering.

Aren’t there differences, though, that set terminally ill suicides apart? One alleged difference is that only the non-terminally ill person genuinely wishes to die. However, if we are going to qualify the idea that terminally ill patients who take their own lives “want to die,” then we need to do the same for others who die by suicide. There is almost always ambivalence about the suicidal decision. Any individual who chooses suicide would prefer to go on living were it not for the problem he is trying to escape.

The most commonly proposed difference between terminally ill patients who die by suicide and others who do is that the former do not suffer from mental illness. State laws typically forbid individuals who are suffering from mental illness from partaking in “death with dignity.” In Oregon, for example, less than 4% of individuals who request lethal drugs from a physician are referred for a psychiatric evaluation.

There is considerable evidence, however, that terminally ill patients who seek suicide are suffering at least some symptoms of mental illness at non-negligible rates. In a number of studies, depression is correlated with a desire for hastened death. One publication summarizes the data by saying that “every study that has looked for an association between depression and the desire for death has found one.”

While supporters of assisted suicide who are intellectually honest accept that “suicide” is the most accurate term, the case for it goes beyond the mere need for linguistic accuracy. It also has significant moral implications. The effort to avoid the term “suicide” is often an effort to sanitize and refuse responsibility for a vital moral choice. The person who engages in “aid in dying” can comfortably assure himself that his action is no different from undergoing a round of chemotherapy. In this fiction, he is emboldened by both a doctor, who tells him he is not killing himself but receiving palliative care (even though no symptoms are palliated), and the law, which prohibits his act from being classified as a suicide and requires the falsehood that his underlying illness be listed as the cause of his death.

“Aid in dying” is neither neutral nor accurate terminology. To help a person in his dying, this term implies, is not to provide hospice, to alleviate his symptoms, to comfort him, to encourage him, or to suffer with him, but to give him lethal poison. Upon diagnosis of a terminal illness, the Orwellian question, “would you like aid in dying?” must be answered carefully indeed.

Advocates of assisted suicide claim that we “offend” the terminally ill by describing their act as a suicide. What they mean is that suicide is performed only by mentally ill people and the terminally ill still have their “dignity.” This claim further stigmatizes a different group of people deserving of compassion in order to protect an aureate self-image of those who would prefer not to take responsibility for their choice.

As the march for assisted suicide progresses, genuflecting before the contemporary Western gods of autonomy, independence, and control, its shameful and perverse campaign to distort descriptive language for political ends needs also to be seen for its allegiance to a lesser contemporary Western god, moral nihilism. In a world where suicide is “aid in dying” and killing oneself is health care, not only words but also moral choices mean nothing.

Philip Reed is Professor of Philosophy and Associate Dean of Arts and Sciences at Canisius College in Buffalo, NY where he works on ethics, applied ethics, and moral psychology. He serves on two hospital ethics committees and has published papers recently in the Journal of Medical Ethics and the Journal of Medicine and Philosophy. He is a fellow at the Romanell Center for Clinical Ethics and the Philosophy of Medicine at the University at Buffalo. He has also written for Aeon, Psyche, and Public Discourse.

https://www.realclearhealth.com/articles/2023/05/30/suicides_euphemisms_111508.html