First, Do No Harm

Trends in the Western world to encourage assisted suicide for the mentally ill give us a crude, but necessary awakening

The Canadian advertisement promoting state-sponsored euthanasia for the mentally ill has sent a chilling effect to many across the Western world. It glamourized suicide, apparently for any condition deemed appropriate by the patient. The ad opens with the caption “the most beautiful exit,” and features a middle-aged woman, in what appears to be physical health, claiming, “Last breaths are sacred, when I imagine my final days, I see bubbles, I see the ocean, I see music. Even now, as I seek help to end my life, there is still so much beauty, you just have to be brave enough to see it.”  

It ascribes sacredness to suicide, depicts the act as an idyllic utopia, and proceeds to claim that towards the end of this life there is still beauty, which prompts one to ask: then why attempt suicide? The literary and conceptual cloudiness is utilised in an attempt to justify the moral void at the heart of the message; terminating a life over depression is ethically counterintuitive and irrational. It is difficult to imagine, if faced with a loved one saying, “I feel depressed, I don’t see an escape, I want to kill myself,” one’s response being, “I think that’s the right solution, let me help you with it.” The advertisement reflects a terminal degradation of the medical industry, and the moral dead-end surrounding debates about mental health. Several countries, including Belgium and the Netherlands, have, in recent decades, relaxed euthanasia laws. Canadia, however, is known to have the loosest requirements for euthanasia:  

“Have a serious illness, disease or disability, to be in an advanced state of decline that cannot be reversed, experience unbearable physical or mental suffering . . . that cannot be relieved under conditions that you consider acceptable. You do not need to have a fatal or terminal condition to be eligible for medical assistance in dying.” 

The vagueness and ambiguity of these requirements mean that anyone who seeks to end their life is eligible to do so. The Hippocratic oath, the most fundamental piece of virtue ethics from Ancient Greece that has guided Western medicine throughout millennia to the modern day, is known for its succinct and commonly used phrase, “First, do no harm.” Other parts of the text provide a more detailed explanation of what the oath requires: 

“I swear by Apollo Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture … I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course… Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman... Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I break it and forswear myself, may the opposite befall me.”  

While medicine has travelled some distance since the third century BC, the injunctions remain clear to a consideration of euthanasia for the mentally ill. Not to administer a “poison”, even when asked to do so, nor to suggest it, stands in evident contrast to the idea of doctor-assisted suicide. In this case, we’re not discussing mere harm, but death itself, which is being advocated for physically healthy patients who could otherwise live fulfilling lives.  

This shift in the attitudes of the medical community is reflective of a wider shift in the Western world’s perception of suicide. British PMs are also now inquiring into assisted suicide. Prior to 1961, attempting suicide was a crime in the UK, punishable by a custodial sentence—its decriminalisation in the Suicide Act was the culmination of an increasingly permissive outlook on suicide. Throughout history, the opposite was true. In ancient Greece, suicide was viewed as a disgraceful act, so much that a person who had committed suicide did not receive the death rites according to common citizens. Because life was considered a gift bestowed by the Gods, it was subject to their will. In ancient Rome, suicide was, in rare cases, viewed as an act of honour if living meant being treated dishonourably. The concept of “patriotic” or “glorious” suicide existed if it meant avoiding the fate of humiliation at the hands of your enemy. It was also viewed as punishment. Seneca the Younger, a Stoic Roman philosopher, committed suicide when he was ordered to do so by the tyrannical emperor Nero, after he was accused of taking part in a conspiracy against him. In Christianity, suicide is viewed as a sin, and perhaps the most tragic sin of all, since repentance for that sin is impossible. Life is in God’s hands; if you end it, you disobey His will.

This is not to say that suicide should be stigmatised or demonised, quite the opposite: We should live in a society where those who suffer from suicidal ideation receive the support they need. But the definition of support has been manipulated. Opposition to suicide, from the ancient world until the middle of the 20th century, was intimately entwined with religion and spirituality; in taking the step from withdrawing sanction to offering assistance, the Canadian ad reveals a deeper message—that in a society lacking a form of transcendence, which fails to ascribe meaning to suffering, suicide is reduced to just another option to wide range of weightless choices. Suicide is also encouraged in an empirical, societal vacuum; society fails to provide the pillars to sustain a dignified life. The spiritual and social atrophy inflects on the medical industry too; the Hippocratic oath was once dedicated to the pagan Gods, later to the Christian God, but doctors are now accountable to no higher power, only to a state bureaucracy in the thrall of the prevailing modern mantra—unfettered freedom of choice. 

Freedom of choice is a particularly thorny issue in grappling with voluntary euthanasia for people suffering from mental illnesses. There has been an increasing emphasis on the equivalence of mental and physical health in the West; in the UK, according equal priority to each, was enshrined in law by the Health and Social Care Act (2012). This false-equivalence has resulted in the misapplication of approaches appropriate to physical health to the psychiatric sphere. While voluntary euthanasia for terminal physical conditions may be justifiable by reference to well-defined and readily predictable decline, our limited understanding of mental health conditions precludes charting its trajectories with any accuracy. Stories of individuals who have endured, and eventually overcome their mental health conditions, rising with more strength than they formerly believed was possible are testament to this reality. Michel Foucault once warned that the birth of psychiatric medicine would dehumanise patients, when madmen were once left to their own devices, to live within their humanity, they are now thrust into a medical industry that dehumanises them through the use of ascetic scientism. We are witnessing Foucault’s predictions fulfil themselves. Now, suicide is justified through “individual choice”, but this conception of choice fails to grasp the relativity of choice; when one is consumed by suffering, judgement is impaired, rather than clarified. When one is surrounded by power structures that encourage harmful decisions, virtuous paths become obscured. 

Canada provides a particularly stark example of the poverty of free choice in the context of mental illness: Alan Nichols, a 61-year-old Canadian with a history of depression and other medical issues, was hospitalised in June 2019 over suicidal tendencies. After a month, Nichols submitted a request to be euthanised and was killed, despite his family and nurse practitioner claiming he “lacked the capacity” to understand his decision, and was “not suffering unbearably”—among the requirements for euthanasia. Similarly, it was tragically revealed that the woman in the advertisement was failed by the same system which brought about her death. In an interview with CTV in June, Hatch, using a pseudonym, stated, “I feel like I’m falling through the cracks so if I’m not able to access health care am I then able to access death care?”

A healthcare system that glorifies freedom of choice, while simultaneously failing to provide meaningful options for cures or treatments, is one that has replaced the Hippocratic Oath with hypocrisy. It is a medical, spiritual and moral dead-end, but the silver lining is that through death there is rebirth; the fight towards valuing life and meaningful choice must commence.