Recall that in England, back in the day, it was technically illegal to commit suicide. Actually the English cared nothing about whether they offed themselves, it just gave them a chance to confiscate their property. This from the guys that shipped the Irish to America because it was cheaper than feeding them during the potato famine and shipped social undesirables to Australia simply to get rid of them.

Taking one’s life in America is not technically illegal, but very, very unfashionable. Any unsuccessful attempt landed the individual in a position of “substituted judgement” where they can land in an emergency department or a psychiatric facility with no civil rights until they “get their mind right”.

https://www.youtube.com/watch?v=8CBqjZX6FjE

Suicidal ideation has been a marker for “incompetence” to understand that “life”is always better than death” (italics mine), and choosing death for whatever reasons is a marker for “involuntary treatment” to get the afflicted person to understand that reality. After treatment, the afflicted person has their mind right and voluntarily chooses life because they have come to understand it’s always preferable.

However, as I mentioned in my previous missives about aging musicians and others choosing death, those rationales are different than endogenous depression. They feel they lived what they wanted to and after the blaze of their streak across the sky extinguishes, they no longer have any desire to live in the new world. That’s a different thing, and we’ll see much more of it as there are a LOT of persons out there (much of it because of the baby boom) that are out of the loop and life in the new loop doesn’t work. That said, many are prosperous in their 70s (Paul McCartney, Neil Young et al). But there are a LOT of their ilk out there that no one hears from till their obit appears.

Now, in the new millennium, a whole different agenda for suicide is appearing, that of terminally ill persons that aren’t quite bad off enough for traditional hospice but definitely suffering with no respite. The classic example that has been brought up is that of Robin Williams, deciding to cope “his way” with progressive Lewy Body Dementia, a particularly cruel, progressive disease that doesn’t spare the victim any misery

https://en.wikipedia.org/wiki/Dementia_with_Lewy_bodies

Again, traditionally, the best course for many is hospice where suffering can be alleviated by a titrated treatment plan. But Hospice is usually thought of as an end stage remedy, when it’s “time to die”. Because of our ability to “prolong life” by a high intensity clinical care program, we’re lengthening the distance between ambulatory, functional suffering and the “death spiral”. As this distance increases, suffering persons want the legal and moral ability to decide when they’ve had enough, and that time may come before the “death spiral”.

More people are now deciding it should be their call as to when to end their suffering, but the nuts & bolts on how to accomplish that goal remain murky. The way out for some of these afflicted is sometimes painful and uncomfortable. Death by hanging or shooting. Robin should not have had to hang himself when he decided his time was up. He should have received “humane” treatment by someone that cared enough about him to respect his wishes and that he was competent to express those wishes.

This will inevitably become a legal issue, the reciprocal of the issue of a woman controlling what goes on within her own body, a firestorm that’s on the way. There are a few States that allow physicians to assist in a suicide and as far as I can see, those plans work well and are not misused. I think it’s time for us as physicians to start looking at this issue through the lens of the new millennium. It’s isn’t our father’s world anymore.

A great many of us are aging reasonably well but the specter of “not so well” is always shadowing us. At age 73 I’m still doing pretty much everything I want to do, albeit a bit more clumsily but I still feel the same passions I felt in my 20s. I’m working pretty hard to maintain my physical strength to match my expectations for as long as I can. But the day will come when I will not function as I desire due to progressive age and God knows what other disease that could grasp me.

When that day comes and I’ve hopefully reached the bottom of my bucket list, I could deal with lying around in a personal care home for a while, photos of glory days on the wall, with a cable TV and a laptop to keep up with what’s happening in the world. If the day came where I was a burden to anyone, was uncomfortable and unable to get around, I have a hidden stash of sixty tabs of 10 mg Propranolol and ninety 10 mg Ambien tabs. I might very well decide when it’s right to exit stage left, and you know me, I’m neurotically maintaining notebooks of virtually everything I’ve ever done in my life so those that come after me will get a chance to know me.

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Though wise men at their end know dark is right,
Because their words had forked no lightning they
Do not go gentle into that good night.

Good men, the last wave by, crying how bright
Their frail deeds might have danced in a green bay,
Rage, rage against the dying of the light.

Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.

Grave men, near death, who see with blinding sight
Blind eyes could blaze like meteors and be gay,
Rage, rage against the dying of the light.

                  Dylan Thomas (1952)

David Crippen, MD, FCCM
Professor Emeritus
University of Pittsburgh (Ret)