Comments on “Knowing When to Say Goodbye”

John L. McIntosh, PhD

The use of fiction in ethical discussion has not been a usual practice in the social sci- ences or medicine. A primary reason for this might well be that the author of fic- tion may include details, insights, and comments that influence readers in one di- rection while discounting or omitting de- tails and points of information that might lead to other conclusions. “Knowing When to Say Goodbye” offers some balance and less biased components, but it predomi- nantly advances and advocates rational decision-making processes in suicide. If the final paragraph were either more am- biguous or omitted altogether, individual readers would be forced to ponder what would be the “appropriate” decision in each case (Mr. Johnson vs. the healthy but death-desiring grandparents), if indeed there is a “correct” or “appropriate” single answer. Instead, the issue is “resolved in the final paragraph. This ending creates an atmosphere in which other discussion or alternatives seem almost unnecessary or even inappropriate.

I contend that the resolution of this story, as detailed, is not nearly as obvious as implied in the last paragraph-physi- cian-assisted death is not inherently “wrong” and personal rational suicide “cor- rect.” The issues in this story and in the re- ality of the world are fa r from obviously resolved and no simple fictionalized or even real-life account will convince anyone otherwise, unless they have already de- cided. I believe the reader would be better served by this fictionalized story without the “solution” provided.

Why does Dr. Martin suddenly have the insight to understand the answers to

these lifelike dilemmas? Therapists in fields such as psychology, psychiatry, and social work constantly grapple with the clinical issues of transference and counter- transference with clients (see, e.g., Lee- naars, 1994, pp. 56-57; Richman, 1993, pp. 78-83). Under similar circumstances, this medical professional, Dr. Martin, seems to instead ignore his own feelings toward Mr. Johnson as well as his per- sonal experience with his grandparents and their circumstances. Recognition of countertransference by Dr. Martin would seem important. How are his personal feelings about his grandparents affecting his judgment in Mr. Johnson’s case? How does his medical experience with the sick, and often elderly, affect his thoughts about his grandparents’ decision? Why should Dr. Martin feel his own family was so fortunate to be spared decisions about withholding of nutrition (or decisions about institutionalization) if counter- transference issues are not relevant?

Looking at the “balance sheet” for these two elderly grandparents, several positive and negative elements are described. On the positive side are: each other’s com- pany, their long marriage (over 65 years), their grandchildren and the recent birth of their first great-grandchild, their contin- ued independent living circumstances, and their long and fulfilling lives together. The negatives chronicled are: the percep- tion of inevitable infirmity and depen- dence and their abhorrence of that thought, Grandpa’s deafness and the pres- ence of an electively untreated kidney tu- mor, and Grandma’s bad hip and her in- ability to work in the garden, the feeling

John L. McIntosh is with Indiana University South Bend

Suicide and Life-Threatening Behavior, Vol. 25(4), Winter 1995 0 1995 The American Association of Suicidology 513

514 SUICIDE AND LIFE-THREATENING BEHAVIOR

that they are not enjoying life as they once did, and the deaths of their friends. These two fiercely independent elders desired control over the end of their lives. They perceived that the negative elements of their lives (most of which were feared and not yet present) outweighed the positive factors. Therefore, they opted for a pre- emptive strike while they possessed the ability to take personal action.

A troublesome aspect in this fictional set of events was the knowledge of the family members and their apparent strug- gling with their grandparents’ plans. We are told that Laura, for example, wanted to make sure they were not depressed. She and others wondered if they should let their doctors know (apparently their phy- sicians, but no direct contact with a men- tal health professional). After listening to their arguments, Laura accepts them and does nothing. We could never be certain whether clinical depression and clouded cognitions were present in one or both of these older adults. By accepting the logic of the suicidal individuals, an action about which Shneidman (1985, e.g., pp. 137-138) cautions, Laura has also provided indirect consent and permission for their actions. Could nothing be done to help these old people enjoy old age (new friends, new ac- tivities, etc.)? In fact, without providing or seeking any outside help, the family has accepted that there are no new ways for this elderly couple to find more enjoyment in life. Rushing into death when one per- ceives few or no options is also a feature often mentioned in suicidal cognitions (See Shneidman, 1985, pp. 138-140). Al- ternatively, Richman (1992, p. 134) dis- cusses the potential affirmative outcomes of confronting life’s problems in late life. Could not more have been done to provide this opportunity before accepting and con- senting to actions that ended their lives? Did the family do enough, or as they won- der after the deaths, should they have tried harder to stop them? Was simply discussing the plan and attempting to dis- suade them by the family the only actions that should have been taken? Did the grandparents believe that waiting would

have resulted in coercive, preventive mea- sures being taken? Did they lack basic trust in the family to such a degree that they instead chose to abruptly take their own lives and forego being able to say goodbye?

The reader may well ponder why this el- derly couple chose to commit suicide at this time. Can suicide only be rational if decided when no physical threat or illness exists? Does fear of the future warrant death? Does extreme old age alone? Would the actions of these two individu- als have been supported if they had de- cided the same thing 10, 20, or 40 years earlier? There are ageist aspects of this story that suggest that the answer to this latter question might be no. For example, we read that Grandma on several occa- sions has accidentally burned dinner. Are we to wonder, as she might be, whether her mental faculties are slipping; perhaps these are early symptoms of Alzheimer’s or other dementia? Although the long lives of these individuals certainly may warrant the avoidance of advice giving and interference, does attainment of the age of 90 imply that we do not attempt to take all reasonable measures that we would have taken earlier in these same in- dividuals’ lives?

The story’s definitive conclusion seems to suggest that suicide is the logical choice in these circumstances, in fact “their deci- sion to end their lives reflected how fulfill- ing their lives had been.” Would someone be irrational if they had lived so long and fulfilled, feared for health problems that almost inevitably come, and would prefer to die on their own terms if possible, but they did not commit suicide? Would it not be rational to prevent their children from having to make the tough decisions that might eventually come? Selfish if they did not? The devaluing of the time remaining to these two older adults, simply because it would probably not be very long, seems ageist. Is it relevant that if these two healthy elders had chosen to wait (future opportunities for suicide did not seem to be threatened with imminent loss), their great-grandson would perhaps get to

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know them and have memories of them that would be cut off by their choice to die while still healthy? Chronic health prob- lems like those described here (deafness, hip problems, etc.), especially in someone in their 9Os, are the norm in old age. Is it only logical that life is not worth living un- der these circumstances; and after all, is it not true that they will probably only get worse anyway? Is this the viewpoint of the 90-year-old or the younger individuals pondering how they would feel if it were them?

As a final issue, it seems odd to equate Mr. Johnson’s nearly comatose condition, accompanied by his do-not-resuscitate wish, with these two older grandparents who were lacking in debilitating mental or physical conditions. In Mr. Johnson’s case we have an 80-year-old who is being given comfort care only and who could take no action to end his life. His case would neces- sarily be a case of euthanasia, not only be- cause he could not perform the action him- self, but also because his wish to have the action performed has not been given. This is not the same as physician-assisted sui- cide as currently defined. The death would be physician-performed, not assisted, and meets no currently accepted definitions of suicide. To accept the grandparents’ ac-

tion says little in relation to any circum- stance similar to Mr. Johnson’s. These two cases are not parallel and one cannot be instructed about one from the other.

The complexity of the ethical issues seems poorly served by the definitive solu- tion presented in the final paragraph of this fictional story. If the story and its de- tails are left unchallenged, an opportunity is lost for essential dialogue, necessary to advance debate of this very real issue. In this reader’s opinion, this fictional ac- count leaves more questions about the is- sue of rational suicide in late life than it answers. I am not convinced by it that an obvious answer exists.

REFERENCES

Leenaars, A. A. (1994). Crisis intervention with highly lethal suicidal people. In A. A. Leenaars, J. T. Maltsberger, & R. A. Neimeyer (Eds.), Treat- ment of suicidal people (pp. 45-59). New York: Taylor and Francis.

Richman, J. (1992). A rational approach to rational suicide. In A. A. Leenaars, R. Maris, J. L. McIn- tosh, & J. Richman (Eds.), Suicide and the older adult (pp. 130-141). New York Guilford Press.

Richman, J. (1993). Preventing elderly suicide: Over coming personal despair, professional neglect, and social bias. New York: Springer.

Shneidman, E. S. (1985). Definition of suicide. New York: Wiley- Interscience.