Rational Suicide in Late Life: A Systematic Review of the Literature
Abstract
1. Introduction
2. Materials and Methods
3. Results
3.1. Main (Quantitative) Features of the Included Studies
3.2. Main Topics Covered in the Included Studies
3.3. Depression, Self-Determination, and Mental Competence
3.4. Views of Rational Suicide: Physicians’ and Population’s Perspectives
3.5. Approach to Rational Suicide
3.6. Ageism
3.7. Slippery Slope
4. Discussion
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
- WHO. Suicide in the Western Pacific. Available online: https://www.who.int/westernpacific/health-topics/suicide (accessed on 16 August 2019).
- Cheung, G.; Douwes, G.; Sundram, F. Late-Life Suicide in Terminal Cancer: A Rational Act or Underdiagnosed Depression? J. Pain Symptom Manag. 2017, 54, 835–842. [Google Scholar] [CrossRef] [PubMed]
- Conwell, Y.; Thompson, C. Suicidal behavior in elders. Psychiatr. Clin. N. Am. 2008, 31, 333–356. [Google Scholar] [CrossRef] [PubMed]
- Zeppegno, P.; Manzetti, E.; Valsesia, R.; Siliquini, R.; Ammirata, G.; De Donatis, O.; Usai, C.; Torre, E. Differences in suicide behaviour in the elderly: A study in two provinces of Northern Italy. Int. J. Geriatr. Psychiatry 2005, 20, 769–775. [Google Scholar] [CrossRef]
- Institute of Medicine (US) Committee on Pathophysiology and Prevention of Adolescent and Adult Suicide. Reducing Suicide: A National Imperative; Goldsmith, S.K., Pellmar, T.C., Kleinman, A.M., Bunney, W.E., Eds.; National Academies Press (US): Washington, DC, USA, 2002. Available online: http://www.ncbi.nlm.nih.gov/books/NBK220939/ (accessed on 16 August 2019).
- Zeppegno, P.; Gramaglia, C.; di Marco, S.; Guerriero, C.; Consol, C.; Loreti, L.; Martelli, M.; Marangon, D.; Carli, V.; Sarchiapone, M. Intimate Partner Homicide Suicide: A Mini-Review of the Literature (2012–2018). Curr. Psychiatry Rep. 2019, 21, 13. [Google Scholar] [CrossRef] [PubMed]
- Simon, R.I. Silent suicide in the elderly. Bull. Am. Acad. Psychiatry Law 1989, 17, 83–95. [Google Scholar]
- Conwell, Y.; Duberstein, P.R.; Cox, C.; Herrmann, J.H.; Forbes, N.T.; Caine, E.D. Relationships of age and axis I diagnoses in victims of completed suicide: A psychological autopsy study. Am. J. Psychiatry 1996, 153, 1001–1008. [Google Scholar]
- Turvey, C.L.; Conwell, Y.; Jones, M.P.; Phillips, C.; Simonsick, E.; Pearson, J.L.; Wallace, R. Risk factors for late-life suicide: A prospective, community-based study. Am. J. Geriatr. Psychiatry 2002, 10, 398–406. [Google Scholar] [CrossRef] [PubMed]
- Sokero, T.P.; Melartin, T.K.; Rytsälä, H.J.; Leskelä, U.S.; Lestelä-Mielonen, P.S.; Isometsä, E.T. Suicidal ideation and attempts among psychiatric patients with major depressive disorder. J. Clin. Psychiatry 2003, 64, 1094–1100. [Google Scholar] [CrossRef] [PubMed]
- Fässberg, M.M.; Cheung, G.; Canetto, S.S.; Erlangsen, A.; Lapierre, S.; Lindner, R.; Draper, B.; Gallo, J.J.; Wong, C.; Wu, J.; et al. A systematic review of physical illness, functional disability, and suicidal behaviour among older adults. Aging Ment. Health 2016, 20, 166–194. [Google Scholar] [CrossRef] [PubMed]
- Rurup, M.L.; Pasman, H.R.W.; Goedhart, J.; Deeg, D.J.H.; Kerkhof, A.J.F.M.; Onwuteaka-Philipsen, B.D. Understanding why older people develop a wish to die: A qualitative interview study. Crisis 2011, 32, 204–216. [Google Scholar] [CrossRef]
- Balasubramaniam, M. Rational Suicide in Elderly Adults: A Clinician’s Perspective. J. Am. Geriatr. Soc. 2018, 66, 998–1001. [Google Scholar] [CrossRef] [PubMed]
- Erikson, E.H. Childhood and Society; WW Norton & Company: New York, NY, USA, 1993. [Google Scholar]
- Muskin, P.R. The request to die: Role for a psychodynamic perspective on physician-assisted suicide. JAMA 1998, 279, 323–328. [Google Scholar] [CrossRef] [PubMed]
- Arie, T. On Aging. In Revolt and Resignation; Jean Amery; Indiana University Press: Bloomington, IN, USA, 1994; p. 132. [Google Scholar]
- Siegel, K. Psychosocial aspects of rational suicide. Am. J. Psychother. 1986, 40, 405–418. [Google Scholar] [CrossRef]
- Mayo, D.J. The concept of rational suicide. J. Med. Philos. 1986, 11, 143–155. [Google Scholar] [CrossRef] [PubMed]
- Valente, S.M.; Trainor, D. Rational suicide among patients who are terminally ill. AORN J. 1998, 68, 252–258, 260–264. [Google Scholar] [CrossRef]
- Moody, H.R. Ethics in an Aging Society; Johns Hopkins University Press Books: Baltimore, MD, USA, 1992; Volume 1, Available online: https://jhupbooks.press.jhu.edu/title/ethics-aging-society (accessed on 17 August 2019).
- Siegel, K. Rational suicide: Considerations for the clinician. Psychiatr. Q. 1982, 54, 77–84. [Google Scholar] [CrossRef]
- Werth, J.L.; Cobia, D.C. Empirically based criteria for rational suicide: A survey of psychotherapists. Suicide Life Threat. Behav. 1995, 25, 231–240. [Google Scholar] [PubMed]
- Motto, J.A. The Right to Suicide: A Psychiatrist’s View. Suicide Life Threat. Behav. 1972, 2, 183–188. [Google Scholar]
- Diekstra, R.F.W. The significance of Nico Speiler’s suicide: How and when should suicide be prevented? Suicide Life Threat. Behav. 1986, 16, 13–15. [Google Scholar] [CrossRef]
- Humphry, D. Rational suicide among the elderly. Suicide Life Threat. Behav. 1992, 22, 125–129. [Google Scholar]
- A Cliff, Not a Slope: A Response to Margaret P. Battin. Centre for Suicide Prevention. Available online: https://www.suicideinfo.ca/resource/siecno-19890235/ (accessed on 17 August 2019).
- Graber, G.C. The rationality of suicide. In Suicide and Euthanasia: The Rights of Personhood, 1st ed.; Wallace, S.E., Eser, A., Eds.; University of Tennessee Press: Knoxville, TN, USA, 1981; pp. 51–65. [Google Scholar]
- Rich, K.L.; Butts, J.B. Rational suicide: Uncertain moral ground. J. Adv. Nurs. 2004, 46, 270–278. [Google Scholar] [CrossRef] [PubMed]
- Moher, D. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann. Intern. Med. 2009, 151, 264. [Google Scholar] [CrossRef] [PubMed]
- Fortin, A.; Lapierre, S.; Baillargeon, J.; Labelle, R.; Dubé, M.; Pronovost, J. Suicidal ideation and self-determination in institutionalized elderly. Crisis 2001, 22, 15–19. [Google Scholar] [CrossRef] [PubMed]
- Gibbs, L.M.; Dombrovski, A.Y.; Morse, J.; Siegle, G.J.; Houck, P.R.; Szanto, K. When the solution is part of the problem: Problem solving in elderly suicide attempters. Int. J. Geriatr. Psychiatry 2009, 24, 1396–1404. [Google Scholar] [CrossRef]
- Uncapher, H.; Areán, P.A. Physicians are less willing to treat suicidal ideation in older patients. J. Am. Geriatr. Soc. 2000, 48, 188–192. [Google Scholar] [CrossRef]
- Van Wijngaarden, E.; Leget, C.; Goossensen, A. Caught between intending and doing: Older people ideating on a self-chosen death. BMJ Open 2016, 6, e009895. [Google Scholar] [CrossRef]
- Winterrowd, E.; Canetto, S.S.; Benoit, K. Permissive beliefs and attitudes about older adult suicide: A suicide enabling script? Aging Ment. Health 2017, 21, 173–181. [Google Scholar] [CrossRef]
- Lerner, B.H. Knowing when to say goodbye: Final Exit and suicide in the elderly. Suicide Life Threat. Behav. 1995, 25, 508–512. [Google Scholar]
- Wand, A.P.F.; Peisah, C.; Draper, B.; Jones, C.; Brodaty, H. Rational Suicide, Euthanasia, and the Very Old: Two Case Reports. Case Rep. Psychiatry 2016, 2016, 4242064. [Google Scholar] [CrossRef]
- Battin, M.B. The Concept of Rational Suicide. 1984. Available online: https://scholar.google.com/scholar_lookup?title=The+concept+of+rational+suicide&author=M.+P.+Battin&publication_year=1984 (accessed on 16 August 2019).
- Conwell, Y.; Caine, E.D. Rational suicide and the right to die. Reality and myth. N. Engl. J. Med. 1991, 325, 1100–1103. [Google Scholar] [CrossRef]
- Fontana, J.S. Rational suicide in the terminally ill. J. Nurs. Scholarsh. 2002, 34, 147–151. [Google Scholar] [CrossRef] [PubMed]
- Karlinsky, H.; Taerk, G.; Schwartz, K.; Ennis, J.; Rodin, G. Suicide attempts and resuscitation dilemmas. Gen. Hosp. Psychiatry 1988, 10, 423–430. [Google Scholar] [CrossRef]
- Werth, J.L. Contemporary Perspectives on Rational Suicide [Internet]; Brunner/Mazel: Philadelphia, PA, USA, 1999. Available online: https://trove.nla.gov.au/work/8768140 (accessed on 16 April 2019).
- Gallagher-Thompson, D.; Osgood, N.J. Suicide in later life. Behav. Ther. 1997, 28, 23–41. [Google Scholar] [CrossRef]
- Battin, M.P. Rational suicide: How can we respond to a request for help? Crisis 1991, 12, 73–80. [Google Scholar]
- Moore, S.L. Rational suicide among older adults: A cause for concern? Arch. Psychiatr. Nurs. 1993, 7, 106–110. [Google Scholar] [CrossRef]
- Prado, C.G. Ageism and elective death. Ethics Med. Public Health 2015, 1, 442–449. [Google Scholar] [CrossRef]
- Richards, N. Old age rational suicide. Sociol. Compass 2017, 11, e12456. [Google Scholar] [CrossRef]
- McCue, R.; Balasubramaniam, M. Rational Suicide in the Elderly—Clinical, Ethical, and Sociocultural Aspects; Springer Ebooks: New York, NY, USA, 2017; Available online: https://www.springer.com/gp/book/9783319326702 (accessed on 16 August 2019).
- Ruckenbauer, G.; Yazdani, F.; Ravaglia, G. Suicide in old age: Illness or autonomous decision of the will? Arch. Gerontol. Geriatr. 2007, 44 (Suppl. 1), 355–358. [Google Scholar] [CrossRef]
- Clark, D.C. “Rational” suicide and people with terminal conditions or disabilities. Issues Law Med. 1992, 8, 147–166. [Google Scholar] [PubMed]
- Den Hartogh, G. Two Kinds of Suicide. Bioethics 2016, 30, 672–680. [Google Scholar] [CrossRef]
- Torre, E.; Zeppegno, P.; Usai, C.; Rudoni, M.; Ammirata, G.; De Donatis, O.; Manzetti, E.; Marangon, D.; Migliaretti, G. Suicide in Verbano-Cusio-Ossola province: Decade 1990–2000. Epidemiol. Psichiatr. Soc. 2002, 11, 277–283. [Google Scholar] [CrossRef] [PubMed]
- Clarke, D.M. Autonomy, rationality and the wish to die. J. Med. Ethics 1999, 25, 457–462. [Google Scholar] [CrossRef] [PubMed]
- Maris, R. Rational Suicide: An Impoverished Self-Transformation. Suicide Life Threat. Behav. 1982, 12, 4–16. [Google Scholar] [CrossRef]
- Richman, J. The Case against Rational Suicide. Suicide Life Threat. Behav. 1988, 18, 285–289. [Google Scholar] [CrossRef] [PubMed]
- Shneidman, E.S. Psychotherapy with suicidal patients. Suicide Life Threat. Behav. 1981, 11, 341–348. [Google Scholar]
- Stiefel, F.; Die Trill, M.; Berney, A.; Olarte, J.M.; Razavi, A. Depression in palliative care: A pragmatic report from the Expert Working Group of the European Association for Palliative Care. Support. Care Cancer 2001, 9, 477–488. [Google Scholar] [CrossRef] [PubMed]
- Passik, S.D.; Dugan, W.; McDonald, M.V.; Rosenfeld, B.; Theobald, D.E.; Edgerton, S. Oncologists’ recognition of depression in their patients with cancer. J. Clin. Oncol. 1998, 16, 1594–1600. [Google Scholar] [CrossRef] [PubMed]
- McDonald, M.V.; Passik, S.D.; Dugan, W.; Rosenfeld, B.; Theobald, D.E.; Edgerton, S. Nurses’ recognition of depression in their patients with cancer. Oncol. Nurs. Forum 1999, 26, 593–599. [Google Scholar] [PubMed]
- Block, S.D. Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians—American Society of Internal Medicine. Ann. Intern. Med. 2000, 132, 209–218. [Google Scholar] [CrossRef]
- Periyakoil, V.S.; Kraemer, H.C.; Noda, A.; Moos, R.; Hallenbeck, J.; Webster, M.; Yesavage, J.A. The development and initial validation of the terminally illgreif of depression scale (TIGDS). Int. J. Methods Psychiatr. Res. 2005, 14, 202–212. [Google Scholar] [CrossRef] [PubMed]
- Osgood, N.J. Suicide in the Elderly. A Practitioner’s Guide to Diagnosis and Mental Health Intervention; Aspen Systems Corporation: Rockville, MD, USA, 1985. [Google Scholar]
- Kerkhof, A.; de Leo, D. Suicide in the elderly: A frightful awareness. Crisis 1991, 12, 81–87. [Google Scholar] [PubMed]
- Schneewind, E.H. Of ageism, suicide, and limiting life. J. Gerontol. Soc. Work 1994, 23, 135–150. [Google Scholar] [CrossRef]
- Reggler, J. The slippery slope argument and medical assistance in dying. CMAJ 2017, 189, E471. [Google Scholar] [CrossRef] [PubMed]
- Potter, J. The psychological slippery slope from physician-assisted death to active euthanasia: A paragon of fallacious reasoning. Med. Health Care Philos. 2019, 22, 239–244. [Google Scholar] [CrossRef]
- Kaufman, S.R. Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line (Critical Global Health: Evidence, Efficacy, Ethnography); Duke University Press: Durham, NC, USA, 2015. [Google Scholar]
- Gawande, A. Being Mortal Illness, Medicine and What Matters in the End; Profile Books Ltd.: London, UK, 2014. [Google Scholar]
- Farberow, N.L. (Ed.) The Many Faces of Suicide: Indirect Self-Destructive Behavior; McGraw-Hill: New York, NY, USA, 1980. [Google Scholar]
- Shneidman, E.S. Deaths of Man; Quadrangle: New York, NY, USA, 1973. [Google Scholar]
- Conwell, Y.; Pearson, J.; De Renzo, E. Indirect self-destruptive behavior among elderly patients in nursing homes: A research agenda. Am. J. Geriatr. Psychiatry 1996, 4, 152–163. [Google Scholar] [CrossRef] [PubMed]
Definition/Criteria of Rational Suicide | |
---|---|
Siegel [21] | Realistic assessment of the situation on behalf of a person whose mental processes are not impaired by either psychological illness or severe emotional distress. The motivational basis for the decision could be understandable on behalf of uninvolved observers. |
Cheung et al. [2] | Add further details about Siegel criterion (3):
|
Werth & Cobia [22] | Presence of an unremitting hopeless condition (such as terminal illness, severe pain, both physical and psychological, deteriorating conditions, no longer acceptable quality of life, etc). The decision is a free choice. The decision results from a sound decision making process including the consultation with a mental health professional, and with objective and significant others; a non-impulsive assessment of alternatives, of the possible impact of the decision on significant others, and of the congruence of the decision with the individual’s personal values. |
Valente & Trainor [19] | Rational decisions reflect careful planning and consideration of adequate information (e.g., complete and accurate medical facts); preparations (e.g., wills, funeral arrangements); consideration of effect on others, treatment options and alternatives. |
Motto [23] | A rational decision should be realistic (i.e., should be made after a realistic assessment of the individual’s situation and after gaining full knowledge of options and consequences) and have minimal ambivalence (i.e., a decision should not be made on the basis of a transient desire and should not be inconsistent with the individual’s longstanding and fundamental values). |
Diekstra [24] | Enduring wish to die in a person with a condition of enduring unbearable physical and/or emotional pain, no hope for improvement. The person, who is not mentally disturbed, makes a free will decision which would not cause “unnecessary or preventable harm” to others. |
Humphry [25] | “Considered decision” on behalf of a mature adult individual, after reasonable medical help has been sought and the treating physician has been informed. A will should be made and a note should be left. The suicide should not involve others criminally. |
Weber [26] | Two meanings of right to die:
|
Graber [27] | A reasonable appraisal of the situation reveals that one would be really better off dead. |
Empirical Studies Including Data | ||||||
Author, Year | Perspective/Approach | Sample Features/Specialists | Rating Scales | Topics Covered/Reasons Mentioned for RS | RS Criteria and/or Definition | Main Results and Conclusions |
Cheung et al. 2017 [2] | Focus on the comparison between older people with and without terminal cancer who died by suicide, and analysis of motives for suicide. Hypothesis: in older people with terminal cancer, suicide can be considered a rational choice rather than the result of depression. | Source: Coroner records about suicides in ≥ 65-year-old 07/2007–12/2012, with available data about terminal cancer, N = 214, 74.3% males, 60.7% aged 65–79-year-old N = 23 (10.7%) terminal cancer. | n.a. |
| Siegel, 1986 [17] (3rd characteristic: a motivational basis that would be understandable to uninvolved observers) Werth & Cobia, 1995 [22] |
|
Fortin et al. 2001 [30] | Focus on suicide prevention. Health care personnel (not mental health professionals) performing assessment. | N = 66 French-Caucasian older adults (age range between 69 and 96 y.o.) with no cognitive deficit, from 7 long-term facilities. N = 11 suicidal (N = 7 males). N = 55 non suicidal (N = 22 matched for age, gender, civil status). | PAQ GDS |
| Werth & Cobia (1995) [22], mentioned (but not used) |
|
Gibbs et al. 2009 [31] | Focus on problem solving strategies, closely related to the topic of suicidality in old age. | N = 64 > 60-year-old MMSE >18
| SPSI-R MMSE HAM-D BHS B-SIS SIS B-SLS CIRS-G |
| n.s. |
|
Uncapher and Arean 2000 [32] | To determine the influence of patients’ age on primary care physician recognition of suicidal symptoms and the willingness to treat the suicidal patient. | N = 342 physicians (63% response rate), of whom N = 215 primary care physicians, asked to assess 2 vignettes of depressed suicidal patient, either geriatric, retired, age 78 y.o. (N = 100), or young, employed, 38 y.o. (N = 115). | 21-item Suicidal Patient Treatment Scale | n.s. | n.s. |
|
Van Wijngaarden et al. 2016 [33] | Qualitative in-depth interview study aimed at a phenomenological characterization of the phenomenon “life is completed and no longer worth living”. | N = 25, > 82 y.o., N = 11 males form the Netherlands, ideating on self-chosen death. Inclusion criteria: (1) considered their lives to be ‘completed’; (2) suffered from the prospect of living on; (3) current wish to die; (4) 70 y.o. or older; (5) not terminally ill; (6) considered themselves to be mentally competent; (7) considered their death wish reasonable. N = 23 members of RTD organizations. | Interview HADS |
| n.s. |
|
Winterrowd et al. 2017 [34] | To examine beliefs/opinions (most likely precipitants and protectors) and attitudes about older adults’ suicide, in a cultural perspective. | N = 255 older adults (86% European American), 70.95 y.o. mean age, 38% males. N = 281 younger adults (81% European American), 19.04 y.o. mean age, 30% males. | Ad hoc attitudes Scale Personal Attribute Questionnaire-Short Form | n.s. | n.s. |
|
Case Studies Specifically Focused on Late Life Rational Suicide | ||||||
Author, Year | Perspective/Approach | Sample Features/Specialists | Rating Scales | Topics Covered/Reasons Mentioned for RS | RS Criteria and/or Definition | Main Results and Conclusions |
Balasubramaniam 2018 [13] | Case presentation: 72 y.o. male, retired, widowed, with adenocarcinoma. | Geriatricians Psychogeriatricians | MCAS (used) DDRS and SATHD (mentioned) | Ageism Control (loss of) Dependence Frailty Gerontophobia Loss QoL Sense of identity/Sense of self (loss of) | n.s. |
|
Lerner 1995 [35] | Case Story of a Couple and Review of Humphry’s Book Final Exit. | n.s. | n.a. | Autonomy (loss of) Terminal illness Terminal old age | n.s. |
|
Simon 1989 [7] | Clinical/legal issues of silent S + 2 cases (clinical) + case law examples. | Clinicians | n.a. | Autonomy (loss of) Factors including psychological, social, ethical, cultural, economic and situational Losses Medical complaints | n.s. |
|
Wand et al. 2016 [36] | 2 cases discussed in the light of the importance of a narrative and bio-psycho-social approach to the management of the wish to die. | Psychiatrists Psychogeriatricians | MCAT | Autonomy (loss of) Burden Control (loss of) Coping strategies Dependence Disability External support Helplessness Hopelessness Loss of purpose/meaning/role in life QoL Scared of institutional care Tiredness of living | Battin 1984 [37] Conwell & Caine, 1991 [38] |
|
Case Studies Not Specifically Focused on Late Life Rational Suicide (But Mentioning It in the Text) | ||||||
Author, Year | Perspective/Approach | Sample Features/ Specialists | Rating Scales | Topics Covered/Reasons Mentioned for RS | RS Criteria and/or Definition | Main Results and Conclusions |
Fontana 2002 [39] | Historical and philosophical perspective + case description. RTD, PAS, euthanasia mentioned; Hemlock society mentioned. | Nurses | n.a. | Autonomy (loss of) Control (loss of) Dignity Loss of meaning/purpose in life Pain QoL Self-determination | Siegel, 1986 [17] Werth, 1995 [22] |
|
Karlinsky et al. 1988 [40] | Psychological, ethical, legal issues + 2 cases, one advanced age, one terminal illness; euthanasia mentioned; Hemlock Society mentioned. | n.s. | n.a. | Competency Control (loss of) Dependence Disability, physical Mental state/psychiatric illness QoL | n.s. |
|
Rich 2004 [28] | Historical, ethical + case description of chronic AIDS; PAS, euthanasia mentioned; Hemlock Society mentioned; VSED and terminal sedation mentioned. | Nurses | n.a. | Escape from life Terminal illness Disability, permanent Autonomy (loss of) Pain | Siegel, 1986 [17] Werth, 1999 [41] Werth & Cobia, 1995 [22] |
|
Opinion Studies Specifically Focused on Late Life Rational Suicide | ||||||
Author, Year | Perspective/Approach | Sample Features/ Specialists | Rating Scales | Topics Covered/Reasons Mentioned for RS | RS Criteria and/or Definition | Main Results and Conclusions |
Conwell & Caine 1991 [38] | Critical position | Psychiatrists Psychogeriatricians Researchers Consultants | n.a. | Ageism Burden Physical illness QoL | n.s. |
|
Gallagher-Thompson &Osgood 1997 [42] | Overview of epidemiology of late life S, demographics and risk factors, assessment, RS. | Healthcare professionals | BHS MSSI BDI GDS SCID | Autonomy (loss of) Control (loss of) Dignity (loss of) Disability Hopelessness Loss of meaning in life Losses Pain Poor self-esteem QoL Terminal illness | Diekstra, 1986 [24] Motto, 1972 [23] Battin, 1991 [43] Humphry, 1992 [25] Werth & Cobia, 1995 [22] |
|
Humphry 1992 [25] | Position of the leader of the National Hemlock Society, mentioning euthanasia and PAS + case narrative. | n.s. | n.a. | Choice (loss of) Control (loss of) “Living death”Pain/suffering, both physical and emotional Terminal illness | n.s. |
|
Moore 1993 [44] | Historical perspective and discussion of supportive and opposing arguments; implications for nursing. “Old age in our society needs to be viewed once again as a valued status, rather than a cursed disease or a burden”. | Nurses Psychologists | n.a. | Burden Control (loss of) Lack of satisfying role Meaning (loss of) | Weber, 1988b [26] Graber, 1981[27] |
|
Prado 2015 [45] | Philosophical and bioethical perspective; discussion of the author’s position. | n.s. | n.a. | Conditions diminishing the individual as a person, irremediable Dependence Hopeless medical situations Irreversible deterioration Pain | n.s. |
|
Richards 2016 [46] | Empirical/theoretical overview to synthesize knowledge, including existential questions about the perception of complete life or tiredness of life. | n.s. | n.a. | Burden Control (loss of) Dependence Disability, functional Illness, chronic Loneliness Loss of meaning/purpose in life Losses Pain, suffering Personality and coping strategies Psychological issues (depression, cognitive decline) QoL Social isolation Tiredness of life | Werth, 1999 [41] Battin, 1991 [43] McCue & Balasubramaniam, 2017 [47] |
|
Ruckenbauer et al. 2007 [48] | Critical revision of RS. Tension between medical care for patients and patients’ autonomy. | Physicians | n.a. | Burden Conflict Illness Loss Pain Traditional family structures falling apart | n.s. |
|
Opinion studies not Specifically Focused on Late Life Rational Suicide (but Mentioning it in the Text) | ||||||
Author, Year | Perspective/Approach | Sample Features/Specialists | Rating Scales | Topics Covered/Reasons Mentioned for RS | RS Criteria and/or Definition | Main Results and Conclusions |
Battin 1991 [43] | S not interpreted as evidence of depression or mental illness; meaning and motivation. | Mental health professionals | n.a. | Terminal illness Disability, severe and permanent Advanced old age | Motto, 1972 (mentioned) [23] |
|
Clark 1992 [49] | Overview of S and terminal illness, PAS, RTD and euthanasia mentioned; Hemlock Society mentioned. Critical position versus the “understandable reasons” for contemplating S. | Mental health professionals General internists Family physicians | n.a. | Dependence Deteriorating health Disability Helplessness Hopelessness Isolation Loneliness Outliving family members Pain Poverty Severe illness | n.s. |
|
Siegel 1982 [21] | Evolving societal values concerning death and S, RTD, RTS; Hemlock Society mentioned. | Clinicians | n.a. | QoL Pain Loss of meaning in life Lack of support Self-determination Control (loss of) | Hoche’s “Balance sheet suicide” |
|
Arguments in Favour of Rational Suicide | Arguments Opposing Rational Suicide |
---|---|
Moral right to self-determination [33] | Should death wishes, and ideation and action aimed at deliberately ending one’s life ever be considered as “rational”? |
Needless suffering [33] | Ageism: old age individuals as a burden; death as a solution for insoluble age-related suffering [12]. |
Exerting control over one’s death: satisfaction and empowerment. | Slippery slope: from right to die to social obligation to die [9]. |
Suicidal ideation and behaviour may be the logical and understandable outcome of a balance sheet where death becomes preferable to life [33]. | Is suicide per se an evidence of mental instability? [33] Having suicidal ideation is often the very reason why an individual is classified as having a mental illness. |
Suicide can be a serious and legitimate answer to the individual’s existential situation, which should not be dismissed as a depressive symptom [20]. A history of mood disorder (as well as of any other mental illness) does not mean that the individual’s decision-making capacity is impaired and should be questioned forever [50,51]. | Suicide itself is an emotional condition precluding the possibility of rationality: the suicidal individual is usually not capable to consider other option than suicide to a condition of perceived intolerable misery. One would rather live, if a better solution than suicide was at hand [22,52,53,54,55]. |
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Gramaglia, C.; Calati, R.; Zeppegno, P. Rational Suicide in Late Life: A Systematic Review of the Literature. Medicina 2019, 55, 656. https://doi.org/10.3390/medicina55100656
Gramaglia C, Calati R, Zeppegno P. Rational Suicide in Late Life: A Systematic Review of the Literature. Medicina. 2019; 55(10):656. https://doi.org/10.3390/medicina55100656
Chicago/Turabian StyleGramaglia, Carla, Raffaella Calati, and Patrizia Zeppegno. 2019. "Rational Suicide in Late Life: A Systematic Review of the Literature" Medicina 55, no. 10: 656. https://doi.org/10.3390/medicina55100656
APA StyleGramaglia, C., Calati, R., & Zeppegno, P. (2019). Rational Suicide in Late Life: A Systematic Review of the Literature. Medicina, 55(10), 656. https://doi.org/10.3390/medicina55100656