Rational suicide and schizophrenia

Abstract

The concept of rational suicide argues that suicide could be a rational choice, in certain circumstances. Such an argument faces criticism when there is an accompanying mental illness, as many view suicide as a symptom of mental illness rather than as a rational choice about one's life. More specifically, the rational suicide debate has mostly excluded individuals with schizophrenia, as it is widely seen as a disorder that impairs rational decision making. This paper aims to examine the concept of rational suicide in schizophrenia: Could it be possible that some acts of suicide are driven from a rational choice by patients suffering from schizophrenia? This paper does not include discussions related to physician-assisted dying in schizophrenia.

Schizophrenia

Schizophrenia encompasses a variety of symptoms including changes in perception, emotion, cognition, thinking and behaviour. ¹ Patients experience a varying degree and range of symptomatology, however, the impact of the illness is invariably severe and mostly long lasting. ¹ A significant negative impact on psychosocial functioning ¹ in combination with a profound alteration of subjective life, ² leads to suffering. Conceivably, schizophrenia is one of the most debilitating diagnoses. ³ The lifetime prevalence of schizophrenia is about 1% ¹ and approximately 20% of patients with schizophrenia attempt suicide and 5–6% die by suicide. ⁴ Risk of dying by suicide in schizophrenia is about 12 times higher than in the general population. ⁵ Though schizophrenia is associated with a high burden of illness and a higher risk of suicide, it is considered a highly treatable illness in a lot of cases. ⁶

Among the core features of schizophrenia is the disorder of self, defined as the disruption of subjective experiences and a sense of agency. ⁷ A disturbance in which a sense of self, ‘mineness’, is alienated from the experience ⁸ ; the self who is experiencing the world is excluded from its very own experiences. Such a disruption of the world-brain relation has been equated to a loss of anchor to the world ⁹ and a diminished sense of existence in the world. ² Thus, it has been argued that schizophrenia could be conceived as an existential disorder. ⁹ Such a concept has been attested by patients as well. ¹⁰ As reported by patients with schizophrenia, self-disorders result in higher levels of suffering than psychotic symptoms, ¹¹ adding further to the devastating effects of schizophrenia.

Despite the ‘usual’ voices, alien thoughts and paranoia, what scared me the most was a sense that I had lost myself, a constant feeling that my self no longer belonged to me. What made such an existential orientation even more intolerable is the voices incessantly telling me that the only way to reunite with my real self is to commit suicide. ¹⁰

It is important to highlight that despite the high burden of illness, many patients with schizophrenia find their way of connecting to and rebuilding a new life, as described by them.

How complete would the recovery be?

That question is a big question – it is in fact the big question everyone has, and it isn't until later that you learn that it's the wrong question. Wrong because it isn't really a recovery. It is a new life, with a new and different way of relating to almost everything. ¹²

Rational suicide

The contemporary view considers suicide predominantly as a by-product of mental illness. As such, the current legal and ethical framework in psychiatry aims to prevent and intervene ‘all’ suicides. ¹³ Frameworks such as zero-suicide assume that all suicides are preventable and ‘ought to’ be prevented. ¹⁴ On the other hand, proponents of rational suicide argue that in some circumstances, suicide could be a rational course of action. ¹⁵ Of course, the opinions around suicide in mental illness are not limited to these two concepts and there is a spectrum of opinions in between the two concepts of zero suicide and rational suicide. Regardless of these concepts, mental health professionals remain diligent in suicide prevention and management.

In consideration of rational suicide, advocates of this concept assert the notion of an individual's rights, liberty and autonomy in making decisions for their ‘own life’.^16,17 In describing rational suicide, Siegel ¹⁸ proposed the following criteria:

1) the individual possesses a realistic assessment of his situation, 2) the mental processes leading to his decision to commit suicide are unimpaired by psychological illness or severe emotional distress, and 3) the motivational basis of his decision would be understandable to the majority of uninvolved observers from his community or social group

Experimental studies have looked into the acceptability of the concept of rational suicide by public and mental health professionals. There seems to be a growing acceptability of the idea of rational suicide in certain circumstances, such as those involving terminal illness or pain. ¹³ However, people with mental illness have been mostly excluded from the rational suicide debate. ¹⁹ In such cases, the suicidal drive in mental illness is attributed to a distorted assessment of life by patients, therefore questioning the notion of the capacity of the patient to make a ‘rational’ decision about ending their life. ²⁰ In this context, suicide has been seen as a ‘symptom’ of a mental disorder rather than as a rational choice. ²¹

One of the counterarguments for the exclusion of rational suicide in mental illness targets the universal assumption of incapacity. ¹³ It has been debated that a patient's decision is likely to be viewed as irrational in the complexity of conflicting values, when the priority of saving lives over autonomy is assumed. ²² The argument for the consideration of rational suicide in mental illness includes concerns related to poor quality of life, ²³ losses and ongoing suffering in the context of mental illness. ¹⁹

It is important to note that most mental illnesses can usually be treated effectively to alleviate the symptoms and enhance the resumption of functioning. ²⁴ Furthermore, treatment of mental illness can effectively reduce suicidality and prevent suicide in many patients. ²⁵ Although not commonly discussed, a small percentage of mental disorders could be considered ‘terminal’. Despite numerous treatment interventions, some patients continue to suffer from debilitating symptoms of their mental illness. In such circumstances, a patient's wish to suicide may originate from a rational decision, after careful examination of alternative options. In a commentary in the American Medical Association (AMA) Journal of Ethics, George discussed that in patients with terminal mental illness, there comes a point when hope for a good outcome is replaced by hope for a good (painless and peaceful) death. ²⁶ The author further argued the limitations of therapeutic hope, that clinicians are obliged to instill hope when there is a foreseeable path to the ‘hoped-for outcome’; by the same token, clinicians are obliged to avoid perpetuating false hope in cases with terminal mental illness. ²⁶

Rational suicide in schizophrenia

To many, schizophrenia equates irrationality by virtue of the status diagnosis ²⁷ and therefore, rational suicide is not considered an option. Here we discuss why some acts of suicide could be rational in schizophrenia. This paper aims to provide a better understanding of suicide in people with schizophrenia and to discuss an alternative to the traditional view that considers all suicides as driven by the illness and instead strives to respect the autonomy of those who choose suicide. It is important to stress that rational suicide is clearly not applicable to all cases and many would be excluded from the concept of rational suicide, such as those with suicidal behaviour driven by psychotic experiences, acute psychological distress, impulsivity, lack of capacity and so on.

Suicide could be a rational desire

Schizophrenia is associated with significant psychological suffering, ²⁸ decreased quality of life, psychosocial losses ¹³ and demoralization. ²⁹ The demoralization model describes that repeated suffering from psychotic symptoms, loss of pre-morbid functioning and awareness of the impact of illness could lead to hopelessness, depression and suicide.^29,30 Supporting the argument, factors such as the presence of insight, fear of mental disintegration, hopelessness and depression have been consistently shown to be risk factors for suicide in schizophrenia. Whereas other factors such as delusions and command hallucinations are reported to have less impact.^31,32 Another factor to consider is the timing of suicide in schizophrenia. ²⁷ Most suicides occur when positive symptoms are in remission, ³¹ earlier in the course of illness and following discharge,^33,34 when psychosis has subsided and awareness of loss is greatest As such, it has been argued that some cases of suicide in schizophrenia could be a realistic perspective of the course of illness and a rational response to suffering, excluding those suicides that are in direct response to psychotic phenomena. ³⁵ For instance, consider a person with schizophrenia who is tortured by their psychotic symptoms such as constant terror and dismay of being sexually assaulted during their sleep. The same individual may have experienced significant losses of pre-morbid functioning since the onset of their illness such as loss of employment, relationship and housing. Once this individual's psychotic symptoms improve as a result of treatment, this person may have a desire of ending their suffering, after realizing the impact of their illness on their life and the suffering it created. While it is important to acknowledge another individual with the same symptomatology may have no suicidal desire, the point here is that the described suffering above, while not psychotic, could be a rational desire in some cases. Hence, it remains important to open a dialogue in recognition of such a possibility and in respect for the individual's autonomy.

The diagnosis of schizophrenia does not exclude rationality

Traditionally, rationality has been discussed in two main domains: (1) content rationality: which is concerned with the content of beliefs and development of norms of rational thinking and (2) instrumental rationality: which concerns the procedure of how one reaches their plans. ³⁶ In other words, instrumental rationality examines the planning and execution of actions.

When examining rational suicide in schizophrenia, one area of debate is the consideration of instrumental rationality even in the presence of overarching content irrationality. ³⁷ Some psychotic symptoms (and the driven behaviour) are considered irrational in schizophrenia (i.e. content irrationality). However, the mere presence of delusions or irrational beliefs does not preclude instrumental rationality in patients with schizophrenia. ³⁷ In fact, patients with schizophrenia have been shown to perform similarly to controls on syllogism tests of rationality. ³⁸

An important consideration of instrumental rationality is the presence of intention for an act, and then to choose a course of action in accordance, to achieve the intended act. ³⁹ That is, the concept of rational suicide requires the presence of a rational intention, which is not driven by ‘irrational’ delusional thoughts, followed by actions in line with that intention.

To illustrate how instrumental rationality could be present despite the presence of content irrationality, consider an individual with schizophrenia who has a persecutory delusion that he is being monitored through a microchip put in his head by the government (i.e. content irrationality). This person may act in a certain way due to this delusion, which could be seen as irrational (instrumental rationality) as those actions are driven by delusional beliefs. However, in many other aspects, he could demonstrate instrumental rationality. As mentioned earlier, for instrumental rationality there needs to be (1) a rational intention and (2) execution and planning to achieve the intended goal. In our example, the individual with the mentioned delusion may decide to visit his family, and therefore plan and execute that; or he may want to purchase something, go to the bank, get money and make the purchase; or he may decide to go see his psychiatrist because of the stress caused by this delusion. In this simple example, despite the presence of content irrationality, the individual is able to demonstrate instrumental rationality in several areas of his day-to-day life.

On the other hand, while our contemporary culture allows the concept of rational suicide in cases of severe physical illnesses or pain, one can raise the question about the impact of such physical illnesses on rationality. In other words, are we too generous in accepting severe physical pain as a ‘rationale’ for suicide without considering its impact on capacity for rational thinking?

Decision-making capacity and schizophrenia

Mental capacity and rationality have been used interchangeably in the literature. ²⁷ Mental capacity in psychiatry primarily focuses on the capacity to make informed treatment decisions and is not an indicator of competence per se. ²⁷ Studies that examined treatment decision capacity in schizophrenia, reported a finding of incapacity in 10–52% of patients, indicating that at least half of the patients maintained the capacity to make treatment decisions.^40,41 Even then, the capacity (or lack of) to make treatment decisions is not universal, rather it is fluid, specific to a particular treatment and can change with time.^42,43 For instance, a patient may not be capable to make decisions concerning the treatment of psychosis but at the same time, they may be capable to make decisions related to their depressive symptoms. As such, the assumption that equates psychosis with mental incapacity does not hold strong ²⁷ when we look at clinical capacity since: (1) not everyone with schizophrenia is incapable for decisions regarding their treatment; and in fact, many are capable of making those decisions, (2) even those who are incapable for treatment decisions, could be capable in many other areas. A number of clinical studies that looked at the impact of psychotic symptoms (i.e. delusions) on tests of rationality have not found any significant difference between patients with schizophrenia and controls.^38,44 In another example, a study by Kemp et al. ⁴⁵ examined the relationship between delusions and mental capacity among patients with delusions and healthy volunteers. The tests required participants to choose between logically fallacious and valid responses, under conditions that were both plausible. Both patients and controls frequently made logical errors, without any significant differences between the two arms with respect to logical reasoning.

To put it into perspective, consider a patient with schizophrenia who may be deemed incapable for making treatment decisions. This person could be capable in many other areas such as day-to-day activities, participating in vocational or leisure activities, self-care etc. This emphasizes that capacity by no means equates to competence. Many patients with schizophrenia (∼28% ⁴⁶ ) manage to live independently and about 10–15% work.^47,48 This is a substantial percentage who demonstrate certain, yet advanced capabilities in their decision-making processes as is required for holding a job or living independently. It is important to note that the discussion of capacity is not limited to those who live independently or hold a job, rather we use these examples as they are fairly easy to conceptualize. As patients with schizophrenia can be capable of making decisions in many aspects of their lives, from day-to-day decisions to major decisions related to housing, occupation or education, then making a decision about one's life should be no exception. In other words, a decision about suicide is another major decision and some people with schizophrenia may have the capacity to make this decision, just as they would for other major decisions. As such, the assessment of capacity regarding making a decision about suicide requires specific examination, and the mere presence of the status diagnosis does not equate to incapacity to make such a decision.

Ethical consideration

The concept of rational suicide in schizophrenia considers a number of ethical principles. Arguments supporting rational suicide consider ethical principles including Respect (regard for individual dignity), Autonomy, and Justice (the act of fair treatment). Rational suicide supports the individual's autonomy in choosing for their own life; furthermore, it offers respect for the dignity of the individual, by considering their insight and experience, regardless of their background. Such a view is supported by qualitative studies looking at the attitude of mental health clinicians towards rational suicide. ¹³ Applying the same principles of rational suicide in patients with schizophrenia also raises the ethical issue of justice for these patients to be treated fairly and not based on their status diagnosis. Another consideration is the ongoing debate about mind-body dualism, and how rational suicide is acceptable in cases of physical pain but not psychological pain. ¹⁹ The question becomes why a patient with other diagnoses is allowed to consider suicide but not a patient with schizophrenia?

Case vignette

Here, we provide a clinical vignette. The following vignette is not reflective of a particular case but rather an illustration of a demographic group with schizophrenia and is provided mainly to further encourage reflection.

Mr A is a young male in his 30s with treatment-resistant schizophrenia who has been diagnosed with schizophrenia since his 20s. He has been hospitalized several times due to the exacerbation of his psychosis. Prior to the onset of his illness, he was enrolled in University and was working part-time. Following his first episode of psychosis, his girlfriend left him and he had to move back to live at his parents’ home. Despite multiple treatment interventions, he continues to suffer from residual symptoms of psychosis, including being constantly tortured by the voices. He has been engaged with a specialized multidisciplinary schizophrenia treatment team, and despite his strong desire and effort, he has not been able to achieve any of his goals, including those related to vocation, relationships or independent living due to residual positive symptoms and ongoing cognitive and negative symptoms. He has found the medication side effects quite bothersome and the suffering from his illness unbearable. He recently moved into a group home as living with the family was no longer an option. He has thought about suicide as an option as he feels he cannot endure the day-to-day pain of his illness, lack of progress and functioning far below where he would like to see himself. He brought up the idea of suicide with his treatment team and family, but those discussions did not go far. The patient feels his family/team do not understand his suffering while dismissing his concerns about his functioning, lack of progress and psychological pain. He does not know who to turn to.

Discussion

It is important to start by highlighting the fact that schizophrenia is considered a highly treatable illness and it remains critical for clinicians to continue to instill a realistic hope.

The purpose of this paper is to examine the concept of rational suicide in patients with schizophrenia, to provide a better understanding and conceptualization. The rational suicide argument is currently mostly ‘accepting’ of those with terminal illnesses or pain, excluding those whose suicide is driven by acute psychological suffering or psychosis.

In this paper, we questioned the acceptability of physical illness in the conceptualization of rational suicide but not mental illness, and most specifically, schizophrenia. We discussed why some cases of suicide in schizophrenia could be considered rational by examining (1) why suicide could be a rational desire in some cases, (2) how some patients with schizophrenia could demonstrate instrumental rationality and (3) how patients with schizophrenia could demonstrate a capacity for certain major decisions, despite a lack of capacity in other domains. We further provided a case vignette for readers to encourage reflection.

Considering these points and the importance of including patients with schizophrenia in the discussion of rational suicide, we propose the following modifications to Siegel's criteria ¹⁸ : to remove criterion #2, which excludes patients with mental illness and replace this criterion with those that consider instrumental rationality and capacity.

As such, the proposed modified version of the rational suicide criteria, based on Siegel's original criteria, includes:

1) the individual possesses a realistic assessment of his situation, 2) the individual demonstrates instrumental rationality relevant to his desired outcome, 3) the individual demonstrates capacity specific to making a decision about suicide, and 4) the motivational basis of his decision would be understandable to the majority of uninvolved observers from his community or social group

Needless to say, many cases of suicide in schizophrenia may not qualify considering the above-mentioned criteria, such as those driven by psychotic symptoms. As such, it remains critical to approach the concept of rational suicide with much caution and delicacy.

Conclusion

While rational suicide remains a debatable concept, the argument becomes even more delicate when considering patients with schizophrenia, an illness that is traditionally equated with irrationality. Such a traditional view of schizophrenia creates tension with ethical principles such as respect, autonomy and justice. At the same time, schizophrenia is associated with significant suffering. While the goal of treatment is to ameliorate suffering and protect individuals from harm, it is important to consider the possibility that some patients in certain circumstances may hope for a different outcome (i.e. a good death) and there is a need to reconcile the overlapping ethical and professional dilemmas that arise from it. The main purpose of this article is to open the discussion about our current conceptualization of suicide in schizophrenia and to call for reflection on the consideration of autonomy and justice in this patient population.