Life or Death, Mad or Sane--Who Decides?

I write as a family doctor, and even though retired, I still think like one and like to base my musings on a case history:

A highly placed diplomat with splendid prospects was married to, and deeply in love with, a very beautiful woman. He was a man of humble origins and could never quite understand how such a gorgeous and good woman could have agreed to marry him--his self-esteem was surprisingly limited considering the position he held.
       One of his colleagues was jealous of him and fed this low self-esteem by suggesting that his wife might be having an affair. Gradually distrust festered and eventually, after being given some false evidence of infidelity, the diplomat strangled his wife. She screamed as he was killing her and instantly the room was filled with people who had heard her.
       They were appalled and quickly made him realize that he had suspected her without justification.
       Using a knife he had on his person he committed suicide.

Should the crowd standing around Othello, for he it was, have tried to stop him? Or was he entitled to make a decision that life would no longer be worth living without his wife, disgraced, and perhaps in prison for the rest of his life? And if a doctor, and in particular a psychiatrist, had been present, would he or she, as part of their professional duty, have been under obligation to stop him on the grounds that anyone contemplating suicide is ipso facto incompetent to make an autonomous decision?

It is part of the human condition to believe that living is better than not living, otherwise life makes no sense and gives us no purpose--unless, of course, we believe that this life is only a preparation for another.

If we accept that life is in general preferable to death, how does suicide fit in? In the United Kingdom, suicide has been legal since the 1960s, on the assumption that a fully competent individual can make an autonomous decision that no life is preferable to life.

Yet many people would argue that no one in their "right mind" would commit suicide--in other words, that persons planning suicide should be restrained from carrying out their plans, to have their autonomy overruled, in order to stop them. Jonathan Glover (1977) has written that one good reason for stopping someone from committing suicide is that it gives the person a second chance, but it is unlikely that Othello would have changed his mind, and many would think he did the right thing.

I have thought about this conundrum over the years, partly in connection with my clinical role as a doctor and partly from the point of view of my contact with psychiatry. My interest was particularly aroused by my colleague and friend, Keith Hawton, now one of the professors of psychiatry in Oxford, who spoke about his work on suicide in the United Kingdom perhaps 15 years ago--he continues to research in this area (Hawton and Fagg 1992). Many learned books and papers have been written around this subject (for instance, those mentioned above and Battin, Rhodes, and Silvers 1998). My article, by a non-specialist, is aimed at triggering discussion rather than examining these issues in detail.

So I would like you to consider a number of diffuse but conflicting statements.Though suicide is legal, to assist someone to commit suicide is not. To give drugs to assist pain relief which have the secondary effect of hastening death is legal and generally considered acceptable (a demonstration of the concept of double effect, which will be considered later). We as doctors are exhorted by the U.K. government to reduce the incidence of suicide, and yet we need to respect the autonomous decisions of our competent patients. But a patient who commits suicide in hospital or prison is considered to have done so as a result...