The current topicality of the subject of dignified death (euthanasia is a term for the SPCA) has been sparked by two senior Anglican clergymen, Archbishops Emeritus Carey and Tutu, both of whom have expressed themselves in favour of the proposition that help in ending unwanted suffering consensually is a better proposition than a long, lingering and painful death that is delayed and perhaps exacerbated by the miracles of modern science which have prolonged life, but not necessarily its quality, in so many ways in recent years.

To those who are contemplating assisted or even self-inflicted means of ending their lives, the debate is one of vital interest to them and their loved ones. It is one that deserves greater exposure and understanding in the public consciousness. Outmoded codes applicable in earlier times, when our human rights culture and humanism were not so well developed tend to muddy the debate. It is however a topic that is not polite dinner conversation fare. Obviously the deliberate ending of one’s life is not commonly understood as the cure-all to mental illness, even though mental illness often leads to just that. Mental illness is regarded, dubiously so in some cases, as treatable, but terminal cancer or a serious stroke justifies only palliative care in a hospice followed by the inevitability of death. The seriously mentally ill are expected to wrestle with their difficulties in the daily grind of modern life; the victim of a blow on the head lying in a coma is regarded as being in a completely different category of pain and suffering. Both are life threatening and actually indistinguishable in many respects.

Looking at the conundrums that the debate throws up, one finds two of the most basic of human rights coming into conflict with each other. The right to life on the one hand, clashes with the right to human dignity on the other. No human right is absolute; some are non-derogable in terms of the Bill of Rights, but the right to life is already capable of being limited by means acceptable in an open and democratic society and according to measures that are reasonable and justifiable in a way that is based on human dignity, equality and freedom. The right to die with dignity intact is constitutionally what the ethical and moral and medical debate has to cover: with honesty, empathy and a clear vision of implementation of the Bill of Rights.

It is currently the case in SA that no death penalties have been imposed since the dawn of the new constitutional era, yet thousands upon thousands of abortions have legally and constitutionally been performed in the exercise of the reproductive rights of women who fall pregnant with an unwanted or unhealthy fetus.

Into this heady cocktail of conflicted and conflicting thinking comes the idea of assisted and dignified termination of an unwanted life of a person, not a fetus, thereby granting the choice to the terminally ill patient to end it all gracefully rather than hanging on by a tenuous thread of life that is really no life at all. Especially if peace has been made with family and friends, goodbyes have been said and the suddenness of death has been cushioned by a period of illness during which those who love the dying person have been able to use available time sensitively and profitably to reconcile themselves with the inevitability of death and the imminence of it in the choice, freely made, of the person who opts for the dignity of choosing to die at a time when it is still possible and open to her or him to make the choice.

The issues around the surprise demise of the mentally ill are far more challenging than those that bedevil the discussion of assisted termination of quality-bereft life neatly arranged and scheduled for the physically terminally ill. Mental illness is not well understood. Not by the public and also not by the medical practitioners who work in the field of major depression. Part of the problem is that major depression can take various forms and is sometimes difficult to distinguish from reactive depression which is capable of striking the sunniest of personalities at the oddest of times. The country of Brazil is probably in a state of reactive depression following the demolition of its soccer team in the World Cup Semi-Final. This reaction will fade, the team will rebuild and games will be won again.

The patient facing an acute attack of major depression is however in a different situation entirely. She may be under treatment which does not appear to be assisting in any discernable way. The road ahead may appear to these patients to have only one signpost, the signpost that reads: “No hope left”. Far too many sufferers from major depression read that sign and turn left, terminating their lives suddenly and sometimes quite unexpectedly with irreversible and catastrophic effect. This leaves a trail of grief, mourning, turmoil and guilt, or worse, denial of the cause of death and secretiveness or shame about it.

A suicide by a person who has major depression is the equivalent of a critical medical emergency. It is like having a massive heart attack or being diagnosed with stage four pancreatic cancer from which there is no return to a normal life, just a rapid descent to an inevitable death caused by easily understood physical symptoms, the arteries are totally blocked, the pancreas is hopelessly diseased.

With mental illness, glib explanations of this kind are not possible. No one really knows how the brain works. Talk of and theories about serotonin and melatonin abound. Some theorise that the balance between the two is the necessary state for good mental health. This may be true. It also may be as far as the paleo-diet is from carbo-loading as the answer to good dietary health.

If one regards the human body as an old-fashioned internal combustion engine, fairly well understood by many more people than those who study the working of the brain, then it is possible to describe, by way of analogy, the workings of good mental health as a carburettor than has a good balance of air and fuel with a well-functioning spark plug. The balance keeps the whole engine on the road and capable of carrying its load. Should the mixture of fuel, air and spark go into imbalance, so that it runs too rich or too lean, the vehicle either blows up or breaks down.

The serotonin uptake in the brain is thought to be like this, without it in circulation in the system a break down is inevitable. Treatments, diets, exercise regimens, lifestyles are designed to keep the right levels and mixtures in circulation to prevent the owner of the body short of serotonin in circulation from reaching the sign that says “no hope left” and following it to that abrupt cul de sac that ends a single life. An event that upsets many others because we all have our different ways of dealing with a shock of the magnitude involved if the suicide victim happens to be someone near and dear to us.

The worst part of the whole scenario around unassisted or, to a lesser extent, assisted suicide is the secretiveness and shame that society allows to linger around the whole tragedy. People speak in hushed tones, they hide the true cause, or don’t even want to know what it was at all. Others make clucking noises and cry, but do not know what to say because mental illness is so misunderstood and also so difficult to distinguish from attempted suicides that are really no more than serious cries for help from troubled souls who would prefer to live but have no better skills for seeking the help they need. The seriously mentally ill, in particular those already in medical care and taking the prescribed medications, are superficially indistinguishable from the attention seekers who really want help rather than death.

All of those caught up in the dilemmas and the pain of contemplating suicide and attempted suicide have to answer one difficult question: If the object of the exercise is to end that awful pain and suffering that life entails, how do you know with certainty and as an article of faith that the death under contemplation actually ends the pain? And if you don’t, ought you not to make every effort to address the causes of the pain before surrendering to it by way of suicide or assisted suicide? The archbishops have long exhorted their flock to “fight the good fight” – surely only when the fight is indubitably lost is in appropriate to end a life.

Paul Hoffman SC
13 July 2014