By Ann Neumann

What is man that thou are mindful of him? And the son of man, that thou visitest him? For Thou has made him a little lower than the Angels and has crowned him with glory and honour. Psalms 8:4-5 KJV

What has a price can be replaced by something else as its equivalent; what on the other hand is raised above price and therefore admits of no equivalent has a dignity. Groundwork of the Metaphysic of Morals, Immanuel Kant (1724-1804)

(1-800-SUICIDE)

I’ve been thinking about suicide lately. It fills the news: a man hangs himself in a garage and is mistaken for a mannequin and taken to the dump; a suicide bomber kills 89 people in Paktika, Afghanistan; The Economist reports that most people in the Western world favor legalization of assisted suicide. These three uses of the word suicide are very different and yet they point to a singular act; ending one’s life. After a marked rise over the past decade, suicide is currently among the top causes of death, after the usual suspects: disease and accidents. Suicide is the tenth highest cause of death in the US; homicide is the sixteenth. More Americans die each year from suicide than from car accidents, Parkinson’s disease or liver disease.

“There is only one really serious philosophical question, and that is suicide,” Albert Camus wrote in The Myth of Sisyphus in 1942. Throughout history, views on suicide have ranged from permissive to condemning. The list of thinkers and academics who have written about suicide is endless as well as timeless: from Aristotle (384-322 BCE) to Pliny the Elder (23-79 CE); from Seneca (who committed suicide in 65 CE) to Saint Augustine (354-430 CE); from David Hume (1711-1776) to Emile Durkheim (1858-1917); from Georges Bataille (1897-1962) to Jean Améry (1912-1978).

However old and ongoing the conversation may be, in our era it is increasingly a political one. A bill that would legalize assisted suicide is now being debated in the British House of Lords. Euthanasia (or assisted suicide) is now legal in The Netherlands, Belgium, Luxembourg and India. Aid in dying (or Death with Dignity, as the laws are called in the US) was legalized by the courts or voter initiative in Washington, Oregon, New Mexico, and Montana, while May 2013 Vermont became the first US state to legalize aid in dying through its legislature.

It’s impossible, even reckless, to summarize the history of taking one’s life, particularly if one does not wish to conflate the importantly distinct concepts of martyrdom, euthanasia and suicide. (The term suicide was only first used in 1634; euthanasia was coined by English philosopher Frances Bacon later that century). Yet my objective is not a history, but rather to show that the acceptability of suicide has fluctuated throughout human history and even when prohibited, in some eras, certain types of self-killing have been expected, tolerated, and even celebrated.

Sparta, the storied Greek city-state in the Peloponnese that was militarily dominant from the 400s until 192 BCE, when it was defeated by the Romans, was intolerant of weakness. Not only in its enemies but in its own citizens. Historians tells us, although it is archeologically unproven, that mothers bathed their newborns in wine then took them to the local doctor who determined if the child would grow to be a strong warrior. If the doctor decided that the child had an unpromising future, it was tossed into a nearby ravine. Elders, invalids, all those “ill-suited for health and service to the state” were expected to take their own lives writes Ian Dowbiggin, a medical historian at University of Prince Edward Island, in his book A Concise History of Euthanasia.

Sparta may be an extreme example but it demonstrates the ideas that ancient societies had toward suicide: in many cases, unless you were a slave, criminal or soldier, it was noble to take your life when you were no longer physically able to contribute to your community or your state. Dowbiggin tells us that the view of self-death as a positive action was new in the Spartan era: “Infanticide, abortion, and suicide were common occurrences in most if not all aboriginal societies from the South Seas to the tundras of the Arctic,” but was usually done for the good of the community, as a necessity. Because of concern for food supplies and the “survival prospects of the clan or tribe.” Sparta raised self death to an honorable action, one that demonstrated an elevated morality.

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Stone slabs now cover the ground where the crumbling remains of the state prison of Athens once stood. It is here, near the law courts, that archeologists believe Socrates drank the hemlock that killed him. Hemlock, a plant that grows to two feet tall and is common to parts of Africa, Europe and the Mediterranean, was the customary means of execution in 399 BCE when Socrates died. For the past 2,400 years, Socrates’ death has been described as a show of discipline, an act that exemplifies dignity. He showed that “true dignity was not a social matter at all, but rather an affair of the individual soul.”

It was easy for Greeks and Romans to find a doctor who would help them die; the rudimentary nature of medicine at the time meant that a disease or illness meant nothing but intolerable suffering–and a drain on society’s resources. The Hippocratic Oath, written sometime between 500 to 300 BCE, denounced mercy-killing and euthanasia but it went largely ignored until the Christian era. Despite the legend of Masada, a plateau overlooking the Dead Sea where more than 900 Sicarii Jews killed themselves (and each other) to “escape” a Roman siege in the first century BCE, Judaism is often cited as the original source of a prohibition against suicide. In the Hebrew Bible, writes Dowbiggin, “God is acknowledged to exercise an absolute sovereignty over life and death. Death was the penalty for sin, and life was a gift from God that his people were meant to choose so they could continue to love, honor, and obey him.”

Suicide is not condemned in the New Testament but church leaders in the first century CE inferred from the gospels that suicide was an affront to God. Saint Augustine, who died in 430 CE, compared “self-murder” to homicide, a criminal sin. But there were always exceptions. Christian martyrdom, dying for one’s belief, “testified to an individual’s faith and was distinguished from suicide undertaken for nonreligious motives,” writes classicist Elizabeth Castelli, a professor of religion at Barnard College. In her book Martyrdom and Memory she notes:

Willing and self-sacrificing death on behalf of one’s religion, one’s political ideals, or one’s community–martyrdom–is hardwired into the collective consciousness of Western culture and is one of the central legacies of the Christian tradition.

Alarming examples of martyrdom occurred throughout the centuries following Saint Augustine. Dowbiggin cites twelfth century Cathars and Abigensians, who were declared heretics by the medieval church; Russian “Old Believers” who saw the Russian Orthodox Church as illegitimate; seventeenth century martyrs who locked themselves in monasteries before burning them–and themselves–down. “These shocking examples of self-destruction help to explain why Christian churches traditionally have opposed either religious or secular attempts to approve of suicide,” Dowbiggin concludes.

By the seventeenth century, suicide was largely illegal across Europe. Suicided bodies were publicly degraded, estates and belongings were forfeited to the state, a punishment to families of the deceased. By the twentieth century, suicide was no longer illegal in much of the Western world and the movement to legalize aid in dying was gaining ground. Dignity is often the defense that opponents and advocates of legalized aid in dying use, an observation that is the premise of University of California, Davis, professor Scott Cutler Shershow’s new book, Deconstructing Dignity: A Critique of the Right-to-Die Debate. In it he writes:

None of the philosophical labors expended to explain why killing one’s self can never be justified has ever been able to spare us the ineluctable possibility that someone might commit to death by the act we call “committing suicide”; and even if we refrain from ever endorsing or approving or esteeming such an act, even if we continue to do all we can to prevent it, it will always in principle be “there,” as a possibility always at least to be entertained.”

Suicide entertained. Dignity is many things: it is an inherent characteristic of all humans, “only a little lower than angels,” something which is “above price.” And yet it is also afforded to some and not to others, as in an undignified death. Too, it is a manner: one can behave with or without dignity. Currently, Western society (and most societies around the world for that matter) agrees that some forms of suicide should be deterred–with fences, 1-800 numbers, and intervention. But we also agree that there are exceptions, situations where our intervention to stop self-death usurps a person’s dignity. This complicated defense and condemnation of suicide, hinged on fluctuating ideas of human dignity, will likely long continue to stymy legal, political and public conversation.

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In the US, suicide is highest among white Americans (28.5% of total suicides). American Indians and Alaskan Natives experience a disproportionately high number; so do military veterans and LGBTQ youth. Last year The New York Times reported that suicide among men over fifty increased by nearly fifty percent; in women ages sixty to sixty-four it increased by nearly sixty percent, although men (predominantly white) kill themselves almost five times more often than women (also predominantly white). More than 38,000 people now commit suicide each year (out of 2.5 million total US deaths). That’s one person every thirteen minutes.

As reasons for this increase, experts point to a faltering economy, access to guns (fifty percent of suicide deaths) and access to opioids like oxycodone. Whatever the causes, experts also agree that suicide is vastly underreported. The stigma of suicide prevents coroners from directly listing it on death certificates and families from discussing it openly.

We tend to think of suicide as an affliction of the young, those in our population who are emotionally overwrought, who don’t yet understand the value of life. And yet, statistics show that elders kill themselves at a rate consistently higher than youth. In recent years, the suicide rate among middle-aged Americans has increased dramatically. In 2010, thirty out of 100,000 twenty-five to forty-four year olds ended their own lives. Of those sixty-five and older the number is forty-seven per 100,000 (although elders make up only thirteen percent of the population).

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In the US, aid in dying is highly regulated, requiring that an eligible patient be diagnosed with six months or less to live, and have doctor referrals, in some cases both verbal and written requests, and a mental evaluation if necessary. The patient must ingest the fatal medication themselves. Many argue that taking one’s life when it is already slated for the taking (by cancer or other disease) is not suicide but “hastening” death, easing into the inevitable.

In a room in an assisted living facility outside Washington DC, John Rehm, the husband of NPR talk show host Diane Rehm, was in the end stages of Parkinson’s disease. In an article last month at NBCnews.com–called a “lobbying piece for ‘aid in dying’” by conservative website Newsbusters–Maggie Fox wrote:

“He just kept getting weaker,” the NPR host told NBC News. “We called in the doctor and John said to him: ‘I am ready today.’ He said ‘I can no longer use my legs, I can no longer use my arms, I can no longer feed myself.’ And knowing with Parkinson’s is going to get worse rather than better, he said ‘I [want] to die.’” He asked the doctor for help.

Parkinson’s disease affects the nervous system, progressively slowing or altering physical motion. Depression and fatigue are also symptoms. It is deadly; there is currently no cure. Sixty thousand new diagnoses of Parkinson’s are made each year. About one million American’s are living with the disease.

Because John Rehm did not live in a state where aid in dying is legal, his doctors were incapable (and unwilling) to help him die. He chose to end his life by VSED, voluntarily stopping eating and drinking, his only legal option other than waiting for Parkinson’s to run its slow, destructive course. “I would like to, in every state across the country, in every city, in every county, I would very much like to see a justification, an allowance, for aid in dying,” Diane Rehm told Fox. John Rehm died nine days after giving up food and water.

Depending on where you live, what–and whether–you think about suicide (or aid in dying, euthanasia, assisted suicide, Death with Dignity…) may soon be asked of you, in the form of a state voting initiative; or asked of your representatives, via a legislative bill.

Advocates see aid in dying as the humane end of needless suffering. Shershaw writes in Deconstructing Dignity that, “self-sacrifice is the exception that troubles the prohibition of self-murder via a certain economy of life and death that, in a paradoxical and at times nearly laughable manner, seems always to be at once affirmed and forbidden.” Whatever the terms used for embracing that good night, many on all sides of the conversation are quite happy to keep the “suicide” in “assisted suicide,” either to enforce the stigma that has long accompanied suicide in Western culture or to expunge it. Or to defy it.

(1-800-SUICIDE)

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“The Patient Body” is a monthly column about the intersection of religion and medicine. Prior columns can be read here:

Reading HuffPo’s “Hospice, Inc.”

The End of Eating

Wakeful Unawareness

Faith, a Chronic Condition

A Special Sustaining Power

Your Ethical and Religious Directives

Hospitals and the Pretense of Charity

A Closely Held Business

What’s a Kidney Worth

An Irresistible Force

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Ann Neumann is a Visiting Scholar at the Center for Religion and Media at New York University and contributing editor at The Revealer and Guernica magazine. Neumann‘s book about a good death, SITTING VIGIL, will be published by Beacon Press in 2015.