The circumstances under which Jane and I met were less than ideal. That day, I had already seen a family of maggots making a happy living in someone’s foot and been chastised by my attending for failing to recognize the imprecision of my visual acuity in assessing a patient’s ascites — how else could I do so without a measuring tape in my pocket and daily charts of his abdominal circumference?
So, when I entered the emergency department and was nearly tackled by all of its commuters and residents, I was ill-equipped to handle the blade that was her tongue.
Jane was a thin, elderly woman with a long neck and subtle overbite. Her half-moon readers complemented her upright posture, which commanded an air of prudence and authority from her stretcher. As I conducted my history and physical exam, Jane’s responses were terse. She was clearly one with a scarcity of words and seemed to pride herself on the brevity and clarity of her diction. If her responses to my questions hadn’t been so punctuated and sharp like daggers, then perhaps I would have appreciated her purist approach to language. So, while ordinarily I take great pleasure in chatting with patients, I could not have been happier to don my measuring tape and record her edematous ankle circumference as a barrier to further conversation.
Not much longer, as if some greater force had measured my own angst, transport arrived to escort Jane to her room on the floor. As she was leaving, her daughter, who had been sitting very deferentially at her bedside, perhaps even scared to speak, quietly apologized for her mother’s demeanor in light of “everything that had happened in the last few months.” I was no stranger to being left in the dark, as most medical students are, and easily assumed that Jane had been in poor health and that her daughter’s reference merely emphasized the gradual worsening of her mother’s condition.
Once again, I was in no way prepared for the blow to come, and so, when she told me that her stepfather, Jane’s husband, had recently taken his own life. I was floored. The wind was knocked out of me, and for some inexplicable reason, suddenly I felt guilty for not magically already knowing this, as if I ought to have shown more compassion — though I’m unsure that I would have acted any differently.
At that point, I immediately began to consider the void left in Jane’s life and the manifestations of her grief. As the length of Jane’s hospital stay progressed, I became privy to her background in academia, her recent fascination with the lyrical styles of W.B. Yeats and his “Fiddler of Dooney,” and the intimate details of her husband John’s suicide: the note that he left, and the isolation and loneliness that it expressed.
Throughout our time together, though I came to enjoy Jane’s company, I found my mind wandering back to the ailments that afflicted John, as if he too had somehow become my patient–the botanist, who I imagine, possessed a deep appreciation for the abstractions of academia and the subtle beauty of nature’s flora. On the one hand, I suspect, or perhaps hope, that he was very grounded to have studied such an earthly discipline, yet on the other hand, my own fascination with philosophy leads me to believe that anyone studying something as organic as plant biology would maintain a certain air of free-spiritedness. In the same way that I was often criticized for studying something so non-pragmatic as ethics or philosophy, but reveled in every moment of it, I can only wish that John too, derived comfort and joy out of his own profound passion for botany.
And so, there I was, attempting to relieve my patient of her own grief and loss, but also finding myself grieving the length and breadth of John’s loneliness and social exclusion, and in many ways, wishing that I had the opportunity to speak with him, to engage him, and to learn from him. John’s death, the magnitude of his emotional torment, and the suffering that his death has inflicted upon Jane brings to light for me many salient points within the philosophy of suicide that will continue to shape my views on the moral permissibility of self-harm and will surely affect the care I offer to suicidal patients and their loved ones in the future. It has reinforced in me the need for strong patient-physician rapport that is grounded in mutual trust and honesty. As someone dedicated to primary care, John’s story compels me to inquire about the ways in which his doctors could have intervened to prevent this outcome and what signs and signals, if any, eluded their history and physical exam. I wonder if I too will succumb to physician burnout, financial pressures, indifference, apathy, and any other reason that results in my failing to recognize a subtle change in a patient’s mood, affect, or behavior. For now, I can only hope that the humanism I vowed to uphold in medicine will continue to remind me of my therapeutic obligations and the compassion so pivotal to patient care.
“I have the right to grieve the way I so desire … as did my late husband the right to end his life,” said Jane one evening. Suddenly, she was not only a literary scholar, but also a voice of contemporary liberalism, the school of moral theory rooted in the ethics of rights. That night, I contemplated the notion of positive freedom: a freedom to do, or to act, so long as one’s right to act does not entail the harm of another. Through this lens, John certainly had the right to end his life and ought to be free to do so, barring the arguable emotional harm he’s done to his family. The thought squares nicely with classical liberalism, which upholds that freedom presupposes free will and our capacity to make choices, and so, it appears that liberalism suggests the moral permissibility of suicide.
As physicians-in-training, it is imperative that we reflect on the moral code to which we ascribe. Perhaps even more importantly, how one’s personal moral integrity overlaps or conflicts with a therapeutic obligation warrants reflection and introspection. A rights-based argument in favor of suicide seems consistent with our profession’s obligation to endorse and uphold patient autonomy. However, one’s personal view of his right to die should not be conflated with a physician’s alleged obligation to promote or act upon such a right. This distinction is nontrivial. And so, while I may agree with John’s ability to rightfully decide if he wishes to end his life, this does not logically entail that I assist in that process or furthermore, that it is my therapeutic obligation to do so.
As Jane and I became more candid in our discussions, she questioned why anyone would intentionally prevent himself from making any further choices in life through an act of suicide. Naturally, it seems counter intuitive that we would do anything to limit our thoughts, our will, and our ability to reason. It was by this principle that John Stuart Mill argued against the act of selling oneself into slavery, which impeded one’s ability to choose for oneself. By the same reasoning, suicide, as the ultimate end to one’s will, is equally impermissible. Unbeknownst to Jane, she had left me pondering a rather interesting paradox of liberalism, a view that both morally permits and prohibits suicide. While her argument is a valid one, I have yet to decide if it is truly contrary to reason to wish to end our will, and if the act entails something actually morally wrong. Suffice it to say that both Jane and John have presented me with dilemmas and arguments that are central to medicine and ethics.
While I struggle to build my own moral compass that will guide my practice of medicine, I hope that my classmates and colleagues challenge themselves by confronting such issues. It is the cruelty of reality, and irony of ironies that while John suffered from a life of solitude and exclusion leading to his suicide, I wish he could have known that his story will forever be included in the memories of experiences that have truly touched me and will accompany me throughout my own lifetime. If only my measuring tape clearly delineated the length of Jane’s grief, the end of John’s torment, and the fine line separating right from wrong, perhaps we might all be so inclined to carry it in our white coats.