Rational and irrational suicide in Plato and modern psychiatry

Summary

Suicide is a complex issue that is sparking increasingly more debate in contemporary society. There is need for an open discussion on the concept of rational suicide, specifically in relation to psychiatric disorders, so as to resolve the conflict between the duty of care of psychiatrists and the autonomy of patients. To be able to conduct such a discussion in an objective manner, we must first be made aware of the potential prejudices that we harbour on the topic of suicide as a result of our societal and historical background. A historical and philosophical approach to the topic, through careful examination of the topic of suicide in the texts of Plato, helps create such an awareness.

LEARNING OBJECTIVES:

After reading this article you will be able to:

• • recognise the potential prejudices behind modern views on suicide

• • put the recent debate on rational suicide into a historical and philosophical context

• • understand the concept of rational suicide and consider the role of psychiatrists in relation to this.

Introducing ancient and modern perspectives

Suicide is an issue that has been widely examined since ancient times and continues to spark debate in present-day medical sciences as well as philosophy. One of the most famous suicide cases in antiquity is that of Socrates, as narrated in Plato's Phaedo. It is often supposed that Socrates' death was not suicide but execution, especially since Phaedo claims that the gods disapprove of suicide, while they do not disapprove of Socrates' death. Consequently, the prevailing view is that Plato was opposed to suicide on all counts, in his particular definition that excluded Socrates' death. Thus, Plato's view would align with that of the later Christian church and subsequently that of most Western societies in general, in particular that often attributed to the medical profession, that suicide must be considered negative at all times (e.g. Mayo 1986).

Assisted dying, the duty of preventive care and patient autonomy

A slight breach in this long-established opinion has occurred with the increasingly more open debate on euthanasia or assisted dying. For example, in 2012 Raymond Tallis, chair of Healthcare Professionals for Assisted Dying (HPAD), made a convincing case for the belief that healthcare professional bodies such as the British Medical Association (BMA) and the medical Royal Colleges ought to adopt a position of neutrality with regard to assisted dying (Tallis 2012). Nevertheless, the topic of non-assisted suicide remains shrouded in controversy: in 2017 a House of Commons report on suicide prevention still stated that the government commends a ‘zero suicide policy’, encouraging ‘any approach which acknowledges that suicide is not inevitable and seeks to prevent all suicide’ (House of Commons Health Committee 2017: p. 11). Accordingly, the role of the psychiatric clinician is often considered to be to take suicidal ideation as indicative of mental illness and to prevent suicide at all times.

The problematics of this duty of preventive care and the patient's rights of autonomy have been discussed most thoroughly by Hewitt (2013), Onkay (2014) and Hatherley (2019). Onkay focuses on the conflict between patient autonomy and the clinician's duty of care, stating that clinicians must allow for the possibility of suicide made under free will and beware of infringing on the patient's autonomy. Hewitt discusses the issue particularly with regard to mental disorders, where the patient is automatically considered irrational and non-autonomous, and has pointed out both the importance of equalling psychological suffering to physical suffering and the capability of (some) psychiatric patients to make rational choices regarding suicide. More precisely, ‘rational suicide’ can be defined as suicide ‘on the basis of realistic beliefs [about one's circumstances] and in light of the fundamental interests which incorporate the agent's “real” – that is, his long-term – values’ (Mayo 1986: p. 154). Hatherley goes one step further and argues that, in certain cases, psychiatric patients should have access to assisted suicide.

Is suicide always negative?

To establish whether rational suicide should be permitted or supported by the medical field, and whether psychiatric patients must be excluded from this debate entirely, we must first discuss the original premise, still widely upheld, that suicide is at all times negative. This premise can be approached not just from a clinical perspective, but also from a theological, philosophical or legal perspective. These perspectives have evolved over a long history of scholarship, founded more than two millennia ago by the renowned Athenian philosopher Plato. The complexity of the problems discussed above is reflected by a potential incongruity within the writings of Plato, who seeks to reconcile the various perspectives, represented in three of his works, into a wider theory on suicide and the value of human life. The perceived incongruity within this theory, which at one point opposes and at another supports suicide, offers an opportunity for the modern reader to consider different perspectives on suicide within the same author, and observe how they develop and unfold differently according to the context in which they are discussed.

Plato's opinion on suicide should nevertheless not be taken as representative of Greek popular opinion, but as independent thought. The more general history of, and attitudes towards, suicide in Ancient Greece have been elaborately discussed by Anton van Hooff (van Hooff 1990) and Elise Garrison (Garrison 1991). In fact, at the time of writing, Plato's views were innovative and revolutionary, and we may learn from them still. The purpose of such a historical and philosophical approach, and this article, is not to allege the existence of direct comparisons with issues in modern psychiatry, but rather to increase our awareness of the prejudices and alternate motivations behind our own, modern views on suicide.

The structure of this discussion

This article begins with a brief discussion of the clinical definition of suicide and its application to the death of Socrates. Subsequently, it discusses the theological–philosophical perspective on suicide in Phaedo, the medical–utilitarian perspective in Republic and the legal–utilitarian perspective in Laws. Through discussion of these fundamental historical works the article aims to demonstrate a potential need both to mollify the persisting concept of suicide as necessarily irrational, especially among people with mental illness, and to raise questions about the role of psychiatric care in relation to suicide.

Defining suicide

A modern definition of suicide entails the non-accidental result of a conscious decision to terminate one's life. The non-accidental aspect is important: if someone is having suicidal thoughts (suicidal ideation), makes a conscious decision to kill him- or herself at some point in the future (suicidal intent) and is then accidentally run over by a car while crossing the street, we do not classify this as suicide. At the same time, if someone with a nut allergy accidentally consumes some praline truffles and dies of anaphylactic shock, we do not consider this a suicide despite the agent being the victim. Suicide must be the direct result of the prior intention to die: one must make a specific plan to die by a specific means (suicidal planning) and then die by said means. Furthermore, the means by which death occurs need not be direct, i.e. one need not be the physical agent of one's own death. For example: if the council decides to pull down a block of flats for redevelopment and one of the inhabitants, fully aware of the approaching bulldozers, decides to stay in her room and is killed in demolition, we would consider this suicide despite the agent of death being the construction company.

According to this modern definition, then, Socrates' death would be considered a suicide, since he expressed a clear wish and intention to die, drank the hemlock voluntarily (knowing that it would kill him) and then died as a result of this (Frey 1978: p. 106). The fact that the original plan to kill Socrates did not come from Socrates himself but from the Athenian court (though one could argue that, in the Apology, Socrates deliberately antagonises the jury so that they pass a death sentence) matters little because Socrates' eagerness to comply with this sentence, despite other options being readily available, is still his own (Eckstein 1981: p. 48; Ahrensdorf 1995: p. 29). Even if we consider Socrates a martyr who died for his views, a perception which is generally considered incorrect by classical scholarship, that does not necessarily mean that his death was not a suicide. The relation between martyrdom and suicide is in fact an interesting one, but irrelevant to the death of Socrates. Our discussion of Plato's texts will focus on a more important question, namely whether Socrates' suicide could be considered rational.

Phaedo: the divine ban on suicide

Most scholarly debate on the topic of suicide in Phaedo revolves around the apparent conflict between Plato's claim that the philosopher is better off dead and his statement (section 61c) that the gods do not allow us to kill ourselves (Novak 1975: p. 15; Bostock 1986: pp. 16, 18–19, 20; Ahrensdorf 1995: pp. 28–29; Miles 2001: pp. 244–6, 251–3; cf. Warren 2001 and Shershow 2013: pp. 99–120). These two beliefs could certainly coexist if it were not for the fact that Socrates (here a character voicing the opinions of Plato) later argues that the gods are ‘the best overseers’ (62d) and ‘good rulers’ (63b; cf. Euthyphro 15a and Theaetetus 151d), and so we expect that they always act in our interest. For Plato's view on suicide to be consistent, then, one of the two aforementioned notions must be incorrect: either it is not in the philosopher's interest to die, or the gods do not prohibit suicide. Since the philosopher's benefit in dying is sufficiently proven by Socrates throughout the dialogue, it remains that we must place our doubts with the divine ban on suicide. There are several reasons to support such doubts, most importantly Socrates' statement at 62c: ‘it is reasonable that one should not kill oneself, until god sends some necessity, such as is now the case for me’ (my emphasis). This statement shows that there is an exception to the ban on suicide, exemplified by Socrates: Plato's teacher did in fact kill himself, but was allowed or even encouraged to by the gods (Gallop 1975: p. 85; Eckstein 1981: p. 45; Bostock 1986: p. 17).

The existence of this exception to the ban on suicide not only reconciles the theory of the benevolent gods with the philosopher's interest in death, but also fits with Plato's agenda of emphasising the importance of philosophy: the gods do not want us to die unless it is to our benefit, in which case they will send ἀνάγκην τινὰ (‘some necessity’), and according to Phaedo it is to our benefit to die when we are true philosophers. We become true philosophers by purifying the soul and ridding it of its bodily components. If, then, the gods do not send some necessity for us to die, it is evidently not in our interest, and it is not in our interest because we are not yet sufficiently purified: we must not hasten the death of the body when the soul is not yet prepared for its own desired death, the release from the bodily passions (van der Horst 1971: p. 285; Cooper 1989: p. 16; Warren 2001: p. 104). And so it appears that ‘Philosophy is not good simply because the gods command it. The gods command it because it is good’ (Novak 1975: p. 29).

It has thus been demonstrated that Plato's argument in Phaedo does not rely purely on the will of the gods (nor is there necessarily a divine ban on suicide) but more so on the significance of philosophy and the individual relationship of each person with their soul. And so, as Raymond Frey expressed: ‘the fact that Socrates died a noble and dignified death does not show that he did not commit suicide, but rather that suicide need not be ignoble and undignified’ (Frey 1978: p. 108). Nor, as Phaedo shows, need suicide always be irrational: Socrates' death is the result of a well-weighed and autonomous choice. Regardless of whether we believe in Plato's promise of a happy afterlife for the philosopher, in the historical context we may understand and sympathise with Socrates' decision not to escape the hemlock and go into exile: he perceived that the right time, for which he had prepared, had come, and there was no point in dawdling. Is this a basis for diagnosing Socrates with mental illness?

Republic: suicide and the state

In Republic Plato offers a more utilitarian perspective and does not mention any ban or taboo on suicide. The text mentions suicide only marginally, but is of particular interest for this article because it discusses the system of medical care.

The untreatable body

Plato praises a carpenter who declines medical treatment, at the risk of death, because ‘he has no time to be ill and it does not benefit him to live in this way, being occupied with this illness, and neglecting the work in front of him’ (406d–e; cf. 407a). We would not immediately associate the refusal of treatment with suicide, but the carpenter's case may be comparable to the conundrum of a person with advanced cancer refusing chemotherapy, when the balance between benefits and risk is unclear: in a situation where treatment is declined despite favourable chances at recovery, a psychiatrist is often involved and the term ‘suicide’ might be mentioned. Nevertheless, regardless of whether we consider the carpenter's death a suicide, Plato's message is clear: not all lives must be continued. Moreover, he even thinks that doctors should take the initiative to refuse treatment: ‘If someone is by nature sickly and intemperate, his life is of no use to himself or others, and the art [of medicine] does not exist for these people’ (my emphasis) ( 408b, cf. 407d–e).

Here it seems that the reason one should die or stay alive is a sense of duty to the community, which contrasts with Plato's view in Phaedo that one should remain alive because it is in one's own interest to practise philosophy until sufficiently prepared for death. Of course, it is natural that Plato alters his perspective to fit the context, and the passages above show that he does not necessarily oppose benefit to the individual to benefit to the community. Indeed, Socrates preferred death to escaping or going into exile because, as he expresses in both the Apology and Phaedo, he would no longer be able to do his ‘work’, namely teaching philosophy, and so contribute to the improvement of his soul and the city. This implies that Plato includes a kind of duty to the state in the practice of philosophy and assumes that an individual who is unable to contribute to the community must therefore live an unhappy, unphilosophical life and himself desire to die. Thus, Plato ultimately focuses on the interest of the individual, as he did in Phaedo.

The incurable soul

One passage in Republic discusses disease of the soul: ‘[the arts of medicine] will treat those of your citizens who are well-natured both in body and soul, but those who are not, who are diseased in their bodies, they will allow to die, and those who are ill-natured in their souls and incurable they will themselves kill’ (409e–410a). Ironically, this is the direct opposite of our modern approach to mental illnesses. However, before rejecting Plato's recommendation as unnecessarily cruel and inhumane, we should consider it more closely. First, ‘ill-natured in their souls’ most likely refers only to those whose mental illness has led them to depraved and criminal behaviour. Therefore, the line between medical treatment and punitive measure is blurred, as it often is even nowadays although capital punishment has all but disappeared in most Western societies. Second, the word ‘incurable’ (ἀνιάτους) is key here and brings to mind the previous comparison to a patient with advanced cancer. At this point, where Republic traverses beyond its utilitarian perspective and mentions the well-being of the soul, Plato bluntly assesses the situation according to his theory on what constitutes a ‘life worth living’: the patient's soul is corrupted and cannot be purified; therefore a philosophical life and subsequent happy afterlife are no longer possible; therefore death is the rational option for the sake of both the state and the patient himself. Admittedly this guideline is vague – how can we know that some corruption of the soul is incurable? – but it indicates that Plato still has in mind Phaedo, and the purification of the soul through philosophy.

‘Rational’ death in Plato

Plato's view, then, as derived from Republic, appears to be that death (through suicide or otherwise) is advisable in two cases: when one can no longer live a philosophical life because one is unable to be of use to the state, and when one can no longer live a philosophical life because one's soul is incurably corrupted. To the modern reader this reasoning may appear unconvincing, for the obvious reason that we have a different idea of when life is worth living. From a medical point of view especially the threshold is quite low, and a psychiatrist must certainly discourage anyone from taking their own life on account of some inability to be of use to the state. Nor do we typically believe in the incurable, or curable for that matter, corruption of souls. But let us briefly consider the latter as a metaphor for some chronic psychiatric disorder: if someone suffering from schizophrenia were to take their own life, in the hypothetical situation that one could determine this decision was reached after careful consideration of their present hardship and lack of future prospects, can such a suicide be termed ‘rational’? The current consensus appears to be that it cannot. But to what extent does that consensus derive from an objective assessment of the patient's situation and ability to make autonomous decisions, or from our own prejudiced ideas that death is always negative and suicide always irrational? We may disagree with Plato's approach to the ‘art of medicine’, but in disagreeing we may also begin to take a closer look at the reasoning behind our own approach.

Laws: suicide as a crime

Plato's Laws start by saying: ‘and he who kills the person that is, as they say, the most closely akin of all, what [punishment] should he suffer?’ (873c). This text (discussed most recently by Shershow 2013: pp. 99–120) details both the cases in which suicide is permitted and the cases in which it should be condemned. Much more clearly than Phaedo or Republic, Laws applies our modern definition of suicide: a non-accidental death resulting from a conscious decision to terminate one's life, by direct or indirect means. Like Republic, Laws approaches suicide from a utilitarian rather than theological perspective, but despite being a legal text shows slightly more understanding for people's personal experiences.

Plato's four exceptions to the ban on suicide

A first exception to the ban on suicide appears in Book 9 (at 854c), where Plato has presented several ways in which temple-robbers might suppress their desire for crime, and states: ‘if by doing these things you abate your disease, good: but if not, consider death the better option and free yourself from life’. The term ‘free yourself’ (ἀπαλλάττου) indicates that death is some sort of release (and thus positive) for the immoral individual. A similar idea is conveyed by the comparison of criminal urges to a disease, which seems to suggest that the temple-robbers are victims and should be put out of their misery. We recall the recommendation in Republic (at 410a) that doctors ‘kill those who are ill-natured in their souls and incurable’. Here Plato applied the same reasoning as in Republic, namely that when it is no longer possible to live a philosophical life and thereby obtain a blessed afterlife, one might as well quit life straightaway and end a miserable existence.

Another three exceptions to the ban on suicide are presented in the following passage:

‘he who kills himself, violently robbing himself of his appointed fate, without [2] being ordered so by decree of the city, nor [3] compelled by an exceedingly painful and inescapable turn of fate, nor [4] sharing in some unmanageable and unendurable shame [should be punished]’ (Laws 873c).

Exception 2 confirms that being ordered by the state to kill oneself, as Socrates was, is considered suicide (Garrison 1991: p. 9). Notably, the phrase ‘robbing himself of his appointed fate’ reminds us of Socrates’ statement in Phaedo that we are assigned to life by the gods and we should not try to escape. The word for ‘fate’, μοῖρα (literally ‘divine fate’), has religious associations, and Novak has pointed out that the divine decree of fate is here equalled to the decree of the city, bringing together the different (theological and utilitarian) approaches to suicide which Plato has shown in Phaedo and Republic (Novak 1975: p. 26).

Exception 3 is, again, somewhat problematic: in Phaedo Plato explains that a happy afterlife awaits the philosopher, and yet the philosopher should never end his life in order to achieve this happiness. Surely, then, ending one's life to avoid some extreme misfortune and improve one's happiness in that way is not allowed either, nor would it lead to a happy afterlife since one is not fully purified yet. However, ‘inescapable’ (ἄφυκτος) carries the same meaning as ‘incurable’ (ἀνιάτος) did above, namely that the situation cannot be repaired and the circumstances that keep the individual from practising philosophy cannot be changed. We also sense a degree of empathy: Plato acknowledges that sometimes someone experiences a misfortune so great that the pain is simply unbearable. In this case suicide, not on account of some sudden flood of emotions but on account of a lack of future prospects, can be rational.

The final exception, suicide as a result of ‘sharing in some unmanageable and unendurable shame’, similarly resembles a mercy killing, but again Plato's point is not so much that the person should hurry to death out of misery, but rather that there is no reason to stay alive when circumstances no longer permit the individual, who is overwhelmed by misfortune or shame, the opportunity to successfully purify themselves through philosophy.

Plato emphasises that outside of the aforementioned exceptions those who ‘inflict on [themselves] this unjust penalty because of laziness and cowardice’ (873c–d) are reproachable. This statement is noteworthy because one could easily argue that people who end their lives ‘compelled by an exceedingly painful and inescapable turn of fate’ or ‘sharing in some unmanageable and unendurable shame’ are in fact also showing laziness and cowardice: the line between inescapable/unmanageable and escapable/manageable is surely very thin. Thus, Plato's reasoning in Laws allows him to argue in favour of or against essentially any case of suicide one may present. This has everything to do with the legalistic purpose of the text: ‘punishments for crimes must vary according to their motive and circumstance’ (Garrison 1991: p. 17). Therefore, it is clear that Plato did not think that all suicides are equally bad, but rather that each case is individual and may be judged as permissible according to circumstances.

A harmonisation of thoughts

Laws, Plato's final work, has brought together aspects of Phaedo, such as Socrates’ suicide as ordered by the state and the idea of life as a gift or task from the divine, with aspects of Republic, such as the individual's relation with the state and the utilitarian view on life. Perhaps Plato in his old age was now seeking, as Carrick aptly described, to ‘harmonize in some condensed fashion his earlier thoughts on the topic of suicide’ (Carrick 2001: p. 160; see also pp. 155, 166).

Conclusions and implications

We may now summarise our findings, and the implications they have for our modern views on suicide and the duties of psychiatric care.

In Phaedo Plato presents a divine ban on suicide, which is likely a metaphor to explain that one should not attempt to die before one's time, i.e. before one has sufficiently prepared oneself for death. The fact that Socrates' death is here deemed a suicide indicates that there are cases in which ending one's own life is permissible.

In Republic Plato leaves out the theological argument and replaces it with a more utilitarian argument (which condones some cases of suicide) of duty to the state.

In Laws Plato combines the ideas of both Phaedo and Republic and discusses situations where suicide is allowed, all of which can be explained through Phaedo's theory that the purpose of life is to practise for death and purify the soul through philosophy; and therefore when the gods send some necessity (e.g. a judicial order) to die it means that one is sufficiently purified, but when on the other hand one is unable to lead such a philosophical life, there is no longer a purpose in living and one is allowed to end one's life. Socrates' death is classified a suicide, but falls into one of the four categories of exception. We may conclude that Plato is in fact neither contradicting himself between texts nor absolutely disapproving of suicide, as it seems that he regards the only life worth living to be a philosophical life, which is in the interest of oneself and others.

Prejudices behind modern views on suicide

Socrates' death, then, offers thought-provoking lessons regarding modern views on suicide: many people from Western societies may have abandoned the Christian belief that God disapproves of suicide, but not the resulting perspective on this manner of death. We may ask ourselves why, if we no longer consider life a treasured gift from God, we consider any violation of it, by one's own hand or that of another, worthy of reproach or pity. Perhaps we do not, like Plato, believe in a continuation of life after death, but we may be able to imagine with him that, when someone is sufficiently prepared for death, the loss of life is not necessarily tragic. Although each suicide case is of course different, and Plato is the first to admit this, Socrates' death reminds us that the value that we attribute to life is by no means absolute, and the perception of certain suicides as rational is not uncommon and may even be justified. And just as Plato considered that only the life of a philosopher is truly worth living, we may, hypothetically, ask ourselves: is a life without, for example, the opportunity of future development and fulfilment still worthwhile? And if not, is there anything beyond our cultural prejudices that dictates suicide is not the appropriate solution? As in antiquity there is no concrete answer, and opinions have remained, and likely will remain, divided.

What can the psychiatrist take from Plato?

What is the role of the psychiatrist in all this? Our discussion of the various perspectives on suicide in Plato suggests that the topic is far more complex than can be encompassed by a universal duty of preventive care. It may be helpful to distinguish, like Plato, between rational and irrational suicides, and what constitutes the difference are essentially two factors: to what extent the patient's life is, to them, ‘worth living’, taking into account both their subjective experience and the factual circumstances, and to what extent they are able to and have made an autonomous decision to end their life.

This article does not venture to propose how exactly these notions may be implemented in psychiatric treatment, and of course there are many more factors to be taken into account that have not been covered by our discussion of Plato. We must take care not to generalise too much on the concept of suicide, and keep in mind the human suffering that prefaces each individual case. With this caveat in mind we can nevertheless reflect on some of the prejudices we may have regarding suicide, and consider the following: which is more important, the patient's life or the patient's autonomy? Currently, it is often believed to be the first, because suicidal intent is seen as a sign of mental illness and therefore a lack of autonomy. But this is a circular argument, and perhaps we should not see suicidal intent as inherently non-autonomous. Socrates certainly did not see it that way when he drank the hemlock. And can one really argue with Socrates?