About the Absurdity of Life
This story is about suicide and begins with a case that shocked everyone in the hospital, even the battle-weary ER nurses. Suicide strikes most of us as horrifying and repugnant, but might it also be gentle and welcome? With physician-assisted suicide so much in the news, there is a social debate raging on that very topic and I hope this case will show that our attitudes about suicide are significantly conditioned by our experiences.
It is difficult to imagine a life so meaningless, futile, and unbearable that suicide is a logical choice. Probably none of us have been there, but many of us have encountered suffering souls who have faced that dilemma.
One hot afternoon late in the summer of 1965, I was the junior interne in the Emergency Room of the Winnipeg General Hospital. I was not only the junior interne, I was also the only and therefore the senior physician in the ER that afternoon. The ER was our proving ground, the front line for all the mayhem, violence, tragedy and despair of the city. Fortunately, few cases were as tragic and pathetic as the one I describe.
The oppressive heat of the afternoon had just abated when the paramedic team called that they were bringing in a patient who had been brutally mutilated. There were few details. Apparently she was attacked in her small apartment where she also carried on business as a seamstress. A late afternoon customer had found her and called the police. The only evidence that might identify her assailant was a pair of blood-stained tailors’ shears, found beside her. The police hoped there would be fingerprints on the shears. She had said nothing to them except to request that someone call the Humane Society to collect her cat.
At first glance there was nothing particularly remarkable about her: she was conscious but uncommunicative, perhaps in her mid-thirties, plain but regular features, overweight, and not in any obvious distress. In fact, considering the report we had received, her affect was remarkably flat and unperturbed.
Only when we removed the sheet covering her torso did we realize the severity of her injuries. Her abdomen had been viciously slashed, and much of her bowel was extruded. The bowel that was visible had also been cut across in several places. It is not easy to open a person’s abdomen; ask any surgeon. Even with a sharp scalpel there are several layers to incise and it takes determination, dexterity and time. This was obviously the work of a determined assailant.
When we had completely removed the sheet, more was revealed. She had an indwelling urinary catheter and both her legs were withered. She was paraplegic, had been for some time, and lived and worked from a wheel chair. All this had already been noted by the paramedics and police. It was the identity and motive of her attacker that had them puzzled. Apparently she lived alone, had no obvious enemies, no immediate family or friends, and there were no signs of a struggle.
There was, in reality, little that we could do for her in the ER. We started an intravenous drip to replenish her lost blood and fluids, called the surgical service and arranged for her admission to the ward. It was not until we were well into the mundane details of admission that we recognized the obvious connection. She had neither complained of pain nor asked for pain medication. She was not only paraplegic but was totally anesthetic (without sensation) from the rib cage down.
This had all the hallmarks of suicide, but the callousness of the method had confused us. She had apparently disemboweled herself with a pair of sharp tailor’s shears just as if she were cutting a piece of wool serge for an overcoat. At the same time, the option she’d chosen was without doubt brutally effective – since neither the abdominal wall nor the bowel had sensation she was able to do it deliberately and methodically.
The surgical team took several hours to identify and repair all the tears in her bowel and to close her abdomen. It was all in vain. She got her wish and died of septic shock from peritonitis three days later in the ICU. No visitors came to comfort her.
This happened almost fifty years ago and the picture still haunts me. Is suicide in such a brutal yet systematic way impulsive or carefully planned? Was she in suicidal depression, or was this a rational decision? Was it a last, desperate attempt for autonomy in a life where she had lost control, or a desperate plea for attention?
I am of that genre of doctors educated in a very traditional system; we have sworn the Hippocratic Oath and earned our public trust as defenders of life. The very core of our professional values is the assumption that every human life has worth. Deliberately discarding life in this manner contradicted all our beliefs; and we had difficulty comprehending what sort of life was so devoid of meaning as to justify this treatment?
I have struggled with these contradictions for most of my career and I still do not have a satisfactory answer. Recently, the essays of Albert Camus has helped me to view suicide and assisted suicide more sympathetically, though I recognize that I cannot share the victim’s emotions and thoughts.
Albert Camus (1913-1960) experienced firsthand the senseless brutality and privation of both the Algerian struggles for independence and the Nazi occupation of France during WWII. During the war he was an active supporter of the French Resistance as an underground journalist, and at various periods he was also an anarchist, communist, and social activist. His writings distilled the public mood of the period. In 1957 he was awarded the Nobel Prize for literature “for his important literary production, which with clear-sighted earnestness illuminates the problems of the human conscience in our times” .
One of his essays, The Myth of Sisyphus , is devoted to a philosophical discussion of suicide and begins with the statement, “There is but one truly serious philosophical problem, and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy”.
Sisyphus was a mythical Greek king who annoyed the Gods with his pranks and, most egregiously, by preying on his guests. This sin particularly angered Zeus, the God of hospitality. The punishment of Sisyphus was, for all eternity, to roll a boulder up a mountain only to have it roll back down again each time. His punishment encapsulates the idea of eternal futility, and Camus calls him “the absurd hero”.
Camus expanded on this age-old theme in his idea of the absurd, which probably reflected the chaos of the world in which he lived. ‘Absurd’ describes the longing for meaning and clarity in a world which seems to offer neither. In Camus’s philosophy life per se has no intrinsic or sacred value; it is the experiences of living that give it meaning. He framed the philosophical idea of ‘the paradox of the absurd’ as a contrast between our expectation that life should have meaning and significance and the harsh reality that despair and mortality are our only sure reward. This leads to the philosophical question: if life has no meaning and no value, is suicide logically justifiable? In such a world is it a rational decision to choose death over hope?
Camus did not discuss the special case of the terminally ill, but on philosophical grounds he rejected suicide as a general solution to the absurdity of life, not because he valued life but because he opposed nihilism. Death does not confer meaning to life. Suicide is the ultimate negation, the decisive act of nihilism which extinguishes both life and hope.
Let us now fast forward to 2016 where physician assisted suicide is the topic of the day, not the ethics of suicide but the guidelines by which patients are to be screened and euthanasia administered. The preferred name now is ‘medical assistance in dying’ (MAID), perhaps a less threatening term, but with the same intent.
Now we can rephrase the question posed in the introduction: Are there circumstances in which suicide is a rational solution to the absurdity of life? We have already discarded the ethics of the past, which were based on a theological construct that has no traction in today’s society. Having accepted that life has no a priori intrinsic or sacred value, we return to Camus. Life is only significant for the experiences it offers. The variety and satisfaction of those experiences define the ‘value of life’ and the absurdity is the paradox of expectations versus reality.
By redefining life in social rather than theological terms we make suicide acceptable and permit an ethical role for physicians. Remember though, that absurdity does not demand death. Sisyphus did not consider suicide and Camus objected to suicide as a nihilistic solution that extinguishes both life and hope. There are no other examples of nihilism in medicine and philosophically nihilism and medicine are not good companions.
I recognize, however, that this argument has been directed mainly at physician participation rather than patient motivation. The decision to request MAID is not just a recognition of the absurdity of living, it may also be an attempt to assert personal autonomy in the final closing of the curtain. This may also reflect a certain apprehension about end-of-life care. Perhaps some terminally ill people prefer the certainty of a gentle, welcome death over the uncertainty of the alternatives. If this is true, palliative-care proponents (that includes me) face a challenge in public perception. The slogan “dying with dignity” has been linked so often with assisted suicide that they are considered inseparable. Patients who choose palliative care must be reassured that natural death in an atmosphere of comfort, love, acceptance, peace and even gratitude is also dignified.
I doubt that our patient had read Camus, but she understood him better than we did. Her extreme self-mutilation may have been her last attempt to draw attention to her misery. If she had had the option, would she have preferred a more gentle and peaceful death? We can’t know. We know only that she had lost control over many aspects of her life, and by Camus’s criteria her life would be considered “absurd”; but she exercised her final and only remaining autonomy in a most dramatic fashion. This story is her legacy and our lesson in humanity. We cannot and must not judge the person who is in that situation. Our ethical aims as physicians are the same today as when I graduated. They are to relieve pain and suffering and observe the “utmost respect for human life” . Respect does not require either futile efforts to prolong life or avoidance of compassionate treatment that may shorten life.
- “The Nobel Prize in Literature 1957” Albert Camus.
- Camus, A., The myth of Sisyphus, and other essays. 1st American ed. 1955, New York,: Knopf. 212 p.
- Hippocratic Oath, Declaration of Geneva. Available from: https://en.wikipedia.org/wiki/Hippocratic_Oath.