On a March morning in 1989, Robert Shoots was found dead in his garage in Weir, Kansas. He had run a tube from the tailpipe of his beloved old Chrysler to the front seat, where he sat with a bottle of Wild Turkey. He was 80.
His daughter wishes he had mentioned this plan when they spoke by phone the night before, because she didn’t get to say a satisfying goodbye. But she would not have tried to dissuade him from suicide.
Years earlier, he had told her of his intentions.
“It wasn’t a big surprise,” she said of his death. “I knew what he was going to do and how he was going to do it.” (Wary of harassment in her conservative upstate New York town, she asked me to withhold her name.)
Shoots, a retired house painter, was happily remarried and enjoyed good health. He still went fishing and played golf, showing no signs of the depression or other mental illness that afflicts most people who take their own lives.
Nevertheless, he had explained why he someday planned to take his life. “All the people he knew were dying in hospitals, full of tubes, lying there for weeks, and he was just horrified by it,” his daughter said. He was determined to avoid that kind of death.
Is suicide by older adults ever a rational choice? It’s a topic many older people discuss among themselves — and one that physicians increasingly encounter. Yet most have scant training or experience in how to respond, said Dr. Meera Balasubramaniam, a geriatric psychiatrist at the New York University School of Medicine.
“I found myself coming across individuals who were very old, doing well, and shared that they wanted to end their lives at some point,” said Balasubramaniam. “So many of our patients are confronting this in their heads.”
She has not taken a position on whether suicide can be rational — her views are “evolving,” she said. But hoping to generate more medical discussion, she and a co-editor explored the issue in a 2017 anthology, “Rational Suicide in the Elderly,” and she revisited it recently in an article in the Journal of the American Geriatrics Society.
The Hastings Center, the ethics institute in Garrison, New York, devoted much of its latest Hastings Center Report to a debate over “voluntary death” to forestall dementia.
Every part of this idea, including the very phrase “rational suicide,” remains intensely controversial. (Let’s leave aside the related but separate issue of physician aid in dying, currently legal in seven states and the District of Columbia, which applies only to mentally competent people likely to die of a terminal illness within six months.)
Suicide has already become a pressing public health concern for older adults, more than 8,200 of whom took their lives in 2016, according to the Centers for Disease Control and Prevention.
“Older people in general, and older men specifically, have the highest rates,” said Dr. Yeates Conwell, a geriatric psychiatrist at the University of Rochester School of Medicine and a longtime suicide researcher.
That’s true even though research shows older adults feeling happier than younger ones, with improved mental health.
A complex web of conditions contributes to late-life suicide, including physical illness and functional decline, personality traits and coping styles, and social disconnection.
But the vast majority of older people who kill themselves also have a diagnosable mental illness, primarily depression, Conwell pointed out.
Suicide often involves impulsivity, rather than careful consideration. That doesn’t fit anybody’s definition of a rational act.
“The suicidal state is not fixed,” Conwell said. “It’s a teeter-totter. There’s a will to live and a will to die, and it goes back and forth.”
When health care providers aggressively treat seniors’ depression and work to improve their health, function and relationships, he said, “it can change the equation.”
Failing to take action to prevent suicide, some ethicists and clinicians argue, reflects an ageist assumption — one older people themselves aren’t immune to — that the lives of old or disabled people lack value.
A tolerant approach also overlooks the fact that people often change their minds, declaring certain conditions unendurable in the abstract but choosing to live if the worst actually happens.
Slippery-slope arguments factor into the debate, too. “We worry that we could shift from a right to die to a duty to die if we make suicide seem desirable or justifiable,” Balasubramaniam said.
But the size of the baby boomer cohort, with the drive for autonomy that has characterized its members, means that doctors expect more of their older patients to contemplate controlling the time and manner of their deaths.
Not all of them are depressed or otherwise impaired in judgment.
“Perhaps you feel your life is on a downhill course,” said Dena Davis, a bioethicist at Lehigh University who has written about what she calls “pre-emptive suicide.”
“You’ve completed the things you wanted to do. You see life’s satisfactions getting smaller and the burdens getting larger — that’s true for a lot of us as our bodies start breaking down.”
At that point, “it might be rational to end your life,” Davis continued. “Unfortunately, in the world we currently live in, if you don’t take control of life’s end, it’s likely to go in ways that are inimical to your wishes.”
Davis cared for her mother as she slowly succumbed to Alzheimer’s disease. She intends to avoid a similar death, a decision she has discussed with her son, her friends and her doctor.
“We ought to start having conversations that challenge the taboo” of suicide, she said.
However heated the arguments become, as religious groups and disability activists and right-to-die proponents weigh in, there’s agreement on that point, at least. Reflexively negative reactions to an older person’s mere mention of suicide — Don’t say that! — shut down dialogue.
“Discussing it doesn’t mean you’re advocating it,” Balasubramaniam said.
Her training has taught her that suicide is preventable, and she looks for interventions. But she also sees her role — one families and friends can play, too — as listening without judgment, helping patients considering suicide to sort out their ambivalence while looking for treatable illnesses that might impact their thinking.
“Sitting with someone who understands, who communicates caring, who is listening, is itself a reason for living,” Conwell said.
But not for everyone.
Shoot’s daughter watched her mother die of Alzheimer’s, too, and shares her father’s conviction that some fates are worse than death.
She has told her four children that she intends to die before her life deteriorates to levels she finds intolerable; they accept her decision, she said.
Accordingly, she avoids tests like mammograms and colonoscopies because she won’t treat the diseases they reveal. To celebrate her 70th birthday, she had the initials DNR — for Do Not Resuscitate — tattooed on her chest, within a decorative circle.
For now, she enjoys her semirural life, but she monitors herself closely for signs of cognitive and functional decline. “When I start to slip too much,” she said, “it’s time.”