Suicide, Euthanasia and Forgoing Treatment

I am often confronted with the question of death. Death is a law of nature: where there is birth, there is death, and death is the fate that no one can escape. We rarely give much thought to how we will die, but when aging or illness brings us unnervingly close to the grim reaper, we are forced to consider it.

Some people choose to forgo treatment when the disease has become untreatable, letting death take its natural course; some hope for euthanasia; and still others choose suicide because they can no longer bear the suffering of body and mind. I have seen many real examples of all these modes of dying.

Recently I have been doing everything I can to intervene with a patient who wanted to commit suicide, but unfortunately no matter how hard I tried I could not reach her; her family had long since abandoned her and had no contact with her. The day before yesterday I heard from others who wanted to help her the definite news that she had taken her own life, and I felt deeply saddened for a long while. This patient was tormented by cancer and depression, was in very poor financial circumstances, and had long lived on the help of others. She herself lived on the margins of society, scraping together a meager grey-area income.

I had previously rarely looked deeply into the group she belonged to; recently, in order to get close to her, I delved into their world to understand their lives, and as a result I heard a pile of heartbreaking stories. Many people, like her, had for one reason or another fallen into dire straits, slipped off the rails of society, and lived in the shadows, enduring torment.

While learning about this group, I found at least three other people who also had suicidal thoughts. From a medical point of view, I know that having suicidal thoughts is a typical symptom of patients with depression. I cannot yet be sure whether they actually suffer from depression, because they were very guarded toward me, and I had no way of knowing whether what they told me was true or invented—in that grey area, lying is commonplace. To carry out social relief work in such a group, one truly must have the salvific spirit of a religious figure, able to accept and embrace everything, and even when knowing full well that one is being deceived, still help those who deceive us with compassion.

They remind me of some things I encountered as a child in the countryside, where rural women and the elderly often drank pesticides to kill themselves. Looking back now, a considerable number of those who committed suicide suffered from depression, while other chronic illnesses tormented them at the same time. They usually lived in rather straitened circumstances, their family relationships were not harmonious, and their lives were bleak. As long as one person was willing to listen to them, to help them, and to give them some warmth, they would not have taken their own lives. But unfortunately, the people around them were usually numb, unable to perceive their suffering, and sometimes even mocked them, so in the end they walked down the road to ruin.

Globally, about 786,000 people die by suicide each year, equivalent to 10.7 deaths per 100,000 people; in our country, 287,000 people die by suicide each year, and more than 80% of suicides are related to depression. The causes of depression are very complex, and depressives are numerous: at least one in five people worldwide will become ill with depression at some stage in their lives.

Depression usually accompanies all kinds of life setbacks and illnesses; although a few well-off people become depressed, most people fall into a depressive state when their economic circumstances are poor. Unless our society is willing to pay attention to and help this group, the overall condition of people with depression cannot possibly improve.

Since the outbreak of the COVID-19 pandemic, the global economy has declined and life has become harder for everyone, so people with depressive moods are more common than before. Over the past two or three years, more people have committed suicide than in the past; statistics show that, after the pandemic, among all the causes of increased deaths, suicide ranks second, second only to diabetes.

Although I am not a psychiatrist or psychological counselor, having long dealt with patients has forged in me an instinctive reaction to prevent death. So sometimes I very much wish to open the heart of every person who wants to commit suicide, to intervene and prevent them. But unfortunately, I often fail at the last moment; saving anyone who has made a suicide attempt is extremely difficult.

One form of suicide has been permitted in certain countries, and that is euthanasia. European countries such as Switzerland, the Netherlands and Luxembourg now allow euthanasia. People suffering deeply from physical and mental illnesses with no hope of cure can apply for euthanasia there; after evaluation by professional physicians, some applicants' wishes can be granted.

This is actually a manifestation of the progress of human civilization. Some diseases make the rest of a patient's life unbearably miserable and also burden the patient's family with enormous financial costs; euthanizing such patients is a more humane approach.

Patients or their families often ask me whether I can teach them some methods of euthanasia, and I always refuse to answer. For one thing, I have not studied euthanasia; for another, the law in our country does not yet permit it. But even so, we know that some patients, at the last moment, have carried out euthanasia on themselves, using an overdose of sleeping pills they had saved up over time.

Currently in our country, only Shenzhen has just legislated to make living wills legal. Article 78 of the newly promulgated Regulations on Medical Affairs of the Shenzhen Special Economic Zone stipulates that medical institutions shall respect the requirements of a patient's living will; after receiving a living will that meets the prescribed conditions from the patient or their close relatives, when the patient is in the incurable terminal stage of illness or dying, the medical institution's implementation of medical rescue measures shall respect the meaning of the patient's living will. The regulation will take effect on January 1 of next year, making Shenzhen the first region in the country to legislate on living wills.

This means that, starting from New Year's Day next year, the Shenzhen Special Economic Zone will allow patients who subjectively wish to forgo treatment to do so and choose a natural death. Under China's filial-piety culture, Chinese people often regard forgoing treatment as something inconsistent with the spirit of filial duty; Shenzhen's latest legislation is expected to change people's perception in the future.

No matter how advanced and developed medicine becomes, there will always be diseases that cannot be cured, and the lifespan extended by treatment will be low-quality life, with the patient suffering in pain through the rest of their days. In such situations, if the patient themselves wishes to forgo treatment, that choice should be respected. At the same time, at the social level, we also need to foster a new ethos that takes a tolerant attitude toward such forgoing of treatment, no longer condemning the patient's family as lacking in morality.

Not long ago I met a patient's family member; there were three seriously ill patients in her family. Her father was already in the late stage of liver cancer, very difficult to cure, and was paralyzed. When she came to ask me what to do, I advised her to let nature take its course. Actually, I think that before coming to me she had already leaned toward a certain opinion, but she herself found it very hard to make that decision. Telling her to choose to let nature take its course could lighten her psychological burden.

Such situations are probably quite common. Before Shenzhen's legislation, some families, at a moment of dire necessity, chose forgoing treatment without speaking of it openly. Doing so could both reduce the suffering of the patient and lighten the family's financial burden. We often see reports that some families have fallen into extreme poverty while simultaneously producing a patient with no hope of cure; at such a time, it is entirely reasonable for family members to choose to forgo treatment, and in fact our folk culture has always taken a tolerant attitude toward this phenomenon.

I hope our society's understanding of death can rise to a higher level, accept more death education, and make decisions more rationally at the moments of parting between life and death. For suicides that can be prevented, we should do our best to prevent them and care more about those who want to die by their own hand. For illnesses that are hard to stop, we should be more at peace, not fighting the disease to the bitter end. Although we cannot yet have euthanasia, we can choose to forgo treatment, let nature take its course, and shorten the process in which the patient suffers.

Life is a process; in this process, both quality and length are of course important, but if the two cannot be had together, one should consider giving up extending the length of life and instead focus on improving the patient's quality of survival.