Dr Saheb Sahu
“There is only one serious philosophical question that is suicide.”
- Albert Camus, The Myth of Sisyphus
“The thought of suicide is a great consolation: by means of it one gets through many a dark nights.”
- Friedrich Nietzsche, Philosopher
The Wall Street Journal published an article on March 15-16, 2025, by Jason Zweig titled- “The Last Decision by the World’s Leading Thinker on Decisions”. The article is about Professor and Nobel Laureate, Daniel Kahneman’s decision to end his life in Switzerland by physician assisted suicide.
Daniel Kahneman (1934-2024) was an Israeli-American psychologist best known for his works on the psychology of judgment and decision-making as well as behavioral economics, for which he was awarded the 2007 Nobel Memorial Prize in Economic Sciences together with Veron L. Smith. Kahneman became the grandfather of behavioral economics. His book (2011), Thinking Fast and Slow, became an international best seller.
Kahneman died by assisted suicide on March 27, 2024, three weeks after his 90th birthday in Switzerland, though the manner of his death was only revealed in March 2025. Around March 22, 2024, he started emailing a personal message to several dozen of the people he was close to. On March 26, Kahneman left his family in Paris and flew to Switzerland. His email explained why:
“This is a goodbye letter I am sending friendsto tell them that I am on my way to Switzerland, where my life will end on March 27. I have believed since I was a teenager that the miseries and indignities of the last years of life are superfluous, and I am acting on that belief.
I am still active, enjoying many things in life (except daily news) and will die a happy man. But my kidneys are on their last legs, the frequency of mental lapses is increasing, and I am ninety years old. It is time to go.
Not surprisingly, some of those who love me would have preferred for me to wait until it is obvious that my life is not worth extending. But I made my decision precisely because I wanted to avoid that state, so it had to appear premature. I am grateful to the few with whom I shared early, who all reluctantly came around to support me.
I am not embarrassed by my choice, but I am also not interested in making it a public statement. The family will avoid details about the cause of death to the extent possible, because no one wants it to be the focus of the obits. Please avoid talking about it for few days.
I discovered after making the decision that I am not afraid of not existing, and I think of death as going to sleep and not waking up. The last period has truly not been hard, except for witnessing the pain I caused others. So if you are inclined to be sorry for me, don’t be.
Thank you for helping make my life a good one.”
Kahneman’s wife Anne had died of stroke in 2018 after several years of suffering from vascular dementia. Her illness was acutely painful to Kahneman; as he emailed to his friend Jason Zweig in July 2015,” I am very preoccupied by Anne’s health and am not functioning altogether well.” Phillip E. Tetlock, a friend and Professor at University of Pennsylvania adds, “I have never seen a better planned death than the one Danny designed.” (WSJ, March 15-16, 2025, C1).
Evolution of Attitude Towards Suicide
Hinduism accepts a man’s right to end one’s life, through the practice of fasting. It is called Pryopavesa in Sanskrit meaning “the act of sitting down to death”, signifying a voluntary, gradual process of fasting until death. The Jains are the strict believers of non-violence. The only life a Jain can take his own. Jainism approves suicide, especially by slow starvation, known as Sallekhana or Samadhi-maran. A central tenet of Buddhism is captured in the word mujo, meaning impermanence. Life is impermanence. For Buddhists, suicide is seen as a negative act but not a sin. Buddhist traditions help to explain the acceptance of suicide in Japan and other S.E. Asian countries where Buddhism prevails.
Most Greek and Roman Philosophers had mixed feeling about suicide. Pythagoreans opposed it, but the Epicureans and Stoics welcome it. Plato accepted suicide for painful and incurable illnesses. Aristotle considered suicide counter to virtue and an act of cowardice.
The Old Testament (the Jewish Bible) offers a neutral account of several voluntary suicides like that of King Saul. Suicide is sometimes acceptable in Jewish laws. There is simply no evidence in either the Old Testament or the New Testament (Christian Bible) to sustain any moral condemnation of suicide. St. Augustine (354-430AD), the greatest of the Latin Church Fathers, considered suicide as a sin. His ideas have influenced the present stand of the Roman Catholic Church, which considers suicide as a sin. Despite recognizing suicide as a sin, many Protestants denominations emphasize God’s grace and the possibility of forgiveness.
Suicide is considered a cardinal sin in Islam. In general, suicide is viewed by Muslims as taking away the gift of life given by God.
Starting from around 10th century England, suicide became increasingly viewed as a sin and a crime. With the spread of Christianity by the colonial powers (England, Spain, Portugal, Denmark, Belgium and others), suicide became a crime in many countries colonized by them. Those laws are still on the books in many countries around the world including India.
Palliative and Hospice Care
Palliative and hospice care, both focus on improving the quality of life for the people with serious illnesses, but they differ in certain ways:
Palliative Care:
. Available at any stage of a serious illness, including alongside curative treatments,
. Aims to relieve symptoms (e.g. pain, fatigue, nausea etc.) and improve overall well-being,
.Care can be provided in hospitals, outpatient clinics, or at home,
. Patients may still be receiving treatments intended to cure or manage their diseases.
Hospice Care:
. Specifically meant for patients who are terminally ill (typically with a life expectancy of six months or less, in US)
. Focuses entirely on comfort care, no active treatment for the main disease
. Care can be provided at home, in hospice facilities, or nursing homes
. Usually covered by most health insurance.
In short, palliative care can be provided at any stage of illness, while hospice care is reserved for end-of-life care when curative treatment is no longer pursued.
While the distinction between palliative and hospice care exists globally, the definitions and implementations differ. Palliative care services are limited in many poor countries especially in the rural areas.
What is physician-assisted suicide?
Physician-assisted suicide (PAS) or Physician-assisted dying (PAD), is suicide undertaken with the aid of a physician. The eligibility criteria vary from jurisdiction to jurisdiction. The patient should meet following criteria:
. Should be suffering from a terminal illness
. Be mentally competent
.Submit a written request to the physician
.The physician confirms the diagnosis and prognosis
After a mandatory waiting period after the request, the physician prescribes life-ending medications, which is self-administered by the patient. The overdose of the drugs depress the central nervous system, and the patient falls asleep within 3-5 minutes, and usually die within 30-40 minutes after the ingestion. Usually an antiemetic drug is given 30-60 minutes before the lethal drug to prevent vomiting. The death is painless and quick.
As of March 2025, physician-assisted suicide is legal in several countries including: Austria, Belgium, Germany, Luxemburg, Switzerland, Netherlands, Portugal, Spain, Australia, New Zealand, Colombia, Ecuador, Canada, and 10 out of the 50 states in the United States.PAS is illegal in India but allowing the withdrawal of life-sustaining treatment for terminally ill patients or those with vegetative state is legal.
Although assisted suicide remains illegal in most countries, it is on the rise. A recent Gallop survey asked whether it should be legal for doctors to assist terminally ill patients in severe pain to commit suicide; 60 percent of Americans said yes.
What is VSED?
Voluntarily Stopping Eating and Drinking (VSED) is an old choice rooted in Hinduism and Jainism, going back to more than 2500 years or more. Suicide by starvation was regarded as particularly meritorious by both Hindus and Jains. It is a choice now being advocated by palliative care professionals and organization like Compassion and Choices.
In VSED, an adult makes a conscious decision to refuse foods and fluids of any kind, including artificial nutrition and /or hydration, in order to advance the time of her /his death. In the first few days of the fast, some people may remain as active as before but many soon will become weak, fatigued and increasingly sleepy.
Death from VSED is a natural process. It is difficult to predict exactly when the end will come. This depends on the person’s: physical condition, nutritional status, age, illnesses, fluid retention and perhaps a readiness to let go. For a terminally ill person in poor nutrition, the process may take several days to 2-3 weeks. Individuals and loved ones who may consider this option should understand the importance of stopping all fluids, including ice chips. Intake of even small amounts of food or water can prolong the dying process. The most frequently reported adverse side effects are: thirst and dry mouth, and occasional hunger. Good oral care (glycerin wipes) can ease the symptoms. Some people may experience increased confusion, delirium and agitation as the body organs shut down. These symptoms can be managed by doctors or hospice workers.
Problems of Old Age
The definition of “being considered old”varies across cultures. Traditionally many developed countries have associated old age with the retirement age, typically around 65 years. The United Nations consider individuals aged 60 and above as older persons. In some African countries old age is recognized at 50, reflecting the different life expectancy and social roles.
As individuals age, they often encounter a range of health challenges that can impact heir quality of life. Common health problems among older adults include:
. Cardiovascular diseases- high blood pressure, heart disease and strokes
. Diabetes and its multiple complications- kidney failure, heart disease, memory loss (dementia)
. Joint pains (arthritis), muscle weakness and balance problems, frailty, falls and broken bones
. Vision and hearing loss
. Cognitive decline- Alzheimer’s disease and other dementias
. Chronic Obstructive Pulmonary Disease (COPD)
. Loneliness and depression
“As we advance in life, the circle of our pain enlarges, while that of our pleasure contracts” said Sophie Swetchine.
How can older people have a peaceful and quick death?
As we get older, discussion about end-of-life choices become increasingly pertinent. Older people, like everyone else wish for a peaceful and relatively quick death, free from pain and suffering. Respecting an individual’s autonomy is a fundamental ethical principle. Older adults, having lived full lives, like Professor Kahneman, may wish to exert control over their final moments, especially when facing a terminal illness. Legal avenues such as physician-assisted dying (PAD) exist in certain jurisdictions, allowing competent adults to end their lives. These practices are often accompanied by stringent safeguards to ensure that the choice is voluntary.
Before considering options like PAD or VSED, older adults suffering from terminal illness, should seek the services of palliative and hospice care. These services provide relief from pain and stress of serious illness both for the patients and their families.
Conclusion
Why don’t we die the way we want to die? Advances in medicine have eased the line between saving life and prolonging dying. Everybody wants to have a “good death”. A “good death” is a deeply personal concept, based on individual values, beliefs, and cultural practices. However common themes often include: minimal pain and distress, dyingat home surrounded by loved ones, resolving conflicts, expressing final wishes and getting support from one’s religious practices. However in real life, “dying is painful, messy and imperfect” said Dr Sherwin Nuland in his bestselling book: How We Die: Reflections on life’s Final Chapter. It can also be expensive.
We have no control when we will die. However we have some control over where and how we will die. To achieve the twin goals, it will take some advance planning on our parts. When we are old or suffering from a terminal illness or illnesses, we should discuss with our loved ones, our end-of-life wishes. Do we want to die at home or in a hospital? Do we want unnecessary and costly treatments just to live few more months? Do we want physician-assisted dying if it is available to us? Do we want VSED? The final decision is ours but we must let our family members and doctors know our wishes.
Steps we can take in preparing for our death are:
Designating an individual to make medical decisions on our behalf in case we become incapacitated. It is called Healthcare Proxy.
. Executing a Living-Will or Advance Health-Care Directive– stating our end-of life wishes like- CPR or no CPR, organ and body donation.
.To have a properly executed Will and Testament (estate planning) – so that our heirs know how our assets will be distributed.
I will conclude this article with a quote from the Panchatantra (200BCE?)
Aging
When the body is shriveled
And another step falters;
When the teeth are decayed
And the face smeared with slobber,
When the sight fails
And the figure is no longer trim;
The kinsfolk find no time for conversation
Even the son despises the man
Overcome by old age, alas!
As some body has said, the only way to have a good death is to lead a good life, a life full of curiosity, compassion, and generosity.
Ps- Dr Sahu is a graduate of AIIMS (New Delhi) and a retired children and premature baby’s physician in USA. He has taught and written about death and dying for more than 45 years. He has written two books on the subject: 1- End of Life Care Issues (2011) and 2- Death, A Necessary End Will Come When It Will Come (2014). He tries to keep up with the literature on the topic of death and dying.
Sources
1- Jason Zweig. The Last Decision by the World’s Leading Thinker on Decision. The Wall Street Journal, March15-16, 2025, P-C1
2-Chat GPT
3-Compassion and choices- compassionchoices.org
4- Death with Dignity- deathwithdignity.org
5- Nuland Sherwin B. “How We Die: Reflection on Life’s Final Chapter. Alfred A. Knopf; New York: 1993
6– Saheb Sahu. Death, A Necessary End Will Come When It Will Come. S.B. Trust; Sambalpur, Odisha, 2014
