German Ethics Council: Strengthening suicide prevention and self-determination

On 26 February 2020, the Federal Constitutional Court declared the criminal offence of facilitating suicide as a recurring pursuit to be unconstitutional and void. This prompted a resurgence of the long-standing debates on the appropriate handling of suicidal crises and the controversial topic of assisted suicide and its regulation.

The German Ethics Council has already addressed issues of assisted suicide in the past in two Ad Hoc Recommendations. In this Opinion, it revisits the topic, with the emphasis more specifically on the importance of suicide prevention. “Anyone who is concerned with whether and, if so, how assisted suicide should be regulated in Germany”, says Alena Buyx, Chair of the German Ethics Council, “must – at the same time – focus on the conditions and responsibilities of genuine and comprehensive suicide prevention.”

The German Ethics Council uses selected case vignettes to illustrate the personal, social and societal aspects of suicidality in order to explore the options for and limits to influencing fully autonomous suicide decisions and possible forms of intervention. It becomes clear that, in most cases, suicidal thoughts are preceded by a lengthier process of internal and external constraints and stresses. However, this process need not necessarily lead directly to a suicidal act. The motives range from psychological and, more particularly, depressive disorders, physical suffering, isolation and loneliness to a feeling of satiety with life. Besides individual factors, the social and societal environment also influences suicidal thoughts and their unfolding. The dynamics of suicidal thoughts and acts underscore the importance of suicide prevention that adequately takes into account potential risk factors.

Nevertheless, the German Ethics Council points out that a fully autonomous decision must be respected legally and ethically as an expression of a person’s right to self-determination, even when it is a question of ending one’s own life. However, due to their irreversible nature, fully autonomous suicide decisions must meet particularly high standards of self-determination. This is dependent on sufficient knowledge of the main factors that are relevant for such a decision and the ability to assess and weigh these factors against each other in an adequate and realistic manner. Furthermore, any such decision must be founded on sufficient deliberation, resolve and autonomy.  Within the German Ethics Council views differ as to when exactly a sufficient degree of self-determination has been acquired and how this can be ascertained, if necessary. There is, however, agreement that the requirements of full autonomy must not deny the persons concerned the possibility to freely dispose over their lives. However, even fully autonomous suicide decisions result predominantly from life situations in which the satisfaction of basic needs is massively impeded. “The right to self-determination, which must also be respected in such cases”, explains Helmut Frister, spokesperson for the Council’s working group, “in no way relieves the state and society of their responsibility to ensure as far as possible that people do not get caught up and remain trapped in situations in which they feel compelled to give preference to death, a supposed lesser evil, over life.”

“If we really want to allow someone in the midst of a suicidal life situation involving considerable psychosocial stress to have an autonomous way of life – and this must be the goal – then numerous stakeholders on various levels must shoulder considerable responsibility”, stresses Andreas Lob-Hüdepohl, deputy spokesperson of the working group. Whether professionals or ordinary individuals, ultimate responsibility rests with the suicidal person. However, family members, friends and professionals also have a responsibility to offer the prospect of alternative options for action and decision-making, thereby enabling people to make fully autonomous decisions. The German Ethics Council is of the opinion that the main responsibility of institutions is to consistently tailor their services to the goals of suicide prevention and to strengthen attachment to life. However, if a person’s desire to commit suicide solidifies into a firm, fully autonomous wish, suicide assistance may be offered. Institutions should further develop their mission statements around considerations of the culture of dying. In this way, they will be able to provide clear information on whether and, if so, how assisted suicide is handled in their setting. In contrast, pan-societal and state institutions bear special responsibility for facilitating comprehensive suicide prevention – over a person’s entire lifespan, in all relevant areas of their life, in a timely and accessible manner. Only if all the stakeholders involved are connected, will it be possible to enable people to lead a self-determined way of life and to take into account the demanding requirements for fully autonomous decisions.

The full text of the Opinion “Suicide – Responsibility, Prevention and Autonomy” can be accessed (in German) on the following link: https://www.ethikrat.org/fileadmin/Publikationen/Stellungnahmen/deutsch/stellungnahme-suizid.pdf. An English translation will be available in due course.