Problem gambling

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Problem_gambling 

 

Problem gambling
Other names	Ludomania, degenerate gambling, gambling addiction, compulsive gambling, gambling disorder
Specialty	Psychiatry, clinical psychology
Symptoms	Spending a lot of money and time in casino/sports betting, Video game addiction

Addiction and dependence glossary

addiction – a biopsychosocial disorder characterized by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences addictive drug – psychoactive substances that with repeated use are associated with significantly higher rates of substance use disorders, due in large part to the drug's effect on brain reward systems dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake) drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose drug withdrawal – symptoms that occur upon cessation of repeated drug use physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens) psychological dependence – dependence that involves emotional–motivational withdrawal symptoms (e.g., dysphoria and anhedonia) reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach sensitization – an amplified response to a stimulus resulting from repeated exposure to it substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose

Problem gambling or ludomania is repetitive gambling behavior despite harm and negative consequences. Problem gambling may be diagnosed as a mental disorder according to DSM-5 if certain diagnostic criteria are met. Pathological gambling is a common disorder associated with social and family costs.

The DSM-5 has re-classified the condition as an addictive disorder, with those affected exhibiting many similarities to those with substance addictions. The term gambling addiction has long been used in the recovery movement. Pathological gambling was long considered by the American Psychiatric Association to be an impulse-control disorder rather than an addiction. However, data suggest a closer relationship between pathological gambling and substance use disorders than exists between PG and obsessive–compulsive disorder, mainly because the behaviors in problem gambling and most primary substance use disorders (i.e., those not resulting from a desire to "self-medicate" for another condition such as depression) seek to activate the brain's reward mechanisms while the behaviors characterizing obsessive-compulsive disorder are prompted by overactive and misplaced signals from the brain's fear mechanisms.

Problem gambling is an addictive behavior with a high comorbidity with alcohol problems. A common tendency shared by people who have a gambling addiction is impulsivity.

Signs and symptoms

Research by governments in Australia led to a universal definition for that country which appears to be the only research-based definition not to use diagnostic criteria: "Problem gambling is characterized by many difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community." The University of Maryland Medical Center defines pathological gambling as "being unable to resist impulses to gamble, which can lead to severe personal or social consequences".

Most other definitions of problem gambling can usually be simplified to any gambling that causes harm to the gambler or someone else in any way; however, these definitions are usually coupled with descriptions of the type of harm or the use of diagnostic criteria. The DSM-V has since reclassified pathological gambling as gambling disorder and has listed the disorder under substance-related and addictive disorders rather than impulse-control disorders. This is due to the symptomatology of the disorder resembling an addiction not dissimilar to that of a substance use disorder. To be diagnosed, an individual must have at least four of the following symptoms in 12 months:

• Needs to gamble with increasing amounts of money to achieve the desired excitement
• Is restless or irritable when attempting to cut down or stop gambling
• Has made repeated unsuccessful efforts to control, cut back, or stop gambling
• Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble)
• Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed)
• After losing money gambling, often returns another day to get even ("chasing" one's losses)
• Lies to conceal the extent of involvement with gambling
• Has jeopardized or lost a significant relationship, job, education, or career opportunity because of gambling
• Relies on others to provide money to relieve desperate financial situations caused by gambling

Factors that lead to gambling addiction

Mayo Clinic specialists state that compulsive gambling may result from biological, genetic, and environmental factors, such as:

• mental health disorders (the presence of substance use disorders, personality disorders, emotional states)
• age and sex (usually found in youth or middle-aged people, and more common to men than women)
• impact of family or friends
• personality traits
• drugs with rare side-effects (for example, antipsychotic medications or dopamine agonists).

Other studies add the following triggers to the mentioned above:

• traumatic conditions
• job-related stress
• solitude
• other addictions

If not treated, problem gambling may cause severe and lasting effects on an individual's life:

• relationship-related issues
• problems with money, bankruptcy
• legal problems, imprisonment
• health problems
• suicide, including suicidal thoughts and attempts

Suicide rates

A gambler who does not receive treatment for pathological gambling when in a desperation phase may contemplate suicide. Problem gambling is often associated with increased suicidal ideation and attempts compared to the general population.

Early onset of problem gambling may increase the lifetime risk of suicide. Both comorbid substance use and comorbid mental disorders increase the risk of suicide in people with problem gambling. A 2010 Australian hospital study found that 17% of suicidal patients admitted to the Alfred Hospital's emergency department were problem gamblers.

Mechanisms

Biology

According to the Illinois Institute for Addiction Recovery, evidence indicates that pathological gambling is an addiction similar to chemical addiction. It has been observed that some pathological gamblers have lower levels of norepinephrine than normal gamblers. According to a study conducted by Alec Roy, formerly at the National Institute on Alcohol Abuse and Alcoholism, norepinephrine is secreted under stress, arousal, or thrill, so pathological gamblers gamble to make up for their under-dosage.

Studies have compared pathological gamblers to substance addicts, concluding that addicted gamblers display more physical symptoms during withdrawal.

Deficiencies in serotonin might also contribute to compulsive behavior, including a gambling addiction. There are three important points discovered after these antidepressant studies:

1. Antidepressants can reduce pathological gambling when there is an effect on serotonergic reuptake inhibitors and 5-HT1/5-HT2 receptor antagonists.
2. Pathological gambling, as part of obsessive-compulsive disorder, requires the higher doses of antidepressants as is usually required for depressive disorders.
3. In cases where participants do not have or have minimal symptoms of anxiety or depression, antidepressants still have those effect.

A limited study was presented at a conference in Berlin, suggesting opioid release differs in problem gamblers from the general population, but in a very different way from people with a substance use disorder.

The findings in one review indicated the sensitization theory is responsible. Dopamine dysregulation syndrome has been observed in the aforementioned theory in people with regard to such activities as gambling.

Some medical authors suggest that the biomedical model of problem gambling may be unhelpful because it focuses only on individuals. These authors point out that social factors may be a far more important determinant of gambling behavior than brain chemicals, and they suggest that a social model may be more useful in understanding the issue. For example, an apparent increase in problem gambling in the UK may be better understood as a consequence of changes in legislation which came into force in 2007 and enabled casinos, bookmakers, and online betting sites to advertise on TV and radio for the first time and which eased restrictions on the opening of betting shops and online gambling sites.

Pathological gambling is similar to many other impulse-control disorders such as kleptomania. According to evidence from both community- and clinic-based studies, individuals who are pathological gamblers are highly likely to exhibit other psychiatric problems concurrently, including substance use disorders, mood and anxiety disorders, or personality disorders.

Pathological gambling shows several similarities with substance use disorders. There is a partial overlap in diagnostic criteria; pathological gamblers are also likely to have a substance use disorder. The "telescoping phenomenon" reflects the rapid development from initial to problematic behavior in women compared with men. This phenomenon was initially described for alcoholism, but it has also been applied to pathological gambling. Also, biological data support a relationship between pathological gambling and substance use disorder. A comprehensive UK Gambling Commission study from 2018 has also hinted at the link between gambling addiction and a reduction in physical activity, poor diet, and overall well-being. The study links problem gambling to a myriad of issues affecting relationships, and social stability.

Psychological

Several psychological mechanisms are thought to be implicated in the development and maintenance of problem gambling. First, reward processing seems to be less sensitive with problem gamblers. Second, some individuals use problem gambling as an escape from the problems in their lives (an example of negative reinforcement). Third, personality factors such as narcissism, risk-seeking, sensation-seeking, and impulsivity play a role. Fourth, problem gamblers have several cognitive biases, including the illusion of control, unrealistic optimism, overconfidence and the gambler's fallacy (the incorrect belief that a series of random events tends to self-correct so that the absolute frequencies of each of various outcomes balance each other out). Fifth, problem gamblers represent a chronic state of a behavioral spin process, a gambling spin, as described by the criminal spin theory.

Spain's gambling watchdog has updated its 2019–2020 Responsible Gaming Program, classifying problem gambling as a mental disorder.

Diagnosis

The most common instrument used to screen for "probable pathological gambling" behavior is the South Oaks Gambling Screen (SOGS) developed by Lesieur and Blume (1987) at the South Oaks Hospital in New York City. In recent years the use of SOGS has declined due to a number of criticisms, including that it overestimates false positives (Battersby, Tolchard, Thomas & Esterman, 2002).

The DSM-IV diagnostic criteria presented as a checklist is an alternative to SOGS, it focuses on the psychological motivations underpinning problem gambling and was developed by the American Psychiatric Association. It consists of ten diagnostic criteria. One frequently used screening measure based upon the DSM-IV criteria is the National Opinion Research Center DSM Screen for Gambling Problems (NODS). The Canadian Problem Gambling Inventory (CPGI) and the Victorian Gambling Screen (VGS) are newer assessment measures. The Problem Gambling Severity Index, which focuses on the harms associated with problem gambling, is composed of nine items from the longer CPGI. The VGS is also harm based and includes 15 items. The VGS has proven validity and reliability in population studies as well as Adolescents and clinic gamblers.

Treatment

Most treatment for problem gambling involves counseling, step-based programs, self-help, peer-support, medication, or a combination of these. However, no one treatment is considered to be most efficacious and, in the United States, no medications have been approved for the treatment of pathological gambling by the U.S. Food and Drug Administration (FDA).

Gamblers Anonymous (GA) is a commonly used treatment for gambling problems. Modeled after Alcoholics Anonymous, GA is a twelve-step program that emphasizes a mutual-support approach. There are three in-patient treatment centers in North America. One form of counseling, cognitive behavioral therapy (CBT) has been shown to reduce symptoms and gambling-related urges. This type of therapy focuses on the identification of gambling-related thought processes, mood and cognitive distortions that increase one's vulnerability to out-of-control gambling. Additionally, CBT approaches frequently utilize skill-building techniques geared toward relapse prevention, assertiveness and gambling refusal, problem solving and reinforcement of gambling-inconsistent activities and interests.

As to behavioral treatment, some recent research supports the use of both activity scheduling and desensitization in the treatment of gambling problems. In general, behavior analytic research in this area is growing There is evidence that the SSRI paroxetine is efficacious in the treatment of pathological gambling. Additionally, for patients with both pathological gambling and a comorbid bipolar spectrum condition, sustained-release lithium has shown efficacy in a preliminary trial. The opioid antagonist drug nalmefene has also been trialled quite successfully for the treatment of compulsive gambling. Group concepts based on CBT, such as the metacognitive training for problem gambling have also proven effective.

Step-based programs

12 Step–based programs such as Gamblers Anonymous are specific to gambling and generic to healing addiction, creating financial health, and improving mental wellness. Commercial alternatives that are designed for clinical intervention, using the best of health science and applied education practices, have been used as patient-centered tools for intervention since 2007. They include measured efficacy and resulting recovery metrics.

Motivational interviewing

Motivational interviewing is one of the treatments of compulsive gambling. The motivational interviewer's basic goal is promoting readiness to change through thinking and resolving mixed feelings. Avoiding aggressive confrontation, argument, labeling, blaming, and direct persuasion, the interviewer supplies empathy and advice to compulsive gamblers who define their own goal. The focus is on promoting freedom of choice and encouraging confidence in the ability to change.

Peer support

A growing method of treatment is peer support. With the advancement of online gambling, many gamblers experiencing issues use various online peer-support groups to aid their recovery. This protects their anonymity while allowing them to attempt recovery on their own, often without having to disclose their issues to loved ones.

Self-help

Research into self-help for problem gamblers has shown benefits. A study by Wendy Slutske of the University of Missouri concluded one-third of pathological gamblers overcome it by natural recovery.

Anti-addiction drugs

Main article: Addiction § Medication

See also: § Biology

Self-exclusion

Main article: Self-exclusion

Gambling self-exclusion (voluntary exclusion) programs are available in the US, the UK, Canada, Australia, South Africa, France, and other countries. They seem to help some (but not all) problem gamblers to gamble less often.

Some experts maintain that casinos in general arrange for self-exclusion programs as a public relations measure without actually helping many of those with problem gambling issues. A campaign of this type merely "deflects attention away from problematic products and industries", according to Natasha Dow Schull, a cultural anthropologist at New York University and author of the book Addiction by Design.

There is also a question as to the effectiveness of such programs, which can be difficult to enforce. In the province of Ontario, Canada, for example, the Self-Exclusion program operated by the government's Ontario Lottery and Gaming Corporation (OLG) is not effective, according to investigation conducted by the television series, revealed in late 2017. |"Gambling addicts ... said that while on the ... self-exclusion list, they entered OLG properties on a regular basis" in spite of the facial recognition technology in place at the casinos, according to the Canadian Broadcasting Corporation. As well, a CBC journalist who tested the system found that he was able to enter Ontario casinos and gamble on four distinct occasions, in spite of having been registered and photographed for the self-exclusion program. An OLG spokesman provided this response when questioned by the CBC: "We provide supports to self-excluders by training our staff, by providing disincentives, by providing facial recognition, by providing our security officers to look for players. No one element is going to be foolproof because it is not designed to be foolproof".

Impact (Australia)

According to the Productivity Commission's 2010 final report into gambling, the social cost of problem gambling is close to 4.7 billion dollars a year. Some of the harms resulting from problem gambling include depression, suicide, lower work productivity, job loss, relationship breakdown, crime and bankruptcy. A survey conducted in 2008 found that the most common motivation for fraud was problem gambling, with each incident averaging a loss of $1.1 million. According to Darren R. Christensen. Nicki A. Dowling, Alun C. Jackson and Shane A. Thomas, a survey done from 1994 to 2008 in Tasmania gave results that gambling participation rates have risen rather than fallen over this period.

Prevalence

Europe

In Europe, the rate of problem gambling is typically 0.5 to 3 percent. The "British Gambling Prevalence Survey 2007", conducted by the United Kingdom Gambling Commission, found approximately 0.6 percent of the adult population had problem gambling issues—the same percentage as in 1999. The highest prevalence of problem gambling was found among those who participated in spread betting (14.7%), fixed odds betting terminals (11.2%), and betting exchanges (9.8%). In Norway, a December 2007 study showed the amount of current problem gamblers was 0.7 percent.

With gambling addiction on the rise worldwide and across Europe in particular, those calling gambling a disease have been gaining grounds. The UK Gambling Commission announced a significant shift in their approach to gambling through their reclassification of gambling as a disease, and therefore that it should be addressed adequately by the NHS.

The World Health Organization has also classified gambling a disease. In its 72nd World Health Assembly held on Saturday, May 25, 2019, ‘gaming disorder’ was recognized as an official illness. The 194-member meet added excessive gaming to a classified list of diseases as it revised its International Statistical Classification of Diseases and Related Health Problems (ICD-11).

North America

Lizbeth García Quevedo, director of the Coordination with Federal Entities (CONADIC), spoke of pathological gambling as a strong addiction in Mexico: "It has very similar behaviors, that is why some experts consider it an addiction because it is similar in the behaviors, in the origins, some risk factors that can trigger pathological gambling, it can also trigger drug consumption". In Mexico there could be between one and three million people addicted to gambling. "They should be aware of what their children are doing, and on the other hand, they should motivate pro-active gambling, healthy gambling", commented Lizbeth García Quevedo. The Ministry of Health document highlights that a study on pathological gambling that analyzed 46 studies carried out in Canada, the United States, Australia, Sweden, Norway, England, Switzerland and Spain, revealed that the prevalence of pathological gambling is relatively higher among adolescents, which shows the continuity of the problem considering that many pathological gamblers state that they started their gambling behavior at an early age.

In the United States, the percentage of pathological gamblers was 0.6 percent, and the percentage of problem gamblers was 2.3 percent in 2008. Studies commissioned by the National Gambling Impact Study Commission Act has shown the prevalence rate ranges from 0.1 percent to 0.6 percent. Nevada has the highest percentage of pathological gambling; a 2002 report estimated 2.2 to 3.6 percent of Nevada residents over the age of 18 could be called problem gamblers. Also, 2.7 to 4.3 percent could be called probable pathological gamblers.

According to a 1997 meta-analysis by Harvard Medical School's division on addictions, 1.1 percent of the adult population of the United States and Canada could be called pathological gamblers. A 1996 study estimated 1.2 to 1.9 percent of adults in Canada were pathological. In Ontario, a 2006 report showed 2.6 percent of residents experienced "moderate gambling problems" and 0.8 percent had "severe gambling problems". In Quebec, an estimated 0.8 percent of the adult population were pathological gamblers in 2002. Although most who gamble do so without harm, approximately 6 million American adults are addicted to gambling.

According to a survey of 11th and 12th graders in Wood County, Ohio found that the percentage who reported being unable to control their gambling rose to 8.3 percent in 2022, up from just 4.2 percent in 2018. The reasons for the increase cited, are the time spent online during the COVID-19 pandemic, gambling-like elements put into video games, and the increased legalization of sports betting in a number of U.S. states.

Signs of a gambling problem include:

• Using income or savings to gamble while letting bills go unpaid
• Repeated unsuccessful attempts to stop gambling
• Chasing losses
• Losing sleep over thoughts of gambling
• Arguing with friends or family about gambling behavior
• Feeling depressed or suicidal because of gambling losses

South America

For Isabel Sánchez Sosa, coordinator of the Compulsive Gamblers Association of Argentina, "gambling addiction is growing a lot in the country because the offer is impressive" and in this sense she asserted that the presence of bingos is a common issue in all neighborhoods. In the province of Buenos Aires there are 46 bingos.

Oceania (Australia)

Casinos and poker machines in pubs and clubs facilitate problem gambling in Australia. The building of new hotels and casinos has been described as "one of the most active construction markets in Australia"; for example, AUD$860 million was allocated to rebuild and expand the Star Complex in Sydney.

A 2010 study, conducted in the Northern Territory by researchers from the Australian National University (ANU) and Southern Cross University (SCU), found that the proximity of a person's residence to a gambling venue is significant in terms of prevalence. Harmful gambling in the study was prevalent among those living within 100 metres of any gambling venue, and was over 50% higher than among those living ten kilometres from a venue. The study's data stated:

Specifically, people who lived 100 metres from their favourite venue visited an estimated average of 3.4 times per month. This compared to an average of 2.8 times per month for people living one kilometre away, and 2.2 times per month for people living ten kilometres away.

According to the Productivity Commission's 2016 report into gambling, 0.5% to 1% (80,000 to 160,000) of the Australian adult population had significant problems resulting from gambling. A further 1.4% to 2.1% (230,000 to 350,000) of the Australian adult population experienced moderate risks making them likely to be vulnerable to problem gambling. Estimates show that problem gamblers account for an average of 41% of the total gaming machine spending.

Pyrrhic victory

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Pyrrhic_victory 

 

James G. Blaine finally gained the 1884 Republican nomination for US president on his third attempt: "Another victory like this and our money's gone!"

A Pyrrhic victory is a victory that inflicts such a devastating toll on the victor that it is tantamount to defeat. Such a victory negates any true sense of achievement or damages long-term progress.

The phrase originates from a quote from Pyrrhus of Epirus, whose triumph against the Romans in the Battle of Asculum in 279 BC destroyed much of his forces, forcing the end of his campaign.

Etymology

Pyrrhic victory is named after King Pyrrhus of Epirus, whose army suffered irreplaceable casualties in defeating the Romans at the Battle of Heraclea in 280 BC and the Battle of Asculum in 279 BC, during the Pyrrhic War. After the latter battle, Plutarch relates in a report by Dionysius:

The armies separated; and, it is said, Pyrrhus replied to one that gave him joy of his victory that one other such victory would utterly undo him. For he had lost a great part of the forces he brought with him, and almost all his particular friends and principal commanders; there were no others there to make recruits, and he found the confederates in Italy backward. On the other hand, as from a fountain continually flowing out of the city, the Roman camp was quickly and plentifully filled up with fresh men, not at all abating in courage for the loss they sustained, but even from their very anger gaining new force and resolution to go on with the war.

— Plutarch, Life of Pyrrhus

In both Epirote victories, the Romans suffered greater casualties but they had a much larger pool of replacements, so the casualties had less impact on the Roman war effort than the losses of King Pyrrhus.

The report is often quoted as

Ne ego si iterum eodem modo vicero, sine ullo milite Epirum revertar.
If I achieve such a victory again, I shall return to Epirus without any soldier.

— Orosius

or

If we are victorious in one more battle with the Romans, we shall be utterly ruined.

— Plutarch

Examples

War

This list comprises examples of battles that ended in a Pyrrhic victory. It is not intended to be complete but to illustrate the concept.

Last stand and final charge from the fortress of Szigetvár (painting by Johann Peter Krafft, 1825)

 

Japanese aircraft prepare to take off from Shōkaku during the Battle of the Santa Cruz Islands

 

The ruined streets of Vukovar ten days after its surrender

• Battle of Asculum (279 BC), Pyrrhus of Epirus and Italian allies against the Roman Republic: the Romans, though suffering twice as many casualties, could easily replenish their ranks. Pyrrhus lost most of his commanders and a great part of the forces he had brought to Italy, and he withdrew to Sicily.
• Battle of Avarayr (451), Vardan Mamikonian and Christian Armenian rebels against the Sassanid Empire: the Persians were victorious but the battle proved to be a strategic victory for Armenians, as Avarayr paved the way to the Nvarsak Treaty (484 AD), which assured Armenian autonomy and religious freedom.
• Siege of Szigetvár (1566), Ottoman–Habsburg wars: although the Ottomans won the siege, it can be seen as a Pyrrhic victory because of the heavy Ottoman casualties, the death of Sultan Suleiman, and the resulting delay to the Ottoman push for Vienna that year which suspended Ottoman expansion in Europe.
• Siege of Ostend (1601–1604), Eighty Years' War: for three years the Spanish attempted to capture this port from Dutch and English defenders, even as the Dutch expanded their territory further east – including capturing the port of Sluis to replace Ostend before surrendering. The vast cost and casualties of the siege were compounded by Spain's subsequent campaign to recapture the Dutch gains, which achieved little, and by 1607 Spain was bankrupt. The resultant Twelve Years' Truce effectively made the Dutch Republic an independent state.
• Battle of Malplaquet (1709), War of the Spanish Succession: the battle was an Allied victory because Marlborough's army kept possession of the battlefield, but it had suffered double the French casualties and could not pursue. The French army withdrew in good order and relatively intact, and it remained a potent threat to further Allied operations.
• Battle of Gangwana (1741) fought between 1,000 strong Rathore cavalry of Jodhpur and combined armies of Mughal Empire, and Jaipur Numbering 100,000 with hundreds of cannons and artillery at Gangwana the Jaipur emerged victorious but with heavy losses of 12,000 and thousands other wounded
• Battle of Bunker Hill (1775), American Revolutionary War: after mounting three assaults on the colonial forces, the British won control of the Boston peninsula in the early stages of the war, but the engagement cost them many more casualties than the Americans had incurred (including a large number of officers) and led them to adopt more cautious methods, which helped American rebel forces; the political repercussions increased colonial support for independence.
• Battle of Guilford Court House (1781), American Revolutionary War: in this short battle, the outnumbered British force defeated an American army; the British lost a considerable number of men, and their drive to conquer the southern colonies changed course.
• Battle of Chancellorsville (1863), American Civil War: General Robert E. Lee split his army in the face of Hooker's larger Union force; the audacious strategy allowed the Confederate army to win the day against a numerically superior foe. However, 20% of Lee's army was injured or killed, including General Stonewall Jackson, and his losses were difficult to replace. Lee's weakened army went on the offensive, but less than two months later was defeated and forced to retreat after the Battle of Gettysburg.
• Battle of the Santa Cruz Islands (1942), World War II, Solomon Islands Campaign: Japanese and Allied naval forces met during the struggle for Guadalcanal and nearby islands. After an exchange of carrier air attacks, U.S. surface ships retreated with one carrier sunk and another severely damaged. The Japanese carrier forces achieved a tactical victory, as none of their ships were sunk, but the heavy loss of irreplaceable veteran aircrews was to the strategic advantage of the Allies. Japanese ground forces on Guadalcanal had also just lost the Battle for Henderson Field and were in no position to take advantage of the new situation.
• Battle of Chosin Reservoir (1950), Korean War: the Chinese army attempted to encircle and destroy the UN forces but in a 17-day battle in freezing weather, the UN forces inflicted crippling losses on the Chinese while making a fighting withdrawal. The Chinese occupied northeast Korea but they did not recover until the spring, and the UN maintained a foothold in Korea.
• Second Battle of Quảng Trị (1972), Vietnam War: The army of the Republic of Vietnam, with the support of ground artillery, ship gunboats, and bombers, attacked the ancient citadel of Quảng Trị. Although the citadel was recaptured after 81 days and nights, the ARVN army was weakened and after only 2 years, the Republic of Vietnam collapsed and the communists unified the North and South.
• Battle of Vukovar (1991), Croatian War of Independence: the Yugoslav People's Army (JNA) laid siege to the city of Vukovar, held by the Croatian National Guard and civilian volunteers. After 87 days, the ruined city fell to the JNA. Although the city was besieged from all sides, it exhausted the Yugoslav army and Serbian paramilitaries that had about twenty times more soldiers and complete armoured and artillery superiority, and they had twice as many losses. It was a turning point in the Croatian War of Independence.

Politics, sports and law

The term is used as an analogy in business, politics and sport to describe struggles that end up ruining the victor. Theologian Reinhold Niebuhr commented on the necessity of coercion in preserving the course of justice by warning,

Moral reason must learn how to make coercion its ally without running the risk of a Pyrrhic victory in which the ally exploits and negates the triumph.

— Karl Paul Reinhold Niebuhr

In Beauharnais v. Illinois, a 1952 U.S. Supreme Court decision involving a charge proscribing group libel, Associate Justice Black alluded to Pyrrhus in his dissent,

If minority groups hail this holding as their victory, they might consider the possible relevancy of this ancient remark: "Another such victory and I am undone".

— Hugo Black

Criminal trials often can result in Pyrrhic victories, as, particularly in misdemeanor cases, the costs of hiring a lawyer and/or missing work to go to trial to be found not-guilty could be significantly larger than the cost of pleading guilty. For example, a conviction for running a stop sign might carry a fine of $200, while missing work to appear in court to enter a not-guilty plea could cost the defendant more. In another example, in a case in which a defendant cannot afford bail that defendant could be held in jail for years while awaiting trial, even if the crime for which he is accused carries a sentence of less than a year. This Pyrrhic victory phenomenon, coupled with the risk of losing at trial (whether innocent or not) is often enough to pressure even innocent parties into accepting plea bargains. Ideally, a person found innocent at trial could recoup his costs by suing the parties responsible for a false accusation, but due to qualified immunity for police and absolute immunity for prosecutors, victory in such suits is unlikely.

Right to die

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Right_to_die

 

The right to die is a concept based on the opinion that human beings are entitled to end their life or undergo voluntary euthanasia. Possession of this right is often understood that a person with a terminal illness, incurable pain, or without the will to continue living, should be allowed to end their own life, use assisted suicide, or to decline life-prolonging treatment. The question of who, if anyone, may be empowered to make this decision is often the subject of debate.

Religious views on suicide vary from the Hindu and Jain practices of non-violent suicide through fasting (Prayopavesa and Santhara, respectively) to considering it a grave sin, as in Catholicism.

Ethics

The preservation and value of life have led to many medical advancements when it comes to treating patients. New devices and the development of palliative care have allowed humans to live longer than before. Prior to these medical advancements and care, the lifespans of those who were unconscious, minimally unconscious, and in a vegetative state were short as they were unable to receive assistance with basic needs such as breathing and feeding. The advancement of medical technology raises the question about the quality of life of patients who are no longer conscious. For example, the right to self-determination questions the definition of quality and sanctity of life—if one had the right to live, then the right to die must follow suit. There are questions in ethics as to whether or not a right to die can coexist with a right to life. If it is argued that the right to life is inalienable, then it cannot be surrendered and therefore may be incompatible with a right to die. A second debate exists within bioethics over whether the right to die is universal, only applies under certain circumstances (such as terminal illness), or if it exists at all. It is also stated that 'right to live' is not synonymous to 'obligation to live.' From that point of view, the right to live can coexist with the right to die.

The right to die is supported and rejected by many. Arguments for this right include:

• If one had a right to live, then one must have the right to die, both on their terms.
• Death is a natural process of life thus there should not be any laws to prevent it if the patient seeks to end it.
• What we do at the end of our lives should not be of concern to others.
• If euthanasia is strictly controlled, we can avoid entering a slippery slope and prevent patients from seeking alternative methods which may not be legal.

Arguments against include:

• It can lead to a slippery slope; if we allow patients this right, it can expand and have dire consequences.
• Give rise to pressuring those to end their lives or the lives of others; ethically immoral by human and medical standards.
• "Throwing away" patients who are deemed no longer capable to be part of society.
• Decrease in palliative end-of-life care due to the expectation of terminal patients to exercise their right to die.

A court in the American state of Montana for example, has found that the right to die only applies to those with life-threatening medical conditions. Physician-assisted suicide advocate Ludwig Minelli, euthanasia expert Sean W. Asher, and bioethics professor Jacob M. Appel, in contrast, argue that all competent people have a right to end their own lives. Appel has suggested that the right to die is a test for the overall freedom of a given society. A professor in social work, Alexandre Baril, proposed to create an ethic of responsibility "based on a harm-reduction, non-coercive approach to suicide. [He] suggest that assisted suicide should be an option for suicidal people." He argued that the voice of suicidal people is viewed as illegitimate and that there are 'injunctions to live and to futurity' where suicidal subjects are oppressed and silenced. Baril suggests the word suicidism to describe the "[...] oppressive system (stemming from non-suicidal perspectives) functioning at the normative, discursive, medical, legal, social, political, economic, and epistemic levels in which suicidal people experience multiple forms of injustice and violence [...]" He suggests creating safer spaces and listening to suicidal people without forcing the 'will to live' upon them.

The 1991 Patient Self-Determination Act passed by the US Congress at the request of the financial arm of Medicare does permit elderly Medicare/Medicaid patients (and by implication, all "terminal" patients) to prepare an advance directive in which they elect or choose to refuse life-extending and/or life-saving treatments as a means of shortening their lives and thus suffering unto certain death. Under US law (1991 PSDA), the treatment refused in an advance directive does not have to be proved to be "medically futile" under some existing due-process procedure developed under state laws, such as TADA in Texas.

By country

See also: Voluntary euthanasia § By country

 

Current status of euthanasia around the world:

  Active voluntary euthanasia legal (Belgium, Canada, Colombia, Luxembourg, the Netherlands, New Zealand, Spain and the Australian states of New South Wales, Queensland, South Australia, Tasmania, Victoria and Western Australia)

  Passive euthanasia legal (refusal of treatment / withdrawal of life support)

  Active euthanasia illegal, passive euthanasia not legislated or regulated

  All forms of euthanasia illegal

As of 2023, some forms of voluntary euthanasia are legal in Australia, Belgium, Canada, Colombia, Luxembourg, the Netherlands, New Zealand, Spain and Switzerland.

Australia

Main article: Euthanasia in Australia

As euthanasia is a health issue, under the Australian constitution this falls to state and territory governments to legislate and manage.

Euthanasia was legal within the Northern Territory during parts of 1996–1997 as a result of the territory parliament passing Rights of the Terminally Ill Act 1995. As a territory and not a state, the federal government under Prime Minister John Howard amended the Northern Territory (Self-Government) Act 1978 (amongst others) to ensure that territories of Australia are no longer able to legislate on euthanasia.However, this was repealed in December 2022 with the passing of Restoring Territory Rights Act. The federal government is not able to legislate restrictions on health issues for the Australian states and territories in the same manner.

Voluntary assisted dying schemes have been in effect in the following states; Victoria since 19 June 2019, Western Australia since 1 July 2021, Tasmania since 23 October 2022, Queensland since 1 January 2023, and South Australia since 31 January 2023. New South Wales was the final state to pass legislation for assisted dying in May 2022, which will go into effect on 28 November 2023.

Belgium

Main article: Euthanasia in Belgium

In 2002, the Belgian parliament legalized euthanasia.

Canada

Main article: Euthanasia in Canada

As of August 2011, a British Columbia Supreme Court judge had been requested to speed up a right to die lawsuit so that Gloria Taylor could have a doctor assist her in dying by suicide. She had Lou Gehrig's disease. She died of an infection in 2012.

A British Columbia civil liberties lawsuit is representing six plaintiffs and challenges the laws that make it a criminal offence to assist seriously and incurably ill individuals to die with dignity.

On 6 February 2015 the Supreme Court of Canada ruled that denying the right to assisted suicide is unconstitutional. The court's ruling limits physician-assisted suicides to "a competent adult person who clearly consents to the termination of life and has a grievous and irremediable medical condition, including an illness, disease or disability, that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition." The ruling was suspended for 12 months to allow the Canadian parliament to draft a new, constitutional law to replace the existing one.

The court decision includes a requirement that there must be stringent limits that are "scrupulously monitored." This will require the death certificate to be completed by an independent medical examiner, not the treating physician, to ensure the accuracy of reporting the cause of death.

The Canadian Medical Association (CMA) reported that not all doctors were willing to assist in a patient's death due to legal complications and went against what a physician stood for. Many physicians stated that they should have a voice when it comes to helping a patient end their life. However, the belief in late 2015 was that no physician would be forced to do so but the CMA was offering educational sessions to members as to the process that would be used.

On 17 June 2016, legislation passed both houses of the Parliament of Canada and received Royal Assent to allow euthanasia within Canada.

The euthanizing agents of choice for animals and pets are the barbiturates Pentobarbital (known popularly for their abuse potential as "Yellow Jackets") in combination with the phenol hypnotic propofol: with new regulations regarding the previous synthetic-opioid euthanizing agent T-61 as illegal or inhumane, with or without the previous use of Ketamine (S-Isomer) to relieve the symptoms of intense anxiety caused by T-61 alone. Given the mixed mechanism of actions of both propofol and nembutal, this is arguably one, if not the absolute most comfortable way of dying for mammals.

Colombia

Main article: Legality of euthanasia § Colombia

On 20 May 1997, the Constitutional Court of Colombia decriminalised piety homicide, for terminally ill patients, stating that "the medical author cannot be held responsible for the assisted suicide of a terminally ill patient" and urged Congress to regulate euthanasia "in the shortest time possible".

On 15 December 2014, the Constitutional Court had given the Ministry of Health and Social Protection 30 days to publish guidelines for the healthcare sector to use in order to guarantee terminally ill patients, with the wish to undergo euthanasia, their right to a dignified death.

Germany

In February 2020, the Federal Constitutional Court ruled that the right to personal identity in German constitutional law encompasses a right to self-determined death, which in turn contains a right to suicide. Notably, this right is not limited to terminally ill patients, instead finding its limits within the requirement for the choice to be autonomous. The ruling has sparked controversy, with opponents arguing that the ruling may enable peer pressure into assisted suicide.

India

Main article: Euthanasia in India

Since 2018, the Supreme Court of India has legalized passive euthanasia in India during a case involving Aruna Shanbaug under strict conditions, namely that the patient's consent (or relatives) is needed, and that the patient must be terminally ill or vegetative state.

Netherlands

Main article: Euthanasia in the Netherlands

The Netherlands legalized voluntary euthanasia in 2002. Under current Dutch law, euthanasia and assisted suicide can only be performed by doctors, and that is only legal in cases of "hopeless and unbearable" suffering. In practice, this means that it is limited to those with serious and incurable medical conditions (including mental illness) and in considerable suffering like pain, hypoxia or exhaustion. Helping somebody to die by suicide without meeting the qualifications of the current Dutch euthanasia law is illegal. These criteria concern the patient's request, the patient's suffering (unbearable), the infaust prognosis (hopeless), the information provided to the patient, the absence of reasonable alternatives, consultation of another physician and the applied method of ending life.

New Zealand

Main article: Euthanasia in New Zealand

Euthanasia is legal in New Zealand. In 2015, a lawyer with cancer Lecretia Seales brought a case (Seales v Attorney-General) to the High Court to challenge New Zealand law for her right to die with the assistance of her GP, asking for a declaration that her GP would not risk conviction. However legislation to legalize euthanasia for terminally ill patients was voted upon in the 2020 general election and was voted in favour of legalisation. The End Of Life Choice Bill took effect on 7 November 2021.

Peru

Peru legally forbids euthanasia. In 2020, a legal challenge to the law was launched by Ana Estrada, aimed at decriminalizing the practice.

United States

Main articles: Euthanasia in the United States and Assisted suicide in the United States

The term right to die has been interpreted in many ways, including issues of suicide, passive euthanasia, active euthanasia, assisted suicide, and physician-assisted suicide.

In the United States, public support for the right to die by physician-assisted suicide has increased over time. In a 2005 survey, the Pew Research Center found that 70% of participants say that there are circumstances in which a patient should be allowed to die; however, only 46% of participants approved of laws permitting doctors to assist patients in ending their lives. In May 2018, a Gallup poll report announced that 72% of responders said that doctors should legally be allowed to help terminally ill patients die. However, framing effects of using language such as "suicide" rather than "ending one's life" have the potential to lower approval rates by 10-15%.

A 2014 survey of physicians revealed that 54% of respondents agreed that physician-assisted suicide should be allowed. In a rigorous survey of physicians in 1996, less than 20% of physicians reported that they received requests from patients to be euthanized, and less than 5% complied. In 2020, the Oregon Death with Dignity Act data summary revealed that the number of prescriptions for lethal doses of medications increased by 25% since 2019, and have been steadily increasing since 1998. Of patients who received these prescriptions, 66% eventually died from ingesting the medications.

Major right to die cases

Karen Quinlan

The right to die movement in the United States began with the case of Karen Quinlan in 1975 and continues to raise bioethical questions about one's quality of life and the legal process of death. Karen Quinlan, 21, lost consciousness after consuming alcohol and tranquilizers at a party. She soon began to experience respiratory problems, which then prevented oxygen from flowing to her brain. That led her to slip into a comatose state in which a respirator and a feeding tube were used to keep her alive and breathing. Quinlan did not have a proxy or living will and had not expressed her wishes if something ever happened to her to those around her, which made it difficult to decide what the next step should be.

Karen Quinlan's parents understood that their daughter would never wake up and that prolonging her life may be more damaging and it would not be of quality life. Her father sought out the right to be Karen's legal guardian and petitioned for the removal of the respirator that was keeping her alive. The court, however, argued that the removal of the ventilator, which would lead to Karen's death, would be considered unlawful, unnatural, and unethical. Quinlan's lawyer made the counterargument that the removal of the respirator would allow Karen to have a natural death, which is natural and ethical. The Quinlans won the court case and were appointed as the legal guardians of their daughter. The respirator was removed in 1976, but Karen continued to live without the ventilator until 1985. The case continues to raise bioethical questions of one's quality of life and the legal process of death. It also brings up many important issues that are still being addressed to this day. One of the critical points that the Quinlan case brings up is the patient's right to deny or withdraw treatment. Cases in which the patient rejected or withdrew treatment were then unheard of and went against medical ethics in preserving one's life. Debates on allowing patients the right to self-determination were controversial, and they would be evaluated for the next couple of decades from state to state. The case also brought up whether family members and those who are close to the patient are allowed in the decision-making process. Since Karen had no written documentation, voiced no decision, and appointed no proxy, a lengthy legal battle was caused between the Quinlan family and the state in determining Karen's best interest and determining if she would want to live or die. That had a significant influence on the use and establishment of advance directives, oral directives, proxies, and living wills.

Nancy Cruzan

Nancy Cruzan's gravestone

Another major case that further propagated the right to die movement and the use of living wills, advance directives and use of a proxy was Cruzan v. Director, Missouri Department of Health. In 1983, Nancy Cruzan had a car accident, which left her permanently in a vegetative state. Her status as an adult and lack of an advance directive, living will, or proxy led to a long legal battle for Cruzan's family in petitioning for the removal of her feeding tube, which was keeping her alive since the accident. Nancy had mentioned to a friend that under no circumstances would she want to continue to live if she were ever in a vegetative state, but this was not a strong enough statement to remove the feeding tube. Eventually, the Cruzan family won the case and had their daughter's tube removed. The case brought great debate if the right to die should be approved from state to state or as a whole nation.

Terri Schiavo

The Terri Schiavo case occurred between 1990 and 2005. This case was controversial due to a disagreement between Terri's immediate family members and her husband. In the Quinlan and Cruzan cases, the family was able to make a unanimous decision on the state of their daughters. Schiavo suffered from a cardiac arrest which led to her collapse and soon after began to have trouble breathing. The lack of oxygen to her brain caused irreversible brain damage, leaving her in a vegetative state and required a feeding tube and ventilator to keep her alive. Terri left no advance directive or had a discussion with her parents or husband about what she may have wanted if something were to happen to her. Soon after, her husband was appointed as her legal guardian.

Years later, her husband decided to remove Terri's feeding tube since the chances of her waking up were slim to none. Terri's family, however, argued against this decision and brought this case to court. The case was very turbulent and occurred over some years and involved the state and its legislators before a decision was made. This brought up bioethical debates on the discontinuation of Schiavo's life vs. allowing her to continue living in a permanent vegetative state. Those who were for preserving Terri's life stated that removing the tube would be ethically immoral since they do not know what she would have wanted. They challenged her physical and mental state and stated that she might have some consciousness; thus she deserved to continue living. Those for removing the tube argued for self-determination and that her quality of life was diminished. The Schiavo case is the most recent and significant right to die case that propagates the thought of having an advance directive or living will. It also further looks into other complications that can arise, such as family disagreements, which should have been accounted for when dealing with a right to die case.

'See also '

• Washington v. Glucksberg
• Vacco v. Quill

Legislation

As the health of citizens is considered a police power left for individual states to regulate, it was not until 1997 that the US Supreme Court made a ruling on the issue of assisted suicide and one's right to die. That year, the Supreme Court heard two appeals arguing that New York (Vacco v. Quill) and Washington (Washington v. Glucksberg) statutes that made physician-assisted suicide a felony violated the equal protection clause of the Fourteenth Amendment. In a unanimous vote, the Court held that there was no constitutional right to physician-assisted suicide and upheld state bans on assisted suicide. While in New York has maintained statutes banning physician-assisted suicide, the Court's decision also left it open for other states to decide whether they would allow physician-assisted suicide or not.

Since 1994, the following states in the US have passed assisted suicide laws: Oregon (Death with Dignity Act, 1994), Washington (Death with Dignity Act, 2008), Vermont (Patient Choice and Control at the End of Life Act, 2013), California (End of Life Option Act, 2015), Colorado (End of Life Options Act, 2016), District of Columbia (D.C. Death with Dignity Act, 2016), Hawaii (Our Care Our Choice Act, 2018), Maine (Death with Dignity Act, 2019), New Jersey (Aid in Dying for the Terminally Ill Act, 2019), and New Mexico (Elizabeth Whitefield End of Life Options Act, 2021) passed legislation that provides a protocol for the practice of physician-assisted suicide. The law in these states allows terminally ill adult patients to seek lethal medication from their physicians. In 2009, the Montana Supreme Court ruled that nothing in state law prohibits physician-assisted suicide and provides legal protection for physicians in the case that they prescribe lethal medication upon patient request. In California, the governor signed a controversial physician-assisted-suicide bill, the California End of Life Option Act, in October 2015 that passed during a special legislative session intended to address Medi-Cal funding, after it had been defeated during the regular legislative session.

In early 2014, New Mexico Second District Judge Nan Nash ruled that terminally ill patients have the right to aid in dying under the state constitution, i.e., making it legal for a doctor to prescribe a lethal dose of medication to a terminally ill patient. The ultimate decision will be made with the outcome of New Mexico's Attorney General's appeal to the ruling. Organizations have been continuously pushing for the legalization of self-determination in terminally ill patients in states where the right to end one's life is prohibited.

Medical Perspective

The American Medical Association (AMA) is the national association that advocates for physicians and provides guidance for the best practices for delivering health care. The AMA is responsible for maintaining the Code of Ethics, which consists of two parts: the Principles of Medical Ethics and Opinions of the AMA's Council on Ethical and Judicial Affairs. The role of physicians in patient's right to die is debated within the medical community, however, the AMA provided an opinion statement on the matter.

Opinion statement regarding physician-assisted suicide

Patients who are terminally ill or suffering from debilitating illnesses may decide that they prefer to die rather than continue suffering. Physicians commit themselves to "do no harm" and by participating in assisted suicide physicians would inherently be causing harm to their patients. Rather than participating in assisted suicide, physicians should provide palliative care to minimize patient suffering. These are recommendations for physicians from the Code of Medical Ethics Opinion 5.7 regarding end of life care:

• Should not abandon a patient once it is determined that a cure is impossible.
• Must respect patient autonomy.
• Must provide good communication and emotional support.
• Must provide appropriate comfort care and adequate pain control.

Religion

Hinduism accepts the right to die for those who are tormented by terminal diseases or those who have no desire, no ambition, and no responsibilities remaining. Death is allowed by non-violent means such as fasting to the point of starvation (Prayopavesa). Jainism has a similar practice named Santhara. Other religious views on suicide vary in their tolerance and include denial of the right as well as condemnation of the act. In the Catholic faith, suicide is considered a grave sin.

Philosophy of suicide

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Philosophy_of_suicide

In ethics and other branches of philosophy, suicide poses difficult questions, answered differently by various philosophers. The French Algerian essayist, novelist, and playwright Albert Camus (1913–1960) began his philosophical essay The Myth of Sisyphus with the famous line "There is but one truly serious philosophical problem and that is suicide" (French: Il n'y a qu'un problème philosophique vraiment sérieux : c'est le suicide).

Philosophical stances on suicide can be divided into two broad groups. Religious philosophy almost universally condemns suicide, while nonreligious stances tend towards toleration, with some seeing it as laudatory, depending on circumstance. Utilitarianism offers perhaps a confusing stance. For example, using Jeremy Bentham's hedonistic calculus, you may conclude that although suicide offers utility by ending personal suffering, the grief it causes others may outweigh its utility. The calculation cannot be determined at a philosophical level.

Arguments against suicide

Common philosophical opinion of suicide since modernization reflected a spread in cultural beliefs of western societies that suicide is immoral and unethical. One popular argument is that many of the reasons for committing suicide—such as depression, emotional pain, or economic hardship—are transitory and can be ameliorated by therapy and through making changes to some aspects of one's life. A common adage in the discourse surrounding suicide prevention sums up this view: "Suicide is a permanent solution to a temporary problem." However, the argument against this is that while emotional pain may seem transitory to most people, in other cases it may be extremely difficult or even impossible to resolve, even through counseling or lifestyle change, depending upon the severity of the affliction and the person's ability to cope with their pain. Examples of this are incurable disease or lifelong mental illness.

Absurdism

Camus saw the goal of absurdism in establishing whether suicide is a necessary response to a world which appears to be mute both on the question of God's existence (and thus what such an existence might answer) and for our search for meaning and purpose in the world. For Camus, suicide was the rejection of freedom. He thought that fleeing from the absurdity of reality into illusions, religion, or death is not the way out. Instead of fleeing the absurd meaninglessness of life, we should embrace life passionately.

Existentialist Sartre describes the position of Meursault, the protagonist of Camus' The Stranger who is condemned to death, in the following way:

The absurd man will not commit suicide; he wants to live, without relinquishing any of his certainty, without a future, without hope, without illusions ... and without resignation either. He stares at death with passionate attention and this fascination liberates him. He experiences the "divine irresponsibility" of the condemned man.

Christian-inspired philosophy

See also: Christian views on suicide

Christian theology almost universally condemns suicide as being a crime against God. G. K. Chesterton calls suicide "the ultimate and absolute evil, the refusal to take an interest in existence". He argues that a person who kills himself, as far as he is concerned, destroys the entire world (apparently exactly repeating Maimonides' view).

Liberalism

John Stuart Mill argued, in his influential essay "On Liberty", that since the sine qua non of liberty is the power of the individual to make choices, any choice that one might make that would deprive one of the ability to make further choices should be prevented. Thus, for Mill, selling oneself into slavery should be prevented in order to avoid precluding the ability to make further choices. Concerning these matters, Mill writes in "On Liberty":

"Not only persons are not held to engagements which violate the rights of third parties, but it is sometimes considered a sufficient reason for releasing them from an engagement, that it is injurious to themselves. In this and most other civilized countries, for example, an engagement by which a person should sell himself, or allow himself to be sold, as a slave, would be null and void; neither enforced by law nor by opinion. The ground for thus limiting his power of voluntarily disposing of his own lot in life, is apparent, and is very clearly seen in this extreme case. The reason for not interfering, unless for the sake of others, with a person's voluntary acts, is consideration for his liberty. His voluntary choice is evidence that what he so chooses is desirable, or at the least endurable, to him, and his good is on the whole best provided for by allowing him to take his own means of pursuing it. But by selling himself for a slave, he abdicates his liberty; he forgoes any future use of it, beyond that single act. He therefore defeats, in his own case, the very purpose which is the justification of allowing him to dispose of himself. He is no longer free; but is thenceforth in a position which has no longer the presumption in its favour, that would be afforded by his voluntarily remaining in it. The principle of freedom cannot require that he should be free not to be free. It is not freedom, to be allowed to alienate his freedom".

It could be argued that suicide prevents further choices in the same way slavery does. However, it can also be argued that there are significant differences in not having any further involvement in decisions about your life and not having any further life to make decisions about. Suicide essentially removes the condition of being alive, not the condition of making choices about your life.

Mill believes the individual to be the best guardian of their own interests. He uses the example of a man about to cross a broken bridge: we can forcibly stop that person and warn him of the danger, but ultimately should not prevent him from crossing the bridge—for only he knows the worth of his life balanced against the danger of crossing the bridge.

Too much should not be read into "disposing of his own lot in life" in the passage as this is not necessarily talking about anything other than slavery. Indeed, it would be odd if Mill had intended it to be about suicide but not explored the issue fully.

Deontology

From a deontological perspective, Immanuel Kant argues against suicide in Fundamental Principles of The Metaphysic of Morals. In accordance with the second formulation of his categorical imperative, Kant argues that, "He who contemplates suicide should ask himself whether his action can be consistent with the idea of humanity as an end in itself." Kant's theory looks at the act only, and not at its outcomes and consequences, and claims that one is ethically required to consider whether one would be willing to universalise the act: to claim everyone should behave that way. Kant argues that choosing to commit suicide entails considering oneself as a means to an end, which he rejects: a person, he says, must not be used "merely as means, but must in all actions always be considered as an end in himself." Furthermore Kant argues that, since objective morality is grounded in one's own ability to reason, suicide is wrong because it involves removing that ability through ending one's life, thereby creating a kind of practical contradiction.

Social contract

The social contract, according to Jean-Jacques Rousseau, is such that every man has "a right to risk his own life in order to preserve it."

Hobbes and Locke reject the right of individuals to take their own life. Hobbes claims in his Leviathan that natural law forbids every man "to do, that which is destructive of his life, or take away the means of preserving the same." Breaking this natural law is irrational and immoral. Hobbes also states that it is intuitively rational for men to want felicity and to fear death most.

Aristotle

Aristotle in his 'discussion of courage, maintains that committing suicide to avoid pain or other undesirable circumstances is a cowardly act. In a later chapter [of Nichomachean Ethics], he further argues that suicide is unlawful and is an act committed against the interests of the state.'

Neutral and situational stances

Honor

Japan has a form of suicide called seppuku, which is considered an honorable way to redeem oneself for transgressions or personal defeats. It was widely accepted in the days of the Samurai and even before that. It was generally seen as a privilege granted only to the samurai class; civilian criminals would thus not have this 'honor' and be executed. In this historical perspective, suicide reflects a cultural view of suicide as noble, acceptable, and even brave, rather than cowardly and wrong.

Utilitarianism

Utilitarianism can be used as a justification for or as an argument against suicide. For example, through Jeremy Bentham's hedonistic calculus, it can be concluded that although the death of a depressed person ends their suffering, the person's family and friends may grieve as well, and their pain may outweigh the release of depression of the individual through suicide.

Arguments that suicide is permissible

There are arguments in favor of allowing an individual to choose between life and death by suicide. Those in favor of suicide as a personal choice reject the thought that suicide is always or usually irrational, but is instead a solution to real problems; a line of last resort that can legitimately be taken when the alternative is considered worse. They believe that no being should be made to suffer unnecessarily, and suicide provides an escape from suffering.

Idealism

See also: Idealism

Herodotus wrote: "When life is so burdensome, death has become for man a sought-after refuge". Schopenhauer affirmed: "They tell us that suicide is the greatest act of cowardice... that suicide is wrong; when it is quite obvious that there is nothing in the world to which every man has a more unassailable title than to his own life and person."

Schopenhauer's main work, The World as Will and Representation, occasionally uses the act in its examples. He denied that suicide was immoral and saw it as one's right to take one's life. In an allegory, he compared ending one's life, when subject to great suffering, to waking up from sleep when experiencing a terrible nightmare. However, most suicides were seen as an act of the will, as it takes place when one denies life's pains, and is thus different from ascetic renunciation of the will, which denies life's pleasures.

According to Schopenhauer, moral freedom—the highest ethical aim—is to be obtained only by a denial of the will to live. Far from being a denial, suicide is an emphatic assertion of this will. For it is in fleeing from the pleasures, not from the sufferings of life, that this denial consists. When a man destroys his existence as an individual, he is not by any means destroying his will to live. On the contrary, he would like to live if he could do so with satisfaction to himself; if he could assert his will against the power of circumstance; but circumstance is too strong for him.

Schopenhauer also addressed arguments against suicide. "That a man who no longer wishes to live for himself must go on living merely as a machine for others to use is an extravagant demand."

Libertarianism

Libertarianism asserts that a person's life belongs only to them, and no other person has the right to force their own ideals that life must be lived. Rather, only the individual involved can make such a decision, and whatever decision they make should be respected.

Philosopher and psychiatrist Thomas Szasz goes further, arguing that suicide is the most basic right of all. If freedom is self-ownership—ownership over one's own life and body—then the right to end that life is the most basic of all. If others can force you to live, you do not own yourself and belong to them.

Jean Améry, in his book On Suicide: a Discourse on Voluntary Death (originally published in German in 1976), provides a moving insight into the suicidal mind. He argues forcefully and almost romantically that suicide represents the ultimate freedom of humanity, justifying the act with phrases such as "we only arrive at ourselves in a freely chosen death" and lamenting "ridiculously everyday life and its alienation". Améry killed himself in 1978.

Philosophical thinking in the 19th and 20th century has led, in some cases, beyond thinking in terms of pro-choice, to the point that suicide is no longer a last resort, or even something that one must justify, but something that one must justify not doing. Many forms of existentialist thinking essentially begin with the premise that life is objectively meaningless, and proceed to the question of why one should not just kill oneself; they then answer this question by suggesting that the individual has the power to give personal meaning to life.

Stoicism

Although George Lyman Kittredge states that "the Stoics held that suicide is cowardly and wrong," the most famous stoics—Seneca the Younger, Epictetus, and Marcus Aurelius—maintain that death by one's own hand is always an option and frequently more honorable than a life of protracted misery.

The Stoics accepted that suicide was permissible for the wise person in circumstances that might prevent them from living a virtuous life. Plutarch held that accepting life under tyranny would have compromised Cato's self-consistency (Latin: constantia) as a Stoic and impaired his freedom to make the honorable moral choices. Suicide could be justified if one fell victim to severe pain or disease, but otherwise suicide would usually be seen as a rejection of one's social duty.

Confucianism

See also: Suicide in China

Confucianism holds that failure to follow certain values is worse than death; hence, suicide can be morally permissible, and even praiseworthy, if it is done for the sake of those values. The Confucian emphasis on loyalty, self-sacrifice, and honour has tended to encourage altruistic suicide. Confucius wrote, "For gentlemen of purpose and men of ren while it is inconceivable that they should seek to stay alive at the expense of ren, it may happen that they have to accept death in order to have ren accomplished." Mencius wrote:

Fish is what I want; bear's palm is also what I want. If I cannot have both, I would rather take bear's palm than fish. Life is what I want; yi is also what I want. If I cannot have both, I would rather take yi than life. On the one hand, though life is what I want, there is something I want more than life. That is why I do not cling to life at all cost. On the other hand, though death is what I loathe, there is something I loathe more than death. That is why there are dangers I do not avoid ... Yet there are ways of remaining alive and ways of avoiding death to which a person will not resort. In other words, there are things a person wants more than life and there are also things he or she loathes more than death.

Other arguments

David Hume wrote an essay entitled Of Suicide in 1755 (although it was not published until the year after his death, in 1777). Most of it is concerned with the claim that suicide is an affront to God. Hume argues that suicide is no more a rebellion against God than is saving the life of someone who would otherwise die, or changing the position of anything in one's surroundings. He spends much less time dismissing arguments that it is an affront to one's duty to others or to oneself. Hume claims that suicide can be compared to retiring from society and becoming a total recluse, which is not normally considered to be immoral. As for duty to self, Hume takes it to be obvious that there can be times when suicide is desirable, though he also thinks it ridiculous that anyone would consider suicide unless they first considered every other option.

Those who support the right to die argue that suicide is acceptable under certain circumstances, such as incurable disease and old age. The idea is that although life is, in general, good, people who face irreversible suffering should not be forced to continue suffering.

Leo Tolstoy wrote in his short work A Confession that after an existential crisis, he considered various options and determined that suicide would be the most logically consistent response in a world where God does not exist. However, he then decided to look less at logic and more towards trying to explain God using a mystical approach in that, for one, he describes God as life. He states that this new understanding of God would allow him to live meaningfully.

Leonard Peikoff states in his book Objectivism: The Philosophy of Ayn Rand:

Suicide is justified when man's life, owing to circumstances outside of a person's control, is no longer possible; an example might be a person with a painful terminal illness, or a prisoner in a concentration camp who sees no chance of escape. In cases such as these, suicide is not necessarily a philosophic rejection of life or of reality. On the contrary, it may very well be their tragic reaffirmation. Self-destruction in such contexts may amount to the tortured cry: "Man's life means so much to me that I will not settle for anything less. I will not accept a living death as a substitute."

Bioethicist Jacob Appel has criticized "arbitrary" ethical systems that allow patients to refuse care when they are physically ill, while denying the mentally ill the right to suicide.