“No matter how profoundly we delve into the human spirit, we never find an isolated being but only relationships with others.”

(Tzvetan Todorov, 2001)

Introduction

Public and scholarly discussion of assisted suicide usually focuses on the ethical legitimacy and legal regulation of the assistance. Ethical and legal assessments start from the assumption of a defined act, which is normatively judged as such in relation to the person wanting to commit suicide and his or her helper. As is well known, the legal aspects are treated differently in the jurisdictions of different countries: in Canada, Belgium and the Netherlands, for example, they are handled very differently than in Switzerland or Germany. The ethical issues are always hotly disputed. The dominant liberal positions, which favour the interests of free and independent individuals and take a generally permissive view of assisted suicide, are confronted with reservations that, through a wide variety of arguments, regarding a person’s life as sacrosanct and the highest good to which one’s own will, with its limited freedom, is subordinate.

These questions and differences are not discussed in what follows. The ethical relevance of this article lies in the fact that good moral decisions need to know what really happens. With this principle in mind, it examines the actual encounter between people wanting to commit suicide and potential helpers. In contrast to the widely disseminated literature, it focuses on suicide assistance as a relational process and is therefore distinctive. From a phenomenological perspective, it aims to illuminate the social–anthropological foundation of the relationship and the experience on the basis of which an assisted suicide really takes place with the help of another person—or does not take place, because the relationship also offers the person wanting to commit suicide the possibility of refraining from this act.

Our starting point for taking a closer look at the mechanics and potential of the special relationship between the person wanting to commit suicide and the assistant is clinical experience and evidence of the volatility of suicidal volition. However, since a certain constancy is raised as proof that suicide is voluntary (in Germany: Bundesärztekammer German Medical Association, 2021a), the assumption of actual voluntariness is shaken by possible exogenous or endogenous fluctuations in disposition, which is a factor in decision-making. The same freedom that makes the decision to commit suicide possible also makes it possible to refrain from doing so. One suicide is committed for every ten attempted suicides, and around 80% of people have suicidal thoughts at some point. Suicidal tendencies are thus associated with volatility. Hence, most people who have survived what was supposed to be a final suicidal act—say, because the rope broke or they survived a fall from a great height—refrain from repeating the attempt both right away and in the next 6 to 35 months (Christiansen and Jensen, 2007; Azcárate-Jiménez et al. 2019; van Aalst et al. 1992). From a clinical perspective, one cannot but agree with the succinct comment in Attia et al. that the desire to bring about one’s own death fluctuates (Attia et al. 2020). Accordingly, the constancy of the desire or intention to commit suicide is fragile, even if it is possible to try again and certain risk factors for doing so have been identified (Liu et al. 2017).

Since a planned suicide, like other decisions, is subject to a process of deliberation and thus to a certain elasticity, suicide assistance, which is performed by people, cannot simply be a rigid instrumental action; it is a part of this fragile situation and a part of its development. Freedom of will (Bieri, 2003) can meaningfully only be a conditional freedom, and it means a determination of the will with the help of one’s own deliberations and those of others that are made one’s own. Freedom of the will does not exist in an abstract space but rather, like every human cognitive function, is bound to a physical body, through which it is subject to natural, modulating influences. This can be seen, for instance, in the voluntary decisions of depressed people, which are completely different from those made by the same people when they are in a manic state. Regulation of the will through deliberation is thus also dependent on mood and, at the same time, on interactional influences on the considerations and motives that determine it. This has enormous relevance for the will regulation of people wanting to commit suicide and for those who are involved in a suicidal act as suicide helpers. Hence, in terms of interaction, conversation (Gespräch)—namely in the sense of the hermeneutic philosophy of Hans-Georg Gadamer (1900–2002)—as a mediator between the Other and the Self is of particular interest for the social action of (pre-)suicide assistance (Gadamer, 1975). The discussion that follows is guided by Gadamer’s dialogical approach, but also by interpretive-psychological (Jaspers, 1973a, 1973b), medical-ethical and social-anthropological approaches.

These preliminary remarks should not, however, give rise to any doubt that, for the authors, the legitimacy of the decision to end one’s own life is beyond question. Rather, our reflections suggest that its legitimacy should not be confused with normativity. In the critical situation of the “last relationship”, suicide prevention and suicide assistance constitute a kind of see-saw whose final movement is uncertain. On the other hand, what we regard as normatively desirable is a medical and social prioritization of scientifically based suicide prevention.

The person wanting to commit suicide and the other

In order for it to be carried out, every internally formed decision to commit suicide requires a chain of coherent and consistent actions with regard to one’s own (physical) body and the (in principle resistant) external material world. The German philosopher Arthur Schopenhauer (1788–1860) speaks of the “last resistance of the destruction of the body” (Schopenhauer, 1977). A rope, for example, must be sufficiently thick, sturdily bound and sure not to rip in order to be able to bring about this destruction of the body by way of fatal structural injuries. Hence, the decision to act must correspond to a competence to act that includes a minimum level of physical knowledge and technical ability. It is not an art, but it requires a certain practical capacity that someone committing suicide ultimately cannot do without. This also applies to less violent, but likewise suicidal manoeuvres (Medieval Latin manuopera = manual work), like, for example, the manual administration of a lethal substance via the mouth. This is where the idea of assistance comes in: if killing oneself is (also) a practical ability that is not available at the moment of need, then the question of suicide assistance as a service makes sense under the circumstances, and it is legitimate, from a legal point of view: suicide assistance, like suicide itself, is not prohibited (in Germany, most recently: BVerfG, Judgment of the Second Senate of 26 February 2020). So far, so good.

But with suicide assistance, a second person now comes into play who is philosophically addressed as “the Other”. (The theoretical possibility of assistance by a robot is bracketed here because the robot would only be a form of useful technical assistance for the person wanting to commit suicide and the latter him- or herself would be the sole moral subject of the action, as is the case with “classical suicide”. The “Sarco-Pod”, which was recently developed by the Australian euthanasia activist Philip Nitschke, is also just a new variant on the purely assistive devices that people committing suicide can use on their own.) The situational change brought about by the appearance of another person can be concretely exemplified by a severely paraplegic patient’s request that one of the authors drive him, in exchange for a large sum of money, to the bank of a local river, where he wanted to then steer his own electric wheelchair into the water in order to commit suicide. In the course of sympathetic dialogue with “the Other”, however, this request was ultimately withdrawn. In the following text, this situational change will be looked at in general, taking into account the subtleties of intersubjective communication. Regardless of the role in which the Other appears—as a layperson or as a doctor, as a member of other medical professions (caregiver, social worker), as a hospital chaplain or, finally, as a (quasi-)professional suicide enabler—the entry of the Other (cf. Reuster, 2001) is a key step in the process that leads to the completed assisted suicide. The Other is the missing link in the sequence of actions taken by people who need help to commit suicide, and he or she is a necessary instrument in their plan of action; however, this only is the case in purely practical terms. That is because, as human beings, suicide helpers are always more than instruments (even if they offer their services as such, as in the case of commercial suicide helpers). They are quite obviously always (also and above all) subjects with the same claim to freedom of choice and action as the person wanting to commit suicide.

Phenomenological aspects of the concrete situation of the encounter

People who provide practical support in suicide can be distinguished according to their typical roles. The roles modify the situation in which the suicide assistance is discussed, and they make it more or less likely that people wanting to commit suicide will successfully realize their intentions, however, neither the roles nor the different international regulations change the fact that the interaction is always inevitably an encounter between two people who enter into a dialogue. The “encounter principle” applies to all concrete scenarios. The following are the most likely:

Scenario one, involving commercial suicide helpers who are not medical professionals. They work on request and are willing, although not obliged, to assist someone wanting to commit suicide in his or her final acts, for instance by procuring or administering the lethal poison or drugs. The corresponding procedure is similar and managed in the same way by every assisted suicide organization (there are currently three such associations active in Germany). It usually involves a prior visit from a doctor and, if necessary, the prescription and dosage of pharmaceuticals. During the visit, the voluntary nature, capacity for judgment, proper deliberation and consistency of the wish to die have to be assessed in particular. It has to be discernible that the person wanting to commit suicide remains in control and will ultimately perform their very last act themselves (drinking, or at least swallowing, the lethal potion). Support from such organizations is subject to payment (e.g., DGHS e.V., 2023).

Scenario two, involving volunteer helpers from the institutional healthcare sphere. This primarily means nurses, social workers, hospital chaplains and doctors. They are taken into confidence and asked. There is no assurance that they will decide in favour of suicide assistance, but it is possible. Interestingly, hospital chaplains in Germany have declared their willingness to actively support people wanting to commit suicide (FAZ, 2021). Doctors play a special role in the discussion and the performance, since it is assumed that they have greater knowledge about the effects of medication and more experience with people who are dying. On the other hand, the objection has been raised that doctors serve life and, in terms of the ethics of their profession, see themselves as providing support during natural death, but not as assisting in suicide. In some countries, such as Belgium, Luxembourg and the Netherlands, they are the only group authorized to provide assistance in dying; in Canada, they are joined by other qualified medical staff.

Scenario 3, involving family members/relatives and personal friends: in addition to the two aforementioned groups, this group is legally authorised in some countries to provide assistance in the event of a freely chosen suicide. In Sweden, this is in fact the only group that is authorised to do so (DGHS e.V., 2024). But that is beside the point here. For the purpose of our discussion, this group is the most interesting, from an interactional point of view, because the shared situation for the person wanting to commit suicide and the suicide enabler is particularly open, unregulated and not predetermined by professional roles. (On the concept of roles in medicine, see Siegrist, 1988; Reibling, 2021). This is somewhat less the case for group two and least of all for group one, in which there is largely a mercantile seller–client relationship that is determined by the roles of both parties and thus allows us to assume that the jointly intended goal is only not achieved in exceptional cases. (This assumption is confirmed by an anonymous suicide enabler [Freitag, 2023]).

Clearly, the encounter between someone wanting to commit suicide and the suicide enabler will take different forms depending on these types. (To date, no empirical investigation into their respective interactional dynamics has yet been carried out.) However, there is a discernible common framework of understanding. First of all, there is the topic of death and only the death of one of the parties. As such, however, it is at the same time a death that contrasts with the life of the Other. The survivor has the advantage of existence over the party who will soon be dead—and this is precisely what automatically constitutes the highly significant and empirically perceptible difference in his or her favour: the enabler remains alive. Hidden behind this trivial observation is an experience that archaically reinforces self-awareness, and needs to be acknowledged as contributing to the dynamics of the situation. But unlike in the case of the natural death of a relative, the survivor has to deal with the peculiarity that the death is not a matter of fate or the unthinking power of nature, nor is it unwanted, but rather of a person who actively wants to put an end to his or her life at the present time—and is only prevented from doing so by physical frailties. Carrying out the suicide requires the support of the Other, the survivor without whom death cannot be brought about—or at least not now. Hence, the person wanting to commit suicide no longer primarily focuses on the suicide, but first on the by no means simple intermediate goal: finding a suitable enabler. This is an expression—and this is also part of the aforementioned framework of understanding—of the need for help, which testifies to the existing loss of autonomy. In Alejandro Amenábar’s well-known film The Sea Inside (Mar adentro, 2004), which is based on a real and indeed highly realistic case, this aspect of the conflicts faced by relatives who are asked for assistance is shown in an exemplary way. Manuela, the sister-in-law who is caring for the paralysed and suicidal Ramón, seems torn, while his brother José categorically rejects euthanasia from the outset. Ramón does not speak to his father about his wish, and his nephew Javier is tortured by the situation, which he tries passively to endure. Ultimately, a lawyer who is not part of the family and who becomes the protagonist’s confidante is willing to provide suicide assistance.

However, a suicide enabler is not only an assistant but more precisely a death facilitator, given the loss of autonomy of the person wanting to commit suicide. On the other hand, the role that has been designated for the helper is merely to be an instrument that, for example, brings over a drug and a glass of water and lifts them up to the mouth of the person committing suicide. In communicating with that person, the assistant is able not only to categorically affirm or reject his or her role, but also shape it. Just like the person committing suicide, the suicide enabler is a free (autonomous) subject and he or she must act as such. The helper is not a robot. As a free subject, the assistant must never be defined “merely as a means”, as Immanuel Kant (1724–1804) wrote, “but always as an end in itself” (Kant, 1997, p 38). “End in itself” means that the end (Greek télos) is not posited by others, but is posited a priori via the corresponding human faculty to determine one’s own actions. Kant calls this dignity (Kant, 1997, pp 42ff). The freedom of the suicide enabler and that of the person wanting to commit suicide are of equal rank. Thus, what could be called a dramatic decision-making situation coalesces when the free Other enters into the events. What is now the common cause of the free interlocutors can turn out differently, one way or another, depending on their interaction, even though the “actual” goal of the action already seems to be established.

A concept from classical drama theory proves fruitful here: peripeteia. Peripeteia refers to the shift to either a happy or an unhappy outcome of the drama once the protagonists’ conflict has matured to the point where a decision can be reached (Aristoteles, 1982). Only the peripeteia brings the decision about. It does not bring it about like a predictable function, but rather it is the suspenseful situation out of which the decision emerges. The situation can be described as a free, but context- and goal-dependent, communicative action, i.e., as a mixture of thoughts, feelings and intentions, but also of individual changes of intent by way of the Socratic back and forth of arguments and messages, through which the respective protagonists understand, misunderstand, interpret, reinterpret, are made unsure or become sure and are continuously reacting meaningfully to the statements of the other protagonist. It is a tense, unpredictable hermeneutic process that makes its goal and outcome appear understandable, but not compulsory or predetermined (Gadamer, 1975, p 361). Conceptually, there is room for surprises. In terms of planned suicide, this can even mean a moratorium, for example, or an alternative form of suicide, such as voluntary stopping eating and drinking, or even a complete renunciation of the suicidal act. The convergence of this phenomenological analysis and the results and conclusions of social scientific research is interesting. Thus, Minson and Chen (2022) empirically concluded that there are many factors at work in the moment of communicative exchange, first and foremost the conduct of the interlocutor. However, they argue that it is, above all, “the power of the situation” that guides the course of events, rather than the characteristics of the individuals. If we replace “situation” here with the Gadamerian concept of “conversation”, it then becomes clearer what this power consists in, namely the inherent dynamics and logic of a conversation that carries the interlocutors along with it (Gadamer, 2000; see below).

The suicide assistant and the person wanting to commit suicide: Not all motives are conscious

Let us take a closer look at the dyad comprising the suicide assistant and the person wanting to commit suicide: Although the action can initially be regarded as purposively rational (Weber, 2003, p 33), this only applies if the assistance is in fact professional assistance, complies with regulations and is not called into question by the suicide enabler, who usually works for pay. In this case, whoever orders suicide assistance receives it. And it is only in this case that we can speak of suicide assistance services in a narrow sense. The roles are fixed to the greatest possible extent and the result is mostly predictable. In contrast to professional suicide assistance, however, a family member, acquaintance, friend or (family) doctor is precisely not predestined to provide suicide assistance on the basis of their specific role; doctors, like relatives or friends, are generally interested in the existence of the Other. Hence, when suddenly faced with the decision whether to help someone commit suicide, they are not at all prepared for this function. Their roles are calibrated to preserving life and hence a contrary decision solely depends on their spontaneous personal freedom and associated responsibility (whereby doctors must respect the applicable professional code of conduct [in Germany, Bundesärztekammmer German Medical Association, 2021b] and, at least in principle, their position as guarantor in relation to patients). When it comes to singular suicide assistance, their communication is not purposively rationally performed but rather unfolds spontaneously and in a familiar way along known communication channels (Pörksen and Schulz von Thun, 2014).

However, the interaction in question has a general premise: two human beings are interacting. They are, as Georg Wilhelm Friedrich Hegel (1770–1831) argued, self-conscious and free beings who relate to each other on the basis of mutual recognition (Hegel, 1988, p 113ff). This presupposition has had to be supplemented by unconscious motives and drives since the unconscious was systematically investigated in the twentieth century. When we feel free in our decisions, the feeling of freedom correlates with our conscious motives, which we consider to be reasons for action. But we are not aware of all the relevant motives and motivations for our actions. Some of them come from our unconscious “dark self”, with its archaic, mostly repressed impulses, which classical psychoanalytical authors such as Anna Freud (1984) or D.W. Winnicott (1984) have already worked on and which literature and art also often discuss, such as the film A Dangerous Method (Cronenberg, 2011).

In contrast to the psychodynamic-psychoanalytical perspective, modern models of volition emphasize the hierarchical structure of the volitional willingness to act. In order for this willingness to be strong, the goal and the intention must be clear before implementation, such as the procurement of a lethal drug or its administration. In light of the dynamics of the situation, concomitant influences and the possibility of controlling them are also to be taken into consideration: mood, nervousness, fear, doubt, discipline, physical strength and others (Goschke, 2016). In the end, it comes down to a will that either overcomes resistance or succumbs to it (Pelz, 2017; Lewin, 1926; Allport et al. 1994). From a psychodynamic perspective, pure volitional models are optimistic about controlling internal and external positive or negative stimuli. But motives that are not conscious cannot be controlled either; they simply take effect and contribute to the dynamics of the situation. (With respect to perpetrators in court, we see that they are also unable to say exactly why they committed a particular offence. Hidden and unconscious motives such as chronic frustration, narcissistic wounds, subtle rivalry and sadistic tendencies, and other motivations sometimes only become apparent in an exploratory dialogue with the judge or an expert).

No matter how we conceptually interpret the events, however, both sides are continually involved: on one hand, someone who wants to commit suicide, wants assistance in doing so, but (actually) does not want counselling, and on the other hand, a potential enabler, who—we are looking at non-explicit suicide enablers—is unprepared and probably has to first find a position or a willingness to act. After all, being asked to take part in the suicide of someone who is close to you, or even not so close, or to act as a suicide enabler, is still a rare experience for non-professional assistants and will often be a person’s first and only such experience.

The way in which a person directly reacts to such a situation can be empirically explored, as can the consequences that are subjectively experienced after an assisted suicide (a task not only psychology, but for empirical ethics as well). This is a separate task, which has only been marginally fulfilled to date (Goldberg et al. 2021; Swarte et al. 2003; Gamondi et al. 2018). These sorts of studies have their justification, but the answers to certain questions in public opinion surveys do not dispense with the need for a theoretical analysis of the problem, which must also prove itself in relation to the (possibly) last relationship.

Ipse and alter: A volatile encounter

The entry of the Other and the shift from ipse to alter signify a decisive and indeed drastic change in the suicidal, but usually solipsistic reflections and intentions of someone wanting to commit suicide. In socio-anthropological terms, the situation of the encounter is complex, and it has been thought through by various philosophers. The most radical formulation of a philosophy based on mutual responsibility comes from Emmanuel Levinas (1906–1995). For him, the encounter with the Other, which he conceptualises as strict responsibility for the Other—completely independently of the Other’s will and also one’s own—is prior to all reflection on the being in an ontological sense. This responsibility, which is necessarily and inevitably invoked by the countenance of the Other, is a philosophical axiom for Levinas, so to speak, and it is only subsequent to it that other questions about the world can be considered. Writing in the aftermath of two world wars and the moral catastrophe of the Holocaust, Levinas links this responsibility to the absolute protection of physical life and the dignity of the Other. He thus also understands the gaze of the Other as a concrete claim: “You will not leave me alone, you will not exploit me, you will not kill me.” The countenance of the Other “expresses the ethical impossibility of my destroying him” (Levinas, 1991). Levinas’ position is as clear as it is provocative, but it cannot be further elaborated here, which also applies for the following, more narrowly phenomenological philosophies of alterity, such as Jean-Paul Sartre’s (1905–1980) analysis of the gaze in Being and Nothingness (1984) or the subtle philosophical investigation The Other by the German philosopher Michael Theunissen (1984). These are outstanding references for descriptions of the complex changes that pre-reflexively arise between “self” (ipse) and other (alter) through the appearance of the Other. In short, we can note that the appearance of the Other necessarily gives rise to a relationship, which not only instantly changes the external situation, but also the state of consciousness and mood, the basic psychological and moral position of those involved – and this is the case even before “anything happens” at all in this relationship. Within the relationship, the experiential space is fundamentally open. With the Other, the situation can change in any way and at any moment. The given Other can become a wolf as well as an angel to the Self, an enemy or a friend, destroyer or supporter. Together, one can achieve more, but also less. Which possibilities are realized depends on many factors, including irrational and dispositional ones, i.e., personality traits and effects. What is most important, however, is the change in the situation that is brought about by coming to an understanding via language as a means of communication. By means of language and its implicit rules and values, the two parties can understand one another, but also misunderstand one another; they can correct, criticize, reinforce or confuse each other. In short, they can do things with words (speech acts), i.e., interact dynamically. In everyday social interaction, there tends to be an effort to mollify others and to find a common ground of acceptance, cooperation or at least neutrality with them, or not to lose this common ground. Rules of politeness serve to promote mutual indulgence and recognition and to curb aggression (cf. Reuster, 2001). But what is important for our topic is the volatility of dyadic communication. What situation will develop and take shape in verbal communication is not predetermined, even if the occasion, intention and goal are known. Since Homer (ca. eighth century BC), doing things with words has meant, on the one hand, knowing about the effect of words (Krapinger, 2007) i.e., being able to pursue goals and achieve them using suitable rhetorical strategies. But it also means responding quickly to a new dialogical situation (a statement or a question, for example)—and doing so reciprocally. There is creative potential here, which can be used in very different ways, depending on the presence of mind, knowledge and intentions, and can give the conversation a new and surprising direction. “Lightning steers everything”, the pre-Socratic philosopher Heraclitus is supposed to have said (Heraklit, 1986). We can say more precisely the flash of inspiration. According to Gadamer’s hermeneutic understanding, volatility corresponds to the openness of genuine conversation, which is not only conducted between two people but, as mentioned, develops its own dynamic and carries the interlocutors along with it. The dialogue itself leads and changes both of them, so that, for example, the insight arises that the Other could be right (cf. Gadamer, 1975, p 360; 2000). Every psychotherapist who works verbally is familiar with such situations (in an exemplary manner). Patients then typically say: I am different when I come out of the therapy session, i.e., I have a new perspective on old problems (Lang, 2000).

A matter of dying and death

Moreover, if we start from the assumption of unconscious motives and impulses and take into account the momentous and dramatic situation of organising a person’s death, the existential scope of which can hardly be overstated, then it becomes clear that the situation is challenging in the best sense, but also “decisive” in the sense that it forces the suicide assistant to make a drastic decision. With a drastic and significant decision, we not only assume special responsibility for something or someone or before an authority, but we also take responsibility for the action before ourselves or, more precisely, before that inner authority that is usually referred to as a “conscience”. The existential philosopher Karl Jaspers (1883–1969) calls such situations limit experiences. For Jaspers, death, struggle, suffering, and guilt are limit situations with imminent death being the most extreme experience. “What remains essential in the face of death is done in existence, what lapses is mere Dasein” (Jaspers, 1973b). For Jaspers, Dasein is ultimately purely biological existence, plus affect; existence, on the other hand, is what the human being ultimately can be, something that goes beyond Dasein. (In Jaspers, existence is not based on Dasein, or purely biological existence, but rather on transcendence.) But without going more deeply into Jaspers or other philosophical authorities here, we can say that, for the suicide enabler, it is obviously a matter of the experience of death, but not the enabler’s own death, rather that of the Other, whose voluntary death is only made possible by the enabler’s actions. The assisted death of someone wanting to die is self-determined both according to the law and from a normative-moral point of view (if the criteria for free self-determination are met); however, it cannot be accomplished by the person’s own actions, but rather only with assistance. The freedom of a person wanting to commit suicide thus comes up against a limit: he or she is forced to rely on someone else, which appreciably restricts their freedom. In the case of people who are disposed to autonomous activity, this could even lead them to refrain from asking for help in order to avoid this dependency. Of course, it is not only a matter of limits on their freedom, but also the fact that their request for help confronts the Other with something obviously extraordinary and psychologically challenging, not to mention burdensome and morally problematic. However, this aspect is qualified and trivialised by the common availability, or purchasability, of suicide assistance, just as death and dying are trivialised by it. A “suicide assistance product” seems to settle the debt obligation by paying off the (moral) debt to the suicide assistant with money, thus removing a last barrier to suicide, namely shame, guilt, pride, or reverence. And from the point of view of the study of suicide, this means that the path to suicide is being widened and the path to suicide prevention is being narrowed. There is a danger that suicide prevention will be neglected at a social and political level.

The situation of the suicide helper

In most European countries, the primordial, procedurally less complicated, and seemingly also the most readily available form of suicide assistance is that provided by friends or family, with or without medical expertise. In the aforementioned film The Sea Inside (Mar adentro, Amenábar, 2004), for example, a confidante of the protagonist assumes the role of the suicide enabler. In fact, requesting suicide help from friends and family is plausible and advantageous from an ethical point of view, inasmuch as the latter knows the person wanting to commit suicide well, understand his or her motives and can integrate their involvement with the suicide into a personal and, in the best case scenario, perhaps a loving relationship. However, although friends and family are undoubtedly often involved, it is interesting to note that, among potential suicide enablers, the public focus is placed on doctors. (The Medical Assistance in Dying [MAID] concept, which, as mentioned, is employed in Canada and the Netherlands, for instance, also especially designates doctors as assistants.) It is possible that the general public and those who want to commit suicide would prefer to spare their friends and family. Why? Due to ethical considerations? Or perhaps due to a moral sense (whereby moral senses also have a cognitive content [e.g. Thies, 2009]), such as a feeling of responsibility for the well-being of those friends and family members, which would possibly be affected by helping with the suicide? If this were the case—and resolving this question is still an outstanding goal for empirical-ethical research—then it would also be evidence that the previously mentioned topicality of suicide assistance for the enablers as a limit experience in a limited situation is not exaggerated and would also be expressed in this reluctance on the part of the person wanting to commit suicide. Leaving aside such speculation, however, moral considerations must be generally valid to be moral considerations. From a phenomenological perspective, several reasons can be given for this validity:

  1. 1.

    The request addressed to the Other: As mentioned, in the case of a friend or family member, the person is often unprepared. Given that the potential suicide assistant is close to the person wanting to commit suicide, he or she may not want to disappoint that person and may therefore put their own concerns, conflicts, feelings, fears, etc., aside. A strange power emanates from someone who actually gives up his or her life for the wish to die. The peculiarity of such a decision, the elevated existential and moral character, the authority that smacks of godliness all fundamentally weigh on the decision of a helper and make it hard to resist the request. Confronting the person who wants to commit suicide with a clear refusal requires courage, self-confidence and moral certainty/firmness. But this alone, i.e., the firm refusal (once assumed), is still not enough to dispose of the moral burden on the helper. In this case, the helper will have to live with having impeded a decision on the part of the person wanting to commit suicide that would have been life-ending, but also vitally important.

    Hence, helpers will tend to take it upon themselves to facilitate the suicide of the person urgently requesting their help. But especially for sensitive and morally or religiously scrupulous people, the consequence can be a considerable disturbance of their mental equilibrium. The suicide enabler’s other option, namely providing assistance and helping in the suicide, is of course not a trivial decision in a limited situation either. Responsibility must be taken for it too. It can be linked to feelings of guilt or blame, to varying degrees, and it may ultimately remain an existential burden. Depending on their psychological constitution, an affected person will reflect on it ex post to a greater or lesser degree or even need to obsessively think about it and suffer because of it. In any case, in addition to the obvious loss, they will have to live with the experience and integrate it into their own self-image. (The condition of family caregivers after an assisted suicide not assisted by them is examined in Goldberg et al. 2021).

    It appears that all of this is being left out of the public debate on assisted suicide, which is essentially conducted from the perspective of the autonomous individual who wants to end his or her life. The potential enablers are probably not even aware of it ex-ante either.

  2. 2.

    Some suicide enablers are more psychologically robust than others: We can assume that there are some people who are relatively indifferent about carrying out suicide assistance, at least with regard to possible psychological conflicts. However, assuming empirical confirmation, this should not lead to us to bracket the potential psychological and psycho-moral burdens on the suicide enabler(s). After all, in a medical context, for example, every decision that has consequences for one’s own well-being must be preceded by detailed information and knowledge about the possible outcomes and, where drug safety is concerned, the manufacturer similarly must refer not only to frequent but also the minor and rare adverse effects of a drug in order to comply with its informed consent obligations. The psychological robustness of some suicide enablers is thus not an argument against making drastic requests of Others, and it is certainly not an argument for moral innocuousness.

  3. 3.

    The freedom to say no: The de facto inner freedom of a suicide enabler to say no may not be eliminated in a crisis or conflict situation, however, it is less stable and can therefore be easily manipulated by the person wanting to commit suicide. (On the concept of inner freedom, cf. Reuster, 2022; Wiehl, 2012). A request made in a critical situation can easily be experienced by the addressee as irresistible, but also as interesting and seductive, depending on their personality type (dependency, insecurity, need for affirmation) and their psycho-moral resonance structure. They encounter certain attitudes, attributes and dispositions, such as a feeling of moral obligation or loyalty, fear of committing a crime, sheer obedience to the person making the request or fear of losing his or her love, but also narcissistic hopes of benefiting from the situation. The spectrum of feelings and attitudes triggered in the helper by a request for suicide assistance is broad. They range from latent death wishes and (sometimes erotically tinged) homicidal urges, from hatred and resentment to sympathy (cf. Max Scheler, 2017) to love (cf. mutatis mutandis the film Amour, Haneke, 2012). Wishes and requests influence the decision without that influence always being transparent for the decision-maker (Goschke, 2016). Especially in this special situation, it is all too easy for some people to fulfil them against their own inner resistance, but for others precisely without any inner resistance. We know at least from anecdotal reports that the decision sometimes leads to regrets later on.

That is hardly surprising: what is at issue is the death of a human being and that is no small matter. In the final analysis, one’s own death is the universal and ultimate threat to one’s own conscious existence. It is the absolute and completely autonomous power in our lives. In Greek mythology, this power was personified by Atropos, the oldest of the three fates, and human mortality is a central topos in philosophy. Even before Martin Heidegger’s existential-ontological analysis of death in Being and Time (Heidegger, 1979), the philosopher Wilhelm Dilthey (1833–1911) very aptly noted that “The relation which most deeply and universally determines the feeling of our existence is that of life to death” (Dilthey, 2022). Death makes us shudder; it is universally feared (from a sociological perspective, see Fuchs, 1973). Medicine owes its prestige and social value to death: its task is to keep death at bay for as long as possible. Hence, it is not surprising that most people do not lightly shrug off the proximity of death, even when it is (for time being) the death of others. As clinical psychiatric experience teaches, and as is publicly known (ZEIT ONLINE, 2021), even soldiers often have to be treated for post-traumatic stress disorder because their comrades or civilians have lost their lives in combat before their eyes.

Hence, helpers’ psychological and moral burden should by no means be underestimated. It is astonishing how this is ignored in the public debate on suicide assistance. It would thus appear all the more important to examine not only the motives and voluntary character of the request for assistance by persons wanting to commit suicide but also the interests and motivations of potential suicide helpers. This could conceivably form part of counselling, which should also make clear the risks involved.

Motives for suicide assistance

Suicide assistants need to have a moral position on voluntary death. They are participants and helpers, and they help shape the concrete situation, even if they are not individually irreplaceable from the suicide. Since they categorically are (and have to be) asked about their willingness, the following question is also justified here: What moral right do people wanting to commit suicide have to ask another person for this service of suicide assistance and to put that person in an existentially burdensome situation just by virtue of being asked? The most obvious answer is: They can and do have the right to because they need help. However, the price and the goal of this desire for help is ending their life, and helping people to end their lives has not yet been given a place in society’s canon of values. Individuals are left to their own devices when it comes to the moral positioning of their actions. Yet it is conceivable that it could be included in society’s canon of values, for instance in the form of a “publicly certified suicide enabler”. Such a person would then have a corresponding privilege, comparable to the services provided by midwives or coroners in the past. Privilege here means that others are excluded from this activity: for their own protection, but also to protect those who request suicide assistance. Suicide assistance is not a complex craft like that of the aforementioned midwives: administering a lethal potion does not require any technical training. It is more a question of personal suitability, meaning, at the very least, the absence of a tendency to abuse power or obvious or latent homicidal urges, trustworthiness, and carefulness to ensure third parties are not harmed.

Yet once again, and with respect to the unregulated free market in suicide assistance, we have to ask what motivates people to provide assistance in suicide. We see different complexes of motives:

  1. 1.

    To serve the cause, i.e., the idea of free suicide. A person regards suicide as a manifestation of human freedom and would like to see it realised. The possibility of providing suicide assistance serves this purpose. We can think of the helper as a sort of engaged ideologue, as personified by the controversial psychoanalyst, anarchist and suicide enabler Otto Gross (1877–1920) (Reuster, 2010).

  2. 2.

    Impulses coming from the unconscious parts of the self, the previously mentioned “dark self”: megalomania and delusions of grandeur, the negation of death and a repressed longing for death, compensation for a weak self, a will to power or homicidal urges. Dark motives can also be acted out in helping someone from life to death as if one were Thanatos, the god of death in Greek mythology, especially in a little-regulated field.

  3. 3.

    Helping in a suicide out of compassion. This is a questionable motive. Even if there is such a thing as selfless, genuine compassion, it is well known—especially since Friedrich Nietzsche’s critique of pity (Nietzsche, 1980)—that narcissistic tendencies or a will to power usually play a role in taking pity on someone. The crime of totalitarian euthanasia under German National Socialism, which was also justified in propaganda as a matter of compassion, underscores this point (Payk, 2004).

  4. 4.

    Heightened friendship: The motive of a personal loving relationship in which the suicide enabler wants what is best for the friend could provide the strongest possible contrast to the previously mentioned motive. What is the best? In an extreme situation, a loved one may wish to commit suicide, bring that into the relationship and hope to realize it with the help of the friend. The love of the suicide enabler may then lead to the fulfilment of the loved one’s desire for help in committing suicide. The problem here, as we have already seen, is that only the assistant is left behind and that person has to integrate the deed into his or her biography and self-image.

A systemic view of relationships

Nothing happens without a relationship (Watzlawick et al. 2000). Regardless of what a suicide enabler and a person who wants to commit suicide want from each other, when the latter addresses the former and asks, a relationship comes into being in which communication must take place. This is why even supposed non-communication between the two parties is a sort of answer. For a relationship to exist as such, the mode (wanting, being permitted, being obliged) is irrelevant; it exists regardless. Each of the parties is involved in this relationship. Moreover, if it is also important to both of them, there is a high probability that the suicide enabler will bow to the wishes of the person wanting to commit suicide under the power of the relationship, which, as will be shown, in the one who wants to end his or her life is initially dominant. This is because breaking off the relationship is likely to be more burdensome for the surviving would-be suicide enabler, especially and perhaps precisely when the person who wants to commit suicide has ultimately done so with someone else’s help, not theirs. As we can see, the mere question or request addressed to a potential suicide enabler leads to a trilemma, depending on their previous attitude: if they fail to perform the service, they blame themselves for having let down their friend. If the friend then commits suicide with someone else’s help, they feel humiliated. If they help in the suicide despite their convictions, they have to endure remorse in the form of an inner conflict.

According to this model, no decision outside or in the absence of a relationship seems to exist at all. In any event, it would not be a decision that comes about between two people and for which they are mutually responsible. The general meaning of a relationship has also been philosophically elaborated in particular by Michael Theunissen in his study The Other (1984) and earlier by Martin Buber (philosophy of dialogue), but also by Hans-Georg Gadamer (conversation), Jean-Paul Sartre (the phenomenology of seeing and being seen) and Emmanuel Levinas (philosophy of the Other). For our present considerations, the yield lies above all in the idea that the individual is only constituted in the encounter, the Thou being primary, so to speak, and the I secondary, and is conceived in dialectical dependence on the Thou. The Other is not only an object but also a subject. Each one is exposed to the Other and the effects of the Other, not only passively, but also intentionally and by reacting to the Other’s signals. The subject, as “I”, feels, thinks and acts dynamically and does so within the framework and under the influence of the encounter with the Other, which is itself in constant motion (Theunissen, 1984). The back and forth of a genuine conversation creates leeway in which motives, emotions and intentions can change. It is precisely and ultimately philosophical reflection that makes the inescapable change clear and that sharpens our awareness of the fact that it is here, in the field of the encounter or the relationship, that what is essential is distinguished and that it guides the actions of both of the partners in the interaction.

But leaving aside the philosophical point of view, from a practical point of view, a contradiction appears: doesn’t this conception overestimate the power of conversation and the force of the better argument? A guiding motive for the act of assistance may well be the relationship, but this situation of suicide assistance is more a matter of a relationship of loyalty than the dynamics of a rational conversation. Additionally, of course, the suicide assistant’s prior attitude toward suicide also plays a role. There are two motives (loyalty and engagement) and they can converge or diverge. In the case of divergence, the acute pressure of the situation makes it more difficult not to submit to the authority of the stronger party. But the stronger party is the person who wants to commit suicide because he or she is intent on doing what many have thought about but never dared to do. Because of this determination, interpersonal superiority in the situation initially lies with the person wanting to commit suicide. That person’s second advantage in this situation is that it is they who address the potential suicide enabler and who take the initiative. (Were matters reversed, the interaction would undoubtedly be objectionable, since it would amount to incitement to suicide. Although this is not usually a crime (Pinkepank, 2022), it is ethically highly problematic.) Hence, it seems clear that the potential suicide enabler is in a weaker position from the outset than the person wanting to commit suicide. The latter dominates the situation by way of his or her gravity and authority. This cannot remain without consequences for the dynamics that come into being through and during the interaction. The potential suicide assistant who has entered the dialogical space of the more powerful party will therefore temper his or her claims to equal footing. Nevertheless, the relationship is, in principle, a relationship between two equals, and the autonomous possibilities for action are ultimately not limited, despite this reluctance. The reciprocal relationship of each in the presence of the Other as described above in the context of mutual change is not suspended in a power relationship either, but only qualified and modified. What is important is thinking deeply about the relationship and strengthening it.

Representation and reality

There is a deep gulf between the reality of direct participation in the last suicidal action and the mere demand and/or personal engagement for the right to suicide assistance. This is exemplified by the previously mentioned film The Sea Inside (Amenábar, 2004) and the story on which the film is based, which, not surprisingly, does not correspond at all to the film’s depiction of the harmonious cooperation between the protagonist and the confidante who helps him commit suicide. According to a Wikipedia entry, the confidante was unable to watch the protagonist die after taking the poison and, feeling nauseous, she fled from the scene of his agony into the bathroom and only came out again after his death (Wikipedia, Das Meer in mir). This is plausible from a psychiatric-psychotherapeutic point of view. Accordingly, it is also not surprising that studies show that support for the legalisation of suicide assistance is declining in close correlation with the reification of its acceptance: there is far greater approval for assisted suicide than for “performing suicide assistance oneself” (Vollmann and Herrmann, 2002). This is also easy to understand since the lived encounter with a dying person casts a strange spell. Doctors experience this, for example, when attending people who are dying as they take their final breath. (A palliative care expert reports: ”But these last seconds or minutes are always an exalted time, great and touching. In terms of their intensity, they are only comparable to a birth” (FOCUS online, 2017). No matter how we describe the situation and or what attitude we may have towards it, a limit situation always remains perceptible (Jaspers, 1973a, p 271, 275; 1973b, p 201ff.) But unlike someone who is facing imminent, unavoidable death, a person who wants to die also constitutes a challenging situation for third parties due to contradictory emotional and cognitive aspects. Even when assisted suicide complies with the law, it may very well remain a peculiar experience that weighs on the conscience of the suicide enabler and that the latter, not the deceased, has to bear and may also suffer socially. It would be good if he or she knew about this in advance.

Conclusion (summary)

The prevailing conception of the suicide assistant in the general discussion of assisted suicide treats the assistant as an “instrument” of the person wanting to commit suicide. By shedding light on aspects that have hitherto received too little consideration, we were able to show in the present article that this conception is inadequate and ignores crucial aspects of the encounter between the person wanting to commit suicide and the suicide enabler. The suicide enabler is not a thing, and even less a mere useful instrument. He or she must not be instrumentalised. Just like the person wanting to commit suicide, the suicide enabler is a moral subject and equally responsible for the situation in which the decision in favour of the final acts is taken. Both of them are not only goal-directed agents, but also participants in a relationship and participants in a conversation that guides the situation according to its own dynamics and its own logic. Both are already constituted by their counterpart even in this critical situation by the simple fact of exposing themselves to that person. The act of planned suicide assistance is not predetermined, but rather revised in this possibly final encounter. A withdrawal of the request for assistance by the person wanting to commit suicide is just as possible as a responsible decision by the addressee to provide the final support.