Hi Max, I've been rereading this since you posted it and puzzling it out. My impression is that the "he" in the poem is contemplating suicide, but with the knowledge that it's something he won't ever do. That seems pretty clear. I personally don't see this as being about non-suicidal self-harm. It also seems to me (though I could be mistaken) that he is struggling with guilt or remorse for something he's done (hence "the hurt he's done" and his "unclean reflection"), and that that may have prompted his thoughts about suicide.
Some questions I have - is he actually a surgeon, possibly even performing surgery in the OR as this is going through his mind? What is the "smudge" mirrored in the blade - his face?
I agree with Joe that the concept of a world in which continuing to exist is the choice, rather than the default, is a powerful one.
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