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Archive for December 2008

More Evidence for Rational Suicide

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A letter in the upcoming January 2009 issue of the journal Psychiatric Services (Psychiatr Serv 60:126, January 2009) reports on the relationship between suicide method and past health care contacts. The authors of the letter report that people who commit suicide by charcoal burning (a method of carbon monoxide poisoning gaining popularity in Hong Kong and Taiwan) are significantly less likely to have had mental health care (or hospital visits for any reason) than people who commit suicide by hanging or solid or liquid poisoning. That is, there is an identifiable population of people who commit suicide using relatively painless means that require preparation, and this population is less likely to be mentally or physically ill than people who commit suicide using other means. These results are in line with past studies, and “corroborate findings from Hong Kong that victims [sic] of charcoal-burning suicide were less likely to have pre-existing mental or physical illness,” say the authors [emphasis mine; citations omitted].

The letter displays problematic logic in the interpretation of its findings. In relevant part, the authors say:

Our results support the point previously raised by researchers from Hong Kong that this new method may have attracted individuals who would otherwise not have considered suicide. Acute stress, particularly economic difficulty, rather than mental disorders may be the major precipitating factor of suicide in this suicide subgroup. Population-based prevention strategies to prevent charcoal-burning suicide that might be considered include efforts to destigmatize mental illness to enhance appropriate help-seeking behaviors, restrictions on access to charcoal (for example, by removing charcoal from open shelves and making it necessary for the customer to request it from a shop assistant), and guidance for the media on how to report on suicide events. [Emphasis mine; citations omitted.]

The authors’ perspective is that the availability of the method is what is causing the suicide. But isn’t it the individual’s choosing to commit suicide that is the proximate cause of the suicide? Is the “cause” of suicide the man or the gun?

The authors assume that suicide should not be allowed and that it is right to prevent it. Why should this be? No reason for or defense of this position is given. People committing suicide using the charcoal burning method are not likely to be mentally ill! Why shouldn’t they be allowed to choose to commit suicide in a relatively painless manner? Even forced life advocate Ezekiel Emanuel purportedly favors a “negative right” to suicide for rational people.

In addition, the authors’ proposed solution to the problem of non-mentally ill people committing suicide is: destigmatize mental illness. Huh? My interpretation of the data is that charcoal burning suicides are likely to be rational suicides – not the product of mental illness. How will destigmatizing mental illness help anything here? The authors also, predictably, recommend coercive suicide prevention methods (using the laughable tactic of restricting the sale of charcoal – no picnic barbecue for you if you look sad!) and media censorship.

There is little evidence that “destigmatizing mental illness” will prevent suicides in these cases. And even if coercive suicide prevention does prevent some suicides, they will be the wrong suicides. Take away the right to charcoal burning (not to mention the right to barbiturates), and you force people to choose between committing suicide by violent or ineffective means, or remaining alive in misery. And that is wrong.

Written by Sister Y

December 30, 2008 at 5:26 am

"Philosophical Therapy" and the Poverty of Psychology

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Since there is no God, can life have any meaning?

Given the serious limitations on human happiness that exist, is there still a possibility for a good life?

Does one have a duty to remain alive if one wishes to die? Does one ever have a duty to die?

Can death be rationally desired?

The above are serious questions. Suicidal people – and even non-suicidal people – may have a deep, mature interest in figuring out an answer to these questions. The domain of philosophy takes questions like these seriously, and allows theories and arguments to develop with respect to them.

Good news for philosophers, however: psychology has magically answered all these questions! How? By taking their answers as axiomatic, and treating any dissent against these axioms as evidence of mental illness.

It is difficult to see, however, how a person with mature doubts as to whether life is desirable or meaningful would be helped by a psychologist repeatedly assuring him that life is meaningful and desirable, dammit and that he need only take his medicine to see it. This sort of “proof by table pounding” is laughable in other domains. Why is it permitted in psychology?

A different sort of approach might be more beneficial in the case of the high-functioning depressed patient with serious, genuine doubts as to whether he should go on living: taking his doubts seriously and engaging them in the manner of philosophy, without taking their answer as axiomatic.

Being able to discuss the core questions seriously, without the threat of involuntary hospitalization and without the irritation of smarmy bullshit, may not “cure depression.” But it would have the effect of allowing the client to clarify his thinking, and there is some benefit to that. Being allowed to seriously consider whether suicide is an appropriate option might, in fact, lead many intelligent people to reject this option; psychology and psychiatry never take patients’ philosophical doubts seriously and may not offer this option, even if it would be helpful. In addition, as I have argued, there may be times in which suicide is genuinely in a person’s interest; psychiatry and psychology, which treat suicide as a product of mental illness and seek to prevent it through coercive means, certainly harm such people in such circumstances.

Medicine involves treating diseases with methods shown to be effective in treating those diseases. But what is a disease? A disease is a set of symptoms – and the FDA approves treatments for diseases – clusters of symptoms – not symptoms themselves. Again the question: what is a symptom?

Most symptoms in medicine are easy to recognize: they are painful or cause distress to the patient, and he seeks medical assistance in treating them. Suicidality and feeling that life is meaningless may sometimes be symptoms under this definition: people may distress because they feel suicidal or feel that life is meaningless, and desire medical assistance to change their feelings. I think this is fine. But what about people who feel suicidal, or feel that life is meaningless, but do not feel any distress about this and merely wish to end their lives? Are the “symptoms” still symptoms if they do not cause distress to the patient?

Within the domains of psychology and psychiatry, such questions are dealt with superficially if at all. “Ethics,” to a psychiatrist, is a solved problem, a set of rules one must apply and not question, not a domain of inquiry. Unquestioningly following the “standard of care” with a patient who is thinking about suicide is a ludicrous and disrespectful way to deal with an intelligent human being. Philosophy does better. Medicine needs to do better.

Lou Marinoff is one of the best-known advocates of the practice of philosophical counseling; unfortunately, his work does not seem to be a serious example of the kind of philosophical counseling I am proposing.

Written by Sister Y

December 30, 2008 at 2:57 am

The Drug Prohibition and the Right to Suicide

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Back in 1997, in The Atlantic, Ezekiel Emanuel wrote:

Rational people should be able to end their own lives; suicide should remain decriminalized. But to say that is a far cry from saying that people have a right to have others, namely physicians and pharmacists, help them to end their lives. The ability to commit suicide is what Isaiah Berlin called a “negative liberty” — a liberty to keep others from interfering with the individual. The right to euthanasia is a positive liberty — a liberty to have others help to realize an individual’s goal. The justifications for negative liberties are widely accepted, and the Bill of Rights is essentially a list of negative liberties; positive liberties are affirmed only when necessary to ensure robust participation in public affairs and to preserve essential opportunities. It is hard to see how granting a right to PAS and euthanasia is necessary to either of those goals.

In any case, the number of dying patients who have unremitting pain or who want to die and are physically incapable of killing themselves is very small — a few thousand of the 2.3 million Americans who die each year.

There is a right to suicide, claims Dr. Emanuel – a right not to be interfered with. Of course, in practical terms, Dr. Emanuel is terribly mistaken, even in his conception of the right to suicide as a negative right: the state regularly and predictably interferes with individuals attempting to commit suicide. Pro-forced-life U. S. Supreme Court Justice Antonin Scalia has stated, in his concurring opinion in Cruzan v. Director, Missouri Department of Health, that

It has always been lawful not only for the State, but even for private citizens, to interfere with bodily integrity to prevent a felony. That general rule has of course been applied to suicide. At common law, even a private person’s use of force to prevent suicide was privileged. It is not even reasonable, much less required by the Constitution, to maintain that, although the State has the right to prevent a person from slashing his wrists, it does not have the power to apply physical force to prevent him from doing so, nor the power, should he succeed, to apply, coercively if necessary, medical measures to stop the flow of blood. The state-run hospital, I am certain, is not liable under 42 U.S.C. 1983 for violation of constitutional rights, nor the private hospital liable under general tort law, if, in a State where suicide is unlawful, it pumps out the stomach of a person who has intentionally taken an overdose of barbiturates, despite that person’s wishes to the contrary. [Citations omitted.]

Justice Scalia unfortunately states the policy of our country: it is decidedly one of interfering, using as drastic and invasive means as possible, with an individual’s decision to commit suicide.

Even if we did live in the fairy land that Dr. Emanuel apparently hails from, in which there exists a “negative right” to suicide, there is still the problem of means. Dr. Emanuel says that there is no need for “assisted suicide,” because one can perfectly well off oneself, and one has no right to have another person assist one in the act. However, again Dr. Emanuel ignores the sad reality that all would-be suicides face: the only means to commit suicide that are reliable and comfortable enough so as to not be objectionably cruel are in the exclusive hands of doctors. With barbiturates under the strict control of doctors, the “right to suicide” doesn’t mean much.

As long as there is a drug prohibition, there will be a moral need for “assisted suicide.” Remove the drug prohibition – at least, the prohibition on barbiturates – and there will no longer be a moral need for “assisted suicide,” at least for able-bodied people.

Dr. Emanuel assures us that “the number of dying patients who have unremitting pain or who want to die and are physically incapable of killing themselves is very small.” I wonder what he means by “physically incapable” of killing oneself. Unable (or unwilling) to shoot oneself in the head with a shotgun? To slash one’s artery with a knife? To hang oneself? Is the “right” to do one of these things – and potentially be dragged back to life if one fails to die – really all the “right” that is morally called for?

Like many forced life advocates, Dr. Emanuel offers a comforting vision of an imaginary world, to distract us from having real compassion for suffering people in the real world.

Tragically, Dr. Emanuel is the Chair of the Department of Bioethics at the National Institutes of Health.

Edit: In summary, my problem is this: there is a general drug prohibition on sleeping pills that are lethal at high doses, and there are policy reasons for that, however misguided. In addition, there are good reasons why a person should not have the right to expect another person – here, a doctor – to assist him in committing suicide. But when you put these two sensible-sounding propositions together (drug prohibition and no right to assistance), they no longer make ethical sense. One of them has to give.

Written by Sister Y

December 16, 2008 at 5:07 am

A Response to Suicide.org on the Right to Suicide

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Kevin Caruso, in a piece titled “Don’t I Have the Right to Die by Suicide?” attempts to scare people into calling a suicide hotline on the grounds that there is, in fact, no moral right to commit suicide. (Note that Caruso is the one who says we should use the unnatural phrase “die by suicide” instead of the more natural construction “commit suicide” because the latter is hurtful to the friends and family of people who commit suicide.)

Many of Caruso’s questions are answered more formally in my essay, “The Harms of Suicide.” But I think it is worthwhile to have a single document answering a representative set of (implied) pro-forced-life arguments.

Caruso poses questions (typeset in bold), to which I propose answers (typeset in regular typeface):

Do you have the right to devastate your family?

We often “devastate” our families by exercising our rights. Some “devastate” their families by coming out of the closet, or by refusing to be doctors, or by moving across the country, or by refusing to have children. Where concerns of personal autonomy and suffering outweigh the interests of others in maintaining our company, then we do indeed have the right to “devastate” others.

Do you have the right to cause intense, almost unbearable pain for all of the loved ones that you leave behind?

Everyone dies. Nothing we can do will prevent our own death, nor the suffering our death will cause to those close to us. Suicide merely causes this pain to be experienced earlier.

In fact, the policy of suicide prohibition and prevention – not the act of suicide itself – must be seen as a major cause of the special pain and grief suffered by suicide survivors. (Also, not everyone is lucky enough to have “loved ones.” Are lonely people free to commit suicide, according to Caruso?)

Do you have the right to take away any possibility that you would get better?

Who has the right to decide whether a given treatment is in one’s best interests, or not? With physical illnesses like cancer, the decision rests with the patient as to whether a given treatment is worth the suffering it entails. We have the right to refuse treatment. With good reason – many treatments for suicidality, while possibly effective, are so damaging as to simply not be worth the cost. And, as with cancer, for some people, nothing works.

Do you have the right to take away all of the wonderful things in life that you have yet to experience?

Who but me has a right to decide whether the suffering the rest of my life will entail exceeds the value of the “wonderful things in life” I have yet to experience?

Do you have the right to take an action that is a permanent solution to a temporary problem?

One of the most common mushy-headed objections to suicide is that it is a “permanent solution to a temporary problem.” In reality, for many of us, suffering is an all-too-permanent problem.

Do you have the right to cause irreversible brain damage to yourself if your suicide is not completed?

Damage to oneself as a result of an unsuccessful suicide attempt is entirely an artifact of the suicide prohibition. Given a genuine right to comfortable, reliable suicide, this would simply not occur.

Do you have the right to cause yourself to become disfigured if your suicide is not completed?

See above. And, yes, one has the right to cause oneself to become “disfigured” by body modification. But an unchosen disfigurement caused by a suicide attempt is a sad consequence of the immoral suicide prohibition.

Do you have the right to cause yourself permanent paralysis if your suicide is not completed?

See above. Paralysis and akinetic mutism caused by suicide attempts are tragic consequences of the suicide prohibition, not of suicide.

Do you have the right to end your life instead of focusing on ending your pain? (It is the pain that you want to end, not your life.)

The pain may well be permanent. Caruso naively assumes that a given suicide has not done anything to try to alleviate his pain. But, yes, one has the right to decide when one has done enough to try to alleviate one’s pain, and when the pain appears permanent enough that a permanent solution is indicated. One’s life is one’s own.

Do you have the right to not receive treatment for the mental illness that you probably have — the treatment that will make you better?

Generally, we do have the right to refuse treatment – even potentially life-saving treatment – in the interest of bodily autonomy.

Again, “treatment” for mental illness is not a sure-fire way of relieving the suffering that leads to suicidality. Caruso assures us that treatment “will make you better,” but that is hardly the case for all suffering people. It is unfair and cruel to cheerfully assume that anyone can get better if he just tries the next experimental treatment.

I have written extensively on the mistaken idea that suicide is caused by mental illness. Even Thomas Joiner proposes that suicide is not caused by mental illness on its own, but rather by the alignment of the ability to commit suicide with the desire to commit suicide.

And mental illness causes severe suffering. Don’t the mentally ill, as much as the physically ill, have a right to end their pain?

Written by Sister Y

December 16, 2008 at 1:37 am

She Let The Tumors Eat Her Face

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Note: Steven Ertelt respectfully commented that the original version of this piece misstated his position, and upon reflection, I agree, and have re-written this piece to hopefully come closer to his position and make my objections clearer.

Chantal Sébire committed suicide by taking black market Nembutal in March of 2008. Before that, she had achieved notoriety by (unsuccessfully) petitioning the French president to allow her physician-assisted suicide. She suffered from the disease esthesioneuroblastoma, a disease that caused tumors to deform and destroy her face.

Pro-forced-life blogger Jill Stanek includes a post by Steven Ertelt about Madame Sébire. Back in April of 2008, Ertelt said that Mme. Sébire was properly denied PAS, and that we should limit our sympathy for her, because she refused treatment and voluntarily allowed the tumors to eat her face:

Well, now come to find out she a) refused medical treatment, b) refused offers of surgery to correct the problem and lead a normal life, and c) refused both drugs and palliative care to help her deal with the pain.

Sadly, this woman appeared to have a death wish and appeared more interested in promoting the pro-euthanasia political agenda than genuinely seeking legitimate medical care. . . .

Sebire’s situation was certainly heart-wrenching and she originally deserved all the support in the world, but these new revelations make it tough to consider her anything but a political opportunist. [Emphasis mine.]

A majority of people support a right to suicide for those with an incurable illness. Those with ideologies that favor forcing people to stay alive, no matter what their state, see their position threatened by this trend; indeed, Washington and Montana have recently joined Oregon in allowing so-called assisted suicide for the terminally ill. A great deal of the support for suicide rights for the incurably ill must come from people’s sympathy for the ill and dying – the empathetic response that if one were dying, or in Mme. Sébire’s condition, one would want the right to die, too. Support for a blanket right to suicide is much less common.

Ertelt wishes to challenge the empathetic response to Mme. Sébire, on the grounds that she was not really incurably ill. But I think Mme. Sébire’s case can increase ordinary, non-suicidal people’s empathetic understanding of the plight of healthy people who nonetheless suffer so severely that they wish to die. She wanted to die more than she wanted to live a normal life. Is that not enough to allow her to die?

How much would a person have to be suffering to willingly allow tumors to destroy her face, in the hopes that she could thereby achieve a peaceful death? How many people are there, right now, in this condition – healthy, but suffering so greatly that death is overpoweringly desired? Do we really want to force such people to stay alive?

Let’s say Madame Sébire really did refuse treatment for her tumors with death in mind. I have considered this horrible possibility myself, though with trepidation: if only one were to get a horrible disease, then they would have to give one Nembutal. Or one could refuse treatment and opt for palliative care, for the haze of morphine, ordinarily denied to a “healthy” person. But what if one were to get cancer and then develop a love for life and a fear of death? It is the most terrible thing.

But Madame Sébire retained her courage through Hell, showing us that it is possible, that the commitment to death is not necessarily a caprice.

No one should have to die this way. No one should have to let tumors eat her face in order to achieve a peaceful death. Peaceful death should be available to all those who are in such pain as to seriously desire it, whether that pain is physical or emotional.

Written by Sister Y

December 12, 2008 at 7:27 am

The Free World

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Written by Sister Y

December 9, 2008 at 4:23 am

Attitudes Toward Suicide

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Note: If you are interested in evolutionary biology, please see my article on Thomas Joiner and the evolutionary psychology of suicide.

The question:

227. Do you think a person has the right to end his or her own life if this person: a. Has an incurable disease?

The General Social Survey, available through the Survey Documentation & Analysis project at the University of California, Berkeley, tracks how attitudes of Americans vary with time and against other variables. The answer to the question above, known as SUICIDE1, tracks attitudes toward a special kind of suicide right – that for the incurably ill. Answers vary strongly with age and over time.

The trend over time indicates that more people are favoring the right to suicide in the case of incurable illness. This chart indicates the percentage of people in the 50-60 age group responding to the above question – red for yes on suicide rights, blue for no on suicide rights – for the years 1972-2006, in five-year increments:

Attitudes within the 50 to 60 age range are clearly changing. Support for suicide rights climbs steeply until 1996, when it flattens out.

Similarly, attitudes toward suicide rights upon incurable illness vary with age; the chart below tracks answers to the above question by age group in ten-year increments, for the years 2002-2006.

Generally, the older the respondent, the less he favors suicide rights for the incurably ill, up until the 71-80 age range – the only age range in which a majority of respondents disfavor suicide rights. This is consistent either with (a) stable attitudes over the lifespan, set at an early age; or (b) changing attitudes over the lifespan toward disfavoring suicide rights – perhaps over concerns with one’s own mortality. However, the data above suggesting that attitudes are changing in favor of suicide rights, controlling for age, makes the first hypothesis more likely.

Interestingly, the direct correlation between age and negative attitudes toward suicide has an exception: the 81-90 age group. 81-90 year olds are more likely to favor suicide rights for the incurably ill than not, and they favor suicide rights more than the 71-80 age group. This may be suggestive of attitudes changing over the life span in response to events (in this case, advanced aging).

Sadly, there seems to be little to no progress in attitudes about suicide when someone is “tired of living.” Attitudes on the question known as SUICIDE4, as follows:

227. Do you think a person has the right to end his or her own life if this person: d. Is tired of living and ready to die?

show little change over time:

There is, unsurprisingly, a strong correlation in religion (THEISM) and attitudes toward suicide. The more one agrees with the question

1387. Do you agree or disagree with the following. . . a. There is a God who concerns Himself with every human being personally.

the more one disfavors suicide rights, both on incurable illness

and when one is tired of living:

What about education? Education is associated with favoring suicide rights. Here is the response to SUICIDE1 (suicide rights for people with incurable illnesses) against highest year of school completed:

The correlation for suicide rights for those tired of living is present but not as strong:

Interestingly, the correlation to college major (COLMAJR1) is the opposite of what I would have predicted: those with a major in fuzzy studies – English, literature, foreign language, fine arts, or other humanities (values 1-4) – were much more likely to favor suicide rights for the incurably ill than were those who majored in science or math (values 8-9):

Written by Sister Y

December 7, 2008 at 1:00 am