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We Live In The Anarcho-Capitalist Utopia

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In my previous essay, “Markets Are Ungrounded,” I undertook to list some of the regulations that are necessary for a market to function. The idea of a “meta-market” is particularly tempting to those opposed to “government” regulation – the idea that we might not only choose our transactions, but choose the rules for our transactions. I think this is an impossible, incoherent fantasy.

In The Machinery of Freedom, David Friedman defines government as “an agency of legitimized coercion.” Friedman believes that government should not exist, and that the functions currently performed by government either should not exist or should be undertaken by private individuals and groups.

He says:

The special characteristic that distinguishes governments from other agencies of coercion (such as ordinary criminal gangs) is that most people accept government coercion as normal and proper. The same act that is regarded as coercive when done by a private individual seems legitimate if done by an agent of the government. (In “What is Anarchy? What is government?”)

Further, Friedman defines “coercion” as “the violation of what people in a
particular society believe to be the rights of individuals with respect to other individuals.”

So how would these private groups work to perform functions now performed by government – for instance, preventing and punishing crimes? Friedman imagines that this would all be done voluntarily – that is, by individuals subscribing to protection agencies that use force to protect citizens from violations of their rights (as defined by the private, competing protection agencies). These protection agencies would then patronize private courts who would compete for jurisdiction.

Here is my problem with the Friedman model: it’s exactly the system that exists today, and has always existed since the beginning of human kind.

At the deepest level, Friedman is not proposing any change to the current system(s) of government at work in the world today.

Friedman proposes not regulations for a market, but a system of markets and meta-markets, a system that resolves everything through voluntary transactions. However, this is an illusion. Ultimately, it can’t be “markets all the way down” (or up) – competing protection agencies use force, and the balance of force is what supposedly protects citizens. The “free market” is at the deepest level founded upon force.

This is exactly the situation that we have today.

For instance, our Federal and state governments today compete with various forms of organized crime, which fill the institutional vacuums created by the “legitimate” governments denying contract enforcement to some transactions. These are perfect examples of competing protection agencies under the David Friedman model.

Let me repeat Friedman’s definition of coercion: “the violation of what people in a
particular society believe to be the rights of individuals with respect to other individuals.”

Friedman wants to eliminate this “coercion” thing, at least by governments.

But the protection agencies themselves define what coercion is, for their subscribers. And they enforce their definitions by force.

How is that any different from . . . all of human history? Are not all anarcho-capitalist protection agencies “agencies of legitimized coercion”?

There is no way to protect oneself from coercion (whatever one’s definition of this is) without engaging in the coercion of others.

(In case it’s not clear, I’m happy to be straightened out here – I’d much rather understand the dimensions of the problem than be “right.”)

Written by Sister Y

January 24, 2011 at 5:16 pm

Force Feeding and Respecting Values

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Is it morally right to force-feed anorexic patients? To interfere with a suicide attempt? I think the better question is not whether it is always acceptable or always unacceptable. Better that we ask, when is it morally correct to intervene in the potentially lethal action of another?

Zarathustra at Mental Nurse wrote a piece in September about using degrading, humiliating, coercive means to force patients with eating disorders to eat. He is extremely candid about the reality of force feeding, detailing the force-feeding protocol:

The protocol for serving a meal to an eating disorder patient is a no-holds-barred affair. She’s made to come to the table with her hair tied back and wearing short sleeves, wearing no watches or jewellery, so that there’s nowhere to secretly stash food. She’s then made to eat everything – everything – on the plate with a nurse watching her like a hawk. No excuses are tolerated. No “that’s got a bit of gristle on it” or “but that’s just a crumb”. The plate has to be completely cleared. Afterwards she’s made to sit resting for a full hour so she can’t go off and purge or exercise.

If she fails to complete the meal, or doesn’t complete the rest period, then she’s ordered to drink a nutritional supplement milkshake. If she refuses to do that, then she’s restrained while a nasogastric tube is passed up her nose and into her stomach to force-feed her. Nasogastric feeding is so unpleasant that few of the girls have to have it done more than once. As coercive psychiatry goes, you don’t get much more coercive than this. [Emphasis mine.]

At the end of this litany of horrors, though, Zarathustra wonders – if it saves the girl’s life, what’s so wrong with that?

The short answer is that, for many people, there are things that are more important than life.

I have written in the past that it is sometimes permissible to save a person’s life against his will. I propose two criteria for this:

  1. Because of a condition that clearly destroys the person’s ability to act in his own genuine interests, such as an acute confusional state in a person who is otherwise lucid, the person is not acting in his own interests (note that I mean his own interests, according to his own values, not his “best interests” as defined by others); and
  2. there is substantial evidence that the person, in his lucid state, values his life more than he values being free from the kind of intrusion that would save his life.

I think it was Dr. Maurice Bernstein of the Bioethics Discussion Blog who said that, faced with an anorexic patient who was refusing to eat and would die without intervention, but still said she wanted to live, he would opt to force-feed. This actually accords well with my model of a time when it is appropriate to intervene: when it accords with the patient’s ascertainable values. (I am not sure my first prong is met – anorexia nervosa seems to be more of a life-long condition rather than a sudden-onset break with reality. This is the hardest prong to define and apply[1].)

But if an anorexic patient values her bodily inviolability, her dignity, more than she values her life – then it is morally wrong, and damaging to her as a human being, to stick a nasogastric tube down her throat. There are some things that are more important – to her – than her life. How can it be right to ignore her values and humiliate her in furtherance of protecting her life from damage she herself may do to it?

A similar model may be helpful in determining when it is appropriate to interfere with a suicide. Some people who attempt suicide really want to die, and coercive suicide prevention is a horror that they would rather die than accept (Group 1). Some people who attempt suicide genuinely want to die but fail to be in a lucid state when they make the attempt; they are forcibly “rescued” and treated, and when more lucid are grateful for the indignity of forced treatment (Group 2). And some people who attempt suicide do not really want to die at all – they have bought into what I have termed the dangerous fantasy of rescue, and count on being saved from their suicide attempts through coercive means (Group 3). (In “Attempted Suicide as a Signal,” I have articulated the way in which a policy of always interfering with suicides actually harms people who don’t wish to die – because it sets up an incentive structure that rewards them for engaging in lethal behavior.)

In my view, it is permissible to interfere with the second group’s suicide attempts if the two prongs of my test above are met – the person is experiencing an acute state of mental confusion or delusion (I don’t think DSM-IV depression qualifies here), and according to the person’s own value system (when lucid), remaining alive is more important than the humiliation and suffering involved in the proposed coercive intervention.

Group 3, suicide attempters who clearly lack a sincere intent to die, seem to me to present the easiest case. Under our current system, rescuing them – following through with the fantasy they have been fed – is the morally correct option. However, as I mentioned above, it would actually be better for them if there were a well-known public policy of not interfering with suicide attempts, because under such a system, they would have no incentive to make a potentially harmful, insincere attempt in the first place.

It is never morally permissible to coerce people in the first group to remain alive.

But, on the bridge or in the ER or on the bathroom floor of the apartment, how do you tell the difference? How can you tell whether the person belongs to Group 1 or Group 2 or Group 3? How do you know whether the bleeding, half-conscious person’s values allow for interference with his suicide attempt?

Many people fail to ask this question at all. They assume without question (a) that anyone who would attempt suicide is in a state of mental confusion sufficient to render his actions and judgment valueless, and (b) that everyone places his own life above all other values – that any humiliation or insult to dignity or loss of liberty is worth it if it saves one’s life.

I think it is true that many people hold the belief in (b), but I don’t think it’s controversial to say that not everyone values his own life over all else. If it were true, I think our race would be a race of cowards. But it is not: people are willing to die for their political and religious beliefs, and for other people, demonstrating that one’s own life is not the supreme value for everyone. And for some of us, dignity and bodily inviolability are values we hold above even life itself.

But we can, and ethically must distinguish between the two groups (Group 1 above – those who value dignity over life – and Groups 2 and 3, who want to live despite any indignities that might entail). I have previously articulated a proposal for distinguishing between these groups, with two options, as follows:

  • Radical option: Cease automatic interference with suicide attempters, and publicize this policy, to destroy the dangerous “fantasy of rescue” that might cause many people who do not genuinely want to die to make a suicide attempt, and
  • set up a procedure for medically assisted suicide (a prescription for a lethal dose of, say, barbiturates to a competent adult requester) that would be unlikely to be used by anyone not extremely serious about suicide, and
  • allow people who value their lives over any possible indignities to enter contracts while lucid to allow them to be “rescued” or forcibly treated should they become suicidal, refuse to eat, etc., as with medical advance directives;
  • Minimal option: or, as an alternative, at a minimum, establish an “opt-out” policy that would allow a competent person to execute a legally enforceable document, revocable only by the person it concerns, that would exempt him from coercive suicide prevention “treatment” and from medical “rescue” in the case of his suicide

Regardless of whether the radical or the minimal option is enacted, the following criteria would apply:

  • the suicide procedure (or execution of the opt-out document) could have a waiting period, like gun purchases or marriage or divorce, and even require multiple requests
  • requesters, to be competent, must understand the nature of death and be able to articulate a non-delusional reason for wanting to die
  • a DSM-IV diagnosis of Major Depressive Disorder would not suffice to render someone incompetent to request suicide assistance

Some things are more important than life. But life is important to many – for some, it is the most important thing. A policy like the one I have outlined would respect everyone’s values.

Thanks to mysterious, modest commenter failed poet for inspiring probably the only thinking I’ve done in weeks, which thinking led to this post.


1. If my neighbor wants to lose weight, and values losing weight, but doesn’t have the will power and determination to achieve it, would it be morally right for me to kidnap my neighbor, feed him only health food, and make him run on a treadmill two hours a day? Of course not – unless, perhaps, his values were such that the humiliation of being kidnapped and forced to run on a treadmill was nothing compared to the value of losing weight. He may hate it in the moment – people sometimes feel this way about their hired trainers or physical therapists – but if his deepest, truest value is losing weight, then I think the action is permissible, and he would probably agree. In this way, it all comes down to value – no mental illness/acute mental confusion prong is even necessary. (The only problem comes in judging which of several “selves” is speaking one’s true values. And it is tempting for a listener to assume that the “self” that articulates values close to one’s own is the true self.)

Written by Sister Y

January 6, 2009 at 1:20 am

On People Not Being Able to "Make It Look Like a Suicide"

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Those in favor of forcing people to remain alive against their will often hypothesize that an institutional right to suicide would put vulnerable people at risk of being coerced or pressured into suicide.

There is no evidence for that position. On the other hand, in a society with an institutional right to comfortable, doctor-assisted suicide by barbiturates, it would be much more problematic for a killer to murder someone and make it look like a suicide. In such a society, why would anyone commit suicide by carbon monoxide poisoning or by gunshot? Some might choose other means of death, of course, but suicides by old-fashioned means would likely become somewhat rare and extremely suspicious, no longer the norm.

Some believe that a right to suicide would harm vulnerable people. But there’s just as much reason to believe that a right to suicide would eliminate some incidences of the worst coercive deaths – murders.

Written by Sister Y

September 20, 2008 at 3:46 am

The Moral Effect of "Being Glad It Happened"

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In my post “When It’s Permissible To Force Someone To Stay Alive For His Own Good” and elsewhere, I have addressed the fact that many people who are forcibly prevented from committing suicide later report being glad they were forced to stay alive. This fact is often used to justify coercive suicide prevention practices.

Similarly, the vast majority of people appear to report that they are glad to have been born. This is occasionally used as a justification for procreation (against antinatalist arguments).

While I am not attempting, in this piece, to address the question of whether suicide or procreation is right or wrong, I wish to question the validity of the argument that goes something like this:

  1. Action
  2. Object of the action is later glad the action occurred
  3. Therefore, Action was morally correct.

I will jump right in with an illustrative counterexample: genital mutilation of children. In many countries, female children are subject to genital mutilation, usually for the purpose of maintaining their chastity by making sex painful or less pleasant, though sometimes for other purposes. Those of us who find the genital mutilation of children horrifying are confronted with the fact that, in many cases, women who were genitally mutilated as children grow up to participate in, and actively perpetrate in many cases, the genital mutilation of their own daughters. The fact that they practice genital mutilation on their own children is strong evidence that these woman are glad to have been genitally mutilated. But does this make forcible genital mutilation of children morally right? Clearly not.

In many cases, we may suffer wrongs that begin a chain of causation that leads to a subjectively good result. It should not take much introspection to come up with cases in our own lives when someone committed a wrong against us for which we were ultimately grateful, because the eventual consequences of the wrong were subjectively pleasant or otherwise beneficial. My claim is that this after-the-fact feeling of gladness does not render the initial act any less wrong.

More on the parallels between birth and female genital mutilation in my piece, “Birth and Consent: An Alternate Philanthropic Route to Antinatalism.”

The “glad it happened” justification seems to be a species of the Golden Rule Argument – if you’re glad you’re alive, have more babies (who will presumably be glad to be alive). If you’re glad you were prevented from committing suicide, prevent others from committing suicide. And so on. The problem with this line of thinking is people like me – people who are not happy to be alive, and who sincerely wish to die. What effect would a Golden Rule have when applied to me – should I go around killing people because I want to die? Hardly. It is moral for me to respect the lives and desires of others, just as I feel it is moral for others to respect my wish to die. I think “do unto others as you would like to have done unto you” has a serious flaw, and the variety of human experience is that flaw.

Obviously, the majority of people are happy to be alive. Perhaps the majority of “rescued” attempted suicides are even happy to have been rescued. But this line of thinking turns action into a consequentialist game of playing the odds. Respecting the values of individuals – even those with unusual desires – and placing a high value on consent, is a more coherent and appealing strategy. “Do unto others as they would have done unto them.”

Thanks to Sister Wolf for crystallizing the argument at her site!

Written by Sister Y

July 26, 2008 at 12:03 am

States Coerce Their Citizens By Prosecuting Their Doctors

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In the UK, Dr. Iain Kerr, a family physician, was suspended from his practice for six months for prescribing 30 tablets of the sleeping pill sodium amytal to an elderly, ill adult patient at her request.

The patient did not use the pills to die, but disposed of them when she found out Dr. Kerr was being investigated for acceding to her request. She later committed suicide using a much less reliable drug cocktail consisting of Temazepam, antihistamines and painkillers.

Dr. Kerr told the General Medical Counsel:

I think when dealing with someone holding a rational view of the circumstances in which they want to end their life, it was my duty to at least consider whether he or she had a reasonable opinion and that it was my duty to assist if I thought I agreed with that patient’s assessment.

Prosecuting physicians who risk sanctions to respect the choices of their patients and treat them as rational adults is yet another way in which governments act coercively to prevent suicides, without addressing the suffering that causes suicides in any way.

It is unfortunate that the General Medical Counsel felt the need to sanction Dr. Kerr for his act. But he may stand before any man or god, confident that his action was the morally correct one and the one most respectful of humanity.

Written by Sister Y

July 25, 2008 at 1:19 am

Sources of Coercion: A Review of California Law

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Since I ultimately hope to make policy proposals, in the form of proposed changes to the law, to end coercive suicide prevention practices (though, of course, with no realistic hope of these being implemented in this generation), and now that I have the philosophical basis for the project at least outlined, it might be helpful to review exactly what the law is, in California at least, regarding coercive suicide prevention.

The single worst document in California law, from the anti-coercion perspective, is Kockelman v. Segal, 61 Cal.App.4th 491 , 71 Cal.Rptr.2d 552 (1998), which I will describe below in Section 2.

1. Forced hospitalization

California’s Lanterman-Petris-Short Act, located in the California Welfare and Institutions Code, is actually a relatively progressive law for people subject to mental health treatment, and regulates (but ultimately allows) forced hospitalization.

The most relevant provision of the act is the famous Section 5150, which allows the involuntary detention, for up to 72 hours, of a person when there is probable cause to believe that, as a result of mental illness, he is a danger to himself, a danger to others, or is unable to care for himself (gravely disabled). (The 72 hour hold can be extended to a 14 day hold upon an administrative hearing; longer holds, up to and including conservatorship, require increasing court involvement.)

The specification that forced hospitalization may only take place if the “danger to self” is a result of a mental illness appears to allow for the possibility of rational suicide. But, of course, in the context of a suicidal person, is it difficult to determine whether the suicide attempt or suicidal intent occurs “as a result of a mental illness.” In practice, any suicide attempt, behavior, or intent is automatically treated as if it were the result of a mental disorder, despite the obvious lack of evidence to support this practice. The most rational suicide in the world, if discovered before the attempt was completed, would certainly be hospitalized. (Socrates would be issued hospital pajamas and slippers, have his jewelry removed, and be given Prozac and group therapy.) This practice fails to accord both with the requirements of the law, important philosophical principals of self-determination, and, as I have mentioned before, the interests of non-suicidal “signalers.”

There is no opt-out. A competent, rational adult has no right to refuse to be “treated” (imprisoned and forced to remain alive).

Another important provision of the Act is the immunity it provides for people who detain and forcibly hospitalize those they think have a mental illness and are either dangerous or gravely disabled. Section 5278 provides that “Individuals authorized under this part to detain a person for 72-hour treatment and evaluation pursuant to Article 1 (commencing with Section 5150) . . . shall not be held either criminally or civilly liable for exercising this authority in accordance with the law.” This has been interpreted to mean that, as long as the detention is supported by probable cause according to a court, the person detaining the individual alleged to be mentally ill may not be sued or prosecuted for imprisoning him. This law essentially encourages police and health workers to detain people, assuring them that there will not be any consequences for interfering with another person’s freedom.

2. Duty to prevent a suicide (by coercive means if necessary)

To explain the duty to prevent a suicide under California law, I will link to the major cases and, as I have time, explain the relevance of each one to the development of a duty to use coercive suicide prevention methods.

  • Meier v. Ross General Hospital, 69 Cal.2d 420 (1968).

    An early case establishing the liability of a hospital for the wrongful death of a patient who commits suicide while involuntarily committed to the hospital’s care.

  • Nally v. Grace Community Church, 47 Cal.3d 278 , 763 P.2d 948; 253 Cal.Rptr. 97 (1988).

    The California Supreme Court found that a member of the clergy, as a “non-therapist counselor,” owed no duty to prevent the suicide of a congregation member he was counseling by referring him to a licensed counselor, even where the suicide was foreseeable. Nally seemed like a victory against coercive suicide prevention practices; Chief Justice Lucas, in his opinion, even quotes an earlier case, Bellah v. Greenson, 81 Cal.App.3d 614 , 146 Cal.Rptr. 535 (1978), in which the court (in dicta) explicitly recognizes the reasons that coercing counselors to use coercive suicide prevention methods could be harmful to patients:

    Similarly, Bellah recognized that creating a duty on the part of a psychiatrist to breach the confidence of a doctor-patient relationship by revealing disclosures made about the suicidal intent of his patient would unduly extend the Tarasoff holding, and “could well inhibit psychiatric treatment.” (Bellah, supra, 81 Cal.App.3d at p. 621.) Bellah reasoned that in Tarasoff, we held only that “where a therapist knows that his patient is likely to injure another and where the identity of the likely victim is known or readily discoverable by the therapist, he must use reasonable care to prevent his patient from causing the intended injury. Such care includes, at the least, informing the proper authorities and warning the likely victim. However, [Tarasoff] did not hold that such disclosure was required where the danger presented was that of self-inflicted harm or suicide. … Instead, [Tarasoff] recognized the importance of the confidential relationship which ordinarily obtains between a therapist and his patient, holding that ‘… the therapist’s obligations to his patient require that he not disclose a confidence unless such disclosure is necessary to avert danger to others. … (Tarasoff, supra, p. 441, italics added.)'” (Bellah, supra, 81 Cal.App.3d at pp. 620-621.) [Nally at 295, quoting Bellah. The Tarasoff case mentioned is the famous California case imposing liability on a psychiatrist for failing to violate confidentiality and disclose his client’s intention to harm a third party. Emphasis mine.]

    Nally, however, interpreted Bellah (again in dicta) as recognizing a duty owed by a psychiatrist or licensed counselor “when a psychiatrist’s (or hospital’s) treatment of a suicidal patient falls below the standard of care for the profession, thus giving rise to a traditional malpractice action.” (Nally at 296). Presumably, the “standard of care” could include coercive means.

  • Kockelman v. Segal, 61 Cal.App.4th 491 , 71 Cal.Rptr.2d 552 (1998).

    The locus of the duty to use coercive means to prevent a suicide is most clearly found in Kockelman, one of the most harmful opinions in the State of California for purposes of counselor-patient relations. Any hopes raised in the Nally opinion were dashed in Kockelman.

    The Kockelman court allowed a woman whose husband committed suicide during the course of outpatient treatment to sue his treating psychiatrist for wrongful death, apparently for failing to prevent his suicide. The court reasoned that whether the doctor had violated the professional standard of care was a question of fact that would have to be determined at trial. Given the facts of the case, it is difficult to see what the court could mean that the doctor could have done, short of using coercive means (forced hospitalization) to prevent the suicide. An excerpt from the factual background:

    Kockelman kept his appointment on September 2, 1993. He reported he was not doing much better, although he appeared neatly dressed and clean-shaven. Dr. Segal wrote that it was “mysterious” to him how Kockelman could rouse himself when needed and at other times could not get out of bed. But again he found it impossible to engage Kockelman in any psychodynamically oriented dialogue. He recommended increasing the Prozac dosage and restarting the lithium, but noted he did not feel “very optimistic” that this would make a difference. He discussed the possibility of ECT with Kockelman and noted he would see what could be arranged.

    Kockelman died on September 5, 1993, three days after his last appointment with Dr. Segal, from an overdose of desipramine. Valerie Kockelman stated that her husband was feeling more energetic and cheerful the last week before his death and had gone to work each day. She said “it was like he was a new person.” They were planning a car trip to visit their daughter in Santa Rosa on the Saturday of a Labor Day weekend, and he was looking forward to it. On Saturday morning Kockelman told her he wanted to stay home and he urged her to go by herself. He did not seem depressed to her and appeared to be in good spirits. He told her he just wanted to “rest up.” She left Saturday and when she returned home the following evening she discovered her husband’s body. [Kockelman at 497. Emphasis and link mine.]

    Apparently, psychiatrists must not only be their patients’ jailers; they must also be mind readers. Also: be sure to hospitalize anyone who looks cheerful!

  • Cruze v. National Psychiatric Services, Inc., 105 Cal.App.4th 48, 129 Cal.Rptr.2d 65 (2002).

    A terminally ill woman was involuntarily hospitalized by her physician after she discussed the possibility of committing suicide. The court denied her right to sue her physician for malpractice, basing its decision on the immunity granted by Section 5278 of the California Welfare and Institutions Code (explained above).

  • Jacobs v. Grossmont Hospital, 108 Cal.App.4th 69, 133 Cal.Rptr.2d 9 (2003).

    The California Court of Appeal confers a bit of hope, this time by determining that the grant of immunity in Section 5278 of the Welfare and Institutions Code (explained above) is not absolute, and does not protect a hospital from claims resulting from improper care. This is still not terribly good news, as it might be used to sue a hospital or other person for failing to use means that were coercive enough. But at least it imposes a duty of care on people who involuntarily detain others.

  • Hernandez v. KWPH Enterprises, 116 Cal.App.4th 170 , — Cal.Rptr.3d — (2004).

    In Hernandez, a recent California Court of Appeal case, the court found that an ambulance service owes no duty of care to a voluntary patient its employees are transporting when the patient exhibits bizarre behavior and then runs away from their custody. (The patient in this case ran onto a highway and was hit by a car and killed.) In my opinion, the court was correct in refusing to impose liability on ambulance personnel for failing to coercively prevent a suicide (or perhaps accidental death). The case does not go far enough, of course, but it signals a good trend. It could have been much worse.

Written by Sister Y

June 18, 2008 at 9:45 pm

Costs of Coercive Suicide Prevention (and an outline of an alternative)

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One of the themes of my project thus far has been to point out that coercive suicide prevention practices do nothing to prevent or decrease actual suffering, and often increase suffering by forcing people who genuinely want to die to stay alive. Coercive suicide prevention, far from reducing suffering, serves the socially negative purpose of masking suffering, so that the true level of suffering is less apparent.

My hypothesis, which I plan to flesh out in greater detail in the coming weeks, is that if the same public funds that are currently spent toward coercive suicide prevention were instead spent on reducing acute suffering in suicidal people though non-coercive means, both suffering and suicide would be reduced.

I am currently in the stage of collecting data on how much money is spent on coercive suicide prevention.

Preliminary data: In the state of Georgia, a 2005 study showed that $40 million was spent in 2002 alone on hospitalization and emergency room treatment of suicides and suicide attempters. 900 people completed suicide that year, 2800 were hospitalized, and 5400 visited emergency rooms for intentionally self-inflicted injuries. Assuming that completed suicide attempts are proportional to attempted suicides and self-inflicted injuries, we can calculate a per-completed-suicide cost in Georgia of about $44,000 (which is not the cost of treating a successful suicide, but rather the average medical expense for suicide treatment per completed suicide). Assuming nationwide costs mirror Georgia’s, that would give a national expenditure of around $44,000 times 32,595 suicides for 2002, which comes out to $1.4 billion for the country.

The Washington State Department of Health gives a higher figure – $4 billion for medical treatment of suicides nationally – though I can’t immediately trace the source.

Of course, these estimates leave out many other hard-to-measure costs of coercive suicide prevention, including police response, the cost of the government maintaining lists of formerly suicidal gun buyers (as in California), and costs associated with preventing would-be suicides from accessing lethal drugs.

Now imagine what things would be like if even a fraction of this money were spent on genuinely trying to reduce the suffering of suicidal people (and even non-suicidal people, for that matter). My proposal, as I now see it, would involve

  • ceasing automatic interference with suicide attempters, and publicizing this policy, to destroy the dangerous “fantasy of rescue” that might cause many people who do not genuinely want to die to make a suicide attempt
  • setting up a procedure for medically assisted suicide (prescribing a lethal dose of, say, barbiturates to a competent adult requester)
  • which procedure could have a waiting period, like gun purchases or marriage or divorce, and even require multiple requests
  • requesters, to be competent, must understand the nature of death and be able to articulate a non-delusional reason for wanting to die
  • a diagnosis of Major Depressive Disorder would not suffice to render someone incompetent to request suicide assistance
  • upon requesting suicide assistance – and, ideally, even if suicide assistance is not requested – some of that aforementioned money could be deployed to provide help with any problems identified by the suicide requester
  • any assistance (counseling, social worker consultation, housing assistance, bankruptcy assistance, etc.) must be offered without conditioning the eventual suicide assistance on the requester accepting the assistance

It must be recognized that coercive suicide prevention is harmful, in that it increases suffering while masking the suffering experienced by the population. And, despite drops in suicide associated with reduction in gun ownership, a high percentage of suicides are ultimately unpreventable through coercive means, as noted in a 2005 UK study tracking the increase and success rate of suicide by hanging (the lethality is around 70%). Hanging requires no special equipment – the study noted successful hangings conducted with belts, sheets, shoelaces, tights, bra straps, shirts, shower curtains, and pajama trousers – and has a 70% rate of lethality, even when the suicide is not fully suspended. (Of course, of the 30% who fail, how many will be subjected to the treatment suffered by the unidentified patient in the Annals of Neurology article?)

But we must consider whether, if there were a comfortable medical option widely available, many of those gun suicides, hanging suicides, and cutting suicides might opt to request it, instead – and, ultimately, many of them might get help solving the problem they originally thought suicide was the only answer to. For many people, of course, it would mean, not rescue from suicide, but a less horrible death – which, I would argue, is a good thing in itself.

For those suicides who really want to be rescued, my proposal serves to provide genuine, 100% certain rescue – before the suicide attempt is even made. And for those who have considered all options and only desire a comfortable death, my proposal would not humiliate or coerce them into accepting questionable “treatment” to which they have not consented, but would provide a way for them to end their lives with minimal harm to themselves or others.

Written by Sister Y

June 14, 2008 at 10:44 pm