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Selling Life-Years

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Adam Ozimek at Modeled Behavior has an interesting piece on whether we should be able to sell years of our lifespans.

This is, I think, exactly the question addressed by J. David Velleman in his article Against the Right to Die, wherein he argues that giving people a choice can make them less well-off, even if, given the choice, they choose correctly. Velleman is concerned with assisted suicide – shortening lifespan to avoid suffering near the end of life. Ozimek is concerned with shortening lifespan to promote other values, but the moral logic is, I think, the same. I respond to Velleman’s article in my piece Velleman’s Sorrow of Options.

Also exactly on point is Velleman’s related article A Right of Self-Termination? in which he argues that it is morally unproblematic to force people to remain alive, because by choosing to shorten our lifespans, we somehow abrogate human dignity, which belongs to everyone, not just to ourselves. Velleman thinks, for instance, that accepting a shorter lifespan in exchange for the pleasure of smoking is morally wrong and an affront to all humanity. I respond to this in my piece Respecting and Erasing, essentially challenging the notion that limiting the span of something in time denies its dignity.

Other writers think that dignity, as distinct from autonomy, is just stupid.

Written by Sister Y

September 16, 2010 at 3:19 pm

Is Webcam Suicide Ever Appropriate?

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The cause of suicide rights seems to suffer anytime someone commits or attempts suicide on camera with folks on the internet watching. When a suicide is completed, the public demands to know why no one intervened. When intervention appears to prevent a suicide, the public unquestioningly gives its support to the intervenor. (In the most recent such case, Chris Matyszczyk cheerfully informs us in rather Orwellian terms that “The police arranged for [the suicide] to receive the appropriate care.”)

Perhaps this is as it should be, since most of the time, someone who attempts suicide in front of a camera is clearly a victim of the dangerous fantasy of rescue, hoping to be “saved” before his suicide is successful. (Of course, changing the law to forbid intervention with suicide attempts would be better than the current situation for both those who genuinely want to die and for those who engage in potentially self-lethal behavior in order to be saved.)

Is there ever a good reason to die on camera? I propose two possibilities, both with limits.

1. Not wanting to die alone

It is understandable for a human being who genuinely wishes to die to also not want to die alone. Many people call suicide hotlines for this purpose, rather than in hopes of rescue. Suicides regularly seek each other out in order to die together. In his book Why People Die By Suicide, Thomas Joiner refers to a 2004 Chicago Tribune article about people who commit suicide by jumping in front of trains:

Almost always, suicide victims [sic] peer into the locomotive cab in their final moments. They stare right into the eyes of the engineer, perhaps reaching for a last human connection.

. . . [Metra engineer Raymond Baxter says] “I’ve heard other engineers say [people committing suicide] look at you. I don’t know why they do it. I sure wish they wouldn’t, because the picture stays with you. You try to forget about it, but you don’t ever, really. It ain’t easy.”

The desire for human contact at the last moment is poignant and understandable – but it is awful to force this attempt at connection on an unwilling train engineer. It would be much better if a suicide could agree with a willing person beforehand to be with him while he died – even if it only meant watching over a web camera. This would spare the feelings of unwilling witnesses, such as the poor train driver, yet it would not force upon a suicide the cruelty of dying alone.

As it is, there are major problems – most of them legal – faced by people who would comfort a suicide in his last moments. In a 2007 This American Life episode (How to Rest in Peace, at 39:35) a son (“Edward”) describes helping his mother to commit suicide, at her insistence – but not being able to be with her while she died, for fear of being prosecuted for having a role in her death. His mother was forced to choose between dying alone and staying alive against her will – and chose to die. But she should not have been forced to make this choice.

Barring major changes in laws against assisting suicides, pre-arranged company via web camera offers a measure of comfort to a dying person. (Still, allowing one’s suicide to be viewed by one person or a few people seems more justifiable than publicly broadcasting one’s suicide to the entire internet.)

2. In the interest of providing information

Despite hysterical claims to the contrary, there is very little information available about dying certainly and comfortably. (Even The Peaceful Pill Handbook is not ultimately helpful without access to barbiturates.)

However, if a suicide were to demonstrate a method in the interest of increasing available information, it would be a public service to other would-be suicides to share the method and experience – good or bad. Others would be able to see first hand the use of the method and its apparent effects. While some viewers might find this disturbing, I think it is ethical as a civil disobedience against the unethical suicide prohibition, especially if the video could only be accessed by those who specifically sought out such information.

From the This American Life episode mentioned above, at 51:20:

Ira Glass: It just seems so sad that she has to be alone at that moment. It seems like that’s the moment where, of all moments, she would want somebody with her to hold her hand and comfort her.

“Edward”: It was terrible. It was terrible. Exactly. That was probably the worst part of it, that she had to do it alone. Me and her other family members could not be there, because we live in a society that does not respect people’s desire to control the end of their life.

Written by Sister Y

February 6, 2009 at 10:41 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

The "Unwanted Life" Diagnosis

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When providing a medical treatment of any sort, physicians are generally expected to produce a diagnosis of a medical problem that the treatment is intended to correct. In most cases, the medical problem is one that anyone would recognize as a medical problem, such as diabetes or a broken leg. However, one of the most widely prescribed medical treatments is contraception. But what “medical problem” do you diagnose in order to prescribe contraception?

People in institutional settings (locked hospitals, homes for the developmentally disabled, etc.) are, of course, sexually active. The doctors that care for them must provide contraception to prevent pregnancy – usually injected hormone contraception. The surprising (to me) diagnosis you most commonly see on the chart of an institutionalized patient, when a doctor is prescribing contraception to her, is “unwanted fertility.” Fertility is something we think of as healthy – but doctors may diagnose “unwanted fertility” as a medical problem for which contraception is the preferred treatment.

I think this is an interesting solution, although the diagnosis is often, strictly speaking, a fiction, as many female residents of group homes and such will tell you they definitely want to get pregnant – what is really meant is that the patient’s fertility is unwanted by her guardian.

A similar diagnostic possibility is necessary in the case of the rational suicide. A diagnosis of “unwanted life” could form the basis for the provision of lethal means of suicide that require a prescription, without requiring general legalization of the lethal drugs. The diagnostic criteria might even include more than just a wish to die – requirements might include that the wish be persistent (repeated requests over a period of time), that it not be accompanied by (or motivated by) delusions, and that the wish to die be clear and unambiguous.

Although I do not think there is a moral right to procreate (for anyone), I am concerned with the use of the “unwanted fertility” diagnosis against the expressed wishes of patients, even though these patients would likely not be able to care for any children borne by them. It is a convenient solution, but it stretches the truth a bit. This worry is even more important in the analogous “unwanted life” case. The “unwanted life” diagnosis would never be appropriate in cases where the life of the subject is unwanted by someone other than himself (his guardian, say) rather than unwanted by the subject of the diagnosis. Likewise, if a person met the criteria for the “unwanted life” diagnosis, despite having some sort of mental illness as defined by the DSM-IV, it would be inappropriate for his wish to be denied because others disagreed with his wish to die.

Written by Sister Y

July 17, 2008 at 7:25 am

Oregon’s Law

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Oregon’s Death With Dignity Act succeeds in many ways. The Act respects patient autonomy, from its definition of “capable” to mean that

in the opinion of a court or in the opinion of the patient’s attending physician or consulting physician, psychiatrist or psychologist, a patient has the ability to make and communicate health care decisions to health care providers, including communication through persons familiar with the patient’s manner of communicating if those persons are available.

to the way it allows patients to decide for themselves whether to notify family members and when – even if – to self-administer the lethal prescription, once requested. (Some people who request suicide assistance don’t use it until months or years after it has been provided.)

Oregon’s law is wrong, however, in limiting access to death to those with terminal illnesses. Although this flawed version is certainly the only version of the law that would have had a chance of being enacted, the fact remains that it is wrong.

First, restricting access to comfortable means of death to those with a terminal illness is actually demeaning to people with terminal illnesses. The idea that human dignity somehow requires that one be able to walk and talk and control one’s bodily functions is demeaning and wrong, as Felicia Ackerman (see Readings) and disability advocates point out. A terminally ill person must decide for him or herself whether to request suicide assistance; it is not the right decision for everyone. But what possible justification could there be for limiting this right to terminally ill people, except that their lives are somehow less valuable than those lives that will (probably) continue on for many years? The designation “Death With Dignity Act,” of course, hints at the demeaning implication of the limit: some deaths are dignified, other are not. The state will decide for you whether you are undignified enough to be allowed to die peacefully. (The Oregon law does not allow assisted suicide to be provided to non-terminally-ill disabled or merely old people, but the implications of the restriction to terminally ill people are clear enough.)

Second, the Oregon law’s restriction against suicide assistance to non-terminally-ill people is wrong because suicide is an important right for everyone, not merely the terminally ill. In fact, if anything, the right is more important for those who are not terminally ill, because their time of suffering will most likely be much longer than those who will die soon naturally. And, as pointed out by Velleman, terminally ill people are much more likely to be harmed by having the option to die than healthy people are, because they are more likely to be dependent on the care of others and therefore to feel themselves to be a burden. A more sensible restriction might be to allow suicide assistance only to non-terminally-ill people! I am not, of course, in favor of this restriction, but it makes more philosophical sense than Oregon’s law, which makes political sense, if anything.

Meanwhile, Switzerland recently extended suicide rights to those with incurable mental illnesses. Jacob Appel, writing in the Hasting Center Report, explains the basic ethical issues:

Another set of objections are from those who support a basic right to assisted suicide in certain situations, such as those of terminal disease, but do not wish to extend it to cases of severe and incurable mental illness. This resistance may be inevitable, considering the increased emphasis that contemporary psychiatry places on suicide prevention, but the principles favoring legal assisted suicide lead logically to the extension of these rights to some mentally ill patients.

At the core of the argument supporting assisted suicide are the twin goals of maximizing individual autonomy and minimizing human suffering. Patients, advocates believe, should be able to control the decision of when to end their own lives, and they should be able to avoid unwanted distress, both physical and psychological. While these two principles might explain why a victim of amyotrophic lateral sclerosis or cancer would choose assisted suicide, they apply equally well in many cases of purely psychological disease: a victim of repeated bouts of severe depression, particularly in cases where treatment has consistently proven ineffective, rationally might prefer dignified death over future suffering. [Hastings Cent Rep. 2007;37(3):21-23. Via Medscape. Emphasis mine.]

Written by Sister Y

June 24, 2008 at 3:40 am

Life Rights and Death Rights

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Many of us consider the right to choose to die to be an important liberty interest. The right to die is often seen as an important counterpart to the right to choose to continue to live. Those in favor of maximizing choice may prefer a society that offers both rights, even if they could not personally imagine wanting to exercise the right to die.

Felicia Ackerman, in her essay “Assisted Suicide, Terminal Illness, Severe Disability, and the Double Standard,” points out there may be another right that is cut off merely by having the option to die, namely, the right to live without explicitly choosing to live:

. . . even on the nonpaternalistic assumption that patients will always make the right decision, they may be made worse off simply by having the option of physician-assisted suicide. The presence of this option may cause families to treat patients differently, and in any case, this option deprives patients of the option of staying alive without explicitly choosing to do so and being seen as choosing to do so, and thus without having to justify their decisions to stay alive. (Bolded emphasis mine, italicized emphasis Ackerman’s; Ackerman attributes this line of thinking to J. David Velleman’s Against the Right to Die.)

The concern for losing the right to live-without-choosing is interesting; I argue that what Ackerman and Velleman miss is a symmetrical concern for the right to die-without-choosing. Perhaps this right isn’t often discussed because most people, fortunately, have not been in the position to notice that they lack such a right. But the suffering, particularly would-be suicides, who feel that life is worth living yet do not commit suicide for various practical or moral reasons, often wish that death would take them in their sleep, without requiring them to be an agent of their death.

Really there are four rights in question, two “life rights” and two “death rights”:

  1. The right to live without explicitly choosing to live
  2. The right to (choose to) live
  3. The right to (choose to) die
  4. The right to die (or not exist) without explicitly choosing to die

In the absence of physician-assisted suicide, Life Right 1, the Velleman right, is generally the only right available. Widely-available physician-assisted suicide, implemented in a way which would remove the barriers to suicide I have earlier identified, would ensure that Life Right 2 and Death Right 3 are available. Again, those who favor the maximization of rights cannot rely on the idea that forbidding death also preserves “a right,” since it preserves that right at the expense of two very important rights.

Almost never is Death Right 4 actually available. The right not to exist without explicitly so choosing is, of course, available to the lucky never-born. It might be available to those with a very different life than ours – post-biological beings, for instance, might someday achieve something like Death Right 4. Most disturbing to those who value Life Right 1, though, is that Death Right 4 is available in cases where another person, or a natural process, kills someone at a time when he has not explicitly requested to be killed. This is the fervent desire of most suicides, I suspect; but we are denied this right because we are saddled, very much against our will, with Life Rights 1 and 2.

It seems to me that the denial of important death rights to those who wish to die must be considered equally with the consideration of life rights for those who wish to continue to live. I can imagine two justifications for considering life rights as more important than death rights, neither of which I find particularly moving; I am interested to know if anyone else has ideas that would justify seeing life rights as more important than death rights.

First, the life rights might be seen as creating a more revocable situation, and preserving more freedoms (if I continue to live, I can always choose to die or to live; but if I die, I cannot choose anything). However, forcing life really does not preserve choice. If we force life, we deny the death options, preserving only the life “options,” which does not really maximize freedom. Being forced to preserve all one’s options, and never allowed to make choices that remove options, is hardly freedom.

Second, the life rights might be more protected because more people prefer life to death. But, in addition to the fact that majority preference is not much of a reason, many freedoms are guaranteed very much in spite of being unpopular choices. Refusing life-saving medical assistance (separate from the suicide cases) is certainly an unpopular choice, but one it is seen to be important to have available.

I feel that a greater recognition of death rights, and of the fact that at least one of the death rights is necessarily violated as a condition of existence, is important for questions of suicide and antinatalism. In fact, Velleman’s examples where having an additional option puts one in a worse position could serve equally well as examples in favor of antinatalism. (I hope to specifically address his negotiation example and his invitation example in a future post.) Once born, we might, in a just society, possess the right to choose to live or to die; but we lack the choice to not exist without explicitly choosing to die, making us worse off in the case that we would prefer never to have existed. Many of us dearly wish for Death Right 4, but nevertheless are either stuck with Life Right 1 or choose Life Right 2.

Basically, I see Velleman as in a bit of a bind – if he’s right, and options often make us worse off, and offering an option is a morally suspect act, then that is a strong argument in favor of antinatalism, which weakens it as an argument against having a choice to die. If Velleman is wrong, on the other hand, then he merely fails to provide an argument against the suicide option.

My position is, if the right to assisted suicide is wrong, because it harms some who would be better off if they didn’t have the option to die (my synopsis of Velleman’s argument), then birth must also be wrong, because it harms some who would be better off if they hadn’t been given the option to live. It’s a good short article if people want to read it (I’ve linked to it above, in the block quote – it’s a PDF). He says, “I argue that we must not harm others by giving them choices, not that we must withhold the choices from them lest they harm themselves.”

Interestingly, along the same vein, perhaps the Velleman piece could be read equally well as an argument against the right to contraception, as much against the right to suicide or in favor of antinatalism, depending on whether the reproductive interest is seen as essential.