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Liberty and the "Real" Decision Maker

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One of the really interesting ethical questions about suicide (among other actions) is, what counts as the choice of the real person – especially if a person making a decision is shown to have conflicting desires and motivations?

Most of the time when we make decisions, we have conflicting motivations – such is the nature of a decision. Cognitive science research suggests that, most of the time, we don’t even know why we make a particular decision. We may feel that we are carefully weighing the pros and cons of action and inaction based on carefully considered criteria, but most of the time that is not how our brain apparatus actually works. (In fact, some suggest that decisions based on instinct are usually better than decisions made based on more rational criteria.)

Given this background of conflict, should we sometimes forcibly prevent a decision maker from acting until he is certain?

With many decisions and consequent actions – whether to eat a cheeseburger, whether to go to work, whether to get a divorce – people have many conflicting motivations, conscious and unconscious. There’s some value to waiting to make a decision until one is sure – which could include a friend forcibly preventing someone from making a decision until the decision maker is sure – especially since many decisions, like suicide, are irrevocable. But there’s also a cost to waiting to be certain (e.g. time spent being hungry until you eat the cheeseburger or being miserable until you get a divorce/commit suicide).

Taking an action is a decision between two options – acting and not acting. Both have consequences. Forcing someone to not act is making a decision for him and imposing the costs of that decision upon him without his consent.

I think a waiting period for serious decisions (like California’s 48-hour waiting period for marriage) – which amounts to forcing someone to take more time to think about a decision (and imposing the costs of that time on him) – is acceptable if the costs of the waiting period were found to be, on average, smaller than the costs of poor decisions without the waiting period. But this would have to be from a perspective of maximizing happiness, rather than promoting liberty. Waiting periods are paternalistic – I’m not a hardcore libertarian, so I think that can be okay at times where it’s not very intrusive. Ultimately, though, I think not only the decision of whether to act, but the decision of how long to wait before acting, should rest with the actor. And the costs (in terms of suffering) of being forced not to commit suicide are substantial – the longer the delay, the higher the potential costs.

The weirder question, which I’ve been struggling with, is what to do about people whose desire to commit suicide changes over time? If I sign something at age 18 that says I want to be forcibly prevented from committing suicide if I ever try it, should that be enforced when I’m 80 and want to die peacefully? If I want to die at 18, should it make a difference that I might change my mind later? I don’t have much of a framework from which to answer that one.

Chip’s suggestion – that we go with the “one that’s speaking, whenever” – is attractive in its simplicity, humanity, and apparent respect for liberty. But if our society followed it strictly, it would prevent us from ever increasing our happiness by binding ourselves. The whole idea of a contract (from sales to employment to marriage) is to increase our overall happiness by binding the actions of our future selves. Similarly, if I had a fairly happy life but very occasionally went into a despairing funk and wanted to die, I might think I’d be better off if I could prevent myself from committing suicide during that period. (Just as I, in my real incarnation, would feel myself better off if I could prevent my future addled self from docilely swallowing the activated charcoal if a future suicide attempt proved unsuccessful.) Are present and future benefits and costs allowed to weigh against each other?

Do I owe anything to my future self – since, in a sense, it is me? Can I take anything from my future self – again, since it is me – by either imposing suffering by not committing suicide, or removing its “chance at life” by committing suicide? Ethically, do I stand in relation to my future self as toward my present self, or as toward a totally different person?

In response to an email from reader Elizabeth, who also pointed me to the Wilson book – thanks!

Written by Sister Y

February 14, 2009 at 10:44 pm

Psychiatric Advance Directives: Worth the Paper They’re Printed On?

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Medical advance directives provide a way for people to be free of unwanted medical treatments if they should become incompetent. There has been a double standard, however, between advance directives that refuse ordinary medical care and those that refuse psychiatric care. A recent decision from the Second Circuit holds that such discrimination violates the Americans with Disabilities Act, at least concerning involuntary non-emergency psychiatric medication. Unfortunately, many still hold that the police power allows forced psychiatric care when a person is not a danger to others, but only wishes to die.


1. The Right to be Free from Unwanted Treatment

Generally speaking, people have a right to be free from harmful or offensive physical contact, especially unwanted intrusions into their bodies. When someone intentionally causes harmful or offensive contact without consent, the person receiving the unwanted contact may sue for battery. In her concurring opinion in Cruzan v. Director, Missouri Department of Health, Justice O’Connor notes that, in other contexts, bodily intrusions raise due process and Fourth Amendment concerns, suggesting a related constitutional right to be free from unwanted medical treatment. Specifically, she states that

The State’s imposition of medical treatment on an unwilling competent adult necessarily involves some form of restraint and intrusion. A seriously ill or dying patient whose wishes are not honored may feel a captive of the machinery required for life-sustaining measures or other medical interventions. Such forced treatment may burden that individual’s liberty interests as much as any state coercion. . . . The State’s artificial provision of nutrition and hydration implicates identical concerns.

While the majority in Cruzan do not find that there is a constitutional right to surrogate or advance decision making by an incompetent person to refuse treatment, all fifty states and the District of Columbia have enacted laws allowing advance or surrogate decision-making through living wills, also known as medical advance directives.

Medical advance directives are a way for people to specify what treatments they do and do not wish to receive in the event that they become incapacitated. Typically, medical advance directives focus on end-of-life care. A typical provision from an advance directive comes from the California statutory medical advance directive:

I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits;

or, alternatively,

I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

States generally enforce medical advance directives; for instance, the California Probate Code allows an individual to sue a health care provider who intentionally violates his medical advance directive for $2500 or actual damages, whichever is greater, plus attorney’s fees.

Unfortunately, much of the power of a medical advance directive is removed by “conscience” provisions, such as California Probate Code 4734, which provides in part that

A health care provider may decline to comply with an individual health care instruction or health care decision for reasons of conscience.

A conscientious objector must notify the patient and arrange transfer as soon as possible to a health care provider who will comply with the advance directive. Meanwhile, he is to provide “continuing care” to the patient – in many cases, exactly what the patient hoped to avoid by creating an advance directive.

2. Psychiatric Advance Directives and the Americans with Disabilities Act

Psychiatric advance directives contemplate future psychiatric care and specify which treatments a person consents to or refuses. Psychiatric advance directives are much less accepted than ordinary medical advance directives, as forced psychiatric treatment is widely considered to be unquestionably ethical, even if the patient refused it in advance while competent. Even where existent, psychiatric advance directives are typically laughably minimal in scope. A typical psychiatric advance directive provision, published by Protection and Advocacy, Inc. of California, provides in part:

If during my admission or commitment to a mental health treatment facility it is determined that I am engaging in behavior that may make emergency intervention necessary, I prefer the following choices to help me regain control:

  • Provide a quiet private place
  • Have a staff member of my choice talk with me one-on-one
  • Assist me with telephoning a friend or family member
  • Allow me to go outside
  • Provide me with materials to journal or do artwork

Other common provisions include the refusal of certain medications and the refusal of electroconvulsive therapy.

What I find striking about the above list (aside from its infantilizing nature) is the level of coercion it assumes and accepts as part of treatment (“allow” me to go outside?). Nevertheless, states have often refused to enforce even such minimal provisions.

In 1999, a schizophrenic Vermont woman named Nancy Hargrave executed a psychiatric advance directive refusing “any and all anti-psychotic, neuroleptic, psychotropic or psychoactive medications,” and electroconvulsive therapy. She then sued to ensure that her directive would be enforced. The state of Vermont argued that it was free to involuntarily medicate Hargrave in violation of her advance directive because of a state law that allowed for forcible medication of “mentally ill” people who posed a danger to themselves or others – even in non-emergency situations. Hargrave argued that the state policy of refusing to honor the advance directives of people with mental illnesses, but not others, violated the Americans with Disabilities Act. The federal trial court agreed with Hargrave, and the state appealed.

In 2003, the United States Court of Appeal for the Second Circuit ruled that Vermont’s discriminatory policy – which applied only to certain mentally ill people – violated the ADA. Hargrave v. State of Vermont, 340 F.3d 27 (2d Cir. 2003). (In 2005, the plaintiffs were granted their attorney’s fees.)

It is important to note that this is a very limited victory for psychiatric advance directives. That said, the trial court’s position is very promising:

The very nature of a [medical advance directive] is to ensure that individuals, competent at the time of its creation, are protected from unwanted medical interventions at a time when they are no longer competent. For individuals facing physical illness and disability, their ability to preclude certain life saving treatment to which they might be subjected at a later point when they are not competent to voice a decision is protected by a previously executed [directive]. There is no question that at the time a particular medical treatment is at issue, an individual’s physical illness might be terminal without the treatment. Thus, a prior decision to forego medical intervention necessary to sustain life is permitted for the physically ill or disabled, even though at the time of the incapacity, rejection of the treatment could be seen as posing a “danger to themselves.” In fact, that is the very purpose behind legislation permitting individuals to execute prior health directives such as Vermont’s [directive]. While there is no provision in Vermont law to compel an incompetent physically disabled individual to undergo treatment in violation of a [medical advance directive], even if that treatment is needed to save the individual’s life, the State would have the Court declare that because a mentally ill individual at a particular point in time poses a danger to herself, her prior wishes to forego medical treatment calculated to abate the danger can be ignored. Hargrave v. State of Vermont, No. 2:99-CV-128 (D. Vt. Jan. 11, 2000). [Bolded emphasis mine; italics in original.]

The Second Circuit likewise focuses on dangerousness to others as the only relevant exception to ADA protection – not danger to oneself – but its language is not nearly as liberty-affirming as that of the trial court.

3. Suicide and the Police Power

An important challenge to the right to die is the idea that the police power of the government applies to the prevention of suicides. Justice Scalia has been a great defender of this idea, as in his concurring opinion in Cruzan. Scalia’s position is that not even a competent person has a Constitutional right to be free from bodily interference if that bodily interference is directed toward preventing his suicide. He writes:

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.

True to form, Scalia provides no hint of an ethical argument justifying his position; he merely repeatedly refers to the fact that suicide was a felony at common law. He specifically states that, under the Constitution, “the power of the State to prohibit suicide is unquestionable.” What is suicide to Justice Scalia? Actually, it includes not only what we would normally consider acts of suicide, but also ordinary advance directives calling for the removal of life support if a person will never regain consciousness.

Scalia is, of course, the same enlightened figure who defended torture because he thought a character on a television show was doing it right. Intellectual giants like Justice Scalia remain on our bench and continue to make decisions that affect the lives – and deaths – of all of us lesser creatures.

Suicide Rate Is Highest Just After Psychiatric Hospitalization

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If psychiatric hospitalization is so effective, why is the suicide rate highest immediately after release from the hospital?

A massive study (1,185,727 patient-years) published in January (“Higher-risk periods for suicide among VA patients receiving depression treatment: Prioritizing suicide prevention efforts,” M. Valenstein et al., Journal of Affective Disorders, Volume 112, Issues 1-3, January 2009, Pages 50-58) on a military veteran population being treated for depression found that suicide rates were dramatically elevated immediately following a psychiatric hospitalization.

The base suicide rate of the population was found to be 114 per 100,000 person-years. Clearly, the depressed VA patients are at a much higher suicide risk than the general population of the United States, for which the suicide rate is estimated at only 16.7 per 100,000 person-years. But the suicide rate for these depressed veterans shot up to 568 per 100,000 person-years during the 12 weeks following a psychiatric hospitalization – five times the already high base rate for the non-hospitalized depressed veterans, and 34 times that of the overall American suicide rate.

But if hospitalization were actually effective in “treating” suicidality, wouldn’t we expect the suicide rate to be quite low after a hospitalization?

One problem with this line of thinking is that we might expect only the most seriously suicidal patients to be hospitalized at all. One hypothesis is that hospitalization is effective in reducing suicidality, and that the suicide rate of hospitalized depressed veterans would have been much higher if they hadn’t been hospitalized. No study I am aware of attempts to compare the suicide rates of patients who meet criteria for hospitalization, but who are randomly assigned to be or not to be hospitalized. Given the widespread faith in hospitalization as a suicide treatment mechanism, to conduct such a study would probably be considered a breach of professional ethics toward the non-hospitalized group.

However, in the absence of data from such a study, I think the alternative hypothesis needs to be considered: that hospitalization is so horrible, demeaning, and above all ineffective, that it does nothing to prevent suicides and may actually increase one’s resolve in that direction. Far from showing caring and compassion, forced psychiatric hospitalization demonstrates to the patient that he is a prisoner. For a prisoner, there is a clear method of escape. Yes, there are people who claim to have benefited from involuntary psychiatric hospitalization, just as there are people who claim to have benefited from childhood beatings and from those wilderness camps they send bad kids to. But there are also people who have suffered involuntary hospitalization and found it to be a life-changing, demeaning experience. In fact, I think we must be suspect of the “glad it happened” group. The psychological defense mechanism of denial, the discomfort of cognitive dissonance, contribute to people interpreting past events with unwarranted optimism. As long as you can convince yourself that the involuntary hospitalization was good for you, you don’t have to admit to yourself what an insult to your dignity was done to you.

Sadly, the authors of the study are using the results to recommend yet more coercive practices. What is really needed is more intensive “treatment” following a hospitalization, they say – or a “firm connection to outpatient services,” in the Orwellian words of the study’s authors.

For those whose link to the study is gated, here’s a Washington Post summary of the study: “With Depression, Vets Face Higher Suicide Risk.”

Update: Commenter Jessa continues the discussion on coercion at her site, Made with Awesome.

Update: Zarathustra responds to my arguments here.

Update: Jim adds to the discussion here and here.

Written by Sister Y

January 12, 2009 at 10:09 pm

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

Suicide, Reeducation, and Reformed Suicides

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Deng Xiaoping’s self-criticism during the Cultural Revolution, leading to his rehabilitation (re-acceptance into the Communist Party):

Whenever I think of the damages caused by my mistakes and crimes to the revolution, I cannot help but feel guilty, shameful, regretful, and self-hateful. I fully support the efforts to use me as a negative example for lasting and penetrating criticism in order to eradicate the evil influence left by me over long years . . . . No punishment is too much for a man like me. I promise that I will never seek to reverse the verdict on me and I will never be a remorseless capitalist roader. My greatest wish is to be able to stay in the Party and I am begging the party to assign me a tiny and insignificant job at an appropriate time . . . I warmly cheer the victory of the Great Proletarian Cultural Revolution. [Deng Xioaping’s autobiography, quoted in David L. Shambaugh, Deng Xioaping: Portrait of a Chinese Statesman, p. 30.]

Langston Hughes, under questioning by the McCarthy-era Senate Permanent Subcommittee on Investigations of the Committee on Government Operations:

Mr. COHN. Let us see if we can get an answer to this: Have you
ever believed in communism?
Mr. HUGHES. Sir, I would have to know what you mean by communism to answer that truthfully, and honestly, and according to the oath.
Mr. COHN. Interpret it as broadly as you want. Have you ever believed that there is a form of government better than the one under which this country operates today?
Mr. HUGHES. No, sir, I have not.
Mr. COHN. You have never believed that?
Mr. HUGHES. No, sir.
Mr. COHN. That is your testimony under oath?
Mr. HUGHES. That is right.
. . . .
Mr. HUGHES. . . . Did you write something called Scottsboro Limited?
Mr. HUGHES. Yes, sir, I did.
Mr. COHN. Do you not think that follows the Communist party line very well?
Mr. HUGHES. It very well might have done so, although I am not sure I ever knew what the Communist party line was since it very often changed.
Mr. COHN. Mr. Hughes, when you wrote Scottsboro Limited, did you believe in what you were saying in that poem?
Mr. HUGHES. No, sir, not entirely, because I was writing in characters.
Mr. COHN. It is your testimony you were writing in character and what was said did not represent your beliefs?
Mr. HUGHES. No, sir. You cannot say I don’t believe, if I may clarify my feeling about creative writing, that when you make a character, a Klansman, for example, as I have in some of my poems, I do not, sir.
Mr. COHN. How about Scottsboro Limited, specifically. Do you believe in the message carried by that work?
Mr. HUGHES. I believe that some people did believe in it at the time.
Mr. COHN. Did you believe in it?
Mr. HUGHES. Did I?
Mr. COHN. Did you personally believe? You can answer that. Let me read you, ‘‘Rise, workers and fight, audience, fight, fight, fight, fight, the curtain is a great red flag rising to the strains of the Internationale.’’ That is pretty plain, is it not?
Mr. HUGHES. Yes, indeed it is.
Mr. COHN. Did you believe in that message when you wrote, it?
Mr. HUGHES. No, sir.
Mr. COHN. You did not believe it?
Mr. HUGHES. No, sir.
. . . .
Mr. COHN. Do you remember writing this: ‘‘Good morning, Revolution. You are the very best friend I ever had. We are going to pal around together from now on.’’
Mr. HUGHES. Yes, sir, I wrote that.
Mr. COHN. Did you write this, ‘‘Put one more ‘S’ in the USA to make it Soviet. The USA when we take control will be the USSA then.’’
Mr. HUGHES. Yes, sir, I wrote that.
. . . .
Mr. COHN. What I asked was if the quote that appears in the Daily Worker from your article is a statement by you, ‘‘If the 12 Communists are sent to jail, in a little while they will send Negroes to jail simply for being Negroes, and to concentration camps just for being colored.’’ . . . . Do you believe that today?
Mr. HUGHES. No, sir, I would not necessarily believe that today.
Mr. COHN. When did you change your views?
Mr. HUGHES. It is impossible to say exactly when one changes one’s views. One’s views change gradually, sir.[From the Executive Sessions of the Senate Permanent Subcommittee on Investigations of the Committee on Government Operations, Volume 2]

Regarding actor Owen Wilson, following Wilson’s suicide attempt:

A source told People magazine: “Owen is in bad mental shape but said he is thankful to be alive.”

“He knows he came close to ending his life, and he is happy that he was saved from himself.”

“He is basically at home with people watching him 24/7.”[Via Fametastic.]

Re-education is usually successful after suicide:

Proof that most individuals attempting suicide are ambivalent, temporarily depressed, and suffering from treatable disorders is the fact that so few, once rescued and treated, ever actually go on to commit suicide. In one American study, less than 4% of 886 suicide attempters actually went on to kill themselves in the 5 years following their initial attempt[32]. A Swedish study published in 1977 of individuals who attempted suicide at some time between 1933 and 1942 found that only 10.9% of those eventually killed themselves in the subsequent 35 years[33]. This suggests that intervention to keep an individual alive, is actually the course most likely to honor that individuals true wishes or to respect the person’s “autonomy.”[Burke J. Balch and Randall K. O’Bannon, “Why We Shouldn’t Legalize Assisted Suicide,” on the National Right to Life Committee’s website. Citations omitted.]

Written by Sister Y

June 9, 2008 at 5:45 am

Is Suicide Illegal?

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Aside from the question, “should a government be able to force people who wish to die to remain alive?” – that is, “should suicide be illegal?” – there is the question as to whether suicide really is illegal, in a meaningful sense. Many people who haven’t devoted much thought to the question don’t understand how a suicide prohibition might work (all charming quotations from All Philosophy):

how the hell do you plan to punish the people if they did it right they’d be FUCKEN dead!!! You can’tr do anything; even if it was illegal people, like me, would think about it and many do it anyway. It would be a waste of time and paper!

How could someone possibly be charged for killing themselves. I almost laugh seing the scenero of a trial. Whats gonna happen, they give someone who attempted suicide the death peanelty?

I don’t think it really matters, I mean if you are really serious about killing yourself, you’ll make sure you get the job done thus making the legality of it moot.

And my personal favorite, which sums the position up most beautifully:

how can they prosecute you when you’re dead?

It’s true – it’s impossible to really criminalize suicide, in the sense that if a person manages to successfully commit suicide, he or she is beyond the reach of the criminal justice system. But there are several ways, beyond a criminal penalty imposed on a successful suicide, that a genuine suicide prohibition is enforced.

First, the most reliable, painless methods for committing suicide are widely criminalized or at least restricted. These restrictions certainly function as prohibitions on suicide. If a would-be suicide cannot obtain a gun or appropriate medication, he or she is stuck either using a much more painful, much less reliable method, or, if he or she is not willing to do so (cut arteries or hang oneself, for instance), he or she is effectively prohibited from committing suicide.

Second, the act of assisting someone to commit suicide – even a competent adult who desperately wants to die – is widely criminalized. Those assisting terminally ill relatives in killing themselves are even routinely prosecuted for murder. This especially includes those with access to the best suicide methods, namely doctors.

Third, if a person attempts suicide but is discovered before he or she dies, he or she will be rushed to the hospital and treated, even against his or her will as stated in a medical advanced directive. The failure to respect the wishes of a suicide to refuse medical treatment functions as a legal prohibition. Some patients survive suicide attempts, only to live with severe brain damage or disfiguring physical injuries for the rest of their lives, especially if they suffer such severe injury that they are no longer practically capable of committing suicide. This is a risk of committing suicide under our current system.

Finally, there are penalties for committing suicide, such as the fact that life insurance policies may exclude suicide as a cause of death for which they must pay the decedent’s family a benefit. This focus on suicide as a decedent’s rational choice, which may respond to penalties, fails to square with the legal position underlying the forced resuscitation of suicide victims. Mandatory resuscitators (and those who support forced hospitalization for failed suicides) must hold the position that a suicide’s refusal of medical treatment is invalid, because he or she was necessarily mentally incompetent, and therefore unable to make rational decisions. However, the refusal of life insurance payouts to families of suicides relies on the assumption that the suicide is in rational control of his or her death, so that either it is unfair to expect the insurance company to pay, or the potential suicide will respond to the disincentive of no insurance payout in deciding whether to commit suicide. The positions are inconsistent. If suicide were really the result of mental incompetence, and the end of a sort of disease process, it would not be fair to exclude the families of suicides from life insurance benefits, any more than the families of cancer victims.

The Myth of the Hospital

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I have been unlucky enough to be the guest of two different psychiatric hospitals. In addition, I have worked in nine psychiatric hospitals in a professional capacity. Most people, even professional psychiatrists, have a rather naive view of what happens in a mental hospital. Private psychiatrists who spend most of their time treating private patients for depression and anxiety may have very little experience with a real psychiatric hospital. Ordinary people may get their views of psychiatric hospitals from books and movies, such as the extremely optimistic “Girl, Interrupted,” during which a forced psychiatric patient rediscovers her joy in life while receiving a great deal of individual therapy and developing relationships with other inmates.

The reality of the psychiatric hospital is, unfortunately, much bleaker than even popular culture would lead us to believe. The hospital is a good place for low-functioning people with thought disorders or severe personality disorders to get stabilized on their meds. The hospital is no place for a high-functioning depressive.

What could you expect if you were involuntarily hospitalized? First, don’t expect for there to be people like you around. Most people involuntarily hospitalized are the aforementioned low functioning folks with thought disorders (like schizophrenia) and severe personality disorders (like borderline personality disorder). “Low functioning” means that these people will mostly have a hard time engaging in normal activities of daily living, like washing themselves, feeding themselves, and having a conversation. You will share a room with one or more of these people.

You won’t get individual therapy (one-on-one talk therapy). It’s too expensive, and not very effective for the hospital’s normal clientele, those low functioning folks with thought disorders. The usual plan for low functioning people with thought disorders is to “stabilize them on meds” – they come in psychotic, they are given antipsychotic medication for a while, and their psychosis disappears. (Medication may be forced in most states. Some states require a hearing before forced medication may happen; these are generally rubber-stamp proceedings.) This process has a very high success rate for low functioning people with thought disorders; individual therapy is not seen as effective or necessary.

Generally, hospitals try to apply the stabilize-on-meds approach to high functioning depressives, with mixed results. As mentioned above, individual therapy is not available. Instead, expect mandatory “group therapy.” Group therapy, in a private, outpatient setting, is often interesting and productive, given a group of intelligent, high-functioning, thoughtful people. You will not find that in a hospital. Instead, you will find yourself in group therapy with that same group of low functioning people with thought disorders that you’ve been rooming with and eating with and smoking with during your stay. Often, group therapy takes the form of practicing activities of daily living – say, writing a letter, or washing oneself. This would be very helpful for a low functioning person with a thought disorder; it is humiliating and harmful for a high functioning depressive.

You may meet with a doctor once or twice during your stay. The doctor does not want to talk to you. The doctor wants to know if you are tolerating your meds, and if you have figured out how to answer questions about your suicidal intent correctly, so that you may be released. Most suicidal high functioning depressives quickly figure this out, and answer that they feel much better, that the meds are working fine, and that they have no further suicidal ideation.

The stabilize-on-meds approach for depressed patients is especially ridiculous, given that anti-depressant medications don’t work any better than placebos. Given that the hospital doesn’t help the high functioning depressive, except to medicate him or her, the purpose of the hospital in this context becomes clear: it is a prison. Hospitalization doesn’t help people become non-suicidal. It merely teaches the high functioning depressive to make sure he or she succeeds the next time he or she attempts suicide. And never to be honest with a doctor again about suicidal ideation.