The View from Hell

Just another site

Archive for the ‘medical ethics’ Category

Is High IQ a Treatable Medical Condition?

with 18 comments

I have argued for a right to suicide grounded in personal freedom and dignity; I have argued that there is, in addition, no right to forcibly prevent people from committing suicide. My views on this extreme example of patient choice still apply; but what about less extreme solutions to suffering?

The predominant view of medicine seems to be a doctor-controlled, paternalist one. We must all get a doctor’s permission to access most drugs; most people apparently do not find this to be a serious intrusion into privacy and dignity. I think a better view of medicine is that of a doctor as a consultant, who assists the patient with medical knowledge and advice, but does not ultimately control the patient’s treatment.

What is the purpose of medicine? (Please feel free to answer this below – it’s not just rhetorical.) Is it to relieve suffering? To enforce proper behavior? To extend life? Certain definitions of medicine’s purpose (like that last one) rely on idiosyncratic values that perhaps should not be forced on others. A fairly radical, but I think value-neutral, definition of the purpose of medicine might be: to assist patients in maximizing their own values by providing knowledge of human biological systems and applying available medical techniques as chosen by the patient.

One of these might be a prescription for Nembutal.

But another of these “available medical techniques” might help a patient reduce his general intelligence in various ways if it is a burden to him.

The DSM-IV definitions of diseases tends to include the rider that the symptoms “cause marked distress” to the patient. Perhaps it is time to consider whether conditions thought to be desirable that “cause marked distress” should also be treatable.

High intelligence is clearly treatable with a variety of substances and treatments, from ECT to antipsychotics to medical cannabis. If, say, extremely good memory or other symptoms of high intelligence are a burden to the patient, shouldn’t he be entitled to use available technology to eliminate them? And why not have a physician’s advice on how to do it in a manner that maximizes the patient’s other values?

Is it different from suicide?


Written by Sister Y

October 1, 2009 at 6:44 pm

Theories of Punishment

with 2 comments

Suicide is the only action that is not a crime that may be prevented by force.

Criminal justice is the formal practice of preventing and punishing proscribed behaviors.

There are five generally recognized theories of punishment, in criminal justice terms:

  • General deterrence means making an example of a criminal so that the population at large will be deterred from committing a crime.
  • Specific deterrence refers to punishing an individual criminal so that he or she will “think twice” and be deterred from committing a crime in the future.
  • Incapacitation means isolating and/or restraining a criminal so that he or she will not be able to commit a crime for the duration of the incapacitation.
  • Rehabilitation refers to providing assistance to a criminal so that he or she will not want or need to commit a crime in the future.
  • Retribution involves taking revenge on a criminal for the crime that he or she committed.

Deterrence, incapacitation, and rehabilitation models aim to prevent crime. Deterrence and rehabilitation models operate on the criminal’s mind, whereas the incapacitation model operates only on his body.

Suicidality is often considered to be a mental illness, properly considered to be within the purview of medicine; however, the interventions that are commonly undertaken in cases of suicidality demonstrate that the act is properly viewed as part of the criminal justice model.

The key feature of suicide: it is the only action that is not a crime that may be prevented by force.[1]

The prevention of suicide generally takes punitive, rather than medical, form. Generally, the methods used are incapacitative:

Because [preventing a determined person from committing suicide] is impossible, psychiatrists enjoy (if that is the right word) virtually unlimited professional discretion to employ the most destructive suicide-prevention measures imaginable, provided the measures are called “treatments.” The authoritative American Handbook of Psychiatry (1959 edition) endorsed lobotomy “for patients who are threatened with disability or suicide and for whom no other method seems likely to relieve or restore them.” In the 1974 edition, lobotomy was replaced by electroshock treatment administered in sufficient doses to destroy the subject’s will to kill himself: “[W]e do advocate its initial use for one type of patient, the agitated patient, often middle-aged and usually a man, who presents frank suicidal intention. We give ECT [electroconvulsive therapy] to such a patient . . . daily until mental confusion supervenes and reduces the ability of the patient to carry out his suicidal drive.” Thomas Szasz, Fatal Freedom: The Ethics and Politics of Suicide, pp. 56-57 (citations omitted). [Emphasis mine.]

However, often the methods used are so obviously unpleasant that they fall under the deterrent models as well – if not the retributional models!

In they Army, anyone reporting suicidal ideation is made to wear a bright orange vest and rubber bands in place of his shoelaces – not to mention watched 24/7 by a “buddy.” As reported by Elspeth Reeve:

Suicide watch (also called unit watch, buddy watch, or command interest profile) is how the Army deals with soldiers in garrison who express suicidal thoughts but don’t appear to be in immediate danger of harming themselves. It’s been around in some form since the 1980s, and generally involves a suicidal soldier being watched by one or two fellow soldiers around the clock, and having his gun, shoelaces, and belt taken away, so he can’t kill himself.

. . . . “You’re in an isolated state,” [a recruit who was under suicide watch] says. The orange vest makes you a pariah. “You’ve got the reason you’re on suicide watch to begin with on top of the fact that you stick out like a sore thumb,” he says. “It’s like you’re walking around in a zoo, and you’re the animal.”

. . . . The purpose of the vest is, ostensibly, to make it easy for others to keep an eye on a suicidal soldier, but forcing a soldier to advertise his own depression creates a powerful stigma. “When you see what happens to someone on suicide watch—the orange vest, the trips to the chaplain, the drill sergeant talking about them when they’re not there, saying they can’t handle the military. … When you see that, you’re going to think twice about speaking up and saying you need some help. It makes you not want to talk to someone. You don’t want to be like that guy,” the recruit from Benning says. [Emphasis mine.]

The Army’s treatment of suicidality is clearly punitive. Indeed, there is a strong incentive for soldiers to express insincere suicidality – that is, removal from combat duty. This would make it seem rational for the Army to institute counterincentives (conceding, implicitly, that suicidal behavior is rational in that it responds to incentives). But, as Reeve indicates, the punishment also dissuades genuine suicides from disclosing suicidal ideation.

At any rate, the “treatment” is clearly not rehabilitative, but punitive. General and specific deterrence are at work here, as well as incapacitation.

Similarly, from prisons to mental hospitals, disgusting and punitive “interventions” are used to prevent suicide. This is “mental health treatment” only in the most crudely and obsoletely behavioralist sense. Humiliating heavy dresses/smocks, presumably worn without underwear, are placed on male and female prisoners (of hospitals and prisons) to prevent them from committing suicide.[2] Again, general and specific deterrence are operative, as well as incapacitation. The smock is awful and undesirable, in addition to preventing one from enacting one’s suicidal wishes.

If suicide is a symptom of a mental illness, though, wouldn’t the distress be treated – not the action? People with trichotillomania do not have their hands forcibly restrained from touching their heads. Rather, the distressing compulsion to pull one’s hair is treated – and that only if it distresses the patient in the first place. In the case of suicide, however, the distress of everyone except that of the suicidal person is considered. If suicidal ideation does not cause one marked distress, why is it a mental illness?

The truth is that, despite the ostensible decriminalization of suicide, modern society still encounters suicide under a criminal model. The extreme position of Justice Scalia is, unfortunately, the one tacitly held by our government in general:

“At common law in England, a suicide – defined as one who “deliberately puts an end to his own existence, or commits any unlawful malicious act, the consequence of which is his own death,” 4 W. Blackstone, Commentaries *189 – was criminally liable. Ibid. Although the States abolished the penalties imposed by the common law (i.e., forfeiture and ignominious burial), they did so to spare the innocent family, and not to legitimize the act.” Cruzan v. Director, MDH, 497 U.S. 261 (1990).

Thanks Rob Sica.

1. I realize it may be necessary to distinguish civil injunctions, and civil contempt actions, here. Civil injunctions are ordered only in the case of irreparable harm to others. And, to be punished – by fine or jail – a contempt action must be proved beyond a reasonable doubt. Neither of these criteria are in place in the case of suicide. And, just to be clear, civil injunctions are by far an exceptional case. Money damages are by far the preferred remedy, when they are at all applicable.

2. Gawker says, “It’s weird these models don’t get more work! They are really selling the look. ‘Show me ‘I sure wish I could kill myself but this smock is impossible to rip into strangle-friendly strips’! Perfect.'”

Written by Sister Y

May 16, 2009 at 3:57 am

Suicide But Not Assisted Suicide

with 2 comments

To say – as Ezekiel Emanuel, the Chair of the Department of Bioethics at the National Institutes of Health, has said – that there should be a right to suicide, but not to medically assisted suicide, is exactly as coherent as saying that there should be a right to abortion, but not to medically assisted abortion.

Telling a would-be suicide that he has a perfectly good legal right to commit suicide, and is free to shoot, hang, or cut himself, makes as much moral sense as assuring a pregnant 14-year-old that she has a perfectly good legal right to an abortion, and is free to self-abort with a knitting needle.

Written by Sister Y

January 30, 2009 at 9:24 pm

"Philosophical Therapy" and the Poverty of Psychology

with 3 comments

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

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

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

Can death be rationally desired?

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

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

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

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

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

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

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

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

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

Written by Sister Y

December 30, 2008 at 2:57 am

The Harms of Suicide

leave a comment »

Citizens considering the issue of suicide generally fall into one of two camps: those who condemn suicide (and people who commit it) on moral grounds, and those who, while acknowledging suicide’s awfulness, excuse those who commit suicide on grounds of mental illness. Along with Thomas Szasz, I fall outside either camp: suicide is a choice for which the actor is responsible – he is not automatically mentally ill for having chosen suicide – but I doubt whether it is often a morally wrong choice. Suicide is both usually morally permissible, and a genuine choice for which the actor bears moral responsibility.

In the interest of clarifying the moral issue of suicide, I wish to catalog the harms attributed to suicide, and, to the degree that space permits, to examine each harm in terms of blameworthiness and in relation to similar types of harm inflicted in other ways.

1. Harm to Survivors – Friends, Relatives, and Others

Suicide opponents often call suicide a form of murder – self-murder. The suicide is viewed as improperly taking himself away from his friends and relatives earlier than they expected – frustrating their expectations.

However, comparing suicide and murder is problematic. People who die by suicide are not “victims” in the sense that people who die by murder are. Consent is a powerful element, transforming rape into consensual sex, slavery into work, kidnapping into a vacation. A suicide’s survivors are not victims, I will argue, because the type of harm that they suffer is a type of harm that the suicide himself, and not a murderer, has a right to inflict as a double effect of refusing to live.

And it cannot be that the harm to survivors is the only – or even the major – reason that murder is wrong. The murder of a lonely person with no relatives is surely no less horrible (or not much less horrible) than the murder of a person with many relatives. Daly & Wilson point out that “tribal people may explain a particular act of seemingly unprovoked homicide to an appalled missionary or anthropologist by pointing out that the victim had no relatives” – that is, there was no danger of retaliation – but to a modern mind, this is hardly a moral defense (Homicide, p. 228).

How much of the harm to survivors is due, not to the suicide itself, but to the suicide prohibition? An ASBS writer writing as “EverDawn” asserts that a great deal of the harm to survivors of suicide – in particular, the perception of suicide as “tragic” – is an artifact of the policy of suicide prevention and its attendant doctrines:

Perceiving an event as tragic makes it difficult to come to terms with, in contrast to an event which is just sad. If a sad event couldn’t have and shouldn’t have been prevented, then there is no blame to be placed, and nobody to be angry at. But a tragic event raises the questions: how could it be prevented, who should have prevented it. This leads to anger (when blaming others) and despair (when blaming self). The questions linger on, unanswered, making it far more difficult to come to terms with the event.

We have been led to believe that suicide should be prevented because suicide is tragic, when in fact, the reason why suicide is tragic is because society has chosen a policy of suicide prevention. Suicide is a sad event, however, the perception of suicide as tragic is a result of the choice society has made – a choice which society is responsible for. Ultimately, society is to blame for the negative consequences of this choice. [Emphasis mine.]

a. Loss of Company, Support, and Other Expected Goods

The most commonly cited harm inflicted by suicide is the harm to the surviving friends and relatives. What, exactly, does that harm consist of? Certainly, it is not merely the fact that the person has died. Everyone dies eventually; suicides are not unique in this. Family and friends must eventually come to terms with all of our deaths. The only special harm attributable to the suicide is that he has died early. The survivors are deprived of an expected period of the company and support of the person who has committed suicide – specifically, that period between the time of suicide and the time the person would have otherwise died. During that time, the lover or spouse no longer enjoys the affection of the suicide, the relative no longer enjoys his visits and presents and sidewalk-shoveling, the friend no longer enjoys his opinions and companionship, the parent may no longer hope for grandchildren.

The problem is that little of this “company and support” (and reproductive capacity) is morally obligatory. A person may, without committing a moral wrong, leave his spouse due to irreconcilable differences or move away from his friends and relatives to pursue a career or refuse to have children. Providing our company is a voluntary act, and we are under no moral obligation to do so. The company and support of a person is a privilege, not a right – with the important exception of a person’s voluntarily conceived children (there is a moral duty to care for one’s children that renders the suicide of a parent of dependent children, rebuttably, wrong).

The losses inherent in a suicide are real, but unlike the losses inherent in a murder, they may be inflicted in the exercise of a moral right. At the very least, we are generally permitted to inflict those losses in other contexts. If suicide is prohibited because of the harm to our mothers, should we also be legally forbidden to move away from our mothers?

(See also, “Is Suicide a Waste?“)

b. Knowledge of Permanent Loss

A loss of companionship and support is upsetting, but perhaps a suicide is worse than moving away, because it creates a knowledge in the survivors that the loss is permanent. It removes hope of an eventual return and reconciliation.

But do people have a right to this (often irrational) hope? Move-away losses and other estrangements are frequently permanent. While the knowledge of the permanence of the loss may be painful, it is also valuable to know the truth. The survivor of a suicide may be in this way better off than the person left behind in an estrangement he stupidly refuses to admit is permanent.

c. Discovering and Disposing of the Body

A very visceral harm must be suffered by someone in any suicide: the discovery and disposal of the body. Where the discoverer is a relative or close associate, the shock must be even greater.

While discovering the body of one’s spouse or friend or child must necessarily be awful, it is (a) an artifact of the suicide prohibition that this must happen, and (b) possibly preferable to a suicide’s being “missing” for days or weeks (or more) prior to discovery. Given the suicide prohibition, privacy and a controlled environment are essential to a suicide’s success; his own home is often the only place where these are possible. Legal, preplanned suicide, perhaps taking place in a hospital, would eliminate this harm. (See “In Defense of the Man Whose Wife Finds Him Hanged” for more on this.)

Frequently, as with suicides who jump in front of trains, another must suffer the great harm of being the unwilling agent of death for the suicide. This is unfortunate, and I see these suicides as particularly morally questionable. However, this harm (in fact, this type of suicide) is an artifact of the suicide prohibition and would disappear if reliable suicide that did not cause harm to bystanders were commonly available.

Everyone dies of something. And we can’t bury ourselves. Therefore, for every human being who has ever lived, someone must discover and dispose of the body (except, perhaps, for those who expect to be bodily lifted to Heaven by fairies upon expiring). It is mistaken to attribute this harm only to suicides. It is part of our humanity that we must inflict this harm on others – suicides and non-suicides alike.

2. Harm to the Suicide Himself

Those comfortable with paternalism often argue that suicide must be prevented – indeed, it displays a lack of compassion to allow it – because of the harm to the suicide himself.

a. Loss of Future Experiences

The harm inflicted by the suicide upon himself must be the deprivation of future experiences. Think of all the puppies and sunsets the successful suicide will miss out on!

However, by committing suicide, a person affirms that, in his evaluation, the expected future gains from living are not worth the expected costs. A number of people support this line of thinking when in comes to people dying of a terminal illness. But why would people dying of a terminal illness be the only people miserable enough to rationally want to die? Hope is not necessarily rational. Prohibiting suicide amounts to substituting one’s own (poorly informed) judgment for the suicide’s own (immeasurably better informed) judgment of the degree to which his life is worth living.

I have argued elsewhere that suicide is not, as many believe, the irrational product of mental illness. But what about suicide committed on impulse? Perhaps a person’s “self” evaluates the situation at time t and decides that suicide is preferable, but later, at time t plus 24 hours, he might decide he was mistaken, and dearly wish to keep living.

First, given the existing barriers to suicide, a suicide that appears “impulsive” may actually reflect the genuine rational desires of the suicide. The person who rationally prefers to die may be unfairly prevented from doing so by legal and practical barriers; he may need an “impulse” to push him over the edge and enact his rational desire. (I experienced this with my most serious suicide attempt, and I would definitely feel benefited from a renewed “impulse.”)

Second, there is evidence that suicidality is not impulsive and fleeting, but is in fact very permanent over the lifespan.

Third, even if we could be certain that a would-be suicide would be glad to be rescued (we can’t), this would not be a strong moral reason to prohibit suicide. The victim’s being “glad it happened” after the fact does not render interference morally justifiable.

b. Harm from an Unsuccessful Suicide Attempt

Harm inflicted by an unsuccessful suicide attempt is entirely an artifact of the suicide prohibition, not a harm inherent in suicide.

c. Failed Signaling

Many consider the proper response to a suicide attempt to be to universally interpret it as a cry for help. A successful suicide may be seen, then, as a failed signal for help. But this attitude benefits neither serious suicides, nor would-be signalers! Again, the idea of “failed signaling” is an artifact of the suicide prohibition.

In order for a person to send a reliable signal, the suicide attempt must appear lethal while not actually being lethal. If comfortable, reliable suicide were legally and practically available, there would be very little value in choosing any other method, and any other method would be less lethal than the medical option. This would interfere with the apparent lethality communicated by a suicide attempt, thereby decreasing the motivation to make a “signal” attempt in the first place.

What an insincere suicide attempter – a “signaler” – really wants is to be rescued. That is, he wants to be forcibly prevented from committing suicide, because he does not really want to commit suicide. Remove the possibility for rescue, and you remove this insincere suicide’s motivation to make the potentially harmful attempt in the first place. It is the suicide prohibition, and not suicide itself, that causes this harm to the would-be signaler.

Written by Sister Y

November 11, 2008 at 5:46 am

The "Unwanted Life" Diagnosis

with 2 comments

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