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Is High IQ a Treatable Medical Condition?

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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?

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Written by Sister Y

October 1, 2009 at 6:44 pm

Theories of Punishment

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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

On Being Your Patients’ Keeper

with 11 comments

Sexy psych nurse Mr. Ian of MentalNurse wonders why “risk assessment” (for harm to others) is the exclusive province of mental health professionals, to the exclusion of other specialties. Medical patients other than mental patients often pose a risk to other people – but doctors and other health care workers are not expected to police them. Whose risk is it, anyway? He says:

Who says it’s my responsiblity to assess, manage and mitigate risk of harm to others?

I could flip the question – why is risk assessment and management only an obligation of the mental health sector?

Why aren’t parole boards required to meet the same standard when releasing a known violent person? They don’t even have an obligation to the offender. Their obligation is to the safety of the public.

Why can’t opticians remove someone’s license to drive when they’ve failed an eye test or GPs remove licenses from those with ‘at risk’ medical conditions? Why aren’t these people risk assessed and arrested if they fail the eye test but found driving a car?

I think the same questions can be asked for risk assessment focusing on “danger to self.”

Written by Sister Y

March 22, 2009 at 5:26 am

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

Force Feeding and Respecting Values

with 8 comments

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

Coercive Treatment: It’s Not Worth It

with 6 comments

mentalnurse.org.uk is one of the only sites I’ve seen that allows the serious consideration of the possibility that allowing suicide can be morally correct, and that forcing people to stay alive through coercive “treatment” is often a moral disaster.

In a post by Mr. Ian, the experience of a commenter known as “Squawk” is related: she was subject to coercive psychiatric treatment, was “cured” and came out the other side, but, like me, she does not feel that it was worth it and continues to suffer from feelings of violation:

Was the coercive treatment worth it? Was going through utter hell every day for more than a year worth it? No. I love my life now, I’m not remotely suicidal, and I hope I do good things for the world. But even for everything I have now, the threats and the heavy meds and the tubes and the completely destroying *everything* I was 5 times a day every day day after day for more than a year – no, it wasn’t worth it. Nothing could be worth that. Not my first boyfriend, or getting my degree, or the first time a patient with PMLD recognised me and smiled when she’d only ever done that to her Mum, or being able to help the people I’m now volunteering full-time with who would otherwise have nothing, or eight years of a bloody fantastic life with ups & downs & friends & adventures & fun. Another eighty years, winning 5 Nobel Prizes, and being the first person to walk on Mars wouldn’t be worth going through a severe ED & treatment. Nothing could be. [Emphasis mine.]

I am sorry for her experience and agree wholeheartedly about the after-effects of coercive treatment.

Some people, of course, are forcibly treated and are later glad about it; I suspect that these are people without a strong sense of personal dignity.

Written by Sister Y

January 1, 2009 at 9:36 pm