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At Last We Know What Causes Suicide

with 2 comments

It’s not personal agency. It’s not mental illness. It’s mixing booze and caffeine:

A wrongful death lawsuit has been filed against Phusion Projects Inc. after a Florida man got drunk on Four Loko, a controversial alcoholic energy drink, and shot himself in the head with a pistol.

The family of Jason Keiran, 20, filed the Four Loko lawsuit in Orange County Circuit Court on Friday, less than a week before the FDA issued warning letters to Phusion and other energy drink makers that it considers caffeine an unsafe additive for alcoholic beverages, which will shut down the entire alcoholic energy drink industry. [Bolded emphasis mine.]

Does this mean I can sue the bar for serving me Irish coffee or Continental Airlines for serving me DVRs?

While my inner plaintiff’s attorney loves this (my students will definitely be hearing about this when we cover product liability in a couple of weeks), I think it functions best as an example of how people are willing to elide considerations of causation when the consequence is suicide, as opposed to some other act. Imagine if the decedent in this case had killed, not himself, but his estranged girlfriend or a rival, and blamed his action on drinking caffeine-laced booze. I doubt we would be so quick to attribute causation to the cocktail in that case; voluntary intoxication and other “Twinkie defenses” to real crimes or torts, as opposed to suicide, tend to get laughed out of court.

Why do people get intellectually lazy when it comes to suicide? Why are people unwilling to attribute causation to anything but personal agency for most actions, but very willing to attribute causation to other factors when the action is suicide?

I suspect that part of it has to do with the commonly-held idea that suicide is actually mysterious. Because non-suicidal people find the act of suicide so puzzling, I think, they are willing to accept the shakiest excuse as a “reason” for the suicide, without the skepticism that is normally present when addressing questions of causation for more understandable events. The task is to make suicide less mysterious and to point out problems in the evidence for causation.

Another reason I have considered for this species of intellectual laziness is that it follows from the mental gymnastics required to pretend that suicides are not actually responsible for their actions, but that suicide is a result of mental illness and outside the control of the actor. As I have previously written:

The more an actor is seen as the agent of his actions, the less outside influences are seen as affecting his actions. Therefore, in cases where moral responsibility is strongly attributed to an actor, outside influences are unlikely to be taken seriously as a cause of his actions – and, therefore, it is not necessary to censor these “outside influences” (such as media reports).

It is my belief that the widespread voluntary censorship of reports of suicide – from use of politically correct language to pervasive norms of message content – are the result of the modern trend to exculpate suicides from moral responsibility and redefine suicide as an act of insanity. There is, however, little evidence that suicides are any less morally responsible for their actions than murderers. Certainly, many other behaviors are media-contagious – but they are not censored, nor are many of them even studied.

I think that one possible explanation is that, at a deep level, people understand that suicide is just not that bad compared to actual acts of violence – despite hysterical language describing suicide as “self-murder.” We want to exculpate people from acts to which we are sympathetic. While we often refuse to define acts outside of societal norms as “not wrong,” we may nonetheless refuse to attribute full moral responsibility to these acts. However, this sort of sympathy backfires in our society. People who are “not responsible for their actions” must be “protected,” often in painful and dehumanizing ways; and society is responsible for their “protection,” often to the detriment of freedom.

Unfortunately, policy recommendations are often built on these shaky connections.

Plus, we all know that it’s actually internet video game addiction that causes suicide.

Thanks Chip.

Written by Sister Y

November 18, 2010 at 8:32 pm

Posted in causation, suicide, tort law

Suicide and Leprosy: The Ethics of Voluntary Isolation

with 10 comments

Imagine a person with leprosy, in the days before the invention of dapsone. This person has done nothing wrong to contract leprosy; nevertheless, there are certain precautions that this person could take to avoid transmitting the disease to others: namely, isolation. This person does not in any sense deserve either leprosy or isolation; nevertheless, the morally right thing to do is for this person to voluntarily isolate herself away from those who have not contracted the disease, including her own family and friends.

Similarly, although a potential suicide has done nothing wrong to be born, and although, I argue, the action of committing suicide is not morally wrong, the suicide can limit the harm his suicide will cause to those close to him by voluntarily isolating himself prior to committing suicide, just like the person with leprosy.

The suicide of one’s spouse or lover is much more devastating and personally affecting than the suicide of one’s former spouse or lover. While the latter may be painful and induce unpleasant feelings on the part of the surviving ex-lover or ex-spouse, it has much less chance of producing the shock and despair that are often the result of the suicide of one’s current spouse or lover. Given this clear differential of harm, I think a suicide owes a duty to his lover or spouse to end the relationship well prior to committing suicide.

This rationale also holds true for one’s friends. The suicide of a close friend is bound to be traumatic; however, the suicide of a former friend to whom one hasn’t spoken in years may barely affect one at all, beyond prodding some interesting reflection on life and mortality. Suicides should think carefully about ending close social relationships well ahead of the act in order to lessen the harm the act may cause.

Family relationships may not, as a practical matter, be ended. I am not sure what can be done to lessen the pain of one’s suicide to one’s relatives. My own informal study of news reports of various suicides seems to indicate, however, that family members are most accepting of the suicide of a close relative when they were aware of the suicidal person making a great effort to live during his life. The suicide of a person who “tried everything,” who struggled mightily during his life, and whose desire to die was obvious for a long time, seems to be less emotionally devastating to his family than a suicide that the family perceives as impulsive or random.

Finally, if a person decides conclusively to commit suicide, it is morally imperative to end any therapeutic relationship with a psychologist or psychiatrist, leaving as long an interval as possible between the end of the therapeutic relationship and the suicide. First, it is hard to imagine a therapist not feeling responsible for the death of his patient, whereas a former therapist may not hear of the suicide at all, and if he does, will likely feel less responsible for the death. Second, the suicide must recognize that his therapist may actually be sued by his survivors for failing to prevent his suicide. Someone who commits suicide months or years after formally ending the therapeutic relationship will not put his therapist in this troubling situation.

Written by Sister Y

September 30, 2008 at 8:10 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

Tort Law and the Harm of Death

with 5 comments

A question related both to philanthropic antinatalism (especially what some see as its apocalyptic implications) and to suicide rights is the question of whether death is a harm to the person who dies. Objections to death being a harm to the deceased person are that nothing can be a harm unless it is perceived by the harmed person, and that, if there are non-conscious harms, it is difficult to assign the harm to a subject. Thomas Nagel, in his essay “Death,” in Mortal Questions, grounds the special harm of death in the idea of deprivation: the subject is deprived (of future experiences), so to the extent that his life would have been worth continuing, he is harmed by death.

But even if death deprives a person of something, what harm is it to him, since he does not suffer by the deprivation? The case that Nagel finds convincing is that of an intelligent adult reduced, through traumatic brain injury, to the mental capacity of an infant. Surely, for Nagel, this person has been harmed, though he does not realize it or perceive it. Nagel, however, imagines this objection, which I imagine would be Jim’s objection:

He does not mind his condition. It is in fact the same condition he was in at the age of three months, except that he is bigger. If we did not pity him then, why pity him now; in any case, who is there to pity? The intelligent adult has disappeared, and for a creature like the one before us, happiness consists in a full stomach and a dry diaper. [Prurient emphasis mine.]

Nagel, of course, does not find this objection persuasive. He sees the harm as occurring, not to the brain-damaged person, but to the healthy person prior to the injury, in having been reduced to such a state. In other words, Nagel is willing to assign harm backwards in time. But is this so strange?

For a long time, I had a hard time intuitively understanding sexual jealousy. It seemed to have about the same objective reality as the cultural tradition of celebrating birthdays or saying “bless you” when someone sneezes. And, as an irrational, ridiculous, harmful social construct, it deserved no respect, and existed only to be eradicated. However, I have since been convinced by evolutionary psychology data that sexual jealousy is very much real, in the sense that it is not “socially constructed” like birthdays, and causes people genuine anguish. Though it is not intuitive to me, it is only proper to recognize that other people feel harmed by it, rather than assume they are making it all up. (Incidentally, the violent sexual jealousy suffered by humans, coupled with the sexual exuberance that humans also display, seems to function as a very real limitation on human happiness, at least given our current biological make-up.)

If harm can never occur unless someone perceives it as a harm, then we must take the position that sexual infidelity does no harm to the cuckolded partner, even where monogamy is promised, unless it is discovered. This presents two problems. First, it conflicts with the widely-held intuition that sexual infidelity is a harm to the unaware partner. If you refuse to sleep with your friend’s girl, you say, “I wouldn’t do that to my buddy” – not “I wouldn’t do that because it might get discovered.” Second, and related to this, is that when a person discovers that he has been betrayed sexually, he does not date the harm to the discovery; he dates it, most certainly, to the incident of the infidelity. (He is not sad that he found out; given the infidelity, he will probably say he is glad to have found out. He is sad that the infidelity occurred.) In cases like this, at least, it is common to backwards-date harm; are we forbidden to do this with the harm of death simply because, given our conception of time, causality cannot actually move backwards?

I must say that I am not entirely convinced of the rightness of either position; the idea that harm can occur when there is no one to perceive it is intuitively strange to me, but the objections commonly offered do not leave my mind easy, either. (See O.H. Green’s “Fear of Death,” in Philosophy and Phenomenological Research, Vol. 43, No. 1, Sep. 1982, pp. 99-105, for a view on how death may be wrong (or “evil”) without actually being a harm.) I am persuaded by the arguments, however, and by the obviously conflicting intuitions of others, to the point where I have severe doubts about the goodness of ending life where a person wishes to continue to live, as prescribed in the “apocalyptic imperative” case.

I want to digress briefly to point out that, in the above-mentioned essay, “Death,” Nagel articulates both a pro-natalist position and the idea that not being born is not a misfortune (usually the more contentious half of the antinatalist asymmetry) in the same paragraph:

The fact that Beethoven had no children may have been a cause of regret to him, or a sad thing for the world, but it cannot be described as a misfortune for the children that he never had. All of us, I believe, are fortunate to have been born. But unless good and ill can be assigned to an embryo, or even to an unconnected pair of gametes, it cannot be said that not to be born is a misfortune.

But back to the harm of death. What I want to explain here is that American tort law, interestingly, accords with the view that death is not a harm to the person who dies, even when that person is killed by the wrongdoing of another!

When a person dies through the wrongful act of another, whether negligent, reckless, or intentional, there are two separate lawsuits (“causes of action,” in legalspeak) that may be pursued. First is what is called the survival action. To call it a “survival action” means that the right to sue existed while the person was alive, and continues after his death. (If someone is legally wronged during his life, he does not lose the right to sue for a remedy if he dies; his estate retains the right to sue for wrongs committed against him during his life.) Second is the wrongful death action, created by statute, to give the relatives of a deceased person a remedy for being deprived of his company and support.

The reason I claim that tort law accords with the notion that death is not a harm to the dead person is that, in the survival action, the decedent may only recover for harm that he experienced during his life. He may recover, for instance, medical expensed incurred prior to death, and for pain and suffering experienced prior to his death. But he gets nothing for being deprived of his life. As the court in the O.J. Simpson civil appeal (Rufo v. Simpson, (2002) 86 Cal. App. 4th 573) noted, in very quick killings, the only “compensatory damages” available may be for the damage to the victim’s clothing. (Punitive damages are available, interestingly, in the survival action for an intentional killing, even if compensatory damages are quite small; this accords with the strange idea proposed by O.H. Green that death may be evil, but not a harm!)

The harm of the death itself is recognized only in the wrongful death action – that is, as a harm to the survivors, not to the decedent himself. Interestingly, this is applied even where the survivors are suing a mental health practitioner for failing to prevent a suicide – the damage is recognized as harming the survivors, not the decedent. It is hard to square tort law’s failure to recognize death as a harm to the decedent with the alacrity with which other areas of the law impede suicide.

Apparently Eliezer Yudkowsky thinks death is a harm, though he doesn’t explain to whom, because “death events” create “negative utility.” Negative utility to survivors? Potential dead people who might fear death? In any case, how can something create negative utility if the people whose utility is to be measured are all dead? Surely there’s someone who’d be very happy to be alone in the world, happier than the average person currently alive. (Average utilitarianism suffers from some of the same problems as utilitarianism based on summing utility.)

[Quotation from poster]Unknown:

“Besides (in the usual single world): is Eliezer willing to kill off everyone except the happiest person, therefore raising the average?”

No. Because that creates Death events, which are very large negative utilities.

Sigh. Seriously, though, dude’s brilliant and I’d like to know what his essential values are.

Edit: Eliezer points to an explanation of his views on happiness and value in his essay, “Not for the Sake of Happiness (Alone).”

Written by Sister Y

June 5, 2008 at 1:22 pm