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Force Feeding and Respecting Values

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Is it morally right to force-feed anorexic patients? To interfere with a suicide attempt? I think the better question is not whether it is always acceptable or always unacceptable. Better that we ask, when is it morally correct to intervene in the potentially lethal action of another?

Zarathustra at Mental Nurse wrote a piece in September about using degrading, humiliating, coercive means to force patients with eating disorders to eat. He is extremely candid about the reality of force feeding, detailing the force-feeding protocol:

The protocol for serving a meal to an eating disorder patient is a no-holds-barred affair. She’s made to come to the table with her hair tied back and wearing short sleeves, wearing no watches or jewellery, so that there’s nowhere to secretly stash food. She’s then made to eat everything – everything – on the plate with a nurse watching her like a hawk. No excuses are tolerated. No “that’s got a bit of gristle on it” or “but that’s just a crumb”. The plate has to be completely cleared. Afterwards she’s made to sit resting for a full hour so she can’t go off and purge or exercise.

If she fails to complete the meal, or doesn’t complete the rest period, then she’s ordered to drink a nutritional supplement milkshake. If she refuses to do that, then she’s restrained while a nasogastric tube is passed up her nose and into her stomach to force-feed her. Nasogastric feeding is so unpleasant that few of the girls have to have it done more than once. As coercive psychiatry goes, you don’t get much more coercive than this. [Emphasis mine.]

At the end of this litany of horrors, though, Zarathustra wonders – if it saves the girl’s life, what’s so wrong with that?

The short answer is that, for many people, there are things that are more important than life.

I have written in the past that it is sometimes permissible to save a person’s life against his will. I propose two criteria for this:

  1. Because of a condition that clearly destroys the person’s ability to act in his own genuine interests, such as an acute confusional state in a person who is otherwise lucid, the person is not acting in his own interests (note that I mean his own interests, according to his own values, not his “best interests” as defined by others); and
  2. there is substantial evidence that the person, in his lucid state, values his life more than he values being free from the kind of intrusion that would save his life.

I think it was Dr. Maurice Bernstein of the Bioethics Discussion Blog who said that, faced with an anorexic patient who was refusing to eat and would die without intervention, but still said she wanted to live, he would opt to force-feed. This actually accords well with my model of a time when it is appropriate to intervene: when it accords with the patient’s ascertainable values. (I am not sure my first prong is met – anorexia nervosa seems to be more of a life-long condition rather than a sudden-onset break with reality. This is the hardest prong to define and apply[1].)

But if an anorexic patient values her bodily inviolability, her dignity, more than she values her life – then it is morally wrong, and damaging to her as a human being, to stick a nasogastric tube down her throat. There are some things that are more important – to her – than her life. How can it be right to ignore her values and humiliate her in furtherance of protecting her life from damage she herself may do to it?

A similar model may be helpful in determining when it is appropriate to interfere with a suicide. Some people who attempt suicide really want to die, and coercive suicide prevention is a horror that they would rather die than accept (Group 1). Some people who attempt suicide genuinely want to die but fail to be in a lucid state when they make the attempt; they are forcibly “rescued” and treated, and when more lucid are grateful for the indignity of forced treatment (Group 2). And some people who attempt suicide do not really want to die at all – they have bought into what I have termed the dangerous fantasy of rescue, and count on being saved from their suicide attempts through coercive means (Group 3). (In “Attempted Suicide as a Signal,” I have articulated the way in which a policy of always interfering with suicides actually harms people who don’t wish to die – because it sets up an incentive structure that rewards them for engaging in lethal behavior.)

In my view, it is permissible to interfere with the second group’s suicide attempts if the two prongs of my test above are met – the person is experiencing an acute state of mental confusion or delusion (I don’t think DSM-IV depression qualifies here), and according to the person’s own value system (when lucid), remaining alive is more important than the humiliation and suffering involved in the proposed coercive intervention.

Group 3, suicide attempters who clearly lack a sincere intent to die, seem to me to present the easiest case. Under our current system, rescuing them – following through with the fantasy they have been fed – is the morally correct option. However, as I mentioned above, it would actually be better for them if there were a well-known public policy of not interfering with suicide attempts, because under such a system, they would have no incentive to make a potentially harmful, insincere attempt in the first place.

It is never morally permissible to coerce people in the first group to remain alive.

But, on the bridge or in the ER or on the bathroom floor of the apartment, how do you tell the difference? How can you tell whether the person belongs to Group 1 or Group 2 or Group 3? How do you know whether the bleeding, half-conscious person’s values allow for interference with his suicide attempt?

Many people fail to ask this question at all. They assume without question (a) that anyone who would attempt suicide is in a state of mental confusion sufficient to render his actions and judgment valueless, and (b) that everyone places his own life above all other values – that any humiliation or insult to dignity or loss of liberty is worth it if it saves one’s life.

I think it is true that many people hold the belief in (b), but I don’t think it’s controversial to say that not everyone values his own life over all else. If it were true, I think our race would be a race of cowards. But it is not: people are willing to die for their political and religious beliefs, and for other people, demonstrating that one’s own life is not the supreme value for everyone. And for some of us, dignity and bodily inviolability are values we hold above even life itself.

But we can, and ethically must distinguish between the two groups (Group 1 above – those who value dignity over life – and Groups 2 and 3, who want to live despite any indignities that might entail). I have previously articulated a proposal for distinguishing between these groups, with two options, as follows:

  • Radical option: Cease automatic interference with suicide attempters, and publicize this policy, to destroy the dangerous “fantasy of rescue” that might cause many people who do not genuinely want to die to make a suicide attempt, and
  • set up a procedure for medically assisted suicide (a prescription for a lethal dose of, say, barbiturates to a competent adult requester) that would be unlikely to be used by anyone not extremely serious about suicide, and
  • allow people who value their lives over any possible indignities to enter contracts while lucid to allow them to be “rescued” or forcibly treated should they become suicidal, refuse to eat, etc., as with medical advance directives;
  • Minimal option: or, as an alternative, at a minimum, establish an “opt-out” policy that would allow a competent person to execute a legally enforceable document, revocable only by the person it concerns, that would exempt him from coercive suicide prevention “treatment” and from medical “rescue” in the case of his suicide

Regardless of whether the radical or the minimal option is enacted, the following criteria would apply:

  • the suicide procedure (or execution of the opt-out document) could have a waiting period, like gun purchases or marriage or divorce, and even require multiple requests
  • requesters, to be competent, must understand the nature of death and be able to articulate a non-delusional reason for wanting to die
  • a DSM-IV diagnosis of Major Depressive Disorder would not suffice to render someone incompetent to request suicide assistance

Some things are more important than life. But life is important to many – for some, it is the most important thing. A policy like the one I have outlined would respect everyone’s values.

Thanks to mysterious, modest commenter failed poet for inspiring probably the only thinking I’ve done in weeks, which thinking led to this post.


1. If my neighbor wants to lose weight, and values losing weight, but doesn’t have the will power and determination to achieve it, would it be morally right for me to kidnap my neighbor, feed him only health food, and make him run on a treadmill two hours a day? Of course not – unless, perhaps, his values were such that the humiliation of being kidnapped and forced to run on a treadmill was nothing compared to the value of losing weight. He may hate it in the moment – people sometimes feel this way about their hired trainers or physical therapists – but if his deepest, truest value is losing weight, then I think the action is permissible, and he would probably agree. In this way, it all comes down to value – no mental illness/acute mental confusion prong is even necessary. (The only problem comes in judging which of several “selves” is speaking one’s true values. And it is tempting for a listener to assume that the “self” that articulates values close to one’s own is the true self.)

Written by Sister Y

January 6, 2009 at 1:20 am

Mark Twain’s Fairy Tale

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The Five Boons of Life
by Mark Twain

1.

     In the morning of life came the good fairy with her basket, and said:
     “Here are the gifts. Take one, leave the others. And be wary, choose wisely; oh, choose wisely! for only one of them is valuable.”
     The gifts were five: Fame, Love, Riches, Pleasure, Death. The youth said, eagerly:
     “There is no need to consider;” and he chose Pleasure.
     He went out into the world and sought out the pleasures that youth delights in. But each in its turn was short-lived and disappointing, vain and empty; and each, departing, mocked him. In the end he said: “These years I have wasted. If I could but choose again, I would choose wisely.”

2.

     The fairy appeared, and said:
     “Four of the gifts remain. Choose once more; and oh, remember – time is flying, and only one of them is precious.”
     The man considered long, then chose Love; and did not mark the tears that rose in the fairy’s eyes.
     After many, many years the man sat by a coffin, in an empty home. And he communed with himself, saying: “One by one they have gone away and left me; and now she lies here, the dearest and the last. Desolation after desolation has swept over me; for each hour of happiness the treacherous trader, Love, has sold me I have paid a thousand hours of grief. Out of my heart of hearts I curse him.”

3.

     “Choose again.” It was the fairy speaking. “The hears have taught you wisdom – surely it must be so. Three gifts remain. Only one of them has any worth – remember it, and choose warily.”
     The man reflected long, then chose Fame; and the fairy, sighing, went her way.
     Years went by and she came again, and stood behind the man where he sat solitary in the fading day, thinking. And she knew his thought:
     “My name filled the world, and its praises were on every tongue, and it seemed well with me for a little while. How little a while it was! Then came envy; then detraction; then calumny; then hate; then persecution. Then derision, which is the beginning of the end. And last of all came pity, which is the funeral of fame. Oh, the bitterness and misery of renown! target fo rmud in its prime, for contempt and compassion in its decay.”

4.

     “Choose yet again.” It was the fairy’s voice. “Two gifts remain. And do not despair. In the beginning there was but one that was precious, and it is still here.”
     “Wealth – which is power! How blind I was!” said the man. “Now, at least, life will be worth the living. I will spend, squander, dazzle. These mockers and despisers will crawl in the dirt before me, and I will feed my hungry heart with their envy. I will have all luxuries, all joys, all enchantments of the spirit, all contentments of the body that man holds dear. I will buy, buy, buy! deference, respect, esteem, worship – every pinchbeck grace of life the market of a trivial world can furnish forth. I have lost much time, and chosen badly heretofore, but let that pass: I was ignorant then, and could but take for best what seemed so.”
     Three short years went by, and a day came when the man sat shivering in a mean garret; and he was gaunt and wan and hollow-eyed, and clothed in rags; and he was gnawing a dry crust and mumbling:
     “Curse all the world’s gifts, for mockeries and gilded lies! And mis-called, every one. They are not gifts, but merely lendings. Pleasure, Love, Fame, Riches: they are but temporary disguises for lasting realities – Pain, Grief, Shame, Poverty. The fairy said true; in all her store there was but one gift which was precious, only one that was not valueless. How poor and cheap and mean I know those others now to be, compared with that inestimable one, that dear and sweet and kindly one, that steeps in dreamless and enduring sleep the pains taht persecute the body, and the shames and griefs that eat the mind and heart. Bring it! I am weary, I would rest.”

5.

     The fairy came, bringing again four of the gifts, but Death was wanting. She said:
     “I gave it to a mother’s pet, a little child. It was ignorant, but trusted me, asking me to choose for it. You did not ask me to choose.”
     “Oh, miserable me! What is there left for me?”
     “What not even you have deserved: the wanton insult of Old Age.”

Written by Sister Y

August 4, 2008 at 8:49 pm

Altruism and the Value of Life: Another Response to Velleman

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Intentionally causing one’s death in order to save another is a type of action often excluded from classification as suicide. Heroic “suicides” – pushing a child out of the way of a train, thereby killing oneself, or undertaking a military mission that benefits one’s country but guarantees death, or jumping out of a leaking lifeboat in order to save one’s companions – do not seem to be of a kind with suicides whose sole end is one’s death. As Jacques Choron puts it,

Heroic suicides are obviously quite different from those brought on by serious illness, grief, or an unbearable situation and in this sense are outside the scope of an investigation primarily for the purpose of preventing suicide as an undesirable psycho-social phenomenon. [p. 17, Suicide: An Incisive Look at Self-Destruction, by Jacques Choron. Charles Scribner’s Sons: New York, 1972.]

Heroic suicides – or, perhaps, “altruistic suicides” – are just not the same thing as “suicide” at all.

The fact remains, however, that altruistic suicides are trading their lives for something else, so that it becomes necessary, in Velleman’s terms, to examine the exchange to see if it undermines dignity. Most altruistic suicides would probably pass muster under Velleman’s terms, because in many cases what is exchanged is life for life – one’s life (and thereby essential dignity) may be exchanged to preserve the life (and thereby essential dignity) of another. The goods exchanged are of the same kind.

However, what about an altruistic suicide that was committed not to save a life, but for some other altruistic purpose? A suicidal act committed to save a child from rape or torture, for instance, or to prevent the release of classified information the leakage of which would result in mass suffering, cannot be said to exchange dignity for a good of a like kind. Suicide undertaken to prevent harm to another short of death must be seen as exchanging one’s life and dignity for “mere” interest-dependent values (such as other people not suffering or not being raped), in conflict with the inherent interest-independent value of life. Of course, we must, in Velleman’s view, allow for an exception where a suicide is committed in order to preserve someone else’s rational faculties – for that purpose, unlike preventing torture, is of a kind with life and dignity (as rational faculties are the condition precedent to dignity).

Three possibilities present themselves. First, we might maintain the strange position that heroic suicide for any purpose other than the preservation of the life of others is wrong – that it is wrong to die to prevent children from being tortured and raped – but that it is not wrong to die to preserve someone’s rational faculties for choosing their ends. Or, in the second case, in recognizing the moral propriety of heroic suicide, we can question whether “exchanging life for mere interest-dependent values” is necessarily a moral harm. Third, we might try to argue that acting in the interest of others in the heroic suicide case is somehow a like exchange after all.

I feel that this response will have little to say to those who see no problem with the first option, and can maintain a position that appears so strongly counter-intuitive and contrived. The more interesting question, for me, is whether an argument can be made that sacrificing one’s life in the mere interests of others – unconnected to maintaining their dignity – is somehow different from sacrificing one’s life in one’s own mere interests.

There seem to be cases where sacrificing oneself in another’s interest would be horrible, perhaps even so horrible as to cheapen the value of human life – such as dying to prevent minor property damage. There cannot be a blanket exception for suicide for the benefit of others. What the distinction seems to me to be is the strength of the interest – dying to prevent or relieve great suffering, in oneself or others, seems to be a morally acceptable option, whereas it’s easy to see how dying to prevent someone from chipping a nail could be morally objectionable.

Velleman indicates that suicide is wrong, even to end severe pain, as long as the pain isn’t so severe as to interfere with one’s rational faculties. I would like to know if it is also wrong, in his view, to die to end severe pain, or prevent serious suffering, in others.

Written by Sister Y

June 30, 2008 at 10:15 pm

Time

with one comment

One of the most serious ethical reasons offered for preventing a suicide is that the suicide will one day be grateful – that is, that a person’s values change over time. The suicide might wish to die now – might value death, or an end to suffering or experience, above all else – but perhaps once rescued and medicated, or perhaps years from now, the person will value life again, and will be happy to have been saved. Today’s suicide could be tomorrow’s reformed suicide.

Some have modeled human existence as consisting of a set of successive selves, such that we might describe the different values, characteristics, and interests of a person at time t, compared to those of that “same” person at time t-sub-one. Is it permissible, then, for an outsider to forcibly intervene in a person’s action at time t, in the interests of protecting the interests of that person at time t-sub-one?

Certainly, I have heard reports of people attempting suicide, being “rescued,” and eventually being grateful and glad to be alive after the fact. It is often assumed that the status of being grateful in the future is a good reason to intervene with force. But the accident of whether someone at time t-sub-one is, in fact, grateful for the intervention at time t seems like a poor justification for intervening at time t. First, there is a problem with whether the outsider actually has better information than the person at time t. Second, as I alluded to in my earlier post on depressed cognition and value, there is a question as to whether this “better information” might not, in fact, be a different set of values held by the outsider and mentally imposed on the hypothetical person at t-sub-one. Third, even if the outsider really possesses better information than the actor at time t, “better information” is not a complete justification for forcibly intervening in the actions of another. (I know alcohol is bad for you; please hand over that pitcher of Pliny the Elder, thank you very much, it’s for your own good. Give me those garlic fries, too. Very high in fat.) And why would it be appropriate to force the person at time t to suffer unbearably for the benefit of the person at time t-sub-one?

My proposition has two parts: first, those who would forcibly intervene to prevent a suicide are unlikely to have better information than the suicide about his future values; second, even if outsiders have better information than the suicide and can somehow prove that the suicide will be happy in a few years’ time, that still does not justify forcing the person to remain alive.

Written by Sister Y

June 2, 2008 at 9:36 pm

Why I Am Not Pro-Suicide

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In the essays that comprise this project, I have been arguing in favor of a general right to suicide, including access to comfortable, effective means of suicide. I am not, however, “pro-suicide” – any more than those that favor reproductive rights are “pro-abortion.” In fact, I have articulated a specifically anti-suicide position in the case of people who have voluntarily reproduced, leaving open the possibility of other cases.

I am not pro-suicide, in the sense that I do not see suicide as a particularly preferable decision, for the same reason that I am not anti-suicide: I believe that each person must be allowed to act on his or her own values, so long as he does not violate the rights of others. I am definitely in favor of kindness and altruism, but I feel that it is neither kind nor altruistic to force a person to stay alive against his wishes. Neither do I think it is kind or altruistic to encourage a person to commit suicide when suicide does not accord with his values.

Written by Sister Y

June 2, 2008 at 8:32 am

Depression, Cognition, and Value

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Loss of appetite, often coupled with weight loss, is commonly seen in what our medical system defines as depression. It is a diagnostic criterion for a Major Depressive Episode under the DSM-IV. (A Major Depressive Episode is, in turn, the building block for a diagnosis of Major Depressive Disorder.) Spefically, Criterion A3 for Major Depressive Episode is (in the amusingly vague, catch-all language of the DSM-IV):

significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.

(Interestingly, anorexia or significant weight loss, but not weight gain, is a diagnostic subcriterion for what the DSM-IV calls “melancholic features,” a sort of diagnostic hanger-on to Major Depressive Disorder that requires either a loss of pleasure in almost all activities, or a loss of reactivity to usually pleasurable stimuli. People exhibiting melancholic features are less likely to respond to placebo, says the DSM-IV.)

Some depressed people, the DSM-IV tells us, overeat, and some fail to eat enough. For simplicity, and to illustrate an aspect of depressed cognition, I will consider in this essay only the depressed people whose appetite is reduced.

Why do some depressed people not eat? Is there some mysterious “chemical imbalance” that causes both depressed feelings and reduced appetite (except that the same imbalance causes increased appetite sometimes)? Instead of reaching for a possible explanation why someone might not eat, let’s consider the opposite question: why do non-depressed people eat?

A model of the eating-related introspection of a non-depressed person might look like this:

  1. The person feels hungry (or, perhaps more commonly in wealthy countries, the person feels bored).
  2. The person imagines various options for food.
  3. The person picks something that triggers pleasurable associations, based on a hope that eating will produce pleasurable sensations (satiety, aesthetic interest).
  4. The person eats.

People eat to relieve hunger or boredom, in a sense, but the cognitive path followed by a person in order to eat must have some basis in hope – hope that eating will make the person feel better, hope that the action of acquiring food, chewing, and swallowing will be worth it.

A model of the eating related introspection of a depressed person, on the other hand, might look like this (and I’m taking this from introspection, and exaggerating a bit for clarity):

  1. The person feels hungry or bored.
  2. The person, being depressed, also feels miserable.
  3. The person imagines various options for food.
  4. While the person remembers food relieving hunger, the person, if very depressed, also remembers that food does not relieve misery.
  5. No imaginary food seems that much better than any other, since all will ultimately lead to misery (by failing to relieve the misery).
  6. Why bother?
  7. The person may often fail to eat.

Failure to eat by depressed folks has nothing to do with body image, as in eating disorders. It merely has to do with a lack of hope for getting relief from food – and, ultimately, a lack of recognition of the value of eating (distinct from an intention to starve oneself to death).

Despite some evidence for depressive realism, there is some sense in which we might say that the cognition of severely depressed people may be impaired – especially their decision-making capabilities. We might easily say that a person who can’t decide what to eat, and so fails to eat, is indeed cognitively impaired, rather than being especially wise. (I feel rather silly when it happens to me.) In fact, “diminished ability to think or concentrate, or indecisiveness, nearly every day” (emphasis mine) is DSM-IV Criterion A8 for a Major Depressive Episode.

Recent work in cognitive science has explored the role that emotion plays in decision-making. For example, in “The role of emotion in decision-making: Evidence from neurological patients with orbitofrontal damage,” Brain & Cognition 55 (2004) 30–40, Antoine Bechara reports that

The studies of decision-making in neurological patients who can no longer process emotional information normally suggest that people make judgments not only by evaluating the consequences and their probability of occurring, but also and even sometimes primarily at a gut or emotional level. Lesions of the ventromedial (which includes the orbitofrontal) sector of the prefrontal cortex interfere with the normal processing of ‘‘somatic’’ or emotional signals, while sparing most basic cognitive functions. Such damage leads to impairments in the decision-making process, which seriously compromise the quality of decisions in daily life.

That decisions, in humans, are based on emotion is an empirical fact, to the extent that there is evidence for it. People with impaired capacity to experience emotion are not perfect rational calculators; their decisions appear very strange, and often poor. But that is a mere description of our meat-based decision-making apparatus. It says nothing as to how the best decisions might be made – or, most importantly, what characteristics distinguish the best decisions. To specify that, we need to know what is valuable – for values must be the ultimate criteria for which decisions are good, and which poor. Why do anything? Here psychology must collide with philosophy.

To the extent that a depressed person does not make a normal decision – including the silly case of failing to eat (for lack of a compelling reason, not for lack of resources) – the depressed person is merely revealing his values. To claim that the depressed person is cognitively impaired in a way that would justify intervention into his decisions is to say that his values are incorrect, or that he is not justified in pursuing his values, and should be required to pursue our values instead. We cannot, I think, ethically intervene (force-feed) when a hunger striker decides that she values, say, women’s suffrage over the continued satisfaction of her hunger, even unto death. When a depressed person concludes that nothing is valuable, except perhaps an end to suffering, we are in no better ethical position to intervene – either to force-feed, or to withhold the means for suicide.

Depressed people who overeat are consistent with my model. These people – less severely depressed, perhaps – have not completely given up on food as a source of relief, and may in fact clearly remember receiving positive feelings as a result of food. Therefore, instead of triggering the “eat” response every time one is hungry or bored, the overeating depressed person triggers it in addition every time he feels miserable, leading to increased eating and perhaps weight gain. As I pointed out above, increased appetite is not a feature associated with “melancholic features,” which might, in a vague sense perceptible from the DSM-IV report on response to placebo, indicate a more severe type of depression. This is consistent with overeaters being less “hopelessly” depressed than undereaters.

Written by Sister Y

June 2, 2008 at 5:57 am

Three Meditations on the Sweetness of Life

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From The Great Wave: Price Revolutions and the Rhythm of History, by David Hackett Fischer:

Then, inconceivably, torrential rains came again in 1316. The grain crop failed a third year in a row. Europe began to experience the worst famine in its history. When other sources of food ran out, people began to eat one another. Peasant families consumed the bodies of the dead. Corpses were dug up from their burying grounds and eaten. In jail the convicts ceased to be fed; we are told that starving inmates “ferociously attacked new prisoners and devoured them half alive.” Condemned criminals were cut down from the gallows, butchered, and eaten. Parents killed their children for food, and children murdered their parents.

From Hungry Ghosts: Mao’s Secret Famine, by Jasper Becker:

There are enough reports from different parts of the country to make it clear that the practice of cannibalism was not restricted to any one region, class or nationality. Peasants not only ate the flesh of the dead, they also sold it, and they killed and ate children, both their own and those of others. Given the dimensions of the famine, it is quite conceivable that cannibalism was practised on a scale unprecedented in the history of the twentieth century.

From the report of the United States Congress Commission on the Ukrainian Famine, reported in Becker, above:

Very frequent is the phenomenon of hallucination in which people see their children only as animals, kill them and eat them. Later, some, having recuperated with proper food, do not remember wanting to eat their children and deny even being able to think of such a thing. The phenomenon in question is the result of a lack of vitamins and would prove to be a very interesting study, alas one which is banned even from consideration from a scientific point of view.

Written by Sister Y

May 30, 2008 at 6:10 am