Monday, December 29, 2008

More Evidence for Rational Suicide

A letter in the upcoming January 2009 issue of the journal Psychiatric Services (Psychiatr Serv 60:126, January 2009) reports on the relationship between suicide method and past health care contacts. The authors of the letter report that people who commit suicide by charcoal burning (a method of carbon monoxide poisoning gaining popularity in Hong Kong and Taiwan) are significantly less likely to have had mental health care (or hospital visits for any reason) than people who commit suicide by hanging or solid or liquid poisoning. That is, there is an identifiable population of people who commit suicide using relatively painless means that require preparation, and this population is less likely to be mentally or physically ill than people who commit suicide using other means. These results are in line with past studies, and "corroborate findings from Hong Kong that victims [sic] of charcoal-burning suicide were less likely to have pre-existing mental or physical illness," say the authors [emphasis mine; citations omitted].

The letter displays problematic logic in the interpretation of its findings. In relevant part, the authors say:
Our results support the point previously raised by researchers from Hong Kong that this new method may have attracted individuals who would otherwise not have considered suicide. Acute stress, particularly economic difficulty, rather than mental disorders may be the major precipitating factor of suicide in this suicide subgroup. Population-based prevention strategies to prevent charcoal-burning suicide that might be considered include efforts to destigmatize mental illness to enhance appropriate help-seeking behaviors, restrictions on access to charcoal (for example, by removing charcoal from open shelves and making it necessary for the customer to request it from a shop assistant), and guidance for the media on how to report on suicide events. [Emphasis mine; citations omitted.]

The authors' perspective is that the availability of the method is what is causing the suicide. But isn't it the individual's choosing to commit suicide that is the proximate cause of the suicide? Is the "cause" of suicide the man or the gun?

The authors assume that suicide should not be allowed and that it is right to prevent it. Why should this be? No reason for or defense of this position is given. People committing suicide using the charcoal burning method are not likely to be mentally ill! Why shouldn't they be allowed to choose to commit suicide in a relatively painless manner? Even forced life advocate Ezekiel Emanuel purportedly favors a "negative right" to suicide for rational people.

In addition, the authors' proposed solution to the problem of non-mentally ill people committing suicide is: destigmatize mental illness. Huh? My interpretation of the data is that charcoal burning suicides are likely to be rational suicides - not the product of mental illness. How will destigmatizing mental illness help anything here? The authors also, predictably, recommend coercive suicide prevention methods (using the laughable tactic of restricting the sale of charcoal - no picnic barbecue for you if you look sad!) and media censorship.

There is little evidence that "destigmatizing mental illness" will prevent suicides in these cases. And even if coercive suicide prevention does prevent some suicides, they will be the wrong suicides. Take away the right to charcoal burning (not to mention the right to barbiturates), and you force people to choose between committing suicide by violent or ineffective means, or remaining alive in misery. And that is wrong.

"Philosophical Therapy" and the Poverty of Psychology

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

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

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

Can death be rationally desired?

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

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

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

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

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

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

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

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

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

Monday, December 15, 2008

The Drug Prohibition and the Right to Suicide

Back in 1997, in The Atlantic, Ezekiel Emanuel wrote:
Rational people should be able to end their own lives; suicide should remain decriminalized. But to say that is a far cry from saying that people have a right to have others, namely physicians and pharmacists, help them to end their lives. The ability to commit suicide is what Isaiah Berlin called a "negative liberty" -- a liberty to keep others from interfering with the individual. The right to euthanasia is a positive liberty -- a liberty to have others help to realize an individual's goal. The justifications for negative liberties are widely accepted, and the Bill of Rights is essentially a list of negative liberties; positive liberties are affirmed only when necessary to ensure robust participation in public affairs and to preserve essential opportunities. It is hard to see how granting a right to PAS and euthanasia is necessary to either of those goals.

In any case, the number of dying patients who have unremitting pain or who want to die and are physically incapable of killing themselves is very small -- a few thousand of the 2.3 million Americans who die each year.

There is a right to suicide, claims Dr. Emanuel - a right not to be interfered with. Of course, in practical terms, Dr. Emanuel is terribly mistaken, even in his conception of the right to suicide as a negative right: the state regularly and predictably interferes with individuals attempting to commit suicide. Pro-forced-life U. S. Supreme Court Justice Antonin Scalia has stated, in his concurring opinion in Cruzan v. Director, Missouri Department of Health, that

It has always been lawful not only for the State, but even for private citizens, to interfere with bodily integrity to prevent a felony. That general rule has of course been applied to suicide. At common law, even a private person's use of force to prevent suicide was privileged. 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. [Citations omitted.]

Justice Scalia unfortunately states the policy of our country: it is decidedly one of interfering, using as drastic and invasive means as possible, with an individual's decision to commit suicide.

Even if we did live in the fairy land that Dr. Emanuel apparently hails from, in which there exists a "negative right" to suicide, there is still the problem of means. Dr. Emanuel says that there is no need for "assisted suicide," because one can perfectly well off oneself, and one has no right to have another person assist one in the act. However, again Dr. Emanuel ignores the sad reality that all would-be suicides face: the only means to commit suicide that are reliable and comfortable enough so as to not be objectionably cruel are in the exclusive hands of doctors. With barbiturates under the strict control of doctors, the "right to suicide" doesn't mean much.

As long as there is a drug prohibition, there will be a moral need for "assisted suicide." Remove the drug prohibition - at least, the prohibition on barbiturates - and there will no longer be a moral need for "assisted suicide," at least for able-bodied people.

Dr. Emanuel assures us that "the number of dying patients who have unremitting pain or who want to die and are physically incapable of killing themselves is very small." I wonder what he means by "physically incapable" of killing oneself. Unable (or unwilling) to shoot oneself in the head with a shotgun? To slash one's artery with a knife? To hang oneself? Is the "right" to do one of these things - and potentially be dragged back to life if one fails to die - really all the "right" that is morally called for?

Like many forced life advocates, Dr. Emanuel offers a comforting vision of an imaginary world, to distract us from having real compassion for suffering people in the real world.

Tragically, Dr. Emanuel is the Chair of the Department of Bioethics at the National Institutes of Health.

Edit: In summary, my problem is this: there is a general drug prohibition on sleeping pills that are lethal at high doses, and there are policy reasons for that, however misguided. In addition, there are good reasons why a person should not have the right to expect another person - here, a doctor - to assist him in committing suicide. But when you put these two sensible-sounding propositions together (drug prohibition and no right to assistance), they no longer make ethical sense. One of them has to give.

A Response to Suicide.org on the Right to Suicide

Kevin Caruso, in a piece titled "Don't I Have the Right to Die by Suicide?" attempts to scare people into calling a suicide hotline on the grounds that there is, in fact, no moral right to commit suicide. (Note that Caruso is the one who says we should use the unnatural phrase "die by suicide" instead of the more natural construction "commit suicide" because the latter is hurtful to the friends and family of people who commit suicide.)

Many of Caruso's questions are answered more formally in my essay, "The Harms of Suicide." But I think it is worthwhile to have a single document answering a representative set of (implied) pro-forced-life arguments.

Caruso poses questions (typeset in bold), to which I propose answers (typeset in regular typeface):

Do you have the right to devastate your family?

We often "devastate" our families by exercising our rights. Some "devastate" their families by coming out of the closet, or by refusing to be doctors, or by moving across the country, or by refusing to have children. Where concerns of personal autonomy and suffering outweigh the interests of others in maintaining our company, then we do indeed have the right to "devastate" others.

Do you have the right to cause intense, almost unbearable pain for all of the loved ones that you leave behind?

Everyone dies. Nothing we can do will prevent our own death, nor the suffering our death will cause to those close to us. Suicide merely causes this pain to be experienced earlier.

In fact, the policy of suicide prohibition and prevention - not the act of suicide itself - must be seen as a major cause of the special pain and grief suffered by suicide survivors. (Also, not everyone is lucky enough to have "loved ones." Are lonely people free to commit suicide, according to Caruso?)

Do you have the right to take away any possibility that you would get better?

Who has the right to decide whether a given treatment is in one's best interests, or not? With physical illnesses like cancer, the decision rests with the patient as to whether a given treatment is worth the suffering it entails. We have the right to refuse treatment. With good reason - many treatments for suicidality, while possibly effective, are so damaging as to simply not be worth the cost. And, as with cancer, for some people, nothing works.

Do you have the right to take away all of the wonderful things in life that you have yet to experience?

Who but me has a right to decide whether the suffering the rest of my life will entail exceeds the value of the "wonderful things in life" I have yet to experience?

Do you have the right to take an action that is a permanent solution to a temporary problem?

One of the most common mushy-headed objections to suicide is that it is a "permanent solution to a temporary problem." In reality, for many of us, suffering is an all-too-permanent problem.

Do you have the right to cause irreversible brain damage to yourself if your suicide is not completed?

Damage to oneself as a result of an unsuccessful suicide attempt is entirely an artifact of the suicide prohibition. Given a genuine right to comfortable, reliable suicide, this would simply not occur.

Do you have the right to cause yourself to become disfigured if your suicide is not completed?

See above. And, yes, one has the right to cause oneself to become "disfigured" by body modification. But an unchosen disfigurement caused by a suicide attempt is a sad consequence of the immoral suicide prohibition.

Do you have the right to cause yourself permanent paralysis if your suicide is not completed?

See above. Paralysis and akinetic mutism caused by suicide attempts are tragic consequences of the suicide prohibition, not of suicide.

Do you have the right to end your life instead of focusing on ending your pain? (It is the pain that you want to end, not your life.)

The pain may well be permanent. Caruso naively assumes that a given suicide has not done anything to try to alleviate his pain. But, yes, one has the right to decide when one has done enough to try to alleviate one's pain, and when the pain appears permanent enough that a permanent solution is indicated. One's life is one's own.

Do you have the right to not receive treatment for the mental illness that you probably have -- the treatment that will make you better?

Generally, we do have the right to refuse treatment - even potentially life-saving treatment - in the interest of bodily autonomy.

Again, "treatment" for mental illness is not a sure-fire way of relieving the suffering that leads to suicidality. Caruso assures us that treatment "will make you better," but that is hardly the case for all suffering people. It is unfair and cruel to cheerfully assume that anyone can get better if he just tries the next experimental treatment.

I have written extensively on the mistaken idea that suicide is caused by mental illness. Even Thomas Joiner proposes that suicide is not caused by mental illness on its own, but rather by the alignment of the ability to commit suicide with the desire to commit suicide.

And mental illness causes severe suffering. Don't the mentally ill, as much as the physically ill, have a right to end their pain?

Thursday, December 11, 2008

She Let The Tumors Eat Her Face

Note: Steven Ertelt respectfully commented that the original version of this piece misstated his position, and upon reflection, I agree, and have re-written this piece to hopefully come closer to his position and make my objections clearer.

Chantal Sébire committed suicide by taking black market Nembutal in March of 2008. Before that, she had achieved notoriety by (unsuccessfully) petitioning the French president to allow her physician-assisted suicide. She suffered from the disease esthesioneuroblastoma, a disease that caused tumors to deform and destroy her face.

Pro-forced-life blogger Jill Stanek includes a post by Steven Ertelt about Madame Sébire. Back in April of 2008, Ertelt said that Mme. Sébire was properly denied PAS, and that we should limit our sympathy for her, because she refused treatment and voluntarily allowed the tumors to eat her face:
Well, now come to find out she a) refused medical treatment, b) refused offers of surgery to correct the problem and lead a normal life, and c) refused both drugs and palliative care to help her deal with the pain.

Sadly, this woman appeared to have a death wish and appeared more interested in promoting the pro-euthanasia political agenda than genuinely seeking legitimate medical care. . . .

Sebire's situation was certainly heart-wrenching and she originally deserved all the support in the world, but these new revelations make it tough to consider her anything but a political opportunist. [Emphasis mine.]

A majority of people support a right to suicide for those with an incurable illness. Those with ideologies that favor forcing people to stay alive, no matter what their state, see their position threatened by this trend; indeed, Washington and Montana have recently joined Oregon in allowing so-called assisted suicide for the terminally ill. A great deal of the support for suicide rights for the incurably ill must come from people's sympathy for the ill and dying - the empathetic response that if one were dying, or in Mme. Sébire's condition, one would want the right to die, too. Support for a blanket right to suicide is much less common.

Ertelt wishes to challenge the empathetic response to Mme. Sébire, on the grounds that she was not really incurably ill. But I think Mme. Sébire's case can increase ordinary, non-suicidal people's empathetic understanding of the plight of healthy people who nonetheless suffer so severely that they wish to die. She wanted to die more than she wanted to live a normal life. Is that not enough to allow her to die?

How much would a person have to be suffering to willingly allow tumors to destroy her face, in the hopes that she could thereby achieve a peaceful death? How many people are there, right now, in this condition - healthy, but suffering so greatly that death is overpoweringly desired? Do we really want to force such people to stay alive?

Let's say Madame Sébire really did refuse treatment for her tumors with death in mind. I have considered this horrible possibility myself, though with trepidation: if only one were to get a horrible disease, then they would have to give one Nembutal. Or one could refuse treatment and opt for palliative care, for the haze of morphine, ordinarily denied to a "healthy" person. But what if one were to get cancer and then develop a love for life and a fear of death? It is the most terrible thing.

But Madame Sébire retained her courage through Hell, showing us that it is possible, that the commitment to death is not necessarily a caprice.

No one should have to die this way. No one should have to let tumors eat her face in order to achieve a peaceful death. Peaceful death should be available to all those who are in such pain as to seriously desire it, whether that pain is physical or emotional.

Saturday, December 6, 2008

Attitudes Toward Suicide

Note: If you are interested in evolutionary biology, please see my article on Thomas Joiner and the evolutionary psychology of suicide.

The question:
227. Do you think a person has the right to end his or her own life if this person: a. Has an incurable disease?

The General Social Survey, available through the Survey Documentation & Analysis project at the University of California, Berkeley, tracks how attitudes of Americans vary with time and against other variables. The answer to the question above, known as SUICIDE1, tracks attitudes toward a special kind of suicide right - that for the incurably ill. Answers vary strongly with age and over time.

The trend over time indicates that more people are favoring the right to suicide in the case of incurable illness. This chart indicates the percentage of people in the 50-60 age group responding to the above question - red for yes on suicide rights, blue for no on suicide rights - for the years 1972-2006, in five-year increments:

Attitudes within the 50 to 60 age range are clearly changing. Support for suicide rights climbs steeply until 1996, when it flattens out.

Similarly, attitudes toward suicide rights upon incurable illness vary with age; the chart below tracks answers to the above question by age group in ten-year increments, for the years 2002-2006.

Generally, the older the respondent, the less he favors suicide rights for the incurably ill, up until the 71-80 age range - the only age range in which a majority of respondents disfavor suicide rights. This is consistent either with (a) stable attitudes over the lifespan, set at an early age; or (b) changing attitudes over the lifespan toward disfavoring suicide rights - perhaps over concerns with one's own mortality. However, the data above suggesting that attitudes are changing in favor of suicide rights, controlling for age, makes the first hypothesis more likely.

Interestingly, the direct correlation between age and negative attitudes toward suicide has an exception: the 81-90 age group. 81-90 year olds are more likely to favor suicide rights for the incurably ill than not, and they favor suicide rights more than the 71-80 age group. This may be suggestive of attitudes changing over the life span in response to events (in this case, advanced aging).

Sadly, there seems to be little to no progress in attitudes about suicide when someone is "tired of living." Attitudes on the question known as SUICIDE4, as follows:

227. Do you think a person has the right to end his or her own life if this person: d. Is tired of living and ready to die?

show little change over time:

There is, unsurprisingly, a strong correlation in religion (THEISM) and attitudes toward suicide. The more one agrees with the question

1387. Do you agree or disagree with the following. . . a. There is a God who concerns Himself with every human being personally.

the more one disfavors suicide rights, both on incurable illness

and when one is tired of living:

What about education? Education is associated with favoring suicide rights. Here is the response to SUICIDE1 (suicide rights for people with incurable illnesses) against highest year of school completed:

The correlation for suicide rights for those tired of living is present but not as strong:


Interestingly, the correlation to college major (COLMAJR1) is the opposite of what I would have predicted: those with a major in fuzzy studies - English, literature, foreign language, fine arts, or other humanities (values 1-4) - were much more likely to favor suicide rights for the incurably ill than were those who majored in science or math (values 8-9):

Thursday, December 4, 2008

Censoring Suicide

Well-meaning anti-suicide groups publish "media guidelines" that promote myths and increase the pain for survivors of suicide.



In London, Paul Day's compelling, emotionally dense frieze was pulled from a rail station because it depicted a skeleton driving a train and a commuter "wobbling precariously" close to the tracks - alluding to suicide by train.

Pepsi apologized for, and retracted, ads (published in a German magazine) that depicted a "lonely single calorie" committing suicide. The self-appointed censor who received the apology indicated that electronic communication will help him carry out his inquisition into commercial art: "The lesson here is that social media has eyes everywhere and the network to make sure that advertisers can no longer hide stuff in niche markets," said Chris Abraham.

Art, advertisements, and video games that deal with suicide - entry points for conversations about suicide among ordinary people - are unjustly criticized, censored, and destroyed. There is only one appropriate way to speak of suicide, one appropriate attitude toward it, and all others are quickly suppressed. This is not the case for other controversial topics - murder, race, gender, drug use - nor should it be. Suicide is tabooed in a unique and unfortunate way.

Joan Wickersham, author of The Suicide Index and daughter of a suicide, thinks that more conversation about suicide would be a good thing:
"I think there is a kind of shame and a kind of taboo attached to suicide," she says. "We would prefer to think it doesn't happen. I think we have to acknowledge it does happen. We have to acknowledge that it's a mystery, that we don't understand it very well. I just wanted to give a sense of what it is really like to go through this."

Wickersham says there is a reluctance to talk about suicide, adding, "I would love to see more honest conversation about it."["World Suicide Prevention Day seeks to raise awareness," Voice of America.]

Contrary to Wickersham's goal, "honest conversation" about suicide is suppressed in the media when a suicide occurs, often based on well-intentioned but flawed "media guidelines" published by anti-suicide groups. In addition to the fact that these guidelines promote the ethical position that suicide is wrong, I see two major problems with these guidelines: one, they promote myths about suicide as if they were facts; two, they increase the guilt of survivors by portraying suicide as preventable.

The "Media Guidelines for Suicide" on suicide.org advise reporters as follows:

Emphasize the number one cause for suicide:

The number one cause for suicide is untreated depression.

And then indicate that depression is treatable, and thus anyone suffering from depression needs to receive IMMEDIATE help.

This is in contrast to the scientific studies, which show that depression only slightly increases the risk for suicide - a fact which in itself carries little weight, since suicidality is one of the possible criteria for diagnosing depression. According to Thomas Joiner (Why People Die by Suicide, p. 195-196), borderline personality disorder and anorexia nervosa are far more predictive of suicide than depression; BPD has a 10% lifetime risk of suicide and a 50% lifetime rate of at least one very severe suicide attempt.

Even given a slight correlation between depression and suicide, it's overstating the case to say that depression causes suicide - even Thomas Joiner would not agree with that, as stated. It would be more accurate, but less satisfying, to say that the desire to die, coupled with the acquired ability to die, is the leading cause of suicide.

The suicide.org guidelines also recommend using the "fact" that "Over 90% of the people who die by suicide have clinical depression or a similar mental illness when they die." I have extensively attempted to debunk this statistic, but the comfortable idea that suicide is caused by mental illness is hard to dislodge and unlikely to be questioned too closely.

Other "media guidelines" offered by suicide.org range from silly to intrusive to "whoa, thought police":

Do not begin a television newscast with a suicide story.

Do not place suicide stories on the cover of newspapers or magazines.

Never portray suicides as heroic.

Never say that a suicide "ended pain" or "ended suffering." Suicide CAUSES excruciating pain for suicide survivors.

Also, people need to be alive to feel relief from pain. Suicide CAUSES pain.

Do not use the terms "successful suicide" or "committed suicide." Use the term "died by suicide" instead.

The term "committed suicide" is NOT accurate and is VERY hurtful to those who have attempted suicide and to suicide survivors. Say "died by suicide."

The media guidelines proposed by suicide.org strictly fit the definition of politically correct bullshit I proposed in an earlier piece: they express majority opinion in a manner unconcerned with truth, and have the function of a moral taboo to protect an important cultural narrative from negation.

The guidelines promulgated by the National Institutes of Mental Health are much more harmful, however, in that they function to increase the pain and guilt experienced by people close to a person who committed suicide. The message promoted by the NIMH guidelines is that suicide is always preventable, and there are always warning signs. The guidelines advise reporters that

Studies of suicide based on in-depth interviews with those close to the victim indicate that, in their first, shocked reaction, friends and family members may find a loved one’s death by suicide inexplicable or they may deny that there were warning signs. Accounts based on these initial reactions are often unreliable.

That is, there are always warning signs; push family remembers until they "remember" the politically correct story. Reporters are advised to ask survivors questions such as

  • Had the victim ever received treatment for depression or any other mental disorder?
  • Did the victim have a problem with substance abuse?

The message is that there were warning signs that, had the family cared enough to look, would have revealed the suicide's intentions so that the suicide could have been prevented. Unfortunately, this serves to increase the guilt of survivors, legitimize increasingly coercive suicide prevention tactics, and increase the survivors' sense that the suicide was a tragedy because it was "preventable."

The problems I identify - promoting false information and unnecessarily increasing survivors' guilt and pain - are in addition to the harm to the marketplace of ideas that is done in the name of curbing the controversial phenomenon of suicide contagion. A single ethical idea is given precedence over all others, and false facts are repeated in the name of protecting it, and of protecting the institutions that depend on it ("Mention that Suicide.org is available 24 hours a day for anyone who is suicidal," advises suicide.org).

Update: zarathustra at MentalNurse discusses media treatment of suicide in "How should the media report suicide?"

Tuesday, December 2, 2008

P-Zombie Suicide

If we accept that each person is the best arbiter of what is in his own best interests, then the primary harm of suicide must be that it is painful to those around us, our friends and family and even, perhaps, our society.

A would-be murderer or rapist who is prevented from murdering or raping by thoughts of the harm that his action would do to his victim may go on living as he wishes, for the most part - he simply may not murder or rape. But a would-be suicide who is prevented from committing suicide by thoughts of the harm his suicide would do to those around him is forced into a different sort of arrangement. He may not go on living as he wishes - he does not wish to live at all. He is living entirely for the benefit of others.

A p-zombie, or philosophical zombie (though David Chalmers at times calls it a phenomenal zombie), is a person who looks and acts just like a regular person, but who has no subjective experience. In explaining a problem in consciousness studies, the exact nature of which is irrelevant to this piece, Raymond Smullyan famously proposed a form of p-zombie suicide:
A man wants to commit suicide but does not want to cause his family any grief. He finds out about an elixir he can take which will kill him, i.e., separate his soul from his body, but leave his body intact to wake up, go to work, play with the kids, keep the wife satisfied and bring home the bacon. [From "zombies and p-zombies" in the Skeptic's Dictionary.]

Indeed, we would-be suicides who wish to cause as little harm as possible to those around us wait anxiously for news from the promising field of p-zombie therapy.

Unfortunately, in addition to being (arguably) a logical impossibility, a p-zombie is a singularly unsatisfying sort of companion. For those who believe that subjective pleasure is all that matters, p-zombiehood is fine; but for those to whom truth matters - for those to whom there is value beyond subjective experience - to love a p-zombie would be as awful as having a faithless lover whose faithlessness went undiscovered. Denying genuine intersubjectivity to those around us must be practically as cruel as simply killing ourselves.

There is a sense, though, in which all genuine would-be suicides are, sort of, zombies. We are living wholly for others - while we retain experience and genuinely interact with others, we are no longer, in a deep way, agents of our lives. We get up in the morning, work, eat, speak, have sex, do the dishes, not out of desire or will, but, ultimately, out of concern for others. Just as others would be harmed by our turning ourselves into p-zombies without subjectivity, they are harmed by having us around minus the will to live.

In David Rieff's memoir of the death of his mother, Susan Sontag, he repeatedly expresses his guilt over not doing enough, over going along with her unrealistic fantasy of survival or not going along with it wholeheartedly enough. And yet he recognizes that to live in such a way as to avoid guilt after the death of another - to live always with another in mind above all - is to void oneself. He says,

To live without guilt after the death of a loved one, a person would have to accede to literally everything the other person wanted. And what this really means is living one's entire life in attendance of the other's death since there is no way of being an emotional Jain in relation to others. The Jain may decide to always walk bent over sweeping the road so as not to inadvertently kill some tiny insect in his path, but deferring completely to another person is, if anything, an even more impossible project. For such deference would render one without personality - without the very qualities, in other words, upon which one's relations with the other person are grounded. [Rieff, p. 99-100, emphasis mine.]

Rieff writes about the futility of living wholly for another, with another's death always in mind. But his words apply equally to the sad project of living wholly for another in a more literal sense - of hesitating to commit suicide out of concern for others. A life lived out of fear for the harm one's death might do is as awful, and as futile, as a marriage maintained for the sake of the children - a horrible, empty hole which does no good for anyone.

Monday, November 24, 2008

How People Die By Suicide

A review of Why People Die By Suicide, by Thomas E. Joiner. Harvard University Press, Cambridge, 2005.

Thomas Joiner provides a robust descriptive model of suicide, but repeatedly refuses to consider the deeper "why" - the answer to which might be evolutionary adaptation in the Pleistocene.


In bathrooms at Disneyland, signs over the sinks offer what are described as "hand washing tips." The alleged "tips" are:
  • Wet hands and apply soap.
  • Scrub hands and rinse.
  • Dry hands thoroughly using paper towels.

People find this sign amusing from an epistemological standpoint: it's not so much a set of hand washing tips as it is a (humorously unnecessary) phenomenological description of the act of hand washing. It is funny because it purports to have normative content, but fails to contain anything but description.

Similarly, Thomas Joiner's Why People Die By Suicide promises, in its title and its project, to provide an explanatory model for suicide. Joiner does provide a useful descriptive model of suicide, but he fails to live up to his title's promise of an explanation of suicide. In fact, he explicitly rejects, on what are essentially aesthetic grounds, the most promising candidate for a genuine explanatory model of suicide - that is, evolutionary psychology.

Joiner's Model

According to Joiner, three factors cause suicide: competence, or the ability to carry out a suicide; the feeling of being a burden; and social failure to belong. The first factor, competence, includes the physical ability, knowledge, and pain tolerance required to carry out a suicide, as well having lost or overcome the fear of death. The second and third factors, burdensomeness and failed belonging, join together to create the desire for death. Both the desire for death and the capability to achieve death must coexist in order for a person to commit suicide; that much is obvious. Joiner's main contributions are setting this up in a clear formulation, and positing the two specific factors that constitute the desire for death.

Importantly, while maintaining that mental illness is relevant to suicide, Joiner does not implicate mental illness in causing suicide - rather, his model explains the elevated suicide levels in people with disorders like Bipolar I and II and Borderline Personality Disorder by the fact that such disorders (a) facilitate comfort with increasingly lethal self-harm, (b) increase feelings of (and perhaps actual) burdensomeness, and (c) decrease the ability to belong.

Joiner's model is clear, helpful, and well-supported by studies. The problem with Joiner's model is that, while it describes who commits suicide and how they manage to do it, it fails to explain why those people commit suicide. Why should people care about being a burden to others? Why should people care about social belonging? Why should they care about these things, but not other things, enough that death is preferable to the pain of burdensomeness and thwarted belonging?

Joiner is comfortable providing an answer as to why it should be difficult to commit suicide, and why the first element of his model, competence, should be necessary: natural selection. He implicates specific genes and brain traits in suicidality (even distinct from the genetic contribution to mental illness). Yet he explicitly refuses to consider the possible role of natural selection in regard to the other elements of his model, or to suicide as a phenomenon.

Why should people care about whether they are burdens on other people? Why isn't it, say, the feeling of being overburdened by others that causes suicide? And why should failure to belong be so painful as to facilitate suicide? Why not anger, or guilt, or physical pain, or even excessive social contact? Joiner makes no attempt to explain. But an adaptive model readily explains the features of Joiner's model, in addition to clarifying Joiner's more questionable results; indeed, the adaptive model has more explanatory power than Joiner's model.

Failure to Consider Suicide as an Adaptive Behavior

Suicide, like filicide, seems upon first consideration to be a ludicrous act, viewed from the perspective of evolutionary biology: how can one's genes go on if one kills oneself or one's child? However, the act of filicide (the killing of one's child or children) is clearly adaptive in many cases. Not only that, but it can be shown through statistical evidence that actors seem to differentiate between adaptive and non-adaptive filicides when they "decide" to commit filicide (as well as other apparently fitness-threatening homicides, like uxoricide and siblicide). What about suicide?

An act is adaptive when it increases the inclusive fitness of an actor - that is, when the act's benefits - in terms of survival, procreation, or nepotistic distribution of resources to one's genetic relatives - exceed the act's costs, in the same terms.[1]

Under certain conditions, one's expected contribution to one's own genetic fitness (likelihood of reproduction, likelihood of the survival of one's future offspring to reproduce, effectiveness at materially supporting one's offspring and other relatives) may fall to virtually nothing. However, as long as one survives under these circumstances, he not only contributes nothing to his own genetic fitness, but also likely drains the resources of his genetic relatives. His continued survival is contrary to his genetic interests. Therefore, suicide, in this limited situation, must be said to be adaptive. (For my earlier thinking on this topic, see my essay, The Evolutionary Biology of Suicide: Is Suicide Adaptive?)

It would be callous and cruel to think of a sick relative as a burden who would be better off dead. And that is not the message of an inclusive fitness model - its message is merely that, in the Pleistocene era when modern humans were evolving, a heritable trait that functioned to tell a human something like "die if you're a net burden on your genetic kin, otherwise stay alive" may have carried benefits in terms of selection. However, Joiner cannot get past the (admittedly substantial) emotional load of the adaptive model of suicide, and rejects it on what are essentially aesthetic grounds:

. . . I do not much like this adaptive suicide view; my own dad died by suicide and the idea that he was an actual burden is offensive. My view is that self-sacrifice is adaptive in some animal species. It may have been adaptive under certain conditions in the course of human evolution, but we will never really know. Most important, it does not really matter now. What matters now is that perceived burdensomeness - and, to the extent that it exists, actual burdensomeness - are remediable through perception- and skill-based psychotherapies. Death is no longer adaptive, if it ever was. [Joiner, p. 115]

This is a strange statement for a scientist. Although Joiner is writing a book called Why People Die By Suicide, he asserts that the essential "why" of his research does not matter - especially to the extent that it might be "offensive." In this, I think he misunderstands the nature of the adaptive view. It is not to say that suicide is good or bad, or that Joiner's dad really was a burden to Joiner or his family - simply that, in the human environment of evolutionary adaptedness, the ability and predilection to commit suicide under certain conditions may have conferred a benefit. Joiner also wrongly asserts that "we will never really know" about the adaptive theory, when he should know that the evolutionary psychology model is perfectly capable of generating testable hypotheses, and has done so in the past with robust results.

Joiner pushes the notion that it is perceived burdensomeness - not actual burdensomeness - that facilitates suicide. However, this may be more nice than true: suicidal persons' perceptions of their own burdensomeness may in fact be highly accurate. Just before he dismisses the adaptive theory of suicide, Joiner summarizes a study supporting the view that suicides really are a burden: "when researchers interviewed the significant others of eighty-one people who had recently attempted suicide, a majority of significant others reported that their support of the patient represented a burden to them."

The adaptive model leads to different predictions (and, in turn, possibly different risk assessments and treatment models) from Joiner's model. For instance, in Joiner's model, "belongingness" is all that matters. But an adaptive model would predict that some forms of belongingness would be more protective against suicide than others - specifically, contributing to the welfare of one's genetic relatives (or, perhaps, surrogates for genetic relatives) would be more protective than other forms of belonging. Relationships with spouses and children would matter more than relationships with friends in an adaptive model, but not in Joiner's model. Joiner does not even consider this to be a question worth researching. Similarly, in Joiner's model, all that matters is "burdensomeness" - no matter who is burdened. An adaptive model might predict that burdensomeness on genetic relatives in particular (or their surrogates) would trigger suicidal behavior, rather than burdensomeness on non-relatives. Again, Joiner is not interested in testing this hypothesis, although it might have major implications for treatment and risk assessment. It cannot be said, with regard to the adaptive view of suicide, that "it does not matter now."[2]

Joiner's model, including a refusal to consider the adaptive view, seems to strain when it encounters certain data. For instance, when explaining the data that pregnant women experience a lower suicide rate than non-pregnant women - one-third the non-pregnant rate in one study - Joiner says: "I would suggest that the protective influence involved feelings of connection to the baby, as well as feeling needed by the baby and thus not a burden." But a relationship to an unborn, unseen person who cannot respond is a strange sort of "relationship." An adaptive explanation - pregnancy confers clear survival value compared to non-pregnancy - is less strained than a belongingness/burdensomeness model, and, in fact, provides a deeper explanation of why a pregnant woman might develop deep feelings for a non-speaking person inhabiting her body.[3]

Joiner's model accounts for sex differences between the suicide rates of men and women in two ways: first, in terms of competence, men are more likely to be exposed to provocative stimulation (all kinds of violence and more) that break down one's fear of death over time; second, in terms of desire for death, men are more likely to be disconnected and more likely to feel they are burdens than women. This is probably true - the first part, in particular, accords well with what I believe to be the most accurate explanation for the differences between the suicide rates of men and women - but, again, why should this be? Why should men be more prone to risky, painful, violent, or as Joiner terms it, "provocative" behavior?

The answer, again, lies in evolutionary biology. Men are not merely "socialized" to be more violent - there are good evolutionary reasons for their greater violence and risk-taking in all areas. A great deal of this is due to what Daly & Wilson term the "effective polygyny" of human beings (at least in the EEA) - that is, that the fertility variance among men is much higher than among women, with many more men than women having a high number of children, and, similarly, many more men than women having zero children. This leads to the sad phenomenon of male disposability - while a woman is "valuable," with a certain, nearly guaranteed level of reproductive success, a man may have no reproductive success at all - but may, by engaging in risky behavior (e.g., successful killing in wars or honor battles), increase his reproductive success to well beyond what a woman might have. A human male is, sadly, invited by his genetic heritage to gamble his life on the chance of a big payoff in reproductive success.[4] What is driving differential violence in general may also drive differential suicides - even independently from the greater access to fear-reducing, provocative experiences.

More specifically, Joiner's model does not explain why, in addition to varying between genders and across age groups, the time pattern in suicides across age groups is different between men and women. Men's suicide rates are a linear function of age: the older the male, the higher the suicide rate. Women's suicide rates vary with time differently, however. While in some countries, the pattern for women matches that for men, in other countries the pattern is very different. In Canada, rather than rising linearly with age, suicide among women peaks during the 35-44 age range; in the United States, the Netherlands, and Sweden, it peaks during the 45-54 age range; and in Australia, Denmark, and Poland, female suicides peak in the 55-64 age range.[5] While belonging and burdensomeness are probably implicated, the fact that these are the age ranges of menopause and post-menopause in women seems to lend support to the adaptive view as to why burdensomeness and thwarted belonging would come into play at those times.

While Joiner's model is compelling, I think there is persuasive evidence that an adaptive model explains suicide better than Joiner's model.[6] At the very least, such a hypothesis deserves to be considered, and should not be rejected on merely aesthetic grounds. To do so is irresponsible and unscientific. An accurate analysis of the etiology of suicide affects both assessment of the risk of suicide and treatment for the suffering that causes suicide.

Failure to Consider Unsuccessful Attempted Suicide as an Adaptive Behavior

Joiner refuses to consider whether a successful, completed suicide may be adaptive. Elsewhere, he refuses to consider data suggesting that making an apparently lethal but ultimately unsuccessful suicide attempt may be not only adaptive, but economically beneficial - provided one does not die in the attempt. In a 2003 article in the Southern Economic Journal, Dave Marcotte presented data that suicide attempters experience an increase in income after the attempt that is proportional to the lethality of the attempt. Charles Duhigg summarizes in his Slate article, provocatively subtitled "Why trying to kill yourself may be a smart business decision":

Marcotte's study found that after people attempt suicide and fail, their incomes increase by an average of 20.6 percent compared to peers who seriously contemplate suicide but never make an attempt. In fact, the more serious the attempt, the larger the boost — "hard-suicide" attempts, in which luck is the only reason the attempts fail, are associated with a 36.3 percent increase in income. (The presence of nonattempters as a control group suggests the suicide effort is the root cause of the boost.)

Marcotte's data suggests that a suicide attempt, particularly an apparently lethal one, acts as a signal that the individual needs help - and, as it is a signal that entails significant cost (the risk of death), it is a particularly believable signal. This signal seems to act to make resources "cheaper" - a suicide attempter may get access to resources that he did not have access to before the attempt.

Again, Joiner is having none of it, and again, it's for aesthetic, not scientific, reasons. Joiner's complaints are two: the economic "viewpoint" is dangerous, in that it may encourage lethal-seeming suicide attempts; and it is callous, in that it denies the reality of the suffering experienced by the suicidal individual. Both of these "complaints" are without merit and are, I think, evidence of shoddy thinking on Joiner's part.

As to the "danger" of the economic model, Joiner says

The danger of viewpoints like this should be pointed out. Any analysis that encourages suicidal behavior in any way - particularly in ways that romanticize or glorify it, or make it seem easy and normative - has potential negative consequences for public health.

But it is hardly the viewpoint that is dangerous - it's the existing incentive structure in our society that encourages apparently lethal suicide attempts in people who often don't really want to die. I have argued that if the suicide prohibition were ended, this dangerous incentive structure - the "fantasy of rescue" - would also end. (I have also proposed an outline of a model for ending the prohibition on suicide, with particular attention to ending the dangerous fantasy of rescue.) Analyses are not dangerous. Problems are dangerous; analyses identify the problems and point the way to solutions. By suggesting that the economic analysis is dangerous, Joiner is contributing to the taboo against speaking about suicide.[7]

Joiner's idea that the economic hypothesis denies the reality of the suffering of suicide attempters is even more ridiculous. He believes that the economic idea is part of some kind of "deconstructionist" philosophy - he actually mentions Jacques Derrida by name (not kidding): "What is left for the deconstructionist, then, is a constant questioning of the very existence of reality and meaning - including the reality of emotional pain. Try telling that to a suicidal person."

This objection makes so little sense that I had to reread the section (pp. 43-44) a couple of times before I understood it.[8] Joiner thinks that the economic model does not account for the pain suffered by those who attempt suicide. But the economic model suggests no such thing! Despite Duhigg's unfortunate opening example in his popular reporting of the Marcotte study, the hypothesis is not that people coldly calculate that they will get a benefit from an apparently lethal suicide attempt. Rather, suffering people are motivated by that awful, extremely real suffering to do something awful - to, essentially, gamble their lives on a chance at making the suffering stop.

Culture, Language, and Occam's Razor

One of the anomalies that Joiner believes he can explain with his theory is the fact that, while, in general, men commit suicide at a much greater rate than women, women in China commit suicide at a greater rate than men. Joiner is quick to find a cultural culprit: Confucianism. Specifically, he says that "the role of Confucianism in Chinese society and its view of the inferior position of women has been emphasized as one explanation, one that is consistent with the current emphasis on effectiveness as a buffer against suicide. (p. 157)" Social scientists, particularly white, Southern social scientists[9], are often quick to reach for a complicated but distancing cultural explanation when there is a perfectly good, but uncomfortable, solution available that might actually survive Occam's Razor.

In the case of female suicides in China - and higher comparative rates of female suicide throughout Asia, including India (a noted hotbed of Confucianism) - the uncomfortable but obvious explanation is that lethal poisons are available in Asia, but not in the United States. Most females who commit suicide in China do so by poison, and the pattern holds true in other areas where female suicides exceed those of males, such as Bangalore, India. In the United States, many people, including females, attempt suicide by poisoning, but few succeed - lethal poisons are just not available in the United States, and in the event of a potentially lethal poisoning, medical care is not only available, but compulsory. The medical care necessary to treat a poisoning is often not available in China, especially in rural areas.

According to Joiner's own model, females, who are exposed to less violent, provocative stimulation than men, should have less capability to commit suicide - by violent means. However, death by overdose or poisoning is not violent and is within the capabilities of many women. One need not reach for what even Joiner admits is speculation - that Chinese women, since they perform well in sport competitions (is he thinking of the Olympics?), are, as a group, encouraged to engage in athletics, leading to the development of more masculine traits, such as violence. Joiner's explanation is, indeed, speculation, and ignores an obvious explanation that is consistent with his model. Perhaps the poison explanation is not as satisfying to Joiner as speculation about the effects of athleticism, because it fails to portray Asian people as sufficiently different from whites.[10]

Joiner indulges in even less responsible speculation when he considers language. Joiner devotes considerable time to the hypothesis that suicidal people fuse themes of life and death - that death becomes a focus for belonging and effectiveness. In contrast to the rest of his book, in which peer-reviewed studies are frequently cited as evidence for his claims, his main evidence for the "fusing of life and death themes" hypothesis is Nirvana lyrics (though he does give us a few isolated quotations of suicidal people that, if you squint the right way, seem to back up his idea).[11] I think that Joiner likes the idea that suicidal people fuse themes of life and death because it makes us seem more psychotic, and less rational in our actions.

The Ethics of Suicide and the Reality of Suffering

Though Joiner clearly has an ethical opinion (suicide is bad), he devotes no time to the question of the ethics of suicide and of forced hospitalization and the suicide prohibition in general. This is not unexpected. It is considered polite and compassionate to do "what is best" for suicidal people, and it is considered to be a serious failure of compassion to suggest that some of us might just know what is best for ourselves. To question suicide prevention on ethical grounds would be extremely foreign to Joiner's way of thinking.

In addition, Joiner is sure that every death by suicide is preventable because treatment is available, but he fails to cite studies of treatments for suicidal misery that have a 100% long-term success rate. Instead, he proposes, in addition to the usual coercive suicide prevention techniques, public service announcements that say "keep your friends and make new ones too - it's strong medicine." He thinks that if more people called a friend every day, just to chat for a few minutes, there would be fewer suicides. He does not seem to apply this thinking to the suicide of his own father, however. His father, at the time of his death, was receiving what Joiner terms "reasonable treatments" (a mood stabilizer and an SSRI), but "his treatment came too late." Joiner notes that his father sought out friends toward the end of his life, as Joiner's patronizing public service announcement would have advised him, but "his efforts were not sufficient . . . . These things were beyond him . . . . (p. 226)"

Based on his (undefended) position that suicide is wrong, Joiner repeatedly describes websites like ASBS (an incarnation of the usenet group alt.suicide.holiday.bus.stop) as "pernicious" (God knows what he would think of my project). He wrongly and tellingly characterizes ASBS as pro-suicide - ASBS is pro-choice, as am I. He approvingly cites restrictive guidelines for news outlets regarding reporting on suicides. Joiner says he is against lying about suicide, and is in favor of removing its stigma, but he doesn't want conversations about suicide to occur if he doesn't approve of their content.

Joiner promises an explanatory model - he calls his book "a comprehensive theory of suicidal behavior (p. 222)" - and makes assertions based on tacit moral assumptions. I think that Joiner owes us not only an explanation of why people die by suicide, but also of why dying by suicide is wrong - and why coercive means of suicide prevention are ethically appropriate.



Notes

1. Of course, traits are heritable, not acts, but the ability and predilection to commit certain acts, and the ability to distinguish when to do so and when not to do so, may be seen as traits to the extent that they are specifically heritable. More precisely, we must say that a trait is beneficial when it increases one's inclusive fitness. A trait may be very specific.

2. There is one sense in which it really doesn't matter, of course, and that is the ethical sense. In fact, this is the sense in which even I have previously stated that an adaptive model makes no difference. But this is not the sense in which Joiner means it. He means that it can have no assessment or treatment consequences and that it is not an appropriate topic for scientific inquiry. As I stated above, the adaptive model has clear assessment and treatment implications. Whether the adaptive model is supported or refuted, it does matter.

3. Another set of data must be explained - a group of "initially pessimistic" teenage mothers reported low depression while pregnant, but high depression postpartum. Joiner attributes this to "the belief that connection to the baby and the baby's father would solve ongoing problems" during the pregnancy, and to the fact that "the idea that motherhood would solve ongoing problems was not confirmed" after birth. However, the adaptive model gives a cleaner explanation: it makes evolutionary sense for the chemical changes during pregnancy to promote positivity and effectiveness, but also for the fitness prospects of the new baby to be evaluated coldly once the baby is born. This is particularly true for a young mother with no mate. This view is supported by Martin Daly and Margo Wilson's work on infanticide.

4. See, e.g., Chapter 6, "Altercations and Honor," in Homicide by Martin Daly and Margo Wilson. Aldine de Gruyter, New York, 1988.

5. Suicide Across the Life Span by Judith Stillion and Eugene McDowell. Taylor & Francis, Washington, D.C., 1996, p. 18.

6. I have not even mentioned the work of Denys DeCatanzaro, whose studies demonstrated a correlation between factors indicating low reproductive value and suicidal ideation. See, e.g., DeCatanzaro, D. (1991). Evolutionary limits to self-preservation. Ethology & Sociobiology, 12, 13-28; and DeCatanzaro, D. (1995). Reproductive status, family interactions, and suicidal ideation: Surveys of the general public and high-risk groups. Ethology & Sociobiology, 16, 385-394.

7. The unquestioning acceptance of the idea of suicide contagion, and of the harm to free speech and freedom of the press done in its name, are also ways in which the taboo against speaking about suicide is maintained.

8. I suspect that Joiner has limited familiarity with economic models and economic thinking, which may be why he seems even more threatened by this idea than by the idea that suicide is adaptive.

9. I don't think this characterization and its implications are unwarranted. Joiner reports two incidents of people doing crazy things that might inure them to the pain of suicide. In one, a man Joiner specifically identifies by name, Huyn Ngoc Son, "swallowed three metal construction rods, each around seven inches long," on a bet from drinking buddies, and had to have them surgically removed. In the other story, a man in England, whose name Joiner does not mention, drank fifteen pints of beer, had an argument, and went home to get a shotgun - which, while he was carrying it back to the bar in his pants, discharged shotgun pellets into his "groin area," potentially rendering him infertile. Research reveals that the man's name in the second incident was David Walker - the non-Vietnamese name was apparently not funny and foreign-sounding enough for Joiner to include in his description of the event.

10. I know that's not warranted, but I have as much evidence for that claim as Joiner does for his claim that Chinese women are "sportier." Also, I am an Internet crackpot, and Thomas Joiner is a goddamn principal investigator.

11. Elsewhere, Joiner reports that he did a "social word" analysis of a suicidal and a non-suicidal Faulkner character - yes, characters from literature - and found that, indeed, the suicidal character used fewer social words. "Faulkner accurately portrayed relatively poorly understood, intense, and rare psychological processes - still more indication of his literary genius." This is a fun stunt, but the fact that Joiner thinks it belongs in a section called "Research on Social Isolation, Disconnection, and Suicidal Behavior" calls his judgment and intellectual honesty into question.

Thanks to Chip Smith for comments on this piece.

Wednesday, November 19, 2008

Punishment as Treatment

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).

Thursday, November 13, 2008

How Do You Want Your Death to Be? Finding Common Ground with Non-Suicides

Each one of us will die. What do you want your death to be like?

What do you want to happen when you die? Do you want to live as long as possible? How long would be ideal? Do you want to die in a hospital, or at home? If you were dying of pancreatic cancer, would you want complete pain relief, even if it meant that you might die from a morphine overdose? Or would you want to live as long as possible, even if in pain? Would you want doctors to introduce a feeding tube? What if the feeding tube gave you severe, constant diarrhea? If you had lived with Alzheimer's for a decade and could no longer recognize anyone and didn't know where you were, and you came down with pneumonia, would you want to be treated for it and cured of the pneumonia? Or would you want to die naturally of pneumonia, even though it is a treatable condition? Do you want to continue living as long as you are conscious? As long as you are able to have meaningful interactions? As long as you are able to maintain your activities of daily living? As long as you can hold your grandchildren? As long as you are, technically, alive? Do you want the ability to control the manner of your death?

There is no right answer to any of the questions above. People's wishes for their own deaths are idiosyncratic, and should be: people's wishes for their lives, and definitions of a good life, are certainly diverse; why should the same not be true of death? The question is: once you have though about your own death and decided what you want, do you want to deny another person his "good death"? Or do you want people to be free to have lives, and deaths, as close to their ideals as possible?

Admitting that death is a natural part of life, and thinking about how we want our own deaths to be, is, I think, an important part of being a mature human being. However, some authors, like Thomas Joiner, think that irrational, visceral fear of death is not only healthy, but that it is pathological to lose this fear of death:
. . . the erosion of fear and the attendant ability to tolerate and engage in lethal self-injury may set into motion still other psychological processes that are important in suicidality; namely, the merging of death with themes of vitality and nurturance. Only when people have lost the usual fear and loathing of death do they become capable of construing it in terms related, ironically, to effectiveness and belongingness. Only those who desire death and have come not to fear it can believe that through death, their need to belong and to be effective will be met. [Why People Die By Suicide, by Thomas Joiner. Harvard University Press, 2005, p. 226.]

But it is far from clear that the "usual fear and loathing" of an inevitable, natural, well-understood process is healthy and in the interests of human flourishing. Such a fear prevents honest and productive reflection on one's own death.

This is not to say that dislike of death, or a strong preference against death, is a problem. A strong preference against death might be an important value held by a person, based upon which the person may make rational decisions. But, except in terms of crude survival, an irrational "fear and loathing" of death is not warranted, nor should it be encouraged.

There are many obstacles to having a mature conversation, as citizens, about death. The irrational fear of death (as opposed to a love of life) is one of these obstacles. But there are other obstacles. One, I think, is the tendency for some in the anti-suicide community to emotional overreaction to any reference to suicide in the wider culture that is not both deadly serious and in accord with their beliefs.

For instance, this week, someone calling himself an "internet safety campaigner" for the British anti-suicide group PAPYRUS, is calling for the "removal" of a computer game called Billy Suicide, in which players try to prevent a character from committing suicide by maintaining his caffeine and antidepressant levels, among other things. (One can only imagine he hasn't heard of Karoshi Suicide Salaryman, in which each level's puzzle calls for the player to help a cute, energetic salaryman commit suicide.) Says the "internet safety campaigner" (in the Telegraph):

This game is completely irresponsible and the people who made the game should realise the damage that it can incur in the terms of somebody taking their (sic) own life

A "spokesperson for the Samaritans" agrees that culture-wide discussions of suicide should never, ever happen with any lightheartedness, based on a credulous acceptance of the poorly understood and controversial phenomenon of suicide contagion:

Suicide is not a light-hearted subject and is (sic) should always be taken seriously.

Certain types of suicide portrayal can act as a catalyst to influence the behaviour of people who are already vulnerable, particularly young people, and result in an overall increase in suicide and/ or an increase in uses of particular methods.

I think that, in the interest of greater cultural maturity on the issues of death and suicide, all conversations about death and suicide should be encouraged - even seemingly immature conversations, and conversations that take place via marginalized art forms like computer games. Good faith should be presumed, rather than malice. It is not pathological, but crucial that we lose our cultural fear of death.

An old family friend used to joke that, when he got so old as to be helpless, he wanted his sons to roll him out into the woods he'd hunted in for years, in his wheelchair, and hang strips of raw bacon over his ears so that the bears would eat him. This was his way, I think, of introducing the somewhat tabooed topic of death control - telling people that he didn't want to die, helpless and intubated, in a hospital. I don't think he was wrong to make such a remark.

A person who does not fear death is not a monster or mentally ill. He is free to pursue his values as he sees them - including, often, a love for life and a desire to avoid death. He may be courageous in the face of death or danger, able to realize that some things are more important than preserving his own life at any cost. He need not be a suicide; usually, he is probably not a suicide. He is not the slave of his genes. He is not a slave at all.

Monday, November 10, 2008

The Harms of Suicide

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

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

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

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

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

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

How much of the harm to survivors is due, not to the suicide itself, but to the suicide prohibition? An ASBS writer writing as "EverDawn" asserts that a great deal of the harm to survivors of suicide - in particular, the perception of suicide as "tragic" - is an artifact of the policy of suicide prevention and its attendant doctrines:
Perceiving an event as tragic makes it difficult to come to terms with, in contrast to an event which is just sad. If a sad event couldn't have and shouldn't have been prevented, then there is no blame to be placed, and nobody to be angry at. But a tragic event raises the questions: how could it be prevented, who should have prevented it. This leads to anger (when blaming others) and despair (when blaming self). The questions linger on, unanswered, making it far more difficult to come to terms with the event.

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

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

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

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

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

(See also, "Is Suicide a Waste?")

b. Knowledge of Permanent Loss

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

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

c. Discovering and Disposing of the Body

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

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

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

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

2. Harm to the Suicide Himself

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

a. Loss of Future Experiences

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

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

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

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

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

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

b. Harm from an Unsuccessful Suicide Attempt

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

c. Failed Signaling

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

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

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

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