Tuesday, June 17, 2008

Attempted Suicide as a Signal

How many completed suicides are actually thwarted rescue fantasies?

The answer to this question is necessarily unknowable, locked as it is inside the minds of people about to die. But the number must be substantial, and those who favor coercive suicide prevention methods often refer to the idea of insincere suicides - people who attempt suicide only to send a signal for help - to justify their preferred policies of intervention in all cases. It is only in keeping with the principal of autonomy to do what the suicide attempter wishes, they argue, and what most of them wish is to be rescued. The National Right to Life Committee puts it this way:
It is not actually a desire to die, but rather the desire to accomplish something by the attempt that drives the attempter to consider such a drastic option. Suicide is the means, not the end.

Often, suicide attempters are apparently seeking to establish some means of communication with significant persons in their lives or to test those persons' care and affection. Psychologists have concluded that other motives for attempting suicide include retaliatory abandonment (responding to a perceived abandonment by others with a revengeful "abandonment" of them through death), aggression turned inward, a search for control, manipulative guilt, punishment, escapism, frustration, or an attempt to influence someone else. Communication of these feelings -- rather than death -- is the true aim of the suicide attempter. This explains why, paradoxically but truthfully, many say after an obvious suicide attempt that they really didn't want to kill themselves. [Citations omitted.]

Certainly, there are insincere suicides - those who use a suicide attempt as a signal that they need help - in addition to sincere suicides, those whose only wish is to die. I will argue that, paradoxically, a policy of intervention and "rescue" for suicide attempters, and a general prohibition on medically assisted suicide, are actually the worst, most harmful possible policies in their effects toward insincere suicide attempters who merely wish to send a signal. These policies ensure that the signal is reliable and effective, thereby encouraging people to "communicate their feelings" through a suicide attempt rather than through more healthy methods. Coupled with widespread ignorance about the lethality of various methods, this means that many people harm themselves and even die when they do not really wish to. A general, well-publicized policy of non-intervention, or at least the possibility to opt out of intervention, coupled with a legal assisted suicide option, would actually discourage insincere suicides from attempting suicide by destroying the effectiveness of the signal of attempted suicide, and removing the perceived benefits (the rescue fantasy) that attempted suicide is currently seen to provide.

In order for a person to send a reliable signal, the suicide attempt must appear lethal while not actually being lethal. If medically assisted 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. (If organ donation were available as part of the medical procedure, any other method must also, incidentally, be seen as selfish.) 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.

An analogy can be made to fights that break out on the popular television show Jerry Springer. Security personnel constantly break up fights and prevent participants from injuring each other - which causes more attacks, because participants feel they can reliably signal their "toughness," without putting themselves in danger, because of the policy of intervention (rescue) by the show's security staff. Remove the possibility for intervention, and participants would likely conduct themselves in a much less aggressive manner, as they do on other talk shows.

Of course, it might be argued that suicide intervention is justified in the case of people who are not rationally capable of making the decision to die - for instance, someone experiencing hallucinations, someone in an acute confusional state due to diabetes, or a small child (though we must be aware that people under the age of 18 and people with thought disorders and developmental disabilities still often respond to rational incentive structures, and setting up a structure that rewards them for harming themselves could itself be a cause of harm). There are two options that would at once remove the incentive for "signal" attempted suicides and protect incompetent people. One is to only allow intervention in a suicide attempt if there is reliable evidence - a judicial finding of incompetence, or underage status - that the attempter is incompetent. (Currently, the policy is to intervene in all cases, no matter what, even if reliable evidence of intent to die and competence is available.) A second option is to allow a legally effective "opt-out" procedure, so that a competent adult could legally execute a document refusing intervention in case of a suicide attempt. This option forces a choice to the would-be signaler: either execute the document, in which case one would give up the hope of rescue, hardly an option an insincere suicide would choose, or fail to execute the document, destroying the effectiveness of the signal he's trying to express.

In addition to the policies I've outlined above, accurate information about the lethality of various methods is necessary to prevent accidental death by people making insincere suicide attempts. For instance, it is difficult to say whether Megan Meier, when she hanged herself, knew that hanging has a lethality rate of 70%, and can be lethal within minutes - or that, when not lethal, it often results in permanent brain damage. Had she known this - and if she intended her behavior as a suicidal gesture, rather than intending to die, which is not known - she might have chosen a less lethal method of expressing her feelings. There is a great deal of evidence that many people do not understand the lethality of hanging asphyxiation, as evidence by the apparently accidental deaths from the "Choking Game," which kills several children every year. Paradoxically, better access to suicide information might actually save the lives of people wishing to send a signal with a suicide attempt but not to die.

As I've outlined above, a general policy of disallowing medically-assisted suicide, coupled with a policy of "rescuing" suicide attempters, is harmful and cruel not only to those who wish to die, but to those who do not. It encourages people to attempt suicide when they do not wish to die, but merely wish to send a signal, and contributes to the dangerous fantasy of rescue.

Posts by the intelligent, compassionate Dr. Maurice Bernstein at the Bioethics Discussion Blog, here and here, helped me clarify my thinking on this. Dr. Bernstein explains some of the difficulties facing emergency room doctors when faced with a patient who has attempted suicide and refuses medical intervention.

2 comments:

  1. What I do not understand is that doctors in the ER keep patients (suicide-attempters) alive when it's clear this will result in serious and permanent bodily harm/brain-damage. Presumably they just follow guidelines and procedures and must do this in order to keep their job but in my mind this is just cruel and immoral and the harshest form of punishment possible (under the repressive/criminal model of approaching suicide). Both for the would-be suicide (obviously) and for his or her family: in most cases people would prefer that person to have died (heartbreaking as it may be) than to have to live in agonizing circumstances. I really am curious as to how they'd justify this and how it could possible be construed as 'helping people'. If a cat was run over and its guts are hanging out the most humane thing to do is get your gun and shoot it or bang it on its head with a shovel, if we'd do this for mere animals (with presumably less capacity for suffering due to their less developped mental capacities) why don't we for our fellow man? Even withholding or blocking access to correct information about the lethality of different suicide-methods is a crime in my eyes: just imagine waking up without the ability to speak or in excruciating pain just because you misjudged the lethality of your chosen method based on faulty information. Adding to his problem is the barbaric law against assisted suicide: if there's someone with you and things go awry he or she can step in and make sure you're dispatched properly (the coup-the grace, even enemies on the battlefield would grant eachother this courtesy). I fail to see why this would make it murder or even manslaughter: if it's clear (beyond any reasonable doubt) that it was your decision soleley and the other party merely acted on your behalf and out of respect and compassion no crime was committed. Since when is caring for someone, respecting their wishes and helping them a bad thing and even worse: an action meriting incarceration? If this is made legal everything's out in the open and it'll be easy to check if someone died voluntarily or not.

    This reminds me of an ancient custom on the island of Cos where anyone who wanted to die and could make a clear and coherent case in front of officals would receive the cup with poison directly from the hands of the highest magistrate. How much more public and transparant can you make this? Truly, we may have progressed alot in terms of scientific and technological advancement but in moral terms the ancients were far superior to us. I blame the perverted jewish faith and its offshoot christianity for this disgusting change in morals and customs: instead of a society of masters, freemen and slaves we have all become slaves (in the moral sense) and we all have to endure the wrath and stupidity of public opinion and the laws that result from it.

    This is what we get when we sacrifice our individual rights and liberties (so important to our forefathers) on the altar of public outrage, misguided morality and misconceptions. Would somebody please think of the children?

    Zara

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  2. It is applying idiosyncratic values to people who do not share those values.

    Most people fail to distinguish between personal (agent-relative) values and objective (agent-neutral) values, only the latter of which are fair to apply to everyone.

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