Saturday, June 14, 2008

Costs of Coercive Suicide Prevention (and an outline of an alternative)

One of the themes of my project thus far has been to point out that coercive suicide prevention practices do nothing to prevent or decrease actual suffering, and often increase suffering by forcing people who genuinely want to die to stay alive. Coercive suicide prevention, far from reducing suffering, serves the socially negative purpose of masking suffering, so that the true level of suffering is less apparent.

My hypothesis, which I plan to flesh out in greater detail in the coming weeks, is that if the same public funds that are currently spent toward coercive suicide prevention were instead spent on reducing acute suffering in suicidal people though non-coercive means, both suffering and suicide would be reduced.

I am currently in the stage of collecting data on how much money is spent on coercive suicide prevention.

Preliminary data: In the state of Georgia, a 2005 study showed that $40 million was spent in 2002 alone on hospitalization and emergency room treatment of suicides and suicide attempters. 900 people completed suicide that year, 2800 were hospitalized, and 5400 visited emergency rooms for intentionally self-inflicted injuries. Assuming that completed suicide attempts are proportional to attempted suicides and self-inflicted injuries, we can calculate a per-completed-suicide cost in Georgia of about $44,000 (which is not the cost of treating a successful suicide, but rather the average medical expense for suicide treatment per completed suicide). Assuming nationwide costs mirror Georgia's, that would give a national expenditure of around $44,000 times 32,595 suicides for 2002, which comes out to $1.4 billion for the country.

The Washington State Department of Health gives a higher figure - $4 billion for medical treatment of suicides nationally - though I can't immediately trace the source.

Of course, these estimates leave out many other hard-to-measure costs of coercive suicide prevention, including police response, the cost of the government maintaining lists of formerly suicidal gun buyers (as in California), and costs associated with preventing would-be suicides from accessing lethal drugs.

Now imagine what things would be like if even a fraction of this money were spent on genuinely trying to reduce the suffering of suicidal people (and even non-suicidal people, for that matter). My proposal, as I now see it, would involve
  • ceasing automatic interference with suicide attempters, and publicizing this policy, to destroy the dangerous "fantasy of rescue" that might cause many people who do not genuinely want to die to make a suicide attempt
  • setting up a procedure for medically assisted suicide (prescribing a lethal dose of, say, barbiturates to a competent adult requester)
  • which procedure could have a waiting period, like gun purchases or marriage or divorce, and even require multiple requests
  • requesters, to be competent, must understand the nature of death and be able to articulate a non-delusional reason for wanting to die
  • a diagnosis of Major Depressive Disorder would not suffice to render someone incompetent to request suicide assistance
  • upon requesting suicide assistance - and, ideally, even if suicide assistance is not requested - some of that aforementioned money could be deployed to provide help with any problems identified by the suicide requester
  • any assistance (counseling, social worker consultation, housing assistance, bankruptcy assistance, etc.) must be offered without conditioning the eventual suicide assistance on the requester accepting the assistance

It must be recognized that coercive suicide prevention is harmful, in that it increases suffering while masking the suffering experienced by the population. And, despite drops in suicide associated with reduction in gun ownership, a high percentage of suicides are ultimately unpreventable through coercive means, as noted in a 2005 UK study tracking the increase and success rate of suicide by hanging (the lethality is around 70%). Hanging requires no special equipment - the study noted successful hangings conducted with belts, sheets, shoelaces, tights, bra straps, shirts, shower curtains, and pajama trousers - and has a 70% rate of lethality, even when the suicide is not fully suspended. (Of course, of the 30% who fail, how many will be subjected to the treatment suffered by the unidentified patient in the Annals of Neurology article?)

But we must consider whether, if there were a comfortable medical option widely available, many of those gun suicides, hanging suicides, and cutting suicides might opt to request it, instead - and, ultimately, many of them might get help solving the problem they originally thought suicide was the only answer to. For many people, of course, it would mean, not rescue from suicide, but a less horrible death - which, I would argue, is a good thing in itself.

For those suicides who really want to be rescued, my proposal serves to provide genuine, 100% certain rescue - before the suicide attempt is even made. And for those who have considered all options and only desire a comfortable death, my proposal would not humiliate or coerce them into accepting questionable "treatment" to which they have not consented, but would provide a way for them to end their lives with minimal harm to themselves or others.

4 comments:

  1. I totally agree with your post but do not see your proposals being in place until a huge shift in society takes place.Working (non coersivley!) with suicidal people I am constantly amazed at the public view of suicide. probably the most insidious is that because you are suicidal you are mentaly ill. the smug rationale behind this is that because i enjoy my life anyone who doesnt is mentaly ill. In my work I have heard horrific stories of abuse,abandonment,bullying etc and often think had i lived those lives i would have gone a long time ago.
    where I live there seems to be a misguided "war on suicide" entirely focused on preventing the act of suicde.
    Imagine if say cancer prevention was entirely aimed at keeping patients alive and ignoring their pain

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  2. Paul, thank you so much for your comment - I'd love to talk to you more about your work if you have the chance.

    I know of a few psychiatrists and psychologists who are opposed to forced hospitalization and refuse to forcibly hospitalize their patients even at risk of a lawsuit should a patient die. I think this is extremely brave (and respectful of their patients), but it's a shame that they have to put themselves at risk of a lawsuit just to do what's right.

    I actually have very little hope of a policy like mine being enacted in the next generation or two, but it does seem that people gradually shift toward correct moral thinking over generations, as has been happening with the treatment of gay people and woman and racial minorities and people with disabilities over the past several decades. All we can hope for is to point people's thinking in a possibly better direction.

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  3. Ive been looking through your blog, very refreshing.I try to keep current on suicide net content and usually find either god loves you or pro suicide sites. my own view concurs with a post I read from someone suicidal saying that all they want is to live volunterely.
    Anecdotely I have come across many people who can only continue with life by knowing they can escape by suicide if things get to bad.It is the freedom of choice that keeps them alive.
    what saddens me is the vast number of people I talk to that are scared to ask for help because they fear being "locked up", some of whom have been.
    Another high number is people who were "saved" by medics and continue in a living hell of oppresive medication hospitalisations,dulled senses and the loss of self that comes with anti psycotics.
    I remember when I was a kid reading I think an arabic proverb that went something like if you save a mans life you are responsable for every thing that happens to him after that.
    I feel the same applies in coercive suicide prevention. you are quite welcome to email me directly if you wish.

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  4. Anecdotely I have come across many people who can only continue with life by knowing they can escape by suicide if things get to bad. It is the freedom of choice that keeps them alive.
    what saddens me is the vast number of people I talk to that are scared to ask for help because they fear being "locked up", some of whom have been.


    I think you hit it right on the nail. The ability to enjoy something seems tied to its being a choice - slavery is bad, employment is good; a forced marriage is bad and rape is bad, freely chosen marriage is good and consensual sex is good. When life is an option, rather than forced on one, I think it increases in value.

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