Tuesday, September 30, 2008

Suicide and Leprosy: The Ethics of Voluntary Isolation

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

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

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

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

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

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

Wednesday, September 24, 2008

Warning Signs

"A broad range of warning signs for suicide has been identified in school-based suicide prevention programs, with little consistency across programs and many simply incorporating signs and symptoms of depression," say the authors of a 2006 study, Warning Signs for Suicide: Theory, Research, and Clinical Applications (PDF), in the journal Suicide and Life-Threatening Behavior, 36(3) June 2006. Indeed, "building awareness" of the warning signs of suicide is often the focus of anti-suicide efforts.

What are those all-important signs of suicide - those signs that, if you're careful and vigilant, can help you stop the suicide of a friend or relative? It depends on who you ask. San Francisco Suicide Prevention provides a set of warning signs, including talking about death, a recent loss (such as death, the end of a relationship, or loss of religious faith), a change in behavior (trouble concentrating on school or work), and menstrual abnormalities. Do you know anyone who exhibits any of those signs? Suicide.org has a different set of warning signs, largely made up of the symptoms of depression, including gaining or losing weight. Neglecting personal appearance, irritability, or lacking a sense of humor could also indicate your loved one is on the brink of suicide, according to suicide.org.

The Substance Abuse and Mental Health Services Administration warns about withdrawal from friends and family, a drop in academic performance, or suspicious cheerfulness. The National Suicide Prevention Lifeline (PDF) is a bit more literal - seeking a way to kill oneself is a warning sign of suicide, as is threatening to kill oneself. WebMD lists calling people to say goodbye and putting one's affairs in order as possible signs of suicide.

All these disparate signs and symptoms could be indicative of a suicide. Whatever the warning signs and however vague and ambiguous they may be, the American Foundation for Suicide Prevention tells us, it's important to take them seriously and act on them. "Seventy-five percent of all suicides give some warning of their intentions to a friend or family member," they assure us, without bothering to cite a source for that statistic. "In an acute crisis, take your friend or loved one to an emergency room or walk-in clinic at a psychiatric hospital." Got that? Also, "[r]emove from the vicinity any firearms, drugs or sharp objects that could be used in a suicide attempt."

My problems with such lists of "warning signs of suicide" are several. First, these lists of "warning signs" are vague and confusing, and leave friends and relatives of a suicide with the feeling that they somehow should have foreseen and prevented the suicide, adding to the survivors' guilt.

Second, these lists of "warning signs" are as likely to be read by people seriously contemplating suicide as by those who would prevent suicides. Given the suicide prohibition and the potential consequences for those caught being suicidal, suicides have every incentive to mask any potential "warning signs," forcing them to live even more inauthentically if they are serious about suicide. Saying goodbye is a warning sign of suicide - so we musn't say goodbye. Putting our affairs in order is a warning sign - so we mustn't do that, either. Most importantly, having serious conversations about suicide, which could help a potential suicide figure out his true desires and, at the same time, help friends and relatives understand the suicide's experiences and motivations, become extremely risky and, therefore, much less likely to occur when placed on the list of warning signs.

Finally, of course, a "list of the signs of suicide," published so that people may forcibly intervene in the lives and decisions of others, assumes that preventing suicide is, in all cases, a worthwhile policy goal.

To sum up, the messages conveyed by these lists of "warning signs of suicide" are three:

1. If someone you know commits suicide, you could have, and should have, prevented it. It's your fault.

2. If you are considering suicide, be careful to avoid exhibiting any of the warning signs - specifically, don't talk to anyone about your potential suicide. Hide your intentions.

3. Suicide is wrong and should be stopped in all cases, by force if necessary. We must all be junior spies in enforcing the suicide prohibition.

Monday, September 22, 2008

Friday, September 19, 2008

On People Not Being Able to "Make It Look Like a Suicide"

Those in favor of forcing people to remain alive against their will often hypothesize that an institutional right to suicide would put vulnerable people at risk of being coerced or pressured into suicide.

There is no evidence for that position. On the other hand, in a society with an institutional right to comfortable, doctor-assisted suicide by barbiturates, it would be much more problematic for a killer to murder someone and make it look like a suicide. In such a society, why would anyone commit suicide by carbon monoxide poisoning or by gunshot? Some might choose other means of death, of course, but suicides by old-fashioned means would likely become somewhat rare and extremely suspicious, no longer the norm.

Some believe that a right to suicide would harm vulnerable people. But there's just as much reason to believe that a right to suicide would eliminate some incidences of the worst coercive deaths - murders.

Tuesday, September 16, 2008

In Defense of the Man Whose Wife Finds Him Hanged

Selfishness and cowardice are traits attributed almost reflexively in our culture to the act of suicide. And what could be more selfish than committing suicide in a manner such that one's spouse, lover, relative, or close friend will be the first to stumble upon the shocking scene of one's dead body?

In this piece, I wish to examine the alleged selfishness of this action, with reference to the practicalities of committing suicide in light of the general suicide prohibition, and to the options available to a suicide.

In light of the suicide prohibition, if one attempts suicide and is interrupted before death is final, one is at risk of being "rescued" and forcibly kept alive. Few methods of suicide are instant (even suicides committed by gunshot carry a risk of survival, especially if discovered and "rescued" soon after the act). Get discovered prior to death, and you stand a good chance at ending up like Patient X from the Annals of Neurology study, forever in a twilight coma while doctors perform medical experiments on your unresponsive body. Therefore, in a society that attempts to forcibly prevent suicide, the single most important consideration for a suicide is to have a controlled environment without the risk of interruption. One's home is often the only place where one is familiar enough with the routines surrounding it to reasonably guarantee against interruption for the crucial hours or even days necessary to ensure successful suicide. What are the other options? Hotels? The outdoors? Unfamiliar environments carry major risks of discovery. Some of the risk is from lack of information and familiarity; some of the risk is from lack of control. But one's home is one's castle, and familiarity and control are both reasonably assured.

But what about those who choose to die far away from loving folk who might discover their dead bodies? There is a risk on the other side: that of subjecting one's family to unnecessary worry and uncertainty prior to discovering one's suicide, during the period that one is missing. Jake Baysinger's family wondered about his whereabouts for weeks (while his dog famously guarded his remains) after he committed suicide way out in a rural field, where his wife would not discover his body. Which is more cruel?

The pain of not knowing, and the pain of being confronted with death, are different sorts of pain. But both of these aspects of suicide's "selfishness" - discovering the shocking scene of the dead body of a close friend or relative, or experiencing the fear and worry of not knowing his whereabouts for weeks - are both artifacts of the suicide prohibition. Legal, physician-assisted suicide for everyone would, in addition to requiring potential suicides to think maturely about their actions, eliminate the fear of not knowing and the shock of discovery.

The suicide is not the selfish party in these situations. He has no other option but to live, and that, for many, is no option at all.

For many survivors of a friend or relative's suicide, the suicide comes as a shock. Survivors may feel angry at the suicide for "abandoning" them, or for not saying goodbye. But the conversation preparing one's family for one's suicide is one that cannot happen, is in effect forbidden from happening, in an environment of suicide prohibition. We cannot say goodbye if we are truly suicides. Saying goodbye or having a serious conversation about one's potential suicide would be perceived as a "cry for help," and carries the risk of forced hospitalization and other miseries.

It is the suicide prohibition, and not the suicide himself, that is responsible for a large part of the pain inflicted on those left behind. I am sorry for the wife who discovers her husband hanged. (Can you imagine your own lover, face drained of blood and distorted, lifeless, hanging dead in your house - when you had expected to come home and have a conversation and cuddle?) But, in his defense, he had little choice. The blame for a great part of her suffering lies with the policies of coercive suicide prevention.

Sunday, September 14, 2008

Say It Isn't So

"Think of the old clich├ę about quote the mind being an excellent servant but a terrible master.

This, like many clich├ęs, so lame and unexciting on the surface, actually expresses a great and terrible truth. It is not the least bit coincidental that adults who commit suicide with firearms almost always shoot themselves in: the head. They shoot the terrible master. And the truth is that most of these suicides are actually dead long before they pull the trigger."

David Foster Wallace, from his 2005 commencement speech at Kenyon College. He died on September 12 of suicide at 46.

A question: Why is our society so much more tolerant of the suicides of artists, writers, and musicians than of those of ordinary folk? Suddenly, when confronted with the suicide of a great artist, people lose their judgmental or pathologizing tendencies and start to think about suicide rationally. (Except this asshole - surprise, he's Australian.)

Thursday, September 4, 2008

Refreshing Honesty About Suicide - From the Army

An AP article quoted Brig. Gen. Rhonda L. Cornum, an assistant Army surgeon general, on the Army's response to record suicide rates among soldiers:
"There are no simple problems and there are no simple solutions," Cornum said. "There is no program that has been shown to be truly effective at preventing suicides . . . ." [Emphasis mine.]

Wednesday, September 3, 2008

Procreation and Responsibility

The sticking point in most discussions of antinatalism that I've witnessed has been whether it is always a harm to bring a child into existence. Most people admit that it is sometimes a harm to bring a child into existence, at least once they are educated past the identity problem. Not so for so-called "religious conservatives," who generally refuse to engage in public reason at all, and use their supernatural beliefs as a shield against moral responsibility for their actions.

Americans are currently preparing for a presidential election. Revelations about the reproductive life of Republican vice presidential nominee Sarah Palin have provoked discussion about procreation and hypocrisy (unfortunately, often at the expense of serious discussion of the real campaign issues).

One of the most morally blameworthy aspects of Palin's situation (though, of course, it is impolite to mention it) is her choice to have unprotected sex at the age of 45, resulting in a pregnancy which, at its outset, carried a 1/30 risk of Down Syndrome (trisomy 21). Palin has consistently been lauded for her "courage" in carrying a child she knew had Down Syndrome to term, rather than aborting; there is little, if any, discussion of her blind selfishness and refusal of responsibility in conceiving that child in the first place, knowing that she would not abort, much less about whether she committed a wrong against her son by not aborting. People of Palin's alleged religious beliefs generally frame children as "gifts from God" - in other words, they assert that people need take no responsibility toward conception or procreation.

I think this is appalling, and I am not alone - the California Court of Appeals agreed with me that a parent should be responsible in tort to a child born with a foreseeable defect (though the California legislature later changed the law to prevent such lawsuits):
One of the fears expressed in the decisional law is that, once it is determined that such infants have rights cognizable at law, nothing would prevent such a plaintiff from bringing suit against its own parents for allowing plaintiff to be born. . . . If a case arose where, despite due care by the medical profession in transmitting the necessary warnings, parents made a conscious choice to proceed with a pregnancy, with full knowledge that a seriously impaired infant would be born, that conscious choice would provide an intervening act of proximate cause to preclude liability insofar as defendants other than the parents were concerned. Under such circumstances, we see no sound public policy which should protect those parents from being answerable for the pain, suffering and misery which they have wrought upon their offspring. Curlender v. Bio-Science Labs, 106 Cal. App. 3d 811, 829 (1980). [Emphasis mine. Citations omitted.]

It is nauseating when religion is used as an excuse to avoid responsibility for processes that are well understood to be under human control.

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