Monday, June 30, 2008

Altruism and the Value of Life: Another Response to Velleman

Intentionally causing one's death in order to save another is a type of action often excluded from classification as suicide. Heroic "suicides" - pushing a child out of the way of a train, thereby killing oneself, or undertaking a military mission that benefits one's country but guarantees death, or jumping out of a leaking lifeboat in order to save one's companions - do not seem to be of a kind with suicides whose sole end is one's death. As Jacques Choron puts it,
Heroic suicides are obviously quite different from those brought on by serious illness, grief, or an unbearable situation and in this sense are outside the scope of an investigation primarily for the purpose of preventing suicide as an undesirable psycho-social phenomenon. [p. 17, Suicide: An Incisive Look at Self-Destruction, by Jacques Choron. Charles Scribner's Sons: New York, 1972.]

Heroic suicides - or, perhaps, "altruistic suicides" - are just not the same thing as "suicide" at all.

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

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

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

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

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

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

More Than Half of Gun Deaths Are Suicides

In 2005, according to CDC statistics, 55% of gun deaths were suicides. Apparently, suicides have outnumbered homicides and accidental deaths by gun for 20 of the past 25 years. An interesting and surprising statistic. But what's missing from this article by Mike Stobbe, released in the wake of the United States Supreme Court decision interpreting the Second Amendment as a personal right to bear arms?

First, and most importantly, it's missing any hint that a perspective might exist recognizing a right to suicide. Second, it fails to provide a single reason justifying the paternalism underlying gun bans enacted to prevent suicide in particular ("You can't have a gun because you might use it to kill yourself"). And, third, there's something glaringly missing from the recital of success rates for different suicide methods:
More than 90 percent of suicide attempts using guns are successful, while the success rate for jumping from high places was 34 percent. The success rate for drug overdose was 2 percent, the brief said, citing studies.

"Other methods are not as lethal," said Jon Vernick, co-director of the Johns Hopkins Center for Gun Policy and Research in Baltimore.

That's right - no mention of hanging, which has a lethality rate of up to 70%. Mention of this fact might have undermined the political point Stobbe was trying to make. (The article also fails to address the paradoxically high suicide rate in gun-free Japan - over twice that of the United States.)

As I have previously written, there is some evidence that reducing guns correlates to reducing suicides. What I object to is taking the "more guns means more suicide" statistic as license to argue in favor of coercive suicide prevention policies, such as gun bans, without examining in the slightest the philosophical basis for such a policy.

Sunday, June 29, 2008

Respecting and Erasing

Ending something does not entail denying its value.

In 1959, the artist Robert Rauschenberg asked the much older and more established artist Willem de Kooning to give him a drawing so that he could erase it. Eventually, de Kooning gave him a drawing, executed in heavy crayon, grease pencil, graphite, and ink. Over the course of a month, Rauschenberg erased the drawing and mounted it in a gold frame. View a large image of it here, on Boing Boing - it's a beautiful object, evocative and moving in its silence.

I relate this here, first, because it is beautiful, and I don't want to hear any crap about the decadence of modern art and blah blah blah - it is beautiful, it is moving, it is haunting, that is enough. Second, I relate it in response to J. David Velleman, whose "A Right of Self-Termination?" (Ethics 109 (April 1999): 606-628) presents an ethical argument against a moral right to suicide, at least suicide committed in order to make things better for oneself.

The core of the paper's argument is that it is wrong for a person to kill himself in his own interest, because by doing so, he devalues that which inheres to him - his dignity, in Kantian terms - that is not his to evaluate, but belongs rather to all of humanity. Velleman thinks that we ought to defer to a person as to a judgment of what is in his interests - he just does not think that killing oneself in one's own interest is morally permissible "solely on the grounds of the benefits [one] will thereby obtain or the harms [one] will avoid."

Velleman proposes that there is a special kind of value to every person, that logically must exist if his interests are to matter. It is an answer to the question, why should we act in the interests of other people? The answer is, because people matter. This mattering Velleman equates with Kantian dignity, which is further equated with man's rational nature. (The capacity to rationally choose one's ends is what gives a person dignity, in Kantian terms.)

Dignity is the reason we respect people (and respect their wishes). Velleman argues that suicide is a form of rejecting this dignity - and that we don't have the right to do that, because it is not ours to reject, exactly, but a feature of humanity. This dignity, says Velleman, is "a value that [a person] possesses by virtue of being one of us, and the value of being one of us is not his alone to assess or defend. The value of being a person is therefore something larger than any particular person who embodies it." Therefore we don't have the right to destroy it. It's not just that suicide is failing to treat oneself with the respect due to persons, though it is certainly that, according to Velleman - it's that suicide undermines respect for persons in general.

The story of the paper is this. Professor Velleman had cancer (in real life). A few years ago he was sitting around after dinner at a philosophy conference with some colleagues and a few people were smoking. One of the smoking professors said something about how he knew smoking would probably kill him, but that his enjoyment of smoking outweighed the probable early death it would cause him. Velleman, fresh from the chemo table, was deeply offended. Over the years, he came to realize that, by joking about trading life for pleasure, the professor was implying that human life lacks serious value (dignity), dehumanizing not only himself but Professor Velleman as well. The core of the paper, as I see it, is this:
My host's remarks implied that an early death, of the sort he was risking and I was hoping to forestall, would be a loss to him that could be offset by sufficient gains. But what would it matter how much I lost or gained if I myself would be no loss? My gains or losses would merit concern only on the basis of concern for me - which, being the basis of concern for them, could not then be offset by that concern. Hence my gains or losses wouldn't matter unless I had value that could not be offset by their.

My host was implicitly denying the existence of such a value. For he claimed that death was worth worrying about only in respects for which he could be compensated by the pleasures of smoking. He was thus implicitly denying the interest-independent value of a person, without which it couldn't really matter whether I lived or died.

In an appendix to the piece, Velleman responds to criticisms from Professor F. M. Kamm, in her article "Physician-Assisted Suicide, the Doctrine of the Double Effect, and the Ground of Value" (Ethics 109 (April 1999): 586-605).

Kamm calls one of Velleman's arguments the Exchange Argument, and interprets it to mean (correctly, says Velleman) that it is forbidden to exchange the intrinsic value of one's humanity merely to benefit one's interests, as in suicide or some kind of voluntary slavery. But, Kamm says,

According to Kant, beautiful things (e.g., art) have a value beyond price, though not the dignity that persons have. Most would say (though perhaps Kant would not, given his theory of beauty) that beautiful things have intrinsic value, even if no one cares about them and they satisfy no human interests. Yet we may permissibly exchange beautiful things for money or food. The permissibility of exchanging them for things that have interest-relative value and a market price does not imply, I believe, that they only have interest-relative value. It implies that what has intrinsic aesthetic value has only finite value and could be permissibly exchanged for what has only interest-relative value (e.g., food). But this does not show that beautiful things have only interest-relative value rather than intrinsic aesthetic value. That we can exchange one thing for another does not mean that they share the same essential nature or type of value. The same might be true of persons.

Velleman responds that the painting analogy fails, because when we sell a painting, we are not destroying it, but entrusting it into the care of another art appreciator. A better analogy, says Velleman, would be burning a painting in the fireplace because one has run out of kindling. "But then," says Velleman, "burning an artwork for kindling would ordinarily be objectionable. Not coincidentally, it's also what would be analogous to self-interested suicide."

But I think that analogy fails as well. I am so glad I heard about that empty, erased de Kooning drawing, because there is the proper analogy for a suicide, and, I think, my greatest objection to Velleman here. The act of erasing or destroying does not imply a lack of respect. There is such a thing as respectful erasing. Rauschenberg could believe heartily in the value of de Kooning's drawing - in fact, the drawing's artistic value is key to the work's success - and still, with the consent of de Kooning, erase it. Similarly, I think it is possible to commit suicide without implying that human life, and even one's own life, lacks value or dignity.

In many cases, as with the de Kooning, the absence of the thing is what heightens its value. When I saw the erased de Kooning, I immediately thought of Miller Williams' poem "The Curator," in which a young assistant curator at the Hermitage in Leningrad comes up with a scheme to ship all the paintings out of the city to avoid their destruction by the German bombs. They ship the paintings out, but leave the frames up to make it easier to put things back in their place when the war is over. Williams says:

Nothing will seem surprised or sad again
compared to those imperious, vacant frames.

Russian soldiers come to the Hermitage from all over Russia, and are disappointed that the paintings are gone, so the staff gives tours despite their absence. And gradually the tour of this "Unseen Collection" becomes more popular:

We pointed to more details about the paintings,
I venture to say, than if we had had them there,
some unexpected use of line or light,
balance or movement, facing the cluster of faces
the same way we’d done it every morning
before the war, but then we didn’t pay
so much attention to what we talked about.
People could see for themselves.

Eventually, blind people begin to come for the tour. Eventually, of course, the war is over and the paintings are replaced, but the blind people never come back, and people don't pay quite as much attention as before.

Can one erase a person in such a manner? Certainly, many who have been erased by death are still valued. Although rational choosing must cease at death, I do not believe that the thing that causes people to matter ceases at death. It is strange that one's biological life - and, especially, one's rational capacity - should be the basis for one's intrinsic claim to matter.

It might even occasionally be true that killing someone else could be done out of respect for his dignity, as in Sharon Olds' poem "Things That Are Worse Than Death," in which the speaker imagines killing her son in order to save him from being tortured by the police. An excerpt:

You are speaking of Chile,
of the woman who was arrested
with her husband and their five-year-old son.
You tell how the guards tortured the woman, the man, the child,
in front of each other,
"as they like to do."
Things that are worse than death.
I can see myself taking my son's ash-blond hair in my fingers,
tilting back his head before he knows what is happening,
slitting his throat, slitting my own throat
to save us that.

And in the recent novel by Cormac McCarthy, The Road, a father in a post-apocalyptic horror of a world is constantly aware that he might have to kill his son to spare him from being raped, tortured, and eaten by cannibals. Late in the novel, the father and son find a baby lying abandoned over a smoldering cooking fire. It is certainly reasonable to conclude that the father's actions, in keeping his son alive in such a world, are wrong - that he has failed to respect his son's dignity and value by keeping him alive even more than the baby's parents have failed to respect his dignity by burning him as if to eat him. (In reality, of course, evolutionary biology-minded studies of familicide, especially data regarding the virtual male monopoly of familicide compared with more equal gender ratios in killings of children alone, seem to suggest that real killings of children are generally motivated by proprietary feelings, rather than committed out of concern for the children's dignity. But the possibility remains.)

And many of us feel that such a world - such an unending stream of horrors - is already upon us, and perhaps has been since humanity's inception. For many of us, the only way to genuinely respect ourselves is to erase ourselves.

I feel compelled to point out that I'm not a fan of Cormac McCarthy and I think his writing is crap. But his book is important, even if he unflinchingly uses words like "vermiculate" and "torsional" and "wimple" (as a VERB) and never met an abstract noun he didn't want to turn into a verb. I hate "lyrical" writing and I hate McCarthy's rhythm. But his miserable writing style only partially detracts from the quality of his novel, in this case.

Saturday, June 28, 2008

The Repugnance of the Forced Life Position

Washington is considering an assisted suicide measure similar to Oregon's. Predictably, churches, especially the Catholic Church, have spoken out against the measure. The Most Rev. Carlos Sevilla, quoted in the Yakima Herald, provides one of the most repugnant, cruel, mean-spirited defenses of the forced life position I have yet heard:
Initiative 1000 is an attack on our most fundamental beliefs and teaching, and placing it on the November ballot would contradict our proclamation of the gospel of life . . . Pain and suffering and illness are important parts of our faith experience. [Emphasis mine.]

In other words, suffering people who don't share his religious beliefs should not have the right to die - in a democracy - because his religious beliefs place a value on suffering! God likes suffering, so suck it up.

Meanwhile, in India, lawmakers consider repealing a law that makes attempted suicide a criminal offense. Its Law Commission offers this compassionate analysis:

If a person has the right to enjoy his life, he cannot be forced to live that life to his detriment, disadvantage or disliking. If a person is leading a miserable life or is seriously sick or having an incurable disease, it is improper as well as immoral to ask him to live a painful life and to suffer agony. It is an insult to humanity. [Emphasis mine.]

Indeed, an insult to humanity in the name of God is exactly what Rev. Sevilla is offering.

Analytically, Sevilla's position appears similar to Velleman's, in that a particular value that "belongs to humanity" cannot be violated, even if upholding that value causes great suffering to individuals. Compassionate followers of Christ also recently opposed the right of an 11-year-old Romanian girl who was raped by her uncle to get an abortion. The interest-independent value of life, and all that.

Monday, June 23, 2008

Oregon's Law

Oregon's Death With Dignity Act succeeds in many ways. The Act respects patient autonomy, from its definition of "capable" to mean that
in the opinion of a court or in the opinion of the patient's attending physician or consulting physician, psychiatrist or psychologist, a patient has the ability to make and communicate health care decisions to health care providers, including communication through persons familiar with the patient's manner of communicating if those persons are available.

to the way it allows patients to decide for themselves whether to notify family members and when - even if - to self-administer the lethal prescription, once requested. (Some people who request suicide assistance don't use it until months or years after it has been provided.)

Oregon's law is wrong, however, in limiting access to death to those with terminal illnesses. Although this flawed version is certainly the only version of the law that would have had a chance of being enacted, the fact remains that it is wrong.

First, restricting access to comfortable means of death to those with a terminal illness is actually demeaning to people with terminal illnesses. The idea that human dignity somehow requires that one be able to walk and talk and control one's bodily functions is demeaning and wrong, as Felicia Ackerman (see Readings) and disability advocates point out. A terminally ill person must decide for him or herself whether to request suicide assistance; it is not the right decision for everyone. But what possible justification could there be for limiting this right to terminally ill people, except that their lives are somehow less valuable than those lives that will (probably) continue on for many years? The designation "Death With Dignity Act," of course, hints at the demeaning implication of the limit: some deaths are dignified, other are not. The state will decide for you whether you are undignified enough to be allowed to die peacefully. (The Oregon law does not allow assisted suicide to be provided to non-terminally-ill disabled or merely old people, but the implications of the restriction to terminally ill people are clear enough.)

Second, the Oregon law's restriction against suicide assistance to non-terminally-ill people is wrong because suicide is an important right for everyone, not merely the terminally ill. In fact, if anything, the right is more important for those who are not terminally ill, because their time of suffering will most likely be much longer than those who will die soon naturally. And, as pointed out by Velleman, terminally ill people are much more likely to be harmed by having the option to die than healthy people are, because they are more likely to be dependent on the care of others and therefore to feel themselves to be a burden. A more sensible restriction might be to allow suicide assistance only to non-terminally-ill people! I am not, of course, in favor of this restriction, but it makes more philosophical sense than Oregon's law, which makes political sense, if anything.

Meanwhile, Switzerland recently extended suicide rights to those with incurable mental illnesses. Jacob Appel, writing in the Hasting Center Report, explains the basic ethical issues:

Another set of objections are from those who support a basic right to assisted suicide in certain situations, such as those of terminal disease, but do not wish to extend it to cases of severe and incurable mental illness. This resistance may be inevitable, considering the increased emphasis that contemporary psychiatry places on suicide prevention, but the principles favoring legal assisted suicide lead logically to the extension of these rights to some mentally ill patients.

At the core of the argument supporting assisted suicide are the twin goals of maximizing individual autonomy and minimizing human suffering. Patients, advocates believe, should be able to control the decision of when to end their own lives, and they should be able to avoid unwanted distress, both physical and psychological. While these two principles might explain why a victim of amyotrophic lateral sclerosis or cancer would choose assisted suicide, they apply equally well in many cases of purely psychological disease: a victim of repeated bouts of severe depression, particularly in cases where treatment has consistently proven ineffective, rationally might prefer dignified death over future suffering. [Hastings Cent Rep. 2007;37(3):21-23. Via Medscape. Emphasis mine.]

Thursday, June 19, 2008

That Statistic that 90% of Suicides Have a Diagnosable Mental Illness

There's a widely reported statistic floating around, unquestioningly reported (often without noting its source) by groups with a stake in its truth, such as the National Institute of Mental Health and the American Foundation for Suicide Prevention. The statistic is this:
Ninety percent of all people who die by suicide have a diagnosable psychiatric disorder at the time of their death.

The statistic is used to imply that, first, mental illness, and not individual choice, is the cause of suicide, and is often cited to justify coercive suicide prevention policies; and, second, that money invested in mental health treatment will reduce suicides. I wish to question the reliability of this statistic, as well as the two implications that are often drawn from it.

What is the source of this alarming statistic? It may surprise advocates of evidence-based medicine to learn that many of the source studies hardly qualify as scientific studies at all, in that many of them are entirely uncontrolled. The studies rely on a technique known as a "psychological autopsy," which tries to diagnose mental disorders in a deceased person based on interviews with family members. The so-called first generation of studies simply chose a study group of known suicides, and tried to identify mental disorders within the study group, with no control at all. This 1996 study, for instance, has no control, but purports to find that 90.1% of suicides have a diagnosable Axis I mental disorder. This is the study that the National Institutes of Mental Health cite as their basis for the figure!

A new generation of studies "during the last decade" has attempted to apply basic scientific control procedures, however. In these studies, a group of known completed suicides was matched with a control group of living people with similar characteristics. Interviews, medical records, and "information from the coroner" are collected and evaluated by psychiatrists who are often supposedly "blind to outcome" - that is, they are not supposed to know who is a suicide and who is alive. If an evaluator knew someone was a suicide, he might be predisposed to look extra hard for information indicating a psychiatric disorder.

Keeping evaluating psychiatrists outcome-blind seems like a particularly difficult task, especially given that "information from the coroner" is included in the case reports. More importantly, those preparing case reports are necessarily not outcome-blind. The idea that their preparation would not be influenced by knowledge of outcome (suicide or living) is rather hard to swallow.

At any rate, one (dubiously) controlled study of young men found that 88% of the suicides, compared with 37.3% of the non-suicides, had a diagnosable mental disorder. To report this study as finding that "90% of suicides have a diagnosable mental disorder" is to ignore its more important implications: well over a third of this population of young males has a mental disorder! But 37.3% of young men do not commit suicide. Clearly, mental illness is not much of a "cause" of suicide. Some scientists characterize it as a necessary but not sufficient condition.

It is also important to point out what counts as a mental disorder in these studies. Depression counts, but also alcohol or drug dependence, and often any Axis I or even Axis II disorder (as in the study of young men). It is instructive (and suspicious) that the percentage of suicides found to have a "mental disorder" does not seem to vary depending on the investigator's definition of "mental disorder."

It is also important to think about the vague, unscientific definitions of mental disorders found in the DSM-IV and its earlier incarnations. Given the vague definition of depression, for instance, is it really any surprise that people who commit suicide would meet the criteria for depression? (Actually, studies vary extremely widely in how many suicides they find to have been depressed - all the way from 30% to 90%. Personality disorders vary even more widely - from 0% to 57%. This variance should make us very suspicious.) What person deciding to end his life wouldn't, for example, experience a loss of pleasure in ordinary activities, or changes in sleep or appetite, or feelings of hopelessness or guilt? As for drug and alcohol use, what person, faced with the desire to die, wouldn't try to assuage his pain by any means available - including alcohol and drugs? In my own case, as a suicide, I view alcohol and drugs as a temporary suicide prevention device. Recent research in nicotine use, for instance, has revealed that nicotine may help symptoms like anxiety and depression, and help people with ADHD to function:

An even more important reason for the link between depression and smoking may stem from the pleasure that smoking can bring. As Dr. Fowler's research suggests, smoking triggers higher dopamine levels in the brain; elevated levels of dopamine have been linked to feelings of well-being and pleasure and have been found in users of heroin and cocaine. Such emotions may be particularly welcome by individuals suffering from depression.

I would like to point out that I do not smoke. But it is easy to see how this logic would apply to alcohol and other drugs. We should expect suicidal people to be more willing to experiment with illicit ways of promoting happiness, compared to the general population. To say that people who commit suicide are likely to have used drugs or alcohol is not to say that alcohol or drug use caused suicide.

Does investing money in mental health care prevent suicide? The relationship is shaky at best. The Japanese government's recent efforts to reduce suicide, through both coercive and non-coercive means, including increased mental health spending, have failed miserably. A 2005 study published in JAMA found that "despite a dramatic increase in treatment, no significant decrease occurred in suicidal thoughts, plans, gestures, or attempts in the United States during the 1990s." While the frequency of treatment of individuals who engaged in suicidal behavior more than doubled, the suicide rate dropped only 6%.

The statistic that 90% of suicides have a diagnosable mental illness, so gleefully reported by those in the anti-suicide industry, is questionable. Even if it has some basis in fact, vagueness of diagnostic criteria and other special factors detract from any conclusions that can be drawn from it. What is most uncertain is whether investing in mental health treatment actually reduces suicide. (This is made even more uncertain by the failure of mental health treatment even to, well, treat mental illness.)

A more realistic and ethical route would be to accept suicide as a relatively rare but natural and acceptable way to end life, to provide means of suicide that are effective and not harmful to bystanders, to allow competent adults to opt out of coercive suicide "rescue," and to focus any government or private spending on alleviating suffering, rather than preventing suicide.

See also: What the DSM-II Got Right, my examination of changes in the diagnostic taxonomy for depression since the DSM-II and their implications for suicide rights.

Update: Jason Malloy points me to this 2004 meta-study, studying suicides in North America, Australia, Europe, and Asia. "Twenty-seven studies comprising 3275 suicides were included, of which, 87.3% (SD 10.0%) had been diagnosed with a mental disorder prior to their death," say the authors. This is far superior to the studies that attempt to backwards-infer mental illness. My main problem with this study is that it’s tracking any and all “mental disorders” and even crap like “alcohol use” is coded as a disorder, not to mention “intermittent depressive disorder” and “neurotic depression” (i.e., they’re not even using the piss-poor standards of the DSM-IV).

(See Malloy's admirably tolerant responses to my increasingly drunken arguments here.)

Wednesday, June 18, 2008

Sources of Coercion: A Review of California Law

Since I ultimately hope to make policy proposals, in the form of proposed changes to the law, to end coercive suicide prevention practices (though, of course, with no realistic hope of these being implemented in this generation), and now that I have the philosophical basis for the project at least outlined, it might be helpful to review exactly what the law is, in California at least, regarding coercive suicide prevention.

The single worst document in California law, from the anti-coercion perspective, is Kockelman v. Segal, 61 Cal.App.4th 491 , 71 Cal.Rptr.2d 552 (1998), which I will describe below in Section 2.

1. Forced hospitalization

California's Lanterman-Petris-Short Act, located in the California Welfare and Institutions Code, is actually a relatively progressive law for people subject to mental health treatment, and regulates (but ultimately allows) forced hospitalization.

The most relevant provision of the act is the famous Section 5150, which allows the involuntary detention, for up to 72 hours, of a person when there is probable cause to believe that, as a result of mental illness, he is a danger to himself, a danger to others, or is unable to care for himself (gravely disabled). (The 72 hour hold can be extended to a 14 day hold upon an administrative hearing; longer holds, up to and including conservatorship, require increasing court involvement.)

The specification that forced hospitalization may only take place if the "danger to self" is a result of a mental illness appears to allow for the possibility of rational suicide. But, of course, in the context of a suicidal person, is it difficult to determine whether the suicide attempt or suicidal intent occurs "as a result of a mental illness." In practice, any suicide attempt, behavior, or intent is automatically treated as if it were the result of a mental disorder, despite the obvious lack of evidence to support this practice. The most rational suicide in the world, if discovered before the attempt was completed, would certainly be hospitalized. (Socrates would be issued hospital pajamas and slippers, have his jewelry removed, and be given Prozac and group therapy.) This practice fails to accord both with the requirements of the law, important philosophical principals of self-determination, and, as I have mentioned before, the interests of non-suicidal "signalers."

There is no opt-out. A competent, rational adult has no right to refuse to be "treated" (imprisoned and forced to remain alive).

Another important provision of the Act is the immunity it provides for people who detain and forcibly hospitalize those they think have a mental illness and are either dangerous or gravely disabled. Section 5278 provides that "Individuals authorized under this part to detain a person for 72-hour treatment and evaluation pursuant to Article 1 (commencing with Section 5150) . . . shall not be held either criminally or civilly liable for exercising this authority in accordance with the law." This has been interpreted to mean that, as long as the detention is supported by probable cause according to a court, the person detaining the individual alleged to be mentally ill may not be sued or prosecuted for imprisoning him. This law essentially encourages police and health workers to detain people, assuring them that there will not be any consequences for interfering with another person's freedom.

2. Duty to prevent a suicide (by coercive means if necessary)

To explain the duty to prevent a suicide under California law, I will link to the major cases and, as I have time, explain the relevance of each one to the development of a duty to use coercive suicide prevention methods.

  • Meier v. Ross General Hospital, 69 Cal.2d 420 (1968).

    An early case establishing the liability of a hospital for the wrongful death of a patient who commits suicide while involuntarily committed to the hospital's care.

  • Nally v. Grace Community Church, 47 Cal.3d 278 , 763 P.2d 948; 253 Cal.Rptr. 97 (1988).

    The California Supreme Court found that a member of the clergy, as a "non-therapist counselor," owed no duty to prevent the suicide of a congregation member he was counseling by referring him to a licensed counselor, even where the suicide was foreseeable. Nally seemed like a victory against coercive suicide prevention practices; Chief Justice Lucas, in his opinion, even quotes an earlier case, Bellah v. Greenson, 81 Cal.App.3d 614 , 146 Cal.Rptr. 535 (1978), in which the court (in dicta) explicitly recognizes the reasons that coercing counselors to use coercive suicide prevention methods could be harmful to patients:

    Similarly, Bellah recognized that creating a duty on the part of a psychiatrist to breach the confidence of a doctor-patient relationship by revealing disclosures made about the suicidal intent of his patient would unduly extend the Tarasoff holding, and "could well inhibit psychiatric treatment." (Bellah, supra, 81 Cal.App.3d at p. 621.) Bellah reasoned that in Tarasoff, we held only that "where a therapist knows that his patient is likely to injure another and where the identity of the likely victim is known or readily discoverable by the therapist, he must use reasonable care to prevent his patient from causing the intended injury. Such care includes, at the least, informing the proper authorities and warning the likely victim. However, [Tarasoff] did not hold that such disclosure was required where the danger presented was that of self-inflicted harm or suicide. ... Instead, [Tarasoff] recognized the importance of the confidential relationship which ordinarily obtains between a therapist and his patient, holding that '... the therapist's obligations to his patient require that he not disclose a confidence unless such disclosure is necessary to avert danger to others. ... (Tarasoff, supra, p. 441, italics added.)'" (Bellah, supra, 81 Cal.App.3d at pp. 620-621.) [Nally at 295, quoting Bellah. The Tarasoff case mentioned is the famous California case imposing liability on a psychiatrist for failing to violate confidentiality and disclose his client's intention to harm a third party. Emphasis mine.]

    Nally, however, interpreted Bellah (again in dicta) as recognizing a duty owed by a psychiatrist or licensed counselor "when a psychiatrist's (or hospital's) treatment of a suicidal patient falls below the standard of care for the profession, thus giving rise to a traditional malpractice action." (Nally at 296). Presumably, the "standard of care" could include coercive means.

  • Kockelman v. Segal, 61 Cal.App.4th 491 , 71 Cal.Rptr.2d 552 (1998).

    The locus of the duty to use coercive means to prevent a suicide is most clearly found in Kockelman, one of the most harmful opinions in the State of California for purposes of counselor-patient relations. Any hopes raised in the Nally opinion were dashed in Kockelman.

    The Kockelman court allowed a woman whose husband committed suicide during the course of outpatient treatment to sue his treating psychiatrist for wrongful death, apparently for failing to prevent his suicide. The court reasoned that whether the doctor had violated the professional standard of care was a question of fact that would have to be determined at trial. Given the facts of the case, it is difficult to see what the court could mean that the doctor could have done, short of using coercive means (forced hospitalization) to prevent the suicide. An excerpt from the factual background:

    Kockelman kept his appointment on September 2, 1993. He reported he was not doing much better, although he appeared neatly dressed and clean-shaven. Dr. Segal wrote that it was "mysterious" to him how Kockelman could rouse himself when needed and at other times could not get out of bed. But again he found it impossible to engage Kockelman in any psychodynamically oriented dialogue. He recommended increasing the Prozac dosage and restarting the lithium, but noted he did not feel "very optimistic" that this would make a difference. He discussed the possibility of ECT with Kockelman and noted he would see what could be arranged.

    Kockelman died on September 5, 1993, three days after his last appointment with Dr. Segal, from an overdose of desipramine. Valerie Kockelman stated that her husband was feeling more energetic and cheerful the last week before his death and had gone to work each day. She said "it was like he was a new person." They were planning a car trip to visit their daughter in Santa Rosa on the Saturday of a Labor Day weekend, and he was looking forward to it. On Saturday morning Kockelman told her he wanted to stay home and he urged her to go by herself. He did not seem depressed to her and appeared to be in good spirits. He told her he just wanted to "rest up." She left Saturday and when she returned home the following evening she discovered her husband's body. [Kockelman at 497. Emphasis and link mine.]

    Apparently, psychiatrists must not only be their patients' jailers; they must also be mind readers. Also: be sure to hospitalize anyone who looks cheerful!

  • Cruze v. National Psychiatric Services, Inc., 105 Cal.App.4th 48, 129 Cal.Rptr.2d 65 (2002).

    A terminally ill woman was involuntarily hospitalized by her physician after she discussed the possibility of committing suicide. The court denied her right to sue her physician for malpractice, basing its decision on the immunity granted by Section 5278 of the California Welfare and Institutions Code (explained above).

  • Jacobs v. Grossmont Hospital, 108 Cal.App.4th 69, 133 Cal.Rptr.2d 9 (2003).

    The California Court of Appeal confers a bit of hope, this time by determining that the grant of immunity in Section 5278 of the Welfare and Institutions Code (explained above) is not absolute, and does not protect a hospital from claims resulting from improper care. This is still not terribly good news, as it might be used to sue a hospital or other person for failing to use means that were coercive enough. But at least it imposes a duty of care on people who involuntarily detain others.

  • Hernandez v. KWPH Enterprises, 116 Cal.App.4th 170 , -- Cal.Rptr.3d -- (2004).

    In Hernandez, a recent California Court of Appeal case, the court found that an ambulance service owes no duty of care to a voluntary patient its employees are transporting when the patient exhibits bizarre behavior and then runs away from their custody. (The patient in this case ran onto a highway and was hit by a car and killed.) In my opinion, the court was correct in refusing to impose liability on ambulance personnel for failing to coercively prevent a suicide (or perhaps accidental death). The case does not go far enough, of course, but it signals a good trend. It could have been much worse.

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.

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.

Thursday, June 12, 2008

Suicide Trends: Antidepressants, They Do Nothing

Suicide trends in the United States: this is what they look like, in case you're confused.

One question often asked, in reference to whether antidepressants are effective, is whether suicide rates have declined in response to widespread antidepressant use. Many authors have attempted to answer this question. One study attempted to demonstrate a time correlation between antidepressant use and declining suicides. Why did these authors cut off the data for the 1950s, and begin their analysis with data for the 1960s? Including the suicide rate data (very low, especially among women) for the 1950s would reduce confidence in the authors' conclusion that antidepressant use is time-correlated with a drop in suicides. (The 1950 data occurred long before SSRIs were available, but undercut the authors' claim that the 1960-1988 data represented the baseline condition from which suicide rates dropped.)

More importantly, given the data that antidepressant use is not associated with a drop in suicidal behavior, such as suicidal ideation and suicide attempts, even if time correlation were properly demonstrated, the effectiveness of antidepressants is not supported. It is difficult to imagine any way in which antidepressant medications could reduce suicides while having no effect on suicidal ideation, behavior, and attempts, especially given that the JAMA study found that "cry for help" insincere suicide gestures decreased slightly between the 1990-1992 and 2001-2003 studies.

Actually, there is a way that antidepressants could reduce completed suicides but not suicidal behavior or ideation: if they interfere with cognitive ability in general, rendering suicides clumsier or more poorly planned.

But the more likely explanation, given all the data, including the February study that the commonly prescribed antidepressants don't work better than placebo, is that some factor other than antidepressant use is responsible for any drop in suicides. The obvious answer is that, to the extent that there has been a drop in suicide rates, it's due to the drop in gun ownership over the past few decades. (Here's a graphic.) As I have previously noted, gun ownership is highly correlated with suicide. Reduction in gun ownership, in addition to reduction in availability of other reliably lethal methods of suicide, such as lethal pesticides (frequently used for suicide by men and women in poor countries) and barbiturate sleeping pills, is much more likely to be responsible for the drop in suicides than increased antidepressant use. These factors - what might be termed coercive suicide prevention methods - would easily explain a drop in suicide not associated with a drop in suicidal ideation or behavior.

Thanks to Overcoming Bias poster Peter McCluskey for the pointer to the PLoS article.

Edit: Cognitive behavioral therapy (CBT), much hyped for depression, apparently doesn't work either. From the study:
Stravynski and Greenberg suggested that all models of psychotherapy, including cognitive behavior therapy, may be "equally unsound scientifically but they energize the therapists and provide useful fictions to activate the patients to lead somewhat more satisfactory lives." [Citations omitted.]

Victims of the Suicide Prohibition: Debbie Purdy

There are certain situations where a right to effective, comfortable assisted suicide might actually be pro-life. Such is the case of Debbie Purdy, the British woman with multiple sclerosis who recently won the right to a hearing to clarify the law on whether her husband would be prosecuted for assisting her suicide should she need his help.

Stories on Debbie Purdy's struggle over the years reveal that her reason for wanting a guarantee of assisted suicide is that, while she loves life and wishes to continue living until her pain becomes unbearable, by then she will no longer be capable of ending her life without assistance. She is concerned that, if she waits and requires assistance to die, her husband will be prosecuted for attempted suicide. From The Guardian in 2004:
Assisting suicides carries a maximum 14-year sentence in Britain, one of the few European countries where it is still a crime. Purdy, like her 55,000 fellow members of the Voluntary Euthanasia Society, believes this is wrong. 'The only thing that will improve the quality of my life now is a change in the law, so I don't have to be thinking about what I'm going to have to do by myself. If that no longer becomes the biggest question in my life, then I can start thinking about overcoming the symptoms I cope with.'

[Purdy] considered going to Holland, where euthanasia for the terminally ill has been legalised. But patients need to have been registered with a Dutch doctor for two years before they qualify for medical assistance that would bring their lives to an end.

Purdy's hopes for a law change look slim, at least for now. 'People want to bury their heads in the sand on this issue. The other day I heard Linford Christie say "oh they could find a cure". That's just grabbing at straws. That's denial.'

The prosecutor characterized Purdy's case as "unarguable" because Britain lacks a specific policy on assisted suicide and has no obligation to produce one. Purdy has said that she is pleased to get a hearing, and is hopeful that assisted suicide will one day be legal in the UK.

A British forced life group, Care Not Killing, responds that assisted suicide should remain a criminal act:

The key issue here remains whether the law should be changed for the very small number of people who press for assisted suicide. Our view is that in order to protect others from exploitation it should not be.

In other words, sorry Debbie Purdy, but you must suffer for our values that you do not share.

Mismatch and Meaning

In my earlier post, I mentioned that the lack of inherent meaning of life functions as a limit on human happiness. It is more accurate to say that the mismatch between the lack of inherent meaning in life and the human desire for meaning is what limits happiness and causes suffering. All of the limits on human happiness I proposed in the earlier post are products of some sort of a mismatch.

That the mismatch between the lack of meaning and the desire for meaning, rather than meaninglessness itself, is the cause of human suffering is a major point in Camus' The Myth of Sisyphus. Camus is interested in the question of suicide; specifically, he appears to be investigating the question of whether intellectual honesty and consistency require suicide, the way a certain view of animal suffering might be said to require vegetarianism. He is concerned with what might be called authenticity. He argues that nearly every philosophical response to the inherent meaninglessness of life takes what he calls a "leap" - toward a belief in God, or even deification of the absurd itself, to escape from the suffering (and contradiction) that meaninglessness, coupled with a desire for meaning, produce.

Camus ultimately concludes that suicide is not the only intellectually honest response to absurdity. The authentic path, he says, is to live at every moment aware of absurdity - not to lose sight of meaninglessness - but to also scrupulously avoid "leaping" into mysticism or some other escape from absurdity. In terms of terror management theory, Camus feels that the only intellectually honest way to live is to be mortality salient at all times, but never to retreat into worldview defense.

It may be true that this could be an intellectually honest life. I certainly don't think that suicide is required. But it is not a path that is realistically available to very many people. In addition, intellectual honesty and consistency cannot be the only things of value in life, in all cases. For many, they do not take precedence over suffering, or even over the subjective value of many "leaps" Camus advises against.

Nonetheless, I think realistic awareness of the many mismatches that guarantee human suffering - not least the simultaneous lack of, and desire for, inherent meaning - is required for intellectual honesty.

Wednesday, June 11, 2008

Limits on Human Happiness

There are certain biologically-determined features of human beings that function as limitations on human happiness, regardless of the system of government that is in place. I wish to list a few of these, sticking to limitations whose existence few would deny and for which there is substantial evidence, without getting into speculative evolutionary biology territory. These are things that are unlikely to be remedied by any system of government or intervention. The only change that might remedy these limitations is a biological one - for instance, a physical change from a human body and human brain to a different sort of cognitive architecture.

I am using the term "happiness" in a broad sense here, not merely in a hedonistic sense, so that it includes things like satisfaction of preferences as determined by the individual (which preferences must, of course, be partially biologically determined).

Parents exercise control over children, despite the mismatch between parental interests and the interests of the child. A child cannot control himself, yet no one else's interests match his own. His parents' interests are frequently extremely different from his own - even a stranger would be more likely to make decisions on the child's behalf that reflect the child's values, rather than the parents. Of course, an unrelated person is also much more likely to abuse or kill the child.

Inequality is ubiquitous, overdetermined, and harmful. Inequality is ineradicable, both in terms of initial endowment (which is determined by necessary genetic variability) and in terms of economic distribution, regardless of the system of distribution. Inequality, in and of itself, causes suffering, regardless of the absolute level of material prosperity of the population. (The murder rate, for instance, more closely tracks inequality than overall poverty.) Even given an initially equal distribution, inequality would be guaranteed by the human preference for comparative well-being, rather than absolute well-being.

Humans' interest in maximizing sex is limited by the suffering caused by violent sexual jealousy. Neither the interest in sex nor the jealousy is likely to change.

Predominant heterosexuality, combined with the fact that the two genders experience different (average) sex drives, ensures frustration. Again, neither of these is likely to change. Widespread polygyny is not a solution that ensures a reduction in overall suffering, even where it is freely chosen by all partners, as it necessarily imposes celibacy and suffering on a large number of men who are not party to the polygynous arrangement.

Exploitation will always be lucrative, and sociopaths and other "cheaters" will always be with us. Sociopathy, as an evolutionary beneficial strategy at low frequencies, occurs (with low frequencies) in all human populations. Given any set of rules, from the ultraminimal state to totalitarian communism, figuring out how to successfully deviate from the rules in a way that benefits the individual will always be a benefit.

And, of course, there's this.

These, along with widely recognized limitations on human happiness such as aging, mortality, limited resources, and the lack of inherent meaning in life, act to limit the realistic expectations for happiness in even the most just nation imaginable. There may be hope for posthumans, but there is no realistic hope for humans to live lives of unlimited happiness. In many ways, suffering is guaranteed.

Edit: Here's another one.

Shame is necessary for human development and social functioning, and necessarily unpleasant. The presence of shame is ineradicable, nor would it be desirable to eradicate it. Nevertheless, it causes intense suffering for many, with the exception of those with antisocial personality disorder.

Tuesday, June 10, 2008

Nonviolent Exploitation: Is It A Problem?

Let me motivate this discussion before I get into it - I have been considering whether the concern for rights and autonomy upon which I'm basing a right to suicide is inconsistent with the regulation of economic activity that I would deem exploitative (such as the marketing behavior of the consumer credit industry, and certainly other industries, that causes suffering that leads to many suicides).

What is exploitation? I wish to try to get at a specialized sense of this word, not its common usage. I would define exploitation as
  1. deliberately "pushing people off" of rationality - using knowledge of cognitive bias to cause people to act in a manner contrary to rational interest maximization
  2. for profit or easily measurable gain
  3. causing great suffering and harm in a fairly direct way

My definition of "exploitation" would not, for instance, cover the case of prostitutes "exploiting" their customers. First, I would not (necessarily) consider a value (we could more pejoratively call it an "appetite") to be a cognitive bias, and sex must certainly be seen as a value. Second, even if prostitutes exploit cognitive bias in "marketing," it must be rare that the prostitute causes great suffering and harm to a client. It might be more accurate to say that the prostitute causes much rejoicing - or, at least, relief from suffering. This is not what I mean by exploitation. (Actually, my concern with exploitation is more in the marketing methods used to secure the exchange, rather than the exchange itself. Here is the tricky part - this might include marketing for any transaction, from prostitution to cars to stocks to food.)

I am aware that it is strange to take the case of "prostitute exploiting client" first in the sex work scenario. The more common case proposed as an example of exploitation is the exploitation of the prostitute by pimps (or, perhaps, clients). I think the most realistic position on this is that not all sex workers are exploited, but that many are. Pimps, for instance, (1) deliberately use a knowledge of cognitive bias (if not outright violence) (2) for profit, (3) often creating great suffering. As with obscenity prosecutions, we must keep our eyes on the real harm - the exploitation, the departures from trustworthy consent - and not some aesthetic judgment. The fairest and most realistic tactic, to me, seems to be to regulate the deliberate exploitation of the individuals whose suffering we worry about - not to directly limit the freedom of the individuals themselves. In other words, the pimp has no claim for a right to ply his "trade" in the just society, whereas the prostitute does.

But why not allow exploiters to exploit, so long as they don't utilize coercion or fraud? To answer this, we must first ask, why should the state protect individuals from violence, theft, and fraud?

There are several possible answers to this question. To the person whose moral system is grounded in utility maximization through rational self-interest (in classical economics, for instance), violence, theft, and fraud are suspect because transactions that take place as a result of violence, theft, or fraud are not utility-maximizing - we have reason to suspect that this type of transaction reduces utility, because the transaction is either not voluntary or entered into with false information. In addition, violence, theft, and fraud cause over-investment in security, again interfering with free market utility maximization. And yet another problem is that violence, theft, and fraud produce nonfunctional income: income unrelated to efficient economic activity (which would be utility-maximizing). (The enforcement of contracts - a function Robert Nozick ascribes to the minimal state - might be justified on similar grounds, such as preventing over-investment in hedging against nonperformance.) To the person more concerned with individual rights, violence, theft, and fraud are serious examples of the violation of what is generally taken to be the most important individual rights. It is actually not clear to me exactly why Nozick would allow the state to protect against violence, coercion, and fraud, and to enforce contracts, but I am currently re-reading Anarchy, State and Utopia with an eye to figuring this out.

Preliminarily, the same reasons that justify a proscription of violence and coercion (and enforcement of contracts) may be applied to what I have termed exploitation. The deliberate, calculated practice of lulling a person away from rationality encourages transactions that are not rationally utility-maximizing. We should have no faith in these transactions, just as we have no faith in "transactions" that are the result of theft or fraud. Exploitation is attractive as a field, and, left unchecked, is likely to draw investment away from economically efficient enterprises and toward its own unproductive, harmful enterprise. Income from exploitation may be seen as nonfunctional income - the income is unrelated to economic efficiency, unrelated to any contribution to the productive economy.

For purposes of comparison (this is really different from anything Nozick is talking about), this is Galbraith's explanation of nonfunctional income:

It is the normal assumption of economists in advanced communities that income rewards economic effort. Since it induces that effort, it is functional. There has been ample dispute over whether particular functions are over- or under-rewarded, and this is the foundation of the ancient quarrel between Marxians and non-Marxians. But the adequacy of reward for service is not the central issue in this model; the problem is that numerous claimants [in the economies of Latin American countries] - landlords, members of the armed services, government functionaries, pensioners - render no economic service at all. And the best rewarded businessman is not the one who performs the best service but the one whose political position or franchise accords him the most secure monopoly. It is useful to have a term for the income which is so divorced from economic function, and one is readily at hand. It may be called nonfunctional income. [John Kenneth Galbraith, "The Causes of Poverty: A Classification," in Economics, Peace and Laughter, Houghton Mifflin, 1971]

Of course, there are ethical reasons to prohibit exploitation - reasons that, I would argue, are not redistributive. Prohibiting exploitation does not redistribute wealth from the savvy to the vulnerable; rather, it acts to prevent a redistribution from the vulnerable to cheaters that does nobody any good (except the cheaters). We should give no more credence to the "right to exploit" than to the "right to defraud" or the "right to violently coerce." In fact, we might properly consider a "right to be free from investment in exploitative tactics" - a right not to be the target of tactics, backed by significant investment, designed to push us off our rationality, and to enter transactions that appear voluntary, but that benefit the exploiter, but not the exploited. This is not the same as saying there should be no right for an individual to enter transactions (or take actions) that appear to be contrary to his self-interest.

Another, less formal way of thinking about this is to imagine the evolutionary arms race that must have occurred in our EEA between cooperators and cheaters. Cheating is an attractive strategy, and mechanisms to successfully cheat, as well as mechanisms to detect cheating, must both have high fitness value (though cheating-prone genotypes occur with much lower frequency than cooperator genotypes if society is not to collapse on itself). The cheating-detecting strategy that is the current human standard model was developed to deal with fairly straightforward cheating by individuals and small coalitions. Faced with massive investment in "cheating technology" by corporations, the natural cheating-detecting mechanisms of individuals must fall short. When predators and prey evolve together, the "arms race" often results in an equilibrium, with both predators and prey surviving in sustainable numbers. Similarly, cooperators and cheaters were able to coexist for millions of years. But when a predator either develops a major new technology, or is faced with prey species with whom he did not evolve, the predator is at risk of wiping out the entire prey species - and, ultimately, the entire ecosystem, including himself. Large mammal extinction was the result of early humans arriving on continents with an existing package of technology that the mammals had no defense against. Massive investment in cheating technology leaves cooperators just as vulnerable to these new super-cheaters as the American megafauna were to the early humans. Some say the cooperator collapse is already here.

Edit: Even Richard Posner thinks that deregulation of the banking industry has shown itself to be bad policy. "I have long thought it troublesome that Alan Greenspan was a follower of Ayn Rand," he quips.

What's the right path, then? "The correct approach," says Judge Posner, "is to carve down regulation to the optimal level but then finance and staff and enforce the remaining regulatory duties competently and in good faith."

Monday, June 9, 2008

Bankruptcy Suicides

I have just watched the clear, insightful, completely tragic documentary called Maxed Out, detailing problems with credit in America, from consumer debt to national debt. The documentary presents an accurate economic picture - it manages not to be dumbed down or reductive, though it's certainly aimed at a popular audience. With that in mind, the most tragic element of the movie is its presentation of three suicides that were almost certainly committed because of debt.

I am in favor of a right to suicide. These suicides - suicides by people who apparently very much valued their lives and ended them in response to a terrible, I would argue unfair situation - are tragedies and should never have happened. These are, to put it simply, bad suicides, in the sense that in a just world, they would not occur.

Coercive suicide prevention is not the answer. In East Germany, hiding statistics of suicides and re-terming suicides "self-murders" only served to mask the suffering taking place in that country. Force feeding of prisoners in Guantanamo Bay only serves to mask the suffering there. Similarly, coercive suicide prevention policies only serve to mask the true suffering that various policies create. The only answer is to change the policies and situations that create suffering so great that individuals feel the proper course is suicide, despite greatly valuing their lives.

On a related note, I have a position statement regarding consumer credit: While the decisions of individuals should be honored, even where they appear irrational, businesses that deliberately exploit cognitive bias of individuals to get them to enter into transactions thereby create a negative externality, and should be forced to absorb the externality. And secondly: most "sales" practices deliberately exploit cognitive bias of individuals, and therefore act against perfect information. (Criticism, links to articles and information, and things like that are, of course, encouraged.)

Sunday, June 8, 2008

Suicide, Reeducation, and Reformed Suicides

Deng Xiaoping's self-criticism during the Cultural Revolution, leading to his rehabilitation (re-acceptance into the Communist Party):
Whenever I think of the damages caused by my mistakes and crimes to the revolution, I cannot help but feel guilty, shameful, regretful, and self-hateful. I fully support the efforts to use me as a negative example for lasting and penetrating criticism in order to eradicate the evil influence left by me over long years . . . . No punishment is too much for a man like me. I promise that I will never seek to reverse the verdict on me and I will never be a remorseless capitalist roader. My greatest wish is to be able to stay in the Party and I am begging the party to assign me a tiny and insignificant job at an appropriate time . . . I warmly cheer the victory of the Great Proletarian Cultural Revolution. [Deng Xioaping's autobiography, quoted in David L. Shambaugh, Deng Xioaping: Portrait of a Chinese Statesman, p. 30.]

Langston Hughes, under questioning by the McCarthy-era Senate Permanent Subcommittee on Investigations of the Committee on Government Operations:

Mr. COHN. Let us see if we can get an answer to this: Have you
ever believed in communism?
Mr. HUGHES. Sir, I would have to know what you mean by communism to answer that truthfully, and honestly, and according to the oath.
Mr. COHN. Interpret it as broadly as you want. Have you ever believed that there is a form of government better than the one under which this country operates today?
Mr. HUGHES. No, sir, I have not.
Mr. COHN. You have never believed that?
Mr. HUGHES. No, sir.
Mr. COHN. That is your testimony under oath?
Mr. HUGHES. That is right.
. . . .
Mr. HUGHES. . . . Did you write something called Scottsboro Limited?
Mr. HUGHES. Yes, sir, I did.
Mr. COHN. Do you not think that follows the Communist party line very well?
Mr. HUGHES. It very well might have done so, although I am not sure I ever knew what the Communist party line was since it very often changed.
Mr. COHN. Mr. Hughes, when you wrote Scottsboro Limited, did you believe in what you were saying in that poem?
Mr. HUGHES. No, sir, not entirely, because I was writing in characters.
Mr. COHN. It is your testimony you were writing in character and what was said did not represent your beliefs?
Mr. HUGHES. No, sir. You cannot say I don’t believe, if I may clarify my feeling about creative writing, that when you make a character, a Klansman, for example, as I have in some of my poems, I do not, sir.
Mr. COHN. How about Scottsboro Limited, specifically. Do you believe in the message carried by that work?
Mr. HUGHES. I believe that some people did believe in it at the time.
Mr. COHN. Did you believe in it?
Mr. HUGHES. Did I?
Mr. COHN. Did you personally believe? You can answer that. Let me read you, ‘‘Rise, workers and fight, audience, fight, fight, fight, fight, the curtain is a great red flag rising to the strains of the Internationale.’’ That is pretty plain, is it not?
Mr. HUGHES. Yes, indeed it is.
Mr. COHN. Did you believe in that message when you wrote, it?
Mr. HUGHES. No, sir.
Mr. COHN. You did not believe it?
Mr. HUGHES. No, sir.
. . . .
Mr. COHN. Do you remember writing this: ‘‘Good morning, Revolution. You are the very best friend I ever had. We are going to pal around together from now on.’’
Mr. HUGHES. Yes, sir, I wrote that.
Mr. COHN. Did you write this, ‘‘Put one more ‘S’ in the USA to make it Soviet. The USA when we take control will be the USSA then.’’
Mr. HUGHES. Yes, sir, I wrote that.
. . . .
Mr. COHN. What I asked was if the quote that appears in the Daily Worker from your article is a statement by you, ‘‘If the 12 Communists are sent to jail, in a little while they will send Negroes to jail simply for being Negroes, and to concentration camps just for being colored.’’ . . . . Do you believe that today?
Mr. HUGHES. No, sir, I would not necessarily believe that today.
Mr. COHN. When did you change your views?
Mr. HUGHES. It is impossible to say exactly when one changes one’s views. One’s views change gradually, sir.[From the Executive Sessions of the Senate Permanent Subcommittee on Investigations of the Committee on Government Operations, Volume 2]

Regarding actor Owen Wilson, following Wilson's suicide attempt:

A source told People magazine: “Owen is in bad mental shape but said he is thankful to be alive.”

“He knows he came close to ending his life, and he is happy that he was saved from himself.”

“He is basically at home with people watching him 24/7.”[Via Fametastic.]

Re-education is usually successful after suicide:

Proof that most individuals attempting suicide are ambivalent, temporarily depressed, and suffering from treatable disorders is the fact that so few, once rescued and treated, ever actually go on to commit suicide. In one American study, less than 4% of 886 suicide attempters actually went on to kill themselves in the 5 years following their initial attempt[32]. A Swedish study published in 1977 of individuals who attempted suicide at some time between 1933 and 1942 found that only 10.9% of those eventually killed themselves in the subsequent 35 years[33]. This suggests that intervention to keep an individual alive, is actually the course most likely to honor that individuals true wishes or to respect the person's "autonomy."[Burke J. Balch and Randall K. O'Bannon, "Why We Shouldn't Legalize Assisted Suicide," on the National Right to Life Committee's website. Citations omitted.]

Thursday, June 5, 2008

Moral Dilemmas Involving Harm to Children

Suppose A, knowing he is HIV-positive, has repeated, unprotected sex with B, whom A knows to be HIV-negative, and to whom A lies about his HIV status. B becomes HIV-positive as well, as he discovers through an HIV test. Deranged with sorrow about his condition, B decides to commit suicide, and stabs himself in the chest with a kitchen knife. Just then, A enters, and is faced with a dilemma: take B to the hospital and save his life (knowing that B will be involuntarily committed to a psychiatric hospital for a while), or let B die from blood loss, even though B has never been suicidal before and has said in the past that he would rather suffer a great deal than die prematurely.

There might be different opinions as to what A should do in this situation. Either decision has problems. A is faced with choosing the lesser of two evils; but, of course, the lesser of two evils is still evil.

There is something strange about this problem, though: the rightness or wrongness of A's action now pales in comparison to the wrongness of his action in knowingly transmitting a terminal illness to B. A's actions directly and foreseeably caused the situation in which he must choose either to violate B's rights by "saving" him and having him forcibly hospitalized, or to let B die in violation of B's stated wishes. No matter what A does now, he is responsible for the harm to B, because A's action put B in the wretched situation.

This concept is what is missing from most discussion on harm to children, the proper way to raise children, and the violation of the rights of children. Knowingly creating a situation in which one will be in a moral dilemma - in which one can opt either to violate someone's rights, or allow harm to happen to that person - is itself a moral wrong. There may be debate about whether it is better to vaccinate or not vaccinate, lie to children or not lie to them (about drugs, sex, or the horrors of the world), spank or not spank, indoctrinate or not indoctrinate, allow genital cutting or not allow genital cutting, educate or not educate. But, regardless of the answers to these "lesser of two evils" questions, to the extent that the parent should have been aware of these double-binds at the time of the decision to procreate, the parent has committed a grievous wrong, and is responsible for whatever harm befalls the child.

Forcing a medical procedure on an adult is wrong. Where a child is concerned, however, it might be said that not forcing a medical procedure on a child could also be wrong - and, when this is said, it is usually grounded in an idea of a child as not having the mental capacity to determine his own values. It is my position that, where a child refuses a medical procedure that he needs to live or to be healthy, both actions are wrong - forcing the medical procedure, and allowing the child to die or to be harmed. Neither action is right. And, where only bad actions are available, knowingly getting into the bad situation should be the locus of moral responsibility for either bad action.

Related: "Fundamental coercive power is power not resting upon any consent of the person to whom it is applied." (Robert Nozick, Anarchy, State, and Utopia.)

Tort Law and the Harm of Death

A question related both to philanthropic antinatalism (especially what some see as its apocalyptic implications) and to suicide rights is the question of whether death is a harm to the person who dies. Objections to death being a harm to the deceased person are that nothing can be a harm unless it is perceived by the harmed person, and that, if there are non-conscious harms, it is difficult to assign the harm to a subject. Thomas Nagel, in his essay "Death," in Mortal Questions, grounds the special harm of death in the idea of deprivation: the subject is deprived (of future experiences), so to the extent that his life would have been worth continuing, he is harmed by death.

But even if death deprives a person of something, what harm is it to him, since he does not suffer by the deprivation? The case that Nagel finds convincing is that of an intelligent adult reduced, through traumatic brain injury, to the mental capacity of an infant. Surely, for Nagel, this person has been harmed, though he does not realize it or perceive it. Nagel, however, imagines this objection, which I imagine would be Jim's objection:
He does not mind his condition. It is in fact the same condition he was in at the age of three months, except that he is bigger. If we did not pity him then, why pity him now; in any case, who is there to pity? The intelligent adult has disappeared, and for a creature like the one before us, happiness consists in a full stomach and a dry diaper. [Prurient emphasis mine.]

Nagel, of course, does not find this objection persuasive. He sees the harm as occurring, not to the brain-damaged person, but to the healthy person prior to the injury, in having been reduced to such a state. In other words, Nagel is willing to assign harm backwards in time. But is this so strange?

For a long time, I had a hard time intuitively understanding sexual jealousy. It seemed to have about the same objective reality as the cultural tradition of celebrating birthdays or saying "bless you" when someone sneezes. And, as an irrational, ridiculous, harmful social construct, it deserved no respect, and existed only to be eradicated. However, I have since been convinced by evolutionary psychology data that sexual jealousy is very much real, in the sense that it is not "socially constructed" like birthdays, and causes people genuine anguish. Though it is not intuitive to me, it is only proper to recognize that other people feel harmed by it, rather than assume they are making it all up. (Incidentally, the violent sexual jealousy suffered by humans, coupled with the sexual exuberance that humans also display, seems to function as a very real limitation on human happiness, at least given our current biological make-up.)

If harm can never occur unless someone perceives it as a harm, then we must take the position that sexual infidelity does no harm to the cuckolded partner, even where monogamy is promised, unless it is discovered. This presents two problems. First, it conflicts with the widely-held intuition that sexual infidelity is a harm to the unaware partner. If you refuse to sleep with your friend's girl, you say, "I wouldn't do that to my buddy" - not "I wouldn't do that because it might get discovered." Second, and related to this, is that when a person discovers that he has been betrayed sexually, he does not date the harm to the discovery; he dates it, most certainly, to the incident of the infidelity. (He is not sad that he found out; given the infidelity, he will probably say he is glad to have found out. He is sad that the infidelity occurred.) In cases like this, at least, it is common to backwards-date harm; are we forbidden to do this with the harm of death simply because, given our conception of time, causality cannot actually move backwards?

I must say that I am not entirely convinced of the rightness of either position; the idea that harm can occur when there is no one to perceive it is intuitively strange to me, but the objections commonly offered do not leave my mind easy, either. (See O.H. Green's "Fear of Death," in Philosophy and Phenomenological Research, Vol. 43, No. 1, Sep. 1982, pp. 99-105, for a view on how death may be wrong (or "evil") without actually being a harm.) I am persuaded by the arguments, however, and by the obviously conflicting intuitions of others, to the point where I have severe doubts about the goodness of ending life where a person wishes to continue to live, as prescribed in the "apocalyptic imperative" case.

I want to digress briefly to point out that, in the above-mentioned essay, "Death," Nagel articulates both a pro-natalist position and the idea that not being born is not a misfortune (usually the more contentious half of the antinatalist asymmetry) in the same paragraph:

The fact that Beethoven had no children may have been a cause of regret to him, or a sad thing for the world, but it cannot be described as a misfortune for the children that he never had. All of us, I believe, are fortunate to have been born. But unless good and ill can be assigned to an embryo, or even to an unconnected pair of gametes, it cannot be said that not to be born is a misfortune.

But back to the harm of death. What I want to explain here is that American tort law, interestingly, accords with the view that death is not a harm to the person who dies, even when that person is killed by the wrongdoing of another!

When a person dies through the wrongful act of another, whether negligent, reckless, or intentional, there are two separate lawsuits ("causes of action," in legalspeak) that may be pursued. First is what is called the survival action. To call it a "survival action" means that the right to sue existed while the person was alive, and continues after his death. (If someone is legally wronged during his life, he does not lose the right to sue for a remedy if he dies; his estate retains the right to sue for wrongs committed against him during his life.) Second is the wrongful death action, created by statute, to give the relatives of a deceased person a remedy for being deprived of his company and support.

The reason I claim that tort law accords with the notion that death is not a harm to the dead person is that, in the survival action, the decedent may only recover for harm that he experienced during his life. He may recover, for instance, medical expensed incurred prior to death, and for pain and suffering experienced prior to his death. But he gets nothing for being deprived of his life. As the court in the O.J. Simpson civil appeal (Rufo v. Simpson, (2002) 86 Cal. App. 4th 573) noted, in very quick killings, the only "compensatory damages" available may be for the damage to the victim's clothing. (Punitive damages are available, interestingly, in the survival action for an intentional killing, even if compensatory damages are quite small; this accords with the strange idea proposed by O.H. Green that death may be evil, but not a harm!)

The harm of the death itself is recognized only in the wrongful death action - that is, as a harm to the survivors, not to the decedent himself. Interestingly, this is applied even where the survivors are suing a mental health practitioner for failing to prevent a suicide - the damage is recognized as harming the survivors, not the decedent. It is hard to square tort law's failure to recognize death as a harm to the decedent with the alacrity with which other areas of the law impede suicide.

Apparently Eliezer Yudkowsky thinks death is a harm, though he doesn't explain to whom, because "death events" create "negative utility." Negative utility to survivors? Potential dead people who might fear death? In any case, how can something create negative utility if the people whose utility is to be measured are all dead? Surely there's someone who'd be very happy to be alone in the world, happier than the average person currently alive. (Average utilitarianism suffers from some of the same problems as utilitarianism based on summing utility.)

[Quotation from poster]Unknown:

"Besides (in the usual single world): is Eliezer willing to kill off everyone except the happiest person, therefore raising the average?"

No. Because that creates Death events, which are very large negative utilities.

Sigh. Seriously, though, dude's brilliant and I'd like to know what his essential values are.

Edit: Eliezer points to an explanation of his views on happiness and value in his essay, "Not for the Sake of Happiness (Alone)."

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