Friday, October 31, 2008

The Unspeakable Solution to Japan's Toxic Fume Suicide Epidemic

Suicides by the use of toxic fumes have increased dramatically in Japan this year, according to an AP article:
More than 870 people have killed themselves in Japan by inhaling toxic fumes from household chemicals this year, 30 times more than the total for all of last year . . . . Japan has long battled a high suicide rate, and is now in the grip of a wave of deaths from mixing commonly available household products to form poisonous hydrogen sulfide gas. The gas can form noxious clouds that also affect those who happen to be nearby, often triggering mass evacuations.

Toxic fume suicides are especially nasty, because the gasses often injure or sicken emergency workers and others who enter the suicide's place of death.

Predictably, the only "solutions" proposed by Japan's government are crackdowns on Internet sites that explain how to make the poison gas, and "anti-suicide programs to help those with depression and other mental health problems" (despite the clearly demonstrated ineffectiveness of the latter).

The obvious, but unspeakable, solution to the problem is to legalize a reliable, comfortable form of suicide that is not dangerous to bystanders - i.e., barbiturate overdose. Legal availability of barbiturates would completely end the practice of toxic fume suicide, at least among those not denied access to the better method.

Thursday, October 23, 2008

The Rationality of Continuing to Live

Suicide is caused by mental illness - isn't it? Because it's irrational to take one's life - you'd have to be crazy. At a minimum, we must prevent those whose rationality is impaired from killing themselves. And we should assume that everyone who attempts suicide is irrational. Shouldn't we?

But what about the decision to go on living?

Put a different way - why is life - objectively, in all cases - better than death?

Choosing life - not committing suicide - is also an act (or, in some cases, an omission). Why should we assume that the act of choosing life is always rational and freely chosen, never the product of a delusion?

In fact, the act of choosing life may frequently be irrational and poorly chosen. Optimistic bias often causes people to overvalue the future utility of their lives. But we do not think to second-guess those who, perhaps foolishly, choose to go on living. Nor should we, by forcing them to die! But no more should we second-guess those who choose to die, by forcing them to live instead.

From Contingency Cannibalism, by "Shiguro Takada":
Starvation is a vicious enemy . . . . Your brain, without your conscious thought, decides which organs to sustain, which ones to break down, and which entrails not to supply with nutrients stolen from other parts of your body. Still, through the communication of pain, your body sends messages to your anguished mind.

Those muscles you worked so hard to acquire deteriorate rapidly. You lose your spleen. Your liver and bladder fail. As you grow decrepit, you can barely walk away from your own waste. You piss your pants and find that something that isn't quite like feces soils your briefs as you literally shit yourself on yourself.

Unrelieved, unrescued, and, after several days of starvation, too enfeebled, your brain, heart, and lungs are among the last to go, so you are aware of your fate - you experience the terror and misery of a lingering death until a merciful coma ensues. (For some odd reason, few people starving to death opt instead to put a bullet into their heads. Perhaps it is because in the final stages they are too weak to do much.) Your emaciated carcass becomes pungent debris beside the road.

"Takada" wisely questions the rationality of the starving person's decision not to end his life. But the reason I reproduce this description of starvation is that, for many of us, this is an accurate description of what life is like all the time. "Pungent debris beside the road" is our most optimistic possible future. Is our pain severe and permanent enough to make living irrational? To make suicide rational?

Or is life a precious gift?

Monday, October 20, 2008

Zócalo Panel: What is a Good Death?

Southern Californians with an interest in suicide rights may be interested in attending a Zócalo panel discussion on November 12, tagged What is a Good Death?

Zócalo presentations are always deep, and feature well-curated panels. From the program description:
Thanks to medical advances, we now live longer, but living longer doesn’t necessarily make death any easier when it comes. Forget the good life, what in this world makes a good death? How does culture affect our choices? Hospice, palliative care, assisted suicide – all offer some relief to suffering, yet it is our uncertainty about the end of life that keeps our dread alive.

Experts visit Zócalo to share first-hand accounts and clinical insight: Dr. Susan Stone, the Director of Palliative Care at the Los Angeles County Medical Center; Dr. Betty Ferrell of the City of Hope National Medical Center; and moderator Dr. Michael Wilkes, Vice Dean for Medical Education at UC Davis, join us for an evening of big questions that demand courage, compassion, and a dash of wit.

The panel is at NPR West in Culver City on Wednesay, November 12, at 7:30 p.m. It's free, and it helps to get an online reservation.

Friday, October 17, 2008

Victims of the Suicide Prohibition: Mark & Julie James

Debbie Purdy may be about to get an answer to her legal question. But probably not.

Mark and Julie James, the parents of British rugby player Dan James, are under investigation for helping their son to end his life. Dan James travelled to Switzerland last month to end his life. How, exactly, his parents may have "assisted" his quest has not been released. The case may - or may not - shed light on how the British legal system will treat those who "assist suicide" in incidental ways. If the Jameses are prosecuted, that is one kind of answer. If the Jameses are not prosecuted, however, it is no assurance for Debby Purdy's husband.

Update: authorities have declined to prosecute Mr. and Mrs. James. (Thanks, Steven.)

The QC, Kier Starmer, is quoted as saying:
This is a tragic case involving as it does the death of a young man in difficult and unique circumstances. While there are public interest factors in favour of prosecution, not least of which is the seriousness of this offence, I have determined that these are outweighed by the public interest factors that say that a prosecution is not needed.

I would point to the fact that Daniel, as a fiercely independent young man, was not influenced by his parents to take his own life and the evidence indicates he did so despite their imploring him not to. I send my condolences to Daniel's family and friends. [Emphasis mine.]

Starmer seems to articulate a rule that it's okay to assist in a suicide as long as one does not influence the decedent to commit suicide, and as long as one "implores" the decedent not to do it. Precedent based on apparent attitude and feeling seems strange to me. In addition, Daniel's act wasn't criminal - even if his parents had influenced him to commit suicide, "influencing" someone to do something that is not a crime is a strange sort of crime. It does seem cruel and impolite - even I don't go around influencing people to commit suicide (quite the opposite, despite my belief that suicide is often rational) - but the requirement that those assisting a suicide must be, at the same time, fighting against the suicide, seems strange to me.

Perhaps it matters that it's the parents or caretakers doing, or not doing, the influencing. Then it is a matter of undue influence or improper use of one's authority. A regular person may influence another to have sex with him, and it is not a crime - but if a person in power (doctor, lawyer, caretaker, parent) uses his power to influence another (patient, client, charge, child) to commit the same sexual act, it may rise to the level of a tort or even a crime - almost as if physical force were used.

But nobody seems to be talking about autonomy here.

At any rate, it's not much guidance for Debby Purdy.

Tuesday, October 14, 2008

Is Suicide a Waste?

A highly publicized suicide of an attractive or talented person is commonly greeted with the sentiment, "what a waste!" The substance that is wasted may be named as talent, intelligence, beauty, or life itself, or may not be named. But, whatever is "wasted," is it fair to blame a suicide for "wasting" it?

"Waste," in this sense, connotes an immoral misuse of resources that might have been better directed elsewhere. It is wrong to misuse or fail to use scarce resources, because they might be better used by others. Wasting may often involve depriving someone else of the resource that is wasted.

The problem with describing suicide as a "waste" is that to do so engages the same fallacy a clever child detects in his mother's command to eat his food, because children are starving elsewhere. "Can I send them this food, then?" the clever child might ask, pointing out that waste is only a genuine moral issue if the resource is truly transferable.

If a clueless benefactor buys me a non-transferable plane ticket for a vacation in Tanzania, but I can't go because I'm an albino, it can't be said that I have wasted the plane ticket (except maybe in a sort of visceral, aesthetic sense). I did nothing to waste the plane ticket - it was a useless gift, and could not be transferred to others with pressing business in Tanzania. The waste was committed by the person who ill-advisedly bought me the ticket - the money used to buy it could have been transferred to more worthy endeavors.

Where the substance allegedly wasted by the suicide is "life," waste in the moral sense is clearly not present. Until laws are changed so that we suicides may donate our organs prior to suicide, life, like the ticket to Tanzania, is a non-transferable resource. The waste, in the case of a suicide, occurred when the suicide's parents made the decision to give the "gift" of life to a person who, it turns out, had no use for it.

What if the substance "wasted" is not life itself, but rather talent, intelligence, or beauty? All these are scarce things, and others in the community may have benefited from the beauty or talent of a suicide, had he not decided to end his life. The potential to benefit is lost.

There are two responses to the idea that a suicide "wastes" his talent or beauty. One is the same response a wealthy person might make to a poor person in justifying his decision to "waste" money on a tenth automobile rather than buy the poor person a house; that is, "it's not yours." Or, to put it a different way: it is radically collectivist to think that we have a right to the resources of others - beyond perhaps guaranteeing a certain level of subsistence for all, we do not have a right even to each others' money. Why should we have a right to each others' physical and personality characteristics? Is a Muslim woman who veils committing a wrong by hiding her beauty from others? The person who, on finding out about a suicide, says "what a waste," is really saying - "it's too bad, I could have used him (or her)." This is hardly a noble sentiment.

The second response is the utilitarian calculation at the community level, including the suicide himself. While others may have benefited from a would-be suicide's continued existence, their benefit would come only at an extreme cost to the suicide himself. If the overall cost of utilizing goods exceeds the benefit to be gained thereby, how can it be a "waste" to fail to use them?

Sunday, October 12, 2008

Worries about Oregon's Law are Without Merit

Katharine Whitehorn has an article in The Guardian about Oregon's assisted suicide law (How to die 'the Oregon way'). It's a valuable article that's worth reading in its entirety - she examines the strict safeguards of the law (a woman who had lived in Oregon all her life, but moved to Hawaii to retire two years before being diagnosed with terminal cancer, didn't qualify), the effects of the law on the treatment of patients (better pain management and better hospice care), and Oregonians' attitudes toward assisted suicide.

Here is an excerpt, dealing with the difficulties of accessing peaceful death under Oregon's law:
So, is it all dead easy in Oregon? Not really. The very safeguards in the rules also serve to exclude some who might dearly love to have access to a planned and dignified death. It is the educated, the competent, those with a decent relationship with a doctor - which, in practice, usually means those with a decent relationship with health insurance - who are likely to seek it. The very poor have Medicaid, (which doesn't pay too well so not all doctors welcome it), those in employment or pensioned retirement have good insurance, and the elderly have Medicare. But it is very difficult for those who are hard up, in erratic employment but not actually on the streets - those who make up the 17% of those who have no insurance at all - to raise the required cash to form a satisfactory relationship with the doctor, who has to certify the patient has less than six months to go. This often excludes those with Aids or MS or, of course, Alzheimer's. Of the European countries that have assisted death, only Holland does not require death to be more or less imminent. Yet if you are bleakly in pain and not going to die pretty soon anyway, you might ache even more for an ending to it all.

Clearly, privilege and money play a role in assisted suicide - the privileged are more likely to have access to it, and to choose it. And those who are not on death's door might often desire death even more than those who are about to die anyway.

(Please see this synopsis of Washington's proposed law in Scientific American for the most hilariously contrived piece of stock photography I've probably ever seen.)

Friday, October 10, 2008

Brandt's Utilitarian Thinking on Suicide's Perceived Immorality

Suppose it could be shown that it would maximize the long-run welfare of everybody affected if people were taught that there is a moral obligation to avoid suicide - so that people would be motivated to avoid suicide just because they thought it wrong (would have anticipatory guilt feelings at the very idea), and so that other people would be inclined to disapprove of persons who commit suicide unless there were some excuse . . . . One might ask: how could it maximize utility to mold the conceptual and motivational structure of persons in this way? To which the answer might be: feeling in this way might make persons who are impulsively inclined to commit suicide in a bad mood, or a fit of anger or jealousy, take more time to deliberate; hence, some suicides that have bad effects generally might be prevented. In other words, it might be a good thing in its effects for people to feel about suicide in the way they feel about breach of promise or injuring others, just as it might be a good thing for people to feel a moral obligation not to smoke, or to wear seat belts. However, it might be that negative moral feelings about suicide as such would stand in the way of action by those persons whose welfare really is best served by suicide and whose suicide is the best thing for everybody concerned.

From Richard R. Brandt, "The Morality and Rationality of Suicide" (1975), in Life, Death, and Meaning: Key Philosophical Readings on the Big Questions, ed. David Benatar (2004).

Wednesday, October 8, 2008

The Evolutionary Biology of Suicide: Is Suicide Adaptive?

See also "How People Die By Suicide," my review of Thomas Joiner's book, Why People Die By Suicide, challenging Joiner's refusal to consider an adaptive model for suicide and attempted suicide.

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

We can define an act to be adaptive when the act increases the genetic fitness of the actor - that is, when the act's benefits - in terms of survival, procreation, or nepotistic distribution of resources to one's genetic relatives - exceed the act's costs, in the same terms. When considering adaptiveness of acts or traits, it is important to consider not only the particular acting organism and its existing offspring, but all its genetic relatives, including possible future offspring and non-offspring relatives. (A judgment about whether an act is adaptive or not implies no moral judgment. An adaptive act may be praiseworthy, horrible, or neither.)

Filicide is adaptive when the resources to be expended raising a particular child would be better spent on others, in terms of benefit to genetic relatives, present or future. If a child is likely to die or otherwise fail to reproduce, or if raising the child will adversely affect the parent's ability to have future children that may be a better genetic "bet," then filicide - while certainly a gruesome act - must be said to be adaptive. Perhaps even more obviously, filicide of a partner's offspring that is not one's own genetic offspring is almost always adaptive.

Are people more likely to kill their children under circumstances where the act is adaptive? A major body of work in evolutionary psychology suggests that this is so. For instance, stepparents are much more likely to kill their stepchildren than birth parents are to kill their genetic children. People are much more likely to kill babies than older children, and younger mothers are more likely to kill their babies than older mothers. It seems that not only is filicide sometimes adaptive, but that humans possess mechanisms to prevent themselves from committing filicide when it is not adaptive, and to allow themselves to commit filicide when it is adaptive.

Does the same hold true for suicide? There are two related questions: first, is suicide ever adaptive? Second, if suicide is sometimes adaptive, do humans appear to possess mechanisms to limit suicide to cases where it is adaptive?

As to the first question, it can be clearly demonstrated, at least in the abstract, that suicide is sometimes adaptive. The easy case is one in which a person sacrifices her life so that genetic relatives may live. Such cases must be rare, and are so different from the usual connotations of "suicide" as to barely be considered suicide at all. The more common case where suicide is adaptive is this: one's total expected future contribution to one's genetic fitness is exceeded by one's total expected drain on the resources of one's genetic relatives.

To put this in more concrete terms, there are many cases - old age, crippling disability - where all measures of genetic fitness approach zero. Once one may no longer reproduce, and is no longer an effective nepotistic distributor of resources (including wisdom), one's expected contribution to one's own genetic fitness is likely to be nil. However, as long as one survives in this condition, he not only contributes nothing to his own genetic fitness, but also likely drains the resources of his genetic relatives. His continued survival is contrary to his genetic interests. Therefore, suicide, in this situation, must be said to be adaptive.

The second question is: given that suicide is sometimes adaptive, do human beings tend to commit suicide in circumstances where it is adaptive?

Unfortunately, I lack the quantitative tools and study design knowledge to answer this question. But I will point to two conflicting bodies of evidence on this question.

In support of the idea that humans tend to commit suicide when it is adaptive is data demonstrating that the suicide rate increases dramatically for elderly people. Using age as a rough estimate of expected genetic contribution, the suicide rate (inversely) tracks genetic fitness. Excluding children, the suicide rate is lowest for those with the highest expected evolutionary fitness - those ages 15-34. The suicide rate climbs from there. In 1950, before the age of nursing homes, the suicide rate for those ages 75-84 was more than double the average suicide rate for the country. In addition, suicides by the elderly are more likely to be planned, with less likelihood of warning prior to the act.

In addition to data on suicide among the elderly, suicide is particularly likely in elderly people with poor health, and particularly those with low vision - both conditions that, in the environment of evolutionary adaptedness, might be expected to indicate low expected contribution to the fitness of one's genetic relatives.

Contrary to this is the data on familicide. Familicide is the killing of one's spouse and children. It is almost the exclusive province of males. There are two key features of familicide that are relevant to the discussion of the adaptiveness of suicide: a familicide is much more likely to kill his biological children than a mere filicide, and a familicide is much more likely to commit suicide than a simple filicide or uxoricide (wife killer).

Familicide seems to be an extremely counter-adaptive act, especially since the killer's biological children are commonly involved, compared to simple filicides, which are more likely to involve stepchildren. The fact that suicide is much more likely in a familicide, as opposed to a simple uxoricide or filicide, suggests, by association, that suicide is frequently a counter-adaptive act.

Note: the question of whether suicide is adaptive is an entirely different question from whether it is rational, in the lifetime-utility-maximizing sense.

Is Suicide Difficult?

A scribd.com user posts a document cataloging first-person reports of a large number of suicide attempts:
I recently tried to exit using the helium method. I couldn't stand it and yanked the bag off. The gas was NOT 'innocuous and odorless' as the Humphrys/Final Exit crowd had led me to believe. It felt like inhaling poison gas. Made me nauseous, headachey, and there was a terrifying feeling of falling through space. Now I am suffering, not from fear of death, but from fear of the ways of getting there.

And another:

I was in a coma for three days. I woke up in ICU with tubes everywhere. My first thought was one of annoyance at all the tubes. I immediately pulled the one from my nose, not realizing it was threaded into my stomach. I retched but out it came. The IVs in my arms were another story, my arms were tied with bandages to boards, and bending them was annoying that's how I realized they had IVs in them. A nurse came over and spoke to me but I drifted in and out of awareness for the next few days.

When I finally was able to engage in conversation my cousin who is a nurse told me that had the paramedics arrived twenty minutes later they'd not have attempted to revive me....

So, that's the unlovely story of my first and most serious attempt. I classify it that way because subsequent attempts have not resulted in anywhere near the same recovery time. I think it is because medicine is now better equipped to deal with such things, but I can't be sure. What I am sure of is that I have never made a 'gesture,' I have always intended to die.

Saturday, October 4, 2008

Debbie Purdy, "Death Plants," and the Suicide Prohibition

Catherine Bennett writes a forceful article addressing Debbie Purdy's battle to clarify Britain's law regarding assisted suicide ("Let this woman die as she chooses, not in a death plant").

Bennett argues that forcing people to die in a "corporate" manner rather than as they choose - that is, according to the religious whims of other people - is barbaric. And it is doubly awful to force dying people to travel to creepy "death plants" in Zurich, rather than allowing them to die peacefully in their own homes.

Bennett is too optimistic, however, about the prospects for suicide in able-bodied people. She writes:
The whole country now knows that Ms Purdy, who suffers from multiple sclerosis, has thought in detail about when and how she wishes to die. When the pain of her illness becomes intolerable, she would like to have the choice, as the able-bodied do, of taking her own life. [Emphasis mine.]

I think one of the biggest problems for those who favor an institutional right to suicide is this tendency for non-suicidal people to assume that suicide is a simple thing to accomplish. I think many people favor a right to suicide - but they wrongly assume that able-bodied people today currently enjoy a meaningful right to suicide. It's not true. Reliably lethal means of committing suicide are difficult to acquire, especially means, such as barbiturates, that are not violent and traumatic to administer. If a suicide is "caught" before death has occurred, he will be forcibly restrained and brought back to life. If he suffers severe brain damage from the ordeal, he will be maintained on life support, despite his clear wish to refuse this sort of "life-saving" treatment.

The truth is that no one has a right to suicide, either in Britain, or in the United States. Suicide may not be a crime, but as a practical matter, it is prohibited all the same.

Thursday, October 2, 2008

Take My Ten Kids - Please.

The biggest shock to public officials came last week, when a single father walked into an Omaha hospital and surrendered nine of his 10 children, ages 1 to 17, saying that his wife had died and he could no longer cope with the burden of raising them.

(From a New York Times article on parents abandoning older children pursuant to a law designed to prevent "dumpster babies.")

Frequent abandonment of older children, considered by some to be an abuse of the Nebraska safe surrender law, is just another piece of evidence that children and their parents often have radically different interests. The most you can say about procreation is that it might, under very special conditions, be altruistic (unless David Benatar is right). Even heathen evolutionary biologists tell us that parents have a strong genetic predisposition to behave altruistically toward their children, once those children are born.

But, in practice, it is more complicated than that. Parents and children have somewhat overlapping, but largely opposed, evolutionary interests. Parenting is often far from altruistic. Parents abandon their difficult children. Parents maim, kill, and rape their children. In jurisdictions that allow it, they sell their children. Under conditions of starvation, they eat their children.

Are we really sure that parents, in general, have their children's best interests at heart?

The Public Thinks (Or Not) About Suicide

In a pair of comment threads, anonymous citizens confront two police suicides: one about an officer who killed himself after he was involved in a car accident that killed a fellow officer, and one about an officer who killed himself after he was involved in a deadly tasering incident.
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