Zarathustra at Mental Nurse wrote a piece in September about using degrading, humiliating, coercive means to force patients with eating disorders to eat. He is extremely candid about the reality of force feeding, detailing the force-feeding protocol:
The protocol for serving a meal to an eating disorder patient is a no-holds-barred affair. She’s made to come to the table with her hair tied back and wearing short sleeves, wearing no watches or jewellery, so that there’s nowhere to secretly stash food. She’s then made to eat everything - everything - on the plate with a nurse watching her like a hawk. No excuses are tolerated. No “that’s got a bit of gristle on it” or “but that’s just a crumb”. The plate has to be completely cleared. Afterwards she’s made to sit resting for a full hour so she can’t go off and purge or exercise.
If she fails to complete the meal, or doesn’t complete the rest period, then she’s ordered to drink a nutritional supplement milkshake. If she refuses to do that, then she’s restrained while a nasogastric tube is passed up her nose and into her stomach to force-feed her. Nasogastric feeding is so unpleasant that few of the girls have to have it done more than once. As coercive psychiatry goes, you don’t get much more coercive than this. [Emphasis mine.]
At the end of this litany of horrors, though, Zarathustra wonders - if it saves the girl's life, what's so wrong with that?
The short answer is that, for many people, there are things that are more important than life.
I have written in the past that it is sometimes permissible to save a person's life against his will. I propose two criteria for this:
- Because of a condition that clearly destroys the person's ability to act in his own genuine interests, such as an acute confusional state in a person who is otherwise lucid, the person is not acting in his own interests (note that I mean his own interests, according to his own values, not his "best interests" as defined by others); and
- there is substantial evidence that the person, in his lucid state, values his life more than he values being free from the kind of intrusion that would save his life.
I think it was Dr. Maurice Bernstein of the Bioethics Discussion Blog who said that, faced with an anorexic patient who was refusing to eat and would die without intervention, but still said she wanted to live, he would opt to force-feed. This actually accords well with my model of a time when it is appropriate to intervene: when it accords with the patient's ascertainable values. (I am not sure my first prong is met - anorexia nervosa seems to be more of a life-long condition rather than a sudden-onset break with reality. This is the hardest prong to define and apply.)
But if an anorexic patient values her bodily inviolability, her dignity, more than she values her life - then it is morally wrong, and damaging to her as a human being, to stick a nasogastric tube down her throat. There are some things that are more important - to her - than her life. How can it be right to ignore her values and humiliate her in furtherance of protecting her life from damage she herself may do to it?
A similar model may be helpful in determining when it is appropriate to interfere with a suicide. Some people who attempt suicide really want to die, and coercive suicide prevention is a horror that they would rather die than accept (Group 1). Some people who attempt suicide genuinely want to die but fail to be in a lucid state when they make the attempt; they are forcibly "rescued" and treated, and when more lucid are grateful for the indignity of forced treatment (Group 2). And some people who attempt suicide do not really want to die at all - they have bought into what I have termed the dangerous fantasy of rescue, and count on being saved from their suicide attempts through coercive means (Group 3). (In "Attempted Suicide as a Signal," I have articulated the way in which a policy of always interfering with suicides actually harms people who don't wish to die - because it sets up an incentive structure that rewards them for engaging in lethal behavior.)
In my view, it is permissible to interfere with the second group's suicide attempts if the two prongs of my test above are met - the person is experiencing an acute state of mental confusion or delusion (I don't think DSM-IV depression qualifies here), and according to the person's own value system (when lucid), remaining alive is more important than the humiliation and suffering involved in the proposed coercive intervention.
Group 3, suicide attempters who clearly lack a sincere intent to die, seem to me to present the easiest case. Under our current system, rescuing them - following through with the fantasy they have been fed - is the morally correct option. However, as I mentioned above, it would actually be better for them if there were a well-known public policy of not interfering with suicide attempts, because under such a system, they would have no incentive to make a potentially harmful, insincere attempt in the first place.
It is never morally permissible to coerce people in the first group to remain alive.
But, on the bridge or in the ER or on the bathroom floor of the apartment, how do you tell the difference? How can you tell whether the person belongs to Group 1 or Group 2 or Group 3? How do you know whether the bleeding, half-conscious person's values allow for interference with his suicide attempt?
Many people fail to ask this question at all. They assume without question (a) that anyone who would attempt suicide is in a state of mental confusion sufficient to render his actions and judgment valueless, and (b) that everyone places his own life above all other values - that any humiliation or insult to dignity or loss of liberty is worth it if it saves one's life.
I think it is true that many people hold the belief in (b), but I don't think it's controversial to say that not everyone values his own life over all else. If it were true, I think our race would be a race of cowards. But it is not: people are willing to die for their political and religious beliefs, and for other people, demonstrating that one's own life is not the supreme value for everyone. And for some of us, dignity and bodily inviolability are values we hold above even life itself.
But we can, and ethically must distinguish between the two groups (Group 1 above - those who value dignity over life - and Groups 2 and 3, who want to live despite any indignities that might entail). I have previously articulated a proposal for distinguishing between these groups, with two options, as follows:
- Radical option: Cease automatic interference with suicide attempters, and publicize 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, and
- set up a procedure for medically assisted suicide (a prescription for a lethal dose of, say, barbiturates to a competent adult requester) that would be unlikely to be used by anyone not extremely serious about suicide, and
- allow people who value their lives over any possible indignities to enter contracts while lucid to allow them to be "rescued" or forcibly treated should they become suicidal, refuse to eat, etc., as with medical advance directives;
- Minimal option: or, as an alternative, at a minimum, establish an "opt-out" policy that would allow a competent person to execute a legally enforceable document, revocable only by the person it concerns, that would exempt him from coercive suicide prevention "treatment" and from medical "rescue" in the case of his suicide
Regardless of whether the radical or the minimal option is enacted, the following criteria would apply:
- the suicide procedure (or execution of the opt-out document) 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 DSM-IV diagnosis of Major Depressive Disorder would not suffice to render someone incompetent to request suicide assistance
Some things are more important than life. But life is important to many - for some, it is the most important thing. A policy like the one I have outlined would respect everyone's values.
Thanks to mysterious, modest commenter failed poet for inspiring probably the only thinking I've done in weeks, which thinking led to this post.
1. If my neighbor wants to lose weight, and values losing weight, but doesn't have the will power and determination to achieve it, would it be morally right for me to kidnap my neighbor, feed him only health food, and make him run on a treadmill two hours a day? Of course not - unless, perhaps, his values were such that the humiliation of being kidnapped and forced to run on a treadmill was nothing compared to the value of losing weight. He may hate it in the moment - people sometimes feel this way about their hired trainers or physical therapists - but if his deepest, truest value is losing weight, then I think the action is permissible, and he would probably agree. In this way, it all comes down to value - no mental illness/acute mental confusion prong is even necessary. (The only problem comes in judging which of several "selves" is speaking one's true values. And it is tempting for a listener to assume that the "self" that articulates values close to one's own is the true self.)