Monday, April 28, 2008

Victims of the Suicide Prohibition

A 2007 single-patient study in the Annals of Neurology focused on a 48-year-old woman who has been kept alive for over two years in a state of akinetic mutism - she cannot move or speak. She experienced severe brain damage from a suicide attempt and has been kept alive ever since, apparently against her expressed wishes, while scientists perform experiments on her. From Medscape:

March 13, 2007 — A new study reports that the insomnia drug zolpidem (Ambien, Sanofi Aventis) temporarily improved brain function in an adult patient with akinetic mutism caused by anoxia.

The 48-year-old woman suffered akinetic mutism related to a postanoxic encephalopathy a few days after a suicide attempt by hanging.

Two years later, she was prescribed zolpidem to treat a bout of insomnia. Within 20 minutes of receiving a 10-mg dose of the drug, the subject, who had been unable to speak or walk and was fed by a gastrostomy, was able to communicate, walk, and eat without assistance. These effects lasted for up to 3 hours.

David Benatar's Better Never to Have Been: The Harm of Coming Into Existence

I haphazardly linked to David Benatar's Better Never to Have Been: The Harm of Coming Into Existence in my previous post, but since this is the single most important piece of philosophy I have yet come into contact with on this topic, I am posting it again. I am both surprised and heartened to find that my views have a compassionate champion in the world of professional philosophy. I am currently reading Professor Benatar's book and expect to be posting about it in the coming weeks.

Summary from Google Books:
Better Never to Have Been argues for a number of related, highly provocative, views: (1) Coming into existence is always a serious harm. (2) It is always wrong to have children. (3) It is wrong not to abort fetuses at the earlier stages of gestation. (4) It would be better if, as a result of there being no new people, humanity became extinct. These views may sound unbelievable--but anyone who reads Benatar will be obliged to take them seriously.

Procreation and Suicide

An important reason that it is unfair to force a being to stay alive is that the being took no voluntary action in order to come into being.

Voluntariness is a key element of fairness is much of our legal system. Our law of contract requires that the parties voluntarily enter the contract in order for it to be enforceable. Likewise, marriage must be entered voluntarily, or it is not legally effective. Crimes require a voluntary act before punishment may attach. (See note.)

Given this framework, voluntary procreation (choosing to have children) has two important consequences. One, given that the act of procreation forces existence on others, it may be a moral harm in and of itself. Second, and more relevant to our purposes, procreation is a voluntary act, like signing a contract, that creates a moral obligation for the parent toward the child. A non-parent (or an involuntary parent, such as a rape victim) has given no assent to life, and retains the right to remove himself from the world; the voluntary parent has given his assent to life, and created obligations toward his child.

An interesting question is whether there are acts other than voluntary procreation that cement the agent to the world, potentially destroying his moral right to suicide. One candidate would be intentionally forming or continuing a close relationship; although of course this does not involve creating an entire new being dependent upon the agent, it does, perhaps, encourage others to become dependent upon the agent. Perhaps potential suicides have a moral obligation not to form or continue close relationships, just as they have a moral obligation to avoid procreation.

(Note that voluntariness cannot account for the basis of authority of the state over people who have not consented to be governed by that state. In a state with a broad suicide proscription, in which there is even less of a possibility to "opt-out" of state control, the authority of the state over non-consenting individuals is weaker than in a state where life is not compulsory.)

Friday, April 25, 2008

The Myth of the Hospital

I have been unlucky enough to be the guest of two different psychiatric hospitals. In addition, I have worked in nine psychiatric hospitals in a professional capacity. Most people, even professional psychiatrists, have a rather naive view of what happens in a mental hospital. Private psychiatrists who spend most of their time treating private patients for depression and anxiety may have very little experience with a real psychiatric hospital. Ordinary people may get their views of psychiatric hospitals from books and movies, such as the extremely optimistic "Girl, Interrupted," during which a forced psychiatric patient rediscovers her joy in life while receiving a great deal of individual therapy and developing relationships with other inmates.

The reality of the psychiatric hospital is, unfortunately, much bleaker than even popular culture would lead us to believe. The hospital is a good place for low-functioning people with thought disorders or severe personality disorders to get stabilized on their meds. The hospital is no place for a high-functioning depressive.

What could you expect if you were involuntarily hospitalized? First, don't expect for there to be people like you around. Most people involuntarily hospitalized are the aforementioned low functioning folks with thought disorders (like schizophrenia) and severe personality disorders (like borderline personality disorder). "Low functioning" means that these people will mostly have a hard time engaging in normal activities of daily living, like washing themselves, feeding themselves, and having a conversation. You will share a room with one or more of these people.

You won't get individual therapy (one-on-one talk therapy). It's too expensive, and not very effective for the hospital's normal clientele, those low functioning folks with thought disorders. The usual plan for low functioning people with thought disorders is to "stabilize them on meds" - they come in psychotic, they are given antipsychotic medication for a while, and their psychosis disappears. (Medication may be forced in most states. Some states require a hearing before forced medication may happen; these are generally rubber-stamp proceedings.) This process has a very high success rate for low functioning people with thought disorders; individual therapy is not seen as effective or necessary.

Generally, hospitals try to apply the stabilize-on-meds approach to high functioning depressives, with mixed results. As mentioned above, individual therapy is not available. Instead, expect mandatory "group therapy." Group therapy, in a private, outpatient setting, is often interesting and productive, given a group of intelligent, high-functioning, thoughtful people. You will not find that in a hospital. Instead, you will find yourself in group therapy with that same group of low functioning people with thought disorders that you've been rooming with and eating with and smoking with during your stay. Often, group therapy takes the form of practicing activities of daily living - say, writing a letter, or washing oneself. This would be very helpful for a low functioning person with a thought disorder; it is humiliating and harmful for a high functioning depressive.

You may meet with a doctor once or twice during your stay. The doctor does not want to talk to you. The doctor wants to know if you are tolerating your meds, and if you have figured out how to answer questions about your suicidal intent correctly, so that you may be released. Most suicidal high functioning depressives quickly figure this out, and answer that they feel much better, that the meds are working fine, and that they have no further suicidal ideation.

The stabilize-on-meds approach for depressed patients is especially ridiculous, given that anti-depressant medications don't work any better than placebos. Given that the hospital doesn't help the high functioning depressive, except to medicate him or her, the purpose of the hospital in this context becomes clear: it is a prison. Hospitalization doesn't help people become non-suicidal. It merely teaches the high functioning depressive to make sure he or she succeeds the next time he or she attempts suicide. And never to be honest with a doctor again about suicidal ideation.

Monday, April 21, 2008

Robin Hanson on Medical Paternalism

Robin Hanson discusses paternalism, and the need to check our intuitions about intervening in other people's decisions, in a thoughtful short article, including a parable about when it is appropriate to stop someone from walking near the edge of a cliff. The article primarily focuses on the moral basis for public health interventions, such as drug regulation and physician licensing, and presents models that illustrate problems with trusting someone else's judgment of what's best for you.

An excerpt:
Do you support imposing limits on the food and drugs people can buy, or the medical advisors they can choose?

If you want to convince yourself and the rest of us that your support for such paternalism is based on more than a simple arrogant presumption that people like you can run other people's lives better than they can, you should make some effort to explain to yourself and the rest of us exactly why you think your paternalism is justified.

Full article here.

Sunday, April 20, 2008

Problems with Compassion

Suppose you are a member of one of the Christian sects that believes that everyone who does not believe according to the teachings of that sect will suffer eternal punishment in Hell. What is compassionate behavior on your part? One view is that, "knowing" what you do, it is your duty to convert as many people as possible to your sect, to protect them from Hell - by argument, by harassment, even by force, if possible. No violation of others' "rights" to live as they choose can compare to the eternal damnation they face in Hell. The only compassionate thing to do is to convert everyone by any means possible.

Another view of compassion is that even though you might choose to save yourself from Hell by believing as you do, and even though you might use persuasion to try to convert others, it is wrong to impose your beliefs on others.

The second view is that which I believe is most common in our culture - certainly among atheists, but even among believers, it would be seen as wrong to convert a person to a belief system using force or other improper means, even though the believer might feel that failure to do this will result in the unbeliever spending eternity in Hell.

People who feel that their own lives are meaningful and worthwhile often assume that living is necessarily a great thing for everyone, and if anyone seems to want to die, it isn't really his wishes - or, even if it's what he wishes now, he will eventually come around and see that life is great fun, meaningful, and worthwhile. Protecting him from his own liberty is in his interest in the long run. These folks subscribe to the view that forcing every person to live, even against his wishes, is the compassionate thing to do. I propose that this is like saying that the compassionate thing for a Christian believer to do is to convert all non-believers at sword-point.

Sunday, April 13, 2008

Suicide Contagion, "Impulsive" Suicides, and "Excess" Suicides

The work of sociologist D. P. Philips, and researchers after him, suggest that the suicide rate rises after the media widely publicize a suicide. (In addition, in a related phenomenon, the rate of automobile "accidents" and airplane "accidents" rise in the wake of a highly-publicized suicide, as well.) This phenomenon is known as suicide contagion, or the Werther Effect. Philips noted that the rate of suicide after a well-publicized suicide rises substantially for a few days to a week after the suicide, then falls back to normal levels - though not below the baseline level. This is taken as evidence that the suicides that follow a well-publicized suicide are "excess" suicides, needless suicides that could have been prevented and, by implication, should not have happened. (For an excellent popular description of this line of thinking, see chapter four of Robert B. Cialdini's book Influence: They Psychology of Persuasion, the chapter on "social proof.")

This idea of "excess suicides" is related to a widely-accepted notion in psychology circles, that of "impulsive suicide." Impulsive suicide, the story goes, occurs when someone not fully committed to suicide by rational investigation commits suicide on an impulse, perhaps in response to a difficult life event (or to a news story about a suicide). The idea that some suicides are "impulsive" and, therefore, should be prevented, is rarely challenged.

It is my view that most people, non-suicidal themselves, have very little idea of the thought processes of a suicide. I explored in an earlier post one cognitive bias that might contribute to this. Based on this, I wish to explore the implicit model of the "good" suicide, that is, one accepted to be inevitable and non-preventable, as distinct from the "bad" suicide, one that is impulsive, ill-considered, and preventable. It is my belief that many suicides that appear to be impulsive and preventable (in response to life stresses, for instance) are actually well-considered suicides where the suicide needed an extra push to overcome improperly-placed practical barriers to suicide.

The idea of "excess suicides" or "impulsive suicides" implies, ipso facto, that some suicides are inevitable, and even well-considered and rational. (Note that this is farther than most people espousing an anti-suicide viewpoint are willing to go, at least explicitly.) Some suicides, on the other hand, are poorly-considered products of impulse, irrational, and by their nature preventable. A certain rate of suicide is inevitable, the argument goes, but some suicides - the "excess" suicides, the "impulsive" suicides - can be prevented, and preventing them is good, an end we should actively pursue.

This model presumes that the current set of barrier in place to prevent suicide - barriers for accessing prescriptions drugs or guns, or lack of information and education about how to successfully commit suicide - are set at an ethically ideal level. It ignores the possibility that it might be ethically superior to remove those barriers and raise the suicide rate to the natural rate - that is, raise the suicide rate so that it achieves parity with the percentage of people who genuinely want to die. Meanwhile, people who can't bear, under normal circumstances, to overcome the barriers to suicide (set somewhat arbitrarily) - people who won't or can't shoot themselves in the head, slit their throats, or suffer the pain of poisoning with inferior poisons - genuinely want to die, and can't. They live with their decision, but also live with feeling of ambivalence regarding their choice, since they can't bring themselves to die in ways available to them. I would denote these people "would-be suicides."

Would-be suicides, however, often wait in hope of a personal stress to push them over the edge and help them suffer the pain of overcoming the barriers arbitrarily placed in their way. A would-be suicide might wait for years for a personal tragedy to push him over the edge and give him the courage - the "push" - to slash his throat or jump from heights. A news report of a famous suicide might function in the same way as a personal tragedy or stress - pushing the well-considered but practically inhibited suicide toward a much-desired death.

We must recognize, above all, that many in our number deeply and genuinely desire death. The numbers of the "excess suicides" and "impulsive suicides" give voice to the number who desire death, but cannot, under normal conditions, achieve it.

Saturday, April 12, 2008

Men, Women, Suicide, and Guns

The generally accepted figure is that American women attempt suicide about twice as often as men, but men actually commit suicide about four times as often as women. The disparity between male and female suicides is often explained in terms of psychological sex differences:
"Women process their experiences with friends. They discuss their feelings, seek feedback and take advice," Murphy says. "They are much more likely to tell a physician how they feel and cooperate in the prescribed treatment. As a result, women get better treatment for their depression."

And the usual story to explain the disparity between female suicide attempt and female suicide success goes something like this:

"An attempted suicide is not really an attempt at suicide in about 95 percent of cases. It is a different phenomenon. It's most often an effort to bring someone's attention, dramatically, to a problem that the individual feels needs to be solved. Suicide contains a solution in itself," he says.

In attempted suicide, both men and women tend to use methods that allow for second thoughts or rescue. Murphy says that when people intend to survive, they choose a slowly effective, or ineffective, means such as an overdose of sleeping pills. That contrasts to the all-or-nothing means like gunshots or hanging used by actual suicides.

Those are the numbers, and that is the traditional story: more men want to kill themselves, so they choose more lethal methods. More women are just being dramatic, so they choose pills.

Now consider the data from my previous post. When lethal methods are more known and available to women (physicians, chemists, veterinarians), they commit suicide more often (as do men, but not as much). And consider the most lethal, most frequently used method of all for suicides: the gunshot. Couldn't the fact that women successfully commit suicide less frequently than men be explained by the fact that women, by and large, own fewer guns?

How big is the disparity in gun ownership? Based on Gallup polls and census data, a man is about three times as likely as a woman to own a gun. Women are, of course, not prohibited from gun ownership as a group, but they are much less likely than men to be exposed to guns and learn how to use a gun. A factor of three difference in gun ownership may go a long way to explaining the disparity in suicide success compared to attempt, rendering the psychological explanation largely unnecessary. Of course, women who choose gunshot as a method of suicide frequently succeed; but we should not be so quick to claim that those who choose other methods that don't succeed just don't really want to die. Perhaps large numbers of them do not know enough about gun acquisition and use to feel comfortable choosing this method.

This brings up another issue, which is how we tell when a suicide or attempted suicide "really wanted" to commit suicide. Just because someone refuses to use a method available to him, should not in and of itself make us suspect that he "doesn't really want" to kill himself, any more than someone's rejection of a particularly nasty medical intervention should tell us that person "doesn't really want" to live. Suicides face different barriers, legal and practical, in achieving their ends. It's ridiculous to use willingness to overcome one particular society's set of barriers as the litmus test for whether someone wants to die enough. Many people do not wish to die by gunshot wound, but definitely wish to die, and would gladly die if better means were available - easier to accomplish, more comfortable, more certain, less ghastly for discoverers, and less likely to result in sequelae. Just because someone will not, or cannot, shoot himself in the head or slit his jugular vein should not entitle us to presume that he does not really want to die.

Edit: In Bangalore, India, more women commit suicide than men. The most common method is to use the extremely lethal industrial poisons available in India but not in the United States. This casts doubt on the theory that fewer women commit suicide because fewer women want to, and inclines one to think about the alternative hypothesis that women and men prefer different means, which are differentially available in the United States.

Cultural factors are, of course, not ruled out, but neither are they ruled out in the case of fewer female suicides in the United States.

Tuesday, April 8, 2008

Compassion, Motivation, and Cognitive Bias

There is a major cognitive barrier preventing most people from taking suicide seriously as a right, rather than classifying it as pathology. The barrier is that most people cannot imagine wanting to die.

Because people cannot conceive of wanting to die, they come up with all kinds of far-fetched explanations for suicide-related statistics. For example, Eva Schernhammer and Graham Colditz's review of twenty-five studies about doctors who committed suicide revealed that women doctors commit suicide at about twice the rate of women in the general population. In some studies, the women physicians' suicide rate approached parity with the rate of men in the general population (men commit suicide about four times as often as women, though women attempt suicide more often). Schernhammer proposed that a possible reason for the result could be gender bias in the medical profession. However, this theory does not explain the study's other result, which is that male doctors have a 41% increased risk of suicide over men in the general population. When we see more data - for instance, that British veterinarians have a suicide rate four times that of the general population, or that women chemists also commit suicide at an increased rate (as do male chemists, though not as much) - a more sensible answer presents itself. Physicians, like veterinarians, have access to comfortable, sure methods of committing suicide. A small minority of the populations wishes for death, but lacks appropriate means of achieving it - unless they happen to be doctors, vets, or chemists. (Incidentally, studies like these probably tell us approximately what the suicide rate would be if comfortable means were generally available - that is, still quite low.) It is ludicrous to suppose that people in these professions - but not, for instance, finance - are driven to suicide by gender bias or other career pressures. However, people naturally search for explanations like gender bias or job pressure, because they can't conceive of people in the general population wanting to die and not being able to do it.

In general, people find it hard to understand motivations of others that they do not share. Last night, for instance, four people shared a fish head casserole. Why did they eat this? If you have strong feeling against eating fish heads, your first thought is probably that poverty or desperate circumstances forced them to eat this dish. Or perhaps they ate it on a dare, or they were contestants on Fear Factor. But none of these is true. Three of my friends and I ordered the giant fish head - a Hunanese delicacy - and eagerly awaited it for thirty minutes while it steamed in a rich, garlicky poaching liquid with hot peppers. We had read a review of this dish and sought it out, and we ate it eagerly when it arrived. Neither coercion nor pathology is the proper explanation here - we did it because we wanted to.

A common reaction to an act motivated by a preference the observer finds mysterious is to attribute the act not to a preference, but to pathology, coercion, or some other motivation. In trying to understand the behavior, the observer thinks, "what would cause me to engage in that act? I'd have to be crazy, or someone would have to force me. Therefore this person must be crazy, or experiencing coercion." Perhaps this attempted-but-failed empathy and the confusion it generates could explain the hostile reaction to sexual practices the observer does not share, in a similar way to that posited by Nagel in his Personal Rights and Public Space.

Ultimately, of course, this principal explains why compassionate, kind people often have a hard time accepting suicide as a right. It is an empirical fact that most people do not want to die. They must find it very hard to imagine that others do want to die, that death is their genuine end. They use their own preferences as a model, and assume that the suicidal desire is a product of pathology (depression, a type of "crazy" conveniently defined to include almost anyone with suicidal thoughts) or coercion of some sort (temporary, remediable life problems, such as the "job pressures" mentioned above). The most important thing for the compassionate reader to realize is that some people genuinely want to die, and can't.
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