"It is not a thing to do while one is not in one's best mind. Never kill yourself while you are suicidal." ---Edwin Shneidman(252)
"Never do today what you can put off till tomorrow. Delay may give clearer light as to what is best to be done."---Aaron Burr
When is Suicide Justified?
People have been arguing this question for millennia. There are about one thousand books in print on suicide in the United States. Sherwin Nuland, physician and author of How We Die, puts it well when he says, "...the importance of airing different viewpoints rests not in the probability that a stable consensus will ever be reached but in the
recognition that it will not. It is by studying the shades of opinion expressed in such discussions that we become aware of considerations in decision-making that may never have weighed in our soul-searching."(253)
Some people think suicide is never justified. A minority argue the merits of suicide: it allows one to choose (as much as one can choose these things) the time, place, manner, cause, purpose, and painfulness of death,(254) and maintain that it is a decision each individual must make.(255) Most of us would understand why someone might prefer suicide if she were in uncontrollable pain.(256f) Many would, I think, agree with Nuland when he says, "Taking one's own life is almost always the wrong thing to do. There are two circumstances, however, in which that may not be so. Those two are the unendurable infirmities of a crippling old age and the final devastations of a terminal disease."(257)
As philosopher Richard W. Momeyer puts it more formally,
"Suicide is an act that does not occur in a vacuum, and it is ordinarily not without very serious and often devastating consequences for others. Even if it can be claimed as a right, it is not inappropriate that one be very careful to assure that exercising that right is the right thing to do. Having a right to do something provides us some entitlement to do it; it does not assure that doing it is right. It is appropriate to set very high standards of justification for exercising a right to suicide, given how often it is
undertaken in an ill-considered manner, how frequently suiciders suffer diminished competence from mental illness, and how widespread and serious are the consequences for others..."(258)
Intervention in Suicide
There seem to be two central questions about intervention to stop suicide: (1) under what (if any) circumstances and (2) by what means, is it appropriate?
Most people would argue that suicide intervention is justified in the absence of terminal illness. This is especially true if the potential suicide is young; her thinking is
impaired(259f) by depression, alcohol, or other drugs; she is ambivalent; or there's likelihood of "improvement", i.e., a change of mind or condition. On the other hand, about two thirds of Americans feel that suicide or euthanasia is sometimes proper for people who are dying.(260)
However, the issue becomes less clear when one asks, "For how long, and by what methods, may the exercise of the right to suicide be limited?" For example, should someone be locked up or drugged(261f) solely because she may commit suicide? If so, for how long? In the U.S.,
"...suicidal persons are the only people who may be held against their will for weeks, months, or even years on the sole basis of what they `might' do in the future rather than what they have done in the past---and not to others but to themselves. One Arizona woman spent fifty-eight years without comprehensive review in a state mental hospital after a suicide attempt. "If a sociologist predicted that a person was 80 percent likely to commit a felonious act, no law would permit his confinement," comment the authors of an article on "Civil Commitment of the Mentally Ill: Theories and Procedures" in the Harvard Law Review. "On the other hand if a
psychiatrist testified that a person was mentally ill and 80 percent likely to commit a dangerous act, the patient would be committed." "(262)
The Supreme Court, in its wisdom, has seen fit to provide weaker safeguards of due process and standards of proof in civil commitment cases than in criminal cases. In criminal cases the standard of proof for guilt is "beyond a reasonable doubt" and accepts that it's better for a guilty person to go free than for an innocent one to be unjustly
imprisoned. In spite of this principle, the Court does not "...appear to believe, as it does in criminal cases, that it is better for a mentally ill person to go free than for a normal
individual to be committed."(263)
Whether someone is involuntarily hospitalized depends, to a substantial extent, on social factors: age, sex, status---older, female, and lower socio-economic-class people are more likely to be involuntarily committed---(264) and whether the patient has a lawyer at the commitment proceedings.(265)
In addition, psychiatrists consistently overestimate the danger to and by the patient in commitment hearings. This is not surprising, since (1) psychiatrists' ability to accurately predict who will commit suicide is small; and (2) the consequences to the psychiatrist, and (perhaps) to the patient, are much more severe if a released patient commits suicide than if the psychiatrist mistakenly hospitalizes someone.(266) And, if the patient kills himself while hospitalized, this can be cited as evidence of the need for the
hospitalization, however regrettable the outcome.
Is ambivalence about suicide---for example, seeking help, calling a hotline, or standing on a ledge---sufficient grounds for intervention? Ambivalence means wanting, or being undecided between, two mutually exclusive things, in this case, "life" and "death". The problem with suicide is that we can go from life to death but not from death to life; a hundred decisions for life are overcome by a single one for death. One can argue that what suicides want is not death but the end to their pain, however it be achieved, and that life=pain and death=end-of-pain. The results, however, are the same.
Ambivalence toward suicide is indicated by the fact that three fourths of all suicides communicate their intentions, often with the hope that something will be done to make their suicide unnecessary. In a high proportion of cases, such communications are varied, repeated, and expressed to more than one individual. Studies of those who have survived serious suicide attempt have revealed that a fantasy of being rescued is frequently
present.(267)
But even if you and I can agree that intervention is sometimes appropriate, what are we to do with the suicidal people who do not agree? May we force them to take mind-altering drugs? For how long? Electroshock? How many times? Lock them up? For how many days, months, years? By what right may we continue to intervene in the face of
someone's persistent demand to make the decision as to the time and manner of his death? Ultimately the question cannot be evaded: "Whose life is it?"
As Frederick Ellis puts it more eloquently, "[Death] is my final civil liberty, and I do not choose to surrender it to the state, a church or a physician."(268)
Does Hospitalization Help?
In the heat of this argument, an important question is often overlooked: Does
hospitalization help? The answer is far from clear. Suicide rates in psychiatric hospitals are roughly five times higher than on the outside.(269) and there have been suicide epidemics inside such institutions.(270) Some of the anti-suicide regimens, such as 24- hour-a-day watch, or isolation may be terrifying or enraging to the patient/prisoner, and may be imposed because of the staff's fear of being accused of not having done
everything possible to prevent a potential suicide.
Some evidence that has been uncritically used to support hospitalization is subject to other interpretations. For example, one study found that a significant number of
hospitalized mental patients killed themselves while temporarily at home on leave. This was taken to mean that it was the return to the scene and situation at home that triggered the suicide.(271) The notion that an unwillingness to go back to the hospital might have been the catalyst was never examined.
Similarly, the fact that seven percent of a group of recently released psychiatric patients killed themselves was used to make a case for hospitalization.(272) But, as psychiatrist Herbert Hendin notes,
"There is as much justification for concluding that...the experience of hospitalization contributed to the suicide as there is for maintaining that hospitalization would have prevented it....For some acutely suicidal patients it may be life saving....Other suicidal patients are made more upset by their confinement. The decision for hospitalization is too often made, not on the basis of a realistic evaluation of whether it will help a particular patient, but because therapists want to shift the responsibility for a possible suicide onto an institution."(273)
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We're all going to die eventually; the only uncertainties are "when" and "how". Why, then, does suicide bother us in a way and to a degree that numerically greater---and easier to prevent---causes of death, like automobile wrecks (40,000-50,000/year) or cigarette smoking (400,000/year) don't? Writer Jaques Choron speculates,
"It has been suggested that suicide "troubles and appalls us because it so intransigently rejects our deeply held conviction that life must be worth living."(274)
"While there is undoubtedly some truth in this, in more cases than one would like to admit the reason for the shock may not be the challenges to the belief that life is good, but the fact that one is not really quite sure that it is. As...[Spanish philosopher] Jose Ortega y Gasset noted, for most people at all times "life" meant limitation, obligation, dependence, and oppression. They go on living simply because they happen to have been born, sustained by the force of habit, sometimes out of curiosity or vague hopes for a better future, and because they are afraid of the alternative-- death.(275) But the suicide seems to have conquered this fear. Thus he confirms not only the suspicion that life may not be the highest good but the one that death may not be the greatest evil."(276)
Choron goes on to ask,
"Should not the multitudes who die painfully and miserably each year be allowed to decide for themselves what is best for them? Moreover, it would be interesting to ascertain how many among physicians, whose
suicide rate is many times that of the average population, are actually euthanatic suicides, due to the discovery of their own terminal illness, their knowledge of how prolonged and painful dying can be, and the easy accessibility of quick-acting lethal drugs."(277)
Good question. There are high suicide rates among physicians: about 3% of male and 6.5% of female U.S. physicians' deaths in 1986 were suicides,(278) 35% of premature deaths among physicians were due to suicide,(279) suicide is the leading cause of death for physicians under 40 years old,(280) and the suicide rate for psychiatrists is almost twice that for other doctors.(281)
Data from Australia also show moderately elevated suicide rates for male physicians, and substantially higher rates for female doctors.(282) And in Switzerland, the problem is so severe that the life expectancy of female physicians is ten years less than that of the general female population.(283)