Curse God and Die
Kevin Drum admirably – in my view – gets personal in his back-and-forth debate with Ross Douthat over assisted suicide:
I suspect that one big difference between Douthat and me is that I’ve suffered from chronic depression nearly my entire life and he hasn’t. Luckily, my case is moderate, and I’ve never felt like drowning myself in a bathtub. Still, I understand keenly what it feels like, which makes it easy for me to have a pretty good sense of what it would feel like if it were more serious. And that deep-seated understanding of what serious, long-lasting, incurable depression probably feels like is part of what drives my policy preferences here. I can actually imagine myself being in a situation where I’d want that prescription available to me, so reasons of self-interest dictate that I’d prefer it to be legally available. If you can’t even conceive of such a situation in your own life, you’ll probably feel differently.
I suspect he’s right, but, at the risk of treading on Drum’s personal toes, I also suspect Douthat would say that Drum’s evidence cuts both ways.
To step back a bit first, it should be acknowledged that there are perfectly strong ethical systems that not only permit suicide but encourage it. In some, suicide is the right and proper response to severe shame and dishonor; indeed, in these ethical systems, the only way to redeem one’s honor in certain shameful circumstances is to kill oneself, and honor is valued more highly than life. Less stringently, other ethical systems view suicide as the ultimate exercise of personal freedom – the determination to fully shape one’s life narrative, including its conclusion. “Call no man happy until he is dead,” is the saying; a properly timed suicide could make sure that one, indeed, died happy.
Neither Drum nor Douthat is engaging with these ethical systems. Drum is not arguing that it’s a right and good choice to kill oneself because one always planned to die at eighty. Indeed, he thinks that suicide is “tragic” even in circumstances where he can accept it as someone’s legitimate decision. Douthat, also, is not arguing against these alternative systems of ethics. He simply presumes that, as such, suicide is wrong, and is engaging with the question of whether there are exceptions to that rule.
The grounds of their dispute, therefore, is over the traditional liberal terrain of prevention of harm versus preservation of personal autonomy.
Now, to return to Drum’s claim. He says that he values a right to suicide because he can imagine wanting to exercise it in a circumstance where he had a serious, longstanding, incurable depression. He can imagine what such a state feels like because he’s experienced, over the course of his life, milder but still terrible forms of organic depression.
The problem for his argument is that the very facts that strengthen his case – I know what it would feel like, because I’ve experienced something similar, and if I were in that circumstance I know I would want to die – are the very same facts that Douthat might say strengthen his case: you know what it would feel like, and you know that, in the worst moments of depression, those feelings would overwhelm any ability to see beyond that moment, to maintain hope. And so, you know you would be susceptible to the counsel of despair. Precisely because you know that’s how vulnerable you would be, you know that you would need external restraint to resist that counsel.
The stronger-minded you assume your depressive is, and the more sure you are that he is right about the salient facts – that the depression really is incurable, really will never abate – the more inclined, I would think, you would be to take Drum’s view: it’s terrible that he’s got to choose between death and that kind of life, but I respect his choice for death. Nobody has the right to tell him what constitutes the worse choice. The weaker-minded you assume your depressive is, though, and the less sure you are that he is right about the salient facts – how can he possibly know that the depression will remain incurable? last month he really seemed not too bad; how does he know that next month won’t be another period of relative respite? – the less comfortable I would think you would be taking that perspective, and the more inclined to conclude that the call to die was a siren’s song that the depressed person must be restrained from hearing, for his own good.
Where you’re dealing with people in the late stages of terminal disease, the question “is this decision one that the person would regret in a different frame of mind” kind of goes away. There isn’t much more life to theoretically regret the loss of, and the confidence interval about what that life would be like should be very high. But once you push natural death well off into the future, I don’t see how that question can be avoided. It’s precisely this question that is waved away by sweeping statements about the actor being of “sound mind.” “Soundness” of mind, after all, isn’t binary. A personal can be of perfectly sound mind to sign a second mortgage and also be a gambling addict who plans to blow all the money he borrows on a trip to Vegas. (I’m not suggesting that people with gambling problems should be prevented from taking out second mortgages; I’m pointing out that, from the outside, most of us would say that the gambling addict needed help, and that the availability of the second mortgage made his situation objectively worse.)
Douthat has religious reasons for taking an absolute position on this. A less-religiously-minded person, though, might simply say: I care more about protecting vulnerable depressed people who might feel like there is no hope from taking an irrevocable action that, in a different frame of mind, they would deeply regret. And I care less about relieving the suffering of those who are strong-minded enough for me to be sure that they would not regret their choice in a different frame of mind. And someone else might take a different view of the same question, preferring to protect the autonomy of the strong-minded even at the cost of some weaker-minded people making the “wrong” decision.
(An opponent of assisted suicide might also say that if the state permits assisted suicide, then a variety of financial and other incentives might lead to the encouragement of suicide, effectively the corruption of the profession of the counselor. The counter-argument might be that a formal structure for assisted suicide might actually bring people who would otherwise kill themselves on their own into the counselor’s orbit, where they might actually be convinced to live – and from a consequentialist’s perspective, suicides prevented would directly offset suicides “incorrectly” encouraged, and the balance could be evaluated empirically after small-scale experiments. This kind of dispute mostly reveals what one thinks of the social work and psychiatric professions – if your level of trust in these professions is low, you lean one way; if high, you lean the other. To a non-consequentialist, of course, this whole way of framing the dispute would be inadequate.)
I don’t think there’s any categorical way to resolve these kinds of disputes. Neither Douthat nor Drum is a dogmatic libertarian who believes that nobody should ever by prevented from making a decision they would later regret, and neither is a totalitarian who believes that nobody should have any autonomy at all. In general, the more irrevocable and serious the consequences of a personal decision, the more inclined we are to try to protect people from making a decision they would later deeply regret. On the other hand, the more deeply personal a decision, the more inclined we are to try to protect a zone of autonomy within which an individual is free to make whatever mistakes they make. And as these change, our views change. For example, as we have come to understand sexual choice and expression as deeply personal, and as technological and economic changes have reduced the consequences of female sexual activity to a level far lower than was historically the case, the sphere of female sexual autonomy has expanded to historically unheard-of levels.
Suicide hasn’t changed, though. It has always been, and always will be, about as personal a question as can be imagined. And it has always been, and always will be, utterly irrevocable. I suspect that it will always, therefore, be a topic around which dispassion, on either side, is difficult.
Noah,
First of all, you’ve been on a roll lately — keep up the good work. Now with respect to this post, I have to disagree with this analysis:
“The grounds of their dispute, therefore, is over the traditional liberal terrain of prevention of harm versus preservation of personal autonomy.”
As Kevin Drum himself says, he doesn’t think Ross provides a good reason for why suicide should be considered immoral or forbidden because he rejects Ross’ religious beliefs about suicide. Of course, Ross could easily respond with a natural law argument about life and its purpose which does not involve the “liberal terrain” you reference above — that’s why it is in fact important to establish what ethical system is guiding your decisions (or laws). First things, as Father Neuhaus liked to say!
I should mention, to get personal for a minute, that I too have strong personal feeling about the subject as I actually did try and commit suicide when I was younger while suffering from a major depressive episode. Of course, I’m now very glad I was unsuccessful and like your hypothetical weak-minded depressive, I didn’t know what what good for me when I did what I did (I was literally mentally ill). Knowing now what I know in general about depression, I wonder if anyone can ever be in their right mind and want to kill themselves. I just don’t think our brains work that way…but I’m no expert, I’ve just read a lot about depression.
Finally, speaking of natural law and ethical systems, this reminds me a bit of your previous post about our “true” selves. There too, I think a natural law understanding of what it means to be human is necessary to establish up front before we can evaluate how to think about an individual wrestling with his or her sexual feeling for someone of the same sex. Obviously as a Christian Catholic I would argue those feeling are sinful and I would also argue they are not very surprising (see e.g. Paul’s letter to the Romans, especially Chapter 7, versus 19 – 25). But you could also argue the same thing, just like in the case of a suicidal person, from a natural law perspective — what is human sexuality designed for and what is its best use? You are correct to say our true self or real self is the self in conflict. But like the suicidal person, what that means is that we need something other than “What decision here is most connected to ‘the real me’?” to guide our footsteps. “The real me” is a mess. “The real me” has bad traits and good traits. “The real me” is both the Old Man and the New Man (to use Pauline terminology).
Think of someone who you knew to be a good husband and father leaves their wife and children for another woman after 20 years of marriage. There is a sense in which I would say that he was not being true to his real self by doing that. But on the other hand, the meaning of that sentence is just simply that the man you had known as a good husband and father was by definition a man who was true to his word and his commitments, a man his wife, children, and friends could trust. So the statement that he “was not being true to his true self” is really a kind of lazy shorthand for saying that he was not being true to his better self, which had heretofore been the only aspect of him that you had known. And what counts as one’s “better self” can only be defined by a standard other than “self” talk.
— Fake Herzog · Jun 10, 07:29 PM · #
I also think that Drum’s comment cuts both ways.
And I also think that, given our culture, and the Darwinian model of health care (especially mental health care) we have in the USA, this is not about empowering people but relieving doctors and healthcare providers of liability – the freedom to have them help you die will, unless we first change our culture, become the duty to die for anyone who is not a privileged and self-empowered person.
This shift will likely have strong negative externalities along these lines.
Right now, the issue liability has the prudential effect of keeping healthcare providers on their toes so that they don’t so readily invite patients to leave this mortal sphere unless all concerned are in agreement. Which won’t satisfy absolutists on either end, but is, given our culture, probably the best we can do from a legal perspective.
— Liam · Jun 10, 08:53 PM · #
Who is prevented from committing suicide? Very few. The question really is what should public policy be toward suicide. In every state of which I am aware, suicide is a crime. You might ask how one prosecutes a successful suicide. But that is not the point. The point is that society makes a claim that suicide is not acceptable. As an aside, assisting a person to commit suicide is also a crime. There is a gestalt to living in a society because we are more than monads, individuals who have no effect on others and who live just for themselves. At least, we used to be more than monads. Nowadays, with everyone’s eyes fixed on their cell phones, Blackberries, IPods, etc., we are becoming more and more estranged from each other. We are committing societal suicide by focusing just on ourselves. And therein lies the lure of suicide. If you are all alone in the world, you are without God and you may as well die because you already have spiritually. This is true despair.
— LDM · Jun 10, 11:41 PM · #
LDM, if we accept your observation about cell phones and ipods turning brothers into strangers, why not throw central air into the mix? Have you ever been in a poor neighborhood, where even window units are infrequent, this time of year? If you haven’t, there’s a lot more people outside on porches, a lot more life in the street, a lot more human interaction than in the tonier precincts. Are the former neighborhoods more spiritually vital? Seems like a loopy conclusion, but, well, maybe.
Someone even said once— with more humor, granted, than LDM could muster— that air conditioning killed Southern writing, making would-be artists too comfortable, too indoors.
Somebody in my family attempted suicide many years ago. Like Fake Herzog describes above, my family member was ill. He seemed gone, in a way, during that time. Fortunately, he came through, and for a long time he has been, or at least has seemed, well. To my knowledge, he no longer requires even medication.
In his attempt, he used an overdose of pills. While this approach obviously works for some. In other cases— his— the body’s digestive organs at least manage to overrule the mind’s imperative. My hesitation about an allowance for suicide by medical prescription is that it would greatly increase the odds of success.
Of course, a suicidal individual, without the help of a doctor, can choose a gun or a bridge to practically assure his act. But many other depressed people, like my relative, do not exploit such conclusive options because those options are simply that much scarier, that much harder to contemplate. My fear is that an option, sanctioned at some level within the medical profession, to provide death for the depressed would make the decision less scary. Had it been available to my relative, he might have grasped it and succeeded, never realizing that he could reemerge from despair and get life back out in front of him, again.
However, this concern holds for those who are relatively young more so than it does for the elderly. As Millman observes, terminal patients already near the ends of their lives, very very rarely have much rebound to hope for. In these cases, attempts to isolate severe depression from severe pain or severe loss of mobility as the cause of suicidal thoughts are vain. And it’s precisely these cases, where the patient is practically incapacitated from taking her life, that may in fact need an easier, less scary option. The medically supervised suicide, here, seems the more merciful prescription than the alternative— continuing to suffer with the assistance of medical supervision.
— B Levaster · Jun 11, 03:34 AM · #
When we talk about the pros and cons of suicide, the focus has been on the depressed, not the elderly or medically terminal. Surely, in the latter instance, there may be valid reasons to choose death. Someone facing Alzheimer’s for instance or constant pain from cancer would, in states that permit medically assisted suicide, find it preferable to die sane or avoiding further pain. But for those in the throes of despair, whether young or old, public policy has opposed any right to death. Certainly, the constitutional right to life is an express directive opposed to a right to death. My comments about the continuing trend toward isolation in developed countries based on insular activities can be extended even further into ridicule if you like. Why not eliminate housing and live in the streets? Why have walls between classrooms? But a reductio ad absurdum argument like the typical straw man argument is not an argument against the public policy against suicide. People mistake their constant need for electronic stimulation as just alternate socialization. But all it does is lead to infantilization, self-prepossession, and pseudo-autonomy. We see this working out in popular entertainment, where movies written by 14-year-old boys who are chronologically men are watched by 14-year-old boys who are chronologically men. We are a nation waiting to be entertained and there is a lingering sense of unfulfillment and sadness in a life devoted to the lonely pursuit of individual thrills. Hence, modern boy-man’s despair. It used to be drugs (turn on, tune in, drop out) and now it is handhelds.
— LDM · Jun 11, 08:32 PM · #
LDM, suicide was a crime at common law, but it is no longer a crime in England (as of 1961) and I don’t know of any American jurisdiction that retains it as a crime. I’m not going to do a 50-state survey to find out, but it’s definitely not a crime in the three states where I’ve lived (MA, NY, CT), and I haven’t heard of any criminal prosecution for attempted suicide in the United States during my lifetime. In short, if suicide is a crime in every state of which you are aware, I’m curious which states you’re aware of.
— Patrick · Jun 11, 08:48 PM · #
I wonder if some people are confusing laws against suicide with laws against assisted suicide. The latter tends to get into some dangerous, abusive territory.
I’ve long advocated that if we do allow assisted suicide, that the medical profession not be allowed to be a part of it. With all the unemployment we have, suicide-assistant could easily be made into a separate profession. No need to contaminate our medical schools with this one, though. Having suicide-assistants as separate professionals would eliminate any confusion on the part of patients as to which procedures their doctors and family have in mind.
— The Reticulator · Jun 12, 03:21 AM · #
You simplify your ‘vulnerable’ vs. ‘strong-minded’ example (ΒΆ11) by omitting to reckon with non-assisted suicide. Who’s to say that either depressed person wouldn’t commit suicide in your example even if it wasn’t lawful and assisted? ‘Vulnerable’ might mean ‘less able to get out of the trough, so more likely to want to end things irrevocably’ or ‘too afraid of the experience of dying to commit the act’; ‘strong-minded’ might mean ‘able to push through depressive episodes without coming to a minimum where suicide represents hope’ or ‘willing to cut his carotid artery if it means entry to oblivion’ (like George Price).
Still, it seems evident the ‘strong-minded’ don’t need assisted suicide to relieve their suffering by suicide. But do ‘vulnerable’ people need assisted suicide to be illegal to be protected from it? This question strikes me as open. In a suicidal state, are such people just as likely to be dissuaded from suicide by a counsellor as to kill themselves by their own hand? Must we resort to statistics for an answer?
— ovaut · Jun 12, 06:38 AM · #
by ‘state’ there i mean ‘state of mind’, not ‘polity’
— ovaut · Jun 12, 06:58 AM · #
I stand corrected. Thanks, Patrick. According to wiki.answers, “By the early 1990s only two US states still listed suicide as a crime, and these have since removed that classification. In some U.S. states, suicide is still considered an unwritten “common law crime,” as stated in Blackstone’s Commentaries. (So held the Virginia Supreme Court in Wackwitz v. Roy in 1992.) As a common law crime, suicide can bar recovery for the family of the suicidal person in a lawsuit unless the suicidal person can be proven to have been ‘of unsound mind.’”
Read more: http://wiki.answers.com/Q/Why_is_it_illegal_for_people_to_kill_themselves#ixzz1P6S6HcUO
— LDM · Jun 12, 07:27 PM · #
I don’t find Drum’s argument all that admirable. That sort of personal experience is simultaneously non-refutable and disconnected from any larger moral or ethical framework. It’s really nothing more than an expression of personal preference and while that’s not unimportant, the proper regulation of personal preference is sort of what civilization is all about.
I think assisted suicide has, to some extent, become the secular version of The Last Rites or other religious death rituals. It’s a way for the secular to comfort themselves when faced with the awful realities of decline and death by letting them think they can just avoid them.
Mike
— MBunge · Jun 14, 02:55 AM · #
The significant difference between suicide in mental health cases and in terminal illness, is that depression is treatable and it can get better. It just doesn’t feel like that at the time. The form of depression with the highest suicide rate is bipolar depression, which is easily treatable in almost all cases. However few people in that state are able to see that there is an end in sight. This is why I’m strongly against assisted suicide in mental health cases (even though I support its availability for terminal illness), and it horrifies me that the Dignitas performs these regularly. I know this because I’ve been there too. I had terrible bipolar disorder for many years, including the most dangerous mixed states. Now, thanks to good medication, I am basically asymptomatic and have been for years. If at the bottom of my depression I had been told that in a few years I’d be happily married with a good job and a baby on the way, I’d not have believed you. At the time, there didn’t seem to be many ways out. I’m just lucky I never managed to take the obvious one.
— Matt · Jun 14, 08:04 AM · #