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.