A “Hot-Potato” Topic and a “Rational” Book: Burstow Reviews: Rational Suicide, Irrational Laws

This year Oxford University Press and renowned scholar Susan Stefan (2016) released a very thoughtful book on one of the most controversial subjects with which any tome could ever deal—the question of suicide and the laws and public policies surrounding it. A long book of 540 pages, it is called Rational Suicide, Irrational Laws.

This is without question an excellent book. It is highly comprehensive, including an examination of a vast number of related laws and issues. While focusing on the US, it has international scope and provides a critical overview, for example, of assisted suicide laws throughout the world. It explores the criminalization and decriminalization of suicide. It analyzes laws by which “mental health” professionals and organizations are held accountable or “liable”. It exposes horrific contradictions in how laws are applied, particularly problematizing the assumption that people who kill themselves are suffering from a “mental illness” which makes them “legally incapable”, also the legal contradiction of mental health professionals deeming people capable when they go along with the professionals’ wishes while assessing these very same people as incapable otherwise. It weaves throughout real cases and the plight of very real people. Moreover, the underlying research includes at once depth analyses of statutes and legal journeys, and personal interviews with a large number of different folk, including health professionals, and what is especially gratifying, including people who have tried to kill themselves—a group arguably with the most relevant expertize and yet one which recognized “experts” on the topic characteristically sideline.

Finally, it is at once a compassionate and an intelligent book, written by a researcher who listens intently and who is trying to do justice to a complex issue about which she deeply cares. All of which is obvious right from the introductory remarks.

As the title of the book suggests, the story which Stefan tells and the analysis proffered is largely one of “rational” suicide and “irrational” laws and processes. Positions arrived at/articulated include: The state has an interest in preserving life and as such, a balance between the interests of the state and those of the person need to be struck. The vast majority of people who opt to end their life, including psychiatric survivors, have the legal capacity to make this choice and should be treated accordingly. The state should be getting rid of suicide magnets such a bridges with no barriers and should require the safe lockup of personal firearms. We should be moving away from an emphasis on detection and the immediate stopping of suicide to addressing the systemic issues that incline people toward suicide. A full range of help options should be made available to people, including safe houses, peer counseling, even long term 24 hour wrap-around services. While there are some who are “suicidal” for whom short term involuntary confinement is necessary given their lack of capacity, contends Stefan, in most cases, this is not so. It is critical that people who are considering killing themselves be able to talk about it freely—without the threat of being apprehended (an outcome traumatizing in itself and which increases the likelihood of suicide). What goes along with, so that professionals are not predisposed to avoid the topic of suicide or call 911, laws should be changed making “mental health professionals” not liable for the suicide of their non-committed clients.

Assisted suicide should be legal, Stefan goes on to state, but only if a number of stringent conditions are met, including the existence of capacity, the fact of having no more than 6 months to live, and having considered one’s options carefully. Correspondingly, she makes a sharp distinction between “assisted suicide” and “euthanasia” and regardless of whether or not euthanasia is actively solicited by the capable person themselves, wants it utterly prohibited and treated like ‘homicide”. And optimally, neither strangers nor family members should be allowed to “assist”.

Do I agree with all of the above? Decidedly not. However, before I touch on disagreements and what I see as problems (some of them major), let me say, there is much in this book that makes me want to stand up and cheer. The deep awareness of problems caused by trying to control people would top that list. Stefan is understandably horrified by the ease with which police are summoned, with vulnerable people concomitantly cuffed and dragged to “hospital” simply because they have mentioned suicide. As part of countering this expectable reaction, correspondingly, Stefan recommends legal, policy, and educational changes so that therapists, for example, stop focusing on control and start focusing on connection. Correspondingly, she is crystal clear that the status quo generally makes the suicidal person’s plight worse. Consider in this regard this thrilling passage:

People who are struggling with a reason to stay alive don’t want to be “assessed”. They don’t want to be asked endlessly if they have a plan, if they have the means, if they will contract for safety.  They want to talk about someone who cares, about hope, about solving the problems that seem insolvable, about how to get through the night (309).

Or consider this one:

The most skilled mental health professionals doing their best work must necessarily take risks that their patients will commit suicide. The journey to a life that a suicidal person considers meaningful and worthwhile must carry some risk. To increase the quality of life and the absolute number of lives saved, we have to be prepared to tolerate the reality that some people may kill themselves, We cannot continue creating unnecessary misery, increasing costs, and reducing both the availability and the quality of treatment to nurture the myth that all suicides are preventable. They never have been and never will be. (277)

She opines, correspondingly, that there would be considerably less suicide if we put less emphasis on controlling people and more on connecting with them.

In this last regard, while our opinions are far from identical on this issue for I place greater emphasis on freedom and personal autonomy than Stefan, let me share a bit of my own professional history for it solidly supports Stefan’s point: As a therapist, for well over three decades my specialties have been adult clients who: a) self-injure; b) are psychiatric survivors; c) have been profoundly traumatized; d) live with alternate realities; and e) want to kill themselves. As a matter of principle, I am clear with clients right from the start that I will not prevent them from killing themselves, will not call 911, so they have no need to censor themselves. Bottom line positions for me are that people desperately need to be safe to talk about “suicidal” thoughts, that we should not presume to know what is best for others, nor make decisions for them, moreover, that people in dire distress need to connect, and to deny them the possibility to do so safely is ultimately to make counseling and therapy unavailable to those in the most dire distress. What is significant in this regard, while no doubt some degree of luck has been involved, in all these decades, despite my having a specialization that makes the suicide of my clients a statistically strong possibility, not a single client of mine has ever killed themselves. As such, I am highly aware that there is wisdom in what Stefan is alleging and recommending here.

More generally, what this book does well is introduce us bit by bit to the legal territory, and the place of culture in determining what conceptualizations are viable. Praiseworthy and major contributions similarly are the author’s insistence that whatever laws are created, psychiatric survivors must not be discriminated against, must be treated like everyone else; the sharp distinction that she draws between adults and children; the argument that we should prioritize addressing the systemic problems that commonly underlie people’s desire to kill themselves (e.g., in the case of children, bullying); the push toward less control and more connection/compassion; the highlighting of psychiatric contradictions; the unmasking of so many current practices in this area as illegal and/or irrational; the downplaying of medical solutions as well as the recognition of how causal they can be in suicide; the recommendation that society consider the different types of suicide and find ways of providing the various types of help needed; and finally, what goes along with this, the caution against the advent of assisted suicide becoming just another way of letting society “off the hook”.

Which brings me to the problems.

From my perspective—and I suspect most people would critique Stefan from the opposite perspective—the author seriously understates the problems caused by psychiatry, and in no way touches on the invalidity or the inherently damaging nature of all its biological “treatments”. As such, while she wants to protect people’s rights as far as they are “legally capable” and while she remains very critical of psychiatry, she still sees a place and a privileged place for psychiatry. More generally, while she would greatly reduce it, she ultimately accepts the “need” for involuntary psychiatric detention—and no, I do not.

What relates to this, while once again being critical, Stefan accepts a view of incapacity that would still have a huge number of people declared incapable (albeit far less than are so deemed today). For example, she sees as obviously incapable people who are “floridly psychotic” and as such, would have no compunction over 911 being called on them, if, for example, they are actively suicidal. What this position invisibilizes is that there are people with such different ways of processing that they are automatically seen as lacking reason. As demonstrated in Burstow (2015, Chapter Nine), this failure to comprehend is largely a limitation of the “sane”, as well as a deficit—and indeed correctable deficit—in our education systems. Correspondingly, society’s failure to understand people whose minds work differently does not per se make such people “incapable”.

An example pertinent to the issue at hand: A client of mine that at once dwelt in an alternate reality, was “suicidal”, and who would certainly have been seen by most as ‘incapable” announced one day she was going to kill herself forthwith in order to join the trees. To the average person, it would look as if she had lost her power of reasoning and so could not conceivably be competent. An understandable reaction, sure, but what this view leaves out is that she was literalizing a metaphor. What she was saying, in “sane parlance”, is that she wanted to return to nature, to dust, as it were. That is, finding life meaningless, she wanted to rid herself of the existential burden of being a separate and cognizant being. Now I can well understand why a situation like this gives us and indeed must give us pause. Nonetheless, is not a variant of this position held by most people considering ending their lives—including those, I would add, that the average person would “recognize” as “capable”? Indeed, to step totally outside pathologizing frameworks (always a good thing), is not her question a variant of the ultimate existential question that philosopher Albert Camus (1975) sees facing all of us? To be clear, I am not suggesting that anyone “support” her decision. However, how in good conscience can we uphold a framework which would not only thoroughly invalidate it but would inevitably lead to her apprehension?

Less obviously but more fundamentally problematic is the statist framework which Stefan uncritically employs. Note, while I well understand the need to balance community rights with individual rights, weighing the needs of the individual against “the interests of the state” (in this case in “preserving life”) which the author is advocating, is a different matter altogether. To be clear, while I am decidedly “on board” with wanting to improve society and people’s situation for a variety of reasons, including so that fewer end up feeling that they have no recourse but to kill themselves, not one of those reasons is that the “state” “has an interest in preserving life”. By the same token I see as inherently problematic concepts like “suicide prevention” so rampant in this book and indeed, the very conceptualization of people “committing suicide”. Note, in this regard, “committing suicide” is a concept tied to the state. And as institutional ethnographer Dorothy Smith (1983) so astutely put it decades ago, while people indeed end their lives, “no one commits suicide.” While shifting a framework this hegemonic is hard, I appreciate, and runs directly counter to legal training, attempts to bring about a more humane approach, I would suggest—are minimally jeopardized by statist ways of thinking and statist problem-solving. By the same token, while I applaud the author for wanting and pushing for better services, I question the degree of improvement possible in our current statist arrangements, for states have their own interests, as do their representatives—note, the very people in whose hands lies the state’s parens patriae powers—ergo, the power (and responsibility) to commit and to intrude (see Burstow, 2015).

Finally, we come to Stefan’s positions on assisted suicide and euthanasia (issues with which, I would agree that as things currently stand, we need to involve the state).

To put this simply, people in dire distress and who rationally choose to end their lives often need more than either decriminalization or assistance to live, significant though both are. As a society, of course we need safeguards and of course we need standards, and of course, contrary to how we currently act, we need to prioritize doing whatever we as a community can to help improve the quality of everyone’s lives. And of course, having the right to end one’s lives does not automatically translate into having the right to assistance with this—far from it. Nonetheless, let me suggest such assistance is often in order. 

On a simple level, no one wants to die alone; most people would greatly prefer having the peace of mind that comes from knowing that the procedure will not be botched.  Correspondingly, allowing assistance of this ilk only in those cases where the person has but six months to live (one of Stefan’s provisos) is woefully inadequate. What for example, about the person who is not in the least terminally ill but is in terrible pain that cannot be stopped, that in essence cannot be “made comfortable”. Take the person who has advanced arthritis, together with exceptionally severe gastro-intestinal problems along with such a dire case of multiple chemical sensitivity, along with a body with such low intolerance that no pills will alleviate her suffering, for no medication whatever, however introduced, can be tolerated. Imagine further that she has spastic conditions that will not allow her to tolerate even seemingly non-intrusive measures like acupuncture or mindfulness or indeed any of the other options in the medical repertoire. Do we as a society really want to say to such a person that while we will not stop her from ending her life, unless she has but six months to live, we will neither help her nor allow others to?

Enter the author’s recommendation for how assisted suicide might work. Understandably worried about the involvement of doctors, Stefan recommends that persons with six months only to live enter a hospice, whose operator in turn gives them a voucher which allows them to receive a fatal dose of medication from a pharmacy. To go back to the previous example, which as it happens is not a hypothetical but a real situation with which I am highly familiar, besides that the person in question would not be eligible—for she has way more than six months to live—she is unlikely to be able to enter a hospice for the presence of everything in it would instantly make her vilely ill. Moreover, the medication is highly unlikely to be something her body would tolerate. And it is hit-and-miss with injections or other like solutions. Nor would starvation (a method suggested in this book) be endurable for her body reacts even worse to food deprivation than to eating.

Which brings me to the question of euthanasia. Stefan unequivocally rules it out and equates it with homicide even where the person in question actively requests it, waits the required amount of time, carefully considers their options. To be clear, of course far more stringent oversight is needed if we allow direct second party involvement, and of course, we need to keep in mind what has been called “the slippery slope”, but at the bare minimum people’s peace of mind in dying can at times be greatly enhanced by making more direct assistance possible. Again, take the person referenced earlier.

With solutions that work with others habitually backfiring with this person, do we not want her to have a medical expert there to deal with physical reactions that might suddenly happen, that might make an otherwise seemingly uncomplicated procedure unworkable and/or tortuous? Or do we want to leave what happens to her to chance? Correspondingly, are we okay leaving as one of the only options that does not leave her trapped or feeling guilty (the latter because of a route that involves legal jeopardy for potential helpers), the lonely and indeed frightening option of crawling away and shooting herself?

The point is clear. Society has been moving to assisted suicide because we do not want people in agony stuck with such dilemmas. However, we cannot provide what is needed without considering the real dilemmas that real people in extremis face. Correspondingly, we cannot just accept models that might work for many. Any model that places anyone in such dilemmas is unacceptable. 

Time for greater clarity on the example at hand: In short, what I have done here is draw on several of my own conditions, while leaving out the vast majority of disabling but nonterminal physical conditions I have (e.g., inability to sit, to eat more than 4 specific foods, to travel at all, to see anything without significant distortion, to treat a single ailment, to be around sounds louder than a hush, etc.). Factor in all of these and the need for active help to be available is even more apparent.

To be clear, I am 71 years old. I have a wonderful life, continue to be highly productive, work with awesome students and fellow activists, am a professor at a leading university, have just become head of my program; and I have no intention whatever of retiring any time soon, never mind killing myself soon—if ever.  However, if things got so bad that life was no longer tolerable irrespective of the help offered, a society that could only push “solutions” at me that would make my plight worse and/or would in any way penalize anyone who helped me bring my life to a peaceful conclusion would surely be failing me—not to mention the helpee. And mine is just one set of circumstances.

Who knows what worse circumstances others and indeed younger individuals might be facing? Bottom line, the criteria for qualifying for assisted suicide stipulated in this book, together with the dismissal of more active help, seriously “misses the mark”.

Two final observations: While there are unquestionably people, including doctors, whose “help” in this area qualifies as undue influence and/or borders on criminal negligence, moreover, others where it is downright murder—both of which are “beyond unacceptable”—at this point in history, that is hardly typical; and processes and laws that operate as if it is are themselves sadly wanting. Moreover, often people, including doctors and including family members who go “the extra mile” do so because individuals who are by conventional standards demonstrably “capable” want them to—are clear that they urgently need them to. Question: Can we not find better processes and ways of distinguishing what is happening? And cannot we not respond accordingly? As for bone fide helpers who cross the still-to-be-negotiated line, let us deal with that for sure, but in a way that factors in their predicament and society’s inevitable role in this.

And finally: Like Stefan, like virtually all disability activists, I too consider “beyond unacceptable” any slippage whereby states start using assisted suicide as the ultimate solution to their “problems”, as a cost-effective and convenient way of ridding themselves of whatever or whoever they see as burdensome. Correspondingly, as I too see a danger here and as I want better, not worse services, I personally would favour a policy whereby for every penny that a state spends on the combination of assisted suicide and requested euthanasia, an equal amount has to be added to the coffers supporting programs intended to help people in difficult circumstances live—that is, to help them lead lives of meaning to them.

Closing Remarks

As I stated at the outset—and I would reiterate it at this juncture—Rational Suicide, Irrational Laws is a ground-breaking, brilliant, indeed courageous book; and I encourage people to read it. There is information, analyses, wisdom to be gleaned from it. What is also important, it is written by someone who is clearly highly ethical. And reading the reflections and considered opinion of those who are guided by a strong sense of decency is in itself good for the soul.

My invitation? Pick up the book, engage with it, where you find yourself agreeing, ask yourself why, similarly for when you find yourself disagreeing, and continue thinking about the issues raised. Through the lens of suicide and societal responses to it, it implicitly asks what kind of society we want, and as such, it holds significance for all of us, addressing in the detail it does issues that cannot but touch each of our lives. At the same time, it holds special significance for psychiatric survivors, for survivors of childhood trauma, for lawmakers, for therapists, for educators, for people who are sick or dying, for anyone who has themselves or whose loved ones has ever seriously entertained killing themselves—hence my particularly drawing your attention to it.

In ending, additionally, I would say this to the author: I hope that some of what I have written holds meaning for you, including where we agree, including where we disagree.

And regardless, Susan, thank you for penning this book.

References

Burstow, B. (2015). Psychiatry and the business of madness. New York: Palgrave.

Camus, A. (1975). The myth of Sisyphus. New York: Penguin.

Smith, D. (1983). No one commits suicide. Human Studies, 6, 309-359.

Stefan, S. (2016). Rational suicide, irrational laws: Examining the current approaches to suicide in policy and in law. New York: Oxford University Press.