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.