Saturday, October 01, 2005

The Case Against Suicide Prevention?

A few days ago I was covering an afternoon shift in the Pedi- ER. The ER by nature is always hectic, we have 11 exam rooms, 3 triage, 2 trauma rooms, and a rather large waiting room in the Pediatric ER alone…. Most of the time there are children sitting on gurneys in the hallway of the unit waiting to be seen. But this particular day was relatively slow (for which I was thankful), only a few patients who were all older and perfectly content to play videogames while awaiting results from Radiology. But about an hour into my shift, one of the med students approached me, explaining that they were bringing in a 12 year old with suicidal ideations.

The girl was placed in an isolation room upon her arrival, and it wasn’t long before she was restrained to the bed. I’m not usually involved in the care of psych patients, but the girl refused to talk to the psychiatrist on call, commenting that she was too old to understand her problems. This was when I was asked to step in, and try to gain some insight. I was more than hesitant… within the span of my high school years I had attended 4 funerals for students who had taken their lives. During a span of 2 months my junior year, one suicide occurred each week, making my school a subject for national news. The media scrutinized the pressure put on kids by teachers, and likened the “cliquey” atmosphere of my high school to that of Columbine. They claimed that my district’s response to the initial suicides (closing school, creating memorials outside) only served to glorify the act, and perpetuate the “trend”.

However, the girl whom I met in the ER differed from the students I knew in high school in one aspect: rationale. The students I described all attributed their suicides to a bad grade, a break-up with their boyfriend, or not being accepted by a particular group. The girl I met in the ER expressed wanting to end her life because of her recent diagnosis of end stage cancer. She spoke of the bleak odds of survival that were starring her in the face, and of the painful rounds of chemotherapy that she had already endured, only to be told that the tumor was resistant to the therapy. She was going to die; she knew this, she simply wanted to choose when and under what terms it occurred. I was stunned by the rawness of her pain, and of her justification, which seemed almost logical given the circumstances she faced. But, does she have the right to make that decision? Thomas Szasz published a now famous article in 1986 entitled “The Case Against Suicide Prevention”, where he argued that committing suicide should be considered a basic human right:

I submit that there is an instructive symmetry between procreation and suicide: one consists of multiplying one’s life, the other of nullifying it, with both decisions and acts having a profound impact, for good or ill, on the actors, their families, and the society of which they form a part. In the case of procreation, we recognize the moral complexity; namely, that a newborn baby’s life is infinitely precious, but that irresponsible procreation is dangerous, destructive of the welfare of both individuals responsible for it and society. Nevertheless, we in the West, impose no coercive measures on anyone (not even on minors) to prevent procreation, as if procreation were never undesirable enough to warrant coercive measures to prevent it. In contrast to procreation, when it comes to suicide we deny the moral complexity; namely, that although life is precious, disease, disability, and dishonor may render a person’s life not worth living and thus may make suicide a blessing for himself or herself as well as for others and society. Nevertheless, we, in the West, impose coercive measures on every would-be suicide (even the hopelessly sick and very aged), as if suicide were never desirable enough to justify it. All this points to the desirability of according suicide the status of a basic human right (in its strict, political-philosophical sense). I do not mean that killing oneself is always good or praiseworthy; I mean only that the power of the state should not be legitimately invoked or deployed to prohibit or prevent persons from killing themselves.

Should medical professionals have a moral obligation to report suicidal ideations in all situations? Specifically, are there conditions under which the act of suicide is justifiable, and are we denying people a fundamental right by using what Thomas Szasz argues are “coercive measures” to prevent it? Just some food for thought....