Szasz does not believe that society should support or encourage suicidal people in their desire to kill themselves; he considers counseling, therapy, or any other voluntary measures desirable. In his own practice Szasz readily offers help when and if requested. “In fact, I firmly believe that psychiatric help, including help concerning suicide, can be given more effectively if there is no threat of coercion overhanging it,” he observed in a spirited debate with Edwin Shneidman. “I think I can be more effective in my work with persons who are suicidal because they know that they can talk as freely about suicide as they can talk about the stock market or divorce, and I will not intervene in the one any more than the other. I do not get uptight about it. And the ultimate decision remains in their hands.” (It is hard not to wonder whether Szasz got uptight in 1994, when he agreed to pay $650,000 to settle a lawsuit filed by the widow of one of his patients. The suit charged that Szasz had advised his patient, a physician suffering from bipolar disorder, to stop taking his lithium; six months later, the doctor hanged himself with battery cables.)
Suicidologists insist that the opposition of Szasz and other civil libertarians to suicide prevention is based on a misunderstanding of suicidal thinking. They note that right-to-suicide advocates ignore the ambivalence and impulsiveness of most suicide attempts. They point to the many people who have attempted or contemplated suicide and survived to live productive lives, including such well-known figures as the pianist Arthur Rubinstein, who tried to hang himself with his belt at age nineteen (the belt broke); the philosopher Bertrand Russell, who considered suicide as a teenager; and Abraham Lincoln, who was suicidally depressed after breaking off his engagement to Mary Todd. “The ‘right’ to suicide is a ‘right’ desired only temporarily,” writes psychiatrist George Murphy. “Every physician should feel the obligation to support the desire for life, which will return even in a patient who cannot believe that such a change can occur.” Over the years Herbert Hendin has interviewed four people who survived six-story jumps. Two changed their minds in midair, two did not, and only one attempted suicide again. In another instance, a depressed twenty-eight-year-old who survived a leap from the Golden Gate Bridge in 1985 recalled the moment he left the rail: “I instantly realized I had made a mistake. I can’t tell you how frightening that was.” One thinks of Tolstoy’s Anna Karenina jumping in front of the train and trying to get up—“Where am I? What am I doing? What for?”—even as the train crushed her.
In any case, say suicidologists, someone prevented from killing himself can always try again. Research shows that 10 percent of attempters will complete suicide within ten years. Most suicidologists believe that if someone is truly determined to kill himself, he will. “The right to kill oneself can be exercised quietly, without involving society, by anyone sufficiently determined to do so,” writes Hendin. “Someone on the window ledge of a tall building threatening to jump or someone who is found unconscious after swallowing sleeping pills has forced society to notice him, whether or not he is hoping to be saved or helped. Surely confinement for a limited period for the purpose of evaluation with a view to providing help is indicated.” Edwin Shneidman puts it more pungently: “Suicide is not a ‘right’ any more than is the ‘right to belch.’ If the individual feels forced to do it, he will do it.”
Additionally, suicidologists point out that in exercising the “right to suicide,” one may violate the rights of others. People who jump from high places occasionally land on innocent passersby, injuring or even killing them. Carbon monoxide may seep from garages into adjoining houses or apartments, poisoning family or neighbors. People who use an automobile to complete suicide often injure or kill passengers in other cars. Suicide also inflicts psychological injury, most deeply on surviving relatives and friends but also on bystanders. “Although such cases have not been studied, individuals have been severely traumatized by seeing another person kill himself or herself,” writes sociologist Samuel Wallace. “Do people in public places, in train stations, or on sidewalks beside tall buildings have a right to be free of the grotesque spectacle of public suicide?”
Although most right-to-suicide arguments describe suicide as a voluntary expression of free will and “rational” choice, most suicidologists insist that suicide is not an act of free will at all. They would argue that it was not Szasz’s physician who had made the decision to die, it was the physician’s bipolar disorder calling the shots. “Suicidal persons are succumbing to what they experience as an overpowering and unrelenting coercion in their environment to cease living,” writes sociologist Menno Boldt. “This sense of coercion takes many familiar forms: fear, isolation, abuse, uselessness, and so on.” If we accept that suicide is not voluntary, says Boldt, “the ethical question of the right to suicide becomes largely academic.” Because the suicidal person is psychologically coerced, Boldt implies, physical coercion is justified as a protective measure taken on behalf of someone incapable of protecting himself—the same reasoning by which parents assume responsibility for their children.
At the bottom of such arguments is the widespread opinion that, as the medical historian Ilza Veith has put it, “the act [of suicide] clearly represents an illness.” Finding suicidal people mentally ill has practical implications. Although standards vary from state to state, most involuntary commitment statutes specify that the individual must be considered dangerous to himself or to others and also mentally ill—criteria to be determined by the admitting psychiatrist. Although efforts by civil libertarians to abolish involuntary commitment have made it more difficult, suicidal persons are the only people who may be held against their will for weeks, months, or even years on the sole basis of what they “might” do in the future rather than what they have done in the past—and not to others but to themselves. One Arizona woman spent fifty-eight years without comprehensive review in a state mental hospital after a suicide attempt. “If a sociologist predicted that a person was 80 percent likely to commit a felonious act, no law would permit his confinement,” comment the authors of the article “Civil Commitment of the Mentally Ill: Theories and Procedures” in the Harvard Law Review. “On the other hand if a psychiatrist testified that a person was mentally ill and 80 percent likely to commit a dangerous act, the patient would be committed.” Szasz offers another analogy: “If a middle-aged lady goes to the doctor with a terrible gallbladder and says, ‘I really don’t know what to do. Should I have it out or shouldn’t I have it out?’ and the doctor can’t stand it, restrains the patient, takes her to the hospital, and has the gallbladder out, you know what will happen to the doctor!”
To Szasz the logic of suicide prevention is flawed from the start; he believes that mental illness is a myth invented by the mental health professions to consolidate their power and to justify coercive interventions. But even if one accepts the existence of mental illness, the difficulty of drawing the line between sickness and health is strikingly illustrated by the “expert” testimony of opposing psychiatrists in court trials. While one attests to the defendant’s sanity, the other may just as persuasively insist that the defendant is insane. “If everyone who evinces some abnormality is to be regarded as mentally ill, there would hardly be a normal person left among the educated; all of us carry a secret fragment of a neurosis (and perhaps even the makings of a psychosis),” wrote psychiatrist Wilhelm Stekel in 1910. “I think it is the lazy way out to say, in order to relieve our consciences, that all suicides are ill, psychologically inferior persons who are no great loss anyway.”
Ever since 1763, when the French physician Merian asserted that all suicides were deranged, there has been a running debate over exactly what percentage of suicides might be considered mentally ill. As previously mentioned, current thinking maintains that about 90 percent of completed suicides suffer from some sort of psychiatric disorder, a figure that to a good many clinicians seems high, but is, perhaps, not surprising, given that our definition of mental illness has steadily expanded over the past half century. The increasing associ
ation of suicide with mental illness has had the salutary effect of largely removing it from the realm of sin or volition—and may thus help reduce the stigma associated with the act. Yet calling suicidal behavior “sick” may also be an attempt to make ourselves feel better, by distancing us from an act that strikes a disturbing chord. “I remember dealing with my first suicidal patient. I found it very difficult to understand that a person could really choose this,” says psychologist Nancy Kehoe. “I had to go out for a long walk and try to take in how much pain that person must feel to want to take his own life.” Now, dealing with suicidal patients, “I let myself get in touch with the times I’ve felt pretty desperate, the fleeting moments of driving down the turnpike and wishing a truck would hit you. We’ve all had those moments where we say, ‘Enough—I can’t take it anymore.’”
The diagnosis of mental illness is especially suspect when it comes to self-destruction. “The argument connecting suicide and mental illness is tautologically based upon our cultural bias against suicide,” Zigfrids Stelmachers, director of a Minneapolis prevention center, has said. “We say, in essence, ‘All people who attempt suicide are mentally ill.’ If someone asks, ‘How do you know they are mentally ill?’ the implied answer is ‘Because only mentally ill persons would try to commit suicide.’” For many years the Los Angeles Suicide Prevention Center reflected this bias, listing one of the symptoms of mental illness as “functional changes in which there is less achievement than usual of life-preserving and other valuable goals.” A Harvard University study giving doctors edited case histories of completed suicides found that the highest estimate of mental illness when a sample had been diagnosed before suicide was 22 percent. Afterward the highest estimate was 90 percent.
“Suicide is pre-judged by the medical model of thought,” wrote Jungian analyst James Hillman in Suicide and the Soul. “It can be understood medically only as a symptom, an aberration, an alienation, to be approached with the point of view of prevention.” The analysts’s goal, he stated, was not to be for or against suicide but to explore “what it means in the psyche.” Believing suicide to be an attempt at transformation, Hillman observed that the analyst who tries to prevent suicide with tranquilizing drugs or confinement might be depriving the person of what might be the most significant experience of his or her life. “The analyst cannot deny this need to die. He will have to go with it. His job is to help the soul on its way. He dare not resist the urge in the name of prevention, because resistance only makes the urge more compelling and concrete death more fascinating.” This emphasis on the soul rather than on the body, on the spiritual rather than on the medical, on exploration rather than on prevention, “may release the transformation the soul has been seeking. It may come only at the last minute. It may never come at all. But there is no other way.” Paradoxically, implied Hillman, not preventing suicide is the most effective form of suicide prevention. “By preventing nowhere, the analyst is nevertheless doing the most that can be done to prevent the actual death. By his having entered the other’s position so fully, the other is no longer isolated. He, too, is no longer able to break freely the secret league and take a step alone.”
The notion that a “death experience” or even death itself may provide a necessary “transformation” for the patient fascinates a few therapists, disgusts others, and, in either case, is dismissed as irrelevant in the clinical situation, an attitude expressed by one therapist who, scoffing at the right to suicide, points out, “No therapy can work with a corpse.” In a review of Hillman’s book, Robert Litman maintained that if philosophical and ethical theory are to have any relevance to the clinician, they cannot be developed apart from the clinical setting. Yet can clinical practice be developed apart from philosophical and ethical issues? Szasz writes:
In regarding the desire to live, but not the desire to die, as a legitimate human aspiration, the suicidologist stands Patrick Henry’s famous exclamation, “Give me liberty, or give me death!” on its head. In effect, he says, “Give him commitment, give him electroshock, give him lobotomy, give him life-long slavery, but do not let him choose death!” By so radically illegitimizing another person’s (but not his own) wish to die, the suicide-preventer redefines the aspiration of the Other as not an aspiration at all: the wish to die becomes something an irrational, mentally diseased being displays or something that happens to a lower form of life. The result is a far-reaching infantilization and dehumanization of the suicidal person.
Perhaps in an ideal world people would not want to die, but as Stelmachers says, “Some of the things that happen in these people’s lives give them pretty rational reasons for ending their lives.” If the cry for help can be translated “help me live,” it can also be translated “help me die.” “A totally open therapeutic relationship must make room for everything, including suicide,” writes philosopher Peter Koestenbaum. “Only in such a way can the freedom of the patient be recognized and nurtured.” Making room for suicide does not mean a clinician must set up suicide facilitation services in a prevention center or refuse treatment to a ten-year-old who has tried to hang himself—or encourage a patient with bipolar disorder to wean himself from lithium—but that he must acknowledge the possibility of suicide at least as much as he fears it. “If the person says, ‘I’m going to kill myself,’” says Stelmachers, “one way to respond is to say, ‘Well, maybe suicide is the best way out for you, but let’s talk about it first.’ This says many things to the person. . . . It says, ‘I really am interested in you and your problems. Even more than in preventing suicides!’ It also negates a sneaking suspicion he might have had about himself that he must be crazy to even consider such an act.” Psychiatrist Herbert Brown, commenting on the physician’s responsibility to the suicidal patient, says, “Our responsibility might be seen as an obligation to genuinely engage the patient and then to help to open him or her to a truly free choice as a whole and separate person, a choice that may be suicide.”
I recall attending a conference on suicide sponsored by Harvard Medical School and the Cambridge Hospital, when the ethics of prevention came up: “Do we have the right to say no?” wondered an audience member. There were appreciative chuckles; it is among the oldest and, by clinicians, least seriously discussed topics in suicide. “Tough question,” commented the late psychiatrist John Mack. “Shall we refer that one to God?” More chuckles. “We have a right to take a different position,” continued Mack. “Our responsibility as clinicians is to choose life.” Another panel member spoke up: “I think the philosophical answer is different from the clinical one.” Until they are part of the same answer, the study of suicide and its prevention may never be complete.
5
THE RIGHT TO DIE
I
A FATE WORSE THAN DEATH
AFTER MOST SUICIDES, friends and family may feel guilt because they could not prevent the death. Billie Press felt guilty that she could not help her father kill himself. After most suicides, friends and family grieve because their loved one chose to die. Billie grieved because her father wanted to end his life but couldn’t. After most suicides, friends and family believe their loved one died too soon. Billie believed her father died too late. In most suicides the tragedy is that someone died an “unnatural” death; for Billie the tragedy was that her father died a “natural” death.
When Billie’s father, Bill, retired as head proofreader of the New York Times at eighty, he could look back on a full life. He had worked on newspapers for more than fifty years. A well-read man, he was fond of quoting Shakespeare and had an old-fashioned, courtly manner of speaking. He loved to sing—in the shower, in the car, or with the barbershop quartet of Times employees he had organized. After his retirement he moved in with his eldest daughter, Billie, a child development specialist, and her family in a Boston suburb. He read books, watched television, and worked in the garden. He joined a Golden Age club and went on excursions to museums and the theater. “He was so gallant,” Billie, who was named for her father, to
ld me. “He was one of the only men in the club, and on trips he always allowed all the women onto the bus first. By the time he got on, the only seats left were in the back, and his guts would get jounced up until his stomach hurt.”
Although Bill had had a heart attack when he was fifty-eight, at a checkup at age seventy-five his doctor had marveled at what excellent shape he was in. But now his eyesight, hearing, and memory grew weaker. Cooking on the gas stove, he couldn’t see well enough to tell when the flame was low; bending over for a closer look, he often singed his eyebrows. Scissors and tape would disappear, and when his daughter asked him where they were, Bill could never remember where he had left them. “His physical condition declined,” recalled Billie, “but he still had a wonderful brain and a marvelous sense of humor.” Although he was often lonely, Bill worked to keep up his spirits. One day his teenage granddaughter asked, “Poppy, isn’t it terrible to be old?” Bill shook his head. “Oh, no,” he said. “Not when you live with people you love.”
At the age of eighty-five, the night before his granddaughter’s wedding, Bill had a stroke and a heart attack. After six months of rehabilitation he was hopeful of a complete recovery when a second stroke left him paralyzed on his right side, unable to walk, and incontinent. Although he wanted to come home to live, his daughter and son-in-law could not afford round-the-clock nursing care. After much discussion and with great reluctance, Bill was moved from a cozy bedroom in his daughter’s house to a cramped, drab room in a local nursing home.
November of the Soul Page 53