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Wednesday, June 22, 2011

The Shame of Medicine: Is Suicide Legal?

What do we mean when we say an act is legal? We mean that we are free to think and speak about it, and plan and perform it, without penalty by agents of the State. Legal acts—for example, cooking and walking—are matters of indifference to the law. Suicide is not. Accordingly, suicide is illegal or potentially illegal.

Today most people in the West regard killing oneself as an abhorrent temptation and avoid thinking about it. When they do think about suicide, they view such thinking as prima facie “abnormal” and readily accept the concept of “suicidal ideation,” a common medical term for thoughts about suicide.

We do not talk about “sex ideation” or “eating ideation” or “vacation ideation.” Why do we need and make up the special term “suicidal ideation”? To enable us to categorize it as a “psychiatric symptom,” a hidden manifestation of “serious mental illness” and “dangerousness to self and others,” a violation of the mental health laws, punished by incarceration in a mental health facility, and augmented by coerced psychiatric drugging. Failed suicide is also illegal, punished by similar psychiatric sanctions. The psychiatrist is regarded as an expert in “evaluating” and “detecting” this symptom and conducting himself accordingly as a coercive agent of the State. Although the psychiatrist who functions thus is an adversary of the nominal patient, law, medicine, and the public define and regard him as a “caring doctor,” an ally of his involuntary “patient.”

Merriam-Webster defines “ideation” as a noun: “the capacity for or the act of forming or entertaining ideas <suicidal ideation>.” This conceptualization is both the cause and the consequence of the psychiatric view of suicide as psychopathological. Thinking about sex, eating, or vacation is “reflection,” “longing,” “planning,” “pondering,” or simply “thinking”—not “ideation.” The psychiatric premise that thinking about suicide is a symptom of the disease “clinical depression” is justificatory rhetoric: Thinking about suicide is simply thinking. It is also, as Nietzsche famously observed, a tool of self-preservation: “The thought of suicide is a powerful solace: by means of it one gets through many a bad night.” The difference between the psychiatric and Nietzschean concepts of thinking about suicide illustrates the problem: For psychiatry it is a disease to be forcibly prevented and treated; for Nietzsche it is a remedy to be appreciated and understood.

The unlawfulness of suicide is further affirmed by the illegality of assisting the act. Assisting legal acts is legal. Assisted cooking, for example, is a common practice, performed and provided by family, friends, restaurants, schools, and other institutions. However, assisted suicide is a criminal offense unless the assistance is provided by a licensed physician in a jurisdiction in which specific legislation explicitly permits it: Then it is a medical service. The truth is that the only thing that makes physician-assisted suicide a medical service is that the means used for it is a prescription for a barbiturate, a document the law treats as if it were a prescription for insulin for a diabetic. Suppose doctors assisted suicide by shooting, stabbing, or strangling us at our request. Would we still call it “physician-assisted suicide”? Would we still classify and condone it as a medical treatment?

Socrates, let us recall, died of assisted suicide: He killed himself by ingesting a lethal dose of a substance the Greeks called pharmakon—a word that means both medicine and poison—procured for him by others. Socrates did not need medical help to kill himself. Why do we act as if we do? Because we like to die peacefully with the help of a drug that puts us to sleep forever; and because, at the same time, we wage wars on drugs especially useful for this purpose and suborn physicians to bootleg them. In the absence of prescription laws—and, more generally, of drug laws—there would be no need for, and no special problem of, physician-assisted suicide.

Although the air we breathe is polluted with anti-suicide propaganda, no amount of psychiatric smoke can obscure our knowledge that at bottom suicide is a solution. Authoritatively repressed, this truism reemerges as humor: “I was depressed last night so I called Lifeline. . . . Got a freakin’ call center in Pakistan. I told them I was suicidal. . . . They got all excited and asked if I could drive a truck.”

Suicide and the Identity of the Psychiatrist

Contemporary discourse about suicide seems to be about understanding the individual who says he intends to kill himself or to whom such intention is attributed by others. In fact the true subject of such discourse is the professional identity of the psychiatrist as bona fide physician, contingent on his presumed medical competence and legal duty to “save lives,” especially the lives of persons who do not want to live.

As a phenomenon, suicide is ancient. As medical problem it is recent. The medicalization of homicide—both auto- and heterohomicide—is an aspect of the birth and growth of pharmacracy and the Therapeutic State. Medical historians William F. Bynum and Michael Neve observe: “By early Victorian times, suicide had been more or less completely medicalized.” What do these writers mean when they use the term “medicalization?” They mean that melanoma is a medical problem by nature, whereas masturbation is a medical problem by culture. One is a disease intrinsically, the other is a disease by imputation. That is why we do not talk about the medicalization of bodily diseases, such as infections and malignancies, but do talk about the medicalization of mental diseases, such as dangerousness and depression.

Understanding a person and coercing him are mutually antagonistic and incompatible functions and roles—and we all know this. I have long objected to the social expectation that the psychiatrist be both his patient’s ally and adversary, and the psychiatrist’s willingness to play both roles. The dilemmas and depravities of double agency are intrinsic to psychiatry and will not go away. Honest psychiatrists cannot help but confront it. Hapless patients are doomed to be injured by it.

That medicalization forms an integral part of the modern zeitgeist is obvious. Some 50 years ago I coined the term “Therapeutic State” and suggested that coercive psychiatric suicide prevention is one of its defining emblems. Opposing this revered ritual is a thankless task but a worthy goal.

“The time is out of joint—O cursed spite, / That ever I was born to set it right!,” soliloquizes Hamlet (act 1, scene 5, 188–190). For the lover of liberty and responsibility, the time always seems out of joint. Setting it right will always be a thankless task.

If suicide be deemed a problem, it is a moral and political problem, not a disease in need of diagnosis, prevention, punishment, or treatment. Managing suicide as if it were a medical problem will succeed only in debasing medicine and corrupting the law. Pretending to be the pride of medicine, psychiatry is its shame.