Friday, March 30, 2012

How the Suicide Prohibition Hurts Non-Suicidal People

In Anglo-American law, recent decades have seen a shift in the treatment of suicide. Suicide was once treated as a crime for which one could be punished if unsuccessful. Now, suicide is treated as the consequence of a mental illness from which one must be "rescued," by coercive means if necessary, for one's own good.

I have argued that there is still a de facto suicide prohibition, for the following reasons:

  1. People who attempt suicide and fail are often imprisoned in a hospital as a result.
  2. People who attempt suicide are forcibly "rescued" and brought back to life against their will, if possible - sometimes to a state of very low quality of life, such as akinetic mutism.
  3. Those who express a desire to commit suicide are often imprisoned in a hospital as a result; this process is much more humiliating and degrading than outsiders might realize.
  4. The drug prohibition (drug war) means that barbiturates are unavailable - barbiturates being the only means of suicide considered humane enough to be used in states that allow physician-assisted suicide for terminally ill people.
  5. Helping another person to commit suicide is prosecuted as a crime in all but the most limited situations in the few states that allow physician-assisted suicide. Suicide is the only act that is not itself a crime, but which assisting another person to commit is a crime.

The suicide prohibition, as outlined above, is often said to be in the best interests of the suicidal persons themselves - a paternalistic justification that does not sit well with those who value personal liberty. I have argued that it would be much better for us to be allowed to kill ourselves securely and peacefully, with a modicum of dignity.

What I wish to discuss in this post is the ways in which the suicide prohibition harms even people who are not themselves suicidal.

1. Coercive Care Costs Money

Forcible treatment of people who attempt suicide in emergency rooms and hospitals costs between one billion and four billion dollars per year in the United States. This unwanted treatment does not benefit anyone and harms taxpayers and the entire medical system.

2. Dangerous Methods Create Externalities

People denied access to comfortable means of suicide (like barbiturates) will often use less reliable means that endanger bystanders, such as chemical reactions inside enclosed areas and traffic collisions. In addition, common means of suicide such as standing in front of a train, shooting oneself at a shooting range, or jumping from heights are emotionally painful for those who witness or involuntarily participate in the event.

3. We Take Our Organs With Us

When a person commits suicide in our system, he or she must do so in a manner that avoids contact with hospitals, preventing him or her from donating healthy organs to those who need them. Over 6,000 people die every year in the United States waiting for an organ; over 34,000 people commit suicide every year, taking with them healthy hearts, lungs, livers, eyes, and skin that could be used to save the lives of people who want to live. In other words, the suicide prohibition kills 6,000 people per year who want to live. Does society's interest in forcing a person to stay alive when he wants to die really justify allowing another person to die when he wants to live? Should society prevent suicidal people from saving the lives of others who actually want to live?

4. The Fantasy Of Rescue Tempts Attention Seekers

The practice of "rescuing" people who attempt suicide by forcibly treating them tempts people who don't really want to die, but are in pain and crave attention, to endanger themselves. If suicide were legal and easy, and suicide attempters were not interfered with, the signalling value of a suicidal gesture would be destroyed. By destroying the signalling value, hence the incentive to self-harm, we could better protect those who don't really want to die. As it is, the fantasy of rescue tempts those who don't really want to die into harming themselves, hoping for a rescue that might not come. Undoubtedly, thousands of people who didn't really want to die, die from suicide every year; if reliably lethal barbiturates were available and "rescue" unheard-of, non-suicidal people would have much less social incentive to engage in dangerous, ambiguous self-harm events.

5. We Can't Say Goodbye To You - Or Talk It Over

Friends and family left behind by a suicide often complain that the suicide didn't give any warning, and didn't say goodbye. Unfortunately, even if a suicidal person wants to talk over his decision with family and friends or say goodbye, he cannot, because he risks imprisonment in a hospital. If suicide were legal, it would be much less unexpected and tragic for those left behind, and suicidal people would be able to rationally talk over their decision with other people. As it is, we're on our own.

Wednesday, March 21, 2012

Tinkerbell Ethics Part I

This is the third post in a series exploring the moral and practical importance of pleasure and meaning; the first is Enhanced Running, the second is The Pleasure You Have Been Denied.

Her wings would scarcely carry her now, but in reply she alighted on his shoulder and gave his nose a loving bite. She whispered in his ear "You silly ass," and then, tottering to her chamber, lay down on the bed.

His head almost filled the fourth wall of her little room as he knelt near her in distress. Every moment her light was growing fainter; and he knew that if it went out she would be no more. She liked his tears so much that she put out her beautiful finger and let them run over it.

Her voice was so low that at first he could not make out what she said. Then he made it out. She was saying that she thought she could get well again if children believed in fairies.

Peter flung out his arms. There were no children there, and it was night time; but he addressed all who might be dreaming of the Neverland, and who were therefore nearer to him than you think: boys and girls in their nighties, and naked papooses in their baskets hung from trees.

"Do you believe?" he cried.

Tink sat up in bed almost briskly to listen to her fate.

She fancied she heard answers in the affirmative, and then again she wasn't sure.

"What do you think?" she asked Peter.

"If you believe," he shouted to them, "clap your hands; don't let Tink die."

Many clapped.

Some didn't.

A few beasts hissed.

J. M. Barrie, Peter Pan, 1911

1. Peter Singer's Drowning Child

You walk past a shallow pond on your way to work, and notice a child drowning in the pond. You could easily rescue the child at no danger to yourself, but you'd get your clothes muddy. Do you have a moral duty to rescue the child?

Peter Singer reports that his students unanimously think there is such a duty - muddy clothes are no excuse to fail to rescue the child. Indeed, few argue that there is not such a duty. Perhaps more importantly, even those who argue that there is not such a duty (as I will, in part, do) would not hesitate for a second to rescue the child if faced with the situation in real life, and would harshly judge others who failed to do so. As Sharon Olds puts it, "Don't speak to me about/politics. I've got eyes, man."

"Having eyes," in Olds' words, is equivalent to being aware of, and moved by, the immediate, serious consequences of our actions. We are moved by pity for the child, for whom we presume continued existence would be a good thing and for whom drowning would be undoubtedly painful, and by pity for its family, which we presume exists. We are very moved by the near suffering of near others. We can't get around it.

The drowning child is an artificial situation in this way: one can take a single action and permanently improve the conditions for another. As I will argue, this is rarely the case in actual ethical dilemmas faced by people.

A consequentialist objection to saving a drowning child is that everyone will assume you're the lifeguard from now on, and adjust parenting accordingly.

2. Risk Compensation and Other Remote Causes

Do improved automobile safety features save lives? Not necessarily. Keeping all variables constant, a safety measure (such as anti-lock brakes) will reduce risk.

But the problem with reality is its tendency to respond to changes, rather than staying tractably constant. Risk compensation refers to the observed tendency of people to adjust their behavior toward more risk-taking when they perceive a reduction of risk - such as when a safety feature is salient. A number of studies have demonstrated that anti-lock brakes, for instance, do not decrease fatalities, because drivers adjust their driving styles toward more risk-taking behaviors.

Behavioral adaptation in the form of risk compensation is an example of an opponent process. The proximate effect of introducing a safety feature (or, really, doing anything to improve someone's life) is the near, tangible improvement; the more remote effect, entirely predictable, is that the effected folks will respond to the feature or improvement, often in perverse ways.

The risk compensation treadmill is a similar opponent process to the hedonic treadmill, otherwise known as adaptation level theory. Brickman et al. in 1978 found that lottery winners were no happier a year after winning the lottery than non-winners, and took less pleasure in "mundane events." As Baumeister et al. put it in the paper "Bad is Stronger than Good" (2000), "The euphoria over the lottery win did not last, and the winners' happiness levels quickly returned to what they had been before the lottery win. Ironically, perhaps, the only lasting effect of winning the lottery appeared to be the bad ones, such as a reduction in enjoyment of ordinary pleasures."

It feels nice to help people, but when we consider the long-term and not just immediate effects of our help, the seemingly innocent idea of help becomes much murkier.

This focus on remote, but foreseeable, consequences is not so far removed from common sense. Once I fed a kielbasa to a hungry coyote that was wandering around my neighborhood. This certainly pleased the coyote, but most moderns agree on a strict policy of non-interference when it comes to wild animals. When chiding me for this action (as I chided myself), you might point out that the kielbasa might encourage the coyote to come back for more, putting its life at greater risk; that the coyote would be less motivated to seek more species-appropriate food, like insects and opossums; that the gift of calories might translate into more baby coyotes, putting even more pressure on wild resources; etc. We take this policy so seriously that when camping in the Sierras, we not only avoid intentionally feeding bears, but hide our food away in bear hangs or bear vaults - not for our own direct safety, but to protect the bears from our food that they very much would like to sample. "A fed bear is a dead bear," we say - bears who get a taste for human food tend to pursue it vigorously, and hence to interact with humans in a way that makes humans feel entitled to shoot them.

The "fed bear is a dead bear" slogan's very existence is evidence that we need to be reminded of far consequences, which without such mnemonics are generally overwhelmed by near feelings. This is nowhere more true than with humans as both near and far victims of our decisions.

3. Treadmill World

The treadmill nature of the world has important consequences for morality. Generally, we want to help, and not hurt, others. If the hedonic treadmill means that our temporary help won't have much long-term effect on happiness and might even be damaging, doesn't that also mean that hurting people won't have much long-term effect, or might be helpful?

The "hedonic treadmill" is often misrepresented as being symmetric for good and bad events, but as demonstrated by the Brickman research on accident victims and lottery winners, it is not. We recover from bad events much more slowly and less completely than from good events. From the Baumeister 2000 paper:

In contrast to the transitory euphoria of good fortune, the accident victims were much slower to adapt to their fate, Brickman et al. (1978) found. They rated themselves as significantly less happy than participants in the control condition. The victims continued to compare their current situation with how their lives had been before the accident (unlike lottery winners, who did not seem to spend much time thinking how their lives had improved from the bygone days of relative poverty). Brickman et al. called this phenomenon the "nostalgia effect" (p. 921). [Emphasis mine.]

Singer presents a moving example of a victim of the hedonic treadmill in the body of the drowning child essay:

Consider the life of Ivan Boesky, the multimillionaire Wall Street dealer who in 1986 pleaded guilty to insider trading. Why did Boesky get involved in criminal activities when he already had more money than he could ever spend? Six years after the insider-trading scandal broke, Boesky’s estranged wife Seema spoke about her husband’s motives in an interview with Barbara Walters for the American ABC Network’s 20/20 program. Walters asked whether Boesky was a man who craved luxury. Seema Boesky thought not, pointing out that he worked around the clock, seven days a week, and never took a day off to enjoy his money. She then recalled that when in 1982 Forbes magazine first listed Boesky among the wealthiest people in the US, he was upset. She assumed he disliked the publicity and made some remark to that effect. Boesky replied: ‘That’s not what’s upsetting me. We’re no-one. We’re nowhere. We’re at the bottom of the list and I promise you I won’t shame you like that again. We will not remain at the bottom of that list.’

What Boesky discovers is yet another treadmill: the treadmill of social status. Rising in status means changing comparison groups; we are wired to care about our position within the group we interact with, not about our absolute position among humans on Earth.

Singer imagines we could stop caring so much about the competitive side of comparative welfare and care more about the welfare of others: "Not only does it fail to bring happiness even to those who, like Boesky, do extraordinarily well in the competitive struggle; it also sets a social standard that is a recipe for global injustice and environmental disaster," he says. "We cannot continue to see our goal as acquiring more and more wealth, or as consuming more and more goodies, and leaving behind us an even larger heap of waste."

The main problem with this (aside from the problem of altering basic human nature, which I'm sure will prove quite simple to do) is that it offloads one's own narrative, self-interested conception of the Meaning Of Life onto the meaning-sense of those we would help.

But if our own native meaning-sense is suspect, what about the meaning-sense of other human beings?

4. One Fewer Meaning

I contend we are both atheists, I just believe in one fewer god than you do. When you understand why you dismiss all the other possible gods, you will understand why I dismiss yours.
Stephen F. Roberts

What is consistent among institutions that have been passed down for many generations is that they all assign life-justifying meaning to specific stories, beliefs, or struggles. The Christian is certain that his God is the true God, and that he is on the right side of his religion's struggles, whether against atheists, Muslims, or fellow Christians of rival sects. It is to this worldview that he runs when he is reminded that he is mortal; his connection with eternal things is what makes him able to psychologically handle the knowledge that he will die.

Every tribe (however broadly defined) stands for a separate worldview, a separate story of eternal connection and meaning, and each member of a tribe imagines victory (perhaps posthumous) over his tribe's enemies. This is a very conservative, even provincial, worldview; it has the drawback of being false in each individual case. Each tribe member believes in his own tribe's story of meaning, to the exclusion of others.

Unfortunately, the pluralistic response to meaning (what I take Singer to be offering, and what I also take liberalism broadly to be offering) is no more true than each conservative, tribal worldview.

Liberalism imagines that all the meaning-stories can be true, at least for each believer; this is its own kind of meaning story. But the pluralistic idea that all meaning-stories can be true includes an implicit recognition that none of the stories have much truth value, at least in the objective sense.

Thursday, March 15, 2012

The Cruelty of Medicine

Should the medical system be concerned with how people feel about their interactions with the medical system? "Patient satisfaction" with medical care has been tracked in recent surveys and studies, often with unanticipated results: for instance, patients with the highest reported satisfaction with medical care are more likely to use more medical care - and more likely to die. Are the feelings of patients something we should care about enough to measure and track? Or are they totally irrelevant?

Oncology nurse Theresa Brown argues in the New York Times that patient satisfaction is irrelevant. Beginning with a description of a horribly painful medical procedure known as pleurodesis, Brown argues that the most effective medicine is often painful.

Brown seems to understand that there is a trade-off between suffering and efficacy. But she does not seem to understand that patients might well wish to trade longer lifespan for less suffering. In fact, that is exactly what doctors facing terminal illness frequently do - avoid the painful, dehumanizing treatments that might possibly buy them more time, in order to enjoy the time they have left (or just to avoid prolonged suffering).

My problem with the medical system is that built into it is a core assumption that longer lifespan is the only concern - that there is such a thing as "health," and all other concerns are properly subjugated to this concern, except - perhaps - in cases of terminal illness. Brown says that "a survey focused on 'satisfaction' elides the true nature of the work that hospitals do. In order to heal, we must first hurt." Some patients may wish to go through painful procedures if it is the only way to prolong life; but this should not be the assumption in every case, and if medical professionals are surprised that people are unsatisfied with torturous-but-life-prolonging medical care, that demonstrates the depth of their bias. One wonders how the average psychiatric patient would rate his or her "satisfaction" with the "care" applied to him or her by force; but non-psychiatric medical care is not another kind of thing, but on a spectrum with psychiatric "care."

Humans have many concerns; one of them is often lifespan, but that is not the sole value that most people care about. I have noticed that many medical professionals are quick to defend awful, dehumanizing procedures on the ground that they save lives - even if the person being "saved" does not want the treatment. I think that measuring "patient satisfaction" is a sideways way of gauging the degree to which painful, degrading medical treatment is truly voluntary.

Our medical systems in the developed world are an arm of government, even where medicine is for-profit and not socialized. Doctors are given a huge amount of police power, such as deciding what treatments or drugs their patients are allowed to access. I suspect that a truly free market in medicine - one in which doctors were advisers only, and not cops - would result in both lower lifespan and greater "patient satisfaction" (happiness). That's only a bad thing if you think lifespan is the only goal, and that everyone should be forced to pursue it.
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