Thursday, March 4, 2010

Suicide Prevention and Assisted Suicide.

There's a clinical reason why advocates prefer to call it aid in dying and not assisted suicide; they recognize that there's a difference between grief, a normal and emotional reaction to trauma, and depression, an illness that with medical and psychiatric treatment can be addressed.

Yesterday Michael Gerson at the Washington Post had a well-meaning column on the prevalence of suicide in the U.S. He starts the column by noting a number of celebrities who have recently committed suicide and works to explain what it is and what signs we can detect in loved ones who may be isolated, depressed and suicidal.

Suicides outnumber homicides in America, making self-hatred more lethal than violence by others. In 2009, the Substance Abuse and Mental Health Services Administration reported that 1.1 million Americans had attempted suicide during the previous year. By one estimate, "successful" suicides have left behind 4.5 million family survivors, who live with ghosts each day.

He encourages us to reach out to those in our community who may be depressed and at risk (The National Suicide Prevention Lifeline is 1-800-273-TALK.) It's not a bad column and while Gerson is not my favorite columnist, I am pleased to see those with soapboxes addressing a tragic issue.

But then along comes Wesley J. Smith who takes up Gerson's column and does what he does best: applies absolutist and convoluted pseudo-rational thinking to conflate the idea of depression (which can cause suicide) and terminal disease. To Gerson's sentence, "For those who yield to the logic of the nightmare, it is difficult to be harsh or judgmental. Empathy, like grace, can reach to the grave," Smith writes:

But that doesn’t mean we shouldn’t criticize those pushing suicidal people toward different conclusions about self destruction. And that’s where Gerson misses the obvious–as so many similar articles do these days. There is a multi million dollar suicide promotion campaign ongoing in the country and around the world–aided and abetted by the mainstream media–that says that if you are sick, or disabled–suicide is empowering and rational. Indeed, it claims that such suicides are so right and worthy of being honored that the state should permit third parties to help make sure the suicidal person is made dead. As far as I am concerned, that is the express and implied fundamental message of assisted suicide advocacy.

It seems to me that society can’t be half against suicide and half for it. You can’t have suicide prevention and assisted suicide promotion at the same time. The former message is subsumed by the latter. Suffering suicidal people don’t think that the quality or reasons for other guy’s suffering makes suicide okay, but theirs does not.

It's an old rhetorical schtick for Smith - and other "pro-life" activists - who make their living subtracting nuance from bioethical debates for their own ideological purpose. For decades, Smith has been writing about "the culture of death," dropping anyone into that category he can and pretending that a growing segment of society is out to kill minority groups like the disabled, the brain dead, the terminally ill, the suffering, the elderly.

By confusing suicide and clinical depression with aid in dying, he capitalizes on the common use of the term "assisted suicide" to attack aid in dying supporters, much as those who deny evolution conflate the scientific term "theory" with the common use of the term meaning "unproven supposition." ("Theory" to scientists means proven fact that needs to have some details flushed out.)

I'm not personally opposed to the use of the term assisted suicide (for the medical practice as it is legalized and strictly regulated in Washington and Oregon) but I do contest the way that Smith and others use it: to perpetuate the terminal suffering of others. As medical advancements have created new definitions of death (end of a heart beat? end of consciousness? end of breathing?) so too has it created new definitions of suicide. (And pregnant, but that's another post. The definition of murder has long been understood to have many meanings.) Ignoring this fact is an absolutist, and frankly, unworkable approach to contemporary bioethical debates. Pretending that we live in a less complicated world does not move us toward ethical discussions of medicine.

This work of Smith's is irresponsible (and disingenuous) for a host of reasons, most importantly because it allows those who oppose assisted suicide to think they are addressing the important issue of suicide. And it removes the focus among his constituents from addressing the very real problem of depression to fighting the right that terminal patients should have to determine how their disease will end their lives.

The aid in dying movement in the U.S. seeks to make Death with Dignity (as the laws in Washington and Oregon are called) legal: a terminal patient with six months to live, one who is going to die because of multiple sclerosis or Lou Gehrig's disease, who is determined of sound mind and who has received the opinion of two doctors, to receive a lethal dose of medication from their doctor which they may then choose to take themselves to end their life before the disease makes it unbearable.

In every case of Death with Dignity, immanent death is certain. The patient has endured most likely years of fighting their disease with a concerted will to live. The patient does not want to die but they have realistically accepted the fact that their disease will soon kill them. Their grief at the loss of life has an absolute physical cause. And their simple objective is singular: to end suffering.

Smith's point that society is pushing isolated individuals to suicide is only correct in that we fail to distinguish the serious difference between suicide-causing depression, and say, a bad day or the natural process of grief that follows a death or an end of marriage. "I'm depressed," we say when our car breaks down. "How depressing," we say when an election is lost or a friend snubs us, detracting semantically from our ability to discern the downward spiral of serious grief that can lead to dangerous depression.

Grief is an emotional process that facilitates recovery from a loss. Depression is an illness. There's a significant and important difference that Smith misses. What he calls "half against suicide and half for it" is a false construct. "The culture of death" is a rhetorical tool used to create fear among the vulnerable and to assert influence over the easily swayed. It takes autonomy away from various patient groups like women, the disabled, the ill. "Culture of death" fear-mongering is prevalent among those who wish to assert their largely religious ideology on our pluralistic society; it seeks power and it imposes suffering.

Accepting death, as Death with Dignity patients do, is not a depression that can be cured. It is a factual analysis of the physical body in immanent, unpreventable demise. Yes it's sad, for both family members and the patient. But statistically, Death with Dignity does not leave behind the same scars as suicide from depression does.

Smith and others only distract from the serious consideration that must be given to treatment of depression.

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