Saturday, 21 May 2016

Scattered Thoughts on a Hard Subject

Spurred by Masuma Rahim's thoughtful piece about the issue, I have been thinking about psychiatric assisted suicide. She points out that this is an issue it is "very difficult to have a settled opinion about". I don't yet have one, but it seems important to understand some of what is at stake. This is a list of thoughts. The topic may be triggering, and this post should be approached with that in mind.

1. Any debate about psychiatric assisted suicide concerns the question of whether there are ever circumstances in which people with mental health problems should be allowed to receive help to die.
2. If healthcare professionals are to have any role in this process, part of it must be in trying to provide the best possible assessment of whether a person can reasonably expect their life to improve.
3. Unless we think assisted suicide is always unconscionable, we have to accept that there exist reasons that bear on those cases in which it is not. Clarifying those reasons will help us think more clearly about the issue in general.
4. Whether or not mental health problems are "illnesses" is of no relevance to the question of whether psychiatric assisted suicide is morally palatable. The desire to die seems driven by the intensity, and particular quality, of individual suffering. It is not clear that this suffering is more real in cases where an illness exists. Whether or not a person wants to die is likely to be a function of whether they think their misery will persist.
5. A domain specific prohibition on assisted dying in psychiatry would appear to suggest that it is not possible for mental health service users to make reasoned choices about whether they can end their lives.
6. Psychiatry has a long history of "great and desperate cures", driven by desire to avoid feelings of hopelessness on the part of the doctor. How would we know psychiatric assisted dying isn't just the latest chapter of this ignoble tradition?
7. I have, in the past, walked on to a psychiatric ward and felt a chill at the idea that I could end up locked in a place that is organised almost entirely around the idea that I should be denied, at any cost, the freedom of killing myself.
8. To characterise this debate in terms of one group of people declaring another group "better off dead" is to fail to engage with the experiences of those who have advocated for their own right to psychiatric assisted suicide, or pursued it for themselves.
9. There is a particularly difficult balance to be struck between emotion and reason in this debate. We need to think calmly and clearly about psychiatric assisted suicide, but it is hopeless to try and avoid appeals to emotion. No-one can hope to understand what is at stake unless they take time to imagine what it is like to spend many years very seriously wanting to die. Equally no-one can hope to understand what is at stake unless they take time to imagine what it is like to lose someone to suicide.
10. We might wonder whether a policy like this would have a positive impact on the suicide rate. If people are aware that it is possible for them to die under medical supervision, that may reduce the intensity of some people's despair and desperation, making them less likely to kill themselves. Hope, even the paradoxical hope for death, might help people feel better.
11. Alternatively, a policy like this might increase the social visibility of suicide and diminish the taboo that surrounds it. This might lead to an increase in thoughts of death and more completed suicides, even in a sort of contagion as the idea occurs to more people. Legal protection would put suicide into the "pool" of acceptable solutions.

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