“No one helps solely in order to do good for someone else.” ― WHO and UNHCR, Mental health of refugees, 1996
By “suicide prevention,” this article refers to those forms that directly attempt to make the act of suicide more difficult or impossible, rather than interventions on the level of society such as the reduction of poverty.
Which alternative satisfies society's interests best: Maintaining the inaccurate appearance of protecting “the vulnerable” (“we are a moral society”), or actually taking into account the vulnerables' interests despite contrary outward appearance?
Ethical exploitation is when a broken, stigmatizing and marginalizing society engages in suicide prevention in order to save face at the expense of its suicidal victims' protracted suffering.
Suicide prevention provides the illusion of solidarity and “help” although, by its nature as the mere prevention of an act, it doesn't solve a single real-life problem that lead an individual to attempt suicide in the first place. Even worse, the individual is prevented from escaping a possibly dire future. A successful suicide not only ends a potentially long history of misery and suffering and precludes further suffering, but, in contrast to psychopathologization, can be a powerful way of directing people's attention to a serious social injustice when used as a form of protest.
Why does society stigmatize and discriminate against the “mentally ill,” thus making them even more suicidal, yet coerce them into existence? Is this population's existence nearly as undesired as their suicide? Could it be that it is primarily society's hypocrisy what keeps society from offering assisted dying to who are undesired anyway?
There are middle-aged and elderly suicidals who state that they have been wanting to kill themselves since their childhood. Could it be that, at this very moment, there are children out there who are suicidal and will be suicidal for their entire life? Could their suicide be rational in the sense that it would be a choice they would never have regretted—despite having a yet-incompletely developed brain?
Exhortations for psychiatrists and suicide preventionists
It is argued that a suicide attempt is a cry for help rather than an attempt to die. Why should we not question the assumption that betrayal of trust (Wipond, 2020), involuntary hospitalization, strip search, labeling with a psychiatric diagnosis, forced drugging, suicide means reduction and other types of paternalism and financial exploitation by “hospitals” (Rizo, 2021) are exactly the kinds of “help” suicidals are crying for so desparately?
Suicide prevention can be akin to locking a person into a torture chamber (incurable, unbearable condition) or a shark tank (stigmatization and bullying), and barricading every conceivable way out. While there may be the promise of “help” and a vague notion of “hope,” nobody will accept to be legally held accountable should the suicidal's life fail to improve.
Would you accept a job as a suicide prevention expert at a forced labor camp? Would you try to prevent the suicide of members of minorities that are persecuted and are at risk of being tortured in a dictatorship, arguing that their decision wasn't free and autonomous and that they were “depressed?”
Acknowledge minorities. Even when it is true that the lives of the majority of suicidals can be improved, do not be silent about the fact that there is a group whose lives cannot. Do not treat the latter as though they were part of the former or didn't exist to begin with. Is it ethical to assume that everybody is heterosexual?
Could it be possible that there are “brain disorders” that cause suffering similar in magnitude to that experienced under actual, real torture? And that there are individuals who are effectively being tortured in this sense? How is it ethical to keep them locked into their hell? How is it justifyable to belittle their suffering as being “only in their head?” How is it reasonable to assume that psychiatry was omnipotent, infallible and benevolent in its domain?
Do not degrade an individual to a slave of other people's emotional well-being, just as you shouldn't regard anyone as slave of someone else's sexual desires.
Do not suggest that there is consensus among professionals on the issue. Rather, admit that some professionals including psychologists and psychiatrists feel that some mentally ill people, or even every competent adult, should have the right to assisted suicide.
Since there is no large additional incentive for you to improve suicidals' quality of life as long as their suicide has been successfully prevented, there is a risk for suicide prevention to merely lock people into their suffering. How does suicide prevention avoid simply trading suicide for years of unbearable pain?
When from the absence of suicide the absence of grave suffering is concluded, suicide prevention may conceal or exacerbate suffering: In the presence of efficient suicide prevention, a very low suicide rate may be taken to suggest that severe suffering in society has been mostly eradicated. However, it is quite possible that suffering has actually increased substantially because suicidals were unable to end it and will not recover in all cases. Do not sweep real human agony under the carpet.
A successful suicide can make some people angry. From a psychological perspective, suicide prevention provides these individuals the opportunity of taking revenge by harming other members of the group the suicider was belonging to: they are stigmatized as “mentally ill,” deprived of their liberty and forced to continue living a potentially unbearable life. Thus, it may be with satisfaction and gratification that the prevention activist learns that a particularly gruesome and traumatizing attempt has been unsuccessful as a result of preventative efforts.
Avoid (unconscious) circular reasoning such as, “patient is suicidal because she is depressed, and depressed because she is suicidal.”
Avoid imprecise and misleading vocabulary such as “help” and “safety.” Instead, use clear and unambiguous language to communicate what you want. Example: “I want you to exist because that is in my best interest, e.g., to cover my ass. I do not care very much what that means for you in terms of your perceived quality of life, and whether the majority of humanity including myself would suicide in your place, too.”
Question the unintended effects of your interventions. Inasmuch resistance can be a response to oppression, suicide forums and the proliferation of suicide manuals can be a response to aggressive, coercive and uncompromising suicide prevention and the stigmatization of suicidals as necessarily irrational. Will some of the teenagers you successfully “protect” today be tomorrow's right-to-die activists?
Which is more “selfish”? A person ending their unbearable suffering, or demanding that someone else go on to suffer so you, who you are enjoying the privilege of a normal, average life, are spared of having to deal with a suicide?
Normally, self-interests of many people overlap well. However, when a particular person's self-interests do not overlap well with those of many other persons, that person is called “selfish.”
Do not confuse or interchange the terms “right” and “duty.” Do not call the duty to live, “right to life,” and do not insinuate that the right to assisted suicide was a duty to suicide.
It is true that suicidals often don't really want to die, but instead desire a better life. However, coercing them into life based on unfounded and naive “hope” and empty promises doesn't solve the problems that make them want to die. Just because suicide may not be the perfect solution doesn't mean that there exist better alternatives.
Consider how you are essentially pushing people into suffering or brutal suicides by restricting access to socially more acceptable means such as suitable chemical compounds.
Nobody will ever force a person to accept a million dollars like people are coerced into an allegedly precious life. Valuable things do not need to and will not be forced onto people. Do you need to be perfectly mentally healthy to take money for free?
To psychiatrists in particular
Do not arrogate to yourself the (exclusive) power of determination whether and to what extent an individual suffers. Do not arrogate to yourself the decision of how much suffering a particular individual is supposed to accept.
You report that some suicidal jumping survivors stated that they regretted jumping during the fall. Are you suggesting that they were of sound mind during the fall, but the period preceding the incident they were not?
You note that suicidals typically are highly ambivalent. A primitive “instinct” should not be assigned the same value as a reasoned, reflected and informed choice. Suicidals are well aware of their ambivalence, and are sometimes indeed critical of it. Why not leave it up to them to think about their ambivalence and choose how to interpret and deal with it rather than urging them in a particular direction?
Your communication with the public should be intellectually honest and ethical. Do not promote false beliefs by spreading half-truths. E.g., if you tell the public that 90 % of suiciders were mentally ill, do not be silent about the fact that that does not necessarily mean that their choice was not reasoned and not thought out well. It is safer to say that for 90 %, it was not known whether they were rational. As for depression, do not be silent about the discussion around depressive realism (Reshe, 2020). Psychiatric uncertainty should not translate into the deprivation of suicidals' freedom and rights, even when that is convenient and safe for psychiatrists.
Do not speak on behalf of the “mentally ill” or other populations without their mandate. At the very least, do make clear that you cannot speak for all of them.
Be aware of possible conflicts of interest. Every party involved in a given case has their own set of interests: you, the patient, their family and society. Do not be quick to suggest that you have a solution that satisfies everyone's interests. Do not simply side with the most powerful party or the majority, although that is easiest for you.
Question how today's ethics of the discipline may be judged 50 years from now.
Understand and accept that, if you are human, you are subject to numerous perceptive and cognitive biases just like everybody else.
Do not assume you know the patient's interests when you are not even aware of your own interests.
Do not justify as “help” what would in other contexts be regarded as clearly unethical or even illegal. Your patients have the right to remain silent and refuse treatment without risking unpleasant consequences. Are psychiatric ethics lagging behind the ethics of crimincal justice?
When you are saying, “a suicide affects X other people,” you are basically stating that suicide was harmful and thus immoral, although you may otherwise avoid moralizing vocabulary on purpose.
If you believe suicide to be harmful and the suicider to be mentally ill, you're essentially suggesting that the suicide attempt should be recriminalized, and the attempt survivor should be a case for forensic psychiatry.
Given how easy suicide is for you as a physician, you should be more humble in your efforts to prevent patient suicide.
To non-psychiatric suicide preventionists in particular
Do not be naive and uncritical of psychiatry (cf. confirmation bias). Rather, critically question psychiatry's assertions and whether their interventions may actually increase suicidality in some cases.
The discussion on assisted suicide
The concern about social pressure against vulnerable groups to request suicide assistance may be a new form of hostility toward suicide and the suicidal, which formed in a context where condemning the suicidal is considered callous. This “ethical paternalism” is a form of arrogance insofar as the various views of the “vulnerable” themselves are ignored—at least to the extent that they don't support the opposition of suicide.
Weak and ill people aren't valued simply because assisted suicide is a crime. When an individual is regarded as a burden for society, there will always be people who will make very sure to let the individual know about it in an unambiguous way. Whether a life of constantly being told how one is a burden for society is preferrable to death should be up the the individual concerned, not some politician or physician who feels better about the former than the latter because the former is better for society's image and is concealed suffering.
Which is preferrable? That a person under social pressure receives assisted suicide with a peaceful method, or that they are forced into a brutal unassisted suicide?
You should not only be concerned about potential pressure on people to request assisted suicide; you should also be concerned about the pressure to lead a life the indiviudal doesn't want.
In opposition to assisted suicide, psychiatrists sometimes refer to studies that have found that most survivors of suicide attempts were still alive ten years after the attempt. Can we be sure that they would be alive even if they had had access to pentobarbital sodium? What does being alive prove really?
If people are locked up until they convince the practitioner that they do not want to suicide anymore, as some psychiatric textbooks demand, how can psychiatrists believe that they can accurately gauge patients' wish for suicide?
With reference to countries where assisted suicide is legal, it is stated that assisted suicide did not reduce unassisted, brutal suicides. Could this partly be due to the frequent requirements of terminal or severe, incurable physical illness or highly advanced age and the comprehensive paperwork involved for suicide assistance?
- Rizo, J. (2021). Billing Psychiatric Patients for Involuntary Treatment is Unethical. Mad in America