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Are Safeguards Enough for Canada’s Medical Assistance in Dying Law?

photograph of empty hospital bed

Just last month the Canadian government announced that it was seeking to delay an expansion to Canada’s medical assistance in dying program. Since prohibitions on assisted suicide were declared to be in violation of Canada’s Charter of Rights and Freedoms, the program has expanded to include those without terminal illness. Now, Maid is set to expand further to include those not only with physical illness, but those with mental illness. While some groups were disappointed by the delay, others welcomed the opportunity to further consider the lack of appropriate safeguards in place. Given that Canadian policy is much more permissive compared to other nations in seeking to allow non-terminal mental illness patients to be eligible, it is worth considering the moral merit of this expansion.

There are a great many reasons supporting and  medically assisted suicide in general. Those who favor the practice tend to emphasize cases where unbearable pain and suffering is present and where the patient’s prognosis is terminal. It seems reasonable to limit or prevent suffering when death is assured. But it is much more complicated to consider cases outside of these narrow limits. What if the patient has some hope of recovery? What if a mental condition undermines their ability to voluntarily request death? What if the patient is suffering, not from a physical illness, but from severe clinical depression, or post-traumatic stress syndrome, or dementia?

Those who defend the idea of expanding the medical assistance in dying program emphasize the suffering that exists, regardless of the condition being neither physical nor terminal. For example, the advocacy group Dying with Dignity responded to the government’s move to delay by noting, “For those who have been denied compassion, autonomy and personal choice, this is not a short delay but yet another barrier.” Mental illness can be difficult to treat, and it seems arbitrary to treat physical suffering so markedly different from mental suffering.

A similar argument goes for those with dementia. Individuals with dementia or Alzheimer’s undoubtedly suffer from their afflictions – many report feeling that the condition has robbed them of their identity. And, if one has dementia, it can undermine the notion that one can with sound-mind voluntarily choose euthanasia for themselves. This is why many have called for the ability to use advance directives. But what if there is a conflict with what the patient comes to desire later once dementia sets in?

Even those who agree, in principle, that people suffering from these conditions deserve equal access to medical assistance in ending their life, might still worry that there are insufficient safeguards in place. As an article from the Canadian Medical Association Journal reports, arguments for the inclusion of mental illness tend to focus only on severe depression, but in Belgium and the Netherlands this has also included chronic schizophrenia, posttraumatic stress disorder, severe eating disorders, autism, and even prolonged grief. “Discussions, much less evidence-based guidance, of how to evaluate people who request assisted dying because of prolonged grief, autism, schizophrenia or personality disorders are lacking.” The health care system is simply not prepared to provide adequate support for these patients.

In Canada, the standard for receiving assistance in dying is that the condition must be “grievous and irremediable,”  indicating a patient is in an advanced state of decline which cannot be reversed. Various legal safeguards are supposed to be in place, including independent witnesses, the agreement of two medical opinions, and a signed written request. Yet, many are concerned about those who might be pressured into receiving assisted death due to lack of alternatives. For example, recently there were reports of Canadian Armed Forces members being offered assistance in dying when they couldn’t get a wheelchair ramp installed.

There was also a report last year of a 51-year-old woman named Sophia, who received medical assistance in dying due to her chemical sensitivity. Sophia was allergic to chemical cleaners and cigarette smoke but was unable to find affordable housing and was instead forced to live in charity-run residential apartment. When COVID-19 forced her to be at home full-time, it only exacerbated the problem until she finally ended her life. The fact that it was easier to receive death than accessible housing is obviously a problem, as Sophia herself remarked, “The government sees me as expendable trash.” Cases like these have led to the United Nations to criticize Canada’s proposed law for violating the UN Convention on the Rights of Persons with Disabilities. Canada’s Minister of Disability Inclusion has expressed shock at the number of cases of disabled people seeking death due to a lack of social supports.

As a recent article points out, “most would be hard-pressed to argue it reflects true autonomy within a range of choices when the marginalized poor are enticed towards ‘painless’ death to escape a painful life of poverty.” This undermines the idea that expansions to medically assisted dying are only being done for the sake of compassion and to preserve dignity. If the concern truly was the preservation of dignity, for example, there would be additional measures put in place to ensure that marginalized people don’t feel like death is their only real choice.

Those who support medically assisted dying for these cases might have good intentions, but good intentions can also lead to horrific outcomes. For example, the road to the opioid epistemic was paved with good intentions in the form of letters in the 1980s calling for the use of the drugs on the basis of compassion, and those who resisted were labeled “ophiophobic” for their hesitancy. Compassion without critical scrutiny is dangerous.

Some might argue that even if the system isn’t perfect and people fall through the cracks, it is still ultimately better off that we have the system available for those who need it. The thinking here holds that while some might receive assisted death when they shouldn’t, it is still better overall that those that are eligible can receive it. However, it’s important to remember this is often not considered a good argument in the case of the death penalty. One might respond that assisted suicide is done for the sake of compassion rather than punishment, so therefore there is a significant moral difference. However, all one needs to say is that the death penalty is used for the sake of compassion for families of victims, and it no longer holds water. Good intentions are not sufficient without a practical concern for the real-world consequences that will follow.

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Treating Psychopathy?

photograph of 1896 sketch of the brain and it's parts

Most of us are familiar with the idea of the psychopath – emotionally vacant, devoid of empathy, and possessing poor behavioral control. Despite psychopathy not being a recognized mental condition in its own right (or at least, not in that exact terminology), as personality disorders go, it is almost undoubtedly archetypal. Many of the names we attach to the idea of evil certainly qualify for the label, including Ted Bundy, Charles Manson, Jeffrey Dahmer, and David Berkowitz. Beyond the real world, the psychopath is also a staple of fiction, with some of the most heartless villains being written with the disorder in mind, including Hannibal Lecter, Annie Wilkes, Patrick Bateman, and Norman Bates.

However, despite these colorful examples, not all psychopaths stalk the night looking for victims. Most real-life psychopaths navigate the world without making the headlines for slaughtering the innocent or starting nationwide manhunts. For every John Wayne Gacy, there are countless more who, while being manipulative and callous, get through their lives without turning their neighbors into a rug. Indeed, estimates place the prevalence of severe psychopathy in the general population at around 1%. That means, statistically speaking, you probably know a psychopath. And while this is the general prevalence, some groups of society appear to have more psychopaths than others, such as those in corporate leadership positions (≈12%) and prisons (≈20-30%).

Several studies examining the brains of psychopaths have found that they appear to have abnormal neurological structures and functionality. Specifically, the areas of the brain associated with empathy are underdeveloped and lack an average level of responsiveness to external stimuli. Some suggest that this is evidence of a neurological basis for psychopathy and that the abnormal brain structure is why psychopaths behave in the way they do. Following this, others argue that, if possible, we might be justified in using medical techniques and technologies, such as neurosurgery, to alter the brains of criminally violent psychopaths, thereby removing the psychopathy and instilling a level of empathy previously absent.

But can medical techniques reducing or eliminating psychopathic tendencies be justified, or are we medicalizing a group of people out of existence to satisfy societal desire?

We often think that medical interventions, be they as minor as a course of antibiotics or as radical as brain surgery, should only occur when said intervention benefits that person. This requirement is one of the central components separating treatment from research; the former benefits the individual while the latter benefits society (and maybe the individual). While there are exceptions to this rule of thumb – living organ donation, for example – the idea that medical treatment must have some individual benefit is both widely accepted and intuitively appealing. For instance, it would be unjustifiable for a surgeon to operate on you if that operation knowingly provided no beneficial outcome. The idea of an intimate link between a medical treatment’s justification and its potential for a positive result is one of the central pillars underlying one of the most influential theories in medical ethics – principlism.

As conceptualized by philosophers Thomas L Beauchamp and James F. Childress, and formulated in their book Principles of Biomedical Ethics (now in its 8th edition), beneficence is one of the four fundamental concerns when it comes to the ethical permissibility of medical interventions; the others being autonomy, non-maleficence, and justice. According to Beauchamp and Childress, each principle is equally important when looking for ‘reflective equilibrium’ (a coherence between the principles). However, here we’ll focus on beneficence, and specifically positive beneficence, which requires persons to provide benefits wherever possible.

So, would treating psychopathy have a beneficial effect on the psychopath?

This question can be broken down into two parts: (i) do psychopaths suffer as a direct result of their psychopathy?; and (ii) do psychopaths suffer as an indirect result of their psychopathy?

Whether psychopaths suffer as a direct result of their psychopathy is, to a degree, disputed for several reasons.

First, it is unclear whether psychopathy is an illness or a disease. While we might think it causes people to act in less than desirable ways from a social standpoint, this is very different from claiming that psychopathy represents an impairment to health on behalf of the person with psychopathy. If the disorder is of a social (rather than medical) basis, then it would seem highly inappropriate to try and use medical techniques to remedy what is socially disvalued.

Second, even if we accept that psychopathy is predominately medical in nature, that doesn’t mean that its removal would provide a direct benefit. This is because the psychopath would need to experience relief from suffering in a subjective sense for such a direct benefit to occur. Much like how taking a painkiller can’t ease your suffering if you’re not in pain, psychopathy’s removal cannot provide the individual with relief if it didn’t cause suffering in the first place. From the evidence available, it’s not clear whether psychopathy does cause direct suffering. Unlike having a broken bone or terrifying delusions, there’s no clear casual line between psychopathy and suffering. Just because psychopathy is a disorder, doesn’t mean it is harmful.

However, psychopaths don’t exist in a vacuum. Like all of us, they’re situated in the world around them, alongside its complex social, economic, religious, educational, and legal systems. And psychopathy might cause suffering by separating the individual from those systems and, more generally, from society. For example, I suspect many of us would experience suffering if we went to prison for committing a crime. This type of suffering exists regardless of our personality, whether ordered or disordered, because prisons are subjectively unpleasant environments that frustrate our life plans. This is just as true for psychopaths as for everyone else; psychopaths generally don’t want to go to jail. So, by eliminating the root cause of psychopathy, we might be able to prevent psychopaths from being sentenced to prison and thus, help them avoid the indirect suffering they would otherwise experience.

This line of arguing applies beyond prisons, though. Without their psychopathic tendencies, those persons might be better equipped to engage with society, find meaningful connections with others, and empathize with the rest of humanity.

However, appeals to such indirect suffering avoidance are rarely effective for justifying medical treatments in other contexts, especially when the therapy offered has the potential to alter one of the foundations of a person’s personality. For example, we wouldn’t think that someone who lives on the street as a matter of personal preference should have their mental state altered because a result of their choice is the ostracization from society’s mainstay.

We might think their choice is odd, and we might try to convince them that they would be better off living another way of life. But this is very different from using their disordered lifestyle as a justification for a medical procedure based on the idea of harm prevention and reduction.

So what does this mean for our psychopaths? Other arguments might justify medical intervention. For example, it could be that removing psychopathy may restore that person’s autonomous decision-making (although psychopathy’s coercive potential is disputed). One might argue that, as psychopathy is so prevalent in prison populations, its elimination from that sector of society might reduce the pressure on valuable social resources (although this opens up a can of worms regarding the value of autonomy vs the interests of the state).

At the end of the day, if the availability of psychopathic-centric media is any indication, the question of how society handles psychopaths isn’t going away anytime soon, and neither are the psychopaths.

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On the Morality of Allowing Euthanasia for Those with Mental Illness: Part 2

photograph of empty hospital bed with curtains closed

In a previous post on Canada’s decision to allow those with a mental illness to seek medical aid in dying, I discussed some of the factors that need to be considered when evaluating the moral permissibility of euthanasia. These considerations, however, are generally raised in response to cases of intolerable and incurable physical suffering. Things become a lot more complicated when this suffering is instead mental.

Why might this be the case? One of the most common arguments in favor of the moral permissibility of euthanasia is based around the idea of autonomy. This concept holds that we should get the final say on decisions that affect the course of our lives. And this includes choices about how and when we die. This is why we might see a case of suicide as tragic or regrettable, but are usually reluctant to say that someone who takes own life does something morally wrong. But what happens when the process used to make such choices becomes unreliable?

One way of understanding autonomy is through the satisfaction of desires. We all have many desires: A desire to see the climate crisis resolved, a desire to study orbital mechanics in college, or the desire to eat an entire cheese pizza for dinner. The extent to which we have autonomy over these things is determined by our ability to satisfy these desires. So, while I can do something to reduce my carbon footprint, the complete resolution of the climate crisis is entirely out of my control. This, then, is something over which I do not have autonomy. When it comes to what I eat for dinner or what I study at college, however, I have far more autonomy. To say that I should have autonomy over the time and manner of my death, then, is to say that I should be able to satisfy whatever desire I have regarding my death. If that desire is to end my life prematurely, then I should be allowed to do so. And if for some reason I need assistance in ending my own life, then there can be nothing wrong with another person providing this.

The problem with desire-based theories like this is that there are many cases in which we don’t desire what’s good for us. This can happen in one of two ways. Firstly, we can desire things that are bad for us. That cheese pizza might be delicious – and give me thirty solid minutes of bliss – but the long-term effects will be bad for me. I’ll gain weight, raise my cholesterol, and suffer through an entire evening of gastric distress. Secondly, we can fail to desire things that are good for us. While I might thoroughly enjoy studying orbital mechanics, it may very well have been the case that a degree in ornithology would have been far more enjoyable and rewarding.

These concerns are compounded in cases of mental illness, as sufferers may be more prone to form desires that are bad for them. But to discount all of the desires of the mentally ill is to show enormous disrespect for their dignity as persons. So how can we discern the good desires from the bad?

One solution might be to refer to distinguish between “first-order” and “second-order” desires. First-order desires are precisely the kind of desires we’ve been considering so far – desires about what to eat, what to study, and when to die. Second-order desires, on the other hand, are desires about desires. To illustrate the difference between these two, consider the case of Mary. Mary is a smoker. Every morning, she wakes up with a powerful desire for a cigarette. A desire that she promptly satisfies. Then, throughout the day, she desires many more cigarettes – a full pack’s worth in fact. Mary, however, deeply regrets being a smoker. She hates the harmful effects it has on her health and her wallet. She wishes that she didn’t desire cigarettes. So, while Mary’s first order desire is to smoke cigarettes, her second order desire is precisely the opposite.

How does this help us? Well, we might argue that when considering how best to respect a person’s autonomy, we should focus purely on an individual’s second-order desires. This, then, would permit us to do something like forcefully prevent Mary from smoking (say, by confiscating her cigarettes and preventing her from buying more). Similar reasoning can be applied to the many cases where someone’s desires have been corrupted by addiction, deception, or general human flaws like laziness and procrastination.

In the case of mental illness, then, we now have a tool that allows us to look past someone’s immediate desires, and instead ask whether an individual desires to have such desires. If we can show that someone’s desire for death has come about as a result of their mental illness (and not, say, by a reliable process of informed reasoning) we could argue that – since the individual does not desire that desire – helping them end their life would not be respectful of their autonomy. If, however, their second-order desire is in favor of the desire to die, respect for autonomy will once again lean in favor of us helping them to end their own life.

All of this is to say that allowing euthanasia in cases of severe and incurable mental illness is enormously complicated. Not only does it involve all of the usual considerations that are relevant to euthanasia, it also contains an additional set of concerns around whether helping a patient end their own life will truly see us acting in a way that respects their autonomy. In order to ensure such respect, we should focus not just on what an individual desires, but on their attitudes towards those desires.

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The Perils of Globalizing Mental Health

Photograph of 1944 poster that says "mental health is your concern"

In an age where self-care is a commonly touted virtue, it’s easy to take for granted what a recent development the gradual de-stigmatization of mental illness is. Celebrities constantly come forward with harrowing stories of struggle and recovery, pop-psychology blogs and websites abound, and every day we see more open and honest discussions about the foundations of and treatment options for mental illness.

Perhaps the globalization of this phenomenon is even more surprising. Mental health has truly become a global concern, with researchers and psychiatrists from a diverse array of cultural backgrounds contributing to our understanding of mental illness. Counseling is now considered an essential part of post-disaster relief packages, trauma being an assumed result of natural disasters. In the wake of the earthquake and tsunami that devastated Indonesia in October of 2018, for one recent example, clinical psychiatrists and trained volunteers were deployed by the World Health Organization to administer psychological first aid. These changes seem to signify the end of stigma, indicating more effective approaches to treating nebulous and painful conditions that afflict people around the world.

But despite the growing global concern over mental illness, the West still acts as a dominant force in the discourse around mental health. The DSM, or the Diagnostic and Statistical Manual of Mental Disorders, a handbook of symptoms and treatment options for mental illnesses compiled by the American Psychiatric Association, is considered the gold standard for diagnosing mental illness around the globe.

We rarely stop to ask whether or not applying American understandings of mental health can have a detrimental effect on the way mental illness is treated in non-Western cultures. Our culture has come to consider conditions like depression and schizophrenia solely through a biomedical lens, as illnesses entirely dependent on a complex set of neurological misfirings rather than cultural causes.

But in his book Crazy Like Us: The Globalization of the American Psyche, Ethan Watters examines the ways in which the biomedical approach taken by Western psychiatry can have a negative effect on those suffering from mental illnesses in places with different understandings of what it means to have a unified sense of self. He argues that importing Western cures for mental illness, which are deeply rooted in our own cultural mores, to other nations is unethical.

Watters distinguishes between the pathoplastic and pathogenic causes of mental illness. Mental illnesses don’t function in the same way that diseases like cancer do, where the  expression of the disease is completely independent of cultural context. There are two ways that mental illness can express itself; the pathoplastic causes, which are individualized and culturally-specific, and pathogenic causes, the underlying psychological imbalances.

The difference between pathoplasticity and pathogenicity is explored by novelist Esmé Weijun Wang in her collection of essays The Collected Schizophrenias. She sees a vital distinction between “explanations”, the “spiritual narratives” that color pain and illness with cosmic significance, and “causes”, the neurological reasons for mental illness that are uniform for humans across the board. In other words, the pathoplastic causes of a disease, the explanations can have meaning for the afflicted, whether these explanations are rooted in culturally-specific expressions of pain or find outlets in things like religion.

Most researchers dismiss the pathoplastic causes as irrelevant, but Watters posits that “culture and social setting play a more complicated role in the disease than simply influencing the content of the delusion.” In Western society, we push the narrative that mental illness is biomedical, an illness as removed from cultural influences as cancer, but research suggests that the biomedical approach, taken solely on its own, can be harmful and even heighten stigma against mental illness.

Despite our growing interest in helping the mentally ill, stigma against mental illness in the West has actually been increasing since the 1950’s. According to a 1996 study,

Among adults who associated mental illness with psychosis, the odds of describing a person with mental illness as violent in 1996 were 2.3 times the odds of describing a person with mental illness as violent in 1950 […] Perceptions of dangerousness were associated with causal attributions of mental illness. Causal attributions of genetics or chemical imbalance increased the odds of perceiving a person with schizophrenia as dangerous to themselves and others.

While “perceptions of dangerousness appear to have stabilized” between different illnesses from 1996 and 2006, with “no significant differences […] in the public’s perceptions of dangerousness of adults with schizophrenia or depression,” the perception of dangerousness hasn’t faded from mental illness as a whole. The biomedical perspective on mental illness, the study suggests, has insidiously increased stigmatization by casting the mentally ill as inherently dangerous, helpless prisoners of their own minds. Watters suggests that the Western approach, while offering valuable insights on the underlying causes of disease, can be dehumanizing for the afflicted. It reflects a very Western sense of the body as divorced from culture, a neutral space only affected by genetic predispositions. Watters argues that what we’re actually importing to other cultures is not Western psychiatry but the Western idea of the self, our conception of what it means to be a functioning member of society. In our culture, we tend to have a strongly internal locus of control, meaning most Americans view themselves as completely in control of their lives, whereas other cultures have a more external locus. Our approach towards mental illness reflects this; those with mental illness are often viewed as lacking the willpower to overcome their condition. Despite the biomedical approach most Westerners subscribe to, which should firmly place the cause of mental illness outside of the afflicted, these beliefs persist.

This issue is part of an important ongoing conversation about the impact of globalization and Western hegemony. In the next century, we’ll see more natural disasters caused by climate change, which will inflict trauma on large populations of those already disenfranchised by poverty and disease. More trauma means more counseling and medication, specifically Western counseling.

Diagnoses can stick, sometimes doing more harm than good. Esmé Weijun Wang remarks that in Western society, “it is easy to forget that psychiatric diagnoses are human constructs, and not handed down from an all-knowing God on stone tablets; to ‘have schizophrenia’ is to fit an assemblage of symptoms, which are listed in a purple book [the DSM] made by humans,” and therefore not infallible. While therapy is undoubtedly useful for many, we should be cautious before applying it as a universal cure-all, and encourage rather than discourage global diversity in the field of mental health.

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Reflection on Responsibility: National Suicide Prevention Month

Photo of a sign at the Golden Gate Bridge that says "Crisis counseling - There is hope - Make the call - The consequences of jumping from this bridge are fatal and tragic".

Content warning: discussion of suicide

September is National Suicide Prevention month, and September 10th marked World Suicide Prevention Day.  Organizations such as the Suicide Prevention Lifeline, American Foundation for Suicide Prevention and the International Association for Suicide Prevention all hosted social media hashtags and encouraged everyone to spread awareness of suicide and how to prevent it. Suicide has long been considered an epidemic in the United States, but a recent study published by the CDC in July showed that the rate of suicide in the U.S. has increased dramatically in the past 20 years. By and large, suicide is considered negative in our society, often framed as tragic due to its preventability. Several pop culture idols have committed suicide since the beginning of 2018, including chef and TV personality Anthony Bourdain and fashion designer Kate Spade. During this month, it is pertinent to examine exactly what our culture’s stance on suicide truly is. Does framing suicide as negative require us to make judgements about those who commit it? Does an anti-suicide stance require us to also oppose assisted suicide? And finally, who should we hold accountable for fixing and preventing the suicide epidemic; our culture, ourselves, or our public institutions?

As quite literally a life or death matter, the way that we talk about suicide is a delicate matter. In an article titled “Is Suicide Selfish?” Senior Director of Suicide Prevention and Postvention Initiatives, Shauna Springer, examines from a psychological perspective if we can truly hold those who attempt or commit suicide can considered selfish. While Springer doesn’t deny that suicide has consequences on those other than the victim, she holds that it ultimately is not a selfish act, due to the fact that “suicidal mode is an altered state of consciousness.” Because those suffering from suicidal thoughts “often have distorted perceptions of reality,” we cannot make judgements about their character and actions in a similar way that we would a healthy person. Others however, feel differently. In an article titled “I Still Think Suicide Is Selfish And No, I’m Not Ignorant For Believing So” Lesly Salazer defends her position by using her personal experience with depression and suicidal thoughts. Salazer explains that growing up, she was told “‘There’s more to life than yourself and your sadness. You can’t let your emotions overpower your common sense. God has a plan for you, and killing yourself is just plain stupid.’” She believes that this attitude toward suicide saved her life, because she felt she was doing a moral wrong by killing herself. The traditional methods of hotlines and therapy did not work for Salazer, though she acknowledges they may help some. In conclusion, Salazer defends her belief that suicide is selfish on the basis that such a belief might prevent people from killing themselves. However, one could argue that such an attitude towards suicide might actually hinder people from finding help, because they do not feel like they can talk about their suicidal thoughts. While it might help some like Salazer, it has the potential to hurt many others.

If we decide as a culture and society to take a negative stance toward suicide, can we also consistently advocate for methods that make ending one’s life easier or less painless? The legalization of physician assisted suicide has been a debate in recent years, with states like Oregon and California passing legislation to legalize physician-assisted suicide. But how do suicide prevention organizations view physician assisted suicide? In October of 2017, the American Association of Suicidology released an article clarifying that they, as an organization, do not considered assisted suicide as suicide, but instead as “death with dignity’ or “physician aid in dying.” The article explains that the organization “ does not assume that there cannot be ‘overlap’ cases, but only that the two practices can in principle be conceptually distinguished and that the professional obligations of those involved in suicide prevention may differ.” The organization goes on to list 15 key differences between physician-assisted suicide and the type of suicide that the AAS aims to prevent. The key distinctions AAS claims exist between suicide and physician-assisted death are medical and conceptual. One observation is that those seeking assisted suicide are often facing physical chronic illness, whereas those seeking to commit suicide are often plagued by mental illness, impairing their judgement and ability to make reasonable decisions. However, those against physician-assisted suicide argue that taking such a stance worsens the stigma associated with mental illness as not as serious or legitimate as physical diseases and conditions. Should the decision to end one’s life be treated differently or more dignified on the basis of physical or mental conditions? A previous Prindle Post article by Amy Elyse Gordon examines this issue. One could surely argue that in the case of terminal illness, physician-assisted suicide provides relief and control to those facing death. Additionally, this type of ending one’s life may not have the same adverse effects on family and friends as other forms suicide do.

If we accept that suicide is detrimental to society, whose responsibility is it to prevent it? This question is a difficult one, because it, in a way, assumes that suicide can be influenced by others, and that they in some way hold a moral responsibility to prevent it. At what level we hold people accountable can be difficult to determine. Giving the government the complete burden of preventing suicide may lead to its criminalization. Indeed, suicide was considered a crime in the U.K. until 1961, when suicide became framed less as a sin or moral wrong and more of a medical and psychological problem. However, the government can help prevent suicide in more ways than criminalization. A 2016 study found that rising poverty rates were highly correlative of rising suicide rates during the 2008-2009 economic recession. This study suggests that poverty and economic burden can influence the rate of suicide and if our goal is to prevent suicide, perhaps we should hold our politicians and government accountable for supporting those that are impoverished or enforcing stricter regulations on financial institutions to ensure economic stability. On the other hand, some might argue this alone is not enough.

Suicide is undoubtedly influenced by mental illness in many cases, regardless of external factors. Perhaps it is the responsibility of organizations such as the American Foundation for Suicide Prevention to help support those who feel suicidal and raise awareness about the topic. Some might argue this still is not effective enough alone because those who are considering suicide may not have access to these resources or may not have the motivation to seek out help.

So, we might then believe that it is every individual’s responsibility to prevent suicide. One example of the application of this type of thinking is the involuntary manslaughter sentencing of Michele Carter in 2017. Carter was a teenager suffering from mental illness, whose boyfriend, Conrad Roy III, committed suicide in 2014 (discussed in detail in this Prindle Post article). Text messages minutes before his Roy’s death show that Carter encouraged him to kill himself, texting him to get back in the carbon monoxide car after he had second thoughts about killing himself. Carter’s verdict implies that people can be held legally and morally responsible for their loved one’s decision to commit suicide. In the case of Carter, it was not just her failure to stop Roy, but also her encouraging attitude toward suicide that made her guilty,  according to the judge. If we decide to hold individuals accountable for preventing suicide, we may have to accept verdicts such as the one in the Michele Carter case. This becomes difficult, because it implies that those surrounding suicidal people, including loved ones, could be held legally and morally responsible for their death. Additionally, is assigning blame in the case of suicide really necessary or morally correct?

Suicide is not an easy topic, and probably never will be. The decision to take one’s own life cannot be boiled down to one or even a few causes. During September, we should all collectively think critically about suicide and how we are failing as a society to prevent it.

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“Unbearable Suffering” and Mental Illness

Photograph of a single bed with a curtain and chair

Trigger warning: suicide attempts, multiple mental illness mentions

This article has a set of discussion questions tailored for classroom use. Click here to download them. To see a full list of articles with discussion questions and other resources, visit our “Educational Resources” page.

List of international suicide hotlines: http://ibpf.org/resource/list-international-suicide-hotlines

Aurelia Brouwers’ Instagram bio is terse and pointed: “BPD, depression, PTSD, anxiety etc. Creative. Writer. Gets euthanasia Januari [sic] 26. Fights till then for this subject.”

Brouwers was a twenty-nine year old Dutch woman who suffered from multiple mental disorders. She received her first diagnoses of depression and Borderline Personality Disorder at the age of twelve. As she recounts: “Other diagnoses followed – attachment disorder, chronic depression, I’m chronically suicidal, I have anxiety, psychoses, and I hear voices.” After an estimated twenty failed suicide attempts, Brouwers thought she found the solution to her suffering via euthanasia or physician-assisted suicide (EAS). EAS has been legal in the Netherlands since 2002, but Brouwers faced obstruction as her request was refused by multiple doctors. She finally turned to The Hague’s End of Life clinic, which approved her request and set a date for January 26 of this year. Scenes from Brouwers’ last fortnight of life were recorded by RTL Nieuws journalist Sander Paulus, who noted the young woman’s ongoing mental distress as well as the conviction with which Brouwers anticipated her euthanasia date. Footage featured by the BBC shows Brouwers collectedly making plans for her cremation ceremony with a funeral consultant. On January 26, surrounded by loved ones and two doctors, Brouwers consumed a liquid poison and “went to sleep.”

Brouwers’ case stoked vigorous debate in the Netherlands and elsewhere regarding the intent of euthanasia legislation. Her youth is one point of contention. Another factor is the nature of her affliction. In the discourses following Brouwers’ life, we see evidence of an assumed distinction between physical and psychiatric disorders. Journalist Harriet Sherwood went so far as to note in the tagline for her Guardian article that ”there was nothing wrong with her [Brouwers] physically.”

While psychiatric disorders are still primarily diagnosed via mental and behavioral markers, it is not strictly correct to assume that mental health disorders lack physical foundations. Often, the ways in which we speak of mental disorders reveal our imperfect knowledge of the biological elements (as differentiated from the more traditionally observed psychosocial components) of mental disease. This relative ignorance exists in part because researching biomarkers for psychiatric disease is a complex undertaking. What is known is that mental illnesses can often be life-long conditions that require ongoing treatment, treatment that appears to have been provided in Aurelia Brouwers’ situation.

The 2002 Dutch act exempting physicians from prosecution in specific EAS cases requires ”due care” by the attending doctor. This includes ascertaining unbearable suffering on the part of the patient without hope of improvement. The Netherlands is joined in this relatively open model by other European nations, including Belgium, Luxembourg, and Switzerland. Several American states, the Australian state of Victoria, and Canada also allow EAS, but in much more restricted circumstances mirroring the “Oregon model,” which stipulates a terminal illness with established life expectancy.

Arguments in favor of euthanasia often rest on the basis of respect for individual autonomy and on compassionate grounds. Here, for the sake of simplicity, I assume ethical assent to these grounds in support of voluntary euthanasia or physician-assisted suicide which is at the informed, long-standing behest of the patient. This is the only form of active euthanasia currently legal anywhere (whereas what some call ”passive” euthanasia or the withdrawal of futile treatment is considered to be normal medical practice). These moral justifications – autonomy and compassion – are taken as reasonable in states in which EAS is legalized. In the Netherlands, however, where EAS has been legal for sixteen years, Brouwers was initially refused by several doctors, and garnered national attention. Why?

Brouwers’ example seems to challenge notions of what constitutes “unbearable suffering,” impossibility of improvement, and “terminal” conditions. Popular conceptions of mental illness present it as something that one can “overcome” through patience or willpower, although the same perceptions do not apply to a broken bone or a cancer diagnosis. Dutch psychiatrist Dr. Frank Koerselman, speaking to the BBC, notes that Borderline Personality Disorder, from which Brouwers suffered, is known to decline in severity after the age of 40. But BPD was only one of Brouwers’ multiple diagnoses, which taken together, caused her immense suffering. Along these lines, some argue that her mental disease was itself terminal, as does Kit Vanmechelen in the BBC article. Brouwers had already engaged in numerous, though incomplete, suicide attempts.

What happens, though, when we allow EAS for psychiatric suffering as well as physical suffering (the more traditionally accepted justification)? As a society, our understanding of mental suffering does not seem to be as advanced as that of physical suffering (only recently was it discovered that emotional pain activates neural correlates similar to physical pain).

Many believe that it is a mistake to open this door. Dr. Koerselman opposes EAS for psychiatric disorders, in part because he posits it is not possible to distinguish a rationalized decision to die from a symptom of mental disease itself. On the other hand, a recent study of Belgian mental health nurses’ attitudes toward euthanasia for unbearable mental suffering found a widely positive response. Nurses were the subjects for this study because of their closeness to patients’ lives and frequent role as intermediate and advocate between patients and doctors.

Ethics is about individual cases, as well as the general principles that they reveal or elicit along the way. The case of Aurelia Brouwers is undeniably a tragic one, although Brouwers herself appeared to find some peace in her capacity to make an informed choice, supported by medical care. But what her life surely reveals is that we need to invest more in exploring the genesis and maintenance of mental disorders within our societies. One in four people world-wide will suffer from some form of mental illness. We need to invest more in understanding the biological bases of mental illness, as well as the social structures that are implicated in psychiatric disorders’ psycho-social components.  In the words of Brouwers, “I think it’s really important to do this documentary [of Brouwers’ life] to show people that mental suffering can be so awful that death, in the end, is the lesser of two evils.” As a society, we need to do better by those who experience mental pain.

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Is it Fair to Blame President Trump’s Behavior on Mental Illness?

A dark photo of Donald Trump clapping.

On October 25, former Oklahoma Senator Tom Coburn (a Republican) said that President Trump has “a personality disorder.”  He was not the first to posit that President Trump has some form of mental illness. The press has been engaging with such speculation since the start of his campaign, though there has been a decided increase of late. On October 26, New York Times columnist David Brooks reported that some Republican senators thought Trump is “suffering from early Alzheimer’s.” In an article titled “Some Republicans are starting to more openly question Trump’s Mental health,” Business Insider reports that “One psychiatric professor at Yale said about half a dozen lawmakers had contacted her over the past several months.”

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Taking Stock of Solitary Confinement’s Mental Toll

In prisons throughout the United States, a total of somewhere around 80,000 prisoners are isolated from human contact for 22 to 24 hours a day. These prisoners are kept in very small cells—spaces of roughly 80 square feet.  In the cell is a bed, a toilet, and very little else.  Prisoners in solitary are fed three meals a day and are often allowed outside every day for an hour, with no contact with other prisoners.  The practice, commonly known as “solitary confinement” has come to be known by a number of euphemisms, including “restrictive housing” and “segregation.”

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Diagnosis from a Distance: The Ethics of the Goldwater Rule

The September/October 1964 issue of Fact magazine was dedicated to the then Republican nominee for president, Barry Goldwater, and his fitness for office. One of the founders of Fact, Ralph Ginzburg, had sent out a survey to over 12,000 psychiatrists asking a single question: “Do you believe Barry Goldwater is psychologically fit to serve as President of the United States?” Only about 2,400 responses were received, and about half of the responses indicated that Goldwater was not psychologically fit to be president. The headline of that issue of Fact read: “1,189 Psychiatrists Say Goldwater is Psychologically Unfit to be President!”

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Split and the Portrayal of Disassociative Identity Disorder

Editor’s Note: This article contains spoilers for the film, Split. 

On January 20, Split, a film about three girls attempting to escape from Kevin Wendell Crumb’s 23 split personalities, was released in theaters. In the film, Crumb suffers from dissociative identity disorder (DID). Dissociative identity disorder, commonly known as multiple personality disorder, is a mental illness that creates one or more personalities within one individual. The disorder also pairs with memory loss; therefore, the individual is sometimes incapable of realizing their multiple personalities.  Normally, the disorder arises from some form of trauma during childhood.

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Depicting Mental Health on Halloween

In a recent post published by the Prindle Post, staff writer Carrie Robinson discussed the ethics behind displaying mental health in Knott’s Berry Farm attraction FearVR 5150, which “sparked concerns about the stigma surrounding mental health.” 5150 corresponds to a California police code that denotes interactions with individuals with mental illnesses. Essentially, the ride took individuals through various scenes displaying their version of what a haunted mental health hospital would entail. This inherently portrays highly polarized and stereotypical views of mental health issues that negatively depicts those who suffer from them.

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From the Cuckoo’s Nest to the Jailbird: What’s Happening to the Mentally Ill in America?

The history of mental illness is riddled with what are now horror stories: mental illnesses “treated” by bleeding patients with leeches, dousing them with hot or cold water, or simply putting them to death. From the 1600s to the 1800s in Europe and in the newly established United States, it was common for mentally ill people to be locked away in asylums, sometimes chained to the walls in what were essentially dungeons. Movements in the 1800s by activists like Philippe Pinel in France and Dorothea Dix in the northeastern states of the US helped to change these dungeons into what better resembled hospitals, with more comfortable housing and medical doctors.

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Rethinking Mental Illness in Light of Mass Shootings

In light of recent mass shootings that have devastated the lives of several U.S. families, I think it is important to take a deeper look into these undeniably difficult situations. Mental health can be a topic that many people do not feel comfortable discussing because so many of us suffer from some sort of mental illness, whether we are aware of it or not. Often times, the individuals guilty of mass shootings are diagnosed with some sort of mental illness. Because of the emotional and mental toll that mass shootings have on the families of the victims and the families of the shooters, many people feel as though there is no right answer for what to do after this kind of tragedy occurs.

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Should We All Take a Bit of Lithium?

Lithium is classically associated with extreme mental illness, and has a somewhat negative connotation in the public. In its concentrated form, it has been documented to alleviate several symptoms of mental illness. But it also can (and has had) severe negative health consequences for people taking it in high doses.

But this op-ed raises the question: Should we all be taking (a very little) bit of Lithium? It turns out that it is naturally occurring, in very small amounts, in many drinking water sources. What is surprising is that there is some evidence that these small amounts potentially have a surprisingly positive effect. Several studies have shown correlations between levels of naturally occurring lithium and positive social outcomes.

Researchers began to ask whether low levels of lithium might correlate with poor behavioral outcomes in humans. In 1990, a study was published looking at 27 Texas counties with a variety of lithium levels in their water. The authors discovered that people whose water had the least amount of lithium had significantly greater levels of suicide, homicide and rape than the people whose water had the higher levels of lithium. The group whose water had the highest lithium level had nearly 40 percent fewer suicides than that with the lowest lithium level.

Almost 20 years later, a Japanese study that looked at 18 municipalities with more than a million inhabitants over a five-year period confirmed the earlier study’s finding: Suicide rates were inversely correlated with the lithium content in the local water supply.

More recently, there have been corroborating studies in Greece and Austria.

This raises several interesting questions. First, should the government and the scientific community be devoting more resources to studying the effects of lithium in these small doses? Second, suppose we found out that there are positive effects. Should we all be drinking water with these naturally occurring levels of lithium or not? Would you want your municipal water supply augmented to achieve this result? What do you think?