Fatal Freedom: The Ethics and Politics of Suicide

Few people spark as explosive discussion of the right to suicide as Thomas Szasz, author of The Myth of Mental Illness. In Fatal Freedom we find repeated Szasz's earlier criticism of medicine in general and of psychiatry in particular. Religious mores, health standards, and civil law naturally are affected by evolving cultural and political dictates, as discussed by Tancredi and myself (1) and others. Birth control, abortion, and homosexuality are taboo in societies requiring high birth rates for economic growth, physical protection, and social welfare of family members at times of population attrition due to the ravages of war, famine, and illness. Once a society has stabilized, population increases can be destructive, and practices that limit the birth rate are encouraged: population containment is valued. Hence birth control, abortion, and homosexuality, once sins or crimes, may be encouraged or passively accepted, as Tancredi and I have explained.

Sanctions against suicide, however, are not quite so simplistic. At a time when advances in medical science allow prolongation of life beyond a point where quality of life is acceptable, I agree with Szasz that some individuals of sound mind and judgment may elect to die rather than suffer. People have the right to a living will limiting the use of extraordinary life-saving measures. Unlike Szasz, however, I believe psychiatric disorders distort thought, mood, and judgment, limiting informed choice and leading to outcomes that would not occur in the absence of a potentially treatable illness. Psychiatric disorders, not physicians or families, restrict informed choice in these instances.

In spite of these criticisms, Szasz should be heard. As he notes, Nazi Germany employed a medical rationale to kill Jews, homosexuals, and the psychiatrically disturbed. Soviet psychiatrists hospitalized political dissidents. Physicians can be transformed from "protector(s) of the individual patient into the patient's prosecutor in the service of the State." Birth control may be approved, but we do not automatically impugn individual competence to protective contraception and do not try to interfere with people's behavior on the ground they are not competent to decide in such a matter. Szasz feels that irresponsible procreation is more deleterious to society than impulsive suicide, and therefore "if we regard the coercive regulation of birth control as morally odious and legally impermissible, as indeed we should, then we ought to regard the coercive regulation of death control as even more odious and impermissible." Prohibiting death control, he feels, reduces personal responsibility for prohibited behaviors, making people more dependent on external control than self-control.

Most suicidologists, including myself, contend that profoundly depressed people do not have that self-control. Those who die by suicide do not want to die, they want to end their pain. If they could perceive another way to do so, they would seek it. But they cannot perceive or seek it, and therein lies the physician's and family's responsibility to help them do so.