Doctors allow suicidal woman to die

[Bourcet]

http://www.telegraph.co.uk/health/6248646/...be-assault.html

This article appeared in the news recently and it concerns the case of a suicidal woman that tried to kill herself with poison, proceeded to call an ambulance and then gave doctors a letter stating that she did not want to be saved but only wanted staff to make her comfortable. Doctors allowed her to die and said she was of sound mind.

Her reason for suicide was her inability to have children. She had attempted it 9 times over the period of 12 months but on those occasions she allowed doctors to save her.

This issue concerns the right to life and mental health and to what extent mental health impacts the right to life in the sense of being free to take your own life.

Depression is referred to as a mental illness and one of its characteristics is distorted thinking that spirals into negative free fall, whereby over time the cognitive ability of the mind decreases and can lead to suicide as the mind cannot see a way out of the problem.

Although the ability of the mind has been reduced, it can still judge the consequences of actions and therefore is considered to be of sound mind.

So is it the case that suicide should only be prevented by doctors in circumstances whereby consequences cannot be seen? which would only apply to the mentally insane? could the mentally insane not know that death is the end?

I'm just seeking some illumination on the matter since it is not clear to me how you can judge the morality of allowing suicide in the sense of knowing when a person should be saved and how you know this in terms of assessing their mental health. How do you know when someone has the capacity to reason, and when someone doesn't?

Edited October 4, 2009 by Bourcet

[DavidOdden]

The choice to exist or not must be made by the individual, and the specific choice to exist is a precondition for further moral evaluation. It is the woman's right to choose not to exist, and neither the doctor nor the government has the right to force her to exist contrary to her choice. It would be morally wrong to override that choice.

There is some moral wiggle-room for benevolent intervention when it is clear that the person is not actually making a choice, for example if their choice is to fly like a bird despite the fact that they cannot. In this case it is clear that the woman clearly understood the true nature of the choice she had made, thus stopping her would be immoral.

[softwareNerd]

I think the relevant laws should have some type of pre-planning/declaration as part of the process that ensures that the decision is made without coercion and by someone of a sound mind. From a brief FAQ, it appears that the Oregon law requires suicidal patients to talk to a doctors and get a prescription from him. I don't know what the law requires of the doctor, but a reasonable doctor should try to judge if they are temporarily in some mental-state where their reason is clouded. Obviously someone who is drunk of high or mad is not competent to make such a decision. Depression is different because the person actually understands the consequences. I assume a good doctor who judges a person to be irrationally depressed would try to counsel them to see a specialist, at least as a first attempt to solve their problems, or to prescribe an anti-depressant. I don't think the law should be such that a diagnosis of depression is allowed to stop a suicide indefinitely. I do think the law should have a waiting period for most cases where the person is not already terminally ill. The Oregon law seems to have a 15 day waiting period.

[brian0918]

There is some moral wiggle-room for benevolent intervention when it is clear that the person is not actually making a choice, for example if their choice is to fly like a bird despite the fact that they cannot.

I wonder, would that apply to someone who believed they were going to have an afterlife, or that they would be reincarnated?

[Jake_Ellison]

I wonder, would that apply to someone who believed they were going to have an afterlife, or that they would be reincarnated?

Are you saying that religious people might be automatically incapable of choice? Do you also wonder if pleading insanity would be resonable when someone who believes in Heaven commits murder?

[brian0918]

Are you saying that religious people might be automatically incapable of choice? Do you also wonder if pleading insanity would be resonable when someone who believes in Heaven commits murder?

How did you get that from what I said? I was responding to DavidOdden's example of a specific incident where the person chooses something that they are incapable of doing, e.g. flying like a bird. If, instead, they chose to "enter the afterlife" or "come back as a grasshopper" - is that the same situation? The person has a false belief that is enabling their death.

If the situation isn't the same simply because the person is acknowledging death, then how about the Heaven's Gate cult, for example, who believed their bodies were just temporary containers, and their spirits needed to be set free from their bodies to get back to their space ship (or whatever the nonsense is)?

Edited October 4, 2009 by brian0918

[Jake_Ellison]

If the situation isn't the same simply because the person is acknowledging death, then how about the Heaven's Gate cult, for example, who believed their bodies were just temporary containers, and their spirits needed to be set free from their bodies to get back to their space ship (or whatever the nonsense is)?

No, you still have no right to make their choices for them. Not even if they subscribe to a cult. If you were able to, then you also shouldn't hold anyone with a similar belief system responsible for murder. If it is your judgment that they don't understand the concept of death, then they cannot be judged for murder either.

(in the case of the Heaven's Gate suicide, Police should be allowed to make sure each member did in fact choose to die, and no one was murdered. I think that in fact some of them might have been forced or intimidated.)

[DavidOdden]

I wonder, would that apply to someone who believed they were going to have an afterlife, or that they would be reincarnated?

I don't know what principle distinguishes actual psychosis from stupidity and evasion -- obviously they have a lot in common. I have never interacted with anyone having hallucinations to the effect that they really believe that they have wings and can fly. I would suppose that they are suffering from some kind of sensory breakdown, where they actually sense things like wings that do not actually exist. People who believe in the afterlife have simply constructed an irrational conclusion at the conceptual level, but they still perceive the world like ordinary people. I'd want to have more knowledge of the nature of psychosis before trying much harder to set forth a principle distinguishing the two kinds of case.

[softwareNerd]

I don't know what principle distinguishes actual psychosis from stupidity and evasion -- obviously they have a lot in common. I have never interacted with anyone having hallucinations to the effect that they really believe that they have wings and can fly. I would suppose that they are suffering from some kind of sensory breakdown, where they actually sense things like wings that do not actually exist. People who believe in the afterlife have simply constructed an irrational conclusion at the conceptual level, but they still perceive the world like ordinary people. I'd want to have more knowledge of the nature of psychosis before trying much harder to set forth a principle distinguishing the two kinds of case.

I think the sensory/perceptual malfunction versus the conceptual falseness is definitely the critical factor from a legal perspective. (Would this be analogous to the case of the law using decimal-level rather than lyrics to determine if some music is legal permissible in a particular location?)

[Bourcet]

The choice to exist or not must be made by the individual, and the specific choice to exist is a precondition for further moral evaluation. It is the woman's right to choose not to exist, and neither the doctor nor the government has the right to force her to exist contrary to her choice. It would be morally wrong to override that choice.

There is some moral wiggle-room for benevolent intervention when it is clear that the person is not actually making a choice, for example if their choice is to fly like a bird despite the fact that they cannot. In this case it is clear that the woman clearly understood the true nature of the choice she had made, thus stopping her would be immoral.

I agree, but what I'm really looking for is an answer as to how you can judge if someone is of sound mind or not and therefore judge the morality of the decision by the doctor.

I think the answer relates to a person being in touch with reality or not.

In an extreme case I can think of someone with paranoid Schizophrenia who would do as this woman did, but the explanation in the letter for the suicide would be out of touch with reality. His explanation could be that aliens have told him to kill himself, if he doesn't then aliens would kill his friends and family.

In this case, for the doctors not to intervene to save his life, they would be condemned as immoral since it is clear that he is of not sound mind and instead mentally ill to an extent that his right to life, specifically his right to take his life, should not be recognised in this situation.

However, if such a person took medication to reduce attacks of paranoia, but then with a clear mind decided to end his life because he did not want to live a life under this terrible condition, then this should be respected.

[DavidOdden]

I agree, but what I'm really looking for is an answer as to how you can judge if someone is of sound mind or not and therefore judge the morality of the decision by the doctor.

I think the answer relates to a person being in touch with reality or not.

From a moral POV, this specific case is crystal clear: intervention would have been immoral. The higher level principle is that one may not rightly initiate force against a person's will (it is allowable to hit a person if they agree to be hit). The concept of implicit permission will play an important role in this discussion.

To take a non-psychotic example, you may not grab a person and shove them. However, if a person steps into the street apparently unaware that a truck 10 feet away is hurtling towards them, you should assume that they did not pick this particular moment to snuff themselves. The facts known to you indicate that the person continues to affirm the fundamental choice -- to exist -- and your only rational conclusion is that they are not in full possession of the facts (they are looking the wrong direction). Another fact is that a calm exposition of Objectivism ethics and the truck / life dichotomy leading to the person's choice to step back is not possible. (If the truck were 100 feet away, you could say something like "Truck on your left, dude! Splat!"). Your choice to grab the person and move them out of harm's way is technically force, but it is reasonable to assume that it is force with implicit permission. The assumption is that if they had perceived the truck, they would not have stepped in front of it.

In an extreme case I can think of someone with paranoid Schizophrenia who would do as this woman did, but the explanation in the letter for the suicide would be out of touch with reality. His explanation could be that aliens have told him to kill himself, if he doesn't then aliens would kill his friends and family.

We would be assuming, as we did in the truck case, that the person was fundamentally inclined to exist, but because of certain perceived "facts" he concluded that life would be unbearable. At some point we might ask why a person would ever decide that life qua man is not possible, but let's take it that the person has reached that conclusion. Well, that conclusion (in this hypothetical) is completely conditioned by the belief that aliens would kill his friends and family. Were it not for that belief, the person would not have abandoned the ultimate goal. His conclusion is based on a false premise, which is caused by "broken axioms", that is, perception that is caused by seriously malfunctioning sensory apparatus. Furthermore, it is reasonable to believe that his perceptions can be corrected, though it's slower than in the truck case (needing a course of medication). If his perceptions are corrected, his ultimate conclusion ("life is possible") would also change.

There is an analogy with the truck case, a significant mismatch between reality and perception. In both cases, they are not perceiving reality correctly (and without correct perception, conceptual conclusions also cannot be correct). There are obvious difference between the truck case and the alien case, but what they have in common is a failure to perceive reality, and that their false perceptions lead to choices that they would not have made if they had perceived reality correctly. Just as we would forgive a man for using force to prevent a blind person from stepping out in front of a truck that he did not perceive, we would forgive a man for using force to prevent a madman from taking his life based on patently false perceptions of aliens.

In this case, for the doctors not to intervene to save his life, they would be condemned as immoral since it is clear that he is of not sound mind and instead mentally ill to an extent that his right to life, specifically his right to take his life, should not be recognized in this situation.

I don't think you can conclude based on mental illness that the person has no right to life because of his mental problem. If that were correct, you could conclude "Aha, he's nuts, we can harvest him for spare parts!". However, you're also complicating the question by injecting doctors and evaluations of immorality for inaction into the discussion. I think it would be better to focus on the more accessible question of whether it is morally permissible to use force to prevent a person from ending their life because of fundamentally false perception. From that we could get to a conclusion about doctors, but that involves bringing into the discussion the specific nature of doctors and why they should act in certain ways.

[2046]

I agree, but what I'm really looking for is an answer as to how you can judge if someone is of sound mind or not and therefore judge the morality of the decision by the doctor.

It is also pertinent to mention that the article says the woman had a living will. That is an advance health care directive, a legal document invented exactly for this type of situation: to declare that you have certain wishes regarding health care, life and death, and that you are of legal capacity to make those decisions. That is how they knew enough to judge that she should not be given treatment.