Wednesday, November 25, 2009

Amy Alkon on Negative Externalities of Breeding

Pamela Root got [a] free flight and [a $300 travel] voucher, plus an apology from Southwest, after her 2-year-old kept screaming ["Go, plane, go!" and "I want Daddy! I want Daddy!"] at the top of his little lungs as their San Jose-bound flight was about to take off. In fact, little Adam reportedly screamed so loudly that the safety announcements couldn't be heard and the pilot turned the plane back to the gate in Amarillo, Texas, where the two were booted off.

. . . Unbelievably, Root demanded the apology she eventually got from the airline (shame, shame, Southwest) and hit it up for the cost of diapers and the portable crib she says she had to buy for the overnight stay. Even more unbelievably, there's still no word of any apology from Root to the other passengers.

There is a notion, reflected in numerous blog comments about the incident, that other passengers should "just deal" and "give a kid a break." This notion is wrong. Parents like Root and others who selfishly force the rest of us to pay the cost of their choices in life aren't just bothering us; they're stealing from us. Most people don't see it this way, because what they're stealing isn't a thing we can grab on to, like a wallet. They're stealing our attention, our time and our peace of mind.

From "Screaming kids and airplanes: Mayday! Mayday!" in the Los Angeles Times, November 24, 2009.

Happy Thanksgiving!

Thursday, October 1, 2009

Is High IQ a Treatable Medical Condition?

I have argued for a right to suicide grounded in personal freedom and dignity; I have argued that there is, in addition, no right to forcibly prevent people from committing suicide. My views on this extreme example of patient choice still apply; but what about less extreme solutions to suffering?

The predominant view of medicine seems to be a doctor-controlled, paternalist one. We must all get a doctor's permission to access most drugs; most people apparently do not find this to be a serious intrusion into privacy and dignity. I think a better view of medicine is that of a doctor as a consultant, who assists the patient with medical knowledge and advice, but does not ultimately control the patient's treatment.

What is the purpose of medicine? (Please feel free to answer this below - it's not just rhetorical.) Is it to relieve suffering? To enforce proper behavior? To extend life? Certain definitions of medicine's purpose (like that last one) rely on idiosyncratic values that perhaps should not be forced on others. A fairly radical, but I think value-neutral, definition of the purpose of medicine might be: to assist patients in maximizing their own values by providing knowledge of human biological systems and applying available medical techniques as chosen by the patient.

One of these might be a prescription for Nembutal.

But another of these "available medical techniques" might help a patient reduce his general intelligence in various ways if it is a burden to him.

The DSM-IV definitions of diseases tends to include the rider that the symptoms "cause marked distress" to the patient. Perhaps it is time to consider whether conditions thought to be desirable that "cause marked distress" should also be treatable.

High intelligence is clearly treatable with a variety of substances and treatments, from ECT to antipsychotics to medical cannabis. If, say, extremely good memory or other symptoms of high intelligence are a burden to the patient, shouldn't he be entitled to use available technology to eliminate them? And why not have a physician's advice on how to do it in a manner that maximizes the patient's other values?

Is it different from suicide?

Monday, August 24, 2009

Habeas Corpus, Political Theory, and More

In lieu of me actually writing something, please take a look at post-length substantive comments by Zara here, here, and here, and also new comments by Shane.

Wednesday, June 24, 2009

The Underground Railroad

He might have done it for ideological reasons. He might have done it for money. I don't care. He is the motherfucking Underground Railroad to me. His name is Jeff George Ostfeld, and he was arrested recently for allegedly smuggling barbiturates into the United States - and potentially supplying these drugs to a 29-year-old Oregon woman who used them to commit suicide.
Authorities say Ostfeld, from Las Vegas, was carrying 1,200 milliliters of pentobarbital — vials with a picture of a Great Dane on the label — when U.S. officials stopped him May 18 at the Progreso International Bridge in South Texas. Officials said at a detention hearing last month that he was also carrying a camera with still photos of what appeared to be a deceased [Oregon woman Jennifer] Malone and videos that included what appeared to be her last words, "I'm scared."

At that May hearing, U.S. Immigration and Customs Enforcement Special Agent Robert Haberkamp III said Ostfeld, 33, told him that he planned to sell the remaining animal tranquilizers he bought in Mexico. He said he wanted to sell them to others seeking to end their lives, including a woman in the United Kingdom and a man in Australia, according to Haberkamp. He has not been charged in Malone's death.[Emphasis mine.]

Suicide is the only act that is not a crime, the assisting of which is a crime.

Fuck that. We would-be suicides are slaves. Those who would assist us, at the price of their own liberty, are no less heroes than the conductors and stationmasters of the Underground Railroad.

From the AP:

Malone's boyfriend, Tom Piazza, says she suffered from chronic depression and had attempted suicide before. But he says she couldn't have done it without help.

To me, it sounds like Jennifer Malone was in the same situation I am in - she was even within two years of my age. Would my last words have been "I am scared?" Possibly. But should that have any effect whatsoever on Ostfeld's criminal liability? How could it? Who would not be somewhat scared on approaching death? But a determined adult who ingests poison is the proximate cause of her own suicide - not the person who provided the poison to her. A person who provided pentobarbital to me would be nothing but an agent of my deliverance.

Ostfeld was charged with importing a controlled substance and intent to distribute.

Yes, let's keep that drug war going. It seems to be working out so far.

Tuesday, June 23, 2009

A Siblicide-Suicide

Followers of The View from Hell know a great deal about murder-suicide - characteristics of the typical shooter, the typical relationship between shooter and victim, etc. Enough to recognize how very, very strange this case of murder suicide is:
Pa. brother, sister die in apparent murder-suicide

YORK, Pa. - Police are investigating an apparent murder-suicide of a brother and sister in south-central Pennsylvania.

Sgt. Rod Varner of the York Area Regional Police says the man was in his 50s and the woman in her 40s. Their names have not been released.

The bodies were found inside an apartment around 9:30 a.m. Tuesday. The woman didn't show up for work at York Hospital, so a co-worker stopped by to check on her. The co-worker found the back door unlocked, discovered the bodies and called 911.

York County Coroner Barry Bloss says the deaths appear to be a murder-suicide , the two appear to have died of gunshot wounds sometime Sunday evening.

Bloss says there were no signs of a struggle inside the home. A gun has been recovered.

While filicide-suicide is fairly common, as is uxoricide-suicide and various combinations of the two, siblicide-suicide is nearly unheard of (thought it is almost certainly more common than stranger homicide-suicide). A murder-suicide happening at all in south-central Pennsylvania must be a very rare occurrence. But do the police in south-central Pennsylvania realize how very strange this particular murder-suicide is?

More details about the incident reveal that the situation of the shooter resembled a maternal filicide-suicide or paternal familicide-suicide in many ways, however:

David Stoner loved his sister, Kathy.

He protected and looked after his sister, who was mentally challenged. He made sure she made it to her job in food services at York Hospital.

But, according to neighbors, David Stoner was sliding deep into depression. He was angry and unhappy after losing his job as a mechanic about a year ago. He became more beaten down each day he could not find work.

The shooter's caretaking role toward his sister, coupled with the loss of his job, closely resemble the failed belonging/burdensomeness perceived by a suicide, and his relationship with his younger, disabled sister seems to be one that would clearly be a candidate for the proprietariness expressed by familicide-suicides.

Tuesday, June 16, 2009

Isadore Millstone


From the St. Louis Post-Dispatch:
Perhaps he wanted us to talk about it. How else to explain the public nature of his final act? In fact, it was the means of his death that most puzzled me. Why not a fistful of pills and a highball? That would have been the easy way. Pour a glass of the finest whiskey, cut it with sweet vermouth — whiskey lovers will argue that that is a waste of good whiskey, but a man about to enjoy a final drink should not worry about such criticism — and then wash down the pills and sip your drink. Let the caregiver find your body.

Maybe because they're fucking impossible to get, asshole.[1] Especially for a 102-year-old saint.


1. I don't actually think Bill McClellan is an asshole. Based on his article, I think he's kind of a mensch.

Wednesday, June 3, 2009

"I regard this as justice"

June Hartley of Lodi, California, was charged with "assisting a suicide" and "causing injury leading to death" for helping her brother to commit suicide. She recently pleaded guilty to a lesser charge of "being an accessory to a crime." (I thought suicide was not illegal?)

Her brother, blues musician Jimmy Hartley, had suffered a series of strokes which left him bound to a wheelchair and in constant neuropathic pain. Prior to his death, at age 45, he had begged others to help him end his life.

Both Hartley's lawyer, Randy Thomas, and the prosecutor in the case, Sherri Adams, expressed approval of the plea agreement.
"I regard this as justice," Thomas said. "It sent two messages: The district attorney had an acknowledgement [sic] that the law was broken but also that it was a unique situation involving mercy."

The prosecutor, Deputy District Attorney Sherri Adams, said the plea agreement was just. Adams said the District Attorney's Office must scrutinize cases of assisted suicide, which are illegal in California, to prevent malicious killings that are masked as merciful.

Hartley's actions, Adams said, were a genuine act of mercy.

"This case did not involve any ill will," Adams said. "The defendant violated the law out of love and support for her own brother." [Emphasis mine.]

Both Hartley's attorney and the prosecutor seem to agree that this is the correct outcome for a case of assisted suicide.[1] Adams and Thomas recognize two kinds of harm:

  1. The harm of living in misery and not being able to die (hence the recognition that the act of helping a person to die can be merciful or compassionate, and that such a person should not be punished);
  2. The harm of a "malicious killing" (presumably a murder, but perhaps something else is meant) going unpunished.

The statement that the outcome in Hartley's case is "justice" indicates that the correct balance has been struck between the two kinds of harm.

In fact, in this case the first interest - the right to choose death over suffering - is almost completely sacrificed at the expense of the second - punishing "malicious" killers. James Hartley's interests, and those of people like him, are ignored. Adams is concerned with "malicious" killers disguising their work as assisted suicide. But what about all the people suffering in misery, who have a longstanding wish to die, but cannot die because anyone assisting them will face prosecution? The idea that June Hartley's actions were "merciful" concedes that her brother had an interest in dying. Prosecuting people who assist suicides does nothing to protect that interest.

Also, as I have previously argued, prosecuting assisted suicides is an extremely poor way (in practical terms) to prevent malicious killings from being disguised as suicides. In Oregon and Washington, for example, it would be extremely difficult to make a murder look like an assisted suicide, at least a murder of a person ill enough to qualify for suicide assistance from a doctor. Since a comfortable means of assisted suicide is legal, with many safeguards to ensure that it is the true wish of the decedent, an "assisted suicide" by any other means would be unlikely and extremely suspicious. I assert that assisted suicide in Oregon and Washington is much harder to fake than in California - and, of course, the right to die is protected better there, as well. Both interests recognized by Adams and Thomas are poorly protected by the solution they claim is "justice."

Elsewhere on the web, TGGP rips apart Frontier Psychiatrist's definition of rationality, in the context of suicide ("Life is a disease, so cut the bullshit please."). Rationality in this context means that a decision is "characterized by reason or ‘makes sense’ to others," FP claims. I manage to comment in both places without rolling my eyes or sighing deeply.

And Bryan Caplan wonders why so few terminally ill people kill themselves.

1. The term "mercy killing" is often used in cases such as Hartley's. I think this term is misleading: "killing" implies that one person caused another person's death - such as by smothering or shooting the person - without his permission. In Hartley's case, she merely helped her brother achieve his own aim of dying. Helping someone to commit suicide who has a longstanding wish to die is not properly considered a killing.

Friday, May 15, 2009

Theories of Punishment

Suicide is the only action that is not a crime that may be prevented by force.

Criminal justice is the formal practice of preventing and punishing proscribed behaviors.

There are five generally recognized theories of punishment, in criminal justice terms:

  • General deterrence means making an example of a criminal so that the population at large will be deterred from committing a crime.
  • Specific deterrence refers to punishing an individual criminal so that he or she will "think twice" and be deterred from committing a crime in the future.
  • Incapacitation means isolating and/or restraining a criminal so that he or she will not be able to commit a crime for the duration of the incapacitation.
  • Rehabilitation refers to providing assistance to a criminal so that he or she will not want or need to commit a crime in the future.
  • Retribution involves taking revenge on a criminal for the crime that he or she committed.

Deterrence, incapacitation, and rehabilitation models aim to prevent crime. Deterrence and rehabilitation models operate on the criminal's mind, whereas the incapacitation model operates only on his body.

Suicidality is often considered to be a mental illness, properly considered to be within the purview of medicine; however, the interventions that are commonly undertaken in cases of suicidality demonstrate that the act is properly viewed as part of the criminal justice model.

The key feature of suicide: it is the only action that is not a crime that may be prevented by force.[1]

The prevention of suicide generally takes punitive, rather than medical, form. Generally, the methods used are incapacitative:

Because [preventing a determined person from committing suicide] is impossible, psychiatrists enjoy (if that is the right word) virtually unlimited professional discretion to employ the most destructive suicide-prevention measures imaginable, provided the measures are called "treatments." The authoritative American Handbook of Psychiatry (1959 edition) endorsed lobotomy "for patients who are threatened with disability or suicide and for whom no other method seems likely to relieve or restore them." In the 1974 edition, lobotomy was replaced by electroshock treatment administered in sufficient doses to destroy the subject's will to kill himself: "[W]e do advocate its initial use for one type of patient, the agitated patient, often middle-aged and usually a man, who presents frank suicidal intention. We give ECT [electroconvulsive therapy] to such a patient . . . daily until mental confusion supervenes and reduces the ability of the patient to carry out his suicidal drive." Thomas Szasz, Fatal Freedom: The Ethics and Politics of Suicide, pp. 56-57 (citations omitted). [Emphasis mine.]

However, often the methods used are so obviously unpleasant that they fall under the deterrent models as well - if not the retributional models!

In they Army, anyone reporting suicidal ideation is made to wear a bright orange vest and rubber bands in place of his shoelaces - not to mention watched 24/7 by a "buddy." As reported by Elspeth Reeve:

Suicide watch (also called unit watch, buddy watch, or command interest profile) is how the Army deals with soldiers in garrison who express suicidal thoughts but don't appear to be in immediate danger of harming themselves. It's been around in some form since the 1980s, and generally involves a suicidal soldier being watched by one or two fellow soldiers around the clock, and having his gun, shoelaces, and belt taken away, so he can't kill himself.

. . . . "You're in an isolated state," [a recruit who was under suicide watch] says. The orange vest makes you a pariah. "You've got the reason you're on suicide watch to begin with on top of the fact that you stick out like a sore thumb," he says. "It's like you're walking around in a zoo, and you're the animal."

. . . . The purpose of the vest is, ostensibly, to make it easy for others to keep an eye on a suicidal soldier, but forcing a soldier to advertise his own depression creates a powerful stigma. "When you see what happens to someone on suicide watch—the orange vest, the trips to the chaplain, the drill sergeant talking about them when they're not there, saying they can't handle the military. … When you see that, you're going to think twice about speaking up and saying you need some help. It makes you not want to talk to someone. You don't want to be like that guy," the recruit from Benning says. [Emphasis mine.]

The Army's treatment of suicidality is clearly punitive. Indeed, there is a strong incentive for soldiers to express insincere suicidality - that is, removal from combat duty. This would make it seem rational for the Army to institute counterincentives (conceding, implicitly, that suicidal behavior is rational in that it responds to incentives). But, as Reeve indicates, the punishment also dissuades genuine suicides from disclosing suicidal ideation.

At any rate, the "treatment" is clearly not rehabilitative, but punitive. General and specific deterrence are at work here, as well as incapacitation.

Similarly, from prisons to mental hospitals, disgusting and punitive "interventions" are used to prevent suicide. This is "mental health treatment" only in the most crudely and obsoletely behavioralist sense. Humiliating heavy dresses/smocks, presumably worn without underwear, are placed on male and female prisoners (of hospitals and prisons) to prevent them from committing suicide.[2] Again, general and specific deterrence are operative, as well as incapacitation. The smock is awful and undesirable, in addition to preventing one from enacting one's suicidal wishes.

If suicide is a symptom of a mental illness, though, wouldn't the distress be treated - not the action? People with trichotillomania do not have their hands forcibly restrained from touching their heads. Rather, the distressing compulsion to pull one's hair is treated - and that only if it distresses the patient in the first place. In the case of suicide, however, the distress of everyone except that of the suicidal person is considered. If suicidal ideation does not cause one marked distress, why is it a mental illness?

The truth is that, despite the ostensible decriminalization of suicide, modern society still encounters suicide under a criminal model. The extreme position of Justice Scalia is, unfortunately, the one tacitly held by our government in general:

"At common law in England, a suicide - defined as one who "deliberately puts an end to his own existence, or commits any unlawful malicious act, the consequence of which is his own death," 4 W. Blackstone, Commentaries *189 - was criminally liable. Ibid. Although the States abolished the penalties imposed by the common law (i.e., forfeiture and ignominious burial), they did so to spare the innocent family, and not to legitimize the act." Cruzan v. Director, MDH, 497 U.S. 261 (1990).

Thanks Rob Sica.

1. I realize it may be necessary to distinguish civil injunctions, and civil contempt actions, here. Civil injunctions are ordered only in the case of irreparable harm to others. And, to be punished - by fine or jail - a contempt action must be proved beyond a reasonable doubt. Neither of these criteria are in place in the case of suicide. And, just to be clear, civil injunctions are by far an exceptional case. Money damages are by far the preferred remedy, when they are at all applicable.

2. Gawker says, "It's weird these models don't get more work! They are really selling the look. 'Show me 'I sure wish I could kill myself but this smock is impossible to rip into strangle-friendly strips'! Perfect.'"

Tuesday, May 12, 2009

With a .22

I. Fourteen Shots

He shot himself fourteen times with a squirrel rifle. "It is probably the most incredible kind of suicide I have ever seen," says P. Boxho, reporting the case in the Journal of Forensic Science ("Fourteen shots for a suicide," 101:1:71-77, 1999).

The man, a 56-year-old Belgian, used such a low-energy weapon (.22 LR cartridges in a 22 mm rifle) that he had to shoot himself fourteen times in the chest in order to effect his end - and, even after fourteen shots, his death was slow. He had to operate the bolt of his rifle between shots, and, most incredibly, he had to reload after the first seven shots. According to Boxho,

The last bullet was certainly the one that went through his left arm for, with a humerus fracture and the fatigue generated by developing hypovolemia, it was getting impossible for him to reload the gun and to keep shooting.

So he had to lie down in the position in which he was found and to wait for death to come.

That death was certainly very slow for, considering their trajectories, the projectiles could only go through his lung, maybe skim past his heart, causing a slow haemorrhage, responsible for death by a hypovolemical shock.

II. Christmas Money

Mychal Bell, best known as one of the Jena Six, shot himself with a .22 pistol. Bell became despondent after being charged with shoplifting, he says.

Police say surveillance video appears to show Bell stuffing merchandise into a bag in a Dillard's store while another male seems to serve as a lookout.

Bell walked out with the bag without paying, officials said, and a security guard approached and took it from him. Police said Bell and the other male fled, and guards chased Bell because he'd had the bag. Authorities say it contained $370 worth of clothes.

Bell hid under a car in the parking lot, and as a store security officer tried to pull Bell out, he hit the guard in the face with his elbow, police said. Bell, who was charged with shoplifting, simple battery and resisting arrest, was released on bail, according to authorities.

Investigators don't know who the other male was, and Bell "admitted to everything" to a detective, Lt. Jeff Harris said.

He decided to use his Christmas money to buy a gun, and eventually obtained the .22-caliber handgun. And then he "went awry" at his grandmother's house, he said.

He aimed it at his head and pulled the trigger, he said, but the gun misfired. Then he pointed the gun at his chest and fired. The bullet clipped his lung, and he was taken to the hospital and treated. It is not clear who found him, or whether he was alone in the house at the time of the shooting.

Does someone who shoots himself in the chest with a .22 really mean to die? It seems that our Belgian man did. However, given the limited availability of reliable means of suicide, I think it is best not to make a hasty judgment that someone did not want to die, and was merely seeking attention and sympathy, based only on the choice of an ineffective method. Perhaps an ineffective method is all the potential suicide could access.

III. Low-Energy Weapons

The term "multiple gunshot wound suicide" is often used sarcastically - a joke, meaning that the alleged suicide was really a homicide, but was (poorly) made to look like a suicide. However, about 1% of gunshot suicides involve multiple wounds. The majority of these multiple gunshot wound suicides involve those aforementioned squirrel guns (or plinkers) - .22 caliber handguns. A .22 is such a low-energy weapon that a single shot may not be enough to bring about death.

IV. Suicide Black Widow

Terry Cottle shot himself behind his right ear with a .22-caliber handgun in 1995. His wife, Cheryl, was present at the time of his death.

Initially, Cheryl told sheriff's investigators she heard 10-year-old Christopher shouting that Cottle had shot himself. She said she ran into the bathroom and found him on the floor with the revolver still in his hand.

In a second version attached to a coroner's report, Cheryl said she was eating oatmeal when one of her boys yelled, "Mom, Dad has a gun!" She said she ran toward the bathroom "and saw Terry standing up and looking at her" with the gun in his hand.

"She said that she yelled something like, `Terry, wait!', and this was at about the same time as she pushed on the door to try to get into the bathroom and at the same time she heard a shot," the report says.

Cottle was taken to the hospital, but was removed from life support and his organs donated. 57-year-old Sonny Graham received Cottle's heart.

What makes the story, though, is that a few husbands later, Cottle's widow Cheryl married Sonny Graham.

Then Graham shot himself.

If your mind weren't poisoned with Cheryl's sordid history and strange behavior, you might be tempted to romantically contemplate "cellular memory" or something. But the story seems darker. There were other gun incidents involving her other three husbands. And there's this shocking failure of proper feminine decorum and chastity:

On her MySpace account - now deactivated - her photo changed from a sweetly smiling portrait to pictures of her on a lake or drinking beer with friends. Her screen name changed, too, from simply "Cheryl" to "PrEttY LAdy," then "BeaUtiFuL MeSs."

Family members monitoring the account noticed that shortly after Graham's death, she posted a man's photo identifying him as her "new boyfriend." A flirtatious message on the man's Web page, from her account, was dated March 26 - six days before Graham's death.

I find this story remarkable because it is the first time I've ever seen a mainstream news outlet imply that a suicide was caused by another person - rather than by, say, mental illness. "Implied" may be too soft a word:

As far as [Cottle's sister] was concerned, Graham's death was less about her brother's heart than about Cheryl - the woman with whom both men had chosen to share it.

Saturday, May 9, 2009

Why Physician-Assisted Suicide is Not Good Enough

The political position in favor of a general right to suicide has few advocates; in terms of numbers, it is a rather extreme position. Much more common - common enough to be the majority in a few states - is support for a limited right to suicide for terminally ill people, with physicians as gatekeepers for that right.

I have often written on why restricting suicide rights to terminally ill people makes no ethical sense. But there is another major problem with "Death With Dignity" laws like that of Oregon and Washington: physicians are the gatekeepers to the right to suicide, taking control of death away from the individual. "Patients" must depend on physicians in order to be allowed to die. And enough physicians are refusing to "assist" that the right to suicide is empty of practical meaning.

It has been months since Washington's Death With Dignity law passed, which allows a terminally ill person to access a prescription for a lethal drug. But the scheme requires the cooperation of doctors; and in areas outside Washington's big cities, doctors simply aren't cooperating, reports Kim Murphy in the Los Angeles Times ("In rural Washington state, law allows assisted suicide, but most doctors don't," May 7, 2009).

Personally affected by this injustice was Stephen Wallace, a victim of terminal pancreatic cancer. Wallace was unable to find a single physician in his area willing to make the lethal prescription at his request. From the article (emphasis mine throughout):
Cancer of the pancreas has a cruel reputation, delivering what some say is the most intense pain humans can imagine. It killed Wallace on April 8.

"It was very hard to watch my father die that way," said Tricia Crnkovich, who took turns with her brothers and sisters in Wallace's small bedroom as he shrank from 250 pounds to 60, losing most of the weight in the two months before he died. "I'll tell you, if I ever get cancer," she said, "I don't want to put my kids through that."

Wallace's treatment at the hands of medical professionals was appalling. Even beyond the fact that his request to die was ignored, his pain was not being adequately managed because of "concerns" of his nurses.

. . . . Crnkovich said her father had been given strong medications when he went home from the hospital, but that his nurses had resisted increasing the dosage as his pain grew more intense.

Soon Wallace's mental state began to deteriorate. Because the assisted-suicide law requires a 15-day waiting period between the first oral and the first written requests for lethal medication, and an additional 48 hours before the prescription can be written, he no longer qualified.

"He couldn't talk for the last eight days," son Steve Wallace said. "He was not in contact with reality. I'd come in there, and he'd call me somebody else."

Mr. Wallace's nightmare had come true. He had, the article states, watched his wife die of cancer, in miserable and unrelieved pain; he did not want to die like that.

Near the end, Steve and Ginny could hardly stand to be in the house because his father was in so much pain. By the time the doctor said his medication should be increased despite the nurses' concerns, it was too late.

"He was just moaning and screaming, and it got really bad on Friday," Ginny said. "By Monday when we left, he was just screaming at the top of his lungs."

Meanwhile, major hospitals in Washington are refusing patients' right to die as a matter of policy, making the extremely limited right to "Death With Dignity" even more meaningless. From the Seattle Times:

Olympia area hospitals won't offer assisted suicide services

OLYMPIA — Providence St. Peter Hospital and Capital Medical Center officials said Thursday that the hospitals will not participate in physician-assisted suicide under the state's new Death with Dignity law, but instead will refer terminally ill patients to their primary doctors.

Providence Health & Services spokeswoman Karina Jennings said Thursday that the same standard applies for all of its medical facilities and nursing homes in Washington and Oregon. The key reason: Providence is a Catholic health care organization, and physician-assisted suicide is "not a path conducive to our values," she said.

"We don't believe that health care providers should be put in the position of taking someone's life," Jennings said.

Because of its extensive involvement in health care, the Catholic church is able to impose its values on millions of non-Catholics - and Washington's law does nothing to prevent this. We have already seen the morally repugnant position of the Catholic Church on assisted suicide and suffering: suffering is good for you. Says the Most Rev. Carlos Sevilla:

Initiative 1000 is an attack on our most fundamental beliefs and teaching, and placing it on the November ballot would contradict our proclamation of the gospel of life . . . Pain and suffering and illness are important parts of our faith experience. [Emphasis mine.]

He would probably be so bold as to say to Stephen Wallace's children that screaming at the top of his lungs in pain as he died was an important part of Wallace's faith experience. Which might have come as a surprise to Wallace.

The ethical arguments about physician-assisted suicide often focus on physicians' autonomy, emphasizing the right of a physician to avoid helping someone commit suicide (or, as hospital spokeswoman Karina Jennings misleadingly puts it above, "taking someone's life"). But the physician's "right" must be considered against the background of "rights" that have, in our system, been taken away from the patient and given to the physician. Perhaps a physician shouldn't have to assist in a suicide; but the patient will not be able to help himself and exercise his own autonomy without the physician's action, because of the drug prohibition. The only comfortable sort of suicide - a suicide by overdose of fast-acting barbiturates - is only "assisted suicide" in that competent adults are generally prohibited from accessing the necessary drugs. Given our existing laws, it is either naive or cruel to refuse physician "assistance" (drug provision) to a would-be suicide.

At any rate, suicide should not be a medical matter. Physicians should not be the gatekeepers of suicide rights - it is unfair to physicians and unfair to people who want to die. The choice to die, and the responsibility for the act, should fall on the individual, not on his physician. From Thomas Szasz, in Fatal Freedom: The Ethics and Politics of Suicide:

Although performing an abortion and developing effective methods of birth control entail the use of medical knowledge and skill, abortion and contraception are not medical matters. The same is true for suicide. Although killing oneself with a drug entails the use of medical knowledge and requires access to the necessary substance, suicide is not a medical matter. We ought to deal with death control the same way we have dealt with birth control: by removing it from the purview of Medicine and the State, by repealing all medical and legal interference with the act. [Bolded emphasis mine; italics in original; citations omitted.]

Thursday, April 30, 2009

The Rape Doctor Hypothetical

Dr. A is a research psychologist who also has a private clinical practice. He specializes in treating Female Sexual Arousal Disorder (DSM-IV 302.72) - similar to what used to be called frigidity. Female Sexual Arousal Disorder consists of a persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement. The inability must cause marked distress or interpersonal difficulty, and is not better accounted for by another disorder (e.g. depression), a general medical condition, or substances, including medication. From the DSM-IV:
The individual with Female Sexual Arousal Disorder may have little or no subjective sense of sexual arousal. The disorder may result in painful intercourse, sexual avoidance, and the disturbance of marital or sexual relationships.

Dr. A has identified a syndrome (a cluster of symptoms) common to a subgroup of his FSAD patients with a particularly severe version of FSAD - Criteria A, B, C, and D. Members of this subgroup, he believes, are unable to achieve sexual arousal except in cases of forced sexual contact. A highly statistically significant number of patients who meet Criteria A, B, C, and D who have been raped report the rape as their only enjoyable sexual experience, compared to rape victims who do not meet the criteria. Dr. A labels his syndrome Forced Sexual Contact Arousal Syndrome (FSCAS). Based on his research, Dr. A has statistical grounds to believe that, of FSAD patients who meet Criteria A, B, C, and D, 99.9% will experience sexual enjoyment exclusively from forced sexual contact. Beyond that, Dr. A notices that his FSCAS patients who have been raped are much more socially and emotionally well-adjusted than those who have not. It is statistically reasonable for him to believe that, out of 1000 patients with FSCAS who have not been raped, 999 will experience a great deal of sexual enjoyment and a much better quality of life if raped; one will experience the usual extreme distress that rape would cause a normal woman.

You can probably guess where I'm going with this. Should Dr. A rape his FSCAS patients?

I think it's hard to answer anything but CHRIST, NO! to this one. The harm of rape is so intrusive and severe that any possible benefits to its victims simply do not count against the harm that may be sustained. It is not conscionable that one person should be raped to provide a pure benefit to even 999 others. (Note, however, that it may be moral to allow the rape of one person in order to prevent extreme harm to an enormous number of others.) Both those who identify as consequentialists and those who subscribe to a more deontological perspective would likely share this conclusion (though some more extreme consequentialists would not).

I have highlighted the common intuition that, in the case of a serious violation or harm, the possible benefits do not count against the possible harms (in an essay about dosing someone with ecstasy against his will - see Inflicting Harm and Inflicting Pleasure on Strangers). My correspondent Arthur Tilley points out that there is a limit to this intuition, however. While the intuition about the ecstasy case is strong, he says, "we probably can't say that doing nothing is ALWAYS better than taking a (teeny tiny) chance at doing harm." His example:

Consider my setting up a cookie stand by the side of the road and offering free cookies to passersby. It is probably reasonable to
assume that a percentage of the population (one not nearly as high as the percentage that doesn't like being dosed, but still nonzero) has some sort of phobia of cookies or aversion to being offered free things.

But it seems that in these cases where the probability of harm is really low, the action (in this case, having the cookie stand) is morally permissible.

Arthur's insightful example illustrates that, though the intuition that inflicting serious harm to strangers cannot be offset by providing them pleasure, taking a chance on inflicting minor harm to strangers can definitely be balanced by the probability that one will do them good. How could we live otherwise, since all actions or inactions entail some possible unconsented harm? The morally restricted action is one that will produce serious or especially intrusive harm.

One antinatalist argument, propounded by Seana Shiffrin, is based on just this intuition: that, while it is fine to inflict harm on a stranger in order to prevent greater harm (e.g., to break his arm in order to rescue him from a burning car), it is not permissible to inflict harm on a stranger in order to provide a pure benefit.

A major, though often unspoken, point of contention between pronatalists and antinatalists is what counts as harm. Pronatalists often only admit that harm has occurred through procreation if, on balance, the person brought into existence finds his life not worth living. Since most people report finding their lives worthwhile, to a pronatalist, the risk of "harm" in bringing a being into existence is slight.

Antinatalists, on the other hand, recognize as harm all suffering inflicted on a being who is brought into existence - pain, hunger, unrequited love, violence, sickness, aging, and ultimately death. Most lives include positive aspects such as pleasure, love, and a sense of meaning - but the persons experiencing these benefits also experience extreme harm - at the very least, the harm of death.

Dr. A may not chance inflicting the harm of rape on a patient in order to likely provide her with pleasure and increased quality of life. It follows that, since the harm of life (separate from its pleasure and meaning) is so serious and so great, it may not be inflicted on a person in order to provide him with a pure benefit (that is, the pleasure and meaning of life). The harm of life is not slight or unlikely. It is extremely great. The pleasures and benefits are also likely and extremely great; what I wish to illustrate is that, in similar cases, that simply does not matter.

Thursday, April 9, 2009

Censoring Murder-Suicide: What If Everything Is Contagious?

Ecological studies suggest that highly publicized suicides cause more suicides. But what other behaviors are media-contagious - and why are we so slow to censor (or even study) them?

Idea Contagion

For good or ill, behaviors among humans pass not only by genes, but by language. A judgmental way to put this is that behaviors and ideas are "contagious." Pathological homesickness, apotemnophilia,[4] multiple personality disorder, and even Ursuline convents in seventeenth-century France[6] have been posited to arise from contagion.

In particular, suicide is widely accepted as a contagious behavior. The posited contagion even has a name - the "Werther effect." Belief in the media contagion of suicide is so strong and pervasive that "media guidelines" - a form of voluntary censorship - are widely observed in reporting on suicide.

There is evidence that many behaviors other than suicide are similarly "contagious," however. Violence against others, in particular, is well-studied in its relation to media contagion. The harm of violence, especially homicidal violence like murder and murder-suicide, is much greater than that of suicide. And the evidence in favor of "violence contagion" is stronger than that of suicide contagion. Why, then, are reports of suicide voluntarily censored, while reports of violence are not?

Suicide Contagion: The Evidence

The evidence for suicide contagion through the media is almost entirely ecological. The studies that provide the basis for the phenomenon of suicide contagion are somewhat questionable.[7] Many suffer from lack of control for important variables; those that are controlled suffer from problems with the control groups or small sample size. Some ecological studies have indicated that the suicide contagion phenomenon is real;[2] others have contradicted those findings. Even among studies that find a correlation between suicide rate and media reports of suicides, the correlation is often much weaker than the correlation of the suicide rate with other factors, such as the unemployment rate.[9]

Of course, there is a more abstract critique of ecological-level data in general. A criticism[1] of David Phillips' ecological data on suicide contagion and fatal aircraft incidents goes as follows:

Phillips asserts that the statistically significant increase in aircraft fatalities can be explained due to suicide, as well as a "consciously or unconsciously" induced motive on the part of the pilot to also murder some person or persons. What Phillips does, in effect, is impute suicidal motives to some deceased persons on the basis of the statistically significant increases in accidents. Such a jump is conceptually unwise because it is based on a tautology: the statistical increase is the basis for defining some cases as suicide, but these cases are also used to explain the increase. [Citations removed.]

At any rate, a major problem with suicide contagion research is a lack of empirical evidence at an individual level. The one case-controlled study that I am aware of[7] fails to demonstrate any link between hearing media reports of suicide and making a suicide attempt - and, in fact, demonstrates that hearing a media report of suicide has a significant protective effect against suicide attempts.

The study authors interviewed 153 people, ages 13-34, who were "victims" of nearly lethal suicide attempts and who had been treated at local emergency rooms in the Houston, Texas, area. A control group of 513 subjects was similarly interviewed. The conclusion? Not only did the study fail to demonstrate any sort of "suicide contagion," but, as mentioned above, the authors note a statistically significant protective effect when a subject heard a news report of suicide within 30 days prior to the suicide attempt or had a friend or acquaintance make a suicide attempt. That is, the ER suicide-attempt group was actually less likely than the control group to be aware of a recent media report of a suicide, or to have experienced the suicidal behavior of an acquaintance! The suicide attempt of a parent or relative had no statistically significant effect on suicidal behavior, whereas the usual "suicide contagion" sources had a statistically significant protective effect - the opposite of what the suicide contagion model predicts.

Violence Contagion?

The evidence for violence contagion is much stronger than that for suicide contagion. But whereas suicide censorship is widely accepted, censorship of other-directed violence in media stories is rare.

Violence contagion is demonstrated by the same type of ecological study as suicide contagion.[8] In addition, unlike the suicide case, there is a body of laboratory evidence suggesting that exposure to violent stimuli increases aggressive behavior. However, despite both sources of evidence, the theory that media reports of violence "cause" real-life violence is not at all universally accepted.[5] And the idea that the media should voluntarily self-censor with regard to reports of violence is much less widely accepted than self-censorship of reports of suicide, despite greater evidence for a causal link in the former case.

Contagion and Moral Responsibility

I believe that the insistence that suicide is media-contagious, but violence is not, is not rational, but is a consequence of the differential attributions of moral responsibility in cases of suicide versus other-directed violence. Suicide is seen as an irrational act; the actor, as the story goes, is not in control of himself, certainly not sane, and is therefore vulnerable to external effects.

On the other hand, the idea that violent acts like homicides are attributable to media suggestion is generally seen as a pathetic excuse. Perpetrators of violence are perceived as much more morally responsible for their acts than suicides; despite evidence to the contrary, idea contagion is psychologically ruled out as a cause of violence, but not of suicides (though there are exceptions to this line of thinking[3]).

Is political corruption contagious? Adultery? Prostitution? Drug abuse? Such questions are rarely even studied. Obesity certainly appears to be contagious. If so, should we censor reports of these topics to avoid a contagion effect? To do so would seem ludicrous and counter-productive, not to mention contrary to our political ideals. But the censorship of suicide goes unchallenged.

Moral Responsibility and Willingness to Censor

The more an actor is seen as the agent of his actions, the less outside influences are seen as affecting his actions. Therefore, in cases where moral responsibility is strongly attributed to an actor, outside influences are unlikely to be taken seriously as a cause of his actions - and, therefore, it is not necessary to censor these "outside influences" (such as media reports).

It is my belief that the widespread voluntary censorship of reports of suicide - from use of politically correct language to pervasive norms of message content - are the result of the modern trend to exculpate suicides from moral responsibility and redefine suicide as an act of insanity. There is, however, little evidence that suicides are any less morally responsible for their actions than murderers. Certainly, many other behaviors are media-contagious - but they are not censored, nor are many of them even studied.

I think that one possible explanation is that, at a deep level, people understand that suicide is just not that bad compared to actual acts of violence - despite hysterical language describing suicide as "self-murder." We want to exculpate people from acts to which we are sympathetic. While we often refuse to define acts outside of societal norms as "not wrong," we may nonetheless refuse to attribute full moral responsibility to these acts. However, this sort of sympathy backfires in our society. People who are "not responsible for their actions" must be "protected," often in painful and dehumanizing ways; and society is responsible for their "protection," often to the detriment of freedom.

Think of the children.

On a largely unrelated note, could this be the stupidest news story about suicide of all time?

Works Cited

1. Altheide, David. "Airplane Accidents, Murder, and the Mass Media: Comment on Phillips." Social Forces 2:593-596 (Special Issue, 1981).

2. Bollen, Kenneth, and David Phillips. "Imitative Suicides: A National Study of the Effects of Television News Stories." American Sociological Review 47:802-09 (1982).

3. Coalition of Law Abiding Sporting Shooters. "Ideas Kill: Science Shines a Light on Port Arthur Deaths." Retrieved from on 04/06/2009.

4. Elliot, Carl. "A new way to be mad." The Atlantic, December 2000.

5. Gunter, Barrie. "Media Violence: Is There a Case for Causality?" American Behavioral Scientist 51:1061 (2008).

6. Jones, Marshall, and Elizabeth Rapley. "Behavioral Contagion and the Rise of Convent Education in France." Journal of Interdisciplinary History 31.4:489-521 (2001).

7. Mercy, James, Marcie-jo Kresnow, Patrick W. O’Carroll, Roberta K. Lee, Kenneth E. Powell, Lloyd B. Potter, Alan C. Swann, Ralph F. Frankowski, and Timothy L. Bayer. "Is Suicide Contagious? A Study of the Relation between Exposure to the Suicidal Behavior of Others and Nearly Lethal Suicide Attempts." (American Journal of Epidemiology 154:2 (2001).

8. Phillips, David. "The Impact of Mass Media Violence on U.S. Homicides." American Sociological Review 48:4:560-568 (1983).

9. Stack, Steven. "Divorce, Suicide, and the Mass Media: An Analysis of Differential Identification, 1948-1980." Journal of Marriage and the Family 2:553-560 (1990).

Monday, April 6, 2009

Disincentives, Time Horizons, and the Irrational Continuation of Life

Social science researcher David Phillips was a pioneer in the theory of suicide contagion. His research has also focused on other fascinating correlates of suicide (and other fatalities), such as day of the month, public holidays, and birthdays.

As these last few professional interests suggest, identification of dates has been important to Dr. Phillips. A 1988 paper * focused on potential difference between deaths from suicide and the suicidal acts or injuries that preceded them. A significant difference in date of suicide attempt and date of death would, of course, be relevant to Dr. Phillips' studies on how date affects suicide rates.

The motivation for the paper is a 1985 study on a San Diego population that found a whopping 22% difference between date of injury (suicide attempt) and date of death in cases of suicide. The San Diego study analyzed 204 cases of suicide; its findings cast doubt on whether date of death was a good proxy for date of suicidal act.

Phillips and Sanzone, however, studied a much larger sample - 42,698 suicides throughout California - and found that 92.6% of suicide deaths occur within one day of the precipitating suicidal act. In terms relevant to my project, that means that only 7.4% of people who commit suicide have to suffer more than a day before dying.

7.4%. About one in fourteen.

To a potential suicide, this is terrifying - not least because these are the people who succeed. This doesn't even include the suffering of those who attempt suicide but fail - and are left miserable, with grievous injuries, trapped in a life worse than the one they attempted to leave.

If life is so bad, though, wouldn't it be worth the risk?

The problem is a possibly irrational time horizon perceived by the potential suicide.

When we decide whether to commit suicide (to shoot ourselves in the head, say, or mix up some community-endangering hydrogen sulfide gas), the risks and benefits of suicide should, rationally, be weighed against the risks and benefits of continuing to live. But "continuing to live" for how long? One rational-sounding candidate would be "continuing to live out one's natural life span." Indeed, for most of us, continuing to live our natural life span is unthinkably horrible - much, much worse than the considerable risks of a careful suicide attempt.

But one's natural life span is difficult to consider. The more tempting, and probably irrational, option - one I find myself preoccupied with - is to weigh the risks and benefits of a suicide attempt with the risks and benefits of living another day or week. Perhaps next week drugs will be legalized. Perhaps next week one will die in an automobile collision or be diagnosed with a fatal illness. Living another day, another week, another month, even six months, is certainly no worse than the alternative - risking extremely serious harm from a suicide attempt. As Dr. Phillips and others demonstrate, even the ones who succeed risk extreme and prolonged suffering.

This is yet another way in which the suicide prohibition encourages irrationality. This is neither just nor compassionate.

*Phillips, David, and Anthony Sanzone. "A Comparison of Injury Date and Death Date in 42,698 Suicides." American Journal of Public Health 78:5:541 (1988).

Rich, Charles, Deborah Young, Richard Fowler, and S.K.S. Rosenfeld. "The Difference between Date of Suicidal Act and Recorded Death Certificate Date in 204 Consecutive Suicides." American Journal of Public Health 75:7:778 (1985).

Friday, April 3, 2009

Murder, Suicide, and Murder-Suicide

The characteristics of murder-suicides differ dramatically from those of simple murders and suicides. What the fuck is going on?

Murders and suicides are individually so common as to rarely merit reporting in the press. Combined murder-suicides are much more rare, but, like simple homicides and suicides, occur with clockwork regularity.

It can be difficult to understand why suicides happen. Is it insanity? Impulse? Crippling despair? If so, why that particular impulse, and why that particular self-destructive despair?

Suicide seems like the most irrational of acts, if not in personal terms than at least in terms of evolutionary fitness. Doesn't suicide cut off one's chance to survive and reproduce?

There are, however, reasons to think that the impulse to self-destruction is often one that is conducive to inclusive fitness, or would have been conducive to fitness in recent environments of evolutionary adaptedness.

Murder is somewhat more understandable without doing genetic math. Despite the modern state prohibition on murder and murder's consequent fitness costs, there is every reason to suspect that most murders are fitness-promoting.[8]

Some murders, however, are not in themselves fitness-promoting, but nevertheless appear to occur as the most extreme effects of a generally fitness-promoting drive. Male violence against women, for instance, seems to be commonly motivated by actual or suspected infidelity, and is of course an effective tool for controlling women and discouraging fitness-damaging adultery. As Johan van der Dennen puts it in his review of David Buss' The Murderer Next Door: Why the Mind is Designed to Kill,

Traits that have been subjected to natural selection often overshoot and undershoot the exact optimum in terms of their reproductive advantage.[10] [Emphasis mine.]

By far, the most common victims of a murder-suicide are one's spouse and/or children. Why would anyone commit such a fitness-damaging act? If they are truly inexplicable flukes, why do murder-suicides happen with such regularity? The Violence Policy Center reports that

Medical studies estimate that between 1,000 and 1,500 deaths per year in the United States are the result of murder-suicide. [Violence Policy Center] analysis reveals that, in the first half of 2005, there were 591 murder-suicide deaths, of which 264 were suicides and 327 were homicides. Using these figures, more than 10 murder-suicide events occur in the United States each week.[11]

There are many factors that indicate that the presumed fitness-promoting motives for murder are not present in homicide-suicides. Children killed in murder-suicides are significantly older than children killed in simple filicides.[12] Infants are the most frequent victims of simple filicide, with rates of filicides falling for preschool children and reaching a low point among elementary school children; child victims of murder-suicide, however, are most likely to be elementary school children and least likely to be infants.[9] An infant is much less valuable in fitness terms than an older child; the murder-suicides therefore seem paradoxical.

In addition, biological children are significantly more highly represented among murder-suicide victims than among simple filicide victims.[13] This is especially remarkable, note the authors of one study, because

the familicide victims’ ages averaged substantially older; this age difference should have had an opposing effect since 12-year-olds (the mean age of familicide victims) are much more likely to have had stepfathers than 4-year-olds (the mean age of other filicide victims). [13]

Of course, killing a biological child is likely to be fitness-threatening, whereas killing a stepchild is likely to be fitness-enhancing; again, the murder-suicide data is perplexing in evolutionary terms.

Another data point is the extreme underrepresentation of women among perpetrators of homicide-suicide, as compared to simple homicide and suicide. Women commit suicide at about a quarter the rate of men in the United States, and kill their spouses at about 75% of the rate at which men kill their spouses.[12] But out of 264 murder-suicide perpetrators in the first half of 2005, only 16 were female.[11] (In contrast, of the 327 murder-suicide victims in the same period, 255 victims were female and 72 victims were male.) Females are particularly underrepresented among perpetrators of familicide, a variety of murder-suicide in which a perpetrator kills both a spouse and one or more children. One study of filicide-suicides [9] found that half as many women as men commit filicide-suicide, but that

[s]ixty-five percent of the fathers attempted to kill their wives as well as their children, whereas no mothers attempted to kill their husbands. In all, 55 percent of the fathers, but none of the mothers, attempted familicide, that is, annihilation of the entire family. [Emphasis mine.]

In simple spousal homicides, as noted above, jealousy is the typical motive. But jealousy is rare as a motive in murder-suicides. Bossarte et al. (2006), using data from the National Violent Death Reporting System, found that only 1.9% of murder-suicides during the study period were associated with jealousy.[5] *

Yet another salient difference between murder-suicides and simple homicides is the victim-offender relationship. Homicide-suicides differ from homicides in that a significant majority of homicide-suicides - ranging from 66% to 84% in various studies - involve killings of "intimate partners." [2] (As noted above, almost all these victims are women.) In contrast, only between 5.2% and 19.2% of simple homicides are wife killings. [7]

The correlation works in both directions. Not only are homicide-suicides more likely to involve intimate partners than simple homicides; intimate partner killers are much more likely to commit suicide than killers of other victims. One study found that only 5% of all homicides were followed by a suicide attempt, but "among men who killed their female intimate partner with a firearm, 59% also took their own life."[3] Another study found that "among male perpetrators, nearly one third (30.6%) of those who killed their intimate partner (n = 438) also ended their own lives, while only 1.7% of those who killed a non-intimate (n = 3459) also killed themselves."[5]

The mental state of perpetrators also varies between homicides and homicide-suicides. Homicide-suicide perpetrators are much less likely to be psychopathic than are those who commit simple homicide. A Swedish study reported that

'Psychopathic' perpetrators, who generally are over-represented in most violent criminality, were comparatively uncommon. Only seven (4%) in the study group [of 164] met the diagnostic criteria for psychopathy . . . [4]

And homicide-suicides are much more likely than ordinary homicides to be premeditated.[2]

To summarize the differences, homicide-suicides are

  • characterized by older (and therefore more valuable) child victims
  • more likely to include biological (and therefore more valuable) children
  • unlikely to be perpetrated by women (especially murder-suicides that include spousal homicide)
  • unlikely to be motivated by sexual jealousy
  • likely to be wife killings
  • unlikely to be perpetrated by 'psychopathic' people
  • likely to be premeditated.

What explains the differences?

One hypothesis is that murder-suicide is motivated by altruism or caring. There is little evidence to support this claim. In one study that reported motive, only seven out of 65 murder-suicides were "mercy killings" - and in six out of seven cases, the victim was over age 55.[5] In addition, a person determined to commit suicide may wish to spare his or her spouse the suffering associated with his or her loss. In fact, men are particularly affected by a spouse's suicide. The male suicide rate, already high compared to that of women, rises by a factor of 46.2 after the suicide of a partner.[1] (The suicide rate for women, already lower than that of men, rose by a factor of 15.8%.) If altruistically preventing suffering were a major motive in murder-suicides, one would expect women to commit spousal murder-suicide and/or familicide at a rate closer to that of men (or, at least, closer to the rate at which women commit simple suicide or homicide).

Vengeance as a motive is belied by the low rate of jealousy-related homicide-suicides, as noted above, and by the high rate of inclusion of biological children.

I propose a model for homicide-suicide as follows. Homicide-suicide is the result of the unfortunate juxtaposition of two ordinarily fitness-promoting drives. On their own, each drive is evolutionarily adaptive; together, they spell disaster. However, the relatively low rate of murder-suicide indicates that this juxtaposition is rare enough as to not counteract the beneficial selective effects of the two drives individually.

The first drive is the drive to self-destruction under conditions of (a) perceived burdensomeness and (b) failed belonging, as described by Thomas Joiner (though he does not concede that this drive is selective). In selection terms, it is reasonable to commit suicide when the burden one's continued existence places on one's genetic kin exceeds one's prospects for future genetic contribution via creating new offspring (or caring for existing offspring). It is therefore reasonable to conclude that the drive to commit suicide under these conditions would be subject to positive selection. In fact, one study found that perpetrators of homicide-suicide were likely to have experienced "recent legal problems (25.3%) [or] a job or financial problem (9.3%),"[5] both indicating perceived burdensomeness and/or failed belonging.

The second drive is proprietariness. Perceiving one's children as one's property is generally fitness-promoting; one protects one's children from harm, utilizes their labor, benefits from their breeding capacity, and directs their life choices. Proprietariness toward children promotes both the nurturing and protection of children and the parental side of parent-offspring competition.

Proprietariness is the explanation that Daly & Wilson [7] propose to explain the enormous overrepresentation of men as perpetrators of spousal homicide-suicide and familicide-suicide as compared to women. It makes evolutionary sense for a man to be proprietary toward a woman; exclusive sexual access is extremely important for a man in fitness terms. It makes much less sense, evolutionarily, for a woman to be proprietary toward her husband. His sexual dalliances make little fitness difference for her, as long as they do not threaten his continued investment in her children. Purdah and related behaviors are relatively common in societies toward women; nowhere do they exist toward men.

Proprietariness tidily explains the relatively high representation of women among filicide-suicides as compared to familicide-suicides and spousal homicide-suicides; women would be expected to feel proprietary toward their children, but much less so toward their husbands.

Murder-suicide, according to my model, occurs when (a) a perpetrator experiences extreme despair as a result of perceived burdensomeness and/or failed belonging, and therefore wishes to commit suicide; but (b) proprietary feelings toward a spouse and/or children lead the perpetrator to take others with him, as if they were tomb ornaments.


It is probably more psychologically comfortable to assume that men are violent toward women because of suspected infidelity, rather than actual infidelity. However, the violent responses of men, while certainly not morally justified, seem to at least reflect genuine female infidelity most of the time. Daly & Wilson [7] cite a study at p. 201 that found that, in eleven out of eleven non-psychotic spousal homicides studied, "the victim was engaged in an affair with another man or had led the offender to believe that she was being unfaithful to him. In 10 of the cases, the victim made no attempt to conceal her other relationships." Another study, cited by Daly & Wilson at 208, found that 47% of women who had been raped and beaten by their husbands admitted to adultery, compared to 23% of those who were battered but not raped, and only 10% of women who were not victimized.

*Bossarte et al. (2006) note that their results contradict a 2005 study[14]) on "intimate femicide" using data from the province of Ontario, Canada, from 1974-1994, which found that intimate partner suicide-homicides were significantly more likely to be motivated by jealousy than simple intimate partner homicides (55% versus 42% respectively). The Ontario study also found a higher percentage of de facto unions versus registered marriages in simple murders than in murder-suicides, which contradicts both the Wilson et al. (1995) data[13] and the Banks et al. (2008) data.[2] What do we make of this?

There is circumstantial evidence that makes the Bossarte et al. result more convincing than the Dawson result. First, married people are highly represented among intimate partner murder-suicides compared to unmarried cohabiting couples; unmarried cohabiting couples, on the other hand, are drastically overrepresented among ordinary intimate partner homicides.[2][13] Why does this matter? Daly & Wilson (1988) [7] at p. 213 think that male investment is low in couples living "common law" (compared to married couples). They say: "Perhaps the material investment of men in common-law unions is relatively low, and the women are therefore more likely to be on the lookout for alternatives, inspiring a more coercive proprietariness in their mates."

Second, a huge proportion of men who kill their estranged wives or wife-equivalents commit suicide. The proportion of men who kill non-estranged adulterous wives are much less likely to also kill themselves (Daly & Wilson (1988) [7] at p. 219). That estrangement is such a trigger fits better with proprietariness than jealousy; losing a female mate, while costly in fitness terms, is nowhere near as costly for the male as potentially supporting non-biological children.

Third, victims of intimate partner murder-suicide are significantly older than victims of simple intimate partner homicide. Barber et al. [3] found a mean age difference of 9.4 years between the two groups. Young wives (who are most valuable and fertile) are extremely highly represented among simple homicide victims; a reasonable interpretation of this is that more valuable women trigger more violent sexual jealousy. Wives who are victims of murder-suicide tend to be older and hence, in evolutionary terms, less valuable (see Daly & Wilson (1988) [7] at p. 206), and so less likely to trigger violent sexual jealousy.

Daly & Wilson [7] (at 219) also dismiss the "remorse" hypothesis (that women rarely commit murder suicide because they lack the highly developed moral sense of men - which assumes that suicides following homicides are committed out of remorse). In fact, murder-suicides often leave evidence of premeditation. In addition, if a murder-suicide is to take place, the suicide generally happens contemporaneously with the homicide; a suicide days or weeks after a homicide, when remorse would be expected to set in, is extremely rare. Daly & Wilson cite a study that found that "whereas 192 homicidal Canadian husbands killed themselves immediately after the homicide, only another 3 committed suicide days or weeks later. Indeed, in the total sample of 6559 Canadian homicides, there were just 8 killers who committed suicide after a delay that might reflect remorseful brooding."

Works Cited

1. Agerbo, E. "Midlife suicide risk, partner's psychiatric illness, spouse and child bereavement by suicide or other modes of death: a gender specific study." J Epidemiol Community Health. 59(5):407–412 (2005).

2. Banks, Laura, Cameron Crandall, David Sklar and Michael Bauer. "A Comparison of Intimate Partner Homicide to Intimate Partner Homicide-Suicide: One Hundred and Twenty-Four New Mexico Cases." Violence Against Women 14:1065 (2008).

3. Barber, Catherine W., Deborah Azrael, David Hemenway, Lenora M. Olson, Carrie Nie, Judy Schaechter and Sabrina Walsh. "Suicides and Suicide Attempts Following Homicide: Victim-Suspect Relationship, Weapon Type, and Presence of Antidepressants." Homicide Studies 2008:12:285.

4. Belfrage, Henrik, and Mikael Rying. "Characteristics of spousal homicide perpetrators: a study of all cases of spousal homicide in Sweden 1990-1999." Criminal Behavior and Mental Health 14:2:121-133 (2006).

5. Bossarte, R M, T R Simon and L Barker. "Homicide-Suicide: Characteristics of homicide followed by suicide incidents in multiple states, 2003–04." Injury Prevention 2006:12(Supplement 2 ):ii33-ii38.

6. Buss, David M. The Dangerous Passion. Bloomsbury, 2000.

7. Daly, Martin, and Margo Wilson. Homicide. New York: Aldine de Gruyter, 1988.

8. -------- Risk-taking, Intrasexual Competition, and Homicide. Nebraska Symposium on Motivation 47: 1-36(2001).

9. Hatters Friedman, Susan, MD, Debra R. Hrouda, MSSA, Carol E. Holden, PhD, Stephen G. Noffsinger, MD and Phillip J. Resnick, MD. "Filicide-Suicide: Common Factors in Parents Who Kill Their Children and Themselves." J Am Acad Psychiatry Law 33:4:496-504 (2005).

10. van der Dennen, Johan M. G. "Review Essay: The Murderer Next Door: Why the Mind is Designed to Kill." Homicide Studies 2006:10:320.

11. Violence Policy Center. "American Roulette: Murder-Suicide in the United States." (2006).

12. Wilson, M. I. & Daly, M. "Who kills whom in spouse killings? On the exceptional sex ratio of spousal homicides in the United States." Criminology 30:189-215 (1992).

13. Wilson, Margo, Martin Daly, and Antonietta Daniele. "Familicide: The Killing of Spouse and Children." Aggressive Behavior 21:275-291 (1995).

14. Dawson, Myrna. "Intimate Femicide Followed by Suicide: Examining the Role of Premeditation." Suicide and Life-Threatening Behavior 35(1) (2005).

Thursday, March 26, 2009

The Source of All My Nightmares

Is suicide difficult? Since there is a prohibition, in our society, on the drugs that provide the only reliable, painless method for suicide, suicide is, in practice, very difficult. Suicides are left with a choice among unsatisfactory methods - to say the least. The suicide must shoot himself in the head, cut his arteries, hang himself, or worse, if he genuinely wishes to die. Failure to appreciate the difficulty of suicide has led many otherwise intelligent people to think that there is no need for "assisted suicide" (provision of drugs). The reality is that suicide is unfairly difficult, the methods available unfairly cruel.

But it gets worse. The terrifying reality is that, even if one shoots oneself in the head or hangs oneself, it is no guarantee of death. Advance directives refusing care after one's suicide are not respected. Plenty of people attempt suicide by one of these methods and survive, with consequences in some cases more horrible than continuing to live would have been. Lying in a state of akinetic mutism while doctors perform medical experiments on one is no one's desire, and is not an acceptable "consequence" to inflict on a suicide.

A poignantly brief article in the Baltimore Sun, "Woman wounded in apparent suicide try," crystallizes the horror of the above dilemma:
A woman was found shot in the head in West Baltimore yesterday afternoon in an apparent suicide attempt, said police spokeswoman Nicole Monroe. The woman was found at Edgemont and Parkwood avenues about 12:51 p.m., Monroe said. The woman, whose name was not released, survived the shooting, Monroe said last night, but her condition was unavailable. [Emphasis mine.]

Saturday, March 21, 2009

On Being Your Patients' Keeper

Sexy psych nurse Mr. Ian of MentalNurse wonders why "risk assessment" (for harm to others) is the exclusive province of mental health professionals, to the exclusion of other specialties. Medical patients other than mental patients often pose a risk to other people - but doctors and other health care workers are not expected to police them. Whose risk is it, anyway? He says:
Who says it’s my responsiblity to assess, manage and mitigate risk of harm to others?

I could flip the question - why is risk assessment and management only an obligation of the mental health sector?

Why aren’t parole boards required to meet the same standard when releasing a known violent person? They don’t even have an obligation to the offender. Their obligation is to the safety of the public.

Why can’t opticians remove someone’s license to drive when they’ve failed an eye test or GPs remove licenses from those with ‘at risk’ medical conditions? Why aren’t these people risk assessed and arrested if they fail the eye test but found driving a car?

I think the same questions can be asked for risk assessment focusing on "danger to self."

Saturday, March 7, 2009

Inflicting Harm and Inflicting Pleasure on Strangers

On ecstasy, peanuts, and how we take care of strangers.

A 2008 report from the United Kingdom's Home Office Advisory Council on the Misuse of Drugs concluded that ecstasy (at least, MDMA) is not nearly as dangerous as was previously thought, either in deadliness or in long-term health consequences. The Council even recommended changing the classification of MDMA from its present status as Class A (heroin, crack, and amphetamines prepared for injection are Class A) to the less-dangerous Class B (which includes marijuana and Ritalin). (The recommendation was, of course, rejected.)

A February 2009 editorial in the New Scientist took the logic a step further:

Imagine you are seated at a table with two bowls in front of you. One contains peanuts, the other tablets of the illegal recreational drug MDMA (ecstasy). A stranger joins you, and you have to decide whether to give them a peanut or a pill. Which is safest?

You should give them ecstasy, of course. A much larger percentage of people suffer a fatal acute reaction to peanuts than to MDMA.[1]

The implication is that, when acting upon a stranger, we should minimize his risk of death.[2]

The lovely and talented Caledonian has a slightly different take: we should focus on the relative likelihood of harm, he says, rather than the relative likelihood of death.

Both of these goals - acting to minimize the risk of death to a stranger, and acting to minimize his risk of harm - are laudable and widely shared. But there's a glaring aspect of the utilitarian calculus that almost no one seriously considers in making the decision to administer a peanut or some ecstasy. This is the differential positive utility to be gained by the stranger in each case. A peanut is marginally sustaining, but unless it's been boiled with star anise and Sichuan peppercorns, it's not particularly enjoyable. Ecstasy, on the other hand, is fucking awesome. Why doesn't anybody consider the relative benefit to the stranger along with the relative harm?[3]

While many of us would certainly consider the pleasure of ecstasy in deciding whether to eat the pill or the peanut ourselves, it's proper and coherent not to consider the pleasurable effects of a potentially harmful action when it will be inflicted upon a non-consenting stranger whose values we do not know. This illustrates Seana Shiffrin's principal that, while it's morally acceptable to harm a stranger without his consent in order to prevent worse harm (e.g., to administer ecstasy in order to avoid administering a peanut or to break someone's arm in order to pull him from a burning car), it's not morally acceptable to harm a stranger without his consent in order to provide a pure benefit. But the ecstasy example supports a stronger inference: when evaluating actions that will harm a non-consenting stranger, his potential pleasure doesn't count. When we're acting toward someone whose values we do not know, we should not think in terms of maximizing his utility, but in terms of minimizing our harm to him.

The distinction between acting toward a non-consenting stranger whose values we do not know, and acting toward ourselves (or toward someone whose values we know), is one that is ignored by S. D. Baum in his article "Better to exist: a reply to Benatar" (J. Med. Ethics 2008;34;875-876). Baum's "reply" (to David Benatar's position that it is always better not to bring people into existence) is, in relevant part, as follows:

The benefits/harms asymmetry is commonly manifested (including in Benatar’s writing) in the claim that no amount of benefit, however large, can make up for any amount of harm, however small. This claim comes from an intuition that while we have a duty to reduce harm, we have no duty to increase benefit. The corresponding ethical framework is often called "negative utilitarianism". Negative utilitarianism resembles maximin in its resolute focus on the worst off—as long as some of those worst off are in a state of harm, instead of just in a state of low benefit. Like maximin, negative utilitarianism can recommend that no one be brought into existence—and that all existing people be euthanised. I find negative utilitarianism decidedly unreasonable: our willingness to accept some harm in order to enjoy the benefits of another day seems praiseworthy, not mistaken. I thus urge the rejection of this manifestation of the benefits/harms asymmetry. [Emphasis mine; citations omitted.]

Our own willingness to accept suffering in the interest of pleasure (or any other value) is no reason to think that it is right to inflict that same suffering on a non-consenting stranger. Negative utilitarianism may not be the proper course to take in our own lives, but thought experiments like mine suggest that negative utilitarianism is the proper course to take toward the lives of others who do not consent to our interference. [4]

Many people think it's morally acceptable to have babies, despite the fact that the babies will certainly suffer a great deal during their lifetimes and may suffer an exceptional amount (that is, bringing someone into existence does him some harm). Pronatalists generally want to point out the good things in life - the pleasant effects of puppies and sunsets - and to balance them against life's harms. But bringing a child into the world necessarily entails harming a stranger (for one doesn't know the values of one's child prior to procreation). It is no different from dosing a stranger with ecstasy for no reason, except that the harms of life massively exceed the harms of ecstasy, and the pleasure of life, for many, is much less. Considering the non-consenting stranger's pleasure in the ecstasy/peanut case is unthinkable; procreation advocates need to explain why considering his pleasure in coming into existence is just fine.

The peanut/ecstasy example functions as a thought experiment that may be closer to real life than Shiffrin's ingenious example in which a wealthy person drops gold bars from an airplane, thereby benefiting some of the people below but also occasionally breaking their arms.

The only case in which it is widely accepted to inflict unconsented harm in order to provide a pure benefit is when acting toward one's children. This is an aspect of viewing one's children as property rather than persons. (Proprietariness is also the best explanation for why parents sometimes kill their natural children - and why men sometimes kill their wives or wife-equivalents - when they decide to commit suicide.)

1. Actually, the New Scientist is oversimplifying; there are two risks of death in each case. The first kind of risk is the risk that the stranger S has particular characteristics which will make any peanut, or any MDMA, lethal for him. The second kind of risk is that a particular ecstasy tablet or peanut will be lethal for any given stranger (e.g., the tablet purporting to be E is really, say, buprenophine, or the peanut is somehow infected with lethal levels of salmonella). The latter type of risk probably isn't that significant, though. UK studies don't seem to be finding lethal chemicals in street ecstasy. In Australia, the most common "fake ecstasy" is methamphetamine, which is not particularly lethal. As for peanuts, the CDC reports that the death rate from nontyphoidal Salmonella like the S. typhimurium that recently caused peanut recalls is about 00.78%.

2. I have to point out that the Mounties claim that "peanut" is a street name for ecstasy. I've never heard this in my life, but I don't go clubbing in Canada much.

3. We might also consider our own willingness to endure, on the one hand, a stranger's slight peanut breath, and on the other, a stranger clinging to our leg like a baby macaque for three hours, but that is a separate calculus.

4. Baum also assumes, contrary to Benatar's express position, that death is not a harm to already-existing people. In fact, Benatar's claims do not rest on any simplistic pleasure/pain conception of value; Benatar argues that death is a harm, even a painless death. It is, in fact, one of the great harms of life - every born person will suffer the harm of death.

Thursday, March 5, 2009

On Pulling the Suicide Debate Out of the Shadows

Jay Bookman's article, "Time to pull the suicide debate out of the shadows" - in a newspaper in Georgia, the site of an idiotic new development in assisted suicide criminalization - articulates the most typical position toward suicide in our society. He is in favor of a limited right to suicide for people who really have a good reason to die - paralyzed people, or people with physically painful, terminal illnesses - but not in favor of a general right to suicide for those of us who are suffering, but don't have a good reason to want to die. His questions, and his responses, are:
[D]o my inalienable rights as a human being extend to the right to self-destruction? If my life is truly my own, shouldn’t I be able to end it as I see fit?

Personally, I think the answer is almost always no. Societal consensus, backed by medical research and experience, dictates that a person in decent physical health who wants to commit suicide is by definition mentally ill — no fully sane person would make such a decision. [Emphasis mine.]

The key to this is the "by definition." Suicide is believed to be a product of mental illness because it is defined as such. Suicidal ideation is one of the criteria for diagnosing DSM-IV Major Depressive Disorder. But defining something as mental illness does not make it so.

I fear that Bookman would not believe how much many of us suffer - to the point of wanting to die - who are not, unfortunately for us, terminally ill - who are not, technically, "suffering intolerably from an irreversible condition which has become more than [we] can bear," a definition that is too "loose," in Bookman's words. Yet this "standard so loose as to be no standard at all" does not nearly cover all of us who deserve to be allowed to die. We have taken all the antidepressants. We have tried all the therapies. We still want to die. Why should we be forced to stay alive? Or forced to choose between a miserable, unwanted existence and a horrible method of suicide, like shooting ourselves in the head or slashing our arteries? A method that carries the risk of ending up paralyzed and suffering even more in a hospital for the rest of our lives?

Bookman is right to argue that sick, dying people should be able to end their lives. But why? Bookman reports of the Georgia case,

Celmer, the man who died in June, was recovering from cancer of the jaw and apparently sought death not because of pain or looming death, but because of shame at the disfigurement the cancer had caused. In those and other cases, if the factual claims against them prove true, Final Exit members appear to have acted irresponsibly and criminally.

Why is it okay to want to die if you're in physical pain or about to die, but not if you're horribly disfigured? Or unbearably miserable, and unlikely to get better?

If the right to die is grounded in autonomy, there's no reason not to extend the right to a comfortable death to those of us who rationally want to die (i.e., who have a serious, longstanding wish to die that is not the product of a delusion) but are not physically ill. There are ways to ensure that only rational people (regardless of DSM-IV diagnosis) are allowed to commit suicide. If anything, those of us who are defined as mentally ill (especially those of us with treatment-resistant DSM-IV "Major Depressive Disorder") have a better reason to die than people with terminal illnesses: we have much longer to live in pain.

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