Suicide Leaves Behind Nothing, Ctd

A reader merges the Leelah Alcorn thread with another popular one:

You’re no doubt unsurprised that I disagree with your reader who characterized Leelah’s suicide as “the worst and most selfish way to get satisfaction.” I can imagine far worse and more selfish ways of receiving satisfaction over grievances. In fact, I don’t have to imagine them, because we’ve seen them at Sandy Hook and earlier this month in Arlington, Texas, when Veronica Dunnachie killed her estranged husband and his daughter. Leelah didn’t shoot up her church or kill her parents – two choices that would have been far worse and more selfish than stepping in front of a truck.

I’m doing more than just objecting to the hyperbole. This loops us back to your “Suicide Leaves Nothing Behind” thread. People who have calmly, rationally decided that death is their best option should have better, more dignified, less violent options. They shouldn’t be forced to put loved ones at legal risk or involve anonymous third parties like that truck driver.

And, yes, it should include counseling, and in the case of minors, consent from either parents or a judge. But if at the end of the counseling the person is still resolved to die, they should have a painless dignified option of doing so on their own timetable. Martin Manley should have a more dignified exit available to him than a bullet to the head in a parking lot, and teens like Leelah should have a place to go to get the support she needs to make a better choice that won’t start by calling her decision to die awful and selfish.

An expert weighs in:

As a psychotherapist, I’d like to push back a bit on the notion expressed by some readers that Leelah Alcorn’s suicide, or that suicide in general, is selfish.

Or that it’s in any way an extension of the “typical” “selfish” behavior of teenagers. I think selfishness is not a helpful adjective to use in this conversation. Suicide is the last, most desperate act of person who is suffering beyond what most of us can imagine. Suicide is no more selfish than having major depression or a terminal illness plus chronic pain is selfish.

And it is developmentally normal for teens and young adults to be somewhat more self-focused than middle-aged or older adults. There is nothing useful to be gained by labeling teens as selfish with the moral sanctimony that conveys.

My reading of the data is that suicide is less common among adolescents than older age groups, which would suggest that it’s misguided to associate the normal increased self-focus of teens with the act of suicide, speaking at the level of trends. At the level of the individual, increased sensitivity to self-image in a teen may be one additional risk factor for those who are already struggling with depression and lack of social support. But the idea that teen behavior is “selfish” and teen suicide an example of this “selfishness” is a terrible and inaccurate notion to perpetuate.

Suicide represents a systemic failure, not an individual failure. It often reveals a lack of adequate family and social support of the individual who is suffering, and often also a lack of access to adequate healthcare and counseling. Suicide is a collective failure that manifests in an individual’s actions. Which isn’t to say that individuals have no responsibility to get help; we all have choices. Of course some of us have more choices than others because of economic of social privilege.

Talk of suicide always makes me think of both David Foster Wallace and a close friend of mine, also a writer, who committed suicide around the same time. Both of these individuals were well into adulthood when they killed themselves and had struggled with depression for many years. They pursued multiple, invasive, and costly treatments, were hospitalized, did talk therapy, and as far as I can tell worked hard to love and be loved in their daily lives. They were people with significant economic resources to avail themselves of all these treatments and with substantial social supports. And yet, after many years of steady, hard work to recover from their depressions, they both took their lives.

If DFW and my friend had been diabetes patients, we would say they did all the right things to safeguard their health, and the illness still took them. If they had been cancer patients, we would have praised them for fighting courageously against their disease before succumbing to it. We would never think to call them selfish. It continues to astonish me how much stigma we still tolerate being assigned to serious and devastating mental health issues.

Are Colleges Failing Their Mentally Ill Students? Ctd

Rachel Aviv reports on a Princeton undergraduate asked to leave the school following a suicide attempt:

In balancing the rights of students against the need for safety and order, many universities require suicidal students to leave campus. At Yale, Brown, George Washington University, Hunter College, Northwestern, and several other schools, students have protested these policies, by initiating litigation, submitting complaints to the Department of Education’s Office of Civil Rights, or writing columns in campus newspapers.

W.P. retained a lawyer, Julia Graff, an attorney at the Bazelon Center for Mental Health Law, who said that she gets calls every month from students who were asked to withdraw after their universities became aware of their mental disorders. “Universities don’t seem to understand that mental-health disabilities are chronic illnesses, and it is not uncommon to have to be briefly hospitalized now and again,” she told me. “It doesn’t mean that you are not competent to be a student.”

Two weeks after being banned from his classes, W.P. appealed Princeton’s decision. In a long letter, he noted that the university prides itself on its diverse student body—he pointed out that his residential college called itself “a place where individuals could be accepted for who they are”—and students with mental disabilities, he wrote, contributed to that diversity. …

W.P.’s private psychiatrist, to whom he’d been referred by Princeton’s health center, submitted a letter that stated that W.P. did not pose a threat to himself. “An important aspect of W.P.’s recovery is a sense of purpose,” the psychiatrist wrote. “Requiring a leave of absence and excluding him from the university community at this time could be detrimental to his health and well-being.”

The appeal was denied.

Previous Dish on the topic here.

Choosing Death, Ctd

Brittany Maynard, the 29-year-old terminal cancer patient who publicized her intention to make use of Oregon’s assisted-suicide law, took her life on Saturday. Sarah Kliff pushes for a broader conversation:

We don’t like to think about death — and so we don’t. State legislatures rarely grapple with assisted suicide laws in any serious way. Regulating death is terrible politics. And so death goes unregulated. But the dearth of debate and discussion doesn’t eliminate assisted suicide. Instead, it pushes it into the shadows, where doctors will only admit anonymously to helping patients end their own lives.

Surveys of oncologists show that some cancer doctors, when asked anonymously, will admit to helping patients die.

A heavily-cited 1996 survey of more than 2,000 doctors, published in the Lancet, found one in seven oncologists had “carried out euthanasia or physician-assisted suicide.” The real number might be much higher. Most doctors don’t like talking about physician-assisted suicide because they work in states where it is technically illegal.

Lindsey Bever cites some resistance to assisted suicide:

“Now we have a young woman getting people in her generation interested in the issue,” [Arthur] Caplan wrote in [an] article published on Medscape. “Critics are worried about her partly because she’s speaking to that new audience, and they know that the younger generation of America has shifted attitudes about gay marriage and the use of marijuana, and maybe they are going to have that same impact in pushing physician-assisted suicide forward. …

Ira Byock, chief medical officer of the Institute for Human Caring of Providence Health and Services, spoke loudly against the practice. “When doctor-induced death becomes an accepted response to the suffering of dying people, logical extensions grease the slippery slope,” he wrote in a New York Times op-ed. He cited statistics in Holland, where the practice is permitted, that claim more than 40 people sought and received doctor-assisted death for depression and other mental disorders. “Even the psychiatrist who began this practice in the 90’s recently declared the situation had gone ‘off the rails.’”

Olga Khazan remarks that there “are a number of questions prompted by Maynard’s death, but one of the most troubling is, what happens when the patient seeking lethal medications isn’t as bright, purposeful, and tranquil as Maynard was?”:

Oregon physicians reject five out of six requests for the lethal medication.

One reason: Physician-assisted suicide requests are less likely to be honored if the patient sees themselves as a burden or if they’re depressed. But because feeling unwanted and suicidal ideation can be two symptoms of depression, physicians may have difficulty knowing whether the patient would have a change of heart if their mental state improved. Does the patient want to die because they’re depressed, or because they’re terminally ill—or some combination?

Reflecting on the ethics, Jazz Shaw makes a distinction:

One commonly mentioned item – and a very valid one – is that we should be careful not to conflate assisted suicide (as was the case here) with the question of Do Not Resuscitate orders and excessive “heroic measures” to bring back those who have slipped beyond our grasp. This is something I may have unwittingly done, and clearly should not have. They are indeed two separate things, and the key feature which distinguishes them is that one involves extraordinary measure to delay a death which is imminent through natural causes while the other is a conscious choice to forcefully terminate a life which would continue for some time without intervention. Put more bluntly, one is suicide by definition while the other is an act of surrendering to the conclusion of events which arrive unbidden. …

I also read some very emotionally powerful arguments from readers about removing such decisions from God’s hands and taking them into our own. I cannot imagine a more heart rending burden than facing that question, and it is something which people of faith may have to deal with in their final days, each in their own way. There is clearly merit in the point that the suffering of Jesus on the cross sets an example for the faithful, but I would also note that not all mortals are born with His level of strength.

Why Do Doctors Kill Themselves So Much? Ctd

A reader writes:

While I think this is important question, I also find the suicide rates not at all surprising.  In fact, it is about as surprising to me as the data about soldiers taking their own lives in record numbers (that is to say, not surprising in the least).

During the middle of my residency in surgery, which was before work hour restrictions, I would go months at time without seeing the sun.  I would typically work 80-100 hours a week, take in-house call every second or third night, and deal with all manner of death, dying, stress, and trauma.  I was single and had little time to date, much less start a family.  Showing fatigue, stating you needed a break, or any other sign that you were suffering resulted in you being labeled weak or whiny.

I could look forward to 2-3 more years of the same before my residency was complete.  After that, I could look forward to an average salary which seemed to be shrinking by the year unless I tacked on 1-2 more years of fellowship training.  Furthermore, I could read in the paper everyday that physicians were losing respect and were perceived as a major source of our country’s health care woes.

I went to work everyday and suffered through nurses with clipboards asking why patient X and Y hadn’t been discharged yet, administrators telling us we had to use instrument A instead of instrument B because A was cheaper (even though B was better or safer), operating rooms that were understaffed (“your case will have to wait until 7 pm to get done because it’s after 2 pm and we’ll have to start paying nurses overtime if we start your case now.”), and patient’s family members who weren’t there at all for the first 10 days of a patient’s hospitalization but are now demanding to see the doctor at 8 pm at night.

So after one snowy February day, after treating a mother whose baby had been decapitated in a car accident and all other manner of horrors, as I was driving home I thought, “wouldn’t it be nice to drive up into the Cascades (my residency was in the Pacific Northwest), get out of my car, walk into the woods for about 30 minutes, find a nice tree, and sit down in the snow and drink a bottle of whiskey until I became numb and fell asleep? I would never wake up.”

The good news is, I didn’t.  And I’m one of those older doctors now who has no interest in or thoughts of suicide.  I make a good salary, and while I still work hard and treat all manner of horrible things that happen to people, I usually make them better.  I have a lovely wife and two beautiful children.

But when I read this question, I think that, like our soldiers (I was one of those too, by the way), most people have no earthly idea about what many physicians experience in training and in practice every day, and how much stress, sleep deprivation, administrative nonsense, medico-legal threats, and continual erosion of autonomy we deal with.  It adds up.  Throw in a sudden lawsuit, marriage break-up, or other major stress and you have the potential for a physician imploding.

We have definitely tried to make things better for doctors in training, and that needed to happen.  We haven’t made things better for new physicians out of training; if anything, things have gotten worse with all the upheaval in the health care system.  We are constantly asked to deliver more with less.  Patients are more demanding, not less.  We have a incredibly skewed perspective on end of life care, a topic which has been previously covered at length in this blog.  The future is uncertain for private practitioners.  There are multiple factors in play, and what leads a troubled physician to take his own life is different for each one.

For many more stories on suicide, read our long discussion thread here. Update from a reader:

Your man Aaron Carroll, a doctor himself, has done a lot of pushback on the “it’s horrible being a doctor, we’re all going to quit” meme – here, herehere, and here.

One of Carroll’s readers had a great line:

Most people have to choose between doing God’s work and being in the 1%. Only doctors get to do both.

The Geography Of Suicide


The World Health Organization recently released a report (pdf) illustrating suicide risk across the globe. Tanya Basu unpacks it:

One dramatic trend the WHO reports is that countries in the developing world have suicide rates that are many times higher than the Western world. “Despite preconceptions that suicide is more prevalent in high-income countries,” the report states, “in reality, 75 percent of suicides occur in low- and middle-income countries.”

The high male-to-female ratio of suicide victims is also rapidly equalizing, particularly in the developing world. The changing makeup of the global workforce and its increasing inclusion of women have made women more susceptible to the socioeconomic stress that increases the likelihood for suicide. While the male-to-female ratio for high-income countries is 3.5, the ratio is almost even in low-income countries at 1.6. The divide is particularly close in the Western Pacific (0.9), Southeast Asia (1.6), and the Eastern Mediterranean (1.4).  Variation in suicide rates by age is also important. Younger women in the 15-to-29 age bracket are as likely as their male counterparts to commit suicide in developing countries at a 1:1 ratio. The gap widens up to middle age, but in general, data indicates that the gender of suicide victims can be male or female, unlike the male dominance of suicides in the developed world.

Steven E. Hyman argues that rich and poor countries alike are failing their mentally ill citizens:

In the United States, for example, the federal Mental Health Parity and Addiction Equity Act, which banned much of the previously existing health insurance discrimination against people with mental illness, was passed only as recently as 2008. However, the regulations needed to implement the law languished for five years, issuing only in 2013. Such late but laudable reforms notwithstanding, in the United States and other high-income countries, many individuals with chronic mental illness become homeless or are imprisoned, often for offenses that stem from their disorders.

The low priority of mental illness in the health care systems of many [low- and middle-income countries (LMICs)] is attested to by health budget allocations that generally lie in the range of 1 to 2 percent of health expenditure. As a result, health care spending on mental disorders is often less than US$0.25 per capita in low-income countries and averages less than US$2.00 per capita globally. The WHO estimates that 80 percent of individuals with mental illnesses in LMICs do not receive meaningful treatment. And when treatments are available, they are often in the form of medications dating from the 1950s that should have been long superseded by more modern medicines.

Bill Gardner considers one reason why:

[W]ith cost-effective means to treat mental illnesses we could relieve an enormous burden of human suffering and greatly increase human productivity. But we neglect the care of the mentally ill relative to our care for those with other disorders. Hyman documents how policy makers discount the importance of mental illness and asks why. One reason is the stigmatization of the mentally ill. But then what explains stigmatization? [Hyman writes:]

I believe that a seemingly more arcane but powerful cognitive distortion also plays a role in the deprioritization of mental illness: the belief that mental disorders should somehow be controllable, if only the affected person tried hard enough or adhered to a better set of beliefs.

The symptoms of mental disorders are derangements of thought and emotion. Our sense of personal autonomy tells us that we determine what we think and can at least shape what we feel. So if we can control ourselves, why can’t they?  The suspicion that the mentally ill are responsible for their state may be built into who we are.