In a recent post, I discussed how the drive for obtaining more data can require that people to participate in recommendations in order to gather more data. In that post, I described the example where the recommendation was to participate in health care’s attempts to extend life even when prospects of survival are very small. Even if one does not participate in health care, the need for data should discourage or even forbid the death-with-dignity option of suicide because that prevents the opportunity to observe data on natural death. As an example of the latter, I referenced the case of a young patient with a terminal brain tumor who had recently announced her plans to use her prescription for lethal medication. Now, I learn she has followed through with that wish.
My motivation for mentioning her case at first was to build on an earlier argument about the painful consequences we must accept in order to follow evidence-based decisions that should obligate our actions. I argued that evidence-based decision-making needs our complete cooperation (or subjugation) for the benefit of the long-term project in order to collect observations about the consequences of its recommendations. To make better recommendations, evidence-based decision-making needs more evidence, especially evidence for what it gets wrong. It needs to observe failure.
I had earlier presented the case of medical doctors when diagnosed with terminal illnesses choosing to decline further medical treatment that was offered to them. They reasoned that the care would not appreciably increase the odds of survival and would result in even more degradation of the remaining life. I argued that their individual wishes are secondary to the need to observe new data of what happens with the recommended procedures. These procedures are always changing so new attempts are not going to be identical to earlier treatments. Their current cases present new opportunities to advance the practice that may eventually lead to a cure. Personally, I side with the terminally ill who choose to live without the additional burden of hopeless medical procedures. It is the need for new data that argues against this choice.
My more recent posts (latest is here) took a different approach to explore the concept of obligated cooperation for the sake of data. This approach involved rethinking policy making based on agile development principles involving frequent releases of new policies. Each release presents new policies that are like minimum viable products: something to use for just the short period until the next release arrives. The agile concept takes advantage of the new data from this minimum viable product in order to learn the requirement for better future products. Agile concepts assume our prior knowledge is incomplete and faulty. The best way to identify requirements is to collect new observations from minimum viable products. Enacting incrementally improving policies will permit us to collect needed data from the population that participates.
My earlier discussions focused more on the current Ebola epidemic crisis. I think the same concepts could also apply to other medical situations especially in terms of terminal illness. An agile concept of a policy as minimum viable product provides an opportunity to collect new data when we put that policy into practice. My last post ended with a suggestion that the policy can recommend physician-assisted suicide or even euthanasia or murder of patients suffering from Ebola virus disease because that may be the only option available to stop or slow the spread of this contagious epidemic. Other scenarios such as managing terminal (but not contagious) illnesses can recommend against suicide either to provide the opportunity to test a new treatment or to provide an opportunity to record the natural course of death. Either will provide new data to use for future decision making.
These examples involving suicides show that obligation to participate can work in both ways: to forbid suicide for terminally ill in order to observe the consequences of recommended medical procedures, or to prescribe suicide (or murder) in order to save the lives of many more people because it is the only remaining option to stop the spread of an lethal epidemic.
I did not intent to revisit the initially mentioned case of assisted suicide. Although the individual chose to bring this case to national attention, my feeling is that it is a local story of one unfortunate individual with a terminal illness. I have read many reactions concerning her decision. Her decision is a controversial one and I welcome that the continuation of the discussion of that controversy.
I returned to this topic after reading a blog post that explored explaining the more typical cases of suicide that do not have medical justifications. The author suggests three explanations for such suicides:
The first is Edwin Shneidman’s concept of “psychache” – the idea that suicide is the result of extreme emotional pain. The second is Thomas Joiner’s “interpersonal theory of suicide” – suicide is the result of thwarted belongingness, perceived burdensomeness and hopelessness about the future. In both of these models, the pain of life overcomes the fear of death. The last is Emile Durkheim’s sociological theory of suicide – suicide is the result of a society’s lack of socially integrating forces (religion or occupational groups) and regulating forces (guides for conduct).
The concept of medically-justified suicide may fall within the second and third theories. The reason a patient considers suicide is from a rational assessment of hopelessness and burden on others. Also, the reason the patient is not persuaded against this choice (as evidenced by many published objections to the case I identified) is because of lack of guides of conduct such as those that come from religion.
Although the intention of that discussion was to target the non-medical suicides, it could apply also to these medical suicides. Medical suicides are controversial where many do consider the practice to be unacceptable. Ideas from the above two theories appear frequently in the arguments against the legitimacy of suicide to avoid the consequences of naturally dying from a terminal illness.
However, my reaction to this list of options is that it misses a key element of human behavior. Perhaps the most distinguishing feature of human behavior that separates humans from all other animals is that humans are the story-telling animal (another book I haven’t read but love the title). The word story usually is used to describe works of fiction, but I use the word more generally to include all ideas in human conscious thought. All of our conscious thoughts involve stories where some have more supporting evidence than others. Even pure fiction often has some elements of truth with evidence to tie it to the real world. A scientific theory is still a story that happens to have strong explanatory power concerning the real world.
I ask the question of why it is even possible for a human to imagine suicide to be an option. Suicide is more than simply engaging in a very risky activity that may have some minuscule chance of survival. All animals take risks that may result in some large but difficult to obtain award. Sometimes those risks result in death. In contrast, suicide is a deliberate action with at least the initial intention of successfully ending one’s own life.
There doesn’t appear to be much evidence of any other animals committing suicide. In my reading, I have encountered some descriptions of behaviors that look suspiciously like suicide among captive elephants or otherwise unexplained cetacean beaching. Although I am inclined to imagine some of these acts as acts of deliberate suicide, there doesn’t appear to be much evidence to prove that is the actual case.
Suicide appears to be a unique behavior of humans. The otherwise inexplicable animal deaths are missing a key piece of evidence for suicide. That evidence is the suicide note. The suicide note or other forms of previous expressions of suicide ideation is the primary evidence we have that a death was in fact a suicide. The suicide note is both a story and a contribution to a larger story.
The medically-approved suicide examples are grounded in stories. The story may be less fictional because there is abundant evidence of the terminal condition of the patient and the inevitability of the degrading conditions that will precede a natural death. But that is still a story we are able to communicate to the patient. Also, to qualify for medically-approved suicide, the patient has to provide the equivalent of a suicide note that describes both the intent and the rational explanation for the choice. Stories surround medically-approved suicide cases.
The most disapproved suicides are of those who take their own lives out of some perceived unbearable frustration or out of depression. If we were not story-telling animals, many suicide victims may not discover this option or its methods on their own. There is also the element of the suicide victim’s opportunity to contribute society’s body of suicide stories his own story in the form of a suicide note (of some form) followed by the act.
Suicide is one of the human behaviors, it just happens to be a behavior that ends ones own life. The humanity of the act is in the story it tells. Often we will object that the reasons for suicide were invalid. The suicide victim was misinformed. The suicide victim was working from incorrect stories.
In the above list of explanations for suicide, the second and third are clearly about stories. The first the influential narrative is of hopelessness and burden. The second is the failure of narratives to set standards to prevent suicide. The idea of story-telling is already covered in these explanations. Alternatively, the two theories may be replaced with a sociological theory centered on story telling.
Animals have an instinct to survive. It is actually quite difficult to successfully complete a suicide. Most natural activities will eventually provoke instincts that will recover life. Humans have advanced methods available that can better guarantee death by poisons or self-inflicted unrecoverable traumas. Animals also have access to poisons (poisonous plants or animals) but it does not appear that they use them for the purpose of ending their lives. Animals lack the stories that describe and justify a death wish and provide instructions for a method to accomplish it.
Suicide is just one human behavior, but it one behavior that seems to be unique to humans. Also even though it is a human behavior, the behavior is widely disapproved often in all circumstances. Suicide is a worthy topic for sociological study because it offers a great opportunity to understand the human condition even for the vast majority who will never consider this option. Although psychologists who study the individual mind have useful insights about the links to depression and self-worth, I think sociological studies may have more to offer to explain how suicide becomes an attractive option.
Society provides the stories in which suicide becomes an option. Society also represents an audience for new stories resulting from individual suicides.
The advantage of the sociological study over the psychological study is that a sociological theory may have better prospect of solutions for preventing suicides.
Psychological explanations focus on the role of depression. Psychologists offer intervention guidance for cases of known depression. Psychology can’t prevent depression and depression will always occur. As a result a psychological remedy requires constant activity to intervene in the current cases of depression where suicide is a risk.
In contrast, a sociological explanation can offer structural solutions to eliminate suicide entirely. There is a wide variety of suicide rates in different countries. When sorted in order of declining suicide rates its hard to associate the rates with depression-causing conditions like freedom, opportunity, or wealth. Suicide rates in USA and Cuba are nearly the same. Meanwhile countries like peaceable Bahamas and conflict-prone Pakistan have similarly very low rates.
I suggest that what may separate the countries are the stories available to their populations. Countries with high suicide rates may vary greatly in terms of opportunities and wealth but may share a common appeal to stories that present suicide as an option and somehow welcomes (though perhaps unintentionally) new suicide-story contributions. Countries with lower suicide rates either don’t talk about suicide or refuses to accept new stories as part of the culture.
The cultures not only have differences in language but also in the stories associated with the words in the language. Take for example our word suicide. The word itself is simply a symbol for the concept of killing oneself, but the specific word shares the same root as homicide. This suggests that the two words are related more than the fact that both involve the death of a human. Suicide is a special case of a homicide where the victim and the perpetrator are the same person. Homicides in general may sometimes be justified (such as in self defense) or even heroic (in defense of others). Justified and heroic homicides are conveyed through stories. Because suicide is just a special case of homicide, there may be a link to the same stories: some suicides may be justified or heroic for similar reasons. The difference is that the person making the decision is judging himself.
We do not have to call self-inflicted death suicide or represent it as a form of homicide. Using a different word, we can detach this form of death from the homicides that include justified or heroic stories. For example, if we instead described the event as a self-execution we may suggest the stories associated with tyrannical executions or the ones we justify only after exhausting all appeals through multiple court hearings. The execution stories may discourage a self-execution either because it is tyrannical or it because it failed to pursue appeals in front of other judges.
It would be interesting to learn more about what is different in the various cultures to cause some countries to have such different suicide rates. I suspect it has to do with the language and the popular stories associated with the words used to describe the event.
Suicide is an example of decision making. Decision makers assess evidence presented in stories that address their fears and doubts. The effectiveness of the stories to influence decisions depends on the overall environment of stories society presents to the decision maker. Two ways to influence decisions are to come up with more compelling stories, or to refine the collection of stories that inform the decision-makers fears and doubts. The first approach is the rhetorical arts of persuasion for a case. The latter is a sociological approach to change the repertoire of stories available to the decision-maker.