In late 2007 a young woman with a history of depression and several previous suicide attempts presented to an emergency department following an overdose. She gave doctors a copy of her living will, written 3 days previously, in which she made it clear that she wanted no measures to be taken to save her life. Earlier this week Roger Crisp and Julian Savulescu argued separately in this blog that the wishes of competent patients to end their lives should be respected. But if we believe that suicide can be rationally sought, and should sometimes not be resisted, should this include those who have been diagnosed with depression?
Depression provides a challenge for those who support assisted suicide and what we might call non-resisted suicide. On the one hand it is a paradigm condition that diminishes individual wellbeing to such an extent that dying can seem preferable. Those who suffer major depression often find that they get no pleasure from many if not all of those things that previously they enjoyed. They may find little benefit from ongoing life other than the prospect of misery and suffering. Although many patients with depression are able to find relief from medication or from therapy, some have persistent severe depression and make repeated attempts to end their lives. Doctors looking after such patients (as I have done) sometimes wonder whether they are doing the patient any favours by saving their lives.
But on the other hand major depression also robs patients of the ability to rationally weigh up the alternatives available to them and the chance of improvement. It is a feature of such depression that the patient is often unable to imagine ever improving or obtaining relief from their misery, even though there may be a significant chance of remission with treatment. Although they may understand and retain information about their future prospects their ability to “to use or weigh that information as part of the process of making the decision” (Mental Capacity Act 2005) is compromised. This is partly what drives them to end their lives, but it is also one reason why many patients, following treatment, are glad that their previous suicide attempts were not successful. Roger Crisp argues that the ‘thank-you theory’ should not be used to override people’s autonomous choices in their best interests. However, if it is the case that many patients with depression are subsequently glad that they did not die, this may cast doubt on whether their previous preferences were fully autonomous.
I do not know whether the unfortunate young woman in this case was competent. The doctors involved believed that she was. But depression provides at least a prima facie reason to question the autonomous nature of a desire to die and a refusal of medical treatment. Our society has long since renounced treating those who attempt suicide as criminals. It may yet embrace assisting patients to end their lives in strictly defined circumstances. But that does not mean that most patients who attempt to kill themselves should be allowed to simply die. The presumption currently is that doctors such should treat such patients unless there is very clear evidence that they have made a competent choice to die. That will not be the case for most overdoses presenting to the emergency department. Arguably it cannot be the case for patients with depression.
I fully agree Dom. I’m not againt a competant persons right to death in certain circumstances, but when someone is depressed clinically, they are unwell and it becomes hard to prove they are competant to make that decision (usually because they are not). I do admit this argument sometimes becomes a bit tautological.
Is there ever a “normal state” in anyone, against which you can measure depression or mania? There are crude indicators, but there is nothing that gives us a way to decide whether a depressed (sad? upset? unhappy?) person is not sufficiently “himself” to decide whether that person really wants to die. There are some people who are basically dark. They tend toward pessimism and seem unable to be “really” happy. Those people get sick of life and want to die. Are they incompetent because of their depression? Given the precision of measurement available to social scientists, I doubt that “clinical” depression is sufficiently clear to give us an idea of competence to make decisions for oneself. Our powerful bias in favor of life is very useful. It makes us hesitate for a long time before accepting the sufficient rationality of a person’s desire to die. That’s enough protection against heedless suicide. But we also have a bias in favor of individual choice, even if we are determinist (a problem I have yet to solve). That bias must make us say, at some point, that depressed person should be allowed to die.
Dennis,
I think there are two separate objections to the ‘depression exception’ in your comment.
The first is that people who are clinically depressed may still be competent to decide about whether to end their lives.
The second is that there is no clear line between clinical depression and what we could call constitutional sadness.
(There is a third potential objection lurking which is that there is no objective way of determining competence).
As Dr K notes above, part of the diagnosis of clinical depression is that the individual is unable to rationally weigh up the positives and negatives of life. It is one of the features that psychiatrists use to separate those who are clinically depressed from those who are reactively depressed (for example following the death of a loved one, or the development of a serious illness). So, by definition, those who are clinically depressed lack competence to decide about suicide. (We should perhaps separate out the question of whether they may be correct that their lives are not worth living. It is possible that someone who is chronically depressed may have a live that is worse than nothing, wants to end their life, but at the same time is incompetent to make that decision.)
There is a potential circularity in this argument, I admit. It does depend whether we are able to identify those who lack capacity. (Again, in parenthesis, it should be noted that those who are depressed may retain capacity to make other decisions).
But I think that psychiatrists would dispute the second ‘sorites’ type argument against the depression exception. Even if the boundary between sadness and depression is vague, and in some cases it may be difficult to know whether a patient has or lacks capacity, there are many others where we can confidently determine that an individual’s ability to weigh up the value in their own life is impaired, and consequently they lack capacity to choose to end their lives.
Dom
Dom — A couple of points. First, I suspect some might want to draw a distinction between competence and autonomy. The standards for competence to make a decision might be significantly lower than those for autonomy. Autonomy here would be seen as a societal ideal, not as a condition limiting interference with the actions of others in their own interests. Second, the ‘thank you’ theory might used to justify a great deal of paternalistic interference. My guess is that most people would prefer to live in a world in which — when they’re competent — they are allowed to make their own mistakes.
Roger
How much of this discussion relies on notions of free will? When one speaks of autonomy, of course, it is not necessarily correct that the statement assumes free will. I suppose one can make autonomy include uncoerced acts of persons who act as a determinist would have them act. In general, I think autonomy is a great buzz word for liberal individualism, but does not help a great deal when it comes to respecting decision making by individuals you think are plainly wrong headed.
It is my experience that when one is severely depressed, one does not assess all possible options and rationally opt for suicide; rather, suicide is the only option that doesn’t strike one as unbearable. Since other options would appear bearable were one not not depressed, this doesn’t seem to me to be a very rational decision-making process. If one were not depressed, one would not wish to die.
I’m all for paternalism. It’s certainly saved me on occasion.
(Besides, if they save you and you’d still rather be gone, you can always make a second attempt.)
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