Canadian Medical Association Journal, June 12, 2001
http://www.cma.ca/cmaj/vol-164/issue-12/issue-12.htm#letindex

Letters • Correspondance

Suicide and psychiatry
M. Latowsky [HTML / PDF]; J.A. Schaler [HTML / PDF]; response: P.S. Links [HTML / PDF]

CMAJ 2001;164(12):1663-4

http://www.cma.ca/cmaj/vol-164/issue-12/1663a.asp

In a book review in CMAJ, Paul Links criticizes Fatal Freedom: the Ethics and Politics of Suicide as a cheap, artificial and ill-conceived attempt at public theatre.1 He claims that it is simply a repackaging of Thomas Szasz' central thesis on the medicalization of mental health, suicide being his latest example.

Although I am tempted to agree, Links has not correctly articulated Szasz' central thesis: that emotional, cognitive or behavioural syndromes without pathologic correlates are not illnesses. It is this belief that must be debated.

Are all people who commit suicide necessarily ill? Studies have shown that the strong psychopathologic correlates of suicide (depressed mood, distorted, negative or psychotic conditions)2 are often balanced by reasons for living.3 If one can agree with the premise that a person who commits suicide might be sane, then despite the more humane trends to medicalize acts of deviance (allowing the person to be labelled sick instead of bad) society's interpretation of the act itself remains flawed: a symbol of the abnormal within. For Szasz, "to be or not to be" is not wholly a moral question nor one entirely brought on by sickness; its meaning is necessarily a question of values, human rights and responsibilities.

It may be easier for us to understand that someone's act of suicide was due to psychosis or depression rather than to understand it as an accumulation of life events and experiences that sanely caused him or her to believe death a less painful existence than life.

Szasz may have repackaged an old idea, but it is still one worth pondering.

Mark Latowsky
Department of Family and Community Medicine
University of Toronto
Toronto, Ont.

References
1. Links PS. An old idea repackaged. CMAJ 2000;163(3):313-4.
2. Scocco P, Mariotta P, Toniotto M, Dello Brono M, De Leo D. The role of psychopathology and suicidal intention in predicting suicide risk: a longitudinal study. Psychopathology 2000;33(3):143-50. [MEDLINE]
3. Malone KM, Oquendo MA, Hass GL, Ellis SP, Li S, Mann JJ. Protective factors against suicide acts in major depression: reasons for living. Am J Psychiatry 2000;157(7):1084-8. [MEDLINE]

See response from: P.S. Links

http://www.cma.ca/cmaj/vol-164/issue-12/1663b.asp

Years ago, while I was teaching at Johns Hopkins University in Baltimore, one of my students, a physician from communist China visiting on a fellowship, told me how deeply she appreciated being able to study the ideas of Thomas Szasz in my class. I remember her telling me about how her parents and siblings had committed suicide together as a way of holding on to what little autonomy they had left in that ghastly totalitarian society.

Suicide is an ethical issue, not a medical issue. In his review of Szasz' book, Fatal Freedom: the Ethics and Politics of Suicide, Paul Links confuses the two.1 This reaction is not new. Institutional psychiatry has felt threatened by Szasz' ideas since he wrote The Myth of Mental Illness 40 years ago. Szasz' writings undermine psychiatric totalitarianism and are the tolling bell of the therapeutic state.

Institutional psychiatry may not go gentle into that good night. Nevertheless, into that good night it will eventually go.

Jeffrey A. Schaler
Adjunct Professor
Department of Justice, Law and Society
School of Public Affairs
American University
Washington, DC

Reference
1. Links PS. An old idea repackaged. CMAJ 2000;163(3):313-4.

See response from: P.S. Links

In response to: M. Latowsky; J.A. Schaler
http://www.cma.ca/cmaj/vol-164/issue-12/1664a.asp

I welcome the opportunity to respond to the letters from Mark Latowsky and Jeffrey Schaler concerning my book review.1 The debate about suicide and the role of psychiatry needs to be encouraged, and both subjects need to be better understood.

Suicide is a multidetermined act; it is not solely an ethical or medical issue. Although "a person who commits suicide might be sane," as Latowsky argues, let us not lose sight of the fact that 9 out of 10 suicide victims have a diagnosable psychiatric illness. Psychiatry is equally misperceived. With major thrusts into community care, psychiatry has evolved far beyond its institutional beginnings. However, psychiatric practices have created the perception of "totalitarianism." In a 1999 report, the US Surgeon General suggested that improving the effectiveness of treatment strategies and accessibility to care could significantly reduce the coercion of psychiatric practices.2 Rather than retreating to the dark of night, let's push forward to the light of better understanding.

Paul S. Links
Arthur Sommer Rotenberg Chair in Suicide Studies
University of Toronto
Toronto, Ont.

References
1. Links PS. An old idea repackaged. CMAJ 2000;163(3):313-4.
2. Mental health: a report of the Surgeon General. Rockville (MD): US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999. (accessed 2001 May 11).

The Left Atrium · De l'Oreille Gauche
CMAJ 2000;163(3):313-6

* An old idea repackaged
* From a Kosovo diary
* One thousand words

http://www.cma.ca/cmaj/vol-163/issue-3/atrium-3.htm

An old idea repackaged
Fatal freedom: the ethics and politics of suicide
Thomas Szasz
Praeger Publishers, Westport, Conn.; 1999
US$12.95 178 pp. ISBN 0-275-96646-1

See also: Suicide and psychiatry M. Latowsky; J.A. Schaler; P.S. Links [Letters]

Dr. Thomas Szasz achieved prominence four decades ago with his book The Myth of Mental Illness and his dire concerns about the powers of psychiatric practice. Time has not changed Szasz's perception of the coercive power of psychiatrists, which is again the central thesis of his new book, Fatal Freedom: The Ethics and Politics of Suicide. Szasz argues that agents of the State have avoided the issues of voluntary death and the right to die by transferring authority to the "therapeutic State" and the profession of psychiatry. He contends that suicide has been transformed and overtaken by the medical profession: "Suicide began as a sin, became a crime, then became a mental illness, and now some people propose transferring it into the category called 'treatment,' provided the 'cure' is under the control of doctors." Psychiatrists, primarily, have defined suicide as the product of mental illness, and according to Szasz "being a 'suicidal risk' is rapidly becoming the only generally accepted justification for inpatient psychiatric treatment, that is for psychiatric detention." He goes further, stating that suicidal risk "justifies the psychiatrist's control of the patient, but makes him responsible for the patient's suicide. It is the psychiatrist's professional duty to commit the suicidal patient and treat him against his will."

The extension of the "therapeutic State," according to Szasz, is to transform physician-assisted suicide into a treatment such that "fatally ill patients need this service the same way that patients with acute appendicitis need an appendectomy." Szasz summarizes his position as follows: "Wanting to die or killing oneself is sometimes blameworthy, sometimes praiseworthy, and sometimes neither; it is not a disease and it cannot be a bona fide medical treatment; and it is never adequate justification for coercion by the State."

The book begins with a discussion of the language of suicide. Szasz notes that there are only a few English terms to connote self-killing. The limits of our language, he writes, "de-mean" suicide, "emptying the act or phenomenon of its rich meaning and imposing on it a single signification, typically of badness or madness." In no way agreeing with Szasz's central thesis, Doris Sommer-Rotenberg has written about how our language of suicide perpetuates a pejorative view of those who end their own lives and of the family members they leave behind.1 Szasz recounts the history of society's response to suicide, including what he calls the "medicalizing of suicide." He declares that suicide victims evade the consequences of their action much as a defendant might avoid incarceration through an insanity defence. In his chapter on suicide prevention, he dismisses such efforts because they rest "on the use of coercive psychiatric practices." In his chapters on death and killing as treatment Szasz discusses his concerns about physician-assisted suicide. He draws a direct line between legitimizing medical killing and Nazi Germany's systematic extermination of mental patients: "Enlisting physicians in the task of killing people, whether they are patients or enemies of the State, is not a new idea." In the final chapter Szasz expresses his hope that suicide may be redefined: "It ought to be morally and politically impermissible to use the coercive apparatus of the State to interfere with 'suicidality'."

Despite my commitment to the issue of suicide, I found Fatal Freedom a tedious read. The conspiracy of psychiatric power is not a new claim for Szasz; this book merely gives an old product new packaging. With the elevation of gossip to news, private misadventure to public theatre and perversions to regular daytime television, Szasz has followed suit, and I am afraid can be as easily dismissed.

The declaration for voluntary suicide was the sound bite to get our attention. Szasz then proceeds to discount the scientific evidence accumulated from a hundred or more years of the study of suicide as "nonexistant." He characterizes suicide as a "future-directed, anticipatory act" and shows little understanding of the nature of the suicidal mind devoid of perspective, planning or problem-solving. He dismisses the suicide prevention movement as solely in the domain of psychiatry and does not acknowledge the central role that volunteerism has always played. (The most recent example from the United States is the Suicide Prevention Advocacy Network, a grassroots organization made up of suicide survivors, which has effectively lobbied Congress and the House of Representatives to initiate a national suicide prevention strategy under the direction of the Surgeon General. This initiative did not, and could not, depend on the power of psychiatric coercion.) He sterilizes the discussion of suicide and its aftermath. His only reference to the trauma of suicide is the unconvincing remark that "There is no reason to believe that Socrates's disciples were damaged by the suicide of their master." What about the pain of parents who have lost their teenaged son, or the horror of a father who has killed his child and himself?

In the end, Szasz's thesis reads as artificial and ill conceived. He speaks of free access to illicit drugs but makes no mention of the consequences of this proposal. He speaks of allowing suicide to be carried out in private but not in public places. But how can coercion be avoided in making this differentiation? Would he allow children and adolescents to commit suicide? At one point, he suggests that early childhood and old age should be exceptions to his principle but never elaborates on this point. Szasz rails against socialized medicine as restricting freedom but glosses over how free-market medicine leaves millions without access to health care.

Psychiatric powers in the new millennium are not going unchecked. Suicide is a complex and painful reality that should not be cheapened to attract renewed attention to old ideas. The issue of physician-assisted suicide needs to be debated openly and honestly. If readers truly wish to explore the faces of suicide - scientific, social and human - I recommend Night Falls Fast: Understanding Suicide, by Kay Redfield Jamison.2 Pass Szasz by, as perhaps time has.

References

1. Sommer-Rotenberg D. Suicide and language. CMAJ 1998;159(3):239-40.
2. Jamison KR. Night falls fast: understanding suicide. New York: Knopf; 1999.

Paul S. Links
Arthur Sommer Rotenberg Chair in Suicide Studies
University of Toronto
Toronto, Ont.