Terry Pratchett on assisted suicide : comments [Matthew's Journal]

I'm wary of a large tin object marked "worms" here, and of accidentally saying something flamboyantly offensive.

Some people who want to kill themselves are mentally ill. I think we fail in our duty of care to them if we allow them to kill themselves while mentally ill. Indeed, if their mental illness can be cured, then the desire to die will go away.

Would you agree with the above paragraph? If so, I'm not sure how we disentangle that from the problem you raise with my statement.

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I think you need to disengage the wish of somebody to kill themselves from the state of mental illness. I think this was the argument at the core of Pratchett's thesis.

It's easier to understand it if someone has a physically measurable disabling and incurable disease; there's a visible reason for their unhappiness that other people i.e. the person not the person who wishes to end their life can engage with and say "OK, we'll let you kill yourself," i.e. it's easier for the outsider to realise that this may be a rational decision.

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There seems not to be a right answer. For a start, while there are some people who pretty much everyone could agree were mentally ill, mental illness shades into mental health, and there is no way to decide anywhere near the margins. Obviously (to me) it makes sense not to allow people who are mentally ill to make a decision for assisted suicide. The question is what should be done for people who are not, on the face of it, mentally ill?

Mental illness of some sorts can be invisible. Yet, if you put in place a criterion of having to prove sanity before making the decision - well - tests have shown that to be a difficult proposition.

Is all mental illness curable? I would guess not, minimally because mental illness can be caused by physical illness or even brain injury, and that may not necessarily be curable. What then? Is there ever a point at which you could justifiably end the suffering of someone in that sort of situation, no matter how sure they were, within their own limitations, that they wanted assisted suicide. I haven't got a suggestion for the right answer.

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Obviously (to me) it makes sense not to allow people who are mentally ill to make a decision for assisted suicide

I would disagree with you here - as juggzy says, "disengage the wish of somebody to kill themselves from the state of mental illness".. For instance, someone with occasional episodes (could be anything from anxiety to schizophrenia) who might have huge physical problems as well, whose therapist could demonstrate that they had the same unstinting wish throughout their remissions as well as their bad episodes...

It just reminds me of how sometimes people who seek gender reassignment are sometimes still asked to provide a psychiatrist's "certificate of sanity" before things can progress. This outmoded approach horribly stuffs those with more than one thing wrong with them :-(

Is all mental illness curable? Sadly not, but I think the more useful distinction is informed rational consent wrt the outlook of their condition, which will be hard to satisfy in many such desperate cases.

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The understanding of some physical illnesses is good, but over the whole field of physical illness understanding is patchy, and clearly there is still a lot to learn. It seems to me that mental illness is at a much earlier stage of understanding, and that seems to me to be part of the problem.

I would argue that if someone wants to kill him or herself because the voices in the head command it, then that is probalby not a good enough justification for an organisation tasked with assisting suicide for some people to make the decision to do so in that case. At least, not unless the voices cannot be silenced by any medication, are not a temporary affliction, and are, in effect, an incurable illness that causes much suffering.

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Obviously (to me) it makes sense not to allow people who are mentally ill to make a decision for assisted suicide. The question is what should be done for people who are not, on the face of it, mentally ill?

Mental illness of some sorts can be invisible. Yet, if you put in place a criterion of having to prove sanity before making the decision - well - tests have shown that to be a difficult proposition.

Er, can I just ask, are you equating mental illness with insanity and irrationality here?

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No, though there is an overlap. If all the details about mental illnesses had been discovered, which I don't believe to be even nearly the case, it just might be possible to determine accurately what types of mental illness would or would not be likely to impair someone's ability to make a rational decision.

At the present level of knowledge, it is probably possible to make estimates in many cases as to whether someone is completely off with the fairies and has little perception of what most people perceive as reality, or whether the person is able to properly consider a serious decision. If the prospect of imminent and painful death causes you to be depressed, I would not expect that that would, of itself, prevent someone from making a rational and informed decision. As rational as life ever gets, anyway.

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I wouldn't agree.

I think I should have the right to decide that the emotional pain I am in is unendurable and I want to end it all, just as I think I should have the right to decide that the physical pain I am in is unendurable and I want to end it all (but I understand that actually giving me this right in law may cause other people to suffer unreasonably).

I don't think anyone should have the right to tell me that it would be endurable if only I would undergo a medical intervention I don't want (for whatever reason I don't want it), so I must do that now, any more than I think people have the right to tell me I can't have the medical intervention I do want and should just bugger off and die already. And of course it shouldn't be forgotten that some people try all the existing medical interventions and find that none of them work.

I believe strongly that mental health care is important and valuable. That it should be available to everyone who wants it. But I also think that (as with any medical intervention) it should be up to the patient to decide whether they want to have it or not.

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October