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
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.
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