Review - Fatal Freedom
The Ethics and Politics of Suicide
by Thomas Szasz
Syracuse University Press, 1999
Review by Matthew Pianalto
Jan 4th 2005 (Volume 9, Issue 1)

Dying voluntarily is an option that all cognizant human beings possess. To intentionally bring about one's own death is to enact suicide. In Fatal Freedom, Thomas Szasz calls attention to the fact that although suicide is not a crime, thinking about it, attempting it, or failing to perform suicide successfully all prompt psychiatric interventions and often involuntary institutionalization, which Szasz refers to as "coercive psychiatric suicide prevention" (CPSP). Szasz explores the historical connections between suicide and depression--a diagnosis which is purported both to explain (psychologically) and to excuse (morally) suicide--and reveals that the psychiatric perspective has gradually diluted the concept of suicide as an intentional act and has increasingly led us to characterize suicide as a disease which needs to be treated. Implicit in this view is the assumption that suicide is never rational or preferable (if there is a difference between the two), which leads us to the irresistible conclusion that anyone who contemplates or attempts suicide is incapable of rational deliberation. The person who commits suicide is not responsible for doing so, as this "happening" (suicide) occurs as a result of a disease (depression). We are then left with the claim that the person who commits suicide does not actually commit suicide, because the presence of depressive illness as a cause of suicide trumps the attribution of intention and choice, which are essential to the definition of suicide. Suicide comes to represent, on the psychiatric view, not an act of human agency, but a loss of agency.

It is open for one to rebut that depression does not cause a loss of intentionality, but rather influences the agent to form irrational intentions. The urge to enact suicide would then fall under the rubric of irrational intentions brought about by depression. This way of formulating the psychiatric theory of suicide brings out precisely what Szasz attacks in his book: the view that suicide is (always) irrational, and that because suicidality is caused by depression, it is the job of the psychiatrist (or other mental health worker) to actively prevent suicide, and to coercively detain the suicidal person when necessary in order to provide treatment. More generally, Szasz argues that the decision to enact suicide, as well as other forms of self-chosen death (i.e. assisted suicide), should in no way involve the psychiatric or medical communities, or by extension, the State--that self-chosen death should be neither blocked nor aided by any of these institutions.

Szasz writes, "We are not responsible for being born. But from the moment we acquire the power of self-reflection, we are, increasingly as we age, responsible for how we live--and how we die" (130). To the degree that psychiatrists, interventionists, or state employees interfere with how we choose to die or specify how we ought to die, our individual autonomy--which includes the ability to take responsibility for our own lives and deaths--is diminished. Szasz argues that dying must be understood as a personal affair, and thus that suicide, insofar as it represents a mode of dying, should be a personal affair, a choice left to the individual.

This argument extends to the issue of assisted suicide, which Szasz urges is not a medical procedure, since death cannot be reasonably understood as a medical treatment. (Death is, after all, what the physician attempts to forestall by curing or alleviating our various ills.) He claims, "If both suicide and access to drugs were unconditionally legal, there would be no technical need for a physician's assistance with it: People could kill themselves or could be helped to do so by family and friends" (66). The problem is that, under the United States' current drug laws, the drugs used to induce a relatively painless death are controlled substances and can only be prescribed by physicians; furthermore, those who express a wish to die, either by suicide or with the assistance of others, may be subjected to psychiatric evaluation (and often, it is no surprise, found to be depressed). Szasz warns that relegating the business of assisted dying to physicians and psychiatrists deprives people of autonomy in how they die because the medical community, in virtue deciding who gets drugs and who is mentally competent to die in such a manner, assume an authoritative, paternalistic role over the person who wishes to die.

Throughout Fatal Freedom Szasz raises the question as to what makes physicians and psychiatrists especially qualified to decide who must live and who has permission to die, when it would seem that the person who is contemplating death, as well as his loved ones, would seem to stand in a better position to grasp the degree of individual suffering and the consequences of bringing about one's own death. Szasz does not approve or disapprove of suicide a priori, for the reasons provoking suicide may be as varied as the lives that people lead and the misfortunes that befall them. He says, "The suicide is a person who feels trapped, often because he has suffered a grave defeat. The defeats that most damage a person's will to live are loss of child, spouse, or lover; loss of health, especially mobility; loss of income or savings; and loss of honor, reputation, or status" (58). The desire to die is born out of intense suffering. Presumably, this is why Szasz finds it unsurprising, and even appropriate, that a terminally ill person, for example, would experience depression. The mere state of depression does not make the desire to die in such a situation ipso facto irrational. He continues, "It follows that if we want to avoid killing ourselves, we must try to avoid becoming trapped. Living a virtuous life may be regarded as an effective program of personal suicide prevention." What is important for Szasz in this relatively commonsense piece of advice is the importance of assuming responsibility for one's own life, including one's own problems, for one cannot be truly autonomous without accepting the responsibility for what one freely chooses to do. This includes taking responsibility for how we die, whether we choose to bear out whatever the aging process throws at us or to take our own lives in order to cut short our suffering.

This is a tall order for a society in which death is often avoided at all costs and suicide is still a great taboo. The fear of death makes it natural to fear a person who chooses death over life. Thus, we offer excuses for the suicides of those we admire: Hemingway shot himself because he was mentally ill, and it was this disease which caused his suicide; James Michener chose not suicide but simply to discontinue hemodialysis; Socrates drank the hemlock, but did not commit suicide, because he was only carrying out his sentence. Every death has its circumstances. But those in which the person actively and intentionally brings about his or her own death, Szasz reminds us, ought properly to be regarded as suicide. Our resistance to doing so highlights the deeply ingrained belief that there is something fundamentally unnatural and wrong with suicide. Contrary to this belief, Szasz holds that the capacity to choose our own death--whether we exercise this capacity or not, which certainly depends upon the circumstances of each individual's life--constitutes the basis of our capacity to live as free, autonomous beings. For in the power to claim our own lives lies also the power to avoid the traps in which suicide offers escape, and thus the power to live. At the heart of Szasz's philosophy is the belief that in order to fully enjoy personhood, we have to learn to live for ourselves. When the "therapeutic state" attempts to intervene, to tell us how to live or to force us not to die, we are deprived of this capacity.

Szasz expresses skepticism about the effectiveness of institutionalized suicide prevention, for the reason that it is nearly impossible to keep alive a person who truly wants to die. This is not to say that we should let people do as they wish without trying to persuade them to act otherwise. He writes, "The phrase right to suicide does not mean that suicide is desirable or that it is desirable that people commit suicide…It means only that agents of the State have no right or power to interfere, by prohibitions or punishments, with a person's decision to kill himself" (110). Rather, he asserts that we must content ourselves with trying to persuade people whom we believe are acting or may act unwisely, while accepting that our best attempts will not always succeed. As beings engaged in all sorts of relationships, we create bonds and agreements with each other, which carry with them responsibilities for others, and it is quite sensible to speak to each other--as friends, lovers, parents, and children--about suicide. In order to engage in such conversation, we must be willing to discuss suicide as an existential possibility, the performance of which may be blameworthy or praiseworthy, tragic or heroic. Such moral determinations cannot be made prior to examination. Szasz's therapeutic aim in writing Fatal Freedom is to show us a way to discuss suicide without masking the reasons one might contemplate death in the language of mental illness.

© 2005 Matthew Pianalto

Matthew Pianalto is a Ph.D. student in philosophy at the University of Arkansas, where he has also taught logic and introduction to philosophy. He holds a B.A. in English, and an M.A. in Philosophy. His master's thesis, "Suicide & The Self," attempts to reinvest in the philosophical nature of the problem of suicide. More info at his website: http://comp.uark.edu/~mpianal. (See "Suicide & Philosophy" link for resources on suicide.)