Fatal Freedom: The Ethics and Politics of Suicide
Thomas Szasz, MD
(177 pp., $25.95, ISBN: 0-275-96646-1, Praeger, Westport, CT, 1999.)
Fatal Freedom, is the latest link in the paradigmatic change of psychiatry, medicine and culture that began forty years ago with the publication of The Myth of Mental Illness by Professor Thomas S. Szasz. The Therapeutic State, The Theology of Medicine, Ceremonial Chemistry and Cruel Compassion, as well as the rest of Dr. Szasz's twenty-five books, bear titles indicating a radical new way to look at our society and the world. Unfortunately, the bulk of the medical profession has only to "suffer" the new insights instead of assimilating them. Prejudicially, the medical profession buries its head in the sand and refuses to read and digest the message. The rest of the world has moved along with the new ideas leaving medicine tottering in the dark. Items such as "health delivery crisis" and "drug problem" could be remedied by a less reactionary medical profession. It's the hope of this reviewer that his colleagues will read Fatal Freedom for it discusses the topics of suicide, a major medical issue, from a very different point of view.
One can read this book from the perspective of moral philosophy, political science or clinical medicine. Of the first two perspectives, readers of previous works of Dr. Szasz will find here many refreshed ideas about civil rights, government coercion, personal autonomy, the therapeutic state, language manipulation, medicalization of ethics and others. Some colleagues and graduate students familiar with these subjects will enjoy reading how those concepts apply to suicide.
This review will discuss, primarily, the practical medical contributions of Fatal Freedom, since other reviewers, such as Ross Levatter, have done excellent jobs discussing Dr. Szasz's basic tenets on this subject.
First of all, Dr. Szasz brings to our attention the fact that the act of killing oneself does not correlate to any known disease or anatomicpathology. As a consequence, the application of medical knowledge to suicide predictability is not any better than non-medical predictability. It is humanly natural for physicians to try to help preventively or post facto, with one of the most disturbing human acts: self-killing. Certainly this is not the first time doctors are asked to solve disturbing human problems of questionable biological nature. Sexual activity of adolescent females ("ninphomania"), masturbation among adolescent males, ("psychiasthenia") and poverty may serve as illustrations of other such human problems.
There is evidence that "suicide prevention," a widespread medical-psychiatric practice, may increase the incidence of suicide rather than decrease it.(1) The book offers abundant authoritative bibliography in support of such observation. Dr. Szasz's contention is that the coercive posture of "prevention" often contributes to a person's ultimate act of (fatal) freedom. Doctors must not ignore the fact that "civil commitment" is the law of the land. All it takes for a judge to order the involuntary hospitalization and treatment of a citizen is the word of a physician to the effect that the person is a danger to himself and/or others. Faced with such "preventive" alternative the citizen is compelled to exercise his existential need of (fatal) freedom. Ernest Hemingway, Sylvia Plath and Virginia Wolf, among others, are people whose suicide may, in part at least, have been provoked by fears of psychiatric incarceration and involuntary psychiatric treatment, Dr. Szasz says.(2) Quoting another famous polemist who said give me freedom or give me death, Szasz adds that the psychiatrist's posture inverts Patrick Henry's cry thus:"Give him (the patient) commitment, give him drugs, give him electric shock, give him lobotomy, but not let him choose death!" Dr. Szasz further states that "by so radically illegitimizing another person's wish to die, the suicide-preventer redefines the aspiration of the other as not an aspiration at all. The result is the utter infantilization and dehumanization of the suicidal person."(2)
It is wise for the practicing physicians to consider the legal exposure when they force "prevention" aided by the judge that orders it upon the doctor's advise. Patients kill themselves even under the most careful watch. Doctors and hospitals are found liable over and over again because of "negligence," logical reasoning based on the (faulted) stated medical preventability of suicide.
For those interested in the subject of Physician Assisted Suicide there is Chapter 5: "Prescribing Suicide --- Death as Treatment." The chapter offers plenty of food for thought. Here again, Dr. Szasz discusses the fallacies of "medicalizing" moral matters, a rabbit hole that the medical profession continues to toil (or toy) with disregard for its terrible consequences. The following chapter discusses one of the consequences: Nazi Germany's "eugenics" ideology that invented the notion that "life" may or may not be worth living in the eyes of third parties. Thus the state proceeded with "the argument that the destruction of 'lives not worth living' is a humane medical act" Here too the medical profession provided society with a "medical-scientific" justification for a morally- or politically-motivated, wrongful act.(3)
In the seventh and final chapter, Dr. Szasz discusses "Final Respon-sibility." Whereas responsibility and rights have been big concerns in most of his books, it is in Fatal Freedom that Dr. Szasz pours his most profound thoughts on the matter. Although these considerations may be more in the realm of moral philosophy or political science, their interface with medical practice, particularly medical ethics, is hard to overlook. Fatal Freedom is a very serviceable book for physicians, who in one way or the other have to deal with suicide in their medical practice.
Fatal Freedom is a scholarly written yet easily readable book. Of its one hundred and seventy-seven pages, thirty-eight pages are dedicated to four excellent sections: Notes, Selected Bibliography, Author Index, and Subject Index.
Reviewed by Nelson Borelli, MD
1.Szasz T. Fatal Freedom. Westport, CT, Praeger, 1999, p. 54.
2. Ibid., p. 55.
3. Ibid., p. 98.
Dr. Borelli is Assistant Professor of Psychiatry at Northwestern University in Chicago, Illinois. His e-mail is: firstname.lastname@example.org.
Originally published in the Medical Sentinel 2001;6(4):141, 144. Copyright©2001 Association of American Physicians and Surgeons (AAPS).