Schizophrenia and the Right to Die…

Hewitt J (2010). Schizophrenia, mental capacity, and rational suicide. Theoretical medicine and bioethics, 31 (1), 63-77 PMID: 20237854

Specific, mental health legislation has often been wrongly touted as a human rights instrument when since its inception, it has always been about controlling a potentially ‘dangerous’ population. Law knows next to nothing about mental illness or mental disorder, and nor does it want to know. It is content to rely on medical orthodoxy not only to tell it what constitutes madness, but also to define and explain the components therein. Arguably, no component is more important in that facile interface between law and medicine than mental capacity. Little understood by most legal practitioners, it nonetheless becomes the cornerstone of whether to detain someone, to divert them into the forensic arena, or to force them to accept treatment against her or his will.

Here, we see the classic paradigm of medico-legal parentalism in practice, assuming to possess all the knowledge, and possessing all the power. The right of any citizen to retain autonomy over her or his own person is relinquished once a psychiatrist or other mental health professional determines that she or he is ‘mentally incapacitated’. That psychiatry and its band of equally inept sycophants do not have a clue about what constitutes mental capacity is irrelevant. They are the ones wearing the white coats. They look important enough to hold ascendancy over any divergent perspectives. The preposterous, textbook chain of events typically starts with the subject person refusing to accept enforced treatment, then because of that, she or he is declared to lack insight into her or his mental disorder or illness, and then that lack of insight becomes ample proof of mental incapacity.

‘Scant research has been undertaken into mental capacity in psychiatric patients. What little has been done challenges the notion that people with schizophrenia are globally irrational, particularly with regard to formal logic. For instance, the presence of delusional beliefs in one area does not cloud general judgment, and hallucinations are not a consistent indicator of reduced mental capacity in all respects. The criteria by which people are judged to have diminished capacity under the Mental Capacity Act [UK] do not readily apply to people with schizophrenia, as the assessment criteria are concerned with the symptoms of organic disorders. Capacity in clinical psychiatry is more concerned with the capacity to consent, and in particular to assent, to treatment. Failure to comply with treatment is seen to be a lack of insight into the presence of a mental disorder and thus a sign of irrationality’ (Hewitt, 2010, p.64).

In this article, Hewitt (2010, p.75) cautions against conferring global mental incapacity upon people who are mentally ill or disordered. Focusing on people living with schizophrenia, she argues that incapacity is rarely ‘global’, and thus the subject person should to the fullest extent possible, retain agency over her or his own life (2010, pp.71-72). That would include the right to commit suicide (Hewitt, 2010, p.71). A highly controversial proposition, it flies in the face of medical orthodoxy’s view that suicide by any person living with schizophrenia is always an irrational act carried out by someone who is devoid of mental capacity. Hewitt (2010) challenges that view by stating that ‘the risk of suicide for people living with schizophrenia is highest when positive symptoms are in remission’ (p.71). Moreover, she suggests that for people living with schizophrenia, quality of life is not associated with ‘the severity of positive symptoms’ but the degree of social functioning (for example, the presence or absence of positive relationships with partners, other family, friends or colleagues) (Hewitt, 2010, p.72).

‘Werth (1996) has discussed the controversial view that the suffering caused by chronic mental illness has parallels with the suffering endured by the terminally ill. He contends that the common thread between both experiences is that of hopelessness. For the person with schizophrenia, who is subjected to repeated relapses and rehospitalisation with consequent psychic, social, and interpersonal losses, the experience of present suffering and prediction of future suffering may lead to a state of hopelessness. Psychological suffering in such circumstances is not necessarily a reflection of a distorted view of present or future reality and may legitimately influence a person’s desire to die’ (Hewitt, 2010, p.72).

The bigger questions for me about all of this are:

1. should any rational person be allowed to commit suicide?;
2. what right do others (for example, family, friends, and health professionals) have to stop such acts from occurring?; and
3. is forcing someone to lead a life of intolerable suffering preferable to death…?