No matter how exciting or mundane the narrative arc of your life, these nursing home residents have all wound up in a corner of a hospital-style room living in a public space where you can't lock your door and strangers walk by and see you lying helplessly in bed. You might be lying next to someone who spends his waking hours screaming, "Help! Please help!" Or you might be the one screaming.
It's not surprising. Moving, even to a better place, is stressful and one of the best predictors of accident or illness. Moving to a worse place, against your will, is even more stressful.
Those in nursing home for reasons other than rehabilitation, the so-called long term, survive, on average, two-and-a-half years.
The reduced circumstances of our elders aside, suicide is the tenth leading cause of death in the U.S., according to the National Institute for Mental Health, accounting for 34,598 deaths in 2007-11.3 deaths per 100,000 Americans. And that doesn't account for the 11 suicide attempts for every suicide death. And that doesn't account for what we in the trade call passive suicide ideation, the person who told me, "I'm not planning to kill myself. But if I woke up dead it wouldn't bother me."
Before old age, people can get suicidal over despair over something as silly as unrequited love. The prototype was Goethe's The Sorrows of Young Werther. Caught in a love triangle, Werther concludes that either murder or suicide is the only way out. He can't bring himself to hurt anyone but himself, and a self-inflicted gunshot takes care of business. This was not only Goethe's first big success, but led to some of the first copycat suicides.
I don't know if it were because of Werther directly, but Goethe's contemporary, the poet and writer, Heinrich Kleist, headed out into the woods with a woman and committed murder and suicide in a pact.
Overall-although trauma, shame, and illness are among other precipitants--the NIMH estimates that depression accounts for close to 90 percent of suicides.
Depression is an often treatable, and although the vast majority of people with depression do not attempt suicide, treat it and you reduce the risk.
Two types of interventions are often effective.
Psychotherapy, particularly cognitive therapy, can help at risk people re-frame their despair and devise alternatives to self-harm.
Antidepressants, together with psychotherapy, or on their own also reduce risk.
But do we have a duty to prevent people from killing themselves?
In some countries-India and Singapore, for example-if your suicide attempts falls short, you can have the insult of imprisonment added to your failed self-inflicted injury. As late as the 1990s, it was still a felony in some U.S states. Even today there may be civil consequences, such as making it a problem for the relatives of an incarcerated or institutionalized suicide to sue for damages.
Forty-eight states make it a crime to assist in suicide. Dr. Kevorkian did serious jail time for this offense. But Oregon and Washington, alone, allow physician assisted suicides of terminally ill people. But even where it is a crime to assist in a suicide, virtually every jurisdiction allows Do Not Resuscitate orders that allow the withholding of heroic measures to keep gravely ill people alive. There is a consensus, not shared by all, that withholding care to someone who would otherwise be in a coma or vegetative state is within the moral and legal bounds.
But it's not as simple as saying it's okay to let people kill themselves as long as you don't actively assist them, or that it may be okay to withhold some life sustaining measures in the case of a terminally ill patient.
As a psychologist, I am a mandated reporter. Although the exact duty varies from state to state, generally, if someone walks into my office and says she is going to kill herself, and I believe it's a credible statement, I have to report this to an authority who could take steps to prevent harm. Other mandated reporters-and this is relevant for self-harm and harm to others-include clergy, teachers, doctors, EMTs, protective service workers, camp counselors, and commercial film processors.) In my work in nursing homes, if someone says he is going to kill himself, even if he is a stroke victim with limited means for self-harm, I have to report it-usually to the unit nurses-who will then observe the resident-typically with 15 minute checks, sometimes with a person in the room. (Often understaffed, I'll soon get requests to go and see the resident and please say he's no longer dangerous to ourselves so we can pick up the pace of more important stuff like changing diapers.)
But even though there is a limited class of mandated reporters-typically those who may become aware of people at risk through their professional role-the man or woman in the street has no legal duty to prevent someone from harming himself (or harming others).
If you see someone about to jump in front of a train, you're perfectly within your rights to watch it happen.
The law is quite Szaszian here. You are left with only a moral responsibility, if you feel it, to stop the jumper.
Many people would find it hard to resist the impulse of preventing the leap in front of the train. But it's not clear whether that would be a moral impulse-that we're doing it because we believe suicide is wrong. You or I might be just as likely to stop the jumper to avoid the emotional trauma of experiencing the death of another. There is a reason counselors are offered to people who experience deaths-whether they be first responders or innocent bystanders. Who wants ignore a suicide and experience the post-traumatic stress of nightmare and flashbacks?
But what if it's not the case of a jumper to whom we react on an impulse-whether that impulse is moral or self-protective? What if you have a significant other or a roommate who is at risk for suicide?
Aside from the difficulties involved it would be illegal for you to tie up your roommate or slip anti-depressants into his lunch. The government will tie him down or drug him for you. Although you have no duty, you could call the police and if they agree that your roommate is potentially dangerous to himself, they could bring him to an emergency room against his will where a psychiatrist could involuntarily place him in a psychiatric ward. After 3-5 days, depending on the jurisdiction, your roommate would have a hearing, with legal representation, but if a judge found him still dangerous, he could be committed for treatment. Against his will he could be medicated or even given shock treatment-electro convulsive therapy.
You might feel bad about this, but your roommate would have a hard time suing you about it, if the initial institutionalization decision by the police where based on your reporting in good faith.
Ironically, a motivated people, those who really want to kill themselves, once institutionalized, learn to keep their mouths shut. They know they will be locked up if they talk about it.
So your roommate comes home and he's still depressed, but denies ever wanting to kill himself. He could be committed for simple mental illness, but it's much tougher. You're back to thinking about slipping the antidepressant in his morning coffee.
Someone who is truly determined cannot be stopped, and the truly determined may or may not be among the significant numbers for whom otherwise effective treatments are useless. For some people depression-and the possibility of suicide-is characterological, more like a personality disorder such as psychopathy or pedophilia, for which there is no reliable treatment.
A number of legal jurisdictions civilly commit sex offenders beyond their criminal terms, in part, out of the belief that their urge to commit offenses against others is intractable to treatment.
Should we do the same for the intractably suicidal?
My book, Nasty, Brutish, and Long: Adventures In Eldercare
(Avery/Penguin, 2009), was a Finalist for the 2010 Connecticut Book Award. Click here
to read the first chapter It provides a unique, insider's perspective on aging
in America. It is an account of my work as a psychologist in nursing homes, the story of caregiving
to my frail, elderly parents--all to the accompaniment of ruminations on my own mortality. Thomas Lynch, author of The Undertaking, calls it "A book for policy makers, caregivers, the halt and lame, the upright and unemcumbered: anyone who ever intends to get old."
My web page.