I very much appreciated Tom Flynn’s editorial “The Signature of Freedom” (Free Inquiry, October/November 2018), which refuted the unfounded presumption that, by definition, suicide results from mental illness. In exposing that intellectual cop-out for what it is, Flynn breaks the false, presumed-causal connection between mental illness and suicide. Building on that, I would like to break the false, presumed-causal connection between mental illness and irrationality. The vast majority of those who suffer from mental illness are perfectly capable of making a rational choice to end their lives. Presuming otherwise is demeaning and denies millions of individuals their humanity, dignity, and right to self-determination.
Surrounded by the Rational Mentally Ill
It was well known that Abraham Lincoln suffered from severe major depression1. No one is arguing that he wasn’t rational or competent to make decisions. Tens of millions of Americans suffer from mental illness, and most of them are likewise perfectly able to make rational decisions. Certainly, some who suffer from mental illness experience psychosis or are otherwise unable to rationally evaluate the world around them, but that is not the case for most who suffer. The 2016 National Survey on Drug Use and Health found that nearly one in five U.S. adults suffered from mental illness (18.3 percent, or 44.7 million adults). Of those, more than one in twenty-four suffered from serious mental illness (4.2 percent, or 10.4 million adults)2. We are surrounded by rational, mentally ill individuals who are functioning, integral parts of our lives, economy, and society.
Most of those who suffer with mental illness make—and are legally allowed to make, and no one is arguing they shouldn’t be allowed to make—important decisions every day. They decide to open a bank account, get a loan to buy a house, get married, forgo medical treatment … and end their lives. It is neither consistent nor logical to acknowledge that most individuals suffering from mental illness are rational and competent to make weighty and consequential life decisions, including major financial decisions and critical healthcare decisions (which may affect when and how they die), but to then assert that they are not rational or competent to decide when and how they die.
Rationality, Competence, and Capacity
Those who suffer from mental illness, those with normal age-related cognitive difficulties, and those struggling with mild cognitive impairment or early-stage dementia are often unfairly painted with the careless, broad brushstroke of “incompetent” or “not thinking rationally.” Competence tends to be used as a binary term: you are or you aren’t. This either-or dichotomy doesn’t recognize the different capacities required for different tasks, and task-specific capacity is often used to capture this. For example, individuals struggling with impaired short-term memory might be unable to organize their schedules or keep track of appointments, but they can still be perfectly clear on their values and wishes when it comes to end-of-life decisions. Likewise, individuals suffering from a mental illness such as depression might be unable to experience pleasure or joy but can still be perfectly rational about their situations and their chosen courses of action.
Do not confuse difficulty retaining recently learned information with general incompetence, and do not confuse the inability to experience joy—or many other symptoms of mental illness—with the inability to reason. Doing so perpetuates a condescending prejudice that, like all prejudice, is used to deny individuals their rights based on characteristics that are not relevant to the situation.
To be competent in the context of a suicide choice, to have decision-making capacity, one must understand the situation, the decision being made, and the consequence of making a given choice. If that threshold is met, one is competent to make the decision, regardless of whether one can track one’s appointments or whether one suffers from mental illness.
Debility and Depression Often Coexist
Along with pain and suffering, illness and debility often lead to social isolation and financial hardship. In such circumstances, it is surprising not to find some level of depression. The very reasons that make a suicide choice rational are also reasons one would be susceptible to depression. For many considering suicide, it is a catch-22 to argue that they cannot rationally evaluate the choice to end their lives if they suffer from mental illness.
Life is messy and complicated, and it is absurd to suggest that only those who are perfectly happy with their suffering, whose finances are in good order, and who are surrounded by loving family and friends could possibly rationally consider suicide. As Flynn points out, arguing that suicide is, by definition, the result of mental illness is an intellectual cop-out that fails to address the often very good reasons individuals put forth for considering suicide and blithely dismisses the reasoning and values of millions of people.
The Mentally Ill Can Be More Rational
In 1975, Ellen Langer’s paper, “The Illusion of Control,” was published in the Journal of Personality and Social Psychology3. As dry scientific papers go, it’s pretty funny. It turns out that we humans do all sorts of nutty—and decidedly irrational—things. In a game of chance, where whoever randomly picks the higher card wins, we bet more money when faced with a nervous competitor than when playing against a confident opponent. Surely, the cards must know that a dupe sits across from us. In an office lottery, when asked to sell our ticket, we ask for considerably more if we personally selected our ticket than if the ticket was assigned to us, and when offered the opportunity to exchange our ticket for a ticket in a lottery with obviously better odds, we’re much less likely to exchange if we personally selected our original ticket. Langer wasn’t the first to look at this quirk of human cognition, but her accumulation of data sparked several investigations into this phenomenon.
One finding to come from the flurry of studies that followed had researchers a little baffled. It turns out that those suffering from depression, whose perceptions are supposedly warped by cognitive distortion, are less likely to make this cognitive error and are often more accurate in determining their level of control than those who don’t suffer from depression. Golin et al. ran two experiments, the first with depressed and nondepressed students and the second with depressed and nondepressed psychiatric inpatients, using a game of dice4. As would be expected from Langer’s work on the illusion of control, nondepressed subjects rated their control over the outcome significantly higher when they rolled the dice than when the croupier rolled the dice.
Interestingly, depressed subjects did not. It is curious to see researchers’ need to pathologize the finding that depressed individuals were less likely to succumb to the illusion of control, as if it had to be excused—there had to be something wrong with the fact that sufferers of depression were getting the question right. Golin et al. state, “the absence of the illusion of control was viewed as reflecting a general sense of personal incompetence among depressed persons.”
This is more than mildly insulting. You have a group of people who are doing something competently, but, because nondepressed people are doing it incompetently, and they’re supposed to be the ones without cognitive distortion, the researchers essentially define doing things competently as a sign of cognitive distortion. It’s a handy trick when you get uncomfortable experimental results.
You wouldn’t choose to be a sickle cell carrier, but if you happen to live where there’s malaria, it does confer some advantages5. Likewise, one wouldn’t choose depression, but we shouldn’t be shocked that depression might confer some cognitive advantages. It is not unreasonable that having a slightly better grip on reality, as depression sufferers seem to in circumstances where they assess their level of control, could have some benefits, even if it isn’t such a good thing for overall well-being.
Dan Gilbert, a Harvard psychologist and author of Stumbling on Happiness, isn’t the first to point out that “if we were to experience the world exactly as it is, we’d be too depressed to get out of bed in the morning.”6 Shakespeare captures this sentiment in Henry IV’s meditation on what it would be like to see truly what lay ahead in life’s trajectory. The Bard makes a good evolutionary argument for why our brains don’t paint too clear a picture of our odds:
The happiest youth, viewing his progress through,
What perils past, what crosses to ensue,
Would shut the book [of fate] and sit him down and die.7
There is a painful wisdom that can come with depression, and a little extra clarity might be a part of it. Certainly, depression impairs the lives of those who suffer, but we should respect the strengths it gives them. Specifically, stop asserting that those with depression can’t rationally assess a choice to end their lives, because situations where it helps to be realistic about how much control one has over what lies ahead are situations in which those suffering from depression might well be thinking more clearly than the nondepressed.
One might argue that I’m making a big leap from a game of dice to a decision for death, but our lives are far more subject to the roll of the dice than we like to think. When looking forward and wondering when a stroke might hit, when a hip might break, when a heart attack might debilitate, when Parkinson’s will turn a corner, it is far better to plan with eyes unclouded by optimism than to bet your future dignity and autonomy as though your hope could somehow load the dice.
Rational Until Proven Otherwise
To be clear, I am certainly not suggesting that every suicide choice is rational or well-considered. I am also not making an argument as to whether those suffering from depression or any other mental illness make more or less rational or well-considered choices than those who are not suffering, but I would like to dispel the notion that those suffering from mental illness cannot make rational decisions about when and how they want their lives to end.
To fully accept and embrace the humanity of our fellow citizens requires that we respect their values and judgments and that we presume them rational unless and until they are clearly shown to be otherwise. Forgetful is not irrational. Mentally ill is not irrational. I fully agree with Flynn that society would benefit from a more nuanced understanding of suicide, and I would further argue that a more nuanced understanding of mental illness is also much needed. Playing on Flynn’s well-put words: to limit the options of those suffering from mental illness as though they were irrational, when they are not, is to traduce their freedoms.
- Shenk, Joshua W. “Lincoln’s Great Depression.” The Atlantic, October 2005. Web. December 22, 2018.
- The survey defined serious mental illness as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.
- Langer, Ellen J. “The Illusion of Control.” Journal of Personality and Social Psychology 32, no. 2 (1975): 311–328.
- Golin, Sanford, Francis Terrell, Jack Weitz, and Patricia L. Drost. “The Illusion of Control among Depressed Patients.” Journal of Abnormal Psychology 88, no. 4 (1979): 454–457.
- Aidoo, Michael, Dianne J. Terlouw, Margarette S. Kolczak, Peter D. McElroy, Feiko O. ter Kuile’, Simon Kariuki, Bernard L. Nahlen, Altaf A. Lal, and Venkatachalam Udhayakumar. “Protective Effects of the Sickle Cell Gene against Malaria Morbidity and Mortality.” The Lancet 359, no. 9314 (2002): 1311–1312.
- Gilbert, Daniel. Stumbling on Happiness. First Vintage Books Edition, January 2007, p. 176.
- Shakespeare, William. Henry IV, Part II. Act 3, Scene 1.