Here I will deal with Chapter 1 only, “Death.” In it Nagel takes up the question of whether anything may be said to be lost—has a misfortune occurred?—when someone has died, since the dead person no longer exists and therefore cannot feel loss of any sort. Why a psychiatrist should take more interest than most people do in this question is immediately apparent when one thinks of the problem of suicide and its contemplation or planning, a problem so often extant in everyday psychiatric practice.
Nagel concludes that death is bad; it is a misfortune. And his working-through to a conclusion follows a thorough rehearsal of the position I’ve stated, namely, that its subject, being absent, cannot mind the absence of life that death represents. He relies on several premises and semi-premises (this latter term is mine, not his), two in particular. First, life is “good” from the experience of it in itself, i.e., independent of what the contents of the experience comprise, whether the sum of the pleasant outweighs the unpleasant or vice-versa. I find this position unpersuasive if taken absolutely or naively.
Who says life is good in itself? When is it so? Those of us who’ve cared for the dying have more than once witnessed someone simply grown too weary, exhausted, with life, and in many such instances, we, the witnesses, do not object to such a person’s judgment. We feel a rightness within it, and most especially, of course, though not exclusively, if the person is suffering pain that cannot be relieved or an intolerable sum of indignities to their personhood compelled by the efforts of caregivers to sustain the life. Some persons seem to know when enough is enough, and their sufficiently empathic friends agree. And another, admittedly extreme, example: we do not critique the decision of someone who leaps to their death from a tall burning building. (One might object that such a person is not giving up a life, because death is inevitable is such a circumstance. But is the decision to jump based on an intolerable suffering from heat, a terror of burning alive, or a conviction that death is very soon to come anyhow? Could or would they cancel the decision to leap were the whir of a rescue helicopter suddenly audible?) We, many of us anyway, do not critique the decision of a lover to risk or sacrifice their life for the sake of saving a belovéd. Ditto, with regard to that of a parent to save their child or of a soldier to spare their comrades or country. Nagel, of course, would have every right to object to my examples, were he listening in, by saying that they do not put at odds his claim that life, in itself, is good and that its loss is a misfortune; they only go to show that enduring that misfortune for the sake of something good is sometimes wise, honorable, or inevitable. Indeed, my word “sacrifice,” where I’ve made use of it, would be meaningless were one’s death not a misfortune. I will counter by saying that his claim that life is good as a general truth, for me, is difficult to endorse independent of context. And my point, I’d suggest, is clarified if we shift our focus from the noun, life, to the participle, living. An absence of living is not in and of itself a misfortune. The noun is an abstraction; the participle, which is derived from the realm of the verb, is grounded in reality— it requires context.
Second, Nagel mounts the argument, and it’s on this that his conclusion rests most firmly in his own view, that a life is not constrained by its strictly temporal-spatial limits, its here and its now. He likens the situation as akin to a subject’s unknowingly being betrayed, despised, or ridiculed, sustaining injury thereby, Nagel claims, behind his back. Hope for and about the future is a part of a life, he goes on to say, so cancelled hope, via death, indeed is a loss and a misfortune, even though the dead person cannot know that misfortune through direct apprehension. In one version, he puts it this way: “If this is correct, there is a simple account of what is wrong with breaking a deathbed promise. It is an injury to the dead man.”
I don’t think I believe in this argument, though I grant that many people do. I’m not at all certain that someone unknowingly may be injured by betrayal, ridicule, loathing, or death; I am reasonably confident that such things can only be injuries when known by the injured; death is included in my phrase “such things.” I may fantasize my life immortal, the spontaneous resolution of my baldness, and my gaining the tenor voice of Luciano Pavarotti; I may hope in time to publish a novel the equal of Joyce’s Ulysses. But do the forever absent realizations of such things constitute misfortunes? Things that never existed beyond a yearning toward them cannot be lost. Hopes cannot be “cheated” by death. The margin between hope and fantasy is tenuous. I will go further. I’ll claim that words like “hope” and “fantasy” bear an intrinsic buyer-beware. A warning not to feel cheated, if they fail a realization, is built right within them.
My own conclusion, then, contra Nagel, is that Lucretius was correct more than twenty centuries ago: death is not to be feared or resented in itself, only for its voiding the realization of goals already and reasonably imagined (i.e., goals not simply hoped or fantasized). One of the most ingenious aspects of Lucretius’s concluding as he did, and one discussed by Nagel, is his pointing out the fact that the eternity preceding our birth we resent not at all, so why should we resent or fear the eternity following our death?
Which brings me to murder and suicide. Murder, so far as I know, (ritual sacrifice excepted) is universally taboo within a culture. One of my favorite mentors during psychiatric training, Salman Akhtar, puts it this way: “Incest is a crime against Humanity, murder a crime against God!” Murder is an attack on the fabric of social cohesion holding a culture together, uniting it. It is a misfortune the community suffers, regardless of whether it is conceived as a misfortune for the victim. Of course, we do pity the victim, but my interpretation of this fact is that it represents our rage within a defensive displacement, because rage over an attack on “social fabric” is harder to grapple with in concrete terms. Every society has the right, the obligation, to place taboo on the act of murder.
Suicide is not so simple. Context matters—the context of culture and the context of circumstance. Its, suicide’s, history is reviewed in the poet Jennifer Michael Hecht’s terrific book Stay (Yale University Press, 2013), a book that might be a candidate for reading by every teenager in a required high school class. As Americans in the early 21st century, we feel the act of suicide is under a taboo, but, even if unconsciously, we know that taboo is relative. Which is why the subjects of do-not-resuscitate and assisted-suicide in the context of end-of-life care have been so discussed and debated in recent years. We view murder of innocents by suicide-terrorists with horror and rage, but because of the murders within their acts, not the suicides. An act of suicide designed to save the life of another we generally celebrate rather than condemn. Suicide, such as Jeffrey Epstein’s (presumed) instance of it, designed to frustrate our society’s judgment and punishment, we condemn, but not because it’s taboo-busting. Suicides of despair—say in the finale of Romeo and Juliet—cause us grief not rage. We should, if we rightly understand, see the matter of despair within suicides caused by medical conditions, such as severe depression (not rarely mixed with mania) and psychosis, and respond, accordingly, with grief not rage. But here we are various. Many among us continue to stigmatize, as if such an outcome of illness is taboo.
How should we speak with someone so despairing as to contemplate suicide? The first step is easily decided on, or should be: yes, speak with them about their despair and their impulse to suicide, and in a non-judgmental, curious, and empathic way. Empathy is easily come by if you pause to imagine bearing within yourself a despair so severe as to want to end your life—that degree of pause is a must. From that point on, however, context is everything. (I shall not take on in this commentary what I might do, what options I consider, in the context of an irremediable cause for despair—a topic for an essay in itself—except to say I never consider assisting a suicide on my own initiative, outside of a legal, officially sanctioned environment authorizing me to do so.) Most despair creating thoughts toward suicide occurs in a context of remediable cause, although that fact is denied by the person who’s suffering. That’s the demonic force within depression and psychosis; these conditions make you think your despair is forever! Not only think it’s forever, insist (because you cannot imagine otherwise)! The malady you suffer has paralyzed your thinking beyond the despair it’s caused. For this reason, the very next step for me, the witness to such suffering, must be that of protecting the sufferer from themselves. I must act to remove their access to the means of killing: first and foremost, ridding them for now of firearms, however that is best accomplished; ridding them of pills and alcohol and other substances potentially lethal; arranging for their companionship, and that it be 24/7 to the degree possible; arranging for their immediate evaluation for suicide by a crisis-team, psychiatric facility, or emergency room. Think M-F-E (means-friends-eval); E can be first, and should be, if it can be truly immediate and the severity warrants.
But despair has not always reached such extremity when suicidal thoughts or yearnings first appear. In such cases, which are common, especially if I am the psychiatrist in an office-setting, I still think first to M and F and begin actions in their regard. Next, I think to the cause of despair: can more be done, and how, for its effective relief (initiation of, or changes in, medication; psychotherapy, especially one tailored to suicidal impulses; electroconvulsive treatment—ECT; inpatient psychiatric care)? And, then, yes, some talk about suicide itself. My experience and my thinking about death and suicide—see above—lead me to put more emphasis on encouraging, so much as I can do empathically, the despairing person’s thoughts toward those left behind—more emphasis than I put to their loss of self—death. Loved and loving ones are those who must bear the experience of loss for them. It’s a smaller community than the one disturbed by murder, but the pain it bears is severe, indeed—unending, a trauma of traumas. One must be gentle, not hectoring. The despairing person will object: “But they will be better off—I am awful, I am useless!” My reply I generally limit to asking them to reflect that just some weeks ago, before depression took hold, for example, such was not their self-evaluation. And, at that point, I’ll put some effort toward pointing out that their current despair has a remedy, if they are alive to receive it.
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R. A. Johnson
ONE PSYCHIATRIST’S TAKE ON THOMAS NAGEL’S MORTAL QUESTIONS: SOME THOUGHTS ON SUICIDE
Reviewed in the United States on 12 November 2019
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