The Left Atrium · De l'Oreille Gauche

CMAJ 2000;163(3):313-6

• An old idea repackaged
• From a Kosovo diary
• One thousand words

Fatal freedom: the ethics and politics of suicide
Thomas Szasz
Praeger Publishers, Westport, Conn.; 1999
US$12.95 178 pp. ISBN 0-275-96646-1

The extension of the "therapeutic State," according to Szasz, is to transform physician-assisted suicide into a treatment such that "fatally ill patients need this service the same way that patients with acute appendicitis need an appendectomy." Szasz summarizes his position as follows: "Wanting to die or killing oneself is sometimes blameworthy, sometimes praiseworthy, and sometimes neither; it is not a disease and it cannot be a bona fide medical treatment; and it is never adequate justification for coercion by the State."

The book begins with a discussion of the language of suicide. Szasz notes that there are only a few English terms to connote self-killing. The limits of our language, he writes, "de-mean" suicide, "emptying the act or phenomenon of its rich meaning and imposing on it a single signification, typically of badness or madness." In no way agreeing with Szasz's central thesis, Doris Sommer-Rotenberg has written about how our language of suicide perpetuates a pejorative view of those who end their own lives and of the family members they leave behind.¹ Szasz recounts the history of society's response to suicide, including what he calls the "medicalizing of suicide." He declares that suicide victims evade the consequences of their action much as a defendant might avoid incarceration through an insanity defence. In his chapter on suicide prevention, he dismisses such efforts because they rest "on the use of coercive psychiatric practices." In his chapters on death and killing as treatment Szasz discusses his concerns about physician-assisted suicide. He draws a direct line between legitimizing medical killing and Nazi Germany's systematic extermination of mental patients: "Enlisting physicians in the task of killing people, whether they are patients or enemies of the State, is not a new idea." In the final chapter Szasz expresses his hope that suicide may be redefined: "It ought to be morally and politically impermissible to use the coercive apparatus of the State to interfere with 'suicidality'."

Despite my commitment to the issue of suicide, I found Fatal Freedom a tedious read. The conspiracy of psychiatric power is not a new claim for Szasz; this book merely gives an old product new packaging. With the elevation of gossip to news, private misadventure to public theatre and perversions to regular daytime television, Szasz has followed suit, and I am afraid can be as easily dismissed.

The declaration for voluntary suicide was the sound bite to get our attention. Szasz then proceeds to discount the scientific evidence accumulated from a hundred or more years of the study of suicide as "nonexistant." He characterizes suicide as a "future-directed, anticipatory act" and shows little understanding of the nature of the suicidal mind devoid of perspective, planning or problem-solving. He dismisses the suicide prevention movement as solely in the domain of psychiatry and does not acknowledge the central role that volunteerism has always played. (The most recent example from the United States is the Suicide Prevention Advocacy Network, a grassroots organization made up of suicide survivors, which has effectively lobbied Congress and the House of Representatives to initiate a national suicide prevention strategy under the direction of the Surgeon General. This initiative did not, and could not, depend on the power of psychiatric coercion.) He sterilizes the discussion of suicide and its aftermath. His only reference to the trauma of suicide is the unconvincing remark that "There is no reason to believe that Socrates's disciples were damaged by the suicide of their master." What about the pain of parents who have lost their teenaged son, or the horror of a father who has killed his child and himself?

In the end, Szasz's thesis reads as artificial and ill conceived. He speaks of free access to illicit drugs but makes no mention of the consequences of this proposal. He speaks of allowing suicide to be carried out in private but not in public places. But how can coercion be avoided in making this differentiation? Would he allow children and adolescents to commit suicide? At one point, he suggests that early childhood and old age should be exceptions to his principle but never elaborates on this point. Szasz rails against socialized medicine as restricting freedom but glosses over how free-market medicine leaves millions without access to health care.

Psychiatric powers in the new millennium are not going unchecked. Suicide is a complex and painful reality that should not be cheapened to attract renewed attention to old ideas. The issue of physician-assisted suicide needs to be debated openly and honestly. If readers truly wish to explore the faces of suicide — scientific, social and human — I recommend Night Falls Fast: Understanding Suicide, by Kay Redfield Jamison.² Pass Szasz by, as perhaps time has.

1. Sommer-Rotenberg D. Suicide and language. CMAJ 1998;159(3):239-40.
2. Jamison KR. Night falls fast: understanding suicide. New York: Knopf; 1999.

Paul S. Links
Arthur Sommer Rotenberg Chair
  in Suicide Studies
University of Toronto
Toronto, Ont.

[Contents]

I found it difficult to get to Kosovo, and difficult to come back. In May 1999, during the height of the refugee exodus, numerous relief agencies politely refused my offers of help. Finally, on June 3 a call came from Relief International, a young, medium-sized group based in Los Angeles. They wanted me to be ready to fly to Rome in two days. I pleaded for two more. On June 7 my apprehensive parents saw me off with a rag-tag selection of books and drugs I hoped would be useful. But neither books, anti-diarrheals nor Harvard graduate studies in international health could prepare me to be a medical officer in Albania.

A demolished mosque and minaret in Prizren, Kosovo (Photo courtesy of Raghu Venugopal)

My work began far from the Albanian capital of Tirana, in a large refugee camp named Qatrom (pronounced "Chaatrom"). The camp was populated by 4000 Kosovars, most of whom were from their capital, Pristina. In those early sweltering days I joined a team of former models, doctors, nurses, high-school drop-outs and ex-lawyers in running a small town of sorts. UN officials in white utility trucks swooped down on us daily with a barrage of inefficient plans. Refugees from cosmopolitan cities bemoaned the repetitious menu and lack of vegetables. Local politicians by turns taxed and withheld our thready supply of essential medicines. Too often I had to politely shoo away government soldiers bearing AK-47s as they crawled under our tents to steal supplies. Local mafia types tried to buy young Kosovar women through the camp fence for the sex-slave market. Old blood feuds erupted. Guns blazed day and night, and a desperate parade of sullen men arrived at the camp, searching in vain for their loved ones.

School books burned in a bucket, Gjonaj village school, outside Prizren, Kosovo (Photo courtesy of Raghu Venugopal)

Amid the chaos and lawlessness, marriages were celebrated, women gave birth and elders were buried. Ballads warmed the night air, and Clowns Without Borders served alongside their better-known cousins. We oversaw the building of schools and the development of counselling centres for unaccompanied women. Thirteen makeshift schools were constructed out of plastic, piping and steel. Staffed by Kosovars, these schools were well attended and provided much-needed diversion for bored and tired children. The counselling centres were also well attended. Staffed in part by Albanian gynecologists and midwives, they offered a secure space where women could discuss issues of concern to them.

On three occasions I was sent on fishing expeditions for analgesics, antihypertensives and oral hypoglycemics. These were in desperate demand, given the deluge of refugees with untreated chronic conditions. There was always a religious or charitable organization willing to donate literally truckfuls of drugs, and so I didn't come back empty handed. Yet, despite minor triumphs like these, no small amount of grief went into our work. We slept fitfully and had nightmares. In our dreams, weathered hands clutched at us and desperate voices pleaded for shoes, food, and sheets of plastic roofing. Most ex-smokers I worked with started smoking again. Many drank too much on weekends to forget the mess that was on our hands. Even now when I'm back home and out for a run along a wooded path, I drop a heartbeat if I see red tape marking a tree to be cut down. I am still conditioned to fear landmines — not by NATO warnings, but by the countless graves of landmine victims I saw along Kosovo highways.

When the NATO–Serb peace plan was forged our camp emptied, even though Kosovo was riddled with mines. For what it was worth, I mediated heated meetings between Kosovar elders and the UN staff who oversaw the repatriation. Refugees asked me why they should wait to go home. I told them they might lose their TV in Kosovo to looters if they stayed longer, but that would be better than losing a child or a limb to a landmine. Nevertheless, some refugees used their last 100 Deutschmarks to rent lorries to trundle home in. After all they'd been through, I found it hard to blame them. As they drove away from the camp we could hear their melancholy songs of home even from two miles away.

The poor, elderly and scared stayed behind to be airlifted home by the UN. Each day in late June, two French jets roared triumphantly over Qatrom with "our" refugees. We waved and honked, and laughed at how these fly-bys made the unsavoury work of dismantling toilets and pairing unmatched shoes go all the better. We struck down Qatrom in early July, and an expatriate group formed an advance party to venture into Kosovo. By that time, two of the relief workers had received divorce notices from their spouses — a sad commentary on the effect that overseas work can have on the personal lives of relief workers and their families.

I arrived in Pristina airport on July 6, en route to Prizren, Kosovo's second-largest city, where I had agreed to be medical coordinator. After negotiating British and Russian security I made the four-hour bus journey from the capital to Prizren. Like other newcomers to the devastation, I sat mute and wide-eyed. Nobody took photographs. The driver turned the music down. The media had reported the carnage well, and we had tried to prepare ourselves. Along the road to Prizren we eyed house after house, village after village, charred by mortar fire. We passed mangled tanks lying beside the pockmarked road and steered around bomb craters big enough to engulf a misdirected car.

The next day, I began hiring doctors and nurses for three villages surrounding Prizren. Doctors were relatively easy to find and were "inexpensive" to hire. Drivers, on the other hand, were "budget-killers," but we desperately needed them to ferry us to remote villages. Writing applications for funding became a crushing necessity. Days were spent in sun-baked cars and in smoke-filled local offices of the UN, WHO, USAID and the UN High Commissioner for Refugees. Nights were spent in closed-door meetings or staring at a laptop, praying that the power wouldn't fail. Not surprisingly, having good data was the key to landing grants. More important, however, were personal and organizational politics and friends in high places. Deals were closed in hushed discussions over gasoline-like Raki in a seedy cafe bleating the latest Turkish hits.

In late July, Kosovo was swept with euphoria and violence. Around our lavish but cheap accommodations, Serb and Gypsy homes went alight daily. The billowing smoke was so thick it was hard to breathe or to see down the narrow cobblestone streets. Any Serbs left in Prizren sought refuge in the still-standing Orthodox monastery. About two murders occurred daily, and Serbs were killed if they so much as left the monastery for cigarettes. The horror and rage of the ethnic Albanians was palpable. Mothers cooking our hearty meals and fathers driving our cars had lost relatives brutally in the recent violence, but they took pains to remind us of the years of atrocities that had occurred before the world had heard of Kosovo. It made them angry to hear naïve foreigners dispassionately preaching tolerance and forgiveness. And we, too, became witness to this violent history, stumbling over the rotting bodies of children as we entered ruined clinics and burned-out schools.

Expatriate staff faced risks in Kosovo, not the least of which were the abominable roads and reckless motorists, which nearly claimed the lives of a fellow medical student and her driver. Others were shot at or threatened by extremists for assisting Serbs. One of our translators was told to quit or die. We took all threats seriously and lived in suspicion and fear.

Staying sane meant focusing on the person in front of you and ignoring politics. If in one day we helped 20 families on one village (among thousands of needy villages), that had to be enough. To worry about how much more there was to do was to drown in despair.

By mid-August, many of us were burned out. Yet we felt we had achieved tangible results. With two other students I had obtained approval for US$450 000 in private and UN grants. With NATO's help, we had established a safe-house for Serbs who were too trusting, too sick or too slow to leave Kosovo. We had started to rebuild and refurbish four clinics in villages near Prizren. We had trucked dozens of shipments of food and essential goods to Kosovo and distributed them in villages. We had worked successfully with over 20 agencies and governments. We had been part of the formation of a new nation of sorts.

And yet, when the time came for me to leave on August 18, I felt dissatisfied. I remembered what a seasoned UN War Crimes Tribunal officer had told me when I boarded my first UN flight in June. Even after working in Kosovo for years, he said, one would feel inadequate. The key was to accept limitations and to be flexible in doing what needed to be done. As I watched high-school dropouts and former models do a good part of the work of psychiatrists and social workers, I realized that effectiveness in humanitarian interventions depends as much on personality and perseverence as on special training.

For me, the tragic Balkan theatre was a frank lesson in the brutality of politics and the fragility of civil society. It was a humbling opportunity to share the pain of the dispossessed and to relearn the value of rule of law and respect for human rights.

Raghu Venugopal
Clinical clerk
Dalhousie University Medical School
Halifax, NS

[Contents]

Canadian Army poster on venereal disease, 1945. (Photo courtesy of the National Archives of Canada / PA-141001)

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