We have, Jonathan Herring argues in this passionate book, a right to be protected against, indeed to be prevented from, committing suicide (it would be worth thinking about the relationship, and differences, between protection and prevention). This right flows from the right to life declared in the European Convention on Human Rights, as interpreted by the European Court of Human Rights. It is a right against the state, that it take steps to prevent suicides, and any suicide “is per se a breach of Article 2. The [suicide’s] human rights have been infringed” (p. 127), although since the state’s duties to prevent suicides are limited, the state might not have breached its duties.
This is a striking claim: theorists typically spend more time discussing a putative right to be allowed, or helped, to commit suicide, rather than a right to be prevented from doing so. I do not think that Herring makes out his radical claim; but he does focus our attention on some of the ways in which we should collectively (and the state should in our name) think more about the causes of suicide and about the steps we should take to reduce its incidence.
A central thread in Herring’s discussion concerns autonomy: for a familiar argument against being prevented from committing suicide and in favour of a right to be allowed (or even assisted) to commit suicide appeals to autonomy; if I choose, autonomously, to end my life, others should not prevent this, and may be permitted (or even morally required) to help me carry out my will. Herring does not deny the importance of autonomy, or the liberty right to carry out a genuinely autonomous decision to kill myself; but he argues that very few suicides are to the right degree autonomous. There are two strands to this argument.
One strand concerns the idea of autonomy itself. Herring notes that autonomy is scalar: we must ask not simply whether a person’s decision was autonomous or not, but how autonomous it was, and whether it was “richly autonomous” – rich autonomy involving such dimensions as self-determination, self-government, authenticity, rationality, and the availability of “meaningful good options” between which one can choose (pp. 81–90). The other strand concerns the ethics of intervention: in determining whether we should intervene to prevent a suicide, we must weigh the seriousness of the harm of suicide against the extent to which the would-be suicide’s choice is a genuinely autonomous one; insofar as it is less than fully autonomous, intervention may be justified to prevent that harm.
As thus abstractly stated, the argument is one that many would willingly accept: we might, following Dworkin, say that the state should treat its citizens (who should also treat each other) with “equal concern and respect”; that concern is for welfare, whilst respect is for autonomy; and that insofar as autonomy is lacking, concern for welfare should take priority (especially when, as Herring notes, preventing someone’s self-harming action protects their future autonomy). What will cause dissent, however, is Herring’s argument that most suicides are not richly autonomous: that “the vast majority” of would-be suicides lack the capacities required for a truly autonomous decision (p. 77); “only in rare cases” is the decision to commit suicide “richly autonomous and the harm limited”, so that suicide is ethically permissible and intervention unjustified (p. 106). (Though Herring takes autonomy to bear on the permissibility both of the suicide and of intervention, it bears primarily on the latter issue: a fully autonomous action might be ethically unjustified; but respect for autonomy might preclude paternalistic intervention.)
It actually appears that, on Herring’s account, no suicide can be richly autonomous: for what makes suicide rational (one dimension of autonomy) is the lack of an acceptable alternative to death; but rich autonomy requires the availability of “meaningful good options”. Someone who chooses suicide because no other option is, as they see it, “meaningful” or “good” (as in some cases of untreatably destructive disease) might display a clear-headed, realistic understanding of their situation: this looks like one of those (rare) cases in which Herring would allow that suicide is permissible, should not be interfered with, and should perhaps even receive assistance; nor does the fact that the person’s choice is not “richly” autonomous give us reason to intervene. We might talk of what is “tragic” or “wretched” (“most suicides are tragic, wretched acts” (p. 221)); but what is tragic and wretched here is not the act, but the situation that made the act rational.
This suggests that Herring’s conception of autonomy is ill-suited to the context of suicide and the issue of paternalistic intervention. What matters in this context is the agent’s own capacity for rational practical thought, not the range or value of the options available to them. And it is indeed capacity on which Herring focuses much of his argument about the way in which many suicides are not (fully) autonomous. He gives an interesting, and troubling, survey of research on the various causes of suicide, highlighting the contribution of social factors – in particular the contribution of various kinds of social deprivation and injustice. “A society in which there are significant numbers of suicides is a … deeply flawed society … marked by inequalities in health and financial provision; a lack of social inclusion; and failure to value each citizen” (p. 61).
Such factors can bear on suicide in two ways, which are worth distinguishing analytically, even if they are hard to disentangle in practice. First, they can undermine capacities for rational, autonomous deliberation (this is what Herring emphasises); second, they can reduce the range of available “meaningful good options”, making it more likely that suicide will not unreasonably be seen as a rational choice. Insofar as such factors are matters not merely of misfortune, but of unjust deprivation (as, Herring argues, is often the case), both kinds of influence give us reason to take preventive steps; it is a social obligation to seek to prevent suicide. However, what kinds of preventive measure are appropriate, or permissible, depends crucially on whether the social deprivation undermines people’s capacity for rational deliberation and action; if it does, that weakens the normative obstacle that autonomy presents to interventions which are coercive in that they frustrate the person’s contemporaneous will; if it does not, that obstacle retains its strength. In the latter case, the point is not that there is then nothing we may do; but what may and should be done consists not in coercive intervention, but in provisions that increase the range of “meaningful good options”, by remedying the injustices. Providing better education, health care, employment opportunities, a more inclusive social environment, will reduce the incidence of suicide (as Herring notes, that is not the only reason to take such steps – indeed, it is not the primary reason); so will providing more support to those in suicidal distress, support they can draw on if they choose: but such provisions are not ethically problematic in the way that coercive interventions (exemplified by detention under mental health law provisions) are. Herring is well aware (p. 178) of the ethical differences between different kinds of “preventive” measure; but it would have been useful to have a more nuanced discussion of this crucial difference.
As far as coercive interventions are concerned (Herring notes that it is unclear how effective they are), he gives a critical survey of current provisions of English law. His central objection is that the law sets the barrier to coercive interventions too high, allowing such intervention only in cases of radical incapacity – which serves not so much to protect rational agents from coercive state interference, as to preclude vulnerable people from receiving the help that they need. He is right to highlight the irreversible harm typically caused by un-prevented suicide, and to caution us against being too quick to treat “autonomy” as a barrier to intervention without inquiring more carefully into the extent to which the person’s rational capacities might be impaired. However, he radically overstates the case when he says that “[i]f we wrongly assess the suicidal person as having capacity when they do not, and a preventable suicide occurs this is a very serious wrong – perhaps the most serious wrong imaginable” (p. 169): it is very difficult to see what could justify such a claim. Furthermore, if we are talking not about interventions that offer potential suicides support and help, or even try to persuade them to seek help, but about coercive interventions that frustrate their expressed contemporaneous will, we must ask more carefully how such crucial judgments about such a complex issue as autonomy can be made, and by whom: in trying to correct our collective failure to take the tragedies of suicide seriously enough, we must also take seriously the difficulty of establishing adequate grounds for such coercive interventions.
We have already moved from the initial discussion of when coercive interventions to prevent suicide might be permissible, to the question of whether and when they might be obligatory; part of Herring’s argument is that “[s]ociety itself has created the conditions that lead to suicide and therefore has the duty to do what it can to prevent suicide” (p. 61). That is surely right, and we anyway have a collective duty to do what we can to support those who need help, whether or not we are responsible for the conditions that led to that need – a welfare state must promote its citizens’ welfare. But Herring goes further than this, to argue that our right to be protected or prevented from suicide is a human right, as an aspect of the human right to life; and that even though the state’s duty to prevent suicide is limited “by practical and theoretical considerations” (p. 110), “where a person has committed suicide, that is per se a breach of Article 2 [of the ECHR]. Their human rights have been infringed” (p. 127). He draws on the ECtHR’s jurisprudence on the scope and implications of the right to life to make this argument, although the cases on which he draws do not seem to assert a right of this all-embracing scope, since they concern suicides that were allegedly caused by state officials, or suicides by people who were detained in prison or in a psychiatric institution. Despite Herring’s argument (pp. 110–11) that we should not define the right on the basis of the corresponding duty (and thus limit the right insofar as the duty is limited), I find it hard to see how a suicide’s right has been infringed by a state that had no duty to prevent it: for an infringement requires an infringer, and I surely infringe a right only if I breach a duty to respect or protect it. Or could Herring argue that the kinds of unjust social condition that often lead to suicide are themselves violations of the rights of those who suffer them, which imposes on the responsible state a stringent remedial duty of suicide-prevention? But this would not be a duty to prevent all suicides, nor does it fit the language of human rights that Herring uses.
It is unfortunate that Herring makes such radical claims without persuasive arguments to support them: unfortunate because they might distract us from the valuable and important aspects of his arguments about the social conditions of suicide, about our collective responsibility to take those conditions seriously, and about the ways in which we can and should do more to prevent suicide – not just or even primarily by way of coercive interventions into the actions of would-be suicides, but by way of remedying the conditions that can lead to suicide, and by offering more adequate kinds of help and support to those who are or might become suicidal.
