Suicide (repost)

I was a little reticent to share this because it ends up going pretty far out there, and I hope this is a place where I can share my true reactions, be they wrong or right, somewhere in between, or just south of normal. Before sharing, I just want to reassure you that I know my ethical obligations under the law and would not come close to considering implementing what I advocate here. Please don't take this as anything more than idle speculation. These were my reactions from my last week's community practice class and the section on suicide in the readings:
Our community-centered practice course featured a woman whose husband had committed suicide. She made many philosophical errors in her subsequent advocacy but made a few courageous stands. Her first act of sheer bravery was to tell her children that their father had committed suicide after it had happened. Society would generally tell her to hide it from them and reveal it when they were older. However, given my experience with adoption and my parents telling me (not the same, but the reveal could be just as powerful or traumatic), that this was an amazing decision! My parents were counseled to do what they did. She made her decision on her own (or as she says, through god). And I'm willing to bet that if she had consulted a mental health professional, slaves to traditionalism as we are, we would uphold the social order and tell her to lie to her children until they were older and ready to handle it (the suicide, that is-- because they might not be ready to handle knowing you have lied to them during the intervening years).
The second act of courage is also where she starts running into philosophical problems. She became and advocate for survivors of suicide (the term for those grieving a completed suicide) as well as suicide prevention. She stands athwart school districts who would rather pretend that suicidal and parasuicidal behavior do not exist, and is working to introduce an educational curriculum into school districts in the suburban Virginia area. However, when I asked her about the sociological impact of introducing that campaign, she seemed only to grasp that her program might reduce suicide. She furthered that sentiment by implying that she would like to eradicate suicide. I asked her if by talking about suicide and putting it out into the open, she might be normalizing suicide, making it less taboo of a subject. This would certainly lessen the shame of survivors and the blaming of the survivors for the suicide (hello, just-world fallacy). I didn't want to push the subject because from the tone of her voice and body language, she was visibly upset. But it was scary to me that she wouldn't have thought of these implications, since she is trying to affect social change and that implies a shift in ideas. Just as harm reduction and rational drug education programs can help those who choose drugs to do so more safely, they also make it less taboo for drugs to be used or to have a member of the family who uses drugs. It's not the intended effect, but it nevertheless exists.
I have some other issues with things she said, but I don't want to ridicule the woman. She obviously found a very positive way to cope with a terrible scenario and did so in a way that questioned the proper behavior for a survivor.
Now, onto the meaty theoretical discussion on why suicide is neither good nor bad. My professor made the terrible mistake of trying to stake out a middle ground between all suicides are bad (or are fomented by mental illness) vs. suicide is neither good nor bad. She intimated that she held some sympathy for those who were chronically physically ill and made the rational choice to end their lives, rather than go through months of torture and pain. This was perhaps acceptable to her, but those who are "mentally ill" and make the same calculations must be saved from themselves. Why?
My original reaction was simply on principle (read below), but in revisiting the topic, I can also see flaws in the utilitarian arguments. First, people in chronic and severe pain, those who are suffering from a long-term degenerative and fatal disease, are going to think differently than those who do not have said ailments. Chronic pain is associated with major depression. Terminal illnesses create existential quandaries whose intricacies must be navigated by someone whose cognitive processes may be altered by physical conditions. So, the population of physically ill and mentally ill may have more overlap than is generally offered in their decision-making capacity. How can a clinician judge a person with a terminal illness to be rational to make a decision when a person with chronic depression would have his or her judgment questioned?
Second, the utilitarian argument that most readily comes to mind that would justify paternalistic intervention would be that a mentally ill patient may not be able to conceive of what the future will be like: once treated in a hospital, they will return to baseline; once they undergo this other type of therapy, they will no longer want to die; or their reasoning makes no sense at the present time. But, the same logic would then have to apply to those who are physically ill and may find a cure, different treatment, or are in an acute crisis. How do you respect one set of people and deny another?
But still, in spite of all of this similarity, the two just FEEL different. On a scale of provisional morality (0 being saintly, 1 being satanic), perhaps accepting a person's suicidal judgment would be a .4 for those who are physically ill (still bad, but not terrible) and .8 for those who are mentally ill. With that in mind, let's explore the "what if." What if you were to accept a client's goal of committing suicide? How would you guide him or her?
There are resources, however unused, on how to kill oneself including a manual called the Peaceful Pill Handbook (now a website) which ranks methods of suicide along a scale which includes the method's reliability, peacefulness, availability, preparation, undetectability, speed, safety, and storage. Apparently, there is also the Hemlock Society which advocates for the rights of those who wish to commit suicide and provides some community support. In practice with the client, grief textbooks can be reverse-engineered to create a way for the person to inform their families of their intentions, allow them to say goodbye, and understand the reasons they are ending their lives. In the invention of the suicide note, it seems as if it is important for the person committing suicide to convey their reasons and feelings. This may lessen the families ambiguity following the death, as well. Furthermore, by becoming educated on the methods of suicide, they may choose to end their lives in the least gruesome way, lessening the trauma on the family even further.
These methods and resources may (and I stress may) be congruent with harm reduction methods. They are certainly consistent with the person's autonomy, dignity, and free will. Social workers cannot ethically act in a paternalistic manner towards their clients, and respecting their wishes, no matter how incomprehensible, must remain paramount; however, we are called on to protect the lives of clients by force (if necessary) if they plan to commit suicide. How do you deal with those conflicting imperatives?
The harm-reduction line of thought came after my initial reaction to the debate, which was slightly more tendentious: My professor made a comment and the words are escaping me, but they belied the most heinous of value judgments. Who decides whether a person's life is worth living? A social worker or the person? If you have a patient who is severely depressed and has exhausted all of his or her treatment options, why is it wrong for them to conclude that suicide is preferable to life? You don't know their life. You can only glean from their statements how they feel on a daily basis. How can a clinician ethically judge another's life worthy objectively and unilaterally? Is it like a reader judging the principle inherent in the death of Socrates?
Do you view people as a means to an end or as ends in and of themselves? If it's the latter, I think these types of questions need to cross your mind.