Suicide and people with disabilities.
Suicide may occur for a number of reasons, including depression, shame, guilt, desperation, physical pain, emotional pressure, anxiety, and financial difficulties. The World Health Organization reported that, "each year, more than 1 million people take their own lives--more than the combined annual deaths from homicide and wars." (3) In the U.S., suicide is the leading cause of death among teenagers and adults under 35 years. Men are three times more likely to attempt suicide than women, but rates among women have risen alarmingly in the last decade. (3)
In 2007 in the U.S., 14.5 percent of high school students reported that they had seriously considered attempting suicide during the past year.
* Hispanic female high school students reported a higher percentage of suicide attempts than their white, non-Hispanic or black, non-Hispanic counterparts.
* Among American Indians/Alaska Natives ages 15 to 34 years, suicide is the second leading cause of death--2.2 times higher than the national average.
* Firearms are the most commonly used method of suicide among males, poisoning among females.
* In 2005, 372,700 people were treated in emergency departments for self-inflicted injuries. (3)
Numerous studies report a high incidence of mental disorders (ranging from 87 percent to 98 percent) in suicide victims at the time of their death. (4,5) As a consequence, it is all too easy to overlook the many related and contributing factors, which may have led to the ultimate action. These may include terminal illness with attendant pain and suffering, depression associated with limited access to care, (e.g., in rural areas ) social and interpersonal conflict, family distress and the pressure and stress of school, (7) unemployment, social isolation, change in health status and institutionalization, (8) or a cascading combination of factors.
HOW DO INDIVIDUALS WITH DISABILITIES FIT INTO THIS PICTURE?
"People with disabilities compose a minority group for which little suicide data have been collected. A great deal is known, however, about the virulent social oppression endured by this population." (9) In employment, interpersonal acceptance, economic stability, freedom of mobility and community access, "...all variables thought to have a significant bearing on suicidal potential, people with disabilities are among the most disadvantaged."( 10) Current research "...indicates people with disabilities experience more environmentally induced depression than average, again suggesting an increased potential for preventable suicide... Particularly alarming is the current trend to deny basic suicide prevention services to individuals who are severely disabled--those most exposed to high risk factors." (11)
For many people with disabilities, "it is more often the discrimination, prejudice, and barriers that they encounter, and the restrictions and lack of options that this society has imposed, rather than their disabilities or their physical pain, that cause (the lives) of people with disabilities to be unsatisfactory and painful." (12)
When non-disabled individuals reveal a desire to die, generally they are categorized as "suicidal," and the person is treated accordingly. For persons with severe disabilities (e.g., who use a respirator, feeding assistance) the desire to die takes on a label of "refusing treatment." The refusal for treatment is seen as an effort to avoid prolonged suffering and refusal to let a terminal disease take its natural course but not as an attempt to committing suicide. (9) The implication is that there is something natural or proper about a person with disabilities dying, as opposed to a person with no disabilities dying. If permanent disability is the problem, death is the solution. From this perspective, "...the wish to die is transformed into a desire for freedom, not suicide." (9) Many people with disabilities are suicidal due to the societal oppression they face. (13) For example, in Canada, "51.8 per cent of disabled women have experienced sexual abuse, 66.3 percent emotional abuse, 43.1 percent neglect, 34 percent have experienced abandonment, (and) 58.7 percent had thought about killing themselves." (13)
Parents' early beliefs about the expectations of the lives of their children with disabilities very often are shaped by healthcare providers. But many people with disabilities acquired their disabilities some time after birth. "Their beliefs about what life with a disability is like are shaped by a society that devalues people with disabilities. Then, when they become disabled, their beliefs about what their own lives with disabilities will be like are shaped by healthcare providers.... Newly injured people may be particularly at risk." (14) Eight thousand people injure their spinal cords each year, and 99,000 are hospitalized with moderate to severe head injuries. In the critical period after injury, many people who now enjoy their lives report that they could easily have been swayed to "choose" death. (14)
"People with disabilities are among society's most likely candidates for ending their lives, as society has frequently made it clear that it believes that they would be better off dead." (12)
One of the features of societal attitudes toward individuals with disabilities has been the tendency of people without disabilities to overestimate the negative aspects and underestimate the positive features of the lives of those who have disabilities. "The attitude of 'I don't see how you can live with that'--sometimes expressed more dramatically as 'I'd rather be dead than have [X disability] (sic).'" (12) Living in fear of having a disability themselves, "...it becomes easier for the public to abdicate the role of making life better for sick and disabled people by suggesting that their needs may indeed be best met by assisted suicide." (15)
It is ironic that despite plans aimed at reducing the suicide rate in the general public, "...efforts to legalize physician assisted suicide continue around the country. Supporters of these efforts point approvingly to the Netherlands, which recently legalized physician-assisted suicide and euthanasia even for children as young as 12 years (with parent's consent) (sic)." (16) Reports on Oregon's experience during the early years under legalized assisted suicide showed that, "the decision to request and use a prescription for lethal medication was associated with concern about loss of autonomy or control of bodily functions."(17) "In short, what has driven many in Oregon to end their lives is fear--primarily of becoming disabled!" (16)
In related issues, the pro-life and the right-to-die groups argue "around" individuals with disabilities but seldom with them. Other concerns related to using prenatal tests for sex selection with the option to abort, is perceived as being wrong because it violates societal values and is against the principles of human life and dignity. "However, disability selection with the option to abort is considered acceptable by many... (in essence) society really doesn't care about discrimination against disabled people." (13)
Consider when Hollywood turns to disability themes, "...the accolades and awards tend to roll in." (18) Films such as My Left Foot, Rain Man, and Born on the Fourth of July come to mind. Then there is the 2004 Oscar winning film, Million Dollar Baby, "...showing that death is preferable to life as a disabled person;" (18) "...(a film that) promotes the killing of disabled people as the solution to the 'problem' of disability." (19) Such a movie "...does a disservice to worldwide attitudes towards disabled people by validating the negative, ableist message of disability as a 'fate worse than death.'" (18) The National Spinal Cord Injury Association's comment on the film was succinct, "Eastwood continues disability vendetta with Million Dollar Baby."' (19) (At the time, when we saw the act of "murder" in the final scenes of the movie, we could "understand" Eastwood's character's motive--indeed, that is the point of the criticism of the movie.)
When death comes not from an accident or illness but from a conscious act, the sorrow is compounded by anguish and regret. But when the victim is an individual with a disability, we tend to "understand it." The American Association of Suicidology estimates 90 percent of suicides can be prevented. (20) "How? End the silence...we barely speak of it, the media rarely cover it, and, until it touches our own lives, we avoid thinking about it." (21)
Our society and an Oscar winning movie may attempt to teach us to "understand why" when the victim of suicide (assisted or not) is a young or old person with a disability. We must counter, however, such efforts with the realities that innumerable numbers of individuals with significant disabilities continue to lead productive lives, including physicians with blindness or quadriplegia, (22, 23) dentists with one arm or double above the knee amputation, (24,25) and yes, as parents.
It is significant to remember that most of those who died using Dr. Jack Kevorkian's "apparatus" were women who had disabilities, not terminally ill. (26)
(1) Centers for Disease Control and Prevention. Suicide. Facts at a Glance. Summer 2008. Web site: http://www.cdc.goc/ViolencePrevention/pdf/Suicide-DataSheet-a.pdf. Accessed April 17, 2009.
(2) Census Bureau. Statistical Abstract of the United States, 2009. Washington, DC; Government Printing Office, 2009.
(3) CIS: UN Body takes on rising suicide rates. Web site: http://www.rferl.org/articleprintview/1071203.html. Accessed April 17, 2009.
(4) Bertolote JM, Fleischmann A, De Leo D, Wasserman D. Psychiatric diagnoses and suicide: revisiting the evidence. Crisis 2004;25(4):147-155.
(5) Arsenault-Lapierre G, Kim C, Turecki G. Psychiatric diagnoses in 3275 suicides: a meta-analysis.
Psychiatry 2004;(Nov 4)4:37 (6) Hughes RB, Nosek MA, Robinsom-Whelen S. Correlates of depression in rural women with physical disabilities. Obstet Gynecol Neonatal Nurs 2007; 36:105-114.
(7) Medina C, Luna G. Suicide attempts among adolescent Mexican-American students enrolled in special education classes Adolesc 2006;41:299-313.
(8) Cleigh C. Attempted suicide, completed. Ragged Edge on line. Web site: http://www.raggededgemagazine.com/0301/0301ft4.htm. Accessed April 17, 2009.
(9) Gill CJ. Suicide intervention for people with disabilities: a lesson in inequality. Health Care Industry. Web site: http://findarticles.com/p/articles/mi_m6875/is_n1_8ai_n25021419. Accessed April 17, 2009.
(10) Hahn H. Disability policy and the problem of discrimination. Am. Behav Scientist 1988;28:293-318.
(11) Turner RJ, Beiser M. Major depression and depressive symptomatology among the physically disabled, 178 J. Nerv Ment Dis 1990;178:343, 345-346.
(12) National Council on Disability. Assisted suicide: a disability perspective. Web site: http://www.ncd.gov/newsroom/publication/1997/suicide.htm. Accessed April 17, 2009.
(13) Wolbring G. Euthanasia Prevention Coalition. Self determination. Web site: http://www.euthanasiaprevention.on.ca/Articles/gregorwolberg/ selfdetermination.htm. Accessed April 17, 2009.
(14) American Bar Association. Individual rights and responsibilities: assisted suicide and disability. Web site: http://www.abanet.org/irr/hr/winter00humanrights/colemand.html. Accessed November 21, 2009.
(15) Morton-Cooper A. Assisted suicide does nothing to bring about dignity in life which disabled people need. The Herald, Nov. 11, 2008. Web site: http://www.theherald.co/uk/misc/print.php?artid=2465080. Accessed April 22, 2009.
(16) Mitchell LR. Suicide prevention double standard excludes disabled. Daily New LA. May 29, 2001. Web site: http://www.geocites.com/capitalhill/lobby7853/DoubleStandard.html?200917. Accessed April 19, 2009.
(17) Sullivan AD, Hedberg K, Hopkins D. Legalized physician-assisted suicide in Oregon, 1998-2000. N Engl J Med 2001;344(8)605-607.
(18) Haller B. Thoughts on 'Million Dollar Baby.' J Res Spec Educ Needs 2006;6:112-114.
(19) Not Dead Yet. Press release Jan. 14, 2005. Web site: http://www.notdeadyet.org/docs/bigotpr.html. Accessed April 20, 2009.
(20) American Association of Suicidology. Web site: http://www.suicidology.org/web/guest/aboutaas. Accessed April 20, 2009.
(21) DiMasi D. Suicide--the silent crisis. The Boston Globe, April 15, 2009. Web site: http://www.boston.com/bostonglobe/editorial_opinion/oped/ articles/2009/04/15/suicide__the_silent_crisis. Accessed April 16, 2009.
(22) Goldman H. Quadriplegic fulfills dream of becoming a doctor -medical school grad pursued goal despite repeated rejections. The Seattle Tines June 5, 1997. Web site: http://seattletimes.nwsource.com/cgi-bin/PrintStory.pl?slug=2543052& date=19970605. Accessed April 20, 2009
(23) Shaw G. Blind medical student beats the odds. Reporter July 2000. Web site: http://www.aamc.org/newsroom/reporter/july2000/blind.htm. Accessed April 20, 2009.
(24) Jakush J. People: Dr. Harry H. Asher. ADA News. 1983; 14(4): Feb 14.
(25) Waldman HB, Perlman SP, Cinotti DA. Health professionals with disabilities. EP Mag 2009;39(3):72-74.
(26) Cleigh C. Attempted suicide completed. Ragged Edge on line. 2001. Web site: http://www.raggededgemagazine.com/0301/0301ft4.htm. Accessed April 14, 2009.
BY H. BARRY WALDMAN, DDS, MPH, PHD AND STEVEN P. PERLMAN, DDS, MSCD, DHL (HON); AND DOLORES CANNELLA, PHD
H. Barry Waldman, DDS, MPH, PhD is a Distinguished Teaching Professor in the Department of General Dentistry at Stony Brook University in Stony Brook, NY.
Steven P. Perlman, DDS, MScD, DHL (Hon) is Global Clinical Director for the Special Olympics Special Smiles program and is Associate Clinical Professor of Pediatric Dentistry at The Boston University Goldman School of Dental Medicine. He is Clinical Professor of Pediatric Dentistry at The Boston University School of Dental Medicine. His private pediatric dentistry practice is in Lynn, MA.
Dolores Cannella, PhD is and Assistant Professor and Director of Behavioral Sciences in the Department of General Dentistry at Stony Brook University in Stony Brook, NY.