Barbara Russell reflects on some ethical issues surrounding the recent death by suicide of actor Robin Williams.

__________________________________________

First, premature death is tragic. This is echoed in many published or broadcasted comments from Robin Williams’ friends, professional colleagues, and fans. Their responses acknowledge the intrinsic goodness of a person living or trying to live a human and humane life, including their hopes, perspectives, and experiences. Instrumentally, goodness resides in the person’s strengths, talents, ideas, and relationships.

Thinking about what is lost from Williams’ death led me to think about all we lose from Canada’s First Nations, Métis and Inuit individuals who take their own lives. Each has talents, hopes, perspectives, and relationships that tragically end prematurely. The suicide rate of these groups of people, especially youth, is 5 to 11 times higher than the suicide rate of other Canadian groups.

The social determinants of health contribute to the high rate of attempted and actual suicide among Aboriginal groups. Contributing factors include historic colonization and contemporary disregard, poverty, un- or under- or unstable employment, insufficient or interrupted education, and inadequate housing. In Williams’ case, I wonder if some people’s shock and surprise reflect a belief that positive determinants of health – such as financial success, employment longevity, ready access to healthcare services, connections with powerful people, public recognition – guarantee or at the very least safeguard mental well-being. 

Some say Williams recently learned he had Parkinson’s disease, a progressive, neurologically disabling condition. Some have reported he has been dealing with severe depression lately. In 2006, he himself spoke candidly about cocaine and alcohol abuse, and how, after 20 years of abstinence, he started drinking excessively again. Legal substances of abuse – alcohol and nicotine-addicting tobacco-based products (e.g., cigarettes, cigars) – cause substantial personal and social harm. Too often, however, attention rests solely on the individual and the choices she makes for herself.

In the course of my bioethics work, I’ve learned that alcohol and tobacco are particularly complex issues. Their commercial history, their legality and continued ubiquity (especially alcohol), their appeal as reliable revenue sources for governments, the lack of highly successful treatment options, the absence or inadequacy of public insurance coverage for existing treatment options, the distorting effects of America’s “war on [illegal] drugs,” the clinical “battle” between abstinence-only and harm reduction treatment paradigms, and differences between promoting and demanding health are all relevant. Relevant for questions about blame, responsibility, and success: “Whose fault is it that Jane drives impaired or can’t breathe?” and “Who must step in to help her?” and “What will help in the short-term and the long-term?

My second and very different reflection is that some early disclosures by local police have been distressingly excessive: details about who found Williams’ body first, what he used to end his life, his body’s position, and so on. I worry that his privacy, even after death, has been ethically disrespected, albeit likely unintentionally. Perhaps legally required approvals for such disclosure were obtained beforehand. Permission aside, however, was there a criminal investigation underway or an existing public safety concern that could justify disclosure by the police? I also cannot formulate a defensible moral right of the public to know such details. Yes, human curiosity is a capacity that is evolutionarily useful in certain situations. But in other situations, what we are curious about can, instead, reflect moral shortcomings.  

Third, thinking about Williams’ death led me to another very different reflection. On the one hand, I’ve spoken with some clinicians who believe all suicide attempts are explained by mental illness. As such, they do not consider these actions as rational or voluntarily chosen. On the other hand, I’ve also spoken with a few mental health clinicians who acknowledge that psychiatric or psychological treatments do not reduce every client’s suffering adequately or reliably. Nor do treatments reduce suffering without causing iatrogenic negative side effects. Such psychic suffering can be similar to the unremitting, deep suffering some people experience from physical illnesses or injuries, despite their families and medical teams’ best efforts. When physical suffering becomes unbearable, the condition is incurable, and all treatment options have been tried, full palliative care becomes the preferred next step. This care can include consensual discontinuation of burdensome life-sustaining interventions.

In some countries and a handful of American states, medically assisted death is a legally permitted end-of-life care option. Recently in Canada, the Quebec legislature approved Bill 52, which is expected to come into effect late next year. This coming October, Lee Carter et al. v. Attorney General of Canada et al., a request for decriminalization of medical assistance in dying, will be heard by the Supreme Court of Canada. Will Quebec clinicians and lawyers work with people who have intractable, refractory psychic suffering due to a mental condition? Will the Supreme Court’s analysis and subsequent ruling address psychic suffering?

Williams’ death has generated a wide range of responses from a wide range of people. I hope my ethics-focused reflections, above, can help expand or deepen Canadians’ discussions about people’s profound suffering, multi-factorial causes, and sustained remedies.  

_________________________________________ 

Barbara Russell is an Assistant Professor in the University of Toronto’s Institute of Health Policy, Management and Evaluation.