Thursday, December 11, 2008

Grand Inquisitor

The heart asks pleasure first
And then, excuse from pain --
And then, those little anodynes
That deaden suffering;

And then, to go to sleep
And then, if it should be
The will of its Inquisitor
The liberty to die.

Emily Dickinson

Several items caught my eye today. It is dark and stormy here, with the potential for sudden catastrophic death looming over the landscape (okay, there's a tornado watch); so forgive the theme of menace.

1. On the brightest note, I was alerted to a comprehensive listing of psych-related blogs at "101 Fascinating Brain Blogs" at Online Education Database. It includes all the well-known ones but also many I wasn't aware of (oh, and it commendably includes Ars Psychiatrica).

2. Art Blog by Bob yesterday featured "The Scream" and several other works of the evidently dysphoric painter Edward Munch (painter of today's illustration here as well). Check it out.

3. For any readers in Kentucky I happened upon a Scientific American article about the United States Narcotic Farm (or Narco) near Lexington. From 1935 until 1975 the huge facility housed many of the nation's criminal addicts, which included some prominent names over the years. It was the setting for a great deal of addictions research involving the prisoners, although toward the end the C.I.A. and others apparently developed concerns that research involving both L.S.D. and less than fully informed consent may have been going on. The article includes a slide show and alludes to a documentary about Narco that would be very interesting.
4. Also in Scientific American is an article on schizophrenia and its relation to language. Schizophrenia is an enormously complex illness and we are far from understanding it, but given the prevalence of auditory hallucinations in the disorder, links to language function have long been a focus. Apparently genes related to language are increasingly suspected in schizophrenia, which may be a casualty of our species' very rapid brain growth over the past million years or so. It is odd to think of such a devastating illness deriving from the same developmental pathway leading to, among many other things, the great poets.

5. The New England Journal of Medicine has an editorial on the current status of physician-assisted suicide in the United States, now legal in both Oregon and Washington state after the latter recently approved it by a decisive 58-42 margin. With 6.7 million people, Washington is twice the size of Oregon and will be an interesting test of the law.

As the article documents, the procedure in Oregon has not drawn the multitudes that were originally feared. From 1998 through 2007 only an average of 34 patients per year carried out the procedure. The law requires two physicians to independently confirm that a patient is both terminally ill and competent to make the decision. As one would expect, the most common diagnosis was terminal cancer. The "physician assistance" usually involves prescription of barbiturates, which the patient apparently must administer himself.

No psychiatrist is required to be involved, although consultation with one is encouraged if there is any suspicion of depression or questionable competence. However, the article notes that no psychiatry consultations were made in 2007, and only 12% of cases involved consultations in the nine previous years.

I have pretty firm opinions on most issues, but this is one I struggle with. We know that suicidal ideation in general is much, much more likely to be related to a mental disorder (most commonly depression, substance abuse, or schizophrenia) than not, and we are familiar with concerns arising from end-of-life suicidality that may stem from inadequate palliative care or fears of being a burden on family members.

A philosophical question in psychiatry is whether suicidal ideation can be anything but a manifestation of disorder. The arguments pro and con are complex and beyond the scope of a blog post (Courtney S. Campbell wrote a heftier review of the issues in The New Atlantis), but I personally believe that it is possible for a terminally ill person, afflicted perhaps with irreversible physical or mental decline, to desire death without being considered clinically depressed.

However, considering the finality of suicide, and the issues of subtle or not-so-subtle suggestion or coercion that can arise, I wonder sometimes if we're making it too easy, too comfortable to make such an existentially stark decision. It may be hard for a psychiatrist to say, but it is a conscious being's inherent right to commit suicide. If someone tells me he's going to, then I will commit him to a hospital or otherwise take steps to prevent him. But if he doesn't tell me or anyone else, then no one is going to stop him.

The question is: why does he think he has a right to get someone else to help him? Some decisions are meant to be excruciatingly difficult and painful; that often means they shouldn't be made at all, or if they are made, certainly not with nonchalance. I think there is some risk to any society of allowing people to go too "gently into that good night." To me this seems the wisest and most conservative approach.


vanderleun said...

An article by another doctor that you may not be aware of can be found at

Unknown said...

If I ever have to be admitted to a nursing home, I'm definitely committing suicide.

It would be nice if there was a way to do this that wasn't messy or painful. Not sure I'd want a physician directly involved, though (maybe write a prescription for chloral hydrate or something), because of the potential for creating a moral burden for someone else (or bad karma, even).

Anonymous said...

Terminally ill patients who have the option of euthanasia on standby report feeling more at peace with their situation. Wielding control over their existence, rather than having it ruthlessly determined by a brutal and merciless disease that shreds their dignity, day after bitter day, hour by excruciating hour, confers a sense of comfort; and patients often find they are able to endure a longer term of their final stages as a consequence of this new found paradoxical peace.

It's a personal choice; and fruitless suffering with its end point in ultimate meaningless misery and indignity is a torture no one has the moral authority to lawfully inflict on any human being.

ON the issue of ambiguity of desire and the irrevocability of such a finality...well, isn't it better to err on the side of caution? And by that I mean on the side of the terminally miserable, not the temporarily depressed suffering existential crises.

Is it morally more palatable to set 10 murderers free or jail 1 innocent person?

Exiting is rarely questionable for the subject suffering; it's mostly a selfish denial of forthcoming grief that friends and families unintentionally (and understandably) inflict.

I think we're all entitled to a happy life; barring that, then a happy death.

Novalis said...

I neglected to mention that in addition to the obvious philosophical interest of this issue, there is a biographical note as well.

I was a medical student in Ann Arbor from 1991 from 1995, during which Jack Kevorkian was carrying out his infamous practice in that same general area. So it was a matter of both local and professional interest at the time. In fact, for a week or so I helped look after a fellow in the hospital with multiple myeloma who, I later learned, eventually availed himself of Kevorkian's services.