PSYCHIATRIC VIEWS ON THE NEWS
What difference does it make if one is terminal? We are all terminal.
–Jack Kevorkian, MD
Recently, I had the daunting and unexpected opportunity to be a discussant at The Farewell Party—a movie about euthanasia. Why not a clergy member instead or in addition, I wondered? I decided that it must have been the organizer’s anticipation of how emotionally difficult the subject may be. After all, she decided to schedule it at an off time to keep the crowd down.
There turned out to be not only one psychiatrist, but two of us! That might help, I thought, since as one of us talked, the other could watch and assess how the audience was reacting. The literal translation of the film’s Hebrew title is “A Good Death”—a serious comedy. I wondered if we psychiatrists could help.
After previewing the movie, I did some due diligence about the current role of psychiatrists in death and dying in general, as well as euthanasia specifically. I did not anticipate, though, that I would also have to look so much into myself.
Suicide and homicide
Because we psychiatrists don’t encounter as much death among our patients as other physicians, death can become more poignant for us. Completed suicide is the most common death related to clinical psychiatry. This fact may account for the ghoulish saying that “you’re not a real psychiatrist until a patient of your commits suicide.”
And our patients can also commit homicide. Traditionally, we kept everything about threats confidential until the Tarasoff decision.
The death of Freud
Like I do when investigating most subjects in psychiatry, I looked to see what Freud may have thought. Although I knew that Freud expounded on a death instinct, I knew much less about his own death.1 I wonder if he left a legacy on how to die as well as how to learn to live.
Freud developed a precursor to throat cancer in 1923. He knew the disease was terminal by 1938, when he got out of Nazi-controlled Austria to move to London with his daughter Anna and his personal physician. He had begun to talk to both of them about dying, having already secured from his physician the promise to help him die when the illness became unbearable.
Despite his throat cancer, he insisted on smoking the cigars that likely contributed to his cancer in the first place. He insisted that smoking helped him concentrate.
Allegedly, Freud once quipped that a cigar can be just a cigar and therefore nothing symbolic. Clearly, that wasn’t the case for him. Nor was it the case for the friends in The Farewell Party, who socially smoked even after helping a friend with cancer “commit euthanasia.”
Freud refused to take painkillers that might cloud his mind: he preferred a sharp mind over pain relief. He chose how and when to die in 1939. His physician gave him graduated doses of morphine over 2 days, not so much for pain relief, but for a peaceful death. So, too, in the movie, when pain with a terminally ill friend became unbearable, the group of euthanizers went into action.
Euthanasia has traditionally referred to providing a peaceful, easy, and comfortable death. In our time, it usually means that a physician prescribes a lethal dose of medication that the patient can take. Another way to hasten death is to voluntarily stop eating and drinking (VSED).
In Israel, where the film was shot, euthanasia is legally forbidden. This may be a legacy of the Holocaust genocidal eugenics toward the Jewish people promoted by German physicians. In the film, a group of aging people in a residential setting takes the matter into their own hands.
Following the example of Dr Kevorkian who designed a machine to cause death, an inventor in the group does so. He is aided by a veterinarian who knows how to euthanize animals peacefully and painlessly, as well as a former police detective. There is debate and disagreement among group members, which shifts over time.
Similarly, the world view toward euthanasia is slowly shifting. Over the past quarter century, several European countries and several American states have legalized it in one way or another. As those laws emerged, the common focus was on suffering and mentally competent patients who were expected to die within 6 months.
The role of the psychiatrist is generally to determine whether psychiatric illness is contributing to the decision to die. The assumption is that the mental illness is treatable if it is diagnosed. Another related role is to assess competence to make a decision.
However, data indicate that psychiatrists are seldom called in by other physicians when they should be. Moreover, in the Netherlands and Belgium, physicians can now be called on to help mentally ill patients die.2
Other than those working in medical liaison or geriatric psychiatry, few psychiatrists have experience with euthanasia-related issues.3 And few of us have enough experience in pain management.4
Polls indicate that like the public, physicians and psychiatrists have mixed and ambivalent opinions about euthanasia, and—for moral reasons—few of us want any involvement.5
The medical-ethical conundrum is this: the Hippocratic Oath forbids assisting in death, but our medical tradition has always emphasized the reduction of suffering. What to do, then, when attempts to relieve suffering are ineffective?
Formally, the AMA has a clear opinion. AMA Opinion 2.2111 states:
“Allowing physicians to participate in assisted suicide would cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician’s role of healer, would be difficult or impossible to control, and would pose serious societal risks.”
The current shift to calling physician-assisted suicide physician-assisted death is more a matter of palatable semantics than professional ethics. As the saying goes, a rose is a rose by any other name.
Physicians, our patients, and the public will die, at least until some high-tech company can prolong life indefinitely. Until then, anxiety about death may also be ubiquitous.
It may be that in recognizing death anxiety more that psychiatrists can expand our death-related impact beyond preventing suicides and homicides in our practice. Existentially-oriented psychiatrists like Irvin Yalom do so already. They suggest that death anxiety may actually be a primary cause of other psychiatric disorders and that it may be so uncomfortable for many that it is unconsciously displaced elsewhere.6
Neither denial of nor preoccupation with death is optimal. Optimal may be something in-between, an intermittent focus on death, a role some religious rituals assume.
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11. Kim S, De Vries R, Poteet J. Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands, 2011 to 2014. JAMA Psychiatry. 2016;73:362-368.
12. Ray D, Arons A, Mitchell T, et al: Memory retrieval by activating engram cells in mouse models of early Alzheimer’s disease. Nature. 2016;531:502-512.
13. Moffic HS. The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare. San Francisco; Jossey-Bass: 1997.