August 30, 2014
By SARAH EDELMAN
As a clinical psychologist I frequently see individuals who are severely depressed. In these cases it is my responsibility to conduct a clinical assessment, and if there is a significant risk of suicide, to intervene.
Calls might be made to family members, and procedures put in place to ensure the person is safe. In some cases admission to a hospital or mental health facility may be arranged. These actions are appropriate because while the despair and hopelessness that accompany serious mental illness are usually transient, death is forever. With time and good treatment most will recover, and will once again experience meaning and purpose in their lives.
But the desire to die is not always caused by a mental disorder. In some cases it is a response to suffering associated with a serious medical illness, and the realistic appraisal of what lies ahead. In spite of extraordinary advances in medical technology, the reality is that not all suffering can be prevented.
Many people who join organisations like Dying with Dignity do so precisely because they have witnessed loved ones undergo terrible suffering from an incurable disease, or a slow miserable death. Pain cannot always be alleviated, and symptoms like overwhelming weakness, breathing difficulties, nausea, insomnia, inability to swallow and loss of control over bodily functions are not always preventable. When each day brings further suffering and there is no hope of recovery, the desire to hasten death may be totally rational. Those of us who work within the medical and mental health professions need to acknowledge this.
Within our professions there is a frequently held assumption that death is the greatest of all harms, and that the wilful ending of one's life must be prevented at all costs. This view is also espoused in religious theology, which puts "sanctity of life" above all other considerations. Paradoxically, it ignores the individual values, beliefs and aspirations of the very people we care for. True compassion requires us to understand and respect the desires of those who are hopelessly ill. In the words of American philosopher and scholar the late Ronald Dworkin, "making someone die in a way that others approve, but the dying person believes to be a horrifying contradiction of his life, is a devastating, odious form of tyranny". This notion is demonstrated in the following two cases.
Last year I recorded an interview with Aina Ranke, a 57-year-old who was suffering from a progressive neuromuscular disease that had made her life intolerable. She was in constant pain and struggled to walk, talk, eat or look after herself. Aina's frank disclosure that she was planning to end her life prompted a psychiatric assessment from the mental health team during a brief stay at Maitland Hospital. Their report concluded that Aina was of sound mind, and was appraising her circumstances realistically. Her manner, clarity of thought and well-reasoned argument were a far cry from what is typically observed in suicidal patients with mental illness.
Aina's plan was almost tragically derailed when she was found too soon after taking the lethal dose. Unconscious but still breathing she was subsequently hospitalised and put on life support with the intention of "rehabilitation", subject to viability of life. It was only after her scans showed massive brain damage that Aina was allowed to die. If not for that, this independently minded, spirited woman would have been forced to live on against her will in a state of increasing pain, disability and despair.
A less publicised Victorian case involved an 88-year-old man suffering from terminal cancer of the oesophagus. The man had discussed his intention to end his life with his GP, and had perceived the latter to be sympathetic. He subsequently informed the GP that he had secured Nembutal, and would be taking it that evening. Unable to dissuade him, the GP called his medical indemnity insurer for advice.
At 8pm that night, the police arrived at the man's home, and the Nembutal was confiscated. They returned early the next morning with a Critical Assessment and Treatment (CAT) team. On the GP's instruction the man was certified, and spent 48 hours in a psychiatric unit where he was assessed, found to be of sound mind, and then released. The following day he was admitted to a public hospital where he died of his illness a week later. The GP was acting to protect his own interests under the law. However, his actions led to a dismal outcome for his patient, who spent the final days of his life in anguish.
In legislatures where assisted dying is legal, the term "suicide" is used in relation to psychiatric illness, while "patient-directed dying" or "voluntary assisted dying" are used in relation to medical illness. The distinction in both concept and terminology is important as it has implications for appropriate response protocols. Acknowledging that the desire to end one's life can be rational may prevent psychiatric teams arriving to schedule a dying cancer patient who has just days to live. It might also avert attempts to revive individuals like Aina Ranke, who are not psychiatrically ill, and have made a considered decision to end their lives.
Dr Sarah Edelman is a clinical psychologist, author and president of Dying with Dignity NSW.
