Assisted Suicide and Mental Illness – Where Do You Stand?

Image by Gerd Altmann from Pixabay

By Marvin Ross with commentary by Dr David Laing Dawson

Numerous countries throughout the world (including some US States) allow for medically assisted death for people who are suffering. The original Canadian legislation contained the caveat that the person requesting must have death as an imminent reality to qualify. The individual had to be competent, agreeable and have grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition. That left out those whose lives met all of those criteria save for imminent death and  those with mental illness.

This past September, the Quebec Superior Court struck down the imminent death section and gave the government six months to amend the law. Once the amendments are in place (consultation with the public are ongoing and government has requested an extension), assisted suicide will be open to all who meet the strict criteria including those with mental illness.

The inclusion of mental illness is causing considerable debate and there have already been cases where those with mental illness have taken their own lives in private because they could not be granted assistance. Andre Picard, in the Globe and Mail, cites a woman in Quebec suffering with intractable bipolar disorder who finally resorted to suicide by putting her head in a plastic bag and crawling into the trunk of her car.

In a letter sent to media just before she took her own life, she wrote “People with cancer can die with dignity and be comforted, surrounded by their loved ones. A person with mental illness must die alone, in the trunk of her car. I so badly wanted to be accompanied and helped.” As Picard wrote Véronique Dorval, a 38 year old biochemist, suffered from bipolar disorder, which she described as a “cancer of the soul.” Medication provided little relief from her suffering, and debilitating side effects.

In Windsor, Ontario, Adam Maier-Clayton attempted for quite some time to be given the right to die with dignity because of the terrible suffering he was experiencing as the result of :

“generalized anxiety disorder, obsessive-compulsive disorder, major depressive disorder, depersonalization disorder and psychosomatic pain that was “just horrible,” a burning in his eyes, head, biceps, chest and elsewhere.He and his father said they tried everything —including medications, counselling and experimental treatments —but nothing worked.”

When he could not qualify for assisted suicide, he checked into a motel alone, and ended his life by overdose.

The arguments against allowing suicide for mental illness patients, according to Picard are that “It is impossible to determine if a mental illness is irremediable, and vulnerable patients will be encouraged to die because of a lack of mental health services or evil-doers who want to rid society of people with disabilities.” Both are not valid says Picard. In the Netherlands that has a very liberal law, fewer than 1% of patients who take this route suffer with mental illness.

Udo Schuklenk who holds the Ontario Research Chair in Bioethics at Queen’s University in Kingston, Ontario and who chaired the Royal Society of Canada International Expert Panel on End-of-Life Decision-Making, also wrote supporting assisted suicide in the Globe. He went through all the arguments used by the opponents and disproved them.

The point of view of a practicing psychiatrist in Dr David Laing Dawson is the following:

I think assisted suicide for refractory mental illness presents three very difficult issues to consider.

Most chronic and debilitating physical illnesses have been so well studied, researched and documented we, or experts in each field, know with a degree of certainty the inevitable course of the illness and whether or not all known effective treatments have been utilized.

For e.g. we know where ALS leads; we know there are no effective treatments beyond the palliative; we know and can see objectively, the suffering entailed in the progression of this disease.

But for bipolar disorder or schizophrenia, for example, the patterns of symptoms and the course of the illness, and the responsiveness to treatment, are almost as variable as the number of people with these illnesses. How do we ensure, when the request for Assisted Death is made, that the course of the illness from this point is predictable and that all known treatments have been tried and failed? And if resources are available to make such a determination and/or to carry out another new treatment plan?

The second problem is making a determination that the request for assisted death is not, in itself, a symptom of the illness. Or of a co-morbid untreated severe depression.

The third problem lies in the transactional nature of the request. That is, for all of us at times, and for some people with certain personality disorders all the time, any such demand or request or statement is driven by transactional needs, such as the need, at this moment in time, to be able to assume or fight for power/control in the current relationship.

A highly contentious topic and I would love to hear what readers of this blog have to say on the issue. Feel free to wade into the debate.

Post Democracy US

Below is a column from David that we published in January, 2017. Who knew just how bad the US political system would get under the leadership of the American Ayatollah but it has become worse. With his impeachment acquittal, he is now being accused of another quid pro quo with New York State trying to stop investigations into his prior tax fraud. And of course, he is going after the dedicated public servants who blew the whistle and testified. As the Toronto Star Washington correspondent wrote Donald Trump is a law unto himself.

And, to remind all, there is a collection of  our posts on his mental state called Two Years of Trump on the Psychiatrist’s Couch with 5 stars on Amazon and available everywhere in print and various e-book formats.

By Dr David Laing Dawson

My optimism was short lived. After watching Trump’s speech at the CIA headquarters and Sean Spicer’s first press conference I wondered how one goes about dismantling a democracy. I assume there is no manual for this. So I thought I would create a Coles Notes version so we can all follow along:

1. Make frequent reference to the utter failure of all previous administrations. Take credit for anything good that happened during the most recent administration.

2. Promote a cult of personality. Suggest the new leader has God-like powers, such as controlling the rain, and solving complex and intractable problems with forceful statements.

3. Paint a bleak picture of the current state of affairs and grossly exaggerate the risk, the dangers posed by outsiders and nonbelievers.

4. Promote law and order and military power as the only forces that can keep us safe.

5. Incrementally reduce voting rights by insisting on regulations that favor your supporters and disenfranchise others. Do this by claiming you are controlling corruption and fraud.

6. Choose an enemy or two, give them names, and promise to eradicate them. Use emotionally inspiring words such as evil, kill, wipe them out, get rid of them once and for all.

7. Exaggerate the size of your support and the crowds attending your rallies. Refer to this as a movement.

8. Lie frequently and often. Use big, bold lies. This is a form of desensitization. More and more will believe your lies. The remaining citizens will stop caring.

9. Undermine the Fourth Estate. Seed distrust of news and information. Call all reporters and truth tellers liars. It will be difficult to fully control the media (this is not Russia) but consider using licensing bodies, libel laws and the courts to tie their hands.

10. Promote the idea that the people of your nation, your followers, are superior human beings, exceptional, and deserve to live better than others. American Exceptionalism. Or is that “Uber Alles”?

11. You will need the armed forces and intelligence agencies so flatter them frequently, while you replace their leaders with your own men.

12. You will need cabinet members and spokespeople who will unabashedly promote you and your statements and policies no matter how unpalatable or ludicrous they become. Some will be willing to do this for money, others for power and glory of their own, and others because of their own anger and resentment from earlier grievances. Unfortunately such people abound. But remember, it is not loyalty that binds them to you, but self-interest. Reward them generously; always be prepared to kill them.

13. Quickly disparage and render impotent any leader who opposes you. Memorable name calling and disinformation will suffice.

14. Create a language of code words for anything that remains unacceptable for most citizens. For example: “alternative facts” for lies, “violence in the inner cities” for racial profiling.

15. Use hyperbole at all times. A person or event is either “great”, “fantastic”, “amazing”, or “a disaster”, “evil”, “total failure”. This fosters a dichotomous view of the world and will help dehumanize victims when the time comes to purge.

16. Find some allies in other countries by directly or tacitly supporting their extreme views. Examples might include Putin, Duterte, Boris Johnson, Marie Penn and Netanyahu. Be unpredictable for the others. Keep them on edge.

17. Finally, incrementally increase your power and authority until you can accurately call yourself “president-for-life” or “Supreme Leader”. This will take time. At some point you will need a crisis at home (Terrorist attack for e.g.) or you will need to provoke a crisis abroad and at home (Palestinian response to moving embassy to Jerusalem for e.g.). This will justify your transfer of a specific power from a democratic body (congress/senate/parliament) to your own office. This can be done on the grounds that only you know all the facts, and quick decisions are required. It is also more acceptable if the democratic bodies are perceived as ineffective or too partisan. Your people can ensure the latter condition is met.

18. In the meantime cater to the dominant political force in the democratic body by quickly implementing all their pet projects (e.g anti-abortion legislation), and by cancelling all the social and health initiatives of that upstart negro president.

19. Build monuments to yourself. Oops. I forgot. You already have. Good. Build more. Start with the Trump Great Southern Wall.

20. Throughout this process continue to emphasize that you are working for the people. Use the words “people”, “working people” and “democracy” frequently. As you usurp power explain that you are protecting democracy.

21. Have patience. Others may deliver you the crisis and fear that will allow an incremental or bold increase in power. When you assume new powers present yourself as reluctant to do so.

22. Use as much pomp and circumstance as possible. People love ceremonies. Emphasize the sacred trust your office embodies.

23. Visit a religious leader (televised of course). Ensure him and the American Public that you understand the enormity of your office and the need for God’s guidance. Try not to sneer or chuckle doing this. It is not wise to compare yourself to God, but you can hint that He favors you in some way.

24. Don’t worry about the physical quirks the cartoonists seize upon, the little black mustache for example, or the blonde comb over. Ultimately these will confer upon you icon status.

25. There will be protests and marches against you. Be gracious in your response to those that remain peaceful. Come down very hard on those that become violent. Emphasize these, and use them to accrue more power. But, be assured that any large gathering of people can become violent with a little help from your friends.

26. Toady up to the leaders of organized religion, the church.  With few exceptions these religious leaders will see you as a means of helping them achieve their long term goals. They will not stand against you for fear of losing their own power.

27. Allow others to live vicariously through you. This is a fine balance. While allowing the people to view your sumptuous life style use colloquial language, talk as they do. Remind them you work tirelessly for them. Pretend that one day they can all live as you do.

28. Women are tricky. Have one or two around you but not many. They tend to have empathy for others, children, small animals. They tend to prefer compromise and cooperation. Reference your own dear mother frequently, and say how much you respect women. But subtly denigrate them by your own actions, and limit their voices and rights through reproductive and child-care legislation.

29. Gain increasing control of your population. You can start this by controlling all immigration and visitation to your country. Then pick the minority group most feared or misunderstood by your followers and order a registration process. This will appear harmless, like getting a driver’s license. Then incrementally increase the strength of this process, include more identifiable groupings, until all citizens must carry “papers” with them and submit to police checks. This will instill fear.

Feb 16, 2020   Donald has been quite masterful making the Republican Party his own cult, and making truth a relative commodity. I thought undermining the independent judiciary would be difficult. (In Canada a politician publicly opining about any case before the court can cost their job). But it is now happening and happening quickly in the US, with Trump, emboldened by his acquittal,  stating publicly he “has every right to intervene”.

We are now in the top of the ninth with two runners on. Political control of the courts is the death knell of democracy.

 

Debunking Another Anti-Psych Myth and Worthwhile Anti-Stigma

 

By Marvin Ross

Another myth claimed by anti-psychiatry advocates is that people with serious mental illnesses like schizophrenia have significantly shortened lives because of the pharmaceutical treatment they get. There is no doubt that psychiatric medications have bad side effects that result in greater susceptibility to physical ailments like diabetes and cardiovascular disease but there is another explanation that is largely overlooked – stigma by medical professionals.

Over the years, there have been a number of studies demonstrating that those with serious mental illness do not receive adequate physical health care. A 2018 study pointed out that “There is evidence of inequitable access to and/or uptake of physical and dental health care by those with schizophrenia”.

A 2011 study suggested that there is sufficient evidence that people with SMI are less likely to receive standard levels of care for most of these diseases (Nutritional and metabolic diseases, cardiovascular diseases, viral diseases, respiratory tract diseases, musculoskeletal diseases, sexual dysfunction, pregnancy complications, stomatognathic diseases, and possibly obesity-related cancers) .

A cross sectional survey in 27 countries found that “More than 17% of patients experienced discrimination when treated for physical health care problems. More than 38% of participants felt disrespected by mental health staff.”

the latest study published in January comes from Sweden where there exists an impressive database of patients to draw upon. What researchers did was to compare 4536 patients (cases) and 44,949 controls. Cases included patients with reported preventable harm in primary health care and emergency departments from January 1st, 2011 until December 31st, 2016.

What they found was that Psychiatric disease, including all psychiatric diagnoses regardless of severity, nearly doubled the risk of being a reported case of preventable harm. The authors pointed out that a significant reason for this is what is called diagnostic overshadowing. This is a process whereby physical symptoms are misattributed to mental illness and therefore ignored.

Most of us (and I suspect mainly women) have been told that our complaints are all in our heads when doctors cannot find a cause for the symptoms. When someone with schizophrenia reports symptoms, they are often overlooked because of the schizophrenia.

The most egregious example of that took place at the ER at St Joseph’s Health Centre in Hamilton Ontario in 2002. Rusty Potter, a 40 year old man with schizophrenia and asthma was sent to the ER by his family doctor because he had pneumonia. Randy was known to the ER staff because he volunteered at the hospital and his address was a group home for people with schizophrenia. As a result, they assumed his problems were psychiatric despite what he told them. When he was having increased difficulty breathing, a nurse handed him a paper bag to breathe into assuming he was having a panic attack.

Randy arrested and died in the waiting room.

I wrote about this in my book Schizophrenia Medicine’s Mystery Society’s Shame and quoted one of the patient advisors who wrote to the local paper and said that:

persons with mental illness do not obtain appropriate medical treatment. All too often, our clients don’t get access to medical services or their concerns go unrecognized because the symptoms are viewed as part of their illness or they are attention seeking by asking for help.

Dr Miriam Schuchman wrote in another Canadian paper (The Globe and Mail), that medical staff in doctor’s offices or in ER’s may be uncomfortable treating these people.

There goes another anti-psychiatry myth and a stigma that does need to be corrected.

And on another note, the world recently lost one of its key anti-psychiatry advocates in Toronto’s Bonnie Burstow who began an anti-psychiatry scholarship. Ms Brstow received numerous obituaries including the New York Tines 

A Psychiatrist Comments on stigma

By Dr David Laing Dawson

Marvin is right about the limitations of the anti-stigma endeavours. In fact I would add that much of the movement downplays the seriousness of some mental illness, and creates a mush of euphemisms. Historically (my experience in the 60’s) the word cancer was not used in hospitals, at least not outside the Doctors’ lounge, the seminar room and the cafeteria. Real progress did not occur until the word Cancer became acceptable, with acknowledgement of the suffering and death it caused. Terry Fox did not run across Canada to raise awareness and money for Bone Health.

Leprosy, the very disease that gave us the term leper, did not lose its stigma when it was renamed Hansen’s Disease, but when it became both understood and medically treatable.

One day we may be able to divide Schizophrenia into several specific forms, each linked to specific genes, as we can now do with several types of cancer, but for now lets just accept the name schizophrenia and use the effective treatments we have. But let’s not confuse this illness with work stress or remorse or insecurity.

And let’s accept that physicians and physician specialists comprise the only professional group that can actually employ a methodology and tools to investigate, diagnose, and treat serious mental illness, with the assistance of several other kinds of “mental health professionals”. I state this bluntly because the anti-stigma movements usually refer to “mental health professionals” as a somehow unified body of equally qualified and knowledgeable helpers.  As I think about this more I wonder if the anti-stigma movement is further stigmatizing mental illness and by extension psychiatry by using such terms as mental health and mental health professionals, making it, I’m sure, far more acceptable to be seeing a counselor for mental health than a psychiatrist for a mental illness.  Which might be contributing, ultimately, through similar prejudices within the medical community, to the diminution of medical graduates entering psychiatry.

And…

I know statistically people suffering from mental illness are more likely to be victims of violence than perpetrators of violence but it is also true that the most gruesome and apparently inexplicable of crimes making the headlines of our newspapers are usually committed by people suffering from severe and untreated mental illness. Emphasis here on the word ‘untreated’.