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Much like other “liberalizing” policy promoters, those who champion assisted suicide have not attempted to determine if it works. If you ask them they won’t tell you because they have no data, whether or not assisted suicide is good for anybody. Is it good for the relatives, doctors, undertakers, country? Nobody knows because where it is now being done, no one is collecting sensitive statistics and those who are eagerly urging government to adopt these “progressive measures” are not going to wait until there is evidence from countries conducting these brave new experiments, if anyone is happier for them. In the absence of hard data here is a strictly pragmatic assessment based on history and clinical experience.
Life is always in the balance both for the individual and for their group. This is true partly because everyone is ambivalent about living and dying. Measured on a visual analogue scale you will find the desire to live fluctuates daily and sometime hourly. There are very few people who haven’t said something like, “It’s pointless. I give up. I might as well kill myself”. To this good family and friends, characteristically say, “Oh, come on. It isn’t that bad. We’ll give you a hand (or an aspirin or both) and in the morning you will see things in a more positive light.” And generally they do. So it appears that people help each other when the desire to live becomes unbalanced. What would happen if every time someone felt suicidal, their supporters would respond with, “You’re right. I can tell it must be terrible for you. We will help you set your affairs in order and call for the “Doctor Assisting Death” (DAD) who is on call tonight.
In my practice I have treated thousands of people who ostensibly wanted to kill themselves, (most had made serious attempts) but I never encountered anyone who wanted to be dead. It wasn’t hard to detect that only part of these people wanted to commit suicide. With the following kinds of understanding and help, they changed their minds and not long after were glad they had.
This is what I taught my students but it could be useful for anyone. How to tilt the balance from wanting to mostly to kill themselves to a determination to continue the struggle we call living:
- Promote insight
Discover and help them see those factors that make them want to murder themselves. Suicide is murder. Ask the patient if they were not so intent on murdering themselves, who would it be. Frequently their expression goes from a puzzled look to anger and then laughter. “You are right. I would really like to murder my mother-in-law but it wouldn’t work. Knowing her, she would come back to haunt me and make my life even more miserable.” The usual factors promoting self murder include: interminable mental turmoil, hopelessness, abandonment, alienation, defeat, pain, new limitations, entrapment etc. all of which can be remediated to some extent.
- Bargain for reasonable betterment
“How much would these death promoting factors need to change to help you feel you could carry on? E.g. How much less pain?” It isn’t surprising to hear, “10% less doc would make it bearable”. To which most doctors would realistically respond with, “Cheer up old chap, we can do better than that. How about 25% better” and then you (medical student) hear. “Doctor, you just saved my life” and you did. However if you say, “Heck, we can take it all away”, you blow your credibility and your patient’s cooperation.
- Start on Life’s Final Ten Tasks
For the dying this involves assistance in working on such end of life tasks as: family and friend reconciliation, making peace with your maker, etc. For the young this usually means gaining insight into the roots of persistent mental conflict, negotiated realistic expectations of peers so deep disappointments don’t keep reoccurring, setting achievable goals,
“I will be here for you until…..e.g. (for physicians), you are well or being cared for by someone else or you fired me or you just up and died.
- Give Reasons to Hope
The hope must be realistic. Offering a complete cure is not honest and is not accepted, rather say, “I am afraid you are going to die in 18 months or so. In the meantime you should be able to enjoy life and visit your grand-kids with little pain.
Death with Dignity nonsense
Post mortem analysis of blood catecholamines shows high levels in almost everyone. This indicates dying is severely stressful. The serum levels vary with the cause of death. It is very high when the person is poisoned. This being the case doctor assisted death with chemicals is the least dignified way for the patient although family and friends may feel at peace, especially if they don’t watch the process.
Reasons Doctor-Assisted Death (Suicide) is unlikely to provide any benefit but a lot to pain to all.
Strained or broken relationships
Not only is individual life in a precarious balance but so is that of a family, social group or nation. There is usually an intergenerational quid pro quo so the efforts of parents for their children is repaid by being cared for when they can no longer meet their own needs. When elders suspect their children might too readily agree to their being institutionalized in a home for “old folks” or euthanized because they are complaining too often of aches, pains and disabilities they begin to: just keep quiet and suffer, mistake any kindness as part of a plot to get to their money, feel family is only coming to visit “because you feel you must”. On their part the “youngsters” are tempted to consider asking the doctor when it (DAD) would be the right time because she/he seems to be in such discomfort. DAD is a temptation only because “it’s legally available now.” Before it was unthinkable.
Hints go back and forth. Sidelong glances are full of suspicious meaning. Missed visits are resented and grumbled about under the breath. “I know they are trying to put us away because they want their part of the inheritance to pay off the mortgage and maybe we should just go along with it and ask the doctor to send us on our way” All these and many more misunderstandings are accentuated because the “poor old couple can’t hear or see very well now” The end result is fractured relationships that have lasted and were counted on at the very point of life when they are most needed. Because they are increasingly alienated the couple become more dependent and expect the government to take care of them.
Between the couple, all previous unmended hurts come to the surface and hostilities erupt. “I know my old man is trying to get rid of me. He has been all our married life. Now he won’t have to divorce me. He just requests that out of kindness to me, there should be DAD which is much simpler.
Weakening instinctual restraints to aggression and/or abandonment
Every species has a Species Specific Instinctual Restraint to Aggression and Abandonment, (SSIRAA) otherwise the species would become extinct. Very few if any species kill and eat their young under natural conditions. Abortion is tantamount to parents killing and eating their young. They can only do so when they are able or coerced into overcoming their SSIRAA. When they have done it once their SSIRAA is damaged and is no longer as effective in preventing outbursts of aggression towards helpless young or enfeebled old people. Agreeing to the hospital order to have nothing by mouth for old dad because “he is in such pain and can no longer make decisions for himself” also weakens the SSIRAA so that it is easier to agree to the next parent’s DAD.
This process may also generalize to situations where the children’s dependency and irritating behaviour may trigger parental rage. Some parents appear to recognize they can no longer be trusted or trust themselves to control their rage and so they place their infants in day care where “they will be better cared for by professionals.”
In this way DAD becomes a slippery slope. Each weakening of the SSIRAA progressively increases the ease with which family and professionals agree to DAD. It goes from, “I would never consider DAD for my parents”, to “well maybe under tightly controlled circumstances” to “I’m sorry but it is your turn to go old women”.
Since medical staff are involved so much more, it is no wonder their SSIRAA is more weakened and there is an increasing incidence of elder abuse.
Decreasing trust in the medical profession results in increasing health care costs
Hippocrates and his colleagues were primarily pragmatic when introducing what became known as the Hippocratic Oath. Ancient Greek physicians had a dual obligation to patients and the state to treat patients as best they could or painlessly hasten their death. If the patient would not become well it wasn’t the doctor’s lack of skill, it was because they had offended the gods. Since the gods had decreed their death, the doctor was being kind to make it as quick and painless as possible. The problem was that the patient was never sure of his physician’s intentions and therefore didn’t’ trust them. This made it difficult for the physician when trying to obtain the patients cooperation for examination and treatment. At times the doctor was reduced to pleading with the patient, “Please take this potion. It’s the latest pain killer from the famous Apothecary in Alexandria”
Of course the more the doctor pleaded the more suspicious the patient became. Patient A. “I don’t trust you doctor. You are in cahoots with my wife who is so eager to get her hands on my estate” Hippocrates. “Alright already, I swear by Jupiter, Aesculapius and the whole pantheon, I will never poison you” Patient A. “Okay doc. Don’t get so worked up. If you are that serious, I’ll take this stuff”
And so over 24 centuries a modicum of trust was built up. But now that Hippocrates is discarded, confidence in the medical profession has rapidly waned. Modern physicians are faced with patients who because they question their doctors intentions, must spend more time persuading patients to have a physical examination and must order more lab tests and agree to a request for a second opinion and are skeptical about the efficacy of the medication. Without trust in the physician’s intentions, patients have little trust in the medication he ordered and therefore the placebo effect (about 80% of the medication’s experienced benefit) has also diminished.
As medical costs escalate, partly because of lowered confidence in physicians, the inclination and pressure to use DAD in order to vacate hospital beds increases and so does DAD, going round in a vicious cycle. The physicians lose confidence in themselves after compromising their determination to always treat and so they don’t try so hard to cure, especially older patients.
Complicated grief leading to depression
Antidepressants are the second most prescribed medication in the world. The reason for this I suspect is the increasing incidence pathological grief, (PG). When-ever anyone losses a friend, pet, family member to whom they are bonded, they must grieve. Uncomplicated grief begins and ends quite naturally. However if a person has contributed to the death of anyone they must now grieve, that grief becomes complicated and often pathological. Pathological grief is often misdiagnosed as depression. If patients are then prescribed antidepressants, they can feel neither the full range of feelings nor the intensity of sorrow, anger, abandonment etc. that is necessary for successful grieving. So now the patient truly becomes depressed. But because they are not able to grieve, that “depression” continues and their brain chemistry becomes distorted by the antidepressant. Now the physician’s statement “you have a chemical imbalance in your brain and may have to take this medication for the rest of your life”, Is inadvertently made to come true by the well-meaning but ill-informed physician.
The patient intuitively perceives medication isn’t the right treatment but something is wrong so he keep returning to the physician who assumes the medication needs increasing or changing to a newer product. Since a psychiatrist can only see so many patients in a day, the waiting list becomes longer and longer until he/she puts up a notice on his/her office door stating “Sorry I am no longer seeing new patients”
It is unlikely that anyone will recognize the basis to the problem is that the patient, a son, feels guilty for having contributed to his father’s DAD by consenting to the physician’s suggestion of DAD. Even if some good professional does understand this dynamic they have no skill in helping the patient deal with his guilt. Since 50 % to 80 % of the population has contributed to the death of a helpless child or pain ridden parent, there is a vast number of depressed patients who are not being properly treated and in despair want to kill themselves. Thus guilt complicated grief (GCG) becomes rampant and the already underfunded psychological and psychiatric treatments become totally inadequate.
As long as DAD is legally prohibited, it is not considered. Once it is legally and socially approved it becomes an option and often a temptation. Then the peace of old age is shattered by the temptation of “doing it”. “Living in a place where the only way out is to die, I feel no joy. Since it won’t be long before I face the final frontier, I would like to die when I chose rather than letting my good for nothing family spring it on me.” So now the fun and wisdom of grandparents is lost to children, not because there was any real necessity but because people will make happen an anticipated horror just because they can’t stand the tension of waiting for their worst fear to come true.
At the same time family in general and the attorney loses peace and sleep trying to decide if they should and if so when is the best time to spring the trap door. Putting the issue into the hands of some DAD designated physician makes both family and elder worry that the decision will be made when they are not ready. The net result is much unnecessary turmoil just when everyone wants to have a good time and happy lasting memories waiting for nature to take its course. Then if death is too soon and too uncomfortable, God can be blamed and God has very broad shoulders. Besides if the dying person has completed the Ten Tasks there is no need to desperately cling to life. These people die in peace.
When all is said and done, there are no known benefits and necessities for DAD but many harms for those wishing to die, family, society and nation. So why are ostensibly enlightened people so eager to push for the legalization of Doctor Assisted Death? Is it because they are so afraid of death and the hereafter, they want to grit their teeth and “get on with it” rather than let is sneak up on them and pounce when they least expect it?