Challenging Dogma

...Using social sciences to improve the practice of public health

Tuesday, April 24, 2007

Ready to Die? One Example of How Public Health May Be Failing the Severely Mentally Ill – Elliot Arnold

Many of us have had days like this. You come home, rough day at work, rough day with your friends, your back is sore, you neck hurts, and it’s dark and cold outside. No one is available on the phone, all three of your favorite sports teams lost, and your dog died last week. You feel horrible, mentally, physically, and emotionally. If you can think back to a day like that, or a week like that, consider making a decision during that time. Probably not the best time to do it. What type of things did you actually consider that you later on looked back on as too extreme? How was your decision-making process? Was it rational? Did you see the big picture clearly? For most of us, as time passes, we can look back on these periods with more wisdom. Often, we are somewhat embarrassed by how we acted. ‘That was silly,’ we say to ourselves. ‘I can’t believe I did that. Good thing I had some restraint and didn’t act completely on how I was feeling.’

Now imagine you didn’t have just a day like that. Or just a week. Imagine you had a month. Or a few months. A year. Or a few years. A decade. Or a few decades. What if every day during that time you got up knowing each day was destined to feel just as terrible as the last? What if you continued feeling that way no matter what you tried to do? What if no one else understood or related to it? What if you lost friends because of your behavior? What if you lost family? And your job. And your home.

What if medical professionals gave you drugs which they said would help? What if they did not? What if you felt bad when you were on them? What if you felt worse when you were not? What if it seemed like nothing would ever work? What if your existence became nothing but pain and despair? What if every day was like this? For decades.

And what if one time, after years of getting up to face another of these days, when it came time to get up, you simply did not?

Then what if you were offered a choice? People who were considered knowledgeable and reasonable told you that you did not have to keep on enduring this pain. They told you they had decided that your life may not be worth living. And they would understand if you chose to end it. They would support you.

Then what if you decided to do it? What would have been the caliber of your decision-making process? Would there have been other options? Would you have failed yourself? And would these knowledgeable and reasonable people have failed you even more?

This situation may seem extreme, but a recent court ruling in Switzerland opens the door for such situations to become a reality.

A ruling by Switzerland’s highest court released Friday has opened up the possibility that people with serious mental illnesses could be helped by doctors to take their own lives…“It must be recognized that an incurable, permanent, serious mental disorder can cause similar suffering as a physical (disorder), making life appear unbearable to the patient in the long term,” the ruling said. “If the death wish is based on an autonomous decision which takes all circumstances into account, then a mentally-ill person can be prescribed sodium-pentobarbital and thereby assisted in suicide,” it added (1).

I think this is a bad idea, with limited advantages at best and disastrous consequences at worst. While it might end some suffering, it also might needlessly cut short lives which may go on to become fruitful.

There are three main reasons I feel this way. First, I believe this violates an important social science principle, Maslow’s Hierarchy of Needs. It states that before we consider higher-order needs such as morality, philosophical questions, etc., we must have lower-order needs met such as physiological needs that maintain life, practical needs which include shelter and personal safety, and emotional needs such as feelings of being loved by family and friends, etc. (2). Making the irrevocable decision of whether to live or die is one of the highest of high-order needs. One would want the person making that decision to be competent to do it. People with severe mental illness, who feel depressed and hopeless, who are habitually in emotional anguish, and who have bad self-esteem and unhealthy relationships do not have many of the low-order needs met which would enable them to properly consider such an important decision.

Second, I feel this initiative is focused in the wrong direction. It deals with people who already have bad quality of life and offers them a very drastic solution. It does not focus on things which might prevent their situation from getting that bad in the first place. It is doing delicate surgery with a jackhammer; even granting that its focus starts once its subjects situations are very bad, it never even considers any other techniques which might ease the pain in their lives, aside from ending their very life itself.

Third, I feel it may be short-sighted in that it assumes people who are mentally ill are doomed to have awful quality of life. This ignores much of the modern history of medicine, in which advances which were previously thought of as fantasy have routinely come about. Modern medicine has eradicated polio, invented the artificial heart, separated conjoined twins, etc. What if people who had these conditions were offered a similar solution before these advances? How many, who may have been cured if they had waited ten more years would have accepted euthanasia? Despite what Tom Cruise says ;), the field of psychiatry is constantly evolving and developing new outlooks and techniques which can improve lives. Why should we consider a mentally ill person more doomed to a despairing existence than a person who had polio a few years before Jonas Salk invented its vaccine? Or a person with a heart ailment a few years before bypass surgery was developed? Considering a condition incurable is a mistake which medical history leads one to reject, but this policy seems based heavily upon that belief.


Examples of Maslow’s Hierarchy of Needs are found all throughout life. A child who does not have enough food may have a talent for math. That talent is not likely to bloom, and may not be expressed at all while the child is in a malnourished state; the higher order need to grow academically will not be addressed until the lower order need to feed herself has been satisfied. The child will be preoccupied with feeding herself, and devote the majority of her energy to that end. A man living in a war zone may have a talent for baseball. He is not likely to concern himself with the higher order need to express himself athletically if he is constantly concerned for his own safety; he will think mostly about what he can do to protect himself. Someone with dysfunctional relationships may engage in self destructive behavior like abusing drugs. This behavior obviously goes against higher order needs like being physically healthy, but because his lower order esteem needs are not met, he is not concerned with the harm he is inflicting on himself. These are real examples where people who might otherwise be dealing with higher order needs are not dealing with them, or are dealing with them in an unhealthy manner. I feel the mentally ill often behave in the same way. Because many of their lower order needs are not being met many either are not dealing with their higher order needs such as their career, their long-term health, etc., or if they are dealing with them, they are dealing with them in an unhealthy manner, as in, ‘I’m depressed, my life must not be worth much, I might as well end it.’ Therefore, I’d say many mentally ill people would not be competent to rationally address self-euthanasia.
The idea that certain people are not competent to make certain decisions goes far beyond the question of the mentally ill. Children are not allowed to sign legal documents because they are not considered mature enough to understand long-term ramifications. Are the mentally ill any more emotionally stable? A judge is not allowed to preside over a case in which he is personally vested, for instance one involving a friend, because his attachment may not allow him to review the situation objectively. Are the mentally ill any less challenged in their ability to objectively decide whether they should end their life?

There are also many cases in which the mentally ill either have not been considered competent to make certain medical decisions or the question of their competency has been challenged. The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research describes the capacity to reason as one of the key components in determining a patient’s competence, and mental illness often drastically affects that (3). There are many examples where judges have ruled that a mentally ill person cannot refuse certain medications or medical procedures. Mentally ill people’s competence to make certain decisions has been called into question in many different areas, including legal matters. Often, they have been found not competent, because of both the lack of a rational decision-making process and the lack of an ability to consider issues from an emotionally stable foundation.


This policy would also go against an outlook that is becoming more popular in Public Health, which is focusing on dealing with problems at their root cause, rather then only concentrating on improving their symptoms. This policy would be better focused on ways we might be able to prevent people’s lives from deteriorating into despair, instead of offering them an irrevocable way out once they already have. That would be a better, more efficient, and more moral use of time. This new approach to mental illness within the Public Health sector is demonstrated here:

Neil Cohen, M.D., New York City's former commissioner of health, has talked about how public health’s outlook on mental illness is changing from only addressing the problem once the illness is apparent to focusing on preventing factors which contribute to mental illness. "We are at the dawn of an era when we can now look at risk-factor epidemiology, examining the causes that contribute to—and the protective factors that decrease risks for—mental illness in communities,” he says…"Despite the need for public health interventions to address behavior, only 5 percent of each health care dollar is devoted to behavior modification," Cohen stated. Related to this have been the historic neglect of mental health and illness and the segregation of public mental health activities from the rest of public health and medicine… (4).

Many of us also know of the commercials for Lucinda Bassett’s Midwest Center for Stress and Anxiety. Hers is also an example of a very successful program that focuses on developing healthy life-coping skills to treat individuals suffering from depression and anxiety. She describes it as: ‘…a clinically validated method for taking control and enjoying your life again…the program moves quickly and is designed to be fun, engaging, and very motivating.’ (5). It focuses on techniques to prevent people from slipping into prolonged despair. Its burgeoning popularity is due to the undeniable fact that it has helped many people improve their lives. The self-euthanasia policy doesn’t focus at all on techniques like these which might genuinely get people feeling like their life is worth living again. And I feel that is a big omission.


I also feel this policy’s outlook ignores a fundamental characteristic of modern medicine: its ability to rapidly evolve and alleviate problems which had seemed intractable. The last quarter century alone is full of numerous examples ranging from Viagra to laser vision correction, and the future seems promising for many more, at an even faster rate, as demonstrated here:

…It might all sound like science fiction, but in the last 10 years, scientists have started to unlock secrets of the human body that may make these technologies possible…the human genome has been unlocked…By essentially mapping out every gene and chromosome in the body, scientists can now look at people who are sick, and those who are not, and compare their genes, looking for abnormalities that might have caused disease. Once the problem is pinpointed, the cure is one step closer…the advances promise the potential to cure cancer, AIDS, and maybe even the common cold…the long-term implications of these triumphs are still becoming apparent…may make it possible to engineer drugs tailor-made for patients based on their genetic makeup, and doctors might even be able to cure or eliminate inherited diseases… Parents will most likely be able to customize the sex of their baby before it's born, and comb through their child's genome to weed out potential anomalies like Down syndrome… (6) (7).

There was also a recent story on 60 minutes about a drug called propranolol, which was able to stop anxiety caused when people who had experienced traumatic events encountered something which triggered that memory. (8). It permanently weakened people’s memory of the event, thus reducing their anxiety. Many people said their lives were better, and they were happy it was available. If one had told someone a generation ago this was possible, they would not have believed it. If this is available now who can tell what will be available in years to come?

With the nature of medical advances being what they are, how can we have a policy which infers the lives of the mentally ill are destined for unwavering misery? To have knowledgeable people accept that they are is not only somewhat insulting, but also contrary to the nature of the current medical field.


There are times when existence is a pain. And after enough pain we may literally do anything to escape it. But if we completely give in to that desire, we lose an essential part of what makes us human. That is our sense of right and wrong. Our ability to move beyond what we are currently experiencing and decide what is best to do long term.

Throughout history, many of the people who are now regarded as great have faced tremendous discomfort and acted on what they felt was best for the future. Many, from Lincoln to Eleanor Roosevelt to Churchill have endured depression, which is one of the common symptoms of mental illness, and achieved great, history-changing things. How would our world be today if they had been offered euthanasia in the depths of their despair and had accepted? We presently live in a world were there are more alternatives than ever before for what ails us. Given these facts, what is it about adopting self-euthanasia that makes it a good thing? A right thing? A necessary thing?

Ending one’s life is a decision that should only be approached with a thorough understanding of our options, and while considering the entire picture, not just how we happen to be feeling at a certain moment in time, even after prolonged periods of suffering. It is extreme to say no one should be allowed to commit suicide, after all, if we have the right to live, we certainly have the right not to. But this potential policy runs against the advanced and progressive elements of modern medicine, and seems more of a throwback to old, crude forms of “treatment”, where if one had a mental illness the authorities would put a stamp on your forehead, put you in the “special” room, lock the door, and throw away the key. With what we have learned by today, we owe ourselves, the mentally ill, and everyone who works hard every day in the field of Public Health much more than that.


1. Mentally ill in Switzerland could win right to die. (2/2/2007)
2. Maslow’s hierarchy of needs.'s_hierarchy_of_needs (4/20/2007)
3. Searight, H. Russel. Assessing patient competence for medical decision making, American Family Physician, February, 1992
4. Moran, Mark. Public Health shifts focus to preventing chronic illness, Psychiatric News December 1, 2006. Volume 41, Number 23, page 15
5. Attacking Anxiety and Depression with Lucinda Bassett. (2007)
6. Sloane, Matt. Medical Advances not Science Fiction, (10/19/2005)
7. Flash forward! Fortune magazine’s top trends. (10/5/2005)
8. Stahl, Lesley. A Pill to Forget? “60 minutes.” (11/26/2006)

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  • At April 26, 2007 at 7:29 AM , Blogger christine peloquin said...

    i like the unique opening to your paper; it results in the reader approaching the paper in an empathic, emotionally-available mindset.

    good, concrete examples of breakthroughs in modern medicine.

    enjoyed learning that lincoln, churchill and roosevelt all suffered depression at some point in their lives AND had large positive impacts on the world.


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