Wednesday, February 11, 2004

Euthanasia, Part 2b: Suffering

(Read the prologue, part 1, and part 2a.)

Why do people with incurable illnesses want to kill themselves? If it surprises you to hear the answer, "for the exact reasons that anyone else wants to kill themselves," that's probably because proponents of Physician Assisted Suicide (PAS) have successfully created the impression that there's a bright line of distinction between (1) crazy people, who want to commit suicide because they're depressed, irrational, and impulsive; and (2) incurably ill people, who want to commit suicide for rational reasons.

If that were the case, then it would make sense to prevent crazy people from committing suicide while offering suicide assistance to the incurably ill. But there's nothing exceptional about the suicidal wishes of people with incurable illnesses. The desire to die is associated with depression, hopelessness, feeling unsupported, and seeing oneself as a burden with nothing of value left to offer the world. That's true for both the physically ill and the physically well. And these symptoms respond to treatment, for the physically ill and the physically well alike.

We owe our clinical and scientific understanding of these phenomena to three brilliant psychiatrists who study dying people: a Canadian, Harvey Max Chochinov, an American, William Breitbart, and an Australian, David Kissane. Last spring, I was privileged to spend an afternoon at a seminar with them, and to hear about how they care for their patients as well as what their research has found. Here's what they taught me, which also fits with what I have learned from my own dying clients:

The desire to die is not universal among the incurably ill. It is strongly related to depression and the feeling of being unsupported. Among people with HIV, interest in PAS is associated with measures of psychological distress and poor social support, and not with "severity of pain, pain-related functional impairment, physical symptoms, or extent of HIV disease." Beyond the simple clinical syndrome of depression, all three of these psychiatrists have written movingly of the loss of meaning, or sense of demoralization, that can occur at the end of life as people struggle to see themselves as worthwhile and valuable to others. When people - medically ill or not - no longer feel that there's a point to their life, they often want to die.

One of the earliest pieces of clinical advice I ever received was that "if you ever find yourself agreeing with the patient that his position is hopeless, you've gotten sucked into his depression and are no longer thinking rationally." Time and again, I've found this to be true. Yet when depressed dying people are concerned, our society too easily falls into sharing their misconception that they no longer have anything of worth to offer. Their depressed and hopeless thoughts sound, to many of us, like the simple and incontrovertible truth.

Fortunately, the psychiatrists I mentioned have found successful treatments which address these problems. Breitbart's got an eight-week therapy program which focuses on restoring a sense of meaning to the lives of people who are slowly dying. Chochinov has developed what he calls "dignity psychotherapy," which in a couple of sessions at the hospital bedside can help dying people regain a sense of purpose, of usefulness, of legacy. They've both found that patients who receive these interventions lose interest in PAS, and are better able to make positive use of their last days.

The success of these interventions belies the claim that depression and loss of purpose are an inevitable component of the end of life. The argument for PAS rests on the assumption that incurably ill people who want to die are making a rational decision untainted by emotional distress which may be treatable or transient. The more we learn about the mental and emotional states of dying people, the less justifiable that assumption proves to be.