Depression, Self-Love, Time, and the "Right" to Suicide*
Harold Bursztajn, M.D., Thomas G. Gutheil,
M. D., Mark J. Warren, M.D., and Archie Brodsky, B.A.
Program in Psychiatry and the Law,
Massachusetts Mental Health Center, Boston, Massachusetts
* This paper and the following commentary by
Dr. Alan A. Stone represent the first presentation in this new series.
Comment and response are invited from our readers and will be considered
for publication subject to editorial standards. —Ed.
Abstract: Elizabeth Bolivia,
whose legal struggle to compel a psychiatric hospital to assist her
in committing suicide ended with a decision that she could be force
fed by the hospital, presented the psychiatric community with a host
of ethical questions concerning the rights of a patient to choose
death, and the obligations of the medical profession to promote life.
What the courts did not decide is when a patient is incompetent to
decide her own fate, and what is the duty of the hospital to intervene
with a suicidal patient. The authors suggest that there is an ambiguity
present whenever a patient presents herself to a hospital or therapist
as suicidal, and that a time limited period, or cooling-off period,
should exist that would allow an alliance to form between patient
and care-giver, if possible, and then permit them to explore underlying
issues of depression. The authors believe that there is a need to
acknowledge the patient's ultimate right to choose death, but that
autonomy should not be confused with impulsivity when anyone is faced
with the irrevocability of the decision to die.
Elizabeth Bolivia's protracted legal struggle to compel a California hospital
to provide her with a secure environment while she starved herself to
death engaged the interest and compassion of the nation. It also brought
into sharp focus ethical dilemmas whose edges are softened when (as is
usually the case) a patient claiming the "right to die" is
elderly or terminally ill. Ms. Bouvia, a 26-year-old cerebral palsy victim
who had virtually no motor functions left, claimed that she was resolved
to die because life offered her no further prospect of usefulness or
enjoyment (both of which she had pursued energetically and with some
success while she could). She and the hospital both asserted compelling
ethical positions—on the one side an individual's right to chose death
for herself, on the other a mission to prevent rather than assist in
suicide. The case thus presented to the public and to the medical and
legal professions two questions of considerable depth, complexity, and
urgency: When is a person to be judged incompetent to decide his or her
own fate? Under what conditions is there a medical duty—and a societal
duty—to prevent suicide?
Bouvia admitted herself to the psychiatric service of Riverside County
General Hospital in September 1983 as a suicidal patient. She then refused
nourishment until the hospital staff threatened to force feed her. With
the aid of the American Civil Liberties Union, Bouvia sought a court
order to prevent the hospital from either force feeding her or discharging
her. In December, a judge ruled that Bouvia was rational and fully competent
to choose between life and death. Nonetheless, the judge decided that
her right to self-determination was outweighed by the detrimental effects
that any compromise of the hospital's ethical mandate would have on others
(including hospital staff, other patients in the hospital, and other
physically handicapped persons). On this basis, together with the fact
that Bouvia was not terminally ill, the judge authorized force feeding
[1].
The case then entered the arena of nationwide publicity and debate. Some
commentators argued that, since Bouvia had made up her mind to die, the
most reasonable solution was to find a setting where she could starve
herself with privacy and in a humane atmosphere. Others were not so sure.
A newspaper columnist asked, "How long does it take before we believe
that Bouvia has permanently, not temporarily, lost the will to live?
One year, five years?" [2]. A prominent authority
on health law stated that, in the case of a competent adult, force feeding
(if it could be justified at all) should not be continued for longer
than a month and preferably should be limited to a week [3].
Subsequent developments have cast a retrospective light on this question.
In April 1984, Bouvia left Riverside and entered a Mexican hospital specializing
in Laetrile and other cancer treatments. When this institution also refused
to abet her self-starvation, she went to a motel, fasted for 3 days,
and then decided she wanted to live. Her change of heart occurred on
Easter Sunday.
Admittedly, hindsight offers an unreliable perspective from which to evaluate
prior decisions or recommendations [4]. We do not mean
to say that previous commentators were wrong simply because the outcome
to date has gone against their predictions. After all, Bouvia might change
her mind again. In this case, however, hindsight only confirms what educated
foresight might have told us. For the instability of Bouvia's resolve
is not extraordinary, but is in fact typical of people with suicidal
intent. Those who regarded her determination to die as set in stone did
not understand that suicide is a dynamic, ambivalent, conflicted act
[5,6], one with magical overtones [7-10].
These characteristics are apparent in the United Press International
account of Bouvia's decision to live.
The renunciation of her wish to die came Sunday as she talked with
Barbara Bradley, a licensed psychiatric technician who had befriended
her at Riverside General Hospital in California. . .
. . .Mrs. Bradley urged Mrs. Bouvia to move in with her and her husband,
Jerry, and try some new medical procedures to ease her suffering.
Persuasion from Friend
As reported in the newspaper [San Diego Union], the weakened Mrs.
Bouvia told the technician: "If I would change my mind I need
someone to help me. I want to get better."
Rigoberto Alvarez, an intern from Hospital Del Mar who was also present,
told her, "There are things to be done. All we need is a chance,
an opportunity."
"What do I do now?" she asked.
"Say yes," Mrs. Bradley said.
"I'll try," said Mrs. Bouvia as Mrs. Bradley hugged her
and both wept.
Mrs. Bouvia then had a Mexican sweet roll and a glass of white wine.
. . . [11]
Aside from the symbolism of Easter Sunday, the magic to which Ms. Bouvia
responded was that of a therapeutic relationship formed at the hospital.
From the evidence of this account it was Barbara Bradley's extending
herself emotionally, as a "friend," that proved decisive. This
denouement (if accurately reported) calls into question the California
judge's earlier opinion, in holding Bouvia to be fully competent, that
her decision to end her life had been motivated by her incurable physical
disability and not by recent personal experiences. A more prescient account
was given by a Boston journalist in February.
Bouvia's physical condition isn't a temporary problem ... But
her depression may be. Any young woman who had just ended a marriage,
lost the hope of childbearing and belief in a career within the same
year, could be despairing. Wasn't there some ambiguity in her decision
to seek suicidal help in a psychiatric ward? [2]
Ambiguity, we concur, and we suggest: even ambivalence.
A person suffering from a physical illness involving severe, permanent,
and even worsening pain may have a rational, competent basis for choosing
to die; yet the wish to end one's life may be motivated by emotional
considerations as well. Physical illness alone, per se, is rarely a cause
of suicidality. On the contrary, people whose physical illness or disability
is compounded by the loss of a loved one (as Ms. Bouvia's was) often
feel lonely, hurt, and angry. These feelings can translate into hopelessness
about one's situation and a profound disbelief in one's ability to improve
it. A person who feels helpless to improve a situation may seek the illusion
of control by trying to end it, as by suicide. Tragically, though, suicide
is permanent even though the feelings that precipitate it may be only
temporary.
When those who are handicapped or in great pain express a wish to die,
the role of the medical professions should be clear. It is to attempt
to elucidate why this particular patient in these particular circumstances
is suicidal. It is tempting to say of someone who is severely disabled, "How
horrible. Perhaps she would be better off dead." In reality, however,
virtually all those who suffer from severe physical illness choose to
live. Suicidality in this population should be seen in the same light
as suicidality in others.
Both medical and legal treatment of suicidal individuals must be informed
by an awareness of clinical realities. Untreated depression has a natural
course of 6-8 months, and sometimes as much as 2 years [12,13].
Thus, there was a sound basis for the chief of psychiatry at Riverside
County General Hospital to state his refusal to consider, for at least
6 months, to honor Ms. Bouvia's wish to starve to death. In fact, it
took 7 months after her hospital admission for her depression to lift.
Approximately 15% of all cases of depression are chronic, and 40% - 50%
show one or more recurrences [12]—a fact that Ms. Bouvia
and those assisting her might wish to take into account in planning future
therapy. A major factor in the prognosis for depression appears to be
the ability to reconstitute the self-love that is undermined by the loss
of a mirroring relationship (i.e., one in which self-love is reflected
in the love one experiences as coming from another) [14].
One who has lost such a loving relationship, as Bouvia did, needs time
to mourn the loss before entering into a new relationship, therapeutic
or personal, that allows one to see oneself once again in a loving light.
Our experience in psychiatric practice and in the Program in Psychiatry
and the Law at the Massachusetts Mental Health Center (MMHC) in Boston
has taught us some useful lessons in the treatment of suicidal depression.
One of our teachers, a former superintendent of MMHC, used to offer suicidal
patients this kind of agreement: "It would be a shame to kill yourself
if depression is clouding your judgment. Let's try to get you undepressed.
If things don't improve for you and if you still feel the same way, I
know I won't be able to stop you from committing suicide." With
this formula the patient and the hospital can reach an understanding.
The patient agrees to a trial of treatment before making a final decision.
The hospital acknowledges the patient's right (and responsibility) ultimately
to make that decision.
There are several reasons for recommending such a therapeutic cooling
off period (of at least 6-months' duration) in cases such as that of
Elizabeth Bouvia.
First, it creates a situation around which a therapeutic alliance may
be established between the patient and the hospital [15],
which is obviously preferable to having the two work at cross purposes
in an adversarial legal proceeding. Most patients who choose death do
so because they feel profoundly and deeply alone and depleted of self-love.
A relationship with a caring clinician (such as Ms. Bouvia found in Barbara
Bradley) can be a first step towards reestablishing human contact. In
contrast, adversary proceedings, although aimed at protecting rights,
may increase—perhaps even fatally—the patient's sense of isolation, by
seeming to place the caretakers "against" the patient.
Second, the agreement respects the patient's dignity by allowing her to
hold on to the "last hope" that suicide represents for her.
By explicitly recognizing her power to make that choice in the future,
it undercuts her sense of helplessness.
Third, the stated goal of treating the patient's depression itself implies
that the patient can recover from this condition and indirectly communicates
the message that there is hope after all, thereby challenging the patient's
posture of hopelessness.
Fourth, and perhaps most critically, the delay can form the basis of a
standard to be applied by the courts in determining a patient's competence
to make life and death choices. The fact that the patient is "lucid" does
not in itself establish competency. In addition, the patient must be
able to make realistic predictions (allowing for uncertainty) about the
course of the illness. A person who suffers excruciating pain from an
incurable ailment may have good grounds for predicting that the pain
will never let up. A person who cannot see, however, that the meaning
and experience of his or her suffering can change with time is in no
position to choose realistically whether it is best to live or die. Someone
who will not wait to make an irrevocable decision, but instead denies
the uncertainty and the possibility of change that are inherent in experience
[16] is exhibiting precisely the sort of magical thinking
found in depression. Such a person cannot uncritically be called competent
to make a life or death decision.
These recommendations may be applied to the terminally ill as well as
the nonterminally ill depressed patient. Recently, the Program in Psychiatry
and the Law was consulted in the case of a socially isolated 55-year-old
man who had become acutely suicidal following a diagnosis of advanced
melanoma with a prognosis of 1 year maximum survival. The patient refused
treatment, was judged incompetent in a court hearing, and was treated
with electroconvulsive therapy for the psychiatric manifestations of
his depression. His response to this treatment allowed for the development
of a supportive relationship with his treating psychiatrist. In the year
that followed, the patient, although experiencing considerable physical
suffering, expressed his gratitude to the psychiatrist for relieving
the unbearable emotional anguish that had accompanied his initial suicide
attempt.
This case, as well as that of Ms. Bouvia, illustrates the difficulty of
trying to set social policy for a situation that cuts across medical,
psychiatric, and ethical boundaries. Knowing the patient and the intricacies
of his or her life situation is far more important in the determination
of the causes of suicidality than a simple statement of physical disability
or infirmity. Simply conceding that there is a right to die does not
mean acceding to the wish of each patient for suicide assistance. Rather,
the length and character of illness, the fact that the patient has presented
to the hospital in the first place, and a host of mitigating factors
must also be considered.
In many ways, the autonomous patient is a myth that has been used to try
and explain many models of medical decision making. However, a suicidal
patient who presents to the hospital in great distress is often seeking
an interaction, perhaps on an unconscious plane, that will help to either
confirm or deny a decision ambivalently made. Often, conflicts that are
presented as between the doctor and the patient or the hospital and the
patient are an expression of the internal conflict within the suicidal
patient. Social policy should allow the process of interaction and conflict
resolution to occur. Once again, the irreversibility of suicide argues
for the mildly heroic effort of keeping the patient alive long enough
to assess the full import of the decision.
Although the question of competence must be considered with the nonterminally
ill as well as the terminally ill depressed patient, one need not set
the same threshold for determining incompetence in the two cases [17].
For the nonterminally ill, a depressed state characterized by inability
to experience self-love, the love of others, and the possibility of change
(i.e., state-dependent pessimism) may be sufficient to raise the question.
For the terminally ill, one may wish to set a higher threshold, so that
the presence of psychotic features (e.g., frank paranoid delusions) would
be necessary.
We hope that the courts will not deem it necessary to confuse respect
for autonomy with respect for state-dependent, time-limited impulsivity.
When people do not have relationships that reflect normal self-love,
the choices they assert may represent temporary states of regression
rather than enduring, mature values. For many who suffer from depression,
true autonomy will be possible only in the context of a relationship
in which one can see oneself as an adult capable of mature, competent
choice.
The authors wish to acknowledge the helpful
comments of Samuel A. Bern, M.D., Sissela Bok, Ph.D., and Ms. Merloyd
Lawrence.
References
-
Bouvia v. County of Riverside: No. 159780,
Supreme Court, Riverside County, CA, Tr. 1238-1250, December 16,
1983
-
Goodman E: When the court must make a decision
on a patient's death wish. Boston Globe 21, February 9, 1984
-
Annas GJ: When suicide prevention becomes
brutality: The case of Elizabeth Bouvia. Hastings Center Report 20-21,
46, April 1984
-
Fischhoff B: Hindsight-foresight: The effect
of outcome knowledge on judgment under uncertainty. J Exp Psychol:
Hum Percept Perform 1:288-299, 1975
-
Maltsberger JT, Buie DH: The devices of suicide:
Revenge, riddance, and rebirth. Int Rev Psychoanal 7:61-72, 1980
-
Bursztajn H, Gutheil TG, Hamm RM, Brodsky
A: Subjective data and suicide
assessment in light of recent legal developments: II. Clinical uses
of legal standards in the interpretation of subjective data.
Int J Law Psychiatry 6:331-350, 1984
-
Abraham K: The first pregenital stage of the
libido (1916). In Abraham K (ed), Selected Papers on Psychoanalvses.
New York, Basic Books, 1960, pp. 248-279
-
Beck AT: Cognitive Therapy and Emotional Disorders.
New York, International Universities Press, 1976
-
Neuringer C, Lettieri DJ: Suicidal Women:
Their Thinking and Feeling Patterns. New York, Gardner Press, 1982
-
O'Keefe DL: Stolen Lightning: The Social
Theory of Magic. New York, Random House, 1982
-
End of starvation effort is reported. New
York Times A14, April 24, 1984
-
Klerman GL: Affective disorders. In Nicholi
AM (ed), The Harvard Guide to Modern Psychiatry. Cambridge, MA, Belknap
Press of the Harvard University Press, 1978, pp. 253-281
-
Robins E, Guze SB: Classification of affective
disorders. In Williams TA, Katz MM, Shield JA Jr (eds), Recent Advances
in the Psychobiology of the Depressive Illnesses. Washington, D.C.,
Government Printing Office, 1972
-
Kohut H: Thoughts on narcissism and narcissistic
rage. Psychoanal Study Child 27:360-400, 1972
-
Gutheil TG, Havens LL: The therapeutic alliance:
Contemporary meanings and confusions. Int Rev Psychoanal 6:467-481,
1979
-
Bursztajn H, Feinbloom RI, Hamm RM, Brodsky
A: Medical Choices, Medical Chances: How Patients,
Families, and Physicians Can Cope With Uncertainty. New York,
Delacorte, 1981.
-
Freedman B: Competence, marginal and otherwise:
Concepts and ethics. Int J Law Psychiatry 4:53-72, 1981