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.


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