Time to Go?

In earlier editions of this blog I have written about the long-standing mental health challenges that the cyclist Graeme Obree has struggled with since his youth, and how close he came as a teenager to taking his own life, as well as subsequent serious attempts on his own life.

The reason I return to the topic of suicide in this week’s edition is that the subject of Physician Assisted Suicide has been in the news recently. While it is beyond the scope of this blog to examine the issue from the point of view of severely physically disabled people
whose only recourse at present is to travel to a clinic in Switzerland to end their lives free from the threat of prosecution, the issue is worth an extended examination in relation to mentally ill people.

I wish to look at the topic from the point of view of depressed patients with severe, chronic clinical depression who have proven to be ‘treatment – resistant’. Should Physician Assisted Suicide be permitted in such cases?

As some one who has been plagued by suicidal thoughts for years, and has made one (somewhat half-hearted) attempt in the past, I feel that I am well placed to talk about
this issue.

For me, cycling has played a key part in my recovery; it is a key component of what
keeps me pedalling across the cobblestones of life. But it has also played an intimate part in my suicidal ideation over the years. About three months after I had first been diagnosed with depression back in the spring of 2001, it was while cycling in the middle of the night along the seafront that I left my bike and staggered across the pebbles towards the soothing sound of the surf. As impulsively as I had made for a watery grave, I turned back at the last moment, and hurtled away from the water’s edge on my bicycle like a flame in the darkness. Last summer, while on a cycling holiday in France with my son, it took all my strength not to guide my bicycle into the path of traffic as it whizzed by in the opposite
direction.

For me, my suicidal thoughts and behaviour are rooted firmly in the impulsivity that comes with my sharply varying moods. ‘It seemed like a good idea at the time’ has a powerful, almost irresistible energy to it, and what drives my mind, and ultimately my body, towards death. At the same time, it is cycling that has, without a shadow of
doubt kept me on the planet, when all else seemed lost, adrift, dragging me away from the shore by a seductive under-current of impulsive, joyful despair. It is these feelings that make up the sinews of my constant companion, Bi Polar Affective Disorder 2 with mixed symptoms, to give it its pompous title.

So what of someone who has suffered chronic, treatment – resistant severe depression?One of the times that a person who is suicidal is most vulnerable to taking their own life is not, in fact,when they are at their lowest point, deep in the pit of despair, disconnected from the world.  No, it is rather at the point when strength, life, returns to such a person, giving them the wherewithal to take matters into their own hands, that they are most likely to act.

One aspect of the issue of Physician Assisted Suicide that is central to the discussion is whether or not the person is of sound mind.

(Socrates put to death by his own hand in 399 B.C.E.  for ‘corrupting the minds of the young’ drinks hemlock with no regrets; he had declared that ‘the unexmined life is not worth living’.)

While Socrates’ death was ordered by the court, he died by his own hand, rational to the end.

This raises the question: can suicide ever be seen as a rational choice?

Throughout Jewish history the act of suicide has provoked much debate. According to the Halacha (Jewish law) it is prohibited. The person is not allowed to be buried together with his fellow Jews, but in a separate section, apart from the community. This severe approach
is a tempered by the need for the person to have been of sound mind when the
decision was made, where it could be shown that this was not the case, then leniency is shown. This was the case when the renowned author, holocaust survivor Primo Levi, died by his own hand in 1987. The Italian rabbinate declared that Levi – who had a history of severe depression dating back to before the holocaust, and his incarceration in the Nazi death camp Auschwitz-Birkenau – to be a victim of the genocide that had engulfed European Jewry over four decades earlier.

During the Jewish revolt against Roman rule in the years 67-70 C.E a group of devout Jews committed an act of mass suicide/murder rather than be taken into captivity from Masada, their mountain – top desert fortress. To this day these men, women and children are revered as martyrs in Jewish lore. Was their murder/suicide a rational act?

In the aftermath of the nationwide destruction instigated by the Nazis of Jewish property during Kristallnacht (‘Night of Broken Glass’) on the night of 9/10 November 1938,
there was a spate of suicides amongst the Jewish community across Germany. Was
their suicidal response irrational? What of the prisoners of the death camps who threw themselves against the electrified fences that surrounded those factories of death? Was theirs a rational act, given the circumstances?

During the holocaust there were numerous acts of resistance that were met with inevitable
death. These people are considered martyrs.

So, suicide is sometimes seen as the honourable thing to do. The phrase ‘to fall on one’s sword’ is taken from the biblical account of King Saul’s death. Suicide in Japanese culture has honour attached to it certain circumstances, too.

In my professional life as a Peer Supporter I offer hope to people without hope, who
feel adrift from who they once were. My job is to connect with people who are struggling with severe and enduring mental health challenges. I am there to remind people that they are worthwhile, they do have a lot to offer, and that the world would be a poorer place without them. Suicide prevention, then, is clearly part of my role.

How does that sit with over-powering feelings that I have that suicide is an attractive option, and one that without which life would be beyond me Why would depressed people need physician-assisted suicide – wouldn’t they just kill themselves, anyway?

Yes and no.

While it is true that some people will take their own lives, and it is difficult to stop someone who is living in the community from taking this step, it’s not true for everyone.

One aspect of suicide that is often overlooked is the failed suicide. When I worked in a
mental health day centre in London around the turn of the century, one of the people who used the service was someone who had tried to take his own life by throwing himself in front of a tube train. As a result of this attempt he was left with brain damage, slurred his words, and he walked with a limp. His behaviour could be erratic – he would steal a car or a motorbike and take it across the channel and drive it through France or Germany, until it broke down, or he crashed it. While it was difficult to ascertain this person’s wishes after his suicide attempt, due to his brain injuries, the point is this; Not all attempts are ‘successful’. Not everyone who throws themselves off a cliff dies. Some suffer horrific injuries that mean a life of physical paralysis, with no prospect of taking their fate into their own hands again. So, a trip to the Swiss clinic is the only option, if a prosecution under the Suicide Act 1961 is to be avoided.

If physical incapacity, such as paralysis, is a good argument for physician assisted suicide, then what about people who suffer from mental incapacity? I can hear the argument that chronic, treatment-resistant depression means that the person has lost the ability to  reason in a way that someone who is physically incapacitated has not. However, this presupposes the idea that a person who is severely physically incapacitated has not lost the ability for lucid, rational thought. Too often doctors who treat severely depressed people take the  view that the person’s views are clouded by the depression. While this may be true
of people who suffer psychosis, it is not true of everyone.

Some of us think that the world we see when we are depressed is the ‘real’ world and it is unbearably painful to be there. Our experience is like an open wound with little or no relief. What of those people I refered to above who took their lives rather than be taken into slavery, or bear the indignities of an increasingly hostile totalitarian regime? Those are world views that many would call rational and accurate. So, why not the world view of someone with severe depression? Is their view of their surroundings wrong by definition, or is it more complex than that?

The recent study on suicide among people suffering from chronic conditions, a spectrum including both terminal cancer and diabetes, concludes: ‘The consultation calls upon health-care professionls to be alert to mental health issues, especially depression, in
the patients that they see for known physical problems, and take the right steps to help people with long-term conditions have a better quality of life.’

Ample make this Bed —
Make this Bed with Awe —
In it wait till Judgment break
Excellent and Fair.

Be its Mattress straight —
Be its Pillow round —
Let no Sunrise’ yellow noise
Interrupt this Ground

Emily Dickinson (1830 – 1886)

www.samaritans.org 08457 90 90 90