De. Jack Kevorkian of Detroit has been in the papers most days this past summer and autumn helping sick people kill themselves. He is said to receive hundreds of calls a week. Although his acts are illegal by statute and common law in Michigan, no one stops him. Many citizens, including members of three juries, believe he means well, perhaps thinking: Who knows? Just maybe, we ourselves shall need his services some day.
To me it looks like madness from every quarter. The patients are mad by definition in that they are suicidally depressed and demoralized; Dr. Kevorkian is "certifiable" in that his passions render him, as the state code specifies, "dangerous to others"; and the usually reliable people of Michigan are confused and anxious to the point of incoherence by terrors of choice that are everyday issues for doctors. These three disordered parties have converged, provoking a local epidemic of premature death.
Let me begin with the injured hosts of this epidemic, the patients mad by definition. At this writing, more than forty, as best we know, have submitted to Dr. Kevorkian's deadly charms. They came to him with a variety of medical conditions: Alzheimer's disease, multiple sclerosis, chronic pain, amyotrophic lateral sclerosis, cancer, drug addiction, and more. These are certainly disorders from which anyone might seek relief. But what kind of relief do patients with these conditions usually seek when they do not have a Dr. Kevorkian to extinguish their pain?
Both clinical experience and research on this question are extensive--and telling. A search for death does not accompany most terminal or progressive diseases. Pain-ridden patients customarily call doctors for remedies, not for termination of life. Physical incapacity, as with advanced arthritis, does not generate suicide. Even amyotrophic lateral sclerosis, or Lou Gehrig's disease, a harrowing condition I shall describe presently, is not associated with increased suicide amongst its sufferers. Most doctors learn these facts as they help patients and their families burdened by these conditions.
But we don't have to rely solely upon the testimonies of experienced physicians. Recently cancer patients in New England were asked about their attitudes toward death. The investigators--apparently surprised to discover a will to live when they expected to find an urge to die--reported in the Lancet (vol. 347, pp. 1805-1810, 1996) two striking findings. First, that cancer patients enduring pain were not inclined to want euthanasia or physician-assisted suicide. In fact, "patients actually experiencing pain were more likely to find euthanasia or physician-assisted suicide unacceptable." Second, those patients inclined toward suicide--whether in pain or not--were suffering from depression. As the investigators noted: "These data indicate a conflict between attitudes and possible practices related to euthanasia and physician-assisted suicide. These interventions were approved of for terminally ill patients with unremitting pain, but these are not the patients most likely to request such interventions. . . . There is some concern that with legislation of euthanasia or physician-assisted suicide non-psychiatric physicians, who generally have a poor ability to detect and treat depression, may allow life-ending interventions,when treatment of depression may be more appropriate." (Italics added to identify mealymouthed expressions: interventions means homicides, and some means that we investigators should stay cool in our concerns--after all, it's not we who are dying.)
None of this is news to psychiatrists who have studied suicides associated with medical illnesses. Depression, the driving force in most cases, comes in two varieties: symptomatic depression found as a feature of particular diseases--that is, as one of the several symptoms of that disease; and demoralization, the common state of mind of people in need of guidance but facing discouraging circumstances alone. Both forms of depression render patients vulnerable to feelings of hopelessness that, if not adequately confronted, may lead to suicide.
Let me first concentrate on the symptomatic depressions because an understanding of them illuminates much of the problem. By the term symptomatic, psychiatrists mean that with some physical diseases suicidal depression is one of the condition's characteristic features. Careful students of these diseases come to appreciate that this variety of depression is not to be accepted as a natural feeling of discouragement provoked by bad circumstances--that is, similar to the down-hearted state of, say, a bankrupt man or a grief-stricken widow. Instead the depression we are talking about here, with its beclouding of judgment, sense of misery, and suicidal inclinations, is a symptom identical in nature to the fevers, pains, or loss of energy that are signs of the disease itself.
A good and early example of the recognition of symptomatic depression is found in George Huntington's classical (1872) description of the disorder eventually named after him: Huntington's disease. Huntington had first seen the condition when he was a youth visiting patients with his father, a family doctor on Long Island. He noted that one of the characteristic features of the condition was "the tendency to ... that form of insanity which leads to suicide." Even now between 7 and 10 percent of non-hospitalized patients with Huntington's disease do succeed in killing themselves. Psychiatrists and neurologists have perceived that Parkinson's disease, multiple sclerosis, Alzheimer's disease, AIDS dementia, and some cerebral-vascular strokes all have this same tendency to provoke "that form of insanity which leads to suicide."
That these patients are insane is certain. They are overcome with a sense of hopelessness and despair, often with the delusional belief that they are in some way useless, burdensome, or even corrupt perpetrators of evil. One of my patients with Huntington's disease felt that Satan was dwelling within her and that she acted in accordance with his wishes. These patients lose their capacity to concentrate and reason, they have a pervasive and unremitting feeling of gloom, and a constant, even eager willingness to accept death. These characteristics of symptomatic depression recur in all the diseases mentioned above. Multiple sclerosis (MS) patients are frequently afflicted by it. Some five or six of Dr. Kevorkian's patients had MS.
The problematic nature of symptomatic depression goes beyond the painful state of mind of the patient. Other observers--such as family members and physicians--may well take the depressive's disturbed, indeed insane, point of view as a proper assessment of his or her situation. It was this point that Huntington, long before the time of modern anti-depressant treatment, wished to emphasize by identifying it as an insanity. He knew that failure to diagnose this feature will lead to the neglect of efforts to treat the patient properly and to protect him or her from suicide until the symptom remits.
Such neglect is a crucial blunder, because, whether the underlying condition is Huntington's disease, Alzheimer's disease, MS, or something else, modern anti-depressant treatment is usually effective at relieving the mood...