"How are you doing, Mr. Podolsky?"
"If I had a gun, I'd shoot myself."
Whatever I might think of Mr. Podolsky's right to shoot himself, as a pscyhologist who works in nursing homes, I have an obligation to snitch on him. All therapists have a legal duty to warn (and violate confidences) if we determine a person is a danger to himself or others. If Mr. Podolsky had merely said, "If I woke up dead, I'd be happy," he would still be in the realm of passive suicidal ideation, and I would not have the duty to warn. When Mr. Podolsky formulates a plan-no matter how far-fetched-I walk back to the nursing station and have to report it.
"I hate to do this, but Mr. Podolsky says he wants to kill himself."
I hate to do it because even though the nurses and I know a Podolsky suicide is highly unlikely, it means they have to put him on fifteen-minute checks-an aide peeks in, checks to see he's still alive, and makes a note of it in the chart. And the checks won't be discontinued until I or one of my colleagues certifies that Mr. Podolsky is no longer a potential danger to himself.
One of the few papers I found about suicidal behavior in nursing homes says it all in its title and brief abstract, "Suicide risk in frail elderly people relocated to nursing homes: In general, elders who consider suicide are over 85 years old, want to retain control of their lives, and have a high degree of self-esteem."
If I were to develop a theory of self-esteem, I'd put control or mastery on the top of the list. When one of my kids lies about having practiced her violin or refuses to do his homework, they are exerting control. When a prisoner in solitary confinement destroys everything in his cell-control. And when a nursing home resident expresses a desire to kill himself, it is an attempt to retain mastery of his immensely shrunken world. Today, I saw a resident, ninety-one, who is refusing his meds. They marked him down as noncompliant and demented. Rosofsky to the rescue, I found him certifiably noncompliant and certifiably nondemented.
Sometimes, I do a little good-retrieving someone from the scrap heap of dementia-that is, if anyone notices my evaluation.
"I don't need to take those pills to go to sleep, and if I don't want to, that's my business, none of theirs. If I want to lie awake all night tossing and turning, make them stop me." E.E. Cummings understood this in his poem of the conscientious objector, "i sing of Olaf glad and big," when he has Olaf exclaim, "there is some shit I will not eat."
Although our lives are at least partly in thrall to our parents, our peers, and our genes, human contentment rests on at least the illusion of control and mastery. Perhaps that is what is encapsulated in Dutch euthanasia. It maintains the illusion of control. Don't have a gun? We'll hand you the drugs. Too disabled to pop the pills? Open your mouth and we'll pop them in for you.
In the United States, there is Oregon and its Death with Dignity Act. This law does not go as far as the Dutch law, because it is limited to terminally ill patients. Intractable physical or psychic pan sufferers need not apply to die, as they can in the Netherlands. Oregon also doesn't allow your physician to assist you directly to die. The law simply allows your physician to prescribe lethal meds for you to take in the privacy of your own home-Socrates style, downing your hemlock with your disciples gathered around while you expound on the meaning of life as you descend into oblivion. You can go to the Oregon state government Web page and download the form-"Request for medication to end my life in a humane and dignified manner"-to apply for the lethal dose. It's kind of a penultimate testament in which you certify that you are of sound mind-if not of body. The law is silent about people who cannot administer the dose to themselves, although no doctor need be present: "Open up, Mom. Here are your last meds." Something about me loves the fact that the Web page asks you to check with your health insurer to see whether this is a covered procedure. Covered procedure? You bet. Suicide is the ultimate cost saver for managed care.
For all the political fuss about this law, terminally ill people are not exactly beating down death's door to get their lethal meds. Since the law was enacted in 1997, a total of 292 patients have kicked the legal suicide bucket. In 2006, for example, under the provisions of the law, there were forty-six deaths per ten thousand-0.0046 percent. In contrast, 2 percent of deaths in the Netherlands fall under the provisions of its euthanasia law.
This does not mean the law is unpopular in Oregon. A state referendum to repeal it went down when 60 percent of the electorate voted to keep it on the books. Perhaps this means that people like the idea that they can end it if they really want to. Perhaps it means that it's harder to get something off the books than to get it on the books in the first place. Several other states have failed to pass physician-assisted suicide voter referendums. Others have failed to enact legislation, and a few State Supreme Courts have decided that physician-assisted suicide is unconstitutional-but not the United States Supreme Court.
In 2006, by a 6-3 margin, it held that is was none of Attorney General Ashcroft's legal business to interfere in a medical procedure. The Supremes ruled that it was up to the states, on an individual basis, to decide if you can get the hemlock prescription.
So if you are terminally ill in Oregon, and want to die, lucky you. But if you are not in Oregon, are you out of luck? Not necessarily. It's not as easy as buying crack on your local street corner, but it's not impossible to get the benefits of Oregon's law without being an Oregonian.
First, if you are capable, you can easily find ways to do yourself in. Suicide research is all over the map, but there is evidence that people with cancer or AIDS, for example, have a significantly higher suicide rate than those who don't. A study in Finland found that women and men with cancer were respectively 1.3 and 1.9 times more likely to kill themselves than the general population. In my own state of Connecticut, a survey found that although men with cancer were 2.3 times more likely to kill themselves than the general population, there was no increase in likelihood of suicide in women. These are not unremarkable numbers. People like the reassurance of knowing they can do it, even if they never pull the trigger.
If you are too cowardly or do not have the means or capability of killing yourself, there is a fair amount of bootleg physician-assisted suicide outside Oregon. In the neighboring state of Washington, a survey found that 26 percent of physicians had received a request for assisted suicide, and that two-thirds of the physicians receiving a request had granted the wish. Among AIDS physicians, the requests are dramatically higher. A survey of San Francisco physicians treating AIDS revealed that 98 percent had been asked for suicide assistance. On average, about 4 percent of the surveyed had granted such requests, and some physicians had granted dozens of requests.
Should we try to dissuade medically or psychically distressed people from killing themselves? There is the argument, against Szasz, that people who are depressed who receive treatment are likely to decide against suicide. This argument is worthy of consideration as long as we don't fall into the circular reasoning trap that anyone who wants to commit suicide is depressed.
In "Physician-Assisted Suicide: The Influence of Psychosocial Issues," published in the journal Cancer Control in 1999, an oncologist and a psychologist, William Breitbart, M.D., and Barry D. Rosenfeld, Ph.D., write, "many terminally ill patients are likely to be experiencing a depression that may be both treatable as well as temporary." Temporary, of course, is a relative term when you are terminally ill, but Breitbart and Rosenfeld accept the idea that not all terminally ill people are depressed and that depression alone does not mean you are incapable of making a competent decision about your own death. They recommend the aggressive treatment of pain and depression, and then reevaluating whether the patient still wants to cash in his chips.
