Putting Suicidal Psychiatric Patients to Death is not Compassionate

The current issue of the medical journal BMJ Open has a disturbing article on the euthanization of people who have mental illnesses. The authors are Belgian psychiatrists whose conception of what it means to be a mental health professional departs significantly from my own. Drs. Lieve Thienpont and Wim Distelmans have certified that suicidal people as young as 24 years old can ethically be put to death under the country’s euthanasia law because their psychiatric disorder (e.g., depression) causes “unbearable suffering”.

The argument for why this policy is compassionate runs as follows. Mental illnesses can make life extremely stressful, sad and challenging. Sometimes treatment helps only a little or not at all. If someone in such a situation wants to end it all, isn’t it therefore a kindness for the physician to step in and put the person to death painlessly and professionally rather than risk a suicide attempt that is painful or is botched?

Well, no, actually. Anyone who has treated people with psychiatric disorders knows that suicidal thoughts and impulses are nearly normative in the population. Many psychiatric patients say things like “I don’t see the point in living”, “I hate my life”, “I wish I had never born” etc., and they really mean it….right up to the point when they don’t. Every mental health professional knows people who have been miserable for years and are now doing well and very much want to be alive. Here is a concrete example, from John Colapinto’s recent New Yorker profile of my colleague Karl Deisseroth. Karl is treating a patient who is anonymized as “Sally”:

Sally, now in her sixties, had suffered since childhood from major depression, and had tried the standard treatments: counselling, medication, even electroconvulsive therapy. Nothing helped. She had spent much of her adult life in bed, and had twice attempted suicide. Seven years ago, she was referred to Deisseroth, who uses a combination of unusual medications and brain stimulation to treat autism and severe depression.

On Deisseroth’s advice, a surgeon implanted beneath Sally’s left collarbone a small, battery-powered device that regularly sends bursts of electricity into the vagus nerve, which carries the signal into a deep-brain structure that doctors think regulates mood. Originally developed for epilepsy, vagus-nerve stimulation has been approved by the Food and Drug Administration for use in the kind of treatment-resistant depression from which Sally suffers, but the exact reason for its effectiveness is not understood. Sally says that VNS has transformed her life, and that, apart from one period of “going pancake,” she has experienced just a few “dips.”

Drs. Thienpont and Distelmans might argue that this is an unfair example: A new treatment is being employed and there’s no way anyone could have predicted that Sally would be so helped by it. But that is precisely the point: It’s always very hard to predict the course of a person’s illness and even moreso the course of their life. No matter how sure Dr. Thienponts and Distelmans may subjectively feel that a psychiatric patient has a life of unending misery in front of them, they are going to be wrong at least some of the time.

A defender of the Belgium law might retort that safeguards are in place to ensure that the decision to euthanize isn’t just based on one psychiatrist’s opinion. Chuck Lane demolishes that rebuttal by pointing out that the committee which is charged with making sure that people like Dr. Distelmans do not engage in unethical euthanasia is co-chaired by…Dr. Distelmans.

An irony struck me as I re-read the Calapinto’s profile of Karl Deisseroth: “He accepts only patients for whom all other treatments have failed.” Drs. Thienpont and Distelmans say the same thing of themselves. If you or your loved one had a serious, hard to treat psychiatric disorder, which doctor would you want to see?

Must we put their names in lights (again)?

Some things never change. When I saw the coverage of the recent Virginia killings, I was reminded of this January 2011 post on related matters.

Must we put their names in lights?

I haven’t posted much on the Arizona killings. The enormity of the tragedy demands a respectful silence, unless one actually has something useful to say. Most everything constructive I would say has already been said by someone else with greater force than I would muster.

I would mention again the importance of long-term care and rehabilitative medicine. The typical 9mm bullet is quite adequate to lacerate human body parts, sometimes beyond repair. Every day, thousands of doctors, nurses, physical therapists, try to repair these lacerating wounds, and try to repair over months and years the human lives lacerated by such gun violence. Most of these men and women labor in relative obscurity. I happen to be away delivering a talk at a VA facility where some of these professionals do their work. Their faces rarely grace the front page of your local newspaper. There just isn’t the space to honor everyone who deserves it.

I’ll bet that your local newspaper found the space for this crazed mug shot of Jared Lee Loughner, the disturbed young man who apparently committed mass murder. He’s gotten his fifteen minutes, which I suspect is what he really wanted: to see his name and his picture in lights.

Can we not do that?

Much in our popular culture—from Silence of the Lambs, to Nancy Grace, ironically, to the death penalty itself—creates in some people an enticing motive for atrocity. Shoot someone famous, and you’ll end up an (anti) celebrity, on the cover of People or Newsweek. That’s a heck of a lot easier than finding the cure for AIDS, winning an NBA championship or “Dancing with the Stars,” not to mention accomplishing the intricate repair of brain tissue damaged by a 9mm round.

I wish there were a way to shun mass murderers the way we shun grimy child molesters. We should know who they are. The police, forensic experts, and the court system should do what they need to do. Yet I wish we lived in a world in which the rest of us gave this necessary work a little more distance and private space, in which it’s considered rather distasteful, even disgusting to publicize without some very good reason the little people who commit huge crimes.

I can’t prove what I believe. If we stopped rewarding these criminals with the massive publicity, we might have somewhat fewer of these atrocities.

O tempora! O Associated Press!

I haven’t been following the St. Paul’s School rape case. Apparently a senior boy told his buddies he’d had sex with a freshman girl when the girl was 15; seducing freshmen seems to have been considered a badge of honor among seniors. He was charged not only with sex with a minor but also with rape; the girl claimed he forced himself on her. He asserted that everything was consensual and stopped short of full intercourse.

The jury convicted him of sex with a minor (a misdemeanor) and using a computer to seduce a minor (weirdly, a felony) but acquitted him of rape.

Rather than lamenting the sexual mores of the rising generation, I want to lament its journalistic standards.

The Washington Post, which in my youth was a newspaper, with reporters and editors, where at least some of the reporters knew something about the topics they covered and at least some of the editors tried to keep obvious falsehoods out of the paper, ran an AP story that included the following sentence:

The jury by its verdict Friday signaled they didn’t believe Labrie’s assertions that he and the girl didn’t have intercourse but also didn’t believe her contention that it was against her will.

No, no, no, no, NO!

The jury “signaled” no such thing. Assuming that the jurors were following instructions, the verdict means that they were unanimously convinced beyond reasonable doubt that the accused penetrated a minor but were not convinced beyond reasonable doubt she had not consented. They could have all gone home saying “Yeah, seems way more likely than not that he forced her, but in a swearing contest it’s hard to be morally certain.” (Of course it’s also possible that the verdict was a compromise among conflicting jurors, which is against the rules but isn’t unknown.)

The more I think about this, the angrier I get. The victim, having been victimized once by the older boy and again by the criminal justice process, now suffers a gratuitous third victimization from the AP and the WaPo, which proclaim to the entire word, indelibly, that a jury found her to be a liar, when in fact it did not.

It seems implausible that there will be a retraction – not that it would do much good – and impossible that she can successfully sue for damages, since for this purpose she’s a “public figure” under the precedent in N.Y. Times v. Sullivan.. Why should reporters, editors, and publishers be allowed to negligently damage people by failing to do their job up to professional standards of competence, and escape scott-free? Note that this isn’t a matter of opinion; what the story says about the meaning of a “not guilty” verdict is simply wrong.

Apparently the strongest evidence against the accused was his own post-incident boasting to his classmates. He and his lawyer had to claim at trial that the boy was bragging about molesting an underage girl but hadn’t actually done so. Who knows? It might even be true. But it isn’t hard to see how the jury could dismiss that claim as far-fetched while remaining in some doubt on the consent question.  

The whole thing – more carefully described in this New York Times story – makes me wonder just how far New Hampshire law allows an eighteen-year-old to go with a fifteen-year old. And, as always, I wonder what a just sentence would look like for what the defendant was convicted of doing, rather than for the even worse thing he may well have actually done.

Weekend Film Recommendation: A Civil Action

The courtroom drama can be a pretty tired plot vehicle for many, perhaps justifiably so. It sometimes seems that the clichés are so well rehearsed that even the counter-clichés appear just as threadbare: people redeeming themselves through the law (e.g., see here and here) are about as compelling as people damning themselves because of it (e.g., see here and here). In this weekend’s film recommendation, Steven Zaillian’s A Civil Action, there’s no attempt to play around with or develop those clichés. Nonetheless, the true story from which this dramatization is lifted is more than enough to hold your attention.

John Travolta plays Jan Schlichtmann, a Boston-based personal injury lawyer. It doesn’t take long to develop an unflattering opinion of Schlichtmann: no sooner has he dismissed the charge of being a mere ‘ambulance chaser’ than he is distributing business cards to car crash victims as he passes by them on the street. There’s no question that Schlichtmann is in it for the money, as he’ll leap to consider the depths of his clients’ pockets—or those of his wretched opponents—far sooner than he will consider the probity of his legal arguments. He’s a money-grubbing lawyer of the scummiest kind.

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Schlichtmann receives a phone call from the distressed mother of a recently deceased child. She entreats him to visit her and the parents of seven other recently deceased children—all taken by leukemia—in the nearby town of Woburn. Schlichtmann’s initial inclination is to decline because of the prospect of a paltry payout; it’s just not good business, as far as he’s concerned. But the suspicion of a huge payout from a big name corporation’s toxic dump upstream spurs him to take the case and pursue it feverishly.

After the initial premise is set, surprisingly little focus is then spent on the film’s original motivations, namely Schlichtmann’s efforts to uncover malfeasance and the thorny mismatch between his venality and his clients’ desire for no more than a formal apology.

Instead, the film’s pace and tone pivots to Schlichtmann’s sparring with the opposing counsel Jerry Facher, played by Robert Duvall. Duvall is as superb as expected, with an understated and unplaceably buffoonish villainy to his demeanor. Facher’s free time is spent lecturing at Harvard, where he delights in instructing his students on how to avoid the very traps in litigation that he has set for Schlichtmann. While Schlichtmann has flair and flourish, Facher has cunning and wile.

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The conceit pitting these two lawyerly styles against one another doesn’t translate into the courtroom bombastics that might typically be expected from late-‘90s Hollywood. However, the juxtaposition of the two characters sets up a nicely developed theme, which recurs throughout the film, of the centrality of prestige and class in the law. It goes to show that it’s not so much the substance of the arguments, and in some instances it’s not even the skill of their delivery, that wins the day; sometimes, the gates remain closed simply because you’re just not cut from the right cloth to compete among the big boys (and boys is accurate—the supporting cast, though tremendous, is almost exclusively male). As Keith pointed out so well in his review of The Spy Who Came in from the Cold, even when at their most subtle these observations on class can be used to devastating effect: Facher has few scruples parading his old-money connections with the judge (a delightfully crabby John Lithgow) for all to see, just as Schlichtmann is evidently perturbed by his dull Cornell pedigree among the Harvard muckety-mucks.

Of course, all of this is merely a prelude to learning that the Woburn case isn’t really the film’s point at all. Rather, it’s Schlichtmann’s search for purpose and his journey toward redemption after his colossal abdication of moral sense at the film’s outset. That journey is troubled and arduous, and he has few compunctions with endangering the livelihoods of his partners in the process.

As mentioned, the supporting cast is a treat. It includes Sydney Pollack, Stephen Fry, William H. Macy, Kathleen Quinlan, Tony Shalhoub, Dan Hedaya, and James Gandolfini in a much more tender role than the macho kind for which he was traditionally associated (e.g., see my reviews of True Romance and In the Loop).

How does Donald Trump get away with it?

My fellow chattering-class members are both amused and deeply puzzled by the Donald Trump phenomenon, as most of us were by the George W. Bush phenomenon (before all those corpses in Iraq drained it of its amusement value). How do people who spout what is, to us, obvious gibberish avoid being laughed at?

The answer, it seems to me, is as obvious as it is depressing. What all of us who think for a living really believe in, even more deeply than our most dearly held principles and prejudices, is the Principle of Noncontradiction. If one of us says X, he’s not going to turn around and say not-X (about the same aspect of the same situation) without changing his mind. [And yes, that includes Rortyans and Taoists.]

This is related to a deeper notion: that regardless of what anyone says or thinks, the real world is at least partially knowable, and that it’s therefore possible (and undesirable) to have a false belief.  [The Rortyans claim to disbelieve this, but I've never been able to understand what they're trying to say. Rorty may be wrong, but as a writer he's the opposite of slipshod.]

But that simple commitment to not talking nonsense is a minority taste, outside working hours. Yes, the minority that has that taste is in some ways dominant; since you can’t build either arguments or dams that hold water without observing it, both our lawyers and our civil engineers  observe noncontradiction in their professional lives. That applies to anyone who actually has to reason accurately – either to make stuff work or to convince sensible decision-makers – with respect to the things he or she has to reason accurately about. Even people whose stock-in-trade is deception – con artists, stockbrokers, lobbyists – have to observe the rules of arithmetic when it comes to totting up the take.  And even a young-earth creationist has to suspend his Sunday beliefs while working as a petroleum geologist.

Most of the time,  though, people aren’t at work, and much of what they think and talk about has little if any relevance to practical decisions in their own non-working lives.  Freed of the need to think rationally, most people seem to prefer the alternative. (That’s called “sports talk radio.”) And lots of them don’t mind if their politicians act the same way, especially when reciting some self-evident falsehood can be depicted as showing “loyalty” or some other virtue.

The deepest mistake is to regard someone who acts as if he doesn’t give a damn whether anything he says is true, or consistent with what he said yesterday, as stupid. That’s the mistake many liberals made (and some still make) about George W.

As far as I can tell, Donald Trump simply isn’t bothered by holding and expressing utterly inconsistent beliefs about immigration, or for that matter denying obvious facts in the face of the crowd that witnessed them. Of course Trump is going to say the Bible is the most important book to him, and of course his voters are going to expect him to say it: doing so demonstrates piety. The fact that he can’t cite a single verse doesn’t bother him; that’s in a different mental compartment. And it doesn’t much bother most of his voters, either.

From the viewpoint of civic virtue, this is horrifying; as George Bernard Shaw once said, democracy will never be a really practical form of government until the man on the street resents a fallacy as much as an insult. But it is a fact. And if we deal with it by imagining that Trump, or Trump voters, are “stupid,” we’re going to make some very bad predictions.


Update Of course Francis Bacon said most of this first, and better. Too bad his rather Latinate prose is just about half a century too early to be easily read by the average college student.







Fr. Jeremy Paretsky, O.P., on the knowledge of God

The last time I visited New York as a mere tourist before my promotion to citizen, I had the privilege of hearing what I – as an orthodox unbeliever – thought was a superb sermon by my old friend Jeremy Paretsky at St. Vincent Ferrer, the lovely Dominican church in the East 60s.

Now, my judgment might have been biased by friendship, but Mike O’Hare – a tough critic, and (if possible) even futher from being a Christian than I am – agreed with me that the sermon was a perfect specimen of its kind.

Jeremy was kind enough to expand the notes he spoke from into a full document, and to permit me to reproduce it below. On the off-chance that some RBC readers might not have the entire Bible memorized, I have provided the four readings for the day as a prologue.

The Texts

Job 38

Then the Lord answered Job out of the whirlwind, and said, Who is this that darkeneth counsel by words without knowledge?

Gird up now thy loins like a man; for I will demand of thee, and answer thou me.

Where wast thou when I laid the foundations of the earth? declare, if thou hast understanding, who hath laid the measures thereof, if thou knowest? or who hath stretched the line upon it? Whereupon are the foundations thereof fastened? or who laid the corner stone thereof, when the morning stars sang together, and all the sons of God shouted for joy?

Or who shut up the sea with doors, when it brake forth, as if it had issued out of the womb? When I made the cloud the garment thereof, and thick darkness a swaddling band for it, and brake up for it my decreed place, and set bars and doors, and said, “Hitherto shalt thou come, but no further: and here shall thy proud waves be stayed?”

Psalm 107

They that go down to the sea in ships, that do business in great waters; these see the works of the Lord, and his wonders in the deep. 

For he commandeth, and raiseth the stormy wind, which lifteth up the waves thereof.

They mount up to the heaven, they go down again to the depths: their soul is melted because of trouble. They reel to and fro, and stagger like a drunken man, and are at their wit’s end. Then they cry unto the Lord in their trouble, and he bringeth them out of their distresses. He maketh the storm a calm, so that the waves thereof are still.

Then are they glad because they be quiet; so he bringeth them unto their desired haven. Oh that men would praise the Lord for his goodness, and for his wonderful works to the children of men!

II Corinthians 5

For the love of Christ constraineth us; because we thus judge, that if one died for all, then were all dead:

And that he died for all, that they which live should not henceforth live unto themselves, but unto him which died for them, and rose again.

Wherefore henceforth know we no man after the flesh: yea, though we have known Christ after the flesh, yet now henceforth know we him no more.

Therefore if any man be in Christ, he is a new creature: old things are passed away; behold, all things are become new.

Mark 4

And with many such parables spake he the word unto them, as they were able to hear it. But without a parable spake he not unto them: and when they were alone, he expounded all things to his disciples.

And the same day, when the even was come, he saith unto them, Let us pass over unto the other side. And when they had sent away the multitude, they took him even as he was in the ship. And there were also with him other little ships.

And there arose a great storm of wind, and the waves beat into the ship, so that it was now full. And he was in the hinder part of the ship, asleep on a pillow: and they awake him, and say unto him, Master, carest thou not that we perish?

And he arose, and rebuked the wind, and said unto the sea, Peace, be still. And the wind ceased, and there was a great calm.

And he said unto them, Why are ye so fearful? how is it that ye have no faith?

And they feared exceedingly, and said one to another, What manner of man is this, that even the wind and the sea obey him?

How Do We Know God?

How do we know God? Is it even possible to know God?

Well, how do I know the world?

Through observation and experience, although sometimes observation and experience are misleading. The sun rises, the sun sets, but I have to learn that it is the earth’s rotation that creates the illusion. I don’t see microorganisms or blood corpuscles except with the aid of a microscope, so that only in comparatively recent times have people been aware of a vast invisible world, and the existence of sub-atomic particles have to be inferred.

And when it comes to people, how do I know another person? In dealing with other people I can evaluate experience, deduce consequences of interaction. But observation is misleading and sometimes we find what we expect to find, prejudices determining our conclusions: is that another person or a creation of my imagination?

In a general way I know another human being because we have the power to bond with one another, to love one another, to enter into one another’s lives. We are all in some ways alike, have something in common – humanity – and know the common human experiences of hope and fear, of hatred and of love.

To truly know I have to be on the inside, find what is common, what is different and what bridges the differences – our common humanity containing sometimes more than we would like to admit. If we do admit the common that
bridges our difference, we can become like the other, like knowing like.

So, back to my first question: How do we, can we know God?

Who and what am I looking for? Job thought he knew God, thought God was just as he imagined him, that he was like knowing like, but every step he took
towards the God he thought he knew increased his bewilderment, his anguish, as he went from being a man who was comfortable with the god who rewarded him for his piety to one who experienced God as raw power, even fearful, bestial, if not outright demonic in his ability to overturn an entire universe.

With each stage of his attempt to confront God Job has to deal with a god created by the human imagination, and must learn that each new “god” is not God. Only when Job strips away from his experience all that is not God,
only when he exhausts all his human knowledge and power, can he meet the voice that speaks from the depths of the unknown in the uncontrollable, ungraspable whirlwind. The voice from the whirlwind taunts, both to put down and to build up.

To know God, unlike must be remade, so God accords Job the dignity of assuming he is like God. He isn’t, but he is still in God’s image, so Job learns what he is and what he is not, when he learns who God is and who God is not.

The disciples in the boat face a similar problem: they thought that Jesus was like them, and so the disciples felt that they understood him, knew all about this man that anyone needed to know. But in a single night their world was overturned. His voice spoke into the whirlwind (the whirlwind out of which God’s voice spoke to Job), the voice which had spoken at the beginning of creation and which continues to echo down through the ages, fashioning creation ever anew.

The voice that spoke to calm the wind and the waves is the voice that makes us all a new creation. There is a great calm. Suddenly the familiar became unfamiliar – who is this?

St. Paul says, “From now on we regard no one from a human point of view; even though we once regarded Christ from a human point of view, we regard him thus no longer.”

There was a time in my life when I regarded Christ from a human point of view, indeed regarded God from a human point of view – there was
nothing to know, no one to know. And if Jesus existed, he was misinterpreted by the church that arose after him, or else he was simply crazy. In short, I recognized nothing in common with God, with Jesus. In my late teens I was first seduced by the desire to know how it was that I could reason and how it was I could insist on a moral universe, that there was really Good and Evil.

When I eventually came up against a wall, I pounded on it and demanded to know if there was anyone on the other side. The answer spoke into my chaos.
It created a new relationship, and in so doing established how alike we are: able to use reason, to create, to know good and evil. Only later did I come to accept that in Christ’s humanity we share the common knowledge of human hope and fear and suffering and love.

In Christ the part of our humanity that is unlike God is remade. Christ knows us as like knowing like, knows God as like knowing like, and puts us into a new
relationship with God. My life has never been the same. Your life has never been the same. A new way of being brought about a new way of knowing, and all of us who now exist in a new way, and know in a new way, can know the hand of God that touches us.

At the edge of our experience, when we have exhausted all strength, realized the limits of human knowledge, the limits of human life, there is where we encounter that ungraspable unknown – the ancient power speaking to us from the heart of the whirlwind. It is this power that the disciples witnessed.

Yet the marvel of God’s saving act is that all that unlimited power and knowledge and life enters into our created world as the calm after the storm. We are not given a name in answer to our question – “who is this?” – but the calm which contains the power of the Name of God, who says that from now on in Christ we have a shared history with God – it is this Name of God which enters into our very humanity in order to make us new creatures, new beings with new ways of knowing: like knowing like, man knowing man, God knowing God.

If we try to control him, we are repulsed by the terrifying storm; if we let the unknown in and let it embrace us, we enter the peace and consolation beyond all understanding.

I admire Campaign Zero. Here’s how I would augment it

It’s been obvious for a while now that the Black Lives Matter movement would benefit from a concrete policy agenda around which it could focus its organizing, public protest, and practical negotiations with public officials. Developing such an agenda is no easy task — especially for a grassroots movement that basically came into existence a year ago.Black Lives Matter took an admirable step forward on this front, however, thanks to the new Campaign Zero documents released Friday, co-authored by a group including DeRay Mckesson and Johnetta Elzie (a.k.a. “Netta”), two of the movement’s leading activists.

Jesse Singal, over at New York‘s Science of Us, asked for my thoughts on their recommendations to reduce police violence. I admired their well-crafted and specific proposals. I hope in their future work that they will layer on a more positive vision of urban policing and link their efforts to an active public safety agenda.

More on how they might do that, here.