It’s an avalanche of blogging at the moment, rather. First I wrote this on the assumption that people with mental health problems have no right to choose to die and then my colleague and Twitter chum Huw (@Huwtube) collected some of his thoughts on the topic. Between this and discovering, in the past ten days, that three of my former patients have died recently, it’s all been rather death-heavy.
Lots of the people I work with want to die. Most of them are old; many have dementia. Some are housebound, or bedbound. They may no longer be continent. Lots have carers who wash and dress and feed them. Some are going blind. Good physical health can be a thing of the past. Frailty and infirmity are what they see coming towards them. Many are terrified.
I often ask the question ‘do you ever think about harming yourself?’ It’s rare my patients say ‘yes’, but many say ‘I want to die but I don’t know how to do it’. I’ve heard that statement more times than I can count but it’s always been something that’s puzzled me – so many of the people I have worked with have known exactly how to kill themselves that the naivety of not knowing almost brings me back to another reality; one which is not so skewed by the desire to not be alive anymore.
When I heard about my patients having died – all from natural causes – I was sad, but that was primarily because I knew their families and I knew that watching their loved one suffer had sometimes been a torment, particularly towards the end. A part of me also felt that at least the patient was no longer in a state they didn’t want to be in. I didn’t wish them dead but I certainly felt a sense of something – I can’t name it – that it was over. ‘It’. I don’t even know what I mean when I say ‘it’. ‘Illness’ seems a silly word; ‘life’ seems cruel’; ‘suffering’ seems pompous.
Perhaps this is why it is so hard to talk about this stuff. No matter how articulate you think you are, how verbose – and I am certainly verbose – the language can elude you. I can’t always describe what I think or how I feel, and that means I might be clumsy or say something ill-judged and then I worry dreadfully that I’ll be misconstrued. As I acknowledged in the post for Discursive, I worried a great deal how people would construe what I was trying to say. 1100 words is nothing on a topic of this magnitude and there is plenty to think about and plenty that needs to change (I freely admit that the comments on that piece are far superior to my original post and they are very much worth your time). What I said, essentially, was that people who find life to be unendurable have a right to an opinion on whether they should continue to live or die and that mental health professionals cannot simply tell them they have no right to die. Conversely, people in distress who express a wish to die should be given the emotional and practical help they need. Ideally, they’d get it long before it gets to that point, but that’s a blog for another day.
Life can be unendurable for many reasons. Classically, we see it through the ’emotional pain’ perspective, but, thinking sociopolitically, there is more to it. The assault on welfare and social housing and the cuts to services have served to make life unendurable for people who may well have been coping before 2010. People are dying and the State is responsible for their deaths. I understand that people who are in a desperate state and who see no way out might want to end their lives. I don’t consider that ‘insane’ in any way; I can see perfectly well that it may be a rational solution to a problem which appears to have few alternative solutions. The difficulty – or one of them, I suppose – is that surely a health professional who supports that wish to die becomes unwittingly part of some kind of social cleansing? But equally, unless you can actually change that person’s circumstances and improve their quality of life, is it not unethical to consign them to an indeterminate period of despair?
I don’t know how you decide if life is worth living or not; not really. And I also don’t know how you can ever come to an conclusion about whether someone else’s life is worth living. I tried having this conversation yesterday with someone and my suspicion is that she was slightly horrified that I – a health professional and a Muslim to boot – could even begin to talk about supporting people’s right to die. I don’t know what impact my being Muslim has on my view of the situation but I’ve always tried to be the kind of clinician whose work is about her patients rather than herself. I try to stick to ethics and my principles and I cannot state where they came from any more categorically than I can state where my desire to do this work came from. The point, dear reader, is that it is not about us as professionals. It is about our patients (the fact I am writing this as a professional has not escaped me). That doesn’t mean we cut our professional selves off from our personal selves, but it does mean we need to get over ourselves and think about what our patients are telling us and what they need more than what we need. Being a psychologist is not about meeting your own needs. It’s about meeting the needs of your patients. It’s obviously easy to type and harder to do, but there it is.
I don’t know how I square that last statement with my earlier statement on being ethical. But then, this post is littered with ‘I don’t know’ statements. And maybe that’s just how it is – we don’t know. We don’t know when someone’s life is worth living and when it is not, and maybe nor does the person who wants to die. And I don’t mean that to patronise; I mean that the future is unknowable and therefore everything we do is based on our best guesswork. In my job there’s a lot I don’t know. I don’t know if my therapeutic approach will work for you. I don’t know if I can help you. I don’t know if I can give you what you need. And sometimes I don’t know whether life or death is the better option. I don’t like to get things wrong, not when it comes to my patients. I want to help you first time round. I want to give you what you need. And so when it comes to life and death I want to get it right. But there are no guarantees. And that’s why, when you ask what I think, I can’t give you an answer. I simply don’t know.