In the wings

Suicidal thoughts are not uncommon in organic diseases of the brain, such as epilepsy, motor neuron disease, multiple sclerosis, strokes, and also some brain tumors. Changes in the brain disrupt normal functioning and alter personality, writes Meera Momtaz Sabeka

THE triumph of the 21st century could not overcome the fare of modern civilization. Suicide is a preventable public health problem and is the 10th leading cause of death. The World Health Organization estimates 7,000,000 deaths from suicide each year, 77% of which occur in low- and middle-income countries. Older men are particularly vulnerable to social, economic, mental and physical health-related risk factors. According to the Centers for Disease Control and Prevention, adult men aged 65 and older were the group with the highest suicide rate in 2016. Research suggests that most suicides are linked to mental health conditions, such as as major depression, psychosis, drug addiction. , anxiety and personality disorders. Negative childhood experiences have led to serious mental health issues and suicide in adulthood. Socio-economic circumstances also contribute to a large extent. Risk factors also include family history of psychiatric disorders, male gender, suicide attempts, more severe depression, hopelessness, and comorbidity.

The cumulative burdens of multiple physical illnesses, cognitive decline, financial loss and social isolation make older adults more vulnerable. People with chronic illnesses or incurable physical illnesses are often the cause of trauma and depression. Debilitating chronic diseases lead to long suffering, where there is no hope of recovery. Social isolation adds fuel to the fire. Life becomes a burden when people feel worthless and less worthy. Thus, they find themselves in a serious life crisis and in despair. Moreover, the lack of resilience and coping mechanisms of the elderly fail to redress the balance. In these circumstances, one may not wish to prolong the suffering. Suicidality is considered “a state of total pain which, together with neurological impairment, limits the perceived options to endure (suffering) or end total agony.” Researchers believe that this paradigm shift leads to suicide in older people. Here is an example of a suicide note written by an elderly man: “Death is a reality just as much as birth, growth, maturity and old age—it is a certainty. I don’t fear death as much as I fear the indignity of deterioration, addiction and hopeless pain…Dear family, I can’t take it anymore’

Studies reveal that suicidal ideation is not uncommon in organic brain diseases, such as epilepsy, motor neuron disease, multiple sclerosis, strokes, and also some brain tumors. Changes in the brain disrupt normal functioning and alter personality. Occasionally, startling evidence can be found behind seemingly grossly disturbed behavior. Famous neuroscientist David Eagleman mentions such an amazing story in his book, Brain: your story. In August 1966, a 25-year-old named Whitman killed several people indiscriminately, including his wife and mother. Before committing suicide, he left a note “…after my death, I would like an autopsy to be performed on me to see if there is any visible physical disorder”. Per his request, the autopsy was performed, the pathologist reported that Whitman had a small brain tumor. The tumor was in the amygdala, the part of the brain involved in fear and aggression. The pressure effect of the tumor resulted in actions that would otherwise be completely out of character. This might be an extreme example, but even small changes in the brain can lead to completely unexpected behavior.

In developed countries, the patient has the right to refuse treatment in the terminal phase. Often the decision to stop treatment is made by the doctor in the best interest of the patient. The idea is not to artificially prolong life which becomes a burden and less worthy. This is called ‘end-of-life care’ or ‘the fast track’. In hospice, care is provided to improve the lives of people with an incurable disease, however long it may be. People can choose to live at home, if there is enough support, or can choose to stay in palliative care on and off. Palliative care places a high value on the dignity, respect and wishes of the patient in order to meet all of their medical, emotional, social, psychological and spiritual needs.

In some countries such as Switzerland, the Netherlands, Spain, Austria, Canada, New Zealand and parts of Australia, assisted suicide is legal in cases of serious illness, the death of which is “reasonably foreseeable”. Conversely, these countries are committed to preventing suicide in mental disorders. In assisted suicide, the drug is self-administered, whereas the term voluntary euthanasia describes a doctor directly administering life-ending drugs to a patient who has given consent. Voluntary euthanasia is authorized in Belgium, Luxembourg, Canada and the Netherlands. In 2018, 104-year-old London-born scientist David Goodall flew from Australia to end his days in Switzerland. He was not terminally ill, but said the decision was prompted by his deteriorating quality of life. “My life has been pretty poor for about a year and I’m very happy to end it,” he said, surrounded by several family members. In England, these practices are illegal; however, in 2021 the British Medical Association reached a neutral position in this regard.

Life is a journey that ends in death. Life is beautiful as long as it deserves to be lived. There are many reasons behind suicide, each having a unique story that immediately breaks people in a society. Suicidal notes often only reveal the tip of the iceberg. A death cannot be judged when the biological and social reasons often exceed human perception and imagination. In most cases it is a disease of the brain or the mind rather than a crime. A patient with Parkinson’s disease once said to me “I don’t live, I exist”. The French philosopher Albert Camus rightly quoted: “But ultimately, it takes more courage to live than to kill yourself.

In my opinion, nature has its own course and people should not have the right to commit suicide. The slippery slope to assisted suicide is real; there had been many deaths in the name of ‘mercy killing’. The assumption that patients should have the right to die would impose on physicians a duty to kill. It is important to remember that the vast number of terminally ill people have found richness and purpose in life despite pain and hardship. Life should offer hope, there is always light at the end of the tunnel. The French biologist and philosopher Jean Rostand once said: “For my part, I believe that there is no life so degraded, degraded, deteriorated or impoverished that it does not deserve respect and does not deserve be defended with zeal and conviction.”

Dr Meera Momtaz Sabeka is Consultant Neurologist at William Harvey Hospital, Kent, England.

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