More sermon prep.
Jun. 23rd, 2010 11:49 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
rivkaMy sermon draft is already 2000 words long and I'm just developing the religious theme now. I've decided to carry it through to the end and then make drastic cuts, instead of trying to shorten it as I go. There's a lot that I know and believe and think that doesn't need to make it into the sermon. I'm pretty sure I'll have to get all of it said before I can figure out which pieces are sermon-shaped.
I'm going to keep posting bits. Feel free to disagree or ask questions or, you know, flounder with the issue; it helps me formulate my thoughts. At this point it's probably not useful to tell me what you think I should leave out or to comment on matters of style. I'm not there yet. I'm just getting it all out.
2. David Kissane and therapy for the dying.
I’m going to admit straight up that I didn’t know what I was doing when I worked with Ray. I knew how to treat depression, but I didn’t know how to do it without the promise of a better life afterward. Ray lived much, much longer than the doctors predicted – perhaps because he willed himself to; I don’t know – but I couldn’t do all the things I knew how to do: entice him with visions of useful work, fun, social relationships, romance, once the shadow of depression was lifted. Even when he was better he was still dying. Ray and I had to grope our way through that without an instruction manual.
A year or so after Ray’s death I went to a conference about psychosocial aspects of cancer care and I heard a presentation by an Australian psychiatrist named David Kissane. Dr. Kissane identified a set of symptoms that are common among persons with terminal illness: hopelessness, the loss of a sense of meaning in life, a feeling of powerlessness, fear of loss of dignity, fear of burdening others. He called these symptoms "demoralization syndrome:" loss of morale on the profoundest level. These feelings of hopelessness and powerlessness, he said, inevitably resulted in a desire to die or to commit suicide.
These feelings of demoralization – hopelessness, powerlessness, fear of losing dignity – may seem to some to be intrinsic to the process of dying. Of course, if you’re dying, why wouldn’t you be demoralized? But in fact, not everyone is. And second: Dr. Kissane was able to develop a psychotherapy that successfully treated demoralization syndrome. It was specifically designed to help people reflect on the meaning of their life and on their legacy – and we’re not necessarily talking about anything huge; I remember that he said, "for some people, it’s that they have a really good borscht recipe, one they want to hand down to their family." He would help people craft a sense of their legacy, his assistants would write down what they came up with, and they’d make it into a beautiful little book and present it to the dying person, so they could share their legacy with their families and friends.
And the thing is: repeatedly, he found that this kind of psychotherapy cured people of the desire for assisted suicide.
3. So...
So it turns out that terminally ill or severely disabled people who want to commit suicide aren’t actually different from anyone else who wants to commit suicide. They are suffering. Their suffering is responsive to treatment. And when they receive appropriate treatment, they lose the desire for suicide.
What does this mean for the assisted suicide movement?
And why did it take so long – some thirty years after the assisted suicide movement began – for anyone to study ill people who wanted to die and figure out what was wrong with them, and what could help them want the time they had remaining? Why weren’t those obvious questions from the start?
4. Things I know about suicide.
I started talking around in my social circle about this sermon I was going to give, and someone said to me very earnestly: “Rebecca, what you may not realize is that I’ve talked to some of these people and they do genuinely want to die. They have logical reasons.”
I don’t think she knew what I do in my work life. I’m not a licensed psychologist – I do clinical research instead – but over the years I have talked to many, many suicidal people, and they always have reasons. Their reasons are always compelling to them, and sometimes they are persuasive enough that they sound pretty compelling to me too. It was for good cause that psychiatrist Aaron Beck said in his famous treatment manual for depression that if you ever find yourself agreeing that your client’s situation is hopeless, it’s a sign that you’ve gotten sucked into their irrational thinking.
I know some things about suicidal people. One of the things I know is that you will never meet a suicidal person who is completely unconflicted, completely lacking in ambivalence. That’s because people like that are already dead before you have a chance to meet them. Anyone who lets another person know that they are suicidal, however certain they may sound, is ambivalent. There’s a part of that person – perhaps just a small part, a weak part – that wants to live. There’s a part of that person that wants to be rescued.
My job, when I meet a suicidal person, is uncomplicated. It is my job to stand with the part of the person that wants to be rescued.
I say “uncomplicated” although of course sometimes actually carrying out that job can be enormously complicated. What is uncomplicated is the part about knowing where my allegiance should be. I don’t try to wade into the person’s situation and figure out whether their problems are in fact hopeless. I don’t try to figure out, from what they are able to tell me about their prospects, whether their life is really worth living or whether they would be better off dead. The law, my professional ethics, my experience, and my personal values all tell me that my allegiance must be with life. That part is uncomplicated.
5. Suicidal dying or disabled people are different.
When the issue of assisted suicide comes up, I talk about the suicidal people I have known. "How come no one says my patients should be allowed to kill themselves? People who are mentally ill, people who are overwhelmed by horrifying life events – where is the assisted suicide movement for them?" Then people get annoyed with me: "Terminally ill and disabled people are different."
How are they different? Why is it that there is literally no disaster, no tragedy, no collection of problems so severe that our society argues that a person ought to be allowed to die rather than suffer them – EXCEPT for physical disability, physical helplessness? What makes being seriously ill or disabled different from every other bad thing that a person could possibly experience?
I’m going to give you a minute here to struggle with that question.
I'm going to keep posting bits. Feel free to disagree or ask questions or, you know, flounder with the issue; it helps me formulate my thoughts. At this point it's probably not useful to tell me what you think I should leave out or to comment on matters of style. I'm not there yet. I'm just getting it all out.
2. David Kissane and therapy for the dying.
I’m going to admit straight up that I didn’t know what I was doing when I worked with Ray. I knew how to treat depression, but I didn’t know how to do it without the promise of a better life afterward. Ray lived much, much longer than the doctors predicted – perhaps because he willed himself to; I don’t know – but I couldn’t do all the things I knew how to do: entice him with visions of useful work, fun, social relationships, romance, once the shadow of depression was lifted. Even when he was better he was still dying. Ray and I had to grope our way through that without an instruction manual.
A year or so after Ray’s death I went to a conference about psychosocial aspects of cancer care and I heard a presentation by an Australian psychiatrist named David Kissane. Dr. Kissane identified a set of symptoms that are common among persons with terminal illness: hopelessness, the loss of a sense of meaning in life, a feeling of powerlessness, fear of loss of dignity, fear of burdening others. He called these symptoms "demoralization syndrome:" loss of morale on the profoundest level. These feelings of hopelessness and powerlessness, he said, inevitably resulted in a desire to die or to commit suicide.
These feelings of demoralization – hopelessness, powerlessness, fear of losing dignity – may seem to some to be intrinsic to the process of dying. Of course, if you’re dying, why wouldn’t you be demoralized? But in fact, not everyone is. And second: Dr. Kissane was able to develop a psychotherapy that successfully treated demoralization syndrome. It was specifically designed to help people reflect on the meaning of their life and on their legacy – and we’re not necessarily talking about anything huge; I remember that he said, "for some people, it’s that they have a really good borscht recipe, one they want to hand down to their family." He would help people craft a sense of their legacy, his assistants would write down what they came up with, and they’d make it into a beautiful little book and present it to the dying person, so they could share their legacy with their families and friends.
And the thing is: repeatedly, he found that this kind of psychotherapy cured people of the desire for assisted suicide.
3. So...
So it turns out that terminally ill or severely disabled people who want to commit suicide aren’t actually different from anyone else who wants to commit suicide. They are suffering. Their suffering is responsive to treatment. And when they receive appropriate treatment, they lose the desire for suicide.
What does this mean for the assisted suicide movement?
And why did it take so long – some thirty years after the assisted suicide movement began – for anyone to study ill people who wanted to die and figure out what was wrong with them, and what could help them want the time they had remaining? Why weren’t those obvious questions from the start?
4. Things I know about suicide.
I started talking around in my social circle about this sermon I was going to give, and someone said to me very earnestly: “Rebecca, what you may not realize is that I’ve talked to some of these people and they do genuinely want to die. They have logical reasons.”
I don’t think she knew what I do in my work life. I’m not a licensed psychologist – I do clinical research instead – but over the years I have talked to many, many suicidal people, and they always have reasons. Their reasons are always compelling to them, and sometimes they are persuasive enough that they sound pretty compelling to me too. It was for good cause that psychiatrist Aaron Beck said in his famous treatment manual for depression that if you ever find yourself agreeing that your client’s situation is hopeless, it’s a sign that you’ve gotten sucked into their irrational thinking.
I know some things about suicidal people. One of the things I know is that you will never meet a suicidal person who is completely unconflicted, completely lacking in ambivalence. That’s because people like that are already dead before you have a chance to meet them. Anyone who lets another person know that they are suicidal, however certain they may sound, is ambivalent. There’s a part of that person – perhaps just a small part, a weak part – that wants to live. There’s a part of that person that wants to be rescued.
My job, when I meet a suicidal person, is uncomplicated. It is my job to stand with the part of the person that wants to be rescued.
I say “uncomplicated” although of course sometimes actually carrying out that job can be enormously complicated. What is uncomplicated is the part about knowing where my allegiance should be. I don’t try to wade into the person’s situation and figure out whether their problems are in fact hopeless. I don’t try to figure out, from what they are able to tell me about their prospects, whether their life is really worth living or whether they would be better off dead. The law, my professional ethics, my experience, and my personal values all tell me that my allegiance must be with life. That part is uncomplicated.
5. Suicidal dying or disabled people are different.
When the issue of assisted suicide comes up, I talk about the suicidal people I have known. "How come no one says my patients should be allowed to kill themselves? People who are mentally ill, people who are overwhelmed by horrifying life events – where is the assisted suicide movement for them?" Then people get annoyed with me: "Terminally ill and disabled people are different."
How are they different? Why is it that there is literally no disaster, no tragedy, no collection of problems so severe that our society argues that a person ought to be allowed to die rather than suffer them – EXCEPT for physical disability, physical helplessness? What makes being seriously ill or disabled different from every other bad thing that a person could possibly experience?
I’m going to give you a minute here to struggle with that question.
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no subject
Date: 2010-06-24 06:01 am (UTC)I am in favor of patients and their families having the right to refuse resuscitation, intubation, and tube feedings. But, with Alzheimers, by the time any of those refusals can affect the outcome, the person inside may have been gone for years.
(My grandmother was diagnosed with Alzheimers more ten years before she died; she spent years in a hospital bed in a near-vegetative state. She was never tube-fed; she survived that long because everything below the brainstem was in excellent condition, and she retained the ability to swallow when food was placed in her mouth. But she, the person, had been gone for years before her body finally followed.)
no subject
Date: 2010-06-24 08:13 am (UTC)no subject
Date: 2010-06-24 11:29 am (UTC)The thing is - and this is going to sound more brutal than I want it to sound - if he wants to kill himself, there's no realistic way for anyone to stop him. If he wants to wait a while longer and kill himself when he starts to notice large decrements in his function, there's no realistic way for anyone to stop him from doing that, either.
What I don't think he should be able to have is the right to ask other people to make a determination that his life is no longer worth living, and to then kill him. Especially because in the case of dementia we're talking about someone who would be past the point of being able to consent.
(No, I don't think you should be able to consent in advance. Millions of people would tell you that they would never, ever want to live if they had to be in a wheelchair full-time, but that turns out not to be the case when people who actually suffer severe accidents.)
I think this is a particularly hard problem for geeks because we put so much of our personal value - like, all of it - on our mental capacities. That's where our self-worth comes from, so it seems rational to us to say that life would no longer be living without them.
no subject
Date: 2010-06-24 11:54 am (UTC)There was a couple locally here recently who killed themselves in their back garden, because they were going to have to go into a care home, and living in a care home they wouldn't be able to choose when their condition was unbearable to them any more - but they also couldn't bear the idea of their children having to care for them as their condition got worse and worse even if they (the elderly parents) were so far beyond meaningful cognitive function that they didn't care any more. The woman here with ME who has spent a lot of time in court over it has a similar argument - she doesn't want to die while she still has enough control over her body and mind to obtain means and carry it out, but as the law stands she has to do it then or put up with the risk of living on past the point at which she finds things bearable, because even if her partner could bear to do it she doesn't want him arrested for murder.
On the other other hand, I have also read about a woman who promised her mother to help her die if she got severe Alzheimers, but hasn't done it because her mother is absent but perfectly happy, even if she's not the same personality any more.
no subject
Date: 2010-06-24 02:54 pm (UTC)no subject
Date: 2010-06-24 03:12 pm (UTC)no subject
Date: 2010-06-24 03:32 pm (UTC)ah! this makes perfect sense to me.
i myself worry about pain, and how the war on some drugs is screwing up the ability to get pain management, and how i can see myself getting to a point where i'd like some options.
but fuck if i want anyone making that decision for me.
no subject
Date: 2010-06-24 11:14 am (UTC)But it also terrifies me to wonder how we, as a society, would go about making rules about how much higher mental function someone needs to have in order for it to not be okay for someone to kill that person.
I think Alzheimer's disease is a bad example because someone who is that far gone is hardly able to make a decision to commit suicide. The discussions wind up being more about what I guess I'd call "assisted homicide" - at what point do your caregivers get to decide that there's nothing left worth keeping? That's a very, very different question.
And I say that with all kinds of respect and empathy for people who are caregivers of Alzheimer's patients, which is right up there on my personal nightmare list and is manifestly recognized by psychologists as one of the most stressful of human experiences.
(I'm sorry, this icon is manifestly inappropriate for the topic. I just couldn't resist using it in response to yours.)
no subject
Date: 2010-06-24 12:57 pm (UTC)That's how things fell out with my mother (terminal cancer). As long as she was mentally with us, she wanted to stay with us. Once she was mentally gone, my dad was absolutely not going to take any measures without her consent - I don't know if she'd given him advanced consent or not. But I think they did discuss it and she knew he wouldn't do anything without her present consent.
It was a very long and awful month, especially for my parents, but I think it was the right thing to do.