Lessons from Amy
CMAJ 1997;157:13
See response by: S. Cameron
See also:
As the psychiatric resident involved in Amy's initial contact with the psychiatric service at the former Camp Hill Hospital, I read "Learning from Amy: a remarkable patient provokes anguished debate about rationality, autonomy and the right to die" (CMAJ 1997;156:229-31), by Dr. Stewart Cameron, with considerable interest. My understanding of the relevant issues are at odds with the author's.
Months before her death, Amy presented as "an alert and intelligent lady" refusing a life-saving treatment with a high benefit-to-risk ratio (high therapeutic index). Despite this evidence of an impaired decision-making process, Amy's attending physician presumed that her later "actions were rational." There is no evidence that patients with serious medical illnesses "rationally" choose to die. In fact, most patients wishing to die are significantly depressed, and, with appropriate treatment, most make a rational decision to continue living.1
There is common belief that the forensic term "mental disorder" is synonymous with psychiatric classification or "clinical" conventions. Hence, Cameron asserts that Amy was not "mentally ill in the clinical sense." Mental disorder is, in fact, very poorly defined in the various mental health acts, and this omission is quite deliberate. The physician need not establish an "identifiable psychiatric illness" as a requirement for involuntary committal. Rather, persons should be detained for evaluation when there is high-risk behaviour and evidence to suggest any form of mental disorder. The brevity of this detention -- a maximum of 7 days in Nova Scotia -- does not represent a significant deprivation of freedom. Rather, the initial priority is to ensure patient safety.
What evidence was there to suggest that Amy was suffering from a mental disorder? Months before, she had refused a life-saving intervention with a high therapeutic index. Her speech and writing demonstrated
significant thought-form disorder. There was psychomotor agitation, irritability and lability of mood. There was social withdrawal and suspiciousness. It seems speculative to conclude that Amy was not mentally ill in the "clinical sense" or, more important, in the forensic sense.
Cameron notes that there was "little consideration of the legal implications." The fact is that this case was exclusively within the legal domain. With recent suicidal behaviour and evidence to suggest a mental disorder, the law requires that an unwilling patient be involuntarily committed. That Amy's clinicians could not agree on the presence of a mental disorder is precisely the reason for detaining high-risk patients for further evaluation. When there is intent to die, sufficient time should elapse to exclude the presence of a mental disorder.2
If Amy's legacy is to be as a "respected teacher," we should strive to learn all of her lessons well.
Crosbie L. Watler, MA, MD
Chief of Psychiatry
Lake of the Woods District Hospital
Kenora, Ont.
References
- Chochinov HM, Keith GW, Enns M, Mowchun N, et al. Desire for death in the terminally ill. Am J Psychiatry 1995;152:1185-91.
- Trevor-Deutsch B, Nelson RF. Refusal of treatment, leading to death: towards the optimization of informed consent. Ann R Coll Physicians Surg Can 1996;29:487-9.
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