Lessons from Amy
CMAJ 1997;157:14
In response to: C.L. Watler; L. Gervais
See also:
I thank my colleagues for their comments, but I think they have missed the point about how different this woman was. Perhaps it is easier to conclude that this was a traditional situation of a mentally ill person who was not really listened to than to admit that we do not have the ability to "fix" every patient we see. I find it illuminating that most people who knew this woman superficially, whether from reading about her or after a single consultation, felt that she was mentally ill. By contrast, those who came to know her well over time, who had established a relationship with her, were convinced she was eccentric but competent.
A few facts: this woman was listened to from the outset, and it is a disservice to her caregivers to suggest that they failed to use the "third ear." She was offered numerous opportunities for support and therapy, all of which she refused. (She went to the hematologist 3 times not of her own initiative but at the insistence of her physicians. Her choice of suicide site and time was designed to ensure that she would not be seen, but she was foiled when she was delayed until dawn by sleeping in.) There was no need to commit her involuntarily. She agreed to admission, where she spent several days under careful professional observation. Several options to suicide were presented to her, and again she made it clear that she was not to be dissuaded. The second psychiatrist who saw her considered all of the matters mentioned in the letters, and he disagreed with Dr. Watler's opinion.
I reject Watler's assertion that anyone refusing treatment with a "high therapeutic index" must be mentally ill. Such a statement neglects the critical importance of patient context and belief systems. People who refuse blood transfusions for religious reasons are not mentally ill, even when their decision does not seem rational when measured against our values. The right of individuals to determine their own choices, even if they seem to be bad ones, is well enshrined in law and ethics.
Yes, as many as 90% of suicidal patients have treatable psychiatric disorders. However, I believe Watler makes a mistake when he concludes that all suicidal people are therefore mentally ill. It is not that simple, and that is why I wrote Amy's story. I believe this woman did not follow the general rule: she was truly exceptional in the literal sense.
Stewart Cameron, MD
Department of Family Medicine
Dalhousie University
Halifax, NS
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