A Way Out

What if, after you die, God asks you: “So, how was heaven?”

Assisted suicide is a contentious subject. People acting like robots, not being able to emotionally conceptualize a circumstance or understand “the spirit of the law” functioning behind rules and standards, is also a delicate subject. Nevertheless, recently, I read some news and I was triggered.

First, I want to state that the self-preservation instinct (the survival instinct) is perhaps the strongest force in the human psyche. When everything falls apart and we’re thinking normally, we revert to the default survival mode and we typically have the following thought: “What am I doing here?! I’m not going to kill myself for this “object” or “person”! I’m not going to die like this, for God’s sake! I’m not going to let myself die now because this or that is not appropriate or according to my wish! Everyone can go to hell, I’m out of here!”

Different people say different phrases, but in general, everything can be done or accepted until the moment when death is being discussed; at that point, people will fight for their life. The survival instinct lies at the very bedrock of one’s personality or being; it is as old as time, and it is the last inner protection that needs to be defeated by a suicidal person. Authoritarian states and tyrants flourish everywhere in this world because people have strong survival instincts that force them to surrender and obey, hence avoiding prison, mutilation, various kinds of torture or immediate death. The survival instinct can be defeated only with a high dose of fanaticism (when one is captured by extreme ideologies, political – various activists, extremist organizations or whistleblowers – or religious – collective suicides in certain sects) or in situations of intense suffering, when hope is lost in a very objective way (terminal diseases). On the other hand, the survival instinct is typically defeated by any suicidal psychiatric patient, but one needs to clearly separate the “rational” suicide or the “philosophical” suicide (you come to the conclusion that life has no meaning, you are the aforementioned fanatic or you are in great pain related to a disease) and the “pathological” suicide (which is the result of a mental disorder, more often depression or schizophrenia). For this reason, in a psychiatric emergency room, every person brought in for a suicidal attempt is systematically hospitalized if the situation is not clearly understood (although many cases are also not hospitalized, because we assess the risk, which can be low, and then there are a lot of suicidal attempts that act like a “cry for help” or an “attention-seeking” hysterical act, these also not being usually hospitalized).

Now, what caught my eye is an article circulating for a couple of days about the assisted suicide of a 28-years old girl from the Netherlands. It is not the only one, as the Dutch are normally euthanizing almost 9000 people annually (which is quite a big number if you ask me), but the circumstances were foggy – a hint to the name of the girl’s blog where she documented her euthanasia journey: Brain Fog.

The reasons for the euthanasia request of this girl were apparently 3: chronic fatigue syndrome, autism and ADHD. Now, I do not know the details of this case (and details matter, as they can change the situation, and the online newspapers will aim for traffic and scandal, so they won’t tell everything), but the fact that you’re chronically tired does not seem to me a plausible reason for demanding to be killed. At a deeper look, I found that the chronic fatigue syndrome was actually myalgic encephalomyelitis, coded in the international repertoire of diseases at G93.3, synonym with the post-viral fatigue syndrome. In plain language, this means that the girl got a flu or some sort of viral infection, and then remained with some sort of lingering fatigue (everybody knows that you feel weak sometime after a flu; well, the girl felt weak for years). The long-Covid symptoms are a good example. In psychiatry, there is also an unofficial chronic fatigue syndrome coded at F48.0 which is called neurasthenia, typically known as the fatigue emerging from too much work or a too demanding job (the burnout), but the Dutch doctors have chosen to use the code for a neurological disorder, and I might suspect that the aim was to convince everyone that it’s physical (neurological) and not psychiatric (psychological, emotional), hence the need for euthanasia being more “grounded” in reality.

Now, there is a problem: the myalgic encephalomyelitis, as its name states, is a continuous pain (=algia) caused by brain (=encephalo) inflammation (=itis). The girl experienced post-exertional malaise (fatigue, cognitive impairment, flu-like symptoms, weakness, nausea, pain and trouble sleeping) and ended up being bed-bound. Exactly the same symptoms are found in neurasthenia, so I cannot see how the doctors differentiated between the 2 disorders. More, I was expecting that the girl complained more about the pain, putting this main symptom in the foreground while pushing the others in the background, but in fact it was the fatigue that took the main place on the stage. So, what I understood is that fatigue was the main reason for euthanasia, but because psychiatric neurasthenia was a weaker diagnosis compared to the neurologic myalgic encephalomyelitis, the latter one was used so as to justify the assisted suicide.

Another problem comes from the other 2 disorders: autism and ADHD. These 2 do not mix well together. Autism is what its name says: being in your own world, not caring about the others. The girl was writing a blog about her journey and extensively spoke on social media about her in relation to others (so, she shared stuff with the outer world). I will quote her: “I chose to make the date and time [of my euthanasia] public because you have all been so excited for this moment with me. I know from experience how supportive it can be to know when it is happening, so that you can reflect on it for a moment or light a candle if you wish.” As you can see, she is able to feel emotions (she is “excited” because she knows that she’ll die – as weird as it can seem to you, I know) and she also takes her audience with her in her own world (“I know how supportive it can be…” – that is, she is able to empathize/connect quite a lot and put herself in other people’s place). Now, this is not autism, not even Asperger’s disorder. This is a fully functional emotional being. Period. But I insist and add her final online message: “This will be my last tweet. Thanks for the love, everyone.” A truly autistic person does not care about others and about what they feel. An autist will not post a last tweet because he/she doesn’t care about what the others think about him/herself and will definitely not thank for “love”, because he/she doesn’t care about love. Well, there were a lot of other unqualifiable human beings who replied to her in comments with “I think of you and the people around you and wish you beautiful last moments!” or “May you find your peace!” or “Have a few loving last hours!”, a proof that there is a generous supply of cynical folks out there, probably seeing themselves as compassionate heroes, convinced that they’re doing good because they’re supportive, something that makes me question my faith in humanity…

Now, about ADHD. This is a disorder recently added to the register of mental disorders, characterized by impulsivity, attention deficit and hyperkinesia (restlessness). It is hard to imagine a person suffering from chronic fatigue syndrome being restless. Dysphoric and agitated inside yes, but not turbulent. As for attention, when you’re in distress, it’s normal to find it hard to focus. As for impulsivity, I can’t see how it fits the constellation of symptoms of this patient (she has carefully planned her euthanasia request, and only the onset of Covid pandemic has delayed her death). So ADHD was probably added as an auxiliary diagnosis, just to make the case “heavier” and more prone to be approved for euthanasia. Truth to be told, ADHD is diagnosed in childhood and often disappears in the adulthood. At 28 years of age, although possible, it’s exceptional.

Then, why don’t autism and ADHD mix well together? Because these 2 disorders are diagnosed on criteria. For instance, it is generally easy to understand when someone is depressed: he/she is sad, lacks energy, has dark thoughts. Autism and ADHD are not straightforward disorders (obvious for the general public), so they are diagnosed if a certain number of criteria is met. And a common criteria is “behavior issues” (or something like that). Both an autist and a patient with ADHD can be agitated, but the reasons and the mechanisms behind this agitation are different. If you think as a robot – or like ChatGPT – you will check positively the criteria: after all, the patient is restless, right? But you should “understand”, not only “execute” a statistically-designed diagnosis assessment (which is basically filling out a survey in this case). My fear is that the psychiatrists who performed the assessment were simply hyper-rational beings who did not care for truly understanding “why” the patient was restless or investigate the “big picture” of the family; they just said that “the patient’s condition satisfies both autism and ADHD criteria” and left the matter just like that, without further deliberation regarding the underlying mechanisms. To make things worse, if you have myalgic encephalomyelitis, which involves distress and pain, you are likely to be restless as well. But you can also be restless because you are in an existential crisis, because you are suffering from an agitated anxious depression or because you are in a fusional relationship with your mother and you are deeply neurotic. So what’s the diagnosis now?

The last image of the girl shows her lying dead, hugging a plush dog (or teddy-bear, can’t say for sure), near other plush toys. It is a disturbing image and I encourage you to seek it online and contemplate it yourself. The photo was taken by her mother who accompanied her through the euthanasia process. I also encourage you to read the online articles that add more “flavor” to the story. You will feel dismayed. I felt the same way and that’s why I stop here with this disheartening story. But, in my favorite style, I will pull the rug from the feet of this entire business:

They said the girl has discernment. I doubt.

The final scene of your life – if you can design it yourself – is always a statement or a declaration about yourself. I sometimes ask others: What would you like your last words be in this world? This is transactional analysis in action, but is has a deep effect. Similarly, the way you prepare your deathbed – or how you design your tombstone or plan your grave or your resting place – speaks “volumes” about who you are… or who you were… The girl – 28 years old, remember?! – is surrounded by toys. We’re dealing with an emotionally “under-18 years old” person, more likely in a fusional relationship with her mother. The picture is so evocative for the trained eye that little more needs to be said. You don’t sleep with toys at 28. You don’t sleep your “eternal sleep” with toys. You are (were) not an adult. Although I do not suspect an intellectual deficiency – the blog she wrote proves normal skills, even an emotional elegance which makes the case even more unsettling – I find it hard to imagine that the girl really sought death and not in fact “a way out” from a dysfunctional relationship or a situation that couldn’t be “solved” in a different manner. For children until a certain age, death is reversible, it is a way to get away or escape. It’s like in a computer game, when after “game over” you can always “restart game”. In real life this sadly doesn’t happen. The fact that you’re suffering from a distress (her disorders) does not entitle you to take your life, but rather to face it with bravery, stoicism and dignity. It is one thing to be in a terminal cancer stage for instance (which I witnessed and for which I agree that euthanasia is an alternative to be discussed), and a completely different thing to ask for euthanasia for a constellation of symptoms led by fatigue as the chief complaint…

My psychiatry-trained brain really ponders on a possible alternative diagnosis: severe (reactive) depression. Severe depression goes well with somatic (body) symptoms like fatigue, pain, insomnia and even nausea. Severe depression also goes well with a cognitive impairment and also with an attention deficit – the “brain fog” that became the name of the girl’s blog. And severe depression finally goes well with suicidal thoughts, a desire to die that was properly satisfied by the Dutch state. I say that it is “maybe” reactive because I suspect that there was something going on in the family, judging by the final scene, but also by several subtle clues left on the girl’s blog (photos with her mother, a song by Taylor Swift titled Never Grow Up posted a month ago, etc.). A deep prolonged conflict can translate itself into somatic, even conversive (dissociative) symptoms, and the neurological symptoms are very frequent. People can have psychogenic seizures (convulsions), blindness, loss of voice, or become bedridden as a way to express their neurosis, so this girl’s symptoms were pretty mild. A fusional relationship leaves little choice; to be bedridden offers the possibility to prolong childhood, to profit from the love and nurturing of the mother, especially since the said mother has already lost your brother to cancer, so she’s eager to do everything so as to avoid losing you. This eagerness to not lose another child has led this mother, paradoxically, to accompany her only remaining child on the road to her respective assisted suicide.

And… what about discernment? Severe depression – if we accept it as a possible diagnosis – alters one’s mental capacity. Mild or moderate depression does not legally affect judgement, but severe depression often does. And then, although legally and rationally this girl did actually have discernment, aren’t we too fast (and too reckless) to evaluate discernment when that girl, emotionally, still plays with toys and perhaps believes that she can “restart the game of life” at a latter point in the future?!

How old should one be, emotionally, so as to truly have discernment?!

As a final note, I cannot fathom how that mother could accept the assisted suicide of her daughter, witness how her daughter literally gasped for her last breath of air in front of her, and then later be philosophical on the internet. On the website of her daughter, following her death, appeared the following statement: “Lauren passed away peacefully at 1.55 PM in the presence of her parents Leonie and Peter, and her best friend Lau”. Later, the mother acknowledged that she is “happy” and that “The only thing I see as a bright spot is that I no longer have to fear losing my children. I know where they are.” This is a twisted mind: if you are “relieved” by your girl’s death and you admit that your “fear of losing” is finally cured by actually losing both your children in a very real way, you definitely have a control issue and indeed, being the daughter of such a controlling mother and then being euthanized, is probably the best thing that could have happened. And this is how even suicide (taking in consideration the context) is completely reasonable and… adequate to one’s particular personal circumstances.

The girl found, indeed, the way out.

Post Scriptum:

The Netherlands, Belgium, Switzerland, and a couple of other states, offer assisted suicide or euthanasia (there is actually a difference between the two). It is a solution for many and I believe that this option must remain free for some people. If you didn’t witness the decay of a human being in the final stages of a disease, you cannot have a proper judgment because you didn’t go through that pain at an emotional and experiential level. However, the cynicism and the lack of insight of those doctors assisting those patients is staggering. The blindness regarding the pathological games being played in certain families comes from too much emphasis on biological and statistical psychiatry, while overlooking psychological issues and what is invisible to the untrained eye. It is incompetence and people suffer uselessly. These countries do make a parade of their forward thinking and high quality of medical service. Judging by this case, they are overrated. They have lost both their insightfulness and their common-sense.

There are several possibilities to escape a fusional relationship. When dealing with devouring mothers, you risk being overwhelmed and finally serve as their dinner in their quest for a meaning – to make themselves useful, to find a purpose through mothering you. They will cut your wings so that you cannot fly. One way of escaping is to get married and escape by marriage. Another way of escaping is to move to a different region or country, as far as possible, and make new friends. But sadly, another way of escaping is suicide, assisted or not. In the end, those mothers will look coldly and detached at your dead body – frozen by death while still holding tight that lifeless teddy-bear in your arms – and they will feel… nothing really… Or perhaps relief… For this very reason, you survival instinct must be intact. Death is one way out, but it is not the only one.