Human Brain

Over the past two months I presented a course on the Human Brain to students in the LIFE (‘Learning is Forever’) Institute at Ryerson University in Toronto. The course was designed for the senior layperson. It introduced the basic anatomy and physiology of the nervous system, and described the various disorders that can affect the elderly human brain.

Human Brain Header

The course was given at a second-year university level. Some of the material may have been more than the students needed to know, but most were able to follow the main points of the talks, and some were fascinated by the details.

The presentations were supplemented with extensive teaching materials – slides, notes, movies, etc. Many of the illustrations were adapted or created specifically for the course. I am now making these generally available through the page entitled Human Brain on my website.

 

 




Euthanasia

We cannot choose the moment of our birth. And death usually comes in its own time, not ours. Sometimes, however, we can decide to end our life. The reasons for suicide are various. Most common is the desire to end intractable suffering. Faced with the prospect of a prolonged period of pain and suffering at the end of life, most rational people would prefer euthanasia – a “good death.” This term first came into English in Francis Bacon’s Advancement of Learning (Book II, X.7). Bacon was encouraging physicians to assuage the pains and agonies of death: to practice what we now call palliative care.

Over the course of time “euthanasia” became differentiated from palliative care, and now generally means the inducement of death so as to prevent intolerable pain and suffering in patients with incurable disease (Young, 2012; Sumner 2011). Euthanasia may be voluntary or involuntary, based on whether the patient provides consent or not. Involuntary euthanasia, where the patient does not provide consent although capable of so doing, is sometimes distinguished from non-voluntary euthanasia (“mercy killing”), where the patient is unable to either object or consent. Some would consider both involuntary and non-voluntary euthanasia as equivalent to murder and limit the term euthanasia to cases wherein consent is explicit. Euthanasia may be active or passive, based on whether death is induced by the administration of a lethal medication or by the withdrawal of life-sustaining treatment, nutrition or hydration. Active euthanasia may be initiated by the patient, in which case it is essentially suicide, or by someone else (a physician or a nurse acting under the direction of a physician), in which case it can be described as assisted suicide or assisted dying. Sometimes voluntary euthanasia, where the lethal medication is administered to the patient, is distinguished from assisted suicide, where the patient takes the drug, but this distinction appears unnecessary. When the word is unmodified, euthanasia generally means physician-assisted suicide performed at the request of the patient.

Historical Backgound

Our attitudes to euthanasia have changed over the centuries (Dowbiggin, 2005). Developments in religion, law, and medicine have all contributed to these changes. Over the past century or so medicine has increased its ability to treat disease and manage pain. We are now more able to make end-of-life decisions than we have ever been. Nevertheless, the decisions remain extremely difficult, since they involve our cherished belief in the sanctity of human life and our ancient laws against killing (Pappas, 2012). Any proposal for euthanasia must address our general prohibition of suicide.

In the Eastern religions, suicide was not forbidden. In India, a wife could cast herself on the funeral pyre of her husband in the process of sati. Elderly yogis with no remaining responsibilities could seek death by starvation – prayopavesa. In Japan, suicide by means of seppuku could preserve one’s honor. Since one of the goals of Buddhism is to relinquish any attachment to the world, suicide might even be considered as a means to this release, though this should only come after enlightenment has been attained (Attwood, 2004). However, some Chinese and Japanese Buddhist monks sought enlightenment through a process of sokushinbutsu or self-mummification, accomplished by slow starvation and self-suffocation.

In the Abrahamic religions, however, suicide was considered an unpardonable sin, tantamount to murder (Cholbi, 2012). Suicide was contrary to the commandment “Thou shalt not kill” (Exodus 20:13). The main scriptures, however, do not specifically prohibit killing oneself. The Bible provides various examples of suicide (Samson, Saul, Judas) without ever stating that this is prohibited. However, the scriptures convey a general sense that one should not interfere with divine providence: “My times are in thy hand” (Psalm 31:15). One verse of the Qur’an (4:29) is sometimes translated as “Do not kill yourselves,” though it is more usually rendered as “Do not kill each other.”

Through most of its history, the Christian Church has adamantly condemned suicide. The body of a suicide was denied burial in consecrated ground and the soul denied access to salvation. In recent years, the churches have relaxed their condemnation, though suicide is still considered a mortal sin. Until recently, suicide was illegal in almost all European countries, and the property of the suicide was confiscated by the state. Part of the reason why Christian societies have been so severe in their condemnation of suicide may have been the attractiveness of heaven. Without severe sanctions, believers might easily choose the happiness of an after-life to the suffering of a present life.

During the Renaissance and Enlightenment, thinkers began to question the Church’s stance. When one is coming to the end of life and faced with unrelenting pain, one should be able to choose a quick and painless death rather than undergo prolonged and unnecessary suffering

In Thomas More’s Utopia

…when any is taken with a torturing and lingering pain, so that there is no hope either of recovery or ease, the priests and magistrates come and exhort them, that, since they are now unable to go on with the business of life, are become a burden to themselves and to all about them, and they have really out-lived themselves, they should no longer nourish such a rooted distemper, but choose rather to die since they cannot live but in much misery; being assured that if they thus deliver themselves from torture, or are willing that others should do it, they shall be happy after death: since, by their acting thus, they lose none of the pleasures, but only the troubles of life, they think they behave not only reasonably but in a manner consistent with religion and piety; because they follow the advice given them by their priests, who are the expounders of the will of God. Such as are wrought on by these persuasions either starve themselves of their own accord, or take opium, and by that means die without pain. (More, 1516, pp 140-141).

One cannot be sure whether More was advocating euthanasia or just presenting the policy for discussion. The title of his book means “nowhere” – only later did it assume the additional connotation of eutopia or “good place.” As a devout Roman Catholic, More likely supported his church’s opposition to euthanasia. Death should come when God wills, not when we want.

In an essay that was only published posthumously, David Hume provided a rational view of suicide. He proposed that it is no more contrary to divine providence than building houses to protect ourselves from the weather or cultivating the earth to prevent ourselves from starving. Furthermore, when we become old and infirm suicide is no longer contrary to our duties to society, since we may have become more of a burden than a benefit to our fellows. Thus

both prudence and courage should engage us to rid ourselves at once of existence, when it becomes a burthen. ’Tis the only way, that we can then be useful to society, by setting an example, which, if imitated, would preserve to every one his chance for happiness in life, and would effectually free him from all danger of misery. (Hume, 1777)

In the concluding note to his essay, Hume quoted Pliny the Elder who described suicide as an advantage that man possesses over God.

Deus non sibi potest mortem consciscere, si velit, quod homini dedit optimum in tantis vitæ poenis. [God cannot put himself to death even if he wanted to, since among the many ills of life he gave away this best of boons to man]. (Pliny, 79, Book II Chapter V)

The modern interpretation of euthanasia can probably be traced to the much-discussed essay on the subject by Samuel D. Williams published in 1870 (Kemp, 2002). He proposed

That in all cases of hopeless and painful illness it should be the recognized duty of the medical attendant, whenever so desired by the patient, to administer chloroform, or such other anæsthetic as may by-and-by supersede chloroform, so as to destroy consciousness at once, and put the sufferer at once to a quick and painless death; all needful precautions being adopted to prevent any possible abuse of such duty and means being taken to establish, beyond the possibility of doubt or question, that the remedy was applied at the express wish of the patient. (Williams, 1870, p 212).

In the decades subsequent to this essay, many groups in England, Europe and North America began to advocate the legalization of euthanasia.

Unworthy Lives

In the 20th Century euthanasia became entrammeled with another idea that promoted the good of society – “eugenics.” Unfortunately, joining the “good death” with the “good birth” led to actions of great evil.

Darwin’s Theory of Evolution had proposed that humanity’s current success derives from the selection of the fittest for survival and propagation. Followers of Darwin warned that we should not alter the course of evolution by social policies to protect the weak and vulnerable. Rather we should encourage our best and brightest to have more offspring, and we should prevent the feeble-minded, criminal and insane from multiplying. These ideas formed the basis of eugenics.

In the first few decades of the 20th Century several jurisdictions in North America and Europe enacted eugenic laws enforcing the sterilization of the mentally defective and the insane. The most efficient of such programs was brought in by the German Nazi government when it came to power in1933 (Proctor, 1988, Chapter 4; Pichot, 2001, Chapter 10). The Law for the Prevention of Genetically Diseased Offspring required the sterilization of patients suffering from feeble mindedness, schizophrenia, manic-depression, Huntington’s chorea and alcoholism. While the program was in operation between 1933 and 1939, about 400,000 patients were sterilized (compared to about 30,000 patients over a much longer period in the USA).

A more effective eugenics program would not only prevent offspring but also remove from society the costs involved in the long-term care of feeble-minded and mentally ill patients. The possibility of the involuntary euthanasia of patients who were a burden to society had been thoroughly evaluated in the 1920 book Permitting the Destruction of Unworthy Life by Karl Binding, a legal scholar, and Alfred Hoche, a physician. They considered the question

Is there human life which has so utterly forfeited its claim to worth that its continuation has forever lost all value both for the bearer of that life and for society?

They answered affirmatively, and proposed that society was justified in putting patients with incurable disease to death.

In 1939 the war began and the German sterilization program ceased. In its place a secret program called Operation T4 was instituted to provide a mercy death (Gnadentod) for the incurably sick and mentally ill. Patients were killed either in specially constructed gas chambers or by such other means as were found expedient. The number of patients euthanized by the time the war ended was probably around 400,000 (Proctor, 1988, Chapter 7; Pichot, 2001, Chapter 11). The techniques developed in the early stages of this program were then used when the Nazi government decided to murder Jews, homosexuals, communists, Gypsies, Slavs and prisoners of war.

The history of euthanasia in Germany is a horrifying example of the “slippery slope.” By accepting that some people have more of a right to life than others or that a doctor may agree to a patient’s request for death, we slide slowly and inexorably toward complete immorality. Leo Alexander, a medical expert at the Nuremberg trials, stated the problem of the “small beginnings:”

Whatever proportions these crimes finally assumed, it became evident to all who investigated them that they had started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans (Alexander, 1949).

Double Effects

For many years after the war, the ethics of active euthanasia were not discussed. We became more concerned with the relief of pain. New protocols were developed to facilitate analgesia, the speciality of palliative care became a medical specialty, and hospices became available to provide a peaceful and pain-free death to patients with terminal illness.

Sometimes, when medication dosages were increased to levels sufficient to relieve severe and unrelenting pain, death also resulted. Such protocols invoked the principle of “double effect:” that an action intended to bring about a morally desirable effect (the relief of pain) is not wrong if it also leads to a morally reprehensible effect (death) even when this second effect is foreseen. This state of affairs is both morally and medically confusing (McIntyre, 2001). Who is to say what is intended and what is just foreseen? The increased pain medication probably does not in itself bring about the death of the patient. Death results from a combination of causes: limiting the patient’s nutrition and hydration adds to the effects of sedation and the ongoing disease. “Terminal sedation” should probably not be considered as an example of double effect, but simply treated as a type of euthanasia.

End-of-Life Decisions

In the second half of the 20th Century, medicine developed techniques for cardiopulmonary resuscitation and mechanical ventilation. Although these procedures often prevented unnecessary death, they sometimes resulted in unresponsive patients being maintained alive without any reasonable hope for the return of normal consciousness.

These developments led to the principle that life need not be artificially continued if recovery is futile. A patient may decide to forego resuscitation or mechanical ventilation in such situations. This decision may be made by means of an advance directive or “living will.” In cases without such directives, the decision can be made by the patient’s family and caregivers. Accepting these protocols has been a long a complicated process that is outside of the main topic of this posting (see discussion in Pappas, 2012, Chapter 4). Issues remain for patients who have no advance directives and when the family and physicians disagree on whether to maintain life support. Nevertheless we have come to general terms with the idea of passive euthanasia when a patient is unresponsive and the prognosis is futile. Outside of a few jurisdictions, however, active euthanasia remains illegal.

Legalization of Voluntary Euthanasia

Voluntary euthanasia has been legal in Oregon since 1997 (Lindsay, 2009; Lee, 2014), in Switzerland at least since 1998, and in the Netherlands (Onwuteaka-Philipsen et al., 2012) and Belgium (Cohen-Almagor, 2009) since 2002. Each of these jurisdictions requires a formal application from a patient judged competent to understand the nature of their suffering and the consequences of their request (Lewis & Black, 2013).

The incidence of voluntary euthanasia is low but varies greatly among the jurisdictions. In Oregon the incidence is 0.2% of all deaths, but in Belgium and the Netherlands the incidence is between 1.5 and 3 % (the incidence in Switzerland is not accurately known). The incidence would be significantly higher if cases of euthanasia without consent, and cases of terminal sedation were included together with those of voluntary euthanasia.

Investigations of patients undergoing voluntary euthanasia indicate no clear evidence that vulnerable populations are unfairly targeted, or that coercion plays a significant role in the patients’ decisions. In Oregon most patients requesting euthanasia were white, well-educated, and medically insured (Lindsay, 2009). Furthermore, euthanasia does not substitute for adequate palliative care, since most patients ultimately seeking euthanasia have already tried palliative care or been admitted to a hospice.

Nevertheless, two significant issues remain unanswered. The first is the incidence of euthanasia without explicit consent. Although this is not reported in Oregon, it has been documented in Belgium and the Netherlands. When faced with an incurable patient in severe pain who is not able to provide consent, a compassionate physician may nevertheless proceed with euthanasia. The incidence of this is extremely difficult to assess, particularly if one includes “terminal sedation.” The incidence of euthanasia without consent probably equals the incidence with consent (Cohen-Almagor, 2009; Lewis &Black, 2013; Meussen et al., 2010, Onwuteaka-Philipsen et al., 2012).

The second issue concerns the euthanasia of patients with psychiatric disorders. This has become particularly frequent in Belgium (Thienpont et al., 2015; Aviv, 2015). By arguing that mental anguish can cause as much suffering as physical pain, one can make a philosophical case for euthanasia to relieve “existential suffering” (Varelius, 2014). However, we usually believe that psychiatric disorders can be treated, and that even without treatment depression will alleviate with the passage of time. Psychiatric patients are certainly vulnerable and often may have difficulty providing fully informed consent. Thienpont et al. (2015) report that the female/male ratio was 3.3 for psychiatric patients requesting euthanasia and 2.9 for those patients who were ultimately euthanized. They suggest that this is in keeping with the increased incidence of psychiatric disease in women, but the ratio is nevertheless disconcerting.

Objections to Euthanasia

Euthanasia has engendered much public debate (Andorno & Baffone, 2014; Materstvedt et al., 2003; New England Journal of Medicine, 2013; Quill & Greenlaw, 2008; Somerville, 1993, 2014; Smith, 2006; Sumner, 2011, Young, 2012). The main reason for making euthanasia legal is that individuals have a right to decide that a rapid painless assisted death is preferable to one that is prolonged and painful, and to have medical assistance in bringing this about. The main objections are

(i) Euthanasia is unnecessary if there is adequate palliative care. A variant of this argument is that if euthanasia becomes legal, patients and physicians will prefer euthanasia to palliative care. Palliative and hospice care can render the end of life peaceful and pain-free in most patients. Nevertheless, pain medication must sometimes be brought to such levels that the treatment of pain becomes essentially the same as euthanasia.

(ii) Patients may not be able to provide proper informed consent. A state of state of severe pain and distress may preclude proper consent – the patient may agree to anything to stop the pain. This objection could be countered if the patient simply confirmed a previous decision made before the terminal period.

(iii) Patients near the end of life may be very vulnerable to coercion. Opponents of euthanasia suggest that families and caretakers may improperly convince disabled or elderly patients to accept euthanasia. Their ulterior motive might be to be relieved of the expense and effort involved in the care of their elderly relative or to free up an inheritance.

(iv) Allowing voluntary euthanasia is a “slippery slope” that will ultimately lead to killing all individuals whose lives are considered “unworthy.” If we become used to letting people die, we may become inured to killing and allow the old, the disabled and the mentally defective to be euthanized without consent. The story of Jack Kevorkian (Pappas, 2012, Chapter 5) represents the horrors of the slippery slope. Though there may have been some support for his early actions, ultimately he was killing patients who were obviously unable to give consent. Refutations of the slippery-slope argument hinge on strong safeguards to guarantee proper consent and strict sanctions against euthanasia outside of the legal guidelines (Stingl, 2010). The slope may be slippery but we can construct barriers to prevent us from falling into the abyss.

Public Opinion

Despite the objections, the great majority of people in North America support the legalization of voluntary euthanasia. Gallup polls (McCarthy, 2014) show that about 70% of respondents in the USA answer yes to the question

When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient’s life by some painless means if the patient and his or her family request it?

Support varies with the wording of the question (Saad, 2010). Only 51% agree if the question is worded:

When a person has a disease that cannot be cure and is living in severe pain, do you think that doctors should or should not be allowed by law to assist the patient to commit suicide if the patient requests it?

Both Somerville (1993) and Callahan (2008) have remarked how easily public opinion on euthanasia may be swayed by the choice of words.

In a Canadian poll taken in 2013 at the behest of an anti-euthanasia group the key findings were that

Canadians are about twice as likely to support (63%) as to oppose (32%) a law allowing physician-assisted suicide in Canada. Support is slightly lower for legalizing euthanasia (55% vs. 40% who oppose it), which is likely due in part to providing respondents with information about the rate of euthanasia deaths occurring without patient consent in Belgium. (Environics, 2013).

A year later, an Ipsos-Reid poll performed for a pro-euthanasia group showed 84% of Canadian respondents in favor of physician-assisted suicide. (Ramsay, 2015).

A final survey worth noting is one conducted by the Canadian Medical Association (2011). They found in a survey of their members that

only 20% of respondents would be willing to participate if euthanasia is legalized in Canada, while twice as many (42%) would refuse to do so. Almost a quarter of respondents (23%) are not sure how they would respond, while 15% did not answer.

The Hippocratic Oath asserts

I will neither give a deadly drug to anybody who asks for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy.

Most present day physicians do not swear to this oath, but the idea that a physician should not bring about death has merit. When one is sick and in pain, a physician who will not kill is preferable to one who might be willing to do so. Even if ultimately one could choose suicide.

Canadian Law

In Canada active euthanasia is a crime though suicide is not. The Canadian Supreme Courts has examined the issues of euthanasia in three cases: Rodriguez vs British Columbia (1993), R vs Latimer (2001), and Carter vs Canada (2015).

In 2001 Sue Rodriguez, suffering from amyotrophic lateral sclerosis, wished to be allowed to die by means of assisted suicide when she became totally incapacitated. She wanted to live life to its fullest, and therefore did not wish to take her life before becoming unable to do so. She proposed that the law prohibiting physician-assisted suicide was discriminatory

since it prevents persons physically unable to end their lives unassisted from choosing suicide when that option is in principle available to other members of the public without contravening the law.

The judgment of the court was that the blanket prohibition of assisted suicide was justified since its purpose was to protect life. The court expressed concerns about the possible abuse of assisted suicide were it to be legalized, the difficulties in creating appropriate safeguards against such abuse, and the need to protect those members of society who might be vulnerable to such abuse. The court therefore decided against her request. Sue Rodriguez committed suicide with the assistance of an anonymous physician in 1994.

In 1993, Robert Latimer brought about the death of his 12-year old daughter Tracy by means of carbon monoxide poisoning. Tracy suffered from severe cerebral palsy, epilepsy and mental retardation. She had undergone numerous operations to relieve her spastic and painful state. Faced with further surgery for her constantly dislocating hip, her father decided that dying would be preferable to continuing a life of pain and torture. Latimer was convicted of second degree murder and given the minimum 10-year sentence allowed for this crime. The case went through several appeals. In 2001, the Supreme Court considered a request to reduce the sentence, but affirmed both the conviction and the sentence. They found no justification for non-voluntary euthanasia. Robert Latimer began serving his sentence in 2001 and was release in 2010.

The Supreme Court of Canada re-considered the law prohibiting physician-assisted suicide in its judgment of Carter vs Canada. The case was instigated by Lee Carter, who had been forced to take her mother, suffering from an incurable neurodegenerative disease, to Switzerland for assisted suicide, since this was not legally available in Canada. The court summarized the reasoning of the 1993 Rodriguez judgment:

The object of the prohibition is not, broadly, to preserve life whatever the circumstances, but more specifically to protect vulnerable persons from being induced to commit suicide at a time of weakness.

However, the court acknowledged that since that 1993 judgment assisted suicide had been legalized in several jurisdictions and that safeguards against abuse have been effective. The court agreed that some people may wish to end their lives but not have the ability to do so without the assistance of a physician. The law prohibiting such assistance thus discriminates against these individuals:

An individual’s response to a grievous and irremediable medical condition is a matter critical to their dignity and autonomy. The prohibition denies people in this situation the right to make decisions concerning their bodily integrity and medical care and thus trenches on their liberty. And by leaving them to endure intolerable suffering, it impinges on their security of the person.

The court therefore temporarily invalidated the law prohibiting physician-assisted dying and called upon the federal government to provide new legislation more consistent with the Canadian Bill of Rights. However, the present government seems loath to address the issue, despite the weight of public opinion (Ramsay, 2015). The government of the Province of Quebec has voted to allow euthanasia, although this decision may be legally contested by the federal government.

Where Do I Stand?

Euthanasia should be legal when a patient with an incurable illness is suffering pain that cannot be adequately relieved by analgesic medication. The diagnosis and prognosis should be confirmed by at least two physicians. Modern palliative care should have been provided and demonstrated to be inadequate. Euthanasia should only be allowed at the patient’s request and only after his physicians have ensured that the request is freely made.

Terminally ill patients who are in obvious pain but unable to consent to euthanasia pose a significant problem for both medicine and the law. We need to develop guidelines and safeguards to allow consent to euthanasia from the family and caretakers in these cases. Otherwise non-voluntary euthanasia may occur and go unreported.

In the absence of unrelenting pain, euthanasia of the elderly, the demented, and the mentally defective should continue to be prohibited.

At the present time there is no adequate justification for assisted suicide for existential suffering. Euthanasia in psychiatric patients is far too susceptible to abuse to be allowed.

Physicians should not be forced to provide euthanasia. Nevertheless, any patient requesting euthanasia should be referred to other physicians who can evaluate the request, judge its validity and conduct the euthanasia. Such referrals should be readily available.

 

References

Alexander, L. (1949). Medical science under dictatorship. New England Journal of Medicine, 241, 39-47.

Andorno, R., & Baffone, C. (2014). Human rights and the moral obligation to alleviate suffering. In R. M. Green & N. J. Palpant (Eds.) Suffering and Bioethics. (pp. 184-199). New York; Oxford University Press.

Attwood, M. (2004) Suicide as a response to suffering. Western Buddhist Review, 4

Aviv, R. (2015). The Death Treatment. New Yorker, June 22, 2015, pp. 56-65.

Bacon, F. (1605, translated by D. Price, 1893). The advancement of learning. London: Casell.

Binding, K., & Hoche, A., (1920, translated by W.E. Wright, P. Deer, & R. Salomon, 1992). Permitting the destruction of unworthy life: its extent and form. Leipzig: Felix Meiner. Translation published in Issues in Law and Medicine, 8, 231-265.

Callahan, D. (2008).  Organized obfuscation: Advocacy for Physician-Assisted Suicide. Hastings Center Report, 38(5), 30-32

Canadian Medical Association (2011). Physician views on end-of-life issues vary widely: CMA survey

Carter v. Canada (Attorney General), 2015 Supreme Court of Canada 5, [2015] 1 S.C.R. 331. Case 35591.

Cholbi, M. (2012). Suicide. Stanford Encyclopedia of Philosophy.

Cohen-Almagor R. (2009). Belgian euthanasia law: a critical analysis. Journal of Medical Ethics 35, 436–439.

Dowbiggin, I. R. (2005). A concise history of euthanasia: Life, death, God, and medicine. Lanham, MD: Rowman & Littlefield.

Environics (2013). Canadians’ Attitudes towards End-of-life Issues. Ottawa: Environics.

Hume, D. (1777). Of suicide.

Kemp, N. D. A. (2002). Merciful release: The history of the British euthanasia movement. Manchester, UK: Manchester University Press.

Lee, B. C. (2014). Oregon’s experience with aid in dying: findings from the death with dignity laboratory. Annals of the New York Academy of Sciences, 1330, 94–100.

Lewis, P., & Black, I. (2013). Adherence to the request criterion in jurisdictions where assisted dying is lawful? A review of the criteria and evidence in the Netherlands, Belgium, Oregon, and Switzerland. Journal of Law, Medicine and Ethics, 41, 885-898.

Lindsay, R. A. (2009). Oregon’s experience: evaluating the record. American Journal of Bioethics, 9, 19–27.

Materstvedt, L., Clark, J. D., Ellershaw, J., Førde, R., Boeck Gravgaard, A.-M., Müller-Busch, H. C., Josep Porta i Sales, J., & Rapin C.-H. (2003). Euthanasia and physician-assisted suicide: a view from an EAPC Ethics Task Force. Palliative Medicine, 17, 97-101

McCarthy, J. (2014). Seven in 10 Americans back euthanasia: Support strong for past two decades.

Meeussen, K., Van den Block, L., Bossuyt, N., Echteld, M., Bilsen, J., & Deliens, L. (2010) Physician reports of medication use with explicit intention of hastening the end of life in the absence of explicit patient request in general practice in Belgium. BMC Public Health, 10, 186

More, T. (1516/edited by S. Duncombe, 2012) Utopia. Brooklyn, NY: Autonomedia.

New England Medical Journal (2013) Clinical decisions: Physician-assisted suicide. With commentary by Boudreau, J. D., & Somerville, M. A. (Physician-assisted suicide should not be permitted) and by Biller-Andorno, N. (Physician-assisted suicide should be permitted). New England Medical Journal, 368, 1450-1452.

Onwuteaka-Philipsen, B.D., Brinkman-Stoppelenburg, A., Penning, C., Jong-Krul, G.J., van Delden, J.J., & van der Heide, A. (2012) Trends in end-of-life practices before and after the enactment of the euthanasia law in The Netherlands from 1990-2010: A repeated cross-sectional survey. Lancet, 380, 908–915.

Pappas, D. (2012). The euthanasia/assisted suicide debate. Santa Barbara, CA: Greenwood (ABC-CLIO).

Pliny the Elder (79 CE, translated by Bostock, J. & Riley, T. H., 1855) Natural History.  Perseus Digital Library

Pichot, A. (2001, translated by Fernbach, D., 2009).The pure society: From Darwin to Hitler. London: Verso.

Proctor, R. (1988). Racial hygiene: Medicine under the Nazis. Cambridge, Mass: Harvard University Press.

Quill, T. E., & Greenlaw, J. (2008). Physician-assisted death. In M. Crowley (Ed.) From Birth to death and bench to clinic: the Hastings center bioethics briefing book for journalists, policymakers, and campaigns. (pp. 137-142).Garrison, NY: Hastings Center.

R vs Latimer (2001). Supreme Court of Canada [2001] 1 SCR 3 1 Case number 26980

Ramsay, B. (2015). On assisted suicide, Ottawa isn’t listening. Toronto Star, July 27, 2015.

Rodriguez vs British Columbia (1993). Supreme Court of Canada [1993] 3 SCR 519 Case number 23476.

Saad, L. (2013). U.S. Support for Euthanasia hinges on how it’s described: Support is at low ebb on the basis of wording that mentions “suicide.”

Somerville, M. A. (1993). The song of death: the lyrics of euthanasia. Journal of Contemporary Health Law and Policy, 9, 1-76.

Somerville, M. A. (2014). Exploring interactions between pain, suffering, and the law. In R. M. Green & N. J. Palpant (Eds.) Suffering and Bioethics. (pp. 201-229). New York; Oxford University Press.

Smith, W. J. (2006). Forced exit: Euthanasia, assisted suicide, and the new duty to die. New York: Encounter Books.

Stingl, M. (2010). Voluntary and nonvoluntary euthanasia: is there really a slippery slope? In M. Stingl (Ed.) The price of compassion: Assisted suicide and euthanasia. (pp. 141-158). Peterborough, ON, Canada: Broadview Press.

Thienpont, L., Verhofstadt, M., Van Loon, T., Distelmans, W., Audenaert, K., & De Deyn. P.P. (2015). Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 5, e007454.

Varelius J. (2014) Medical expertise, existential suffering and ending life. Journal of Medical Ethics, 40, 104–107.

Williams, S. D Jr. (1870) Euthanasia. In Essays by Members of the Birmingham Speculative Club. (pp. 210-237). London: Williams & Norgate.

Young, R. (2012). Voluntary euthanasia. Stanford Encyclopedia of Philosophy.

 




Camille Claudel

cesar camille xb

 

The photograph is striking. A young woman stares defiantly at the camera. One feels her passion and her sensuality. Her unkempt hair is tied back from her eyes. She is in working clothes but for the camera she has wrapped a scarf around her neck and fixed it with a pin. The photographer went by the name of César, but nothing else is known about him. The photograph was taken in 1883 or 1884. The Rodin Museum in Paris has an albumen print. The photograph was published in 1913 in the Parisian journal L’Art Décoratif (Claudel, 1913b).

 

 

 

 

The subject was Camille Claudel (1864-1943). Her younger brother remembered her:

this superb young woman, in the full brilliance of her beauty and genius … a splendid forehead surmounting magnificent eyes of that rare deep blue so rarely seen except in novels, a nose that reflected her heritage in Champagne, a prominent mouth more proud than sensual, a mighty tuft of chestnut hair, a true chestnut that the English call auburn, falling to her hips. An impressive air of courage, frankness, superiority, gaiety. (Paul Claudel, introduction to the 1951 exhibit of Camille’s sculpture, quoted in Claudel, 2008, p. 359).

At the time of the photograph, Camille was twenty. For two years, she had been learning to sculpt, sharing a studio with the English student Jessie Lipscombe, and studying with the sculptor Alfred Boucher, one of the few art teachers in Paris willing to tutor women. When Boucher left Paris for a year in Florence in 1882, he recommended his student to Auguste Rodin (1840-1917). Camille Claudel became Rodin’s student, his model, his lover, his muse and his colleague.

Ten years later Camille left Rodin, and set herself up in her own studio. Rodin tried to send commissions her way, and for several years she was able to work productively. After successful exhibitions in the Galerie Eugène Blot in 1905 and 1908, however, Camille became withdrawn and unable to work. She became convinced that Rodin and his “gang” were trying to steal her ideas. She destroyed many of her maquettes. She boarded up her studio and lived in dirt and squalor, coming out only at night. In 1913, her family had her forcibly committed to an insane asylum near Paris. With the onset of the war, Camille was transferred to the Montdevergues asylum in Provence. There she remained until her death in 1943 at the age of 79.

Passion

The affair between Rodin and Camille was well known to their colleagues. However, it was hidden from society, and little documentation survives to describe their passion. Novelists (Delbée, 1982/1992; Webb, 2015), musicians (Heggie & Scheer, 2012) and actors (Anne Delbée, 1982; Isabelle Adjani in Nuytten, 1988/2011; Juliette Binoche in Dumont, 2013) have imagined what it was like to be Camille, but we remain unsure.

Camille’s position in the affair was by far the more precarious. Rodin already had a mistress – Rose Beuret, a former model. She tolerated Rodin’s affairs but maintained the right of primacy. Rose was indeed considered by many to be Rodin’s wife, although they were not formally married until 1917 (just before both Rodin and she were to die).

Camille came from a conservative Catholic family. Her desire to be an artist ran counter to her family’s wishes. When they learned of her affair with Rodin, they were completely scandalized. Only her father continued to support her both emotionally and financially. Camille spent much effort trying to persuade Rodin to give up Rose, but to no avail. However, she did get Rodin to agree briefly to a “contract” in 1886, wherein he promised that

I will have for a student only Mademoiselle Camille Claudel and I will protect her alone though all the means I have at my disposal through my friends who will be hers especially through my influential friends (Ayre-Clause, 2002, p.71).

The social position of an unmarried woman artist was extremely difficult. Rodin could do as he pleased. Having affairs with beautiful women was one of his pleasures. Camille had no freedom. Even my treatment of the couple shades easily into such differences – I refer to her by her first name and him by his last. (Part of this is to avoid confusion with Camille’s brother Paul, but part is probably because I have picked up the viewpoint of fin-de-siècle France. This issue is discussed by Wilson, 2012.)

Rodin’s passion for his muse was intense. Camille’s biographer Odile Ayre-Clause (2002, p. 60) quoted a recently recovered letter from Rodin to Camille. This appears to have followed one of their quarrels:

Have pity, cruel girl, I can’t go on, I can’t spend another day without seeing you. Otherwise the atrocious madness. It is over, I don’t work anymore, malevolent goddess, and yet I love furiously. My Camille be assured that I feel love for no other woman, and that my soul belongs to you. … Ah! Divine beauty, flower who speaks and loves, intelligent flower, my darling. My dear one, I am on my knees facing your beautiful body which I embrace.

Their physical passion was allied to creative cooperation. Similar themes occur in the work of both artists. Perhaps the most striking parallel is found between Camille’s Sakuntala and Rodin’s Eternal Idol. Camille’s sculpture is based on an Indian legend about a king who married the maiden Sakuntala, but then was cursed and lost the memory of both his wife and his son. Ultimately the curse was lifted, and the sculpture depicts the moment of their reconciliation.

sakuntala idol x

Rodin’s sculpture has no clear derivation. Rainer-Maria Rilke, who served as Rodin’s secretary from 1902-1906, described its effect:

A girl kneels, her beautiful body is softly bent backward, her right arm is stretched behind her. Her hand has gropingly found her foot. In these three lines which shut her in from the outer world her life lies enclosed with its secret. The stone beneath her lifts her up as she kneels there. And suddenly, in the attitude into which the young girl has fallen from idleness, or reverie, or solitude, one recognizes an ancient, sacred symbol, a posture like that into which the goddess of distant, cruel cults had sunk. The head of this woman bends somewhat forward; with an expression of indulgence, majesty and forbearance, she looks down as from the height of a still night upon the man who sinks his face into her bosom as though into many blossoms. He, too, kneels, but deeper, deep in the stone. His hands lie behind him like worthless and empty things. His right hand is open; one sees into it. From this group radiates a mysterious greatness. One does not dare to give it one meaning, it has thousands. Thoughts glide over it like shadows, new meanings arise like riddles and unfold into clear significance. Something of the mood of a Purgatorio lives within this work. A heaven is near that has not yet been reached, a hell is near that has not yet been forgotten. [Ein Himmel ist nah, aber er ist noch nicht erreicht; eine Hölle ist nah, aber sie ist noch nicht vergessen.] Here, too, all splendour flashes from the contact of the two bodies and from the contact of the woman with herself. (Rilke, 1907/1919, pp 42-43).

At the time that she was ending the affair with Rodin, Camille was working on a sculptural ensemble called the L’Age mûr (Maturity). It depicts a man being led away from a pleading young woman by an old woman. The figure of the young woman was also reproduced by itself as L’Implorante (Supplicant). The ensemble can be interpreted as fate leading man away from youth toward death. However, it is impossible not to see the Rose Beuret, Rodin and Camille in the figures.

agemur b

Achievements

lavalse b

 

After her break with Rodin, Claudel worked as an independent artist. She had very little money to support large bronze castings and her major sales involved small pieces for tabletop. Camille became adept at creating sculptures for personal rather than public enjoyment. Two pieces are worth noting. The first is The Waltz, several copies of which were cast in bronze. One graced the piano of Claude Debussy. Its fascination lies in the way it combines both movement and stillness.

 

 

 

This sculpture is evoked in the song cycle Camille Claudel: Into the Fire (Heggie & Scheer, 2012), recorded by Joyce DiDonato and the Alexander Quartet. The following is a brief excerpt:

Is it in the spirit?
Is it in the flesh?
Where do I abide?
Console.
Oh, console my eyes with beauty.
Allow me to forget
That every dance of love
Is mingled with regret.

pensee profonde b

 

Another piece – Deep Thought – shows a young woman kneeling before a fireplace. The piece combines both bronze and onyx in a marvelous mix of texture. It is difficult to say why this resonates so deeply. Perhaps it suggests the dreams of what might be or what might have been.

 

 

Paul Claudel described his sister’s achievement in terms of its “inner thought:”

Just as a man sitting in the countryside employs, to accompany his meditation, a tree or a rock on which to anchor his eye, so a work by Camille Claudel in the middle of a room is, by its mere form, like those curious stones that the Chinese collect: a kind of monument of inner thought, the tuft of a theme accessible to any and every dream. While a book, for example, must be taken from the shelves of our library, or a piece of music must be performed, the worked metal or stone here releases its own incantation, and our chamber is imbued with it. (Claudel , 1913b, translated by Richard Howard in Paris, 1988).

Paranoia

For a sculptor, large compositions were essential to recognition and success. The sales of the small pieces did not bring in very much money, and Camille’s stipend from her father was not large. She lapsed into poverty, depression and paranoia. She attributed her lack of success to Rodin, whom she accused of stealing her work and making money by re-casting her sculptures and selling them to “his pals, the chic artists” (letter to Paul Claudel, 1910, quoted in Paris, 1984/1988, p 132). By 1913, Camille’s condition was dire. Dr. Michaux, the physician who certified that she should be committed to an asylum, said that she had sealed up the windows of her studio, had sold everything except for an armchair and a bed, never washed, never went out except by night, and often went without food (Wilson, 2012).

Camille’s father died on March 2, 1913. As soon as this last support was gone, the Claudel family quickly moved to have Camille committed. On March 10 Camille was forcibly interned in an asylum near Paris. Her diagnosis was paranoid psychosis. Some of her supporters voiced objections, but these came to naught. When the war began Camille was transferred to the Montdevergues asylum in the south of France, where she remained until she died in 1943.

At the asylum, Camille continued to have paranoid thoughts about Rodin. After Rodin died in 1917, Camille transferred her suspicions to his followers (and to various Protestant and Jewish cliques). She insisted on preparing her own food, since she was afraid that her enemies were trying to poison her. Nevertheless, much of the time Camille was quite rational. She was never aggressive or violent. Her doctors continuously recommended that she be taken back to live with the family, or at least transferred to a hospital near the family, where she could be visited more easily. The family refused any such suggestions. For fear of scandal, they insisted that Camille not be allowed to send or receive mail from anyone other than her brother and mother. Paranoia sets up positive feedback loops: when patients perceive that people are acting against them, they actually often are.

Paranoid thinking is common. Delusions of persecution occur more frequently than delusions of grandeur. About 10-15% of people harbors thoughts that they are persecuted (Freeman, 2007). Most of these do not require treatment. Modern cognitive psychology considers persecutory delusions to be largely caused by a willingness to “jump to conclusions” when entertaining theories about the origin of stress (Freeman & Garrety, 2014). Additional factors are social isolation, which decreases the chance of anyone providing meaningful feedback, and a lack of sleep, which leads to dream-like rather than rational thought.

Paranoia is a continuum. Although many people with mild delusions can function normally, more ingrained delusions can lead to problems adjusting to society. In the past, mild forms of paranoia were considered paranoid personality disorder, and more severe forms paranoid psychosis, although these specific diagnostic categories are no longer recognized. The psychiatrists Lhermitte and Allilaire (1984) reviewed the psychiatric history of Camille Claudel and came to a diagnosis of paranoid psychosis.

In 1929, Camille’s old friend and colleague, Jessie Lipscomb, who had returned to England and married, found out where Camille was hospitalized. She and her husband then visited her in Montdevergues. Jessie insisted after their reunion that Camille had shown no signs of madness. Jessie’s, husband, William Elborne, took two photographs. One shows Camille alone, seated with her arms folded. The other shows Camille and Jessie seated together. As noted by Ayre Clause (2002, p.231):

With her arms folded around herself, Camille does not seem to see Jessie’s hand softly reaching out to her. The long years of isolation have taken their toll; Camille looks empty and withdrawn.

elborne photos

Social isolation is probably the worst approach to treating paranoia. Somehow, the patients must be induced to interact with others. They must learn to consider themselves as others see them. Clearly this must be commenced gently with a therapist whom the patient trusts. The treatment must try to decrease the ingrained suspicion of others, and to help the patient to use more rational modes of thought.

None of this was available in Montdevergues. Most of the inmates were far more psychotic than Camille. She lived in a veritable hell. She wrote in 1934 to Eugène Blot, the owner of the gallery where she had exhibited her work:

Je suis tombée dans le gouffre. Je vis dans un monde si curieux, si étrange. Du rêve que fut ma vie, ceci est le cauchemar.  I have fallen into the abyss. I live in a world so curious, so strange. Of the dream that was my life, this is the nightmare. (quoted by Morel, 2009).

Compassion

The position of Claudel family toward Camille is difficult to understand (Lhermitte & Allilaire, 1984; Schmoll gen. Eisenwerth, 1994, pp 109-114; Ayre-Clausse, 2002, pp 237-253). Camille’s mother was so scandalized by her daughter’s behavior and so constrained by her rigid religion that she never once visited her in hospital. Louise also could not bring herself to have anything to do with her wayward sister. Some of this rejection reflected the way mental disorders were considered at the time (Lhermitte & Allilaire, 1984): mad relatives were hidden away from society and ignored.

Paul Claudel (1868-1955) was Camille’s younger brother. In 1886, at the age of 18, he experienced a mystical revelation while listening to the Magnificat in Notre Dame, and thenceforth was a devoted Catholic. He became a renowned poet (e.g., Claudel, 1913a) and playwright (e.g., Claudel, 1960). His poetry is impressive: he used a new form of blank verse with the length of the line related to the time it takes to speak the line before taking a breath. His poetry has the sound of litany and incantation. At times, however, the writing becomes tedious, so closely is it related to his religious beliefs. Paul became a professional diplomat, representing France in the United States, China, Brazil, Denmark and Tokyo. Despite his devoutness, he carried on a long adulterous affair with a married woman, until she finally broke of their relationship.

Paul was Camille’s favorite sibling. One of her first major sculptures was a bust of Paul as a young Roman. Paul promoted his sister’s career, writing articles in magazines glorifying her sculptures (e.g., Claudel, 1913b).

Despite their closeness as children and despite his enthusiasm for her art, Paul had little to do with Camille after she was admitted to Montdevergues. He visited her only a few times, and refused all of her requests to be released or transferred closer to the family. Some of this may have been related to his diplomatic appointments, but he did not visit even when he retired and he settled down in France in 1936. This lack of compassion is strange in a man so religious. Sometimes the mystic forgets himself in his visions and forgets to care for others.

paulclaudel b

 

In a photograph taken in 1951, the elderly Paul Claudel holds onto a bust Camille made of him when he was young. The photograph is imbued with regret. Yet it is not clear whether it is for himself or his sister.

 

 

 

Farewell

We should not leave Camille without seeing her as she was in her time of passion and creation. One of the most insightful impressions of Camille is a plaster cast by Rodin, a portrait of Camille, aptly entitled The Farewell. Both the hands and the face are exquisitely moulded. The sculpture is ambiguous. Are the hands reaching up to stop the tears, to shut out the world, or to gather something in?

rodin adieu

References

Ayral-Clause, O. (2002). Camille Claudel: A life. New York: Harry N. Abrams.

Claudel, C. (2008). Camille Claudel: 1864-1943. Paris: Musée Rodin (Gallimard).

Claudel, P. (1913a). Cinq grandes odes: Suivies d’un processionnal pour saluer le siècle nouveau. Paris: Gallimard.

Claudel, P. (1913b). Camille Claudel: statuaire. L’Art Décoratif. Revue de l’art ancient et de la vie artistique moderne. 30 (July, 1913), 5-50.

Claudel, P. (translated by W. Fowlie, 1960). Two dramas: Break of noon (Partage de midi) The tidings brought to Mary (L’annonce faite à Marie). Chicago: H. Regnery.

Delbée, A. (1982, translated by Cosman, C., 1992). Camille Claudel: Une femme. San Francisco: Mercury House. Delbée also acted in the play Une Femme from which this novel derives.

Dumont. B. (2013). Camille Claudel 1915 (videorecording) Montréal: TVA Films.

Freeman, D. (2007). Suspicious minds: the psychology of persecutory delusions. Clinical Psychology Review, 27, 425–457,

Freeman, D., & Garety, P. (2014). Advances in understanding and treating persecutory delusions: a review. Social Psychiatry and Psychiatric Epidemiology, 49, 1179–1189.

Heggie, J., & Scheer, G. (2012) Camille Claudel: Into the fire. Music for mezzo-soprano and string quartet. San Francisco: Bent Pen Music. Performed by Joyce DiDonato and the Alexander Quartet on the CD: Here/after: Songs of lost voices. Baarn, Netherlands: Pentatone Classics.

Lhermitte, F., & Allilaire, X. (1984). Camille Claudel: Malade mentale. In Paris, R.-M: Camille Claudel: 1864-1943. (pp. 155-208). Paris: Gallimard. (This article is not included in the English translation of the book.)

Morel, J.-P. (2009).Camille Claudel: Une mise au tombeau. Bruxelles: Impressions nouvelles.

Nuytten, B. (1988/2001). Camille Claudel. (videorecording). Santa Monica, CA: MGM Home Entertainment.

Paris, R.-M. (1984, translated by Tuck, L.E., 1988). Camille: The life of Camille Claudel, Rodin’s muse and mistress. New York: Seaver Books.

Rilke, R. M. (1907, translated by J. Lemont & H. Taussig, 1919). Auguste Rodin. New York: Sunrise Turn.

Schmoll gen. Eisenwerth, J. A. (1994, translated by J. Ormrod). Auguste Rodin and Camille Claudel. Munich: Prestel-Verlag.

Webb, H. (2015). Rodin’s lover. New York: Plume.

Wilson, S. (2010). Camille Claudel: ‘Du rêve que fut ma vie, ceci est le cauchemar’ In S. Wilson (Ed.): Voices from the Asylum: Four French Women Writers, 1850-1920. (pp. 184-221). New York: Oxford.

 




Freudian Legacies

Sigmund Freud made significant contributions to our understanding of how the human mind works (Gay, 1988). Recently, however, his ideas have come under intense criticism. Eysenck (1985), MacMillan (1991), Fisher and Greenberg (1995), Webster (1995), Andrews and Brewin (2000) and Gomez (2005) review the issues (with different degrees of politeness and different conclusions). This post comments on some of Freud’s contributions.

cerny freud

The photograph shows the Czech sculptor David Černý’s Hanging Man (1997) in its original location high above Husova Street in Prague. Copies have since been exhibited in various other cities. It is a life-size sculpture of Sigmund Freud, hanging from his right hand which grasps a beam projecting over the street. He seems unconcerned by his precarious position, his left hand remaining insouciantly in his pocket. Like most artists, Černý is noncommittal about the meaning of his art. According to some, the sculpture may represent the role of the intellectual in modern society. Freud goes often unattended, but when noticed he tends to shock. He considers ideas that are not grounded in the normal world; yet he is comfortable in his own thinking.

 

 

(i) The Unconscious

Freud proposed that the unconscious controls much of what we do. He did not invent the unconscious but he certainly demonstrated how great a role it plays in our thinking. Current scientific psychology has recognized how much of our thinking is unconscious. Most of our mental processes occur automatically without ever entering consciousness. Most of our memories are implicit and affect our thought and behavior without our ever noticing. Most of our motivations exercise their effects without our knowing. Westen (1999) reviews the extensive role of the unconscious in modern cognitive psychology.

The unconscious mediates what Freud called the “psychopathology of everyday life.” Unconscious activity often shows up in everyday speech, especially when we are not closely monitoring what we say. We currently use the term “Freudian slip” for those speech mistakes (parapraxes) with a sexual meaning: “we must encourage the breast (instead of best) and the brightest.” However, sex is not the cause of every mistake. There are often other things on our unconscious minds.

Free association, a key procedure in psychoanalytic therapy, may be a productive way for discovering what is active in the unconscious but not readily accessible. Relaxing on a couch and talking about the first thing that comes to mind may be as good a way as any for a patient and therapist to begin to talk.

The defense mechanisms described by Freud and his daughter Anna are the cognitive processes we use for handling stress. Repression, regression, sublimation, rationalization, and somatization all seem to be ways that the mind uses to cope with unwanted desires, to shield us from traumatic memories, and to reduce anxiety.

Dream recall may be an efficient way to trigger free associations. The experience of the dream may reflect what is active in our unconscious. Furthermore the retelling of a dream probably taps into all sorts of other mental information in addition to the actual dream. However, the interpretation of dreams is not the royal road to the unconscious. Freud proposed that a dream could represent the fulfillment of a repressed wish or it could mean exactly the opposite. In either case it could be disguised as something else. With such guidelines, dreams can be interpreted in an infinite number of ways.

Many of Freud’s dream-interpretations seem without any justification. Perhaps, the most famous of the dreams is Sergei Pankejeff’s recurrent nightmare of the white wolves in the tree outside his bedroom window (Gardiner, 1971). The patient drew a sketch of the dream for Freud during his 1910-1914 analysis. Many years later in 1964 he made a painting (shown below), which now hangs in the Freud Museum in Hampstead, London. Freud linked the dream to an eighteen-month-old infant’s memory of seeing his parents copulating. The interpretation seems far-fetched. Perhaps it betrays more the mental associations of the analyst than the repressed memories of the patient. The Wolfman later stated that the supposed memory was unlikely since his cot was in the nurse’s room and not his parent’s bedroom (Obholzer & Pankejeff, 1982, p. 36). We cannot consciously remember events before the age of about two or three years – “infantile amnesia.” Freud claimed that this specific memory from infancy was unconscious, but this was speculation without any corroboration.

3_6_Pankejeff_My_Dream 1964

(ii) Mechanisms of Memory

Freud’s views of childhood sexual abuse provide an intriguing case history on the difficulty of determining truth and the problems of memory (Gleaves & Hernandez, 1999). In his initial writings, Freud acknowledged that children had been sexually abused by their fathers, and suggested that this might be the cause of conversion hysteria. This formed the basis of the seduction theory. Later papers proposed that the abuse was fantasized rather than real, and that the fantasies were the effects of repressed desires on the part of the child. Freud has been both praised for recognizing the reality of childhood sexual abuse and criticized for later suppressing these ideas.

Why did Freud change his ideas? Was the change based on new evidence? Recent psychological investigations of false memories have shown how what we remember may not be what actually happened. Freud himself recognized that the physician may suggest the memories and that the patient may invent them. The actual events behind his patients’ histories are now impossible to determine. Freud’s change of theory may also have been caused by his (consciously or unconsciously) succumbing to social pressures. Viennese society was extremely strait-laced and did not wish to deal with the problem of childhood sexual abuse. One thing that is lost in the controversies is whether the new theory of repressed fantasies rather than repressed memories could explain the available data better than the old. Freud clearly thought that in many cases it did.

The incidence of childhood sexual abuse is likely higher than our sense of morality and decency would suggest. This has led to the idea that many psychological disorders in adulthood may be due to repressed memories of actual (not fantasized) abuse during childhood. Though such cases can occur, memories that are recovered during therapy are often not repressed memories of actual events but imagined memories suggested by the therapist (Crew, 1995).

If we accept that memories can be true or false, it is impossible to evaluate patient’s histories without some corroboration. Freud thought that the new theory was true because it led to success in treatment. Psychoanalytic success typically involved the cessation of symptoms once the patient and analyst came to a convincing interpretation of the symptoms in terms of repressed desires, and a re-integration of the personality so that such desires can be more effectively handled.

(iii) Psychoanalytic Therapy

Nowadays, the success of psychoanalytic treatment is not really clear. Psychoanalysis is resistant to scientific evaluation. In the last lecture of A General Introduction to Psychoanalysis Freud stated that each patient is unique, and “statistics would be valueless if the units collated were not alike.” People are too different from each other to allow comparable treatment groups. Family interactions are too complex to control. Anecdotal evidence of psychoanalytic cures abound. Yet analysts have a biased view of their ability, and patients do not wish to admit that the treatment has been unhelpful despite the huge investment of time and money. Objective outcome measurements are difficult to establish. We can measure improvement in the level of the symptoms and the quality of life. However, does improvement mean that a patient has recovered? Can a patient who has regained some semblance of normality still remain abnormally susceptible to stress?

Studies evaluating psychotherapy using various outcome measurements have shown that it has a beneficial effect compared to no therapy (Wampold, 2001, 2007). The “talking cure” that began with Josef Breuer and Bertha Pappenheim works. However, the different types of therapy (those involving psychoanalytic theory and those not) are similar in the amount of benefit they provide. In patients with major depression, a large NIMH study (Elkin et al., 1989) compared two different psychotherapies (cognitive behavioral therapy and interpersonal psychotherapy), routine clinical management with imipramine and routine clinical management with placebo. The psychotherapy sessions were conducted weekly and lasted one-hour. The clinical management sessions were also weekly and lasted 20-30 minutes. The diagram shows some of the results, based on one of the several scales used in the study. All “treatments” led to improvement, even the placebo. The two psychotherapies and the active pharmacological treatment tended to be significantly better than placebo (though the tests were borderline and varied with the scales used to rate the severity of the depression). Part of the placebo effect may have been related to the passage of time, and part to the minimal psychotherapy involved in the once weekly brief meetings with the physician. The pharmacological treatment condition was better in patients with more severe depression. The results were variable and the differences between conditions were statistically borderline (and varied with the scales).

nimh study
The study is typical. Psychotherapy has a beneficial effect. However, this effect is variable and sometimes different to demonstrate. Furthermore, there are often no clearly demonstrable differences between different types of therapy.

dodo bird xBruce Wampold (2001) described the lack of statistical difference between different therapies as the “Dodo bird verdict,” quoting an earlier paper of Saul Rosenzweig (1936). The reference is to Chapter 3 of Lewis Carroll’s Alice in Wonderland. When asked to determine who had won the “caucus-race” (a competition with no rules or measurements), the Dodo bird thought for a long while and finally decided that “Everybody has won, and all must have prizes”

The general idea of the talking cure is good, but it seems much less used in psychiatry in recent years, particularly in North America. This is unfortunate since for non-psychotic mental disorders the talking cure is probably as good as any pharmacological treatment. Even for psychosis, where medication is essential, the talking cure still helps. Nowadays, the interactions between psychiatrist and patient often serve only to assess symptoms, adjust medications and monitor side-effects. Psychotherapy (of whatever kind) is often not the primary activity.

The fact that all therapies work regardless of the type suggests that the beneficial effect is due to the interaction between the patient and a therapist. What makes a therapist good and the therapy beneficial remains difficult to determine. Clearly the therapist should be rational, sympathetic and supportive. The precise system of therapy does not seem to matter. Perhaps there may be some interaction with the personality of the patient. Some patients may do better with some system of therapy than with another. The therapist must have some bona fide training. The patient should not be treated by any mad charlatan who claims to be a therapist. And we need further evidence-based studies will determine which therapy is better for which patient (Hunsley & DiGiulio, 2002).

Most of the studies comparing different kinds of psychotherapy consider periods of time much briefer than used in classical psychoanalysis. “Psychodynamic therapy” is informed by psychoanalytic ideas but much briefer and much less intense. Although earlier studies have found otherwise, a recent meta-analysis has suggested that a prolonged course of analysis lasting for a year or more has no more benefit than a brief period of therapy lasting several weeks (Smite al al., 2012). On any cost-benefit evaluation, however, classical psychoanalysis involving multiple meetings per week and lasting over multiple years would fare very poorly.

The French Institute of Health recently evaluated published scientific studies of three different types of psychotherapy: psychodynamic therapy, cognitive behavioral therapy and family counseling. Their report (INSERM, 2004) proposed that cognitive behavioral therapy was the best approach to many different mental disorders and that psychodynamic therapy was never the preferred treatment. The report triggered a tremendous controversy (Meyer, 2005; Miller, 2006). Psychoanalysts claimed that a treatment that involved reprogramming and conditioning was inhumane; the opposition said that psychoanalysis was pseudoscience. Cognitive behavioral therapy (Beck, 2011) is designed to help patients cope with their symptoms and prevent their exacerbation. Symptoms are alleviated by training the patients to re-interpret the situations under which these symptoms become manifest. This type of therapy is clearly going to do well on studies with outcome measures that assess the severity of symptoms. The goal of psychoanalysis is a long-term re-education or re-integration of the personality. Psychoanalytic therapy might have done better with outcome measures that assess a patient’s understanding of self and of others (e.g. Berggraf et al., 2014)

(iv) Addiction to therapy

One of the difficulties with any psychotherapy is that it fosters an emotional dependence on the therapist that can become unhealthy. The patient may become unable to live without a weekly session with the therapist. This problem was recognized early in the history of psychoanalysis. The Viennese satirist Karl Kraus (1913) proposed that psychoanalysis is the mental illness whose cure it purports to be (“Psychoanalyse ist jene Geistekrankheit, für deren Therapie sie sich hält”). Even with client-centered therapy, the therapist generally remains the dominant person in the interaction. Psychotherapy has some relations to religion, with confession followed by interpretation rather than absolution.

Some therapies become cults. The patient becomes enslaved to a particular system of thought. Scientology started as a treatment procedure, and therapy continues as a main activity in the movement. Scientology proposes that a person’s achievements may be held back by memories or “engrams” (from early childhood or from another life). The goal of the therapy is to discover (or “audit”) these impediments by using an “e-meter” (a simple psychogalvanometer). Once identified these impediments can be removed (or “cleared”) by therapy, allowing the patient to become a more complete human being (or “thetan”). Therapies are paid for – a patient who is not willing to pay is not going to be cured. As far as I can understand, scientology is nonsense. It exists not to cure the sick but to allow an elite to make money and to exert power.

Although clearly different, scientology and psychoanalysis have some similarities. Both have a background theory that has not been experimentally tested. Both focus on the handling of anxiety. Both are based on a charismatic leader. Psychoanalysis can be beneficial and Scientology is malignant, but the similarities are very worrisome.

(v) Overview

What then is psychoanalysis? It is a system of thought and a way of treatment based on an imaginative interpretation of human development and culture. Psychoanalytic treatment interprets what has happened to a patient to lead to the present situation, and attempts to re-integrate the patient’s personality to reduce the conflict between unconscious desires and ideal goals. Even though Freud considered his work as science, it makes no hypotheses that can be refuted. In a sense anything can be explained. A dream may sometimes represent a wish fulfillment; at other times defense mechanisms may have sufficiently distorted its content to represent the complete opposite of wish-fulfillment.

Psychoanalysis has made significant contributions to our culture. First is the freeing of our minds so that we can recognize our desires, especially those that are sexual in nature. Second is the recognition that most of what we think and do is the result of unconscious processing. Third is the idea that talking to a sympathetic therapist can help us to understand ourselves and to attenuate the stress that results when desires and ideals come into conflict. Fourth is the description of a life narrative wherein we can realistically cope with our unconscious desires.

Psychoanalysis is imaginative rather than scientific According to John Irving, “Sigmund Freud was a novelist with a scientific background” (Plimpton, 1988). Freud’s interpretation of human development according to the story of Oedipus is a powerful metaphor. The meaning is in the way it helps us to see our life, not in how it represents what actually happens. The story of Oedipus encapsulates many aspects of the human condition. (The illustration shows Oedipus being questioned by the Sphinx on a drinking cup from around 470 BCE, Vatican museums, photographed by Carole Raddato).

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Jacques Lacan said many outrageous things about psychoanalysis. Within his hyperbole there are germs of truth. The post concludes with two quotations from his seminars:

La psychanalyse est à prendre au sérieux, bien que ce ne soit pas un science … parce que c’est irréfutable … c’est un pratique du bavardage. (Lacan 1979) [Psychoanalysis is to be taken seriously even though it is not a science … because its propositions cannot be falsified … it is an exercise in conversation. (I have attenuated the translation of “bavardage,” which means “chattering” or “gossip” to better portray the idea of the “talking cure” )]

Le psychanalyste ne doit jamais hésiter a délirer. (Lacan, 1977) [The psychoanalyst must never hesitate to imagine freely. (I have attenuated the hyperbolic “délirer” which means “become delirious”).

Psychoanalysis is an imaginative way of looking at human life that can help patients in distress and suggest ways to understand the workings of the mind.

 

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Eysenck, H. J. (1985). Decline and Fall of the Freudian Empire. New York: Penguin.

Fisher, S., & Greenberg, R.P. (1996). Freud scientifically reappraised: Testing the theories and the therapy. New York: Wiley

Freud, S. (1922, translated by Riviere, J., 1935). A general introduction to psychoanalysis. New York: Liveright.

Gardiner, M. (Ed.). (1971). The Wolf-Man by the Wolf-Man. New York: Basic Books (Contains Freud’s original case history from 1918 and an interview with the patient)

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Gomez, L. (2005). The Freud wars: An introduction to the philosophy of psychoanalysis. London: Routledge.

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INSERM Collective Expert Reports (2004). Psychotherapy: Three approaches evaluated. Paris: Institut national de la santé et de la recherche médicale.

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Macmillan, M. (1991). Freud Evaluated: The Completed Arc. Amsterdam: North Holland.

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Miller, J.-A. (Ed.) (2006). L’anti-livre noir de la psychanalyse. Paris: Le Seuil.

Obholzer, K., & Pankejeff, S. (1982). The Wolf-Man: Conversations with Freud’s patient – sixty years later. New York: Continuum.

Plimpton, G. (1988) Interview with John Irving. In: Writers at Work: The Paris Review Interviews, Eighth Series. New York: Penguin.

Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6, 412–415.

Smit, Y., Huibers,M. J., Ioannidis, J. P., van Dyck, R., van Tilburg, W., & Arntz, A. (2012) The effectiveness of long-term psychoanalytic psychotherapy – a meta-analysis of randomized controlled trials. Clinical Psychology Review, 32, 81-92

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Erlbaum Associates.

Wampold, B. E. (2007). Psychotherapy: the humanistic (and effective) treatment. American Psychologist, 62, 855-873.

Webster, R. (1995). Why Freud was wrong: Sin, science, and psychoanalysis. New York, NY: BasicBooks.

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Story of Anna O

Bertha PappenheimThe case of Anna O., reported by Josef Breuer and Sigmund Freud in their1895 book Studies on Hysteria, provides the initial evidence for the effectiveness of psychoanalytic treatment. The patient’s actual name was Bertha Pappenheim (Gay, 1988; Jones, 1953). For the case study, her initials were shifted one letter earlier in the alphabet, and she was given the pseudonym Anna. Since the publication of her story, so many people have given their opinion of what was wrong with her that truth is difficult to determine in the welter of interpretation (recent review by Skues, 2006).

In 1880, at the age of 21, Bertha Pappenheim became the patient of Josef Breuer. Breuer was 38-years old, a respected Viennese physician, famous for his earlier work in physiology. In 1868 he had shown that inflation of the lungs trigger pulmonary stretch receptors which through the vagus nerve then inhibit the inspiratory centers of the lower brainstem (Hering-Breuer reflex). In 1874 he had shown how the vestibular system was related to the sense of balance and not hearing (Mach-Breuer hypothesis). After his researches, Breuer had become a conscientious and caring physician. He described his new patient:

She was markedly intelligent, with an astonishingly quick grasp of things and penetrating intuition … She had great poetic and imaginative gifts which were under the control of a sharp and critical common sense … Her will-power was energetic, tenacious and persistent  (Freud Standard Edition Volume II, p. 21)

Anna’s history was complex. She had been nursing her father who was ill with tuberculosis when her symptoms began, and who went on to die while she was being treated. Before she presented to Breuer, she had suffered from brief periods where she was apparently unaware – Breuer termed them “absences.” At the time of her treatment, she alternated daily between normal periods and prolonged spells of self-induced “hypnosis,” wherein she experienced strange aphasic symptoms, hallucinations and left-sided weakness. Breuer interacted with her during these periods and together they traced the history of each symptom:

She aptly described this procedure, speaking seriously, as a ‘talking cure’, while she referred to it jokingly as ‘chimney-sweeping’. (p.30)

These descriptive terms were originally in English, in which Anna was fluent. As Anna remembered the situation wherein the symptom had begun, the hysterical phenomenon disappeared:

Each individual symptom in this complicated case was taken separately in hand; all the occasions on which it had appeared were described in reverse order, starting before the time when the patient became bedridden and going back to the event which had led to its first appearance. When this had been described the symptom was permanently removed. In this way her paralytic contractures and anaesthesias, disorders of vision and hearing of every sort, neuralgias, coughing, tremors, etc., were “talked away.” (p. 35)

At the end of the case history, Breuer and Freud speculated about the mechanisms of hysterical symptoms and their treatment. The patient showed evidence of a secondary state of mind with “its wealth of imaginative products and hallucinations, its large gaps of memory and the lack of inhibitions and control in its associations” (p. 45) This “unconscious” state intruded into her normal state of mind to cause her hysterical symptoms.

Breuer and his patient interacted intensely over many, many  hours. It is difficult not to speculate that the relationship between Anna and Josef went deeper than that between physician and patient. Breuer’s involvement with Anna plays an essential role in Yalom’s novel When Nietzsche Wept.

Breuer’s wife became jealous of his fascination with the young woman, and Breuer stopped the treatment. The end of their relationship was terrifying. Anna appears to have undergone an hysterical pregnancy and miscarriage. Later psychoanalytic thought would consider such phenomena in terms of transference and counter-transference.

The case of Anna O marks the beginning of psychotherapy. Reliving the emotions of a past trauma released them. After this catharsis, the repressed emotions no longer needed to manifest themselves in somatic symptoms.

However, Bertha continued to experience various symptoms and her treatment was continued in a Swiss sanatorium (to which she had been referred by Breuer after he ceased to be her physician). Later psychoanalytic thought would suggest that the psychotherapy had not worked because it had not discovered the real repressed emotions – inhibited sexual desires for her father rather than grief at his illness. Furthermore, the goal of psychotherapy evolved not just to release the anxieties that well up from the unconscious but to make the conscious mind understand and control these forces. The unconscious must become integrated into consciousness rather than simply liberated.

The case of Anna O. continues to be extensively interpreted. Some have suggested that she may have actually had a neurological rather than psychiatric disorder: tuberculous meningitis (extremely unlikely), epilepsy with complex partial seizures, or postinfectious encephalomyelitis (the various diagnoses are reviewed by Webster, 1996). Conversion hysteria may occur in conjunction with neurological disorders (Kanaan, 2009), but this is perhaps not as frequent as once was thought (Stone et al., 2005). Others have suggested that Anna’s conversion symptoms were part of a depressive illness (Merskey, 1992).

Many other factors were not fully evaluated in the original case history. Anna had been taking chloral hydrate to help her to sleep in the afternoons so that she could stay up at night to watch over her father. In addition, her facial pains had been treated with morphine. Drug dependence may have played a role in her symptoms and in her hypnotic states. Perhaps Anna’s absences were caused by psychomotor seizures (temporal lobe epilepsy) precipitated (and exacerbated) by drug withdrawal and sleep deprivation (Orr-Andrawes, 1987).

Anna O. ultimately led a very productive life (Kimball, 2000; Loentz, 2007). In 1888, Bertha Pappenheim and her mother moved from Vienna to Frankfurt, where Bertha became active in social work, running an orphanage and presiding over the Jüdische Frauenbund (League of Jewish Women). She was skeptical about psychoanalysis and opposed its use in the children under her care. Pappenheim wrote extensively on social issues and women’s rights. Her most important book dealt with the need to protect women from prostitution and white slavery (Sisyphus-Work).

Under the pseudonym Paul Berthold, Bertha Pappenheim wrote stories and a play Frauenrecht (Women’s Rights, 1899). The play has intriguing parallels to Bertha’s real or fantasized relations with Breuer. The protagonist, who has recently joined the Women’s Relief Society, asks her husband for some of the money that she brought to their marriage to support a sick young female worker and her illegitimate child. The husband refuses on principle. However, he does not realize that he is the father of the child.

Bertha Pappenheim suffered in her youth from a conversion disorder. Her symptoms were triggered by her grief at her father’s illness and her mourning for his death. The suggestion that her disorder was neurological rather than psychological is unlikely given its outcome. She became well. However, she was not cured by her physicians. Whatever psychotherapy occurred during her interaction with Josef Breuer, she had herself invented. Most impressive, however, was what came afterwards (Kimball, 2000). The photograph at the beginning of this article, taken in 1882 after her treatment with Breuer was over, shows an elegant and confident young woman in riding outfit. However, she still had a long way to go. Somehow, over the next five years, she was able to pull herself together, to stop taking the drugs she had been prescribed, and to find an outlet for her intelligence and will in social work.

 

Breuer, J., & Freud, S. (1895). Studien über Hysterie. (Studies on Hysteria). Translated and edited by Strachey, J., & Freud, A. (1955). The Standard edition of the complete psychological works of Sigmund Freud. Volume II. London: Hogarth Press. (Available at arkive.org)

Gay, P. (1988). Freud: A life for our time. New York: Norton.

Jones, E. (1953). Sigmund Freud: life and work. London: Hogarth Press.

Kanaan, R., Armstrong, D., Barnes, P., & Wessely, S. (2009). In the psychiatrist’s chair: how neurologists understand conversion disorder. Brain, 132, 2889-96.

Kimball, M. M. (2000). From “Anna O.” to Bertha Pappenheim: transforming private pain into public action. History of Psychology, 3, 20-43.

Loentz, E. (2007). Let me continue to speak the truth: Bertha Pappenheim as author and activist. Cincinnati: Hebrew Union College Press. Available through Google Books.

Merskey, H. (1992). Anna O. had a severe depressive illness. British Journal of Psychiatry, 161, 185-194.

Orr-Andrawes, A. (1987). The case of Anna O.: a neuropsychiatric perspective. Journal of the American Psychoanalytic Association, 35, 387-419.

Skues, R. A. (2006). Sigmund Freud and the history of Anna O: Reopening a closed case. Basingstoke, Hampshire: Palgrave Macmillan.

Stone J, Smyth R, Carson A, Lewis S, Prescott R, Warlow C, & Sharpe, M. . (2005) Systematic review of misdiagnosis of conversion symptoms and ‘‘hysteria.’’ British Medical Journal, 331, 989 (epub)

Webster, R. (1996). Why Freud was wrong: Sin, science and psychoanalysis. London: HarperCollins. (Chapter 4: Anna O. and the birth of psychoanalysis, pp 103-135).

Yalom, I. D. (1993). When Nietzsche wept. New York: HarperPerennial.