On special occassions

The last time I celebrated a birthday I was 10 years old. People have since asked me if I miss it, is my life boring, do I not receive or give gifts, how can I live a year without having one day of that year designated as special for me? And I’ll tell you honestly, I have not for one day missed it. I could tell you that I don’t enjoy ‘worldly’ so-called “special occasions” because of my religious beliefs, but that’s not the truth. I have in the last week, the week since turning thirty, further cemented my reasons for disliking these kinds of things.

A few years ago, in the week after the Christmas holidays, I found myself in a very interesting scenario while waiting in line at a bank. The bank had been closed a few days over the holidays so I figure that’s why it was particularly popular when it reopened. Tinsel, Christmas trees, coloured lights, and all sorts of Christmas paraphernalia were still around everywhere. Of course, in the week prior to this event the shops had been full of people buying things for others, songs about gifts and Santa (or Jesus), and huge banners reading things about “peace”, “love”, “goodwill”, “sharing”, the goodness of the human (or Christmas) spirit, etc., etc. The atmosphere had been set to inspire the best of humanity, albeit an atmosphere set up by commercial enterprises under the guise of being just a good concept, a religious tradition, a familial tradition, or a combination of any of those things… but I’m digressing.

So, as I waited in line at the bank, an argument broke out between two of the people waiting in line in front of me. I don’t even recall what the argument was about, but it was between a woman who looked to be in her 40s and a man of around 70. It was clear they were strangers to each others and pretty soon they were shouting, calling each other derogative and obscene names, and threatening violence towards each other. The rest of us in the bank stood stunned watching this scene. It continued until the old man said to the woman “Well, merry christmas to you, too”. His words pierced me very deeply because (to me, at lease) it highlighted the irony and hypocrisy of these special occasions.

You know what we do on special occasions? We give gifts. Gifts of our time, effort, material things, courtesy, respect, congratulation, thoughtful gesture, unselfish sacrifice. It’s wonderful to give these things – and to receive them! But… but, that’s exactly what breaks my heart about it. Is that all I’m worth? One day out of every 365? And it’s often not out of the ‘goodness of anyone’s heart’, but rather only because some external party has decided that a particular day constitutes a special occasion. Don’t get me wrong, though, I appreciate the good wishes as much as anyone else, I just can’t deny that some of it feels like tokenism. And you know what I wish most for in the world for my birthday, for Christmas, for Easter, for labour day, for Monday through to Sunday, January through to December? The essential things we all desire of each other every day: love, attention, respect, a smile, a minute of your time, and to know that I’m actually worthy of these things more than one day a year from those that mean a lot to me.

Thanks for your time, guys.

On telling

I remember as a medical student being told by a psychiatrist who was teaching us about clinical communication skills to always ask yourself “is this for the patient or for me?” A little bit of self-disclosure in clinical scenarios is helpful; it helps establish rapport, trust, and confidence that the person we have entrusted with our psychological care knows exactly what it’s like to be human. That’s the purpose of self-disclosure in medicine, that’s how we can justify telling patients our sins, our glories, and just our everyday occurrences. Besides that, all we are being paid to do is provide a clinical service of diagnosis and treatment. Needless to say, it’s not appropriate to start telling our patients intimate details about our personal lives and thus introduce potentially biasing information that will impact on the patient themselves or their views on us as their clinician or the clinical advise/treatment we provide. But this rule about what we tell and don’t tell got me to thinking to how it applies to life in general, not just as it applies to health professionals.

Two key features of a successful and happy relationship are honesty and trust. You want to be able to trust that your spouse/partner/friend/business associate/etc. is an honest person that does not lie or betray you, right? But at the same time you need to be able to trust that they won’t, otherwise the relationship will be ruined by the constant questioning of their (or your) honesty. Consider, for example, an ideal romantic partnership where the two people involved love and care for each other and have romantic interactions exclusively with each other (including sex, but also other forms of physical or psychological intimacy). That would be a good relationship, right? But what if a similar scenario arose where the two people involved in a romantic partnership love and care for each other and have romantic interactions exclusively with each other BUT the partners were repeatedly asking of the other: “have you slept with anyone else today?”, “have you told any lies to me today?”, “do you love me still today?”, etc. etc. Now, the other partner could repeatedly be honest and say “No”, but isn’t it likely that this good and honest relationship will be destroyed by the lack of trust?

Now consider a scenario where you have the trust but not so much the honesty. You could, for example, have two people who love and care for each other but their romantic interactions are not exclusive to each other. They may every once in a while have sex with other people. They don’t, however, ask of each questions of fidelity, it is only assumed – they assume the other person is honest or sexually monogamous or that they have romantic feelings only for them. You could say that these are either happy human beings or you could say that this is not a good relationship, even if the two parties seem outwardly happy with themselves and each other. You may say that even if everyone it is happy then that happiness is invalid because it is predicated on dishonesty – or better said: lack of honesty.

This ‘happy couple’ to me poses a very interesting human dynamic, because as happy as the members of this couple are and as happy as the whole scenario is, it often fails. And it doesn’t fail because of dishonesty or mistrust. No, it fails, because of misplaced and selfish honesty. Again, let me repeat the scenario. There are two people who love and care for each other and are not unhappy in their relationship, but one (or both) of them engages in an act of intimacy (however you wish to define it) with another person (or persons). They’re not unhappy with each other, their relationship works and is otherwise normal. The relationship can function this way for months, years, decades, or until death parts them. What’s wrong with that? What’s wrong with having a happy life and a happy relationship, right? Well, probably nothing, except that it rarely happens. And I’ll tell you why.

After one of the members of a partnership has committed an indiscretion to whatever gravity, something happens but not to the partner who may be blissfully unaware or to the relationship which still has as much potential as it did before, but something happens to the offending partner. You know what it is? Guilt. Guilt creeps in, escalates by the minute, and this thing we call a conscience tell us that we should tell our partner what we did. It goes over and over in your mind, you convince yourself you are a bad person, you are convinced what you did was wrong, but overwhelming the feeling is guilt. Tony Robbins once said that guilt is really a trigger to correct your behavior, it means you have a standard which you haven’t met and as a result of this failure you feel guilt. That’s the point of it, to correct behavior back to what your standard is.

The truth is most of us do sign up to relationships to be an exclusive intimate partnership between only two people; that’s our standard. That’s what we expect to receive and that is what we expect to give in the partnership. So when we fail, when we don’t reach our own standard, we feel guilty. But what a lot of people do is mistake the trigger to change our behavior for one of simply anxiety or an unpleasant sensation. Therefore instead of thinking that what we need to do is change the behavior, we become convinced all we need to is just to relieve the guilt. So maybe we’ve stopped doing what we once did that caused us to feel guilty initially but we continue to experience the guilt because we can’t forgive ourselves. And we’ll keep feeling guilty until the day we decide to do two things: 1) meet our own standards, and 2) forgive ourselves. The second part is actually a lot more difficult than the first one is, so we often – mistakenly – substitute it. You know what we do when we can’t forgive ourselves? We ask others to forgive us.

When you can’t forgive yourself for cheating in a relationship, even if it was a once-off, we often make the mistake of asking our partners to forgive us. And we ask not because we care about them or because we love them and think they deserve to know the truth. No, I don’t believe that at all (although that is what we tell ourselves and our partner)! We tell of our indiscretions purely as a selfish way to ease our anxiety and guilt. This is what I mean by selfish honesty. There is nothing honorable about wiping your filthy hands on someone else just because you want to have clean hands again. That is selfish, self-indulgent, and spiteful. Don’t get me wrong, though, there are cases when we must confess to our indiscretions, such as, if we have placed another person’s health at risk or there are legal ramifications to our acts, etc. And here is where we need to ask ourselves: “is this for the other person or for me?” What exactly do you expect to gain?

If we tell our stories purely to ease your guilt, then don’t expect a reward for your honesty. I think that is so banal. Yet that is often what a lot of people do, confess their “sins” to their partner, tell them that they are confessing because they didn’t want to lie to them anymore (even though they had caused the other person no harm at all), and then expect to be forgiven because that is exactly what they need to ease their guilt. That is an even greater violation to the relationship. We shouldn’t use our partners to wipe our conscience. If the anxiety of holding a secret is really tearing us apart, if the guilt of what we’ve done is eating us away, there are more responsible ways to deal with it. As I said, what you really need to do is change your behavior. And if you must tell, tell a friend or pastor or psychotherapist, etc. The only reason we should tell our partners - hurt our partners, their self-esteem, their self-worth, their trust, their sense of identity, their faith in you – is to benefit them, not selfishly ease our conscience. And then we must expect not forgiveness but consequence. 

On being old enough to know better

Dave Chappelle, comedian, does a very funny yet thought-provoking skit on age and responsibility. The question arose about musician R. Kelly’s 2002 arrest for urinating on a girl who at the time of the alleged incident was 14 years old. The girl in question at one point is said to have consented to being peed on, but still everyone criticized Mr. Kelly because in either case the “girl” was underage and shouldn’t have been sexually involved with an adult. Poor girl, right? Didn’t realise the consequences of her consent, etc. etc.

Then another incident Dave Chappelle discusses is about Lionel Tate, who when he was 12 years old was play-wrestling with a 6 year old girl using moves similar to what he had seen TV wrestlers do. The 6 year old girl died from injuries sustained from this “game”. The boy was arrested and sentenced to life in prison without the possibility of parole. Apparently he should have known by the time he was 12 years old that his actions have consequences, etc. etc.

Finally he talks about Elizabeth Smart, a girl who when she was 14 years old was abducted from her home and taken captive by a couple who lived not very far from her own family home. According to the way Dave Chappelle tells it, she wasn’t physically restrained or locked up, but was advised by her captors not to flee. She obeyed. She remained at this site from June to August 2002 before being relocated elsewhere for a further six or seven months. But for at least two months she was situated very close to her own home, possibly within walking distance, often unsupervised at this place, not locked up or restrained – and yet she remained docile to her captors without allegedly even attempting to flee. Of course, it was unfortunate and not her fault at all that she was abducted, but shouldn’t she have known by the age of 14 years that her actions have consequences, that she could and should act, etc. etc.? Poor girl, right? Didn’t know what to do.... But wait, Lionel Tate knew exactly what to do and how to do it apparently by age 12!

The reason that these stories have come to my mind recently is because of the “poor boy” who was arrested in Indonesia and is being tried for drug-related charges. He is an Australian citizen and he is 14 years old. Those two facts are the main reasons we are enticed to have sympathy for this “boy”. He is alleged to have bought drugs while on holidays in Indonesia. Apparently he didn’t realise the gravity or consequences of his actions either because of his young age or because of his alleged addiction to the drug he sought, etc. etc.

So how old is old enough? How old is 14, really? Old enough to know better, or too young to know what you’re doing? If it’s not old enough, then let the “poor boy” in Indonesia out of prison to live his life and learn what is good and what is right and what isn’t. And let 14 year old girls decide if they want to have sex with adult men or whether they want to get peed on or not without prosecuting the adult involved. But if 14 is really too young to know better, then Lionel Tate deserves a big apology for the malice attributed to him when he was 12 and killed his 6 year old playmate. Luckily for him, this did in fact happen and he was eventually released from prison and went on to learn what is good and what is bad... (Almost a “and he lived happily ever after” story, except for the fact that when he was released from prison he went and committed other crimes  that bought him a fresh 30 years incarceration that he can no longer blame on his young age.)

The ability to make “adult” human decisions relies on the prefrontal cortex of the brain. This part of the human body does not reach its full developmental peak until you hit your early 20s. To me this has some interesting implications not only related to criminal law (as demonstrated in the examples above), but also to medical ethics, and to psychosocial development. In medicine we accept that children (by Australian law, under the age of 18 years) may competently consent to some things like taking a contraceptive tablet, having a blood test, allowing a physical examination by a health professional, etc. By the same token, the same person at the same age may be considered not competent enough to consent to, for example, reproductive sterilization or an organ transplantation / donation. It’s a matter of being competent enough, recognising that a person’s cognitive development is a dynamic thing evolving across multiple tracks until, hopefully, they all eventually reach a maximum and you reach your “adult” competence stage.

The other interesting thing about this gradual stepwise development in our ‘human nature’ relates back to the previous discussion on criminality. Maybe instead of focusing on “is 14 years old enough to be considered responsible for a crime?”, we should consider “is this person who is still in the dynamic stage of their cognitive development able  to be taught or rehabilitated to make choices that will decrease their chances of becoming further involved in criminal activity in the future?” Remember Lionel Tate? He was 12 in 1999 when he killed the six-year-old girl. In 2001 he was sentenced to life in prison without the possibility of parole. He was later released on appeal in 2004. In total he was in criminal detention from the ages of 12 until he was 17. What did Lionel Tate learn from the ages of 12 to 17? Who knows. But this would have been an amazingly opportune time to teach him exactly what the consequences to a person’s actions are, what taking responsibility means, how to get ahead in life without victimizing others for your own advancement. Would he have been a different person if this had happened? Who knows. But really, what have we got to lose?

On euthanasia

Jack Kevorkian served 8 years in prison for second-degree murder, that is murder that is not “premeditated”, or what you may also describe as murder that is not ill-intentioned. Essentially, he was a doctor that assisted many ill patients to die; what we commonly call euthanasia. He argued that he was imprisoned for being merciful, and that his merciful acts were to procure or hasten the death of other human beings. They were merciful because he aimed through his actions to liberate the person from suffering due to illness – when this person had indicated that they wanted or needed his assistance to do just this. The law said that regardless of the intent, procuring or hastening someone’s the death equates to murder and this is illegal even if the other party consents and requests it.

Now, a lot of the issues surrounding euthanasia and death legislation are about semantics, and to a lesser degree also intent. I remember first learning about euthanasia in a bioethics class, and I will describe it briefly now as I was taught it. There were four categories of “euthanasia” described:

1) voluntary active euthanasia (where the patient voluntarily requested help in dying and another person actively helped him achieve this) – E.g. a person asking someone else to inject a fatal substance into them.

2) voluntary inactive euthanasia (where the patient voluntarily requests help in dying and another person acts by withdrawing or ceasing an action that is helping the patient stay alive),  - E.g. a person asking someone else to pull out all tubes providing life-saving support like oxygen or fluids, etc.

3) non-voluntary active euthanasia (where the patient does not actually request or oppose help in dying and he is acted upon so as to hasten his death), - E.g. a non-communicative or possibly brain-dead patient who has made no prior indication of his wishes in this situation being given a fatal substance to hasten their death.

and  4) non-voluntary inactive euthanasia (where the patient does not request or oppose help in dying but another person acts by withdrawing or ceasing an action that is helping the patient stay alive). - E.g. a non-communicative or possibly brain-dead patient who has made no prior indication of his wishes in this situation having all life-supporting measures like oxygen or fluids withdrawn.

“Non-voluntary” is used as opposed to “involuntary” because involuntary implies that it is against the person’s wishes whereas non-voluntary simply that it is not opposed nor is it specifically desired. For example, involuntary active euthanasia could be thought of as common first-degree murder where a person does not want to die but he is purposely killed. Involuntary inactive euthanasia could be akin to a person actively asking for my help to avoid death (which I can presumably prevent by some action) but I withhold from providing this life-saving thing. This is a crime similar to murder in many countries too.

In most countries in the world what the law forbids are active forms of euthanasia, and in fact inactive forms of euthanasia are quite readily accepted – and legal. Every day in intensive care units patients are non-voluntarily actively euthanized, when their treatment is deemed futile by someone other than the patient themselves. And our right to “voluntary inactive euthanasia” is hailed one of the great achievements in medical ethics when doctors were disrobed of the expectation of paternalism to have that same power handed back to the alert, competent patient, in the form of autonomy. Any patient in the world can refuse any treatment in the world even if that treatment is considered life-saving. You can even write down your wishes when you’re still able to communicate them for future reference, for those times when you are non-communicative or no longer medically-competent. But I am digressing here, I could go on for hours on medical ethics, but what I really wanted to discuss is active forms of euthanasia.

Take religion and law away from the argument for a moment and try to discuss why euthanasia is “wrong”. Well, they tell us, it’s inherently bad because it has the potential for abuse and you run the risk of evil people wanting to just kill whoever for whatever trivial reason. Reasons such as, maybe, “he’s no good to society anyway”, “I don’t like him”, “he is of this race or culture”, “he’s poor”, or “he has no family”, or “he will cost more than I am willing to spend to keep alive”, etc. etc. There are many things in medicine with potential for abuse. We often hospitalize and treat the mentally ill; we force-feed those with eating disorders; we prescribe medications with known side-effects; we terminate the lives of foetuses for whom we can’t prove either way whether they are “persons” with an independent right to life or not, etc. I even heard it once said that one of the biggest mistakes in medicine was the idea to try to keep premature babies alive at all costs. Many of these babies will have chronic health problems, and the expenditure on neonatal intensive care units is massive. Some would say we have abused the technology in life-sustaining measures by trying to apply it to each and every patient, even these tiny babies which we are potentially setting up for terrible lives. My point isn’t to argue if these tiny babies are worth it or not worth it; my point is that we do entrust health professionals with many life and death situations all the time. And we do this because we have assumed they won’t abuse their powers just to see a new technology or treatment work without thinking of the consequences.

So then, why else is euthanasia “wrong”? They say because we could make a mistake – and the consequences of that mistake is not reversible. Again, doctors face this potential every day! I think that if you were to filter it down, the real controversies with euthanasia are 1) religion, 2) law, and 3) an expectation (or perhaps misconception?) that the overriding aim of medicine is to prolong an individual’s lifespan (as opposed to other aims like preserving their dignity, ensuring quality of life, and having a social responsibility to the rest of our fellow humans). Unfortunately, like many things in life, when you use one rule to apply to everyone in every situation, you will often get it wrong. Many people do not like to think that their doctor could have the knowledge or ability to perform euthanasia, because they assume doctors are special and, like I mentioned, should only want to prolong a person’s life. However, I believe that keeping euthanasia from the scope of medicine isn’t keeping us from any evil we aren’t already at risk of committing. I also don’t support allowing the scope of euthanasia to evolve without the input of medical professionals. If you’re going to do something, do it right. This is called harm minimization, and is not a new concept to medicine at all.

But why do I personally believe that euthanasia isn’t bad (if it were able to delivered effectively and without inflicting further harm or pain)? Because I believe that every person is free and free to choose to live their life how they choose. I also think it is cruel to deny someone something, especially their freedom of choice, simply because they need someone else’s assistance to achieve their goal. Imagine being denied access to the top floor of a building because you are a paraplegic in a wheelchair and the building isn’t equipped with elevators or ramps. Now, imagine that the reason you want to get to the top floor is because on the ground level where you are there is a fire that keeps intensifying. Don’t you wish someone could help you? But no-one can because then they will be arrested and they would rather not go to prison, even if they’re your friend or relative and they love you. So you’re left to fend for yourself. No-one bans you from going to the top floor, it’s simply a shame you can’t get yourself up there – and that is your only option! Oh well, better just wait for the fire to intensify, your skin to burn, and to watch yourself helplessly, and probably painfully, die. You knew all along that upon going to the top floor you’d only fall asleep and die up there, but hey, wouldn’t it have been nicer? Apparently not. Apparently it is nicer to allow our much-esteemed friends and family members to die in pain and helplessness.

And yet, having said all this, I have to clarify one thing for fear of being called out on my inconsistencies. Fortunately or unfortunately, I am Christian first and foremost, so no, I personally would not help a patient in this way. But I have tremendous respect for people like Jack Kevorkian who were/are courageous enough to serve their patients at all stages of life. Death is simply another stage of life.