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When Family Devotion Leads to Killing: Some Ethical Questions

Posted By Carol Levine and Barry J. Jacobs, Tuesday, April 17, 2012

 

 


Part I:
When Family Devotion Leads to Killing: Some Ethical Questions


by Carol Levine

 

Last October David Brooks, a New York Times columnist, invited readers over the age of 70 to write a brief report about their lives so far as a "gift” to him.

 Among those who responded was Charles Darwin Snelling of Fogelsville, Pa, a small town in the Lehigh Valley, an 81-year-old entrepreneur and recently retired head of the Metropolitan Washington Airports Authority. His long essay, "A Love Story and Redemption,” published online on December 12, 2011, described his successful career and 61-year marriage to his wife Adrienne. With five high-achieving children and 11 grandchildren, two homes, plenty of money, and a variety of interests, they led a "charmed life.”

When Adrienne developed Alzheimer’s disease, six years ago, Snelling made caring for his wife his new life work. He wrote: "We continue to make a life together, living together in the full sense of the word, going about our life, hand in hand, with everyone lending a hand, as though nothing was wrong at all.”

But something was terribly wrong. On March 27, 2012, four months after his essay was published, Snelling killed his wife (no cause of death has been determined) and shot himself. Although rare, this kind of murder-suicide (and that is what it is, despite some attempts to romanticize it), is not unique. Donna Cohen, a researcher at the University of South Florida who studies reported cases like the Snellings, finds that most often it is the elderly husband/caregiver who commits the violence and the wife who is ill.

We will never know what was going on in the Snelling marriage or in Mr. Snelling’s mind. But the incident raises troubling questions. I am not a mental health professional, and I leave that aspect of the commentary to my colleague Barry Jacobs. My views come from my work in medical ethics and my personal and professional experience in family caregiving.

For a start, David Brooks’ response in his column  seems cold and distanced. Rather than expressing some dismay about his own inadvertent role in this drama, he chides Snelling for not "respecting the future.” Brooks says he "bought the arguments that Snelling made in his essay.” How could someone take his "gift” and regift it in this terrible way! He thinks that either Snelling "was so overcome that he lost control of his faculties, or he made a lamentable mistake.”

From my perspective, it was a desperate but entirely thought-out act that can perhaps be explained but not justified legally or ethically. Even an extreme view of autonomy does not include the right to take someone else’s life in addition to one’s own. If he had survived, he should have been charged with a crime, although his status as a pillar of the community might have spared him that indignity. Why is it that so many Americans approve of this kind of violent death but protest withdrawal of treatment from a person in a permanent vegetative state? Why do they refuse to talk about health care proxies and living wills but say that they will rely on a willing relative with pills or a gun?

Some have complained that even to comment on this "family tragedy” violates their privacy. While certainly the surviving family members’ personal privacy should be respected, Snelling took his life story out of the personal realm, first when he wrote his essay and allowed it to be published; and second, when he committed acts of violence that were certain to be reported, investigated, and discussed. These were two very public acts, and he was a man who lived in the public eye.

Nor is this a case of euthanasia, physician-assisted suicide, or that odious phrase "pulling the plug.” The medical community was not involved at all, other than perhaps prescribing medications for Adrienne. (Perhaps some astute clinician might have picked up some clues earlier on.). Refusing unwanted medical treatment is the legal and ethical right of every autonomous person. The facts of this case are not even close to that scenario. There were alternatives. With his resources he could have found a good nursing home with a special dementia program for his wife, visited her as often as he wanted, and found some time for his family and avocations. There is no shame in such a choice, and it should be respected, not criticized as abandonment.

As a person with advanced dementia, Adrienne Snelling did not have the capacity to consent, even if (as seems unlikely), at some point the couple made a verbal pact not to go on living if one partner was terminally ill. Saying, "I wouldn’t want to live without you” is quite different from saying, "Yes, give me that fatal dose of pills today and don’t forget to shoot yourself afterwards.” Nor was this some sort of old-age Romeo and Juliet story. Those who make that connection misremember Shakespeare’s play. In any event, Adrienne was, as far as we know, not imminently dying and not suffering. She might have lived for years in this condition, apparently well cared for (by aides as well as her husband) and happy as long as she could be near him.

And that is probably at the heart of what happened. In rereading Snelling’s essay, I now am struck by the feeling that he was trying to convince himself that this life—a constant caregiver to a person who was and who was no longer his wife—was not only tolerable but good and satisfying. Not a hint of how hard it really was, how diminished he felt, and how difficult it was to imagine the years and years ahead. I have interviewed many caregivers of people with Alzheimer’s; none of them has expressed this kind of total selflessness. The ability to acknowledge one’s losses and limitations is an important asset in surviving caregiving. Friends and family, as well as professionals, should accept and validate these feelings. Perhaps the accolades Snelling received when his essay was published only brought home to him the disjunction between the saintliness ascribed to him and his true feelings.

In the end I feel most deeply for the Snellings’ 11 grandchildren who will live the rest of their lives without the love and pride that is the special contribution of grandparents, but instead with the dark knowledge of violence in their family history.

 Carol Levine directs the Families and Health Care Project and the Next Step in Care campaign at the United Hospital Fund in New York City. She is a Fellow of The Hastings Center, a bioethics institute, and writes frequently about ethical issues in health care.

 

Barry Jacobs
Part 2:
Narrative Means to Homicidal Ends

by Barry J. Jacobs, PsyD


 

What’s your idea of end-of-life redemption? As medical family therapists, we often try to guide our clients—the dying and their family caregivers—to use the last days, weeks and months of life to express love, complete unfinished business, and make reparations—the better to provide healing and lay the groundwork for successful resolution of grief. But do we regard actively trying to end a loved one’s life as a justifiable means of redemption? I believe that’s the crux of how each of us may view the Snelling case.

In the immediate aftermath of the murder-suicide, the Snelling family was reported to have said that its patriarch had acted "out of deep devotion and profound love.” But I agree with my colleague Carol Levine that we can and should make distinctions between ending a loved one’s death’s-door suffering (say, through removal of life-supporting machinery or administering high doses of morphine under hospice guidance) and killing someone with an as yet irreversible disease who is terminal but still viable and who may or may not be suffering.

I also agree with her that Mr. Snelling’s violent acts were probably not the result of a brain addled by depression but of a mind too taken with itself and with its redemptive mission. As Carol points out, cases like these are rare but not unique. A decade ago, I wrote an essay on a similar case (please see "Instructions to the Jury,” Families, Systems & Health, Vol. 20, 2002, 101-104) in which a husband-caregiver was clearly desperate and severely depressed at the time he put a pillow to the face of his wife of 43 years; he soon afterward was placed in a state psychiatric facility. But there is little of the tone of the tormented depressive in Snelling’s long, meandering essay. Rather it is deliberative and full of gratitude even in its allusions to the grinding work of Alzheimer’s caregiving. We all know about "reaction formation,” Freud’s classic defense mechanism in which people state and do the opposite of how they really feel in order to prevent themselves from being plagued by self-condemnation and anxiety. (Shakespeare’s line from Hamlet-- "The lady doth protest too much, methinks”--captures the same insight.) But there is no telling if Snelling were covering up anger or sadness or anything at all negative with his opaquely self-satisfied essay.

Because that essay was undertaken in response to a prompt to provide a "life report” to New York Times columnist David Brooks, it can be read as a narrative in the clinical sense of noted family therapist Michael White—that is, as a construction or justification for a particular life course. Snelling may even have intended it as explanatory back-story for his children of what he already planned to do. So what do we learn from Charles Darwin Snelling’s narrative? He grew up in a materially rich but emotionally impoverished family in which he was subjected to his prominent father’s unremittingly harsh judgments. He developed into an oppositional, disdainful and willful young man who irritated authority figures but still possessed something of his father’s intelligence and determination. Under the nurturing influence of his wife, he softened somewhat but was still known to their 5 children as a curmudgeon. Then his wife became demented. Others didn’t think he had the capacity for nurturance himself to care for her, but he was determined to prove them wrong. He also saw this as an opportunity to redeem himself—to give back to her some of the love he’d received from her.

It made for a nice story in the Times. But, in my opinion, the postscript to this story reveals that Snelling was not redeemed from his upbringing. We know that childhood neglect often produces narcissistic adults —people of shining public facades but with interior lives marked by feelings of inadequacy, despair and resentment. I consider his writing of an essay for national publication to be a grand-standing effort to make a positive impression and garner prominence. I see in his acts of murder and suicide an application of the harshness, bleakness and willfulness he harbored within. These were sharply negative edges to him that his wife had long blunted until she wasn’t competent enough to have that influence on him any longer. Then he was psychologically on his own. In seeking death, Snelling found the severest form of deliverance for himself and, more especially, for her.

Dr Jacobs is the Director of Behavioral Sciences at the Crozer-Keystone Family Medicine Residency in Springfield, PA.  He has written broadly on family and caregiver issues, including the book, The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent

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Richard Anderson says...
Posted Thursday, April 19, 2012
As a long-time Board member and former President of the Well Spouse™ Association, I was very interested to read the dual commentaries by Carol Levine and Barry Jacobs on the issue of spousal caregiver murder suicides. I myself wrote a blog entry on this issue in 2008 here: http://www.carepages.com/blogs/lifeofwellspouse/posts/may_20_2008

My belief is that killing yourself after murdering your chronically ill or severely disabled spouse is far from an act of love -- rather it is a cry of desperation -- after being tragically unheard, as Carol Levine hints at in her comments on NY Times blogger David Brooks's reply to Charles Snelling's essay (http://brooks.blogs.nytimes.com/2011/12/07/the-life-report-charles-darwin-snelling/?pagemode=printhttp://brooks.blogs.nytimes.com/2011/12/07/the-life-report-charles-darwin-snelling/)

Brooks said, "I bought the arguments that Snelling made in that essay: that his wife’s illness had become a call for him to exercise virtue and to serve as an example for others; that people are joined by suffering, and that the life of a community is enriched by the hard tasks placed before it; that dependency is the normal state of affairs."

I am not surprised that Mr. Snelling started out wanting to justify his care for his wife, in the best way possible. Our society romanticizes love and marriage in an over-the-top way. What I am distressed about is that apparently neither he himself nor anyone he came in contact with acquainted him with the dangers of caregiving burnout that can hit spousal caregivers particularly hard, given the very quality of their relationship with the caregivee, which differs from that of other family caregivers -- I mean that a partner's illness can cause such a great emotional toll for the caregiver, due to losses of health and intimacy.

Dr. Barry Jacobs points out that Mr. Snelling's harsh upbringing may have had psychological consequences for him at the tragic end of his life. I would agree that's possible. Nevertheless, if he did not kill out of love, neither was he a monster who said one thing and did the exact opposite.

My views have not changed from 2008 -- there is a great need to raise the consciousness of the general public, family and friends on the need for spousal caregivers to have better access to support. Mr. Snelling obviously felt everything depended on him, and felt very alone in his mission to fulfill his impossible goal that he wrote about. When people feel they are backed into a corner, they can take extreme actions.

I was a spousal caregiver for 29 of the 31 years I was married to my first wife, and I have felt that loneliness. The Well Spouse™ Association, http://wellspouse.org helped me, and has certainly helped many of its members to feel the truth of its twin mottoes, "You are not alone," and "When one is sick, two need help." It is too bad that Charles Snelling or those who came in contact with him never heard of the WSA.

Richard Anderson
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Randall Reitz says...
Posted Thursday, April 19, 2012
This is a very thoughtful commentary on all sides. While I assert that Mr Snelling's murder was not justifiable in any way, I would like to offer a broader perspective of this situation. It would have been a great service to both of the Snellings if our society had at least begun to grapple with the ethical issues presented by ever-expanding lifespans. I believe that the concept of a dignified death will eventually expand to include the ethical, legal, and socially accepted possibility of choosing one's time of death.

On both sides of my own family the grandparents' bodies have persisted in life much longer than their minds. This has led to pitiful, institutionalized endings to once vibrant lives. Being religious people from the "Greatest Generation", I doubt my grandparents would have chosen to willingly end their lives, however any societal effort in this direction would provide a source of peace for future Snellings.
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Terri Corcoran says...
Posted Thursday, April 19, 2012
Hi Barry,

Your comments are very well-thought out and enlightening. And I certainly agree with Richard that the isolation of caregiving is very dangerous. Caring for a spouse with dementia (as I have been!) can be so surreal in a very bad way; it is a very abnormal situation from what we have been used to in our previous lives. We need contact with other people, esp. in a group like WSA.



The way Mr. Snelling was so “upbeat” in his caregiving role when he wrote his essay reminds me of all the people who think you have to keep problems to yourself, “be brave”, “pull yourself up by your bootstraps,” “cup always half full” – and all those clichés. Watching your spouse sink into dementia is a horrifying experience, and if we try to deny it, the stress and sadness could lead to murder/suicide. Better to face the horridness of it, talk it out with others who understand, and not place the burden of perfectionism on yourself (as it appears Mr. Snelling thought he needed to do).

Best -

Terri Corcoran





Co-Editor, Mainstay

Public Relations Chair

Well Spouse(TM) Association

tcorcoran53@verizon.net

http://www.wellspouse.org/
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David Seaburn says...
Posted Thursday, April 19, 2012
Hi Barry: This was a very provocative and thought-provoking set of essays. I wish I had seen the original essay submitted to David Brooks. As I read through both essays, I couldn't help but think about what it must have been like for this gentleman and his wife to have been married 61 years. It boggles the mind. They were merely 20 or 21 when they started their lives together. We can only guess at what their lives were actually like as a couple. How in the hell did they last so long!

I wonder what happened in those days, weeks and months before he acted? It is, of course, a murder-suicide. It does, of course, lie outside the bounds of any ethical or moral standard. But I found myself dissatisfied with that as a summary or conclusion. I guess there is no way to make good sense of it. I liked your narrative metaphor. I think it fits. But do we know what narrative was being concluded?

Oddly, I think that if I were an 80 year old demented man and my wife of 61 years decided it was better for both of us to die, it might make sense to me; it might be okay.
Dave
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Janelle Jensen says...
Posted Friday, April 20, 2012
As I sit in class reading an article about the effects of chronic stress on our brain, in particular the prefrontal cortex, I was immediately reminded of this conversation. Basically, the article relates how chronic stress can weaken the function of our prefrontal capacities, and even relates it directly to decision making about a loved one's medical condition. I wonder what type of chronic stress Mr. Snelling experienced throughout his lifetime and as a caregiver and how this may have also effected his capacities for decision making? This leads me to wonder about our responsibility to incorporate the research and ideas of neuroscience when collaborating with physicians and caregivers. How are we sitting with patients in the midst of compromised brain functioning and how is this impacting medical decision making?

Arnsten, A. (2012). THIS IS YOUR BRAIN IN MELTDOWN. (cover story). Scientific American, 306(4), 48-53.
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Barry J. Jacobs says...
Posted Sunday, April 22, 2012
Thank you all for your comments. This case brings up strong feelings and moral imperatives. I don't agree with Randall's contention that we are moving toward broad societal sanctions for choosing one's time of death. Choosing to not prolong life artificially--yes, we're already there. But sanctioned suicide for dementia or pain or loneliness or poverty or any other of life's ills--no way. We shouldn't even be considering this, however, until we pay better heed to Richard's and Terri's call for greater awareness of and support for spousal caregiver's ordeals. Let's give the Snellings of this world greater sanction to reach out for help before we offer them our endorsement of death.
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Randall Reitz says...
Posted Tuesday, April 24, 2012
Barry,

I feel the need for a 2-point preamble:
1) I apologize for the threadjack.
2) These controversial (or more accurately “ahead of their time”) views are my own, and I provide them as an individual, not as a CFHA staff member.

Choosing the time of one’s death might seem shocking, especially in a clinical field where we go to crazy-making lengths to ensure that people don’t end their lives. However I would assert that it can be a very sensible decision and should be a basic human right. If we stridently defend people’s rights to make poor health decisions (see: tobacco, alcohol, Cheesecake Factory, motorcycles, La-Z-Boy recliners, playing professional sports in Philadelphia…), then we should be equally insistent on the right to end a life that has been sapped of health or purpose.

I believe that the biggest problem with suicide is that because there is no legal or socially endorsed method for doing it, that people do it all wrong. As a result, it wreaks havoc on their loved ones and their personal legacies. The tricky aspect in changing suicide is developing the ethical and professional infrastructure to support the process. By nature of the medical family therapist’s skill set, our profession could have a key role in this developing this infrastructure.

I propose that any person 40 or older (although legally 21 would be more tenable) should have the right to end his or her life, but only after following these steps:
1. Visit an approved care provider (i.e. licensed mental health professional, primary care physician, clergy) and inform this person of this choice.
2. Engage in a clinical protocol lasting at least 1 year and including at least 6 treatment sessions to treat the condition or symptoms that lead to the desire to end one’s life. At each session, the client needs to re-assert intention to end her/his life.
3. Put one’s life in order so that the death and its consequences will be less traumatic for the survivors.
4. Choose an approved method for killing oneself (with or without professional assistance) that inflicts the least pain and is the most probable of being lethal.

Although admittedly brazen, this protocol seems like a much more reasonable approach to ending one's life, especially when compared to the current reality of suicide that we see daily in healthcare settings: people living with the shame and burden of suicidal secrets, people choosing ineffective methods that leave them crippled or disabled, people shocking their loved ones with horrifying displays of gun shot wounds and bathroom hangings, families being left to pick up the pieces after an unexpected loss of a family member.
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Jackie M. Williams Reade says...
Posted Friday, April 27, 2012
Such a polarizing topic, but what a great conversation that ensued here... I believe we need to offer both proper discussion regarding the realities of such significant illnesses and provide supportive resources to help both the patient and the caregiver during these difficulties. That seems like a given, but so often this doesn't happen well and if it had in this case, it could have changed this story dramatically. However, I also think that choosing your own death (via physician-assisted suicide) should become an option for some conditions. There are some long-suffering ailments that some individuals would rather not live through the full illness trajectory, but feel they have no options to die the way they want in our present healthcare system.

I wonder if our problems in both of these areas (discussing realistic expectations of illness and options of choosing our own death) come down to our medical culture - we don't want to talk about failure, we don't want to give up, we want to extend life. These are our typical priorities (and they have their place), but they overshadow or stifle other valuable options. This is where advance care planning is so important. I wonder if the Snellings had a conversation about what would be considered unacceptable at some point in their lives... We'll never know and we'll be left wondering whether the last act was selfish or an act of love and a decision made between them at some point - whether verbal or intuited by Mr. Snelling.

Also, if this family is looking at this as an act of love and that viewpoint is not putting them at risk of a rash of murder/suicides in their own family or they are not in deep denial of what was truly going on, I think, "Why challenge the way they are making sense of this?" It is their story and perhaps they know it best.
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Carol Levine says...
Posted Monday, April 30, 2012
I am taking Randall Reitz’s comment on face value, and not as a Swiftian exercise. It is as troubling to me in its own way as the Snelling case. It also moves the discussion away from the act of murder that preceded Mr. Snelling’s suicide. Mrs. Snelling was unable to consent or probably even understand what her husband planned to do. That is very different from the scenario Reitz contemplates.

My first reaction to Reitz’s comment was that he was trying to drum up business for therapists. After all, in his plan one would have to see an accredited therapist and undergo a series of clinical encounters before being given the magic pill that would tidily erase one’s life. How would one bill for this service? Would there be a new code for suicide planning? Or would it be given a new, more sanitized name? Thana-planning?

From what I know about people who commit suicide (disclaimer: I am not a therapist), they would not easily accept these conditions. And if they did, and then decided not to go through with it, would the therapist have failed or succeeded? Wouldn’t the therapist seal of approval take away what some suicides seek: a dramatic gesture? The demonstration to all in his or her life their inadequacies as parents or partners or ex-lovers?


As to age cutoff, 40? Why? Seems very young to me. And 21? Are you serious? Existential despair seems normal for age 21. And reason? None required?

It is harder to live one’s life than to end it. Let’s keep therapists’ focus on helping people through whatever leads them to consider suicide than on making it easier.

Carol
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