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May 22, 2013

The will to live or die

Reuel S. Amdur

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It is not that uncommon for a long-married person to die shortly after a spouse. Similarly, a parent in his 80's might pass away shortly after the death of an adult child. We all know of such cases. But what can be made of this?

The answer may be simple or it may be more complex.  In the simple case, it may just be a matter of chance.  The more complex situation involves an understanding of the whole person. We can call it "the loss of the will to live."

At least since Descartes, we in the Western world have made a sharp dichotomy between body, mind and soul.  However, we now understand that they are part of a single entity, and there is no clear separation between them.  They are intertwined.

If an older person loses the will to live and the person dies, how can we understand that?  In effect, we are likely talking about depression.  Psychiatrist Martin Cole and psychologist Nandini Dendukuri did a meta-analysis in 2003 of studies of depression in older people.  They found that bereavement was one of the important factors. 

People often look at depression in older people as just part of getting old, a normal reaction to illness and loss.  Nevertheless, depression is not normal.  However, depression in older people has some different symptom patterns than the condition in younger people.  The National Alliance on Mental Health lists symptoms that could be indicative of depression in seniors: memory problems, confusion, social withdrawal, loss of appetite, loss of weight, insomnia, persistent and vague complaints, help-seeking, moving in a slow fashion, demanding behavior, delusions, and hallucinations. 

Bereavement is normal, but when it persists, it is likely depression and should be treated.  Treatment may be by one or more of the following: medication, psychotherapy, and electroshock.  Social interventions are also important.

The relationship between depression and physical illness is complex.  To begin, even if bereavement is one causal factor of depression, there may also be others at play, such for example as an inherited genetic tendency.  But let us leave that aspect aside and look at how depression affects the body.  It appears that the depressed state alters brain chemicals, and these affect production of hormones and enzymes.  Many studies have shown that mood variation—happiness, depression, anger—can have physical results.  Conversely, physical conditions can have emotional concomitants. 

Let’s take a simple situation.  A person who “loses the will to live” becomes depressed and stops eating, eating enough, or eating well.  It is hardly surprising that such conduct could have serious and even fatal consequences.  Other interrelationships are more complex.  Dr. Charles Conway, a St. Louis physician, writes that depression has an impact on other diseases, such as heart disease and infections.  He notes that hormone levels which fluctuate during the day may be kept at an elevated level in depression, with an impact on the cardiovascular and other systems.

While the impact of body and mind on one another is well established, the principle of the will to live can only take us so far.  Thus, a famous study that found that elderly Orientals tended to “hold on” to just after the Chinese Harvest Moon Festival has been refuted.  The statistical analysis did not hold up on re-examination, and efforts to replicate the results in other trials were not successful. 

What does the “will to live” have to say about the current controversy about the right to die? 

While advocates of a right to die have a variety of positions on just when such a right applies, it is often argued that people in a terminal state experiencing great pain and/or serious loss of control of bodily functions should have the right to assisted suicide.  However, regardless of how one feels about that issue, the right to die should not be confused with a loss of the will to live.  Loss of the will to live may be related to a terminal will for death.  More frequently it is another name for depression in the elderly.  That depression is usually treatable, if we take the effort to identify it.

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