PART I : History
- March 25, 2015 : a 27 years old co-pilot crashed his airbus in the Southern French Alps murdering 149 persons
- A premeditated act ?
- Medical history of the co-pilot: (based on BEA report)
Since 2008 : depressive episodes
August 2009 – December 2014 : various psychiatric consultations
December 2014 : Hospitalization suggested : suspicion of psychotic symptoms
Several different mild psychotropic drugs were prescribed
Many medical leaves were given and submitted to the Aero Medical Examiner
March 10, 2015 : admitted to a psychiatric department for a possible psychotic episode, Medical leaves were recommended
The day of the crash : he was on a medical leave but the airline was not informed by the pilot or the doctors
- Protective factor : unknown
Pilot did not seek help of the support group of Lufthansa ;
The family survivors refused to cooperate with the investigators.
- Risk factors :
Evolution of his major depressive condition ;
No alert of danger of suicide or homicide was sent by his doctors : did not provide confidential medical information to the company ;
Critical financial situation ;
He would not be able to fly again as a licensed pilot.
A pilot died by suicide and at the same time murdered 149 people in a probable melancholic act.
Murder–suicide is usually discussed as murder followed by suicide or suicide after a homicide act, as is well illustrated by West (1966).
The pilot identified himself with airplanes, an object choice of his ideal according to Freud theories (1933): “If one has lost a love-object or has had to give it up, one often compensates oneself by identifying oneself with it…” (p. 79). Tanay (1969) proposed the term of dissociative murder (cited by Nancy Allen in her book Homicide – 1980, p. 43), “when the murderer dissociates himself or herself from the consequences of the crime.” The pilot killed innocents, having nothing to live for. Joiner, in his book The Perversion of Virtue: Understanding Murder-Suicide (2014) would probably define it as a perversion of fate or justice.
Many questions are raised from this tentative psychological autopsy (Soubrier, 1982). It concerns the limitations of suicide prevention and prediction issues.
For example, what is the necessary follow-up of depressive patients with or without suicidal ideation who have a profession in the field of public security?
In cases of imminent risk of suicide, how should decisions for involuntary commitments be made (Motto, 1983)?
Police investigators found home several medical certificates torn up at the pilot’s. How should notifications of medical leave change?
How could collaboration between physicians, psychiatrists, and corporate medical departments improve suicide prevention in the workplace (Soubrier, 2016)?
Was it mimetism? The pilot may have known of three past intentional crashes by commercial pilots: Royal Air Maroc, Morocco, 1994; Egypt Air, US East Coast, 1999; and Air Mozambique, Namibia, 2013 (and, possibly, Silk Air Indonesia, Jakarta–Singapore, 1997, although this was not confirmed as intentional).
Was it glory? A former flight attendant heard him say: “One day, I will do something that will change the system and everybody will learn my name and so will remember it.” His credo was “to live to fly, not to fly to die.”
This particular murder–suicide was premeditated with greatly neglected precipitating factors and high predictability. In fact, this confirms the remark by Maltsberger et al. (2015, p. 643) that: “Risk factors research does not have high predictive value.”
It is a major ethical issue to discuss the limitations of suicide prevention.
PART II : Aftermath ethical discussion
I) What are the possible conditions under which one could suspend patient confidentiality due to suicide risk?
The ideal situation would be to legalize the suspension of patient confidentiality, given particular conditions, to facilitate immediate suicide prevention.
a) Prediction of the act following a comparative analysis of existing risk factors and protective factors
b) Refusal of care in addition to the communication of suicidal intention
c) Potential risk inherent in the person’s public role (pilot, train conductor, nuclear security operator)
d) Absence of legal possibility of direct communication of medical leave to the employer or company doctors
These four responses inspired the following reflections:
II) Could the suspension of confidentiality correspond to assistance before a crisis?
“Voluntary abstention of assistance when faced with persisting imminent danger necessitates an immediate action” (Article 223-2eme paragraph of the Penal Code)
This notion could be discussed in relation to imminent risk of suicide and could justify the suspension of confidentiality.
The notion of confidentiality doesn’t concern strictly medicine, but also the healthcare professionals who comprise the field- that is to say, all professionals in the social and medico-social field.
The real situation is complicated given the notion of shared patient information by medical professionals, which requires receiving patient consent for any exchange of information regarding the care of the client. (Health code January 26 2016 and decreed July 20 2016).
III) In the case of a refusal of care and the danger of a suicidal act, what should one do and what does the law permit?
The answer is simple: the duty of care as understood through involuntary commitments in psychiatric institutions (with or without necessity of force.) This is applied through the awareness of the danger posed to self or others. There is reluctance, a reticence in the application of this law, which recognizes this as not simply a measure to confine but to protect. This understanding of risk should exist for all personnel working in charge of the public, as recommends the Bureau of Investigation of Civil Aviation.
This should help protect doctors from legal repercussions. However, it would be better to relieve the doctor from being “trapped in the corset of medical ethics” (JP Soubrier)
It is also appropriate to introduce the concept of prior consent to the suspension of confidentiality for the diffusion of information given suicidal intention.
This consists of- in all circumstances- asking the suicidal person, or those who have recently attempted suicide, their authorization to suspend confidentiality in regards to suicidal intention. This is a delicate interaction for the intermediary, whose position it is to (care, help, listen) and could cause- in a case of refusal of consent- a rupture in this relationship. This rupture could accelerate the suicidal process and a rapid movement to action.
The drama of the German pilot’s murder-suicide raises the question of the validity of transferring a notice of medical leave in a case of serious mental disorder and suicide risk.
Medical leave is not a therapeutic act, nor is it a prophylactic act. It may be established without the agreement of the patient, and thus the patient may not communicate it to their employer, company doctor, or a support group (which existed at Luftansa)
Still, the notice must be registered and correctly treated once transmitted to the employer.
The judiciary investigation of this drama revealed numerous notices of medical leave were discovered torn up in the pilot’s home.
IV) Is suicide purely a medical question with restrictive rules?
An American colleague reinforced this remark in a correspondence commenting, “Suicide should not be the only sector with restrictive rules, homicide should be as well.”
This would be apt if suicide were a sickness that was nosologically defined. However, this is not the case. Many people still consider suicide to be a moral act, not a pathological act, tied to to social malaise.
During a conference held by the Groupement d’Etudes et de Prévention du Suicide on “Ethics and Suicide” in 1985, P. Blachere, in the conclusion of his presentation titled De la morale médicale à l’éthique, stated, “We risk the danger of privileging a medical approach to a social fact, at the detriment of other approaches.”
When an imminent suicide risk is recognized as a mental disorder, the lifting of confidentiality could be approached as if it were an illness (as in the majority of cases, psychosis, the early stages of dementia, alcoholism)
One has to remember that the pilot had been recognized as psychotic and suicidal but no preventative action or diffusion of information had been undertaken.
V) What are the rules regarding medical confidentiality within international and European contexts?
Exceptions to medical confidentiality are possible in criminal cases. For example, in the case of a homicide or an accomplice to a homicide. In a civil context, there is an exception made in regards to automobiles in Canada and Switzerland. That is to say it associates traffic security and suicide prevention.
In Germany, following the crash of the Luftansa plane, a law was proposed for Parliament’s consideration permitting a doctor to inform the employer in a case of danger (suicide or other).
In Belgium (la Wallonie), in June 2016, the High Counsel of Health formulated a series of recommendations concerning the protection of suicidal persons who present a danger to themselves, which included the legal possibility of placing them under observation. A more flexible term than commitment in an institution. This action does not necessitate the consent of the patient.
In Poland, Elwira Marszalkowska-Krzes, Professor of law at the University of Warsaw, in a recent publication, indicates that in the case of a threat on the life of self or other, the suspension of confidentiality could be differentiated between general practioners and psychiatrists. She states that mental health professionals could provide information, but not respond to questions from an investigation.
There seems to be an international consensus as to the recourse as far as institutional placement in the case of a refusal of care or a major risk of imminent suicide.
However, the recourse in terms of law is from time to time (often) difficult to receive due to hesitation, or doctors finding it difficult or complicated to achieve.
VI) Concluding remarks
“Suicidal acts have a social, psychological, and ethical significance but their interrelation is not evident in the practice of caring for suicidal persons.” (Jerry Motto, 1983)
All reflection on the confidentiality and the possibility, or lack thereof, of suspending medical confidentiality as well as the relationship between the question of suicide and consent to care raise questions as to the real limitations of the prevention of suicide. Finally, to what extent could specific legislation support the prevention of suicide?
In 1987, during the joint-meeting of the International Association for the Prevention of Suicide (IASP) and the American Association of Suicidology (AAS) in San Fransisco, with Jacques Vedrinnes, we raised this question, and cited in our conclusion a phrase of Claude Jacquinot, advisor to the court of appeals in Paris (on the subject of the controversy surrounding the publication of the book Suicide: How To Make It):
“The most basic of human duties is to help. “
Loisel (16th century lawyer) said, “Qui peut et n’empeche, pêche” or “He who can prevent, and does not, sins.”
This legal and natural obligation is imperative for all.
What do we learn from the forensic suicidology study of a dramatic event? We learned respect of Ethics may limit prevention of suicide intentions.
“Ethics and suicide” is usually discussed on the issue of ending life by suicidal assistance to death, suicide assisted death or euthanasia according to diverse authors.
In fact, we have to differentiate general ethic, medical ethic, from moral obligation of saving the life of a person in despair. In 1983, Motto (SLTB) wrote : « failure to take immediate action may cost an innocent life ». It is what happened for the pilot of Germanwings.
Erwin Ringel, founder of IASP wrote: “Suicide prevention is perseveration of human life”.
Therefore, is suicide a philosophical issue ?
I remind you, Albert Camus, a french writer and philosopher, wrote in his book Myth of Sysyphus, 1942 : “There is but one truly serious philosophical problem, and that is suicide”. But it was written in the chapter of absurdity and suicide.
I learned recently, Albert Camus had been upset by the many suicide attempts of his wife, considered as probably an absurd behavior.
Murder-suicide of Germanwings air pilot was a helpless hopeless pathological behavior, but not a philosophical act.
Pr. J.P Soubrier