This continues the Spotlight on Suicides Series –
The photograph is of Patrick McGurgan – the coroner. Mr McGurgan appeared to be a decent man. He treated everyone with courtesy and appeared to be listening. His conclusions at the end of the inquest provoked a correspondence from me that will be posted later in this sequence in its entirety – there is nothing in this that impugns him.
The Hold-Up
The second day started on a strange note. Dr Brannigan, Stephen O’Neill’s family doctor, the first witness, and I arrived early. Several hours later nothing had begun and we were both still sitting on the bench for people other than the family, staring across at the family, with me at least wondering what was going on.
Stephen O’Neill had only taken two doses of the sertraline before stopping it and presenting to the hospital telling them he had had a very bad reaction to it. After a brief admission, nearly 6 weeks later he remained agitated – a series of drugs had been prescribed to him. Toward the end of this 6 weeks, a junior doctor working in the unit to which Stephen had been briefly admitted had been called to prescribe something to help Stephen who remained agitated. He prescribed Buspirone without seeing or interviewing Stephen. A few days later Stephen was dead.
Over the course of the 6 weeks, the hospital system and Dr Brannigan prescribed 4 drugs with the junior doctor in the hospital adding Buspirone (Buspar) into a mix that had included mirtazapine and quetiapine.
The addition of Buspirone led to a question as to whether it could have caused Stephen problems. The family’s lawyer called me that evening and asked whether there was any evidence it could. I prepared a Table of the hazards linked to 4 of the 5 different drugs Stephen had been given during this period and gave it to him to produce for the coroner the following morning.
This document shows that a large proportion of the reports on each of these drugs are for behavioural changes consistent with suicide induction. The rates of reports of problems triggered by each of these drugs is likely to be between 10-15% of the total of all reports for anxiety and 10-15% for depression and 10-15% for suicidality – perhaps 33-50% of all reports for each of these drugs. Reports of anxiety to FDA end up being coded under anxiety, stress, nervousness, restlessness etc with depression coded under depression, depressed mood, depressed state, mood disturbance – with no-one in FDA figuring it makes sense to add these up.
This sheet of paper led to a hold-up lasting hours as the coroner and his Q.C decided whether the evidence was admissible. They apparently consulted the FDA website and based on something they saw there about some reports being from patients, almost by definition without knowing what they were doing and without consulting me, they decided the evidence was not admissible.
The figures for Quetiapine bring out an important point. Stephen was given Quetiapine by his family doctor Dr Brannigan and by the secondary health services, as in the agitated state triggered by sertraline he was having difficulties in sleeping. He was told this would help. When later asked about how he was he made it clear that Quetiapine was not helping his sleep. His observations were ignored.
The Table however shows that his observations were almost certainly correct. While Quetiapine can be very sedative and many doctors give it in lieu of a sleeping pill, the FDA figures bring out that many doctors and others report to the companies marketing quetiapine (most FDA data comes from companies not patients) that some patients have just the opposite effect – Q interferes with their sleep.
Stephen was absolutely right when he reported this response but was not heeded. This was typical of what happened in his case from an initial catastrophic response to sertraline which he reported to the pharmacist who had dispensed it and later to anyone who would listen. But aside from a mention in the medical record that it was his view that his medication had caused him problems this view was essentially ignored.
A Wonderful Report
Dr Brannigan took the stand once proceedings started. He appeared nervous to me. Mr McGurgan welcomed him to the stand. He made a point of thanking him for his excellent report. This was a model of clarity and he, Mr McGurgan, indicated an interest to use it if possible as a model of how a report should be done in training sessions he undertook with physicians and others.
It had always been my intention, as per my original report to avoid blaming any of the treating staff but these exchanges made it very clear that viewing Dr Brannigan as anything other than an excellent doctor was not an option.
Dr Brannigan did appear to be a decent man. His testimony took us through till lunchtime. It features in the next post.
Pay Grades
I was called after lunch. A great deal my testimony covered details of Stephen’s case, as will become clear as these posts unfold.
Another chunk of testimony centred on explaining how decent doctors like Dr Brannigan and the doctors linked to the secondary care services could end up flailing around, not knowing what to do, and as a result resorting to throwing psychotropic drugs at the problem with their fingers crossed.
The explanation, a substantial proportion of which was delivered looking at Mr McGurgan straight in the eye hinged on the fact that the greatest concentration of Fake News on the planet centres on the drugs that family doctors, like Dr Brannigan, or hospital doctors, like the ones who had prescribed mirtazapine and buspirone, prescribe to you and me or our families and friends.
As I remember it, I more or less said to Mr McGurgan that he was not in a great position to establish the veracity of what I was telling his inquest, but that I had repeated the same message to Ministers of Health and the Chairman of NICE and others with none ever disputing what was being said. Given this it was rather easy to see how ordinary doctors fed a constant stream of hype about the benefits of treatment with the harms airbrushed out of existence would end up flailing around if a patient’s responses didn’t seem to fit the script.
I say – as I remember it – because I long ago expected to have a transcript of my testimony. This is available ordinarily for a small fee at the request of a family member or an expert but has been withheld in this case with no explanation offered for this withholding.
Coroners are in a tricky position. They are not medical experts and cannot readily come to a view that contradicts the medics who testify. Mr McGurgan had one doctor saying one thing and a number of others essentially saying they had done a good job.
However he did not have anyone contradicting the Fake News point. I didn’t expect he could solve a matter like this but I thought if I was in his position, I’d have written a conclusion (coroner’s verdicts are called conclusions) that bumped the matter up to a Minister of Health or First Minister saying “look I can’t come to a conclusion here without your involvement”.
One function of inquests is to advance the public health. There was another public health issues at stake here which was that Stephen O’Neill had died essentially kneeling rather than hanging. This is not uncommon in people plagued with drug induced thoughts of harming themselves who have no natural inclination to do so. They commonly put their head in a noose – experimenting as it were – not realising that quite minimal pressure from a rope on both sides of a neck can lead to a person losing consciousness and the noose tightening. This is very different to the person who attaches a noose and drops from a height. It’s something the public need to be warned about.
My testimony took up most of the afternoon of Thursday June 19th. The coroner was due to go on holiday that weekend. So the only day he could come to a conclusion was on the Friday. Conclusions are delivered in print but are then posted online.
A written conclusion was delivered before Mr McGurgan went on holiday but nothing has been put online as of the time of writing this post and no explanation has been offered as to why not in response to queries from the family or from me.
I wrote to Mr McGurgan, offering him the courtesy of letting him know that I would be writing to Ministers of Health and others about this case and would be embarking on a series of posts.
Next week – Spotlight on the Family Doctor.
Why did they even bother, with the Expert, one asks oneself?
From where we sit, it looks like a Done Deal and this sort of Done Deal happens much too often when a patient has died from a severe reaction to Sertraline or Seroxat, SSRIs..
I can hardly imagine how frustrating this must have been, but, then again, I can imagine…taking a few Paroxetine tablets can bring on the same result from these pills; it has been recorded, it has been transcripted, cases have gone to US court rooms – where they listened to the Expert..
As you say, Coroners know nothing about psychotropic medications, and akathisia, and even less about possible drug interactions.
But, the point is, no-one listened to Stephen, and the next Doctor Post will be revealing.
The Coroner does his job, mostly, seemingly, from the evidence given to him, but, as you and I know, this is completely biased information – the Coroner was not there when Stephen gave his own diagnosis.
He gave it to everyone, apart from the Coroner.
Once again, no one is listening, not to Stephen who died, not to the Expert.
They hear what they want to hear, they do what they want to do, and they have absolutely no intention of thinking out of the box or being able to take on board vital data and evidence which could mean that Stephen was strangled by his drug..
Going through the formalities …
Threads which need pulling out for me include; would they have been crass enough to want to get a ‘case’ of a person’s suicide off the table before going on holiday? (Housekeeping)
Who compiled the transcript and was s/he, administrator/clerk told to hold it back or withhold if a request for it was made while they were away, or any other time.
It seems when they went into the huddle the family doctor was persuaded to agree a script which was the bigged up in court ‘to be used as a model’. If that ‘model is used to influence others there can be serious consequences on other incidents.Who drew that up? It seems like a joint effort by the members of the huddle with no record of the discussion and a nervous family doctor taking the stand afterwards possibly after being reassured of support for what they had decided should be stated in court. Most of us are experienced enough to know how ‘looks’ can be used in different ways.
The most astonishing thing is that they had an expert in both pharmacology and psychiatry on hand but excluded David H and his evidence relying it seems on what they could get away with using particular elements from the FDA reports. A bunch of non experts couldn’t possibly grasp the knowledge required about the mix or even one of these drugs even in a few hours of the huddle. Were they using the time to undermine David H and who made the comment that he ‘has an agenda’. How much did that influence others which surely should lead to a retrial with a different unbiased set of people? And an investigation of what took place.
This evidence is what a professional such as David has expert knowledge of
Is it any wonder people kill themselves when so many potential adverse effects from not just one but a whole bundle of drugs with potential harms are used without due care.
https://www.drugs.com
buspirone-patient-tips -(another tip – also check out info under ‘professionals’
https://www.drugs.com/mirtazapine.html
https://www.drugs.com/mtm/quetiapine.html#moreResources
It is shudderingly awful how much mis-information is passed around in court-rooms…
Murdered by Sertraline?
Posted on July 5, 2013 by Brian — 4 Comments ↓
‘by forgetting his tablets for two days then taking a triple dose on the day before the killing’
This is information that an expert would surely be familiar with..
http://antidepaware.co.uk/murdered-by-sertraline/
Update (April 2015)
The Court of Appeal dismissed Paul’s appeal on April 29th 2015.
At the appeal, Mr Martin-Sperry criticised the misleading testimony of Professor David Taylor at the original trial. He said that the issue of the potential of Sertraline to induce violence was not explored properly at the trial and that more research should have been done to see if Sertraline could cause violent outbursts in rare cases.
He had, however, been refused permission by the Court of Appeal to call a psychiatrist to testify to this fact.
Dismissing the appeal, Lady Justice Hallett (left) said that any such evidence would not have been enough and that Paul would have had to convince jurors that the drug’s effects had in fact triggered his outburst when he killed his mother. She decided that there was nothing wrong with the way his trial was conducted and that his conviction was “safe”.
(By this time, information had emerged that James Holmes had been prescribed Sertraline before he shot dead 12 members of a cinema audience in Aurora, Colorado)
* Sadly, Dr Herxheimer passed away in February 2016, aged 90.
Oh how I admire people who dare to fight for themselves or their relatives.
But in the light of how utterly ‘bonkers’ politicians and scholars act in my beloved Sweden, I’ve just given up.
I’ve even started to think the ‘socialism’ I was brought up to believe in, is the very thing that prevents me from believing things can change concerning pharmaceuticals.
We give the pharmaceutical companies all the benefits of doubt, while we sit back and socialisticly think “-Oh but they mean well….they don’t want to hurt people”
When infact the cold truth could be the very opposite.
Some facts that are hard to deny: a patient that eats one pill each day of his life, is worth more to them than a healthy person. Either they want to help the patient, or they want to give a pill to the healthy one.
Ove2019
Harry’s Inquest Book: the Death of Harry Horne-Roberts
https://www.ageofautism.com/2012/06/harrys-inquest-book-the-death-of-harry-horne-roberts.html
Neglectful at best to keep adding pills to a guy who clearly could have been suffering from Serotonin Syndrome. Hard to read this for so many reasons.
Some of the info for professionals cant be copied and pasted, looks like due to to plagiarism concerns, but can still be read online
Drugs A to Z Buspirone Interactions
Buspirone Drug Interactions
OverviewSide EffectsDosageProfessionalTipsInteractionsMore
Drug Interactions (414) Alcohol/Food Interactions (1) Disease Interactions (5)
Currently displaying a list of 414 drugs known to interact with buspirone.
85 major drug interactions
327 moderate drug interactions
2 minor drug interactions
Return to the most common drugs checked in combination with this medicine.
Price Guide buspirone
Buspirone Prices, Coupons and Patient Assistance Programs
Buspirone is a member of the miscellaneous anxiolytics, sedatives and hypnotics drug class and is commonly used for Anxiety, Borderline Personality Disorder, Panic Disorder and others.
Buspirone Prices
This buspirone price guide is based on using the Drugs.com discount card which is accepted at most U.S. pharmacies. The cost for buspirone oral tablet 5 mg is around $14 for a supply of 100 tablets, depending on the pharmacy you visit. Prices are for cash paying customers only and are not valid with insurance plans.
Oral Tablet
5 mg
buspirone oral tablet
from $13.57
for 100 tablet
7.5 mg
buspirone oral tablet
from $85.86
for 100 tablet
10 mg
buspirone oral tablet
from $15.83
for 100 tablet
Quantity Per unit Price
90 $0.25 $22.15
100 $0.16 – $0.37 $15.83 – $37.34
500 $0.08 – $0.30 $39.22 – $148.71
1000 $0.29 $287.91
Important: When there is a range of pricing, consumers should normally expect to pay the lower price. However, due to stock shortages and other unknown variables we cannot provide any guarantee.
15 mg
buspirone oral tablet
from $14.96
for 60 tablet
30 mg
buspirone oral tablet
from $117.08
for 60 tablet
Drugs.com Printable Discount Card
The free Drugs.com Discount Card works like a coupon and can save you up to 80% or more off the cost of prescription medicines, over-the-counter drugs and pet prescriptions.
Please note: This is a drug discount program, not an insurance plan. Valid at all major chains including Walgreens, CVS Pharmacy, Target, WalMart Pharmacy, Duane Reade and 65,000 pharmacies nationwide.
Buspirone Coupons and Rebates
Buspirone offers may be in the form of a printable coupon, rebate, savings card, trial offer, or free samples. Some offers may be printed right from a website, others require registration, completing a questionnaire, or obtaining a sample from the doctor’s office.
There are currently no Manufacturer Promotions that we know about for this drug.
Patient Assistance Programs for Buspirone
Patient assistance programs (PAPs) are usually sponsored by pharmaceutical companies and provide free or discounted medicines to low income or uninsured and under-insured people who meet specific guidelines. Eligibility requirements vary for each program.
There are currently no Patient Assistance Programs that we know about for this drug.
Drugs.com
For more info look under the ‘professionals’ header – not allowed to copy and paste
Drugs A to Z Mirtazapine Side Effects
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Mirtazapine Side Effects
Medically reviewed by Drugs.com. Last updated on Dec 22, 2018.
OverviewSide EffectsDosageProfessionalTipsInteractionsMore
Consumer Professional Managing Side Effects
In Summary
Commonly reported side effects of mirtazapine include: severe sedation, constipation, drowsiness, increased serum cholesterol, weight gain, fatigue, insomnia, increased appetite, xerostomia, and decreased appetite. Other side effects include: dizziness, increased serum triglycerides, tremor, dyspepsia, hot flash, palpitations, vertigo, abnormal dreams, bitter taste, decreased libido, and diaphoresis. See below for a comprehensive list of adverse effects.
For the Consumer
Applies to mirtazapine: oral tablet, oral tablet disintegrating
Warning
Oral route (Tablet; Tablet, Disintegrating)
Antidepressants increased the risk of suicidal thinking and behavior in children, adolescents, and young adults with major depressive disorder and other psychiatric disorders in short-term studies. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared with placebo in adults beyond age 24, and there was a reduction in risk with antidepressants compared with placebo in adults aged 65 or older. This risk must be balanced with the clinical need. Monitor patients closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. Mirtazapine is not approved for use in pediatric patients.
Along with its needed effects, mirtazapine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.
Check with your doctor immediately if any of the following side effects occur while taking mirtazapine:
Less common
Decreased or increased movement
mood or mental changes, including abnormal thinking, agitation, anxiety, confusion, and feelings of not caring
shortness of breath
skin rash
swelling
Rare
Change in menstrual cycle (periods)
convulsions (seizures)
decreased sexual ability
menstrual pain
mood or mental changes, including anger, feelings of being outside the body, hallucinations (seeing, hearing, or feeling things that are not there), mood swings, and unusual excitement
mouth sores
sore throat, chills, or fever
Some side effects of mirtazapine may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:
More common
Constipation
dizziness
drowsiness
dry mouth
increased appetite
weight gain
Less common
Abdominal or stomach pain
abnormal dreams
back pain
dizziness or fainting when getting up suddenly from a lying or sitting position
increased need to urinate
increased sensitivity to touch
increased thirst
low blood pressure
muscle pain
nausea
sense of constant movement of self or surroundings
trembling or shaking
vomiting
weakness
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Price Guide mirtazapine
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Mirtazapine Prices, Coupons and Patient Assistance Programs
Mirtazapine is a member of the tetracyclic antidepressants drug class and is commonly used for Anxiety, Depression, Hot Flashes, and others.
Brand names for mirtazapine include Remeron, and Remeron SolTab.
Mirtazapine Prices
This mirtazapine price guide is based on using the Drugs.com discount card which is accepted at most U.S. pharmacies. The cost for mirtazapine oral tablet 7.5 mg is around $65 for a supply of 30 tablets, depending on the pharmacy you visit. Prices are for cash paying customers only and are not valid with insurance plans.
Oral Tablet
7.5 mg
mirtazapine oral tablet
from $64.80
for 30 tablet
15 mg
mirtazapine oral tablet
from $28.81
for 30 tablet
30 mg
mirtazapine oral tablet
from $43.04
for 30 tablet
Quantity Per unit Price
30 $1.43 $43.04
45 $1.33 $59.81
100 $1.00 – $1.21 $99.63 – $121.30
500 $1.14 $568.48
1000 $1.13 $1,127.46
See brand name versions of this drug:
Remeron
Important: When there is a range of pricing, consumers should normally expect to pay the lower price. However, due to stock shortages and other unknown variables we cannot provide any guarantee.
45 mg
mirtazapine oral tablet
from $55.01
for 30 tablet
Oral Tablet, Disintegrating
15 mg
mirtazapine oral tablet, disintegrating
from $58.96
for 30 tablet, disintegrating
30 mg
mirtazapine oral tablet, disintegrating
from $59.86
for 30 each
45 mg
mirtazapine oral tablet, disintegrating
from $63.79
for 30 tablet, disintegrating
Drugs.com Printable Discount Card
The free Drugs.com Discount Card works like a coupon and can save you up to 80% or more off the cost of prescription medicines, over-the-counter drugs and pet prescriptions.
Please note: This is a drug discount program, not an insurance plan. Valid at all major chains including Walgreens, CVS Pharmacy, Target, WalMart Pharmacy, Duane Reade and 65,000 pharmacies nationwide.
Mirtazapine Coupons and Rebates
Mirtazapine offers may be in the form of a printable coupon, rebate, savings card, trial offer, or free samples. Some offers may be printed right from a website, others require registration, completing a questionnaire, or obtaining a sample from the doctor’s office.
There are currently no Manufacturer Promotions that we know about for this drug.
Patient Assistance Programs for Mirtazapine
Patient assistance programs (PAPs) are usually sponsored by pharmaceutical companies and provide free or discounted medicines to low income or uninsured and under-insured people who meet specific guidelines. Eligibility requirements vary for each program.
There are currently no Patient Assistance Programs that we know about for this drug.
According to the complaint, Pfizer engaged in a practice known as publication bias, in which only clinical trials that achieve positive results (i.e., the drug outperforms the placebo) are published in medical journals. This practice makes it virtually impossible for physicians and consumers to reach an informed decision about a drug’s actual effectiveness, and exposes them to side effects and risks associated with these medications.
https://www.baumhedlundlaw.com/consumer-class-actions/zoloft-class-action-claims-drug-company-misled-consumers-about-zolofts-ability-to-treat-depression/
Dr. David Healy, a psychopharmacologist and professor at the University of Wales College of Medicine, and a colleague conducted an analysis of Zoloft articles that were “coordinated” by a medical communications company called Current Medical Direction (“CMD”). Pfizer had hired CMD to promote Zoloft in the 1990’s.
Baum Hedlund first began litigating Zoloft cases against Pfizer in 1999 when it filed one of the first Zoloft suicide cases in the nation and then went on to represent dozens of families in Zoloft suicide and suicide attempt cases against Pfizer.
Drug Seroquel caused AstraZeneca to pay fine of $520 million 28/4/2010
https://www.bing.com/videos/search?q=FDA+Quetiapine&view=detail&mid=F2DBABEB23CCF223FD50F2DBABEB23CCF223FD50&FORM=VIRE
When is a Suicide not a Suicide?
Posted on June 9, 2013 by Brian — No Comments ↓
http://antidepaware.co.uk/when-is-a-suicide-not-a-suicide/
It has been proposed that there should be a separate verdict for those who have taken their lives while under the influence of prescribed medication. This would be a verdict of “Iatrogenic Suicide”, the word iatrogenesis being defined as an inadvertent adverse effect or complication resulting from medical treatment or advice. This would be supported by those who are concerned that suicide figures are underestimated due to the number of self-inflicted deaths registered as open or narrative verdicts.
Coroner’s Progress 1 (Ian Smith)
Posted on February 26, 2013 by Brian — 1 Comment ↓
http://antidepaware.co.uk/coroners-progress-vol-1/
He said: “I have to say this is probably the fifth, if not sixth inquest I’ve heard within a period of three years when somebody either just going on to Citalopram or Seroxat, or coming off it, have killed themselves one way or another, totally out of the blue, totally without expectation, without a history of suicidal thoughts in the past.”
Mr. Smith went on to say that he had dealt with six to eight cases in a short period where people had taken their lives days after starting antidepressant drugs and he had reported these concerns to the health authorities despite coming under criticism for speaking out.
Who was it who criticised Mr Smith for speaking out on an important issue?
Who has the authority to interfere with the free speech of a coroner in his/her own court?
Was Mr Smith the only coroner to be admonished, or were other coroners warned in case they should make similar observations?
Wherever the criticism came from, it seems to have been heeded.
…there is a need for “openness, transparency and candour throughout the system“.
It is evident that this should also apply to the Coronial System.
In 2004, Millie Kieve, founder of the APRIL Charity, called the Manchester Coroner’s office
Millie recorded the conversation with the Manchester Coroner’s office and tells them of her struggles …
https://fiddaman.blogspot.com/2019/11/louis-appleby-knew-about-prescription.html#.XcLuVpr7Rdg
Listen to the 14-minute phone conversation here
https://www.april.org.uk/media/
A day in the APRIL charity office and Millie calls the Manchester Coroner’s office as there has been a Roaccutane suicide. Millie is concerned about the reaction of Professor Louis Appleby and why he ommists to warn about medicines causing Akathisia and suicide risk for some people. She wants to know if the MHRA have written to Coroners to warn of the ban on prescribing antidepressants to under 18’s. Also mentioned are Dianette and Lariam.
https://twitter.com/APRIL_charity
Also; he, is ‘willing to write to all the corners’ … just to tell other coroners about it …
Millie and the Tsar
Posted on November 9, 2019 by Brian — 1 Comment ↓
http://antidepaware.co.uk/millie-and-the-tsar/
If the NCISH is capable of acquiring such detailed and personal information about children who have taken their lives, then it is certainly able to establish which psychotropic drugs, if any, they had been taking at the time. However, since its inception in 1996, this area of research has been omitted.
“Serious concerns about the overprescription of antidepressants such as Seroxat and Prozac will be spelled out by the two bodies regulating the safety and use of medicines in Britain. They will advise that for people with mild to moderate depression, or with moderate anxiety, they may be better off seeking other treatment such as therapy or even daily exercise.”
Meanwhile, at the age of 79, the indomitable Millie Kieve made her debut at the Edinburgh Festival Fringe in August this year, telling the story of the Cruise to Hell (below), in which she relived the tragedy of her daughter’s medication-induced death in 1995.
A Word to the Coroner
Posted on November 15, 2019 by Brian — No Comments ↓
http://antidepaware.co.uk/word-to-coroner/
At the inquest, the widow explained to the coroner how she believed her husband’s actions were caused by SSRI-induced akathisia. The coroner replied that she had never heard the word before. She asked the GP, who had never heard the word either.
The head of NCISH, the UK Government’s official suicide prevention organisation, knows about SSRI-induced akathisia. The head of the Royal College of Psychiatrists knows about SSRI-induced akathisia. And yet, the majority of those who are supposed to be looking after their patients know nothing more than they can read in the BNF. Everybody who prescribes these drugs should know about akathisia.
And as for coroners, if they were made aware of the potentially destructive power of SSRIs, they would realise that the ability of those afflicted by akathisia to make a rational decision as to whether they should live or die is completely impossible.