I’m in my mid-60s and part of a childless friend group whose members depend on one another. One friend, who lives hours away, is married to a man with severe mental-health issues — bipolar disorder and escalating paranoia.
They both have mobility challenges. The husband, believing his car has been tampered with, won’t drive, so I’ve cared for him post-surgery and driven him to his appointments. His paranoia is extreme. He believes a former employee of his has hacked into his life and is somehow controlling him. He won’t carry a phone, believing his ‘‘hacker’’ will find him. While driving, if my GPS suggests an unfamiliar route, he thinks we’re being controlled, or deliberately sent off course. He’s easily triggered and often breaks down emotionally.
Though he uses a cane, he’s strong and quick to anger. He’s spoken of killing his hacker and recently said he would kill his wife too if she colluded with this person. He’s angry about not having access to money his wife has inherited, which he wants to use to hire a contract killer.
I’ve informed his wife that he said he would kill her if he learned that she was part of the conspiracy against him. She has unsuccessfully tried to have him institutionalized (in certain contexts, he behaves rationally). But she’s afraid to leave him. I fear for her safety and, increasingly, my own. I’ve considered reporting his threats, but no crime has been committed. I feel helpless watching this situation deteriorate. What ethically can I do to protect my friend and myself? — Name Withheld
From the Ethicist:
In the meantime, document everything you can; his wife should do the same. That may include recording your conversations with him without his consent (if it’s legal to do so in your state). In normal circumstances, this sort of evidence gathering wouldn’t be ethical in your relations with other people. But when you’re dealing with somebody driven by paranoid delusions to contemplate murder, you’ve got an overriding duty to protect yourself and your friend. Consulting with an attorney who has the relevant expertise could be helpful as well. So could consulting with mental-health services. Yet there’s no skirting the paradox: The measures people may reasonably take toward someone gripped by paranoia may, if the person learned of them, reinforce the paranoia.
Ideally, your friend’s husband would be helped to see that he needs psychiatric care; there are effective medications for bipolar disorder, including the kind that’s accompanied by paranoia. You may have a sense of whether you can safely have that conversation with him. Unfortunately, ‘‘anosognosia’’ — a failure to grasp that you’re ill or impaired — isn’t uncommon among people in his situation. Although some states have, over the opposition of mental-health and civil rights advocates, tried to expand the ability to use short-term ‘‘treatment holds,’’ it seems doubtful that short-term detention will provide a long-term solution. And a man who can present as rational when he wishes isn’t likely to be held for very long.
Given these grim circumstances, you might encourage your friend to come up with a safety plan if things should escalate: a go bag, a friend’s house nearby where she can find refuge, a means of getting there. If you think he may turn on you, you should do the same. Assuming he won’t submit to treatment, I also hope that she’ll explore ways to separate her life from his without putting herself at further risk. It’s helpful that she seems not to be economically dependent on her husband, which removes one of the usual barriers to leaving, and she clearly recognizes him as dangerous. Roughly half of female homicide victims, it’s been estimated, are killed by a spouse or intimate partner. We’re rightly concerned about restricting the rights of individuals. But when you stay with somebody out of fear, you yourself have become a captive.
Readers Respond
The previous question was from a reader who served her ailing mother cannabis gummies. She wrote: “My 78-year-old mother has moderate dementia and suffers from mood swings, depression, anxiety, agitation and disturbed sleep. One of her doctors recommended a low-dosage CBD/THC gummy to alleviate these problems. She takes one daily and, combined with other therapies, now experiences more stable moods and better sleep. The issue is my mother’s conviction that marijuana is for drug addicts and criminals, never mind that medical marijuana is legal in our state. … I have to lie to her about the ingredients in the gummies, which I casually refer to as ‘‘multivitamins.’’ Is it wrong to give my mother a drug that she would never have voluntarily taken on her own?”
In his response, the Ethicist noted: “Here are a couple of issues to take into account. One is — no surprise — the extent of her dementia, because it affects her ability to understand what you’re telling her about these gummies. From what you say, she would be perfectly capable of understanding that the gummies contain chemicals extracted from cannabis plants, one of which is responsible for psychoactive effects she regards with disapproval. And long before her current condition, you evidently weren’t able to reason with her about the possible medical benefits of THC. In general, we shouldn’t lie to people about the drugs we’re giving them, and your mother would want to know what’s in those gummies. Mild dementia wouldn’t justify denying her that information. But the more serious her dementia is, the more you have to treat her not as someone whose rational capacities must be addressed but as someone whose care is entrusted to you.” (Reread the full question and answer here.)
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Since many prescription medications currently available for anxiety are generally not recommended for seniors because of dangerous side effects — they increase fall risk for older adults — I think the letter writer is justified to keep calling the gummies “multivitamins.” — Judith
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Usually, I’m in complete agreement with the Ethicist, but this query on the gummies left out a significant aspect of the issue: the experience of the caregiver. Having been in that same position with my grandmother, “Dr. Caroline’s Magic Vitamins,” our name for the liquid Prozac she prescribed, made the last six months of her life sweet instead of contentious. I say the caregiver gets a vote on this one. — Susan
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My mother passed away after a long period of living with dementia, and so I sympathized with the letter writer and appreciated the Ethicist’s response. We want to honor our parents’ true selves while making decisions to support their well-being. To me, however, an analogous situation is not giving a kosher woman bacon, but rather a porcine heart valve. The Jewish concept of “pikuach nefesh” gives primacy to saving a human life. While we shouldn’t serve a Kosher woman bacon, Jewish law has no restrictions against giving her a pig’s heart valve to save her life. To me, the mother’s objections to the gummies (which are, from the description, of obvious benefit) are similar to objections the kosher mother might have to the lifesaving heart valve, rather than to eating a non-kosher food with no medical benefit. — Naomi
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My husband had Alzheimer’s for eight years before he died. It is common practice in the Alzheimer’s community — an approach known as “therapeutic lying” — to refrain from telling a patient the absolute truth. The letter writer’s goal as a caregiver is to keep the patient safe, content and calm. If it requires her to call a gummy a vitamin, so be it. The patient does not have the mental capacity to understand or process more complicated explanations, and the last thing that you want to do is to argue with them. — Betty
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My mother suffers from dementia and my sister and I manage her care. Her world has gotten smaller and smaller, and she is both grateful for and frustrated by how much we do for her. We try to offer her choices whenever we can, and we avoid lying to her. But we put her safety and comfort above everything. I wouldn’t bother to tell her mother what’s in them unless she asks. In that case, I’d tell her the truth: that the active ingredient is tetrahydrocannabinol, otherwise known as THC, which can help reduce her pain and stabilize her mood. I wouldn’t trigger her by equating the gummy to pot smoking; she’s got long-held views informed by misinformation and stereotypes, and bringing them up obfuscates the truth rather than revealing it. — Diane
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