Thursday 15 November 2018

No place for archaic practices in healthcare

Andreas Lubitz
Andreas Lubitz

Patricia Casey

Almost one year ago, the world was gripped by news that 150 people had lost their loved ones in an air tragedy involving a pilot who, in all probability, had crashed his aircraft as an act of suicide.

The formal investigation by the French Aviation Authority (BEA) has been completed and its findings revealed in a 110-page report, available in English. The French authorities had responsibility for the investigation because the crash occurred in French air space. Its investigating team consisted not only of aviation experts, but also doctors, including psychiatrists.

The questionable role of the medical profession in this incident was remarked upon at the time. In my opinion it was not due to disinterest, disengagement or active malice, but to circumstances that are unique to Germany's history, in which doctors sided with evil to ensure the purity of the Arian race.

Flight 4U9525 left from Barcelona for Dusseldorf on March 24 2015. The co-pilot was Andreas Lubitz, a 27-year-old German. Lubitz had deliberately locked the door of the cockpit to prevent re-entry by the pilot who had left for a bathroom break. The flight went down over the Alps, instantly ending the lives of all 150 on board.

In late 2008 Lubitz had a depressive illness and attended a psychiatrist and a psychotherapist. He required a period of time in hospital sometime between January and July 2009 by which time his psychiatrist said he was off medication and fit to return to his work as a pilot.

Even if he had still been taking antidepressants, that would not have been a deterrent provided they belonged to the products approved by the aviation authority. He complied with the annual aeromedical examinations thereafter.

He became ill again in December 2014 but continued to work with a few sick periods ranging from two to seven days until his death. In February 2015, a physician diagnosed him with a "psychosomatic" condition and anxiety.

He complained of insomnia and a belief that he was losing his eyesight. By then several opthalmologists had said his eyes were normal. That physician referred him to a psychiatrist, who started him on an antidepressant, and a psychotherapist. On March 10 2015 that same physician changed the diagnosis to one of psychosis, and recommended that he be treated as an inpatient. By March 16 he was on two antidepressants, in low doses. He had also seen at least four other physicians privately but they issued him with sick certificates. On March 24 2015 he died by suicide and caused the deaths of 149 others.

According to the BEA report, none of his peers noticed anything untoward and the doctors did not inform his employers, even though he had a prior history of depression and had been complaining of medically unexplained eye symptoms and insomnia for two months. The recommendation that he needed inpatient treatment was not acted upon and the psychotic nature of his symptoms was only identified by one physician.

Delusions about health do occur in depression, even though they are uncommon. People believe they have cancer or heart disease or AIDs for example, when there is no objective evidence of this.

Psychotic depression is the most severe form of that illness and requires inpatient treatment with both antidepressants and antipsychotic agents, and sometimes electrical treatment. Lubitz was only receiving antidepressants.

It is also very uncommon and for this reason is often missed, especially in young people. The investigating team included a psychiatrist who, in my opinion, was correct in considering psychotic depression as the most likely diagnosis.

Despite being seen by numerous doctors, and having had a period off work in 2009, no doctor informed his employer. Whether this was considered or not is unclear because the private doctors and family members all opted not to participate in the BEA investigation.

The greatest deterrent to informing the employers in this case was almost certainly the very stringent sanctions for any doctor breaching the code of confidentiality in Germany.

As well as a period of imprisonment, a civil case would almost certainly be pursued against the doctor. In other European countries, such as Ireland, if there is a likely risk to others then confidentiality can be broken to the relevant authorities, but German law is very specific that it must be "imminent".

Since no doctor can predict suicide or violence in a mentally ill person, especially if nobody has expressed any concerns about the individual, this test can never be met except in very exceptional circumstances. The particular sacredness of the code of confidentiality in Germany stems from the role doctors played in Nazi medicine in identifying vulnerable adults for extermination and subsequently the complicity with the Stasi in East Germany.

So that preventable events like Germanwings do not happen again, the BEA has made a recommendation that, by international agreement, the imbalance between the right of the person to confidentiality and the duty to protect the public should be redressed in new legal codes.

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