The role of the doctor in psychiatry or end-of-life care is not to erase the WHY

Psychiatry once meant thinking deeply about a patient’s life. Dr. Keith Ablow says it has shifted to ten- or fifteen-minute prescription visits. “That very much celebrated part of psychiatry that was about thinking deeply about who you are… has gone by the wayside too much.”

Ablow now does life coaching and develops natural remedies for low mood, not major depression. He warns that patients with mild symptoms can be labeled with a major disorder and medicated unnecessarily. “You might well get put on an antidepressant when you don’t have the signs and symptoms that merit it.”

Third-party payers reward psychiatrists for writing prescriptions, not for psychotherapy. This divides the listener from the prescriber, leaving the patient without someone who understands both their life story and their medical needs.

He rejects the idea that psychiatry and religion are opposites. “The heart of psychotherapy… is really spiritually based.” The self, he says, is independent of the brain but needs the brain to manifest.

I raised the “furry” phenomenon — people whose sexual gratification comes from wearing animal suits — as an example of how psychiatry can go wrong when it simply affirms whatever licentious, libertine, lewd, lunacy comes along. Ablow expanded, recalling a psychiatrist who would approve amputations for a man who saw himself as a double amputee. Ablow… “would disagree. There are some things that speak for themselves… we’re not going there.”

The loss of “why” is not confined to psychiatry. It runs into medicine’s most final decision — whether to live or die.

Andrew Klavan calls Hamlet the first modern man, standing where faith’s certainty gave way to doubt. He asks if it is nobler to endure the “slings and arrows of outrageous fortune” or to take arms against a sea of troubles by ending life. Death may be sleep, but “what dreams may come” gives pause. That pause — the moral hesitation — is the essence of being human.

In Canada’s MAID program — Medical Assistance in Dying — the pause is gone. In 2023, 4.7 percent of all Canadian deaths were by euthanasia. Quebec’s rate is over seven percent, the highest in the world. The system began in 2016 for terminal illness, expanded in 2021 to those not terminally ill, and will soon include the mentally ill. Demand is so high that practitioners struggle to keep up. Conferences for the trade feature lunch buffets, DJs, and tote bags.

Evil often wears a normal face. In The Zone of Interest (2023), a Nazi camp commandant’s family tends their garden, plays music, and paddles the river while the killing happens next door. The euthanasia conference hall, with its music and catering, is not so different in its detachment from the end result.

Hamlet’s hesitation is what makes the play timeless. In Canada’s system, there is no hesitation, only process. If the psychiatrist who validates an amputation fantasy is surrendering his duty, then so is the doctor who treats death as another service line.

The role of the doctor — in psychiatry or end-of-life care — is not to erase the “why.” It is to explore it, hold it up to the light, and help the patient endure until the story reaches its natural close.

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