What Really Killed Matthew Perry?
Reading Time: 6 minutesWhat Killed Matthew Perry? Ketamine Was Only Part of the Problem., The Friends actor died in a hot tub after being injected with ketamine. But the story appears to be more complex than that., Matthew Perry, ketamine: Physicians to the famous owe something
When a mental health disorder combines with fame and money, it can be a siren call for a variety of evil people. On Oct. 28, 2023, it appears that Friends star Matthew Perry became the victim of a group of people willing to poison him through negligence, if a report from the New York Times is to be believed. Central to this group were physicians. For Perry, the culprit poison was ketamine, a complex and vital pharmaceutical that he desperately sought and was increasingly supplied despite warning signs. One of the doctors who prescribed him the drug has claimed, through an attorney, that he was merely doing his job.
But to fully understand what happened to Perry, we must discuss the story of ketamine and depression. We must also understand negligence and why licensed physicians break sacred oaths and cause harm.
From a medical perspective, the scope of action of ketamine is extraordinary. This same drug can treat pain, prevent relapse for alcoholics and heroin addicts in recovery, block seizures, and reverse asthma attacks. This drug can create a deep state of anesthesia and amnesia sufficient to block the pain of a surgeon’s knife or 400 joules of electricity delivered to reset a fibrillating heart. Famously, it creates a state known as dissociation while maintaining near-normal respiratory function and minimal negative impact on the heart. For Perry and thousands more, the actual reason was for yet another ketamine property—for many, it is a powerful treatment to reverse crippling depression.
The enthusiasm for ketamine as an antidepressant has been relatively recent, but this important property has been known for quite some time. In 1975 ketamine was reported to show antidepressant-like effects in animal models. On March 5, 2019, the Food and Drug Administration approved a ketamine nasal spray for treatment-resistant depression, though its use has been limited to certified medical offices or clinics. Apart from the inhalation method, ketamine is generally administered as an intramuscular or intravenous injection. Ketamine is not absorbed when swallowed.
The pharmacological market is dominated by two classes of drugs known as selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors. What is notable about these drugs is their relative ineffectiveness in improving depression symptoms. Worse, they fail to block suicidal ideation and may even increase the risk of suicide. Ketamine is not associated with increased suicidality and is often used in emergency departments on individuals who have attempted suicide or have intense suicidal urges.
Good psychiatrists know when to use antidepressants that will strongly predict success. Melancholic signs predict a higher likelihood of success. The signal-to-noise problem of antidepressant failure is that they are wrongly used for unhappiness or the trauma of existence. Unhappiness is a common and serious concern, but an SSRI or SNRI will not help a patient who is merely unhappy. True medical depression is much less common. The high failure rate of antidepressants may reflect overprescribing and the subsequent medicalization of suffering.
For treatment-resistant depression, doctors may turn to something stronger. Ketamine is structurally like phencyclidine, also known as the street drug angel dust, among many other names, and shares that drug’s ability to cause hallucinations and distorted perceptions. Sometimes, these hallucinations are pleasing and generate feelings of profound insight. At other times, these hallucinations are terrifying—known in the medical lexicon as emergence delirium. Up to 55 percent of patients administered ketamine experience an emergence phenomenon that closely mimics schizophrenia and increases their risk of injury.
Finding the sweet spot between terror and bliss is too irresistible for some users. Case reports of recreational ketamine use by physicians exist. Chronic users also develop a significant tolerance to ketamine without prominent symptoms of physical withdrawal, and cyclical use of very high doses is observed. By accounts, Perry struggled progressively with tolerance, and he sought out ever-increasing dosage in pursuit of the desired effect.
Suffering from ketamine tolerance, Perry asked for increasing dosages, but his clinic doctor refused his requests. Perry found Salvador Plasencia, an internist who went by the nickname ‘Dr. P.’ Plasencia partnered with another physician, named Mark Chavez, who had experience with ketamine. Together, they considered how much to charge Perry to supply him. According to a court-filed document, text messages from Plasencia to Chavez read, ‘I wonder how much this moron will pay’ and ‘Let’s find out.’
When a doctor deviates from the standard of care, leading to measurable harm, we call this negligence. This is a civil wrong, and the restitution is money. Central to negligence is the foreseeable nature of the harm. Sometimes, negligence is so extreme that it is punishable as a crime. Legislatures have generally left the transformation of civil to criminal negligence vague. The onus is on the prosecutor to decide. Criminal negligence occurs when more extreme actions result in more extreme harm. It is not simply a mistake in judgment or carelessness. To prove criminal negligence in California, where Perry died, a prosecutor must show that the person accused knows that what they did created a particular grievous risk to the person they hurt. The prosecutor must show that another person in the same situation would have foreseen the risk and refrained from acting similarly. Plasencia and Chavez almost certainly had no intention of causing Perry to die, but his death was foreseeable. With greed and carelessness, these doctors failed Perry because they should have known better.
In a report dated Dec. 15, 2023, from the County of Los Angeles Department of the Medical Examiner, Perry’s cause of death was listed as the acute effects of ketamine. This doesn’t seem right. Listed contributing factors include drowning, coronary artery disease, and the effects of buprenorphine, a drug used to treat opioid use disorder. If Perry had received ketamine while lying on dry land, he might not have died. Ketamine is not toxic in the way other drugs might be. Opioids cause death because, in an overdose, people stop breathing and they don’t know it. The cause of death is the lack of oxygen.
Ketamine is not an opioid. Some drugs directly cause the heart to stop, and in that case, the drug is more the proximate cause. Even in large and repeated dosages, and all things being equal, ketamine may be harmful, but it’s not predictably deadly on its own. When a critically ill person needs anesthesia, ketamine is commonly chosen because it doesn’t kill. The lack of apparent and established ketamine lethal toxicity may have reduced the concerns of Plasencia and Chavez . This, however, should not clear them of medical wrongdoing. Ketamine is typically administered under the direct supervision of medical professionals because of its strong effects. Perry was, according to the Times’ reading of court papers, injected by his assistant, then left alone.
After the Department of Justice charged the doctors with several drug-related charges, Chavez entered a plea agreement, and Plasencia pleaded not guilty. ‘Ultimately, Dr. Plasencia was operating with what he thought were the best of medical intentions,’ his attorney has said. Nobody has yet been charged with negligence, either civil or criminal, in Perry’s death. However, that could still be coming.
All citizens in civil society are expected to follow the law and observe the social contract, particularly physicians. In exchange for power, the physician swears an oath to protect the public from harm. For the moral physician, beneficence must always exceed maleficence. A state medical board grants a physician a license to practice as an extra layer of public protection. What may need to be more appreciated is that rich and famous people tend to get inferior medical care. In such cases, the reason is a departure from standard practice drawn from a desire to provide something unique and be part of an experience more exciting and beyond the day to day of medical practice.
At the core of the doctor–patient relationship is the duty on the part of the physician to act in the patient’s best interest. Sometimes, a patient makes an unconventional choice, but if the patient is competent and the request is fundamentally reasonable, the physician is duty-bound to comply. Such a request needs no financial sweetening on the part of the patient to get the doctor to agree, nor should the patient’s celebrity sway decisionmaking. When a patient is powerful, addled by illness, and the request is unreasonable, an offer of money to that physician (or the fact that a patient can be charged a high price) makes that request no more compelling. In that case, the physician’s duty is clear: Turn down the money and tell the patient no.
Ref: slate
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