Part 8: Germanwings, From a Medical Perspective

Today I find myself again discussing the 2015 Germanwings crash.  The crash was absolutely pivotal to subsequent FAA policy. I came to this with one pressing question: How was Lubitz, the 27-year-old co-pilot that crashed the plane and murdered 149 others, ever permitted to fly that day? He had 41 doctors in 5 years, 7 in the month prior to his crash. And, his physicians had lots of concerns.

Here is what I have concluded: Lubitz was terrified he was going blind and deaf. But he was also afraid of losing his job. So he spent a lot of time seeing doctors while also hiding his problems. If we are to believe the investigations that followed, his colleagues did not know how ill he was. His girlfriend was also in the dark. And, as for his psychiatrist – well, they wrote the following:

This translates:

“The patient named above appears to be completely healthy from a psychiatric point of view. There is no indication of a psychiatric disease. Regarding illness, Mr. Lubitz does not have a higher risk than the average population.”

I have three thoughts about the note: 

1. It was written Jan 29th, 2015 and Lubitz’s mental illness still had almost another two full months to fester and grow. So, in all fairness, this glowing medical clearance probably would not have reflected the psychiatrist’s opinion in March of 2015.

2. It is the sort of hyper-enthusiastic medical clearances that are, unfortunately, commonly written. When medically clearing people, it has been my observation that honest appraisals filled with doubt and uncertainty make people unhappy. By “people”, I mean “everybody.” The employer or Agency wanting the letter pushes back, asking for certainty where there is none. Failing that, they burden the patient and doctor with more requests, more clarification, more details. Often the requests are unreasonable. As for the patient, if they don’t fire you, they learn to edit what they tell you so that they get the outcome they want. In a field like psychiatry, you want to avoid mandatory reporting as it artificially introduces barriers, manipulations, and coercion into the relationship. Often though, as is the case here, the reports are unavoidable.

3. Despite that, this particular clearance goes deep into fantasy. Lubitz had been hospitalized for depression in the past. That puts him a much higher risk for future hospitalizations or mental health crises. So how the doctor concluded that he “…does not have a higher risk than the average population” is deeply problematic and misleading. Indeed, one might fairly allege that a letter like that might have misled and prevented other physicians from acting appropriately and getting Lubitz out of the air.

Regardless, by March, the month of the murder-suicide plane crash, it is clear that at least one physician wanted him grounded. Redacted notes make it impossible to know if it was the same psychiatrist, with another month of assessment and a newly revised opinion. What is known is that the German newspaper “Bild” reported that 14 days before the crash a physician ordered “hospital treatment” for Lubitz. He was given a “...referral to the Psychiatric Day Clinic of the University Hospital Düsseldorf, diagnosis: impending psychosis with progressive visual disturbances."

So, again, what went wrong? Why wasn’t he sent to the hospital? As best as I can say, he kept flying due to the law and medical culture in Germany.

German law makes it very precarious for physicians to break confidentiality and alert others when someone poses a specific public threat. In Germany, it is rare to break confidentiality, no matter how legitimate the cause, and it is legally risky. This is especially true when working with a high-functioning professional. The alternative, an involuntary hospitalization, would probably be even less appealing. Unless someone is overtly dysfunctional and unable to cover up their illness, an involuntary hospitalization would likely fail. The patient would immediately discharge or never get past the ER. As I already noted, Lubitz had mastered covering up his symptoms.

This dilemma plays out differently from that seen in the USA. Here, each of the 50 States have some variant on the Tarasoff Law, which affords a little more flexibility (the key word being “little”). But that is one of the topics that is coming up; I’ll review it in the near future.

But back to Lubitz. What happened to him likely made matters worse. If we agree the doctor could not or did not (1) force Lubitz into a hospital by calling an ambulance or (2) notify the airline that he was a threat, then what did the doctor do? Well, it appears he recommended Lubitz to go to the hospital voluntarily and wrote a script for him to do so.

If, indeed, this is how events transpired, I’d argue it was probably the worst thing that could have been done. Lubitz would know that a hospitalization – or the mere prescription for a hospitalization – was a career-ender. Nevermind that he was also being prescribed a neuroleptic (Dominol 80 mg), two antidepressants (Remeron, Lexapro 20 mg), and two sedatives (Zopiclone, Ambien). Most of those medications, alone, would ground him. Whether immediately or at his next AME, he was done. So, at that moment, he was in debt, without a career, depressed, and psychotic, believing he was losing his sight and hearing to some ongoing medical malady. In his distorted psyche, I imagine he felt boxed in with lots of bad options. He researched how to kill himself with cyanide or, alternatively, how to rage at the world.

Regrettably, he chose and he chose the latter.

So, was this preventable? Yes. German law should have allowed/encouraged the doctor to take decisive action and hospitalize or inform the airline when the voluntary psychiatric admission fell through. In short, provide a solution or a safety check, rather than back a delusional and desperate man into a corner.  However, what the doctor did was, apparently, standard practice – it was just an intervention with a predictably horrendous outcome. 

The take home is this: Germanwings is what happens when you intrude in the physician-patient relationship and distort it, so no one can be honest. But, more importantly, it is what happens when you overly legislate such that physicians cannot use good judgement to resolve bad situations.

By the way, a shout out to Ms. Paola Lanzi, the project manager of the MESAFE project. Her letter answered some questions I had about the Germanwings incident. Thank you for connecting me to the BEA report and sharing your thoughts. Here is the link to her team’s report:

https://bea.aero/uploads/tx_elydbrapports/BEA2015-0125.en-LR.pdf