As the legalization of \u201cassisted dying\u201d increases around the world, there are risks the practice could be expanded beyond the terminally ill to people suffering different kinds of non-terminal illness.<\/p>\n
There are at least 12 U.S. states that have legalized assisted suicide, as well as several countries that have legalized the practice, including Austria, Belgium, Canada, Germany, Luxembourg, parts of Australia, the Netherlands, Portugal, Spain and Switzerland.<\/p>\n
In many jurisdictions, assisted suicide is already being offered to people suffering mental illness.<\/p>\n
Dr. Mark S. Komrad, M.D. has served on the Faculty of Psychiatry at Johns Hopkins, University of Maryland, Tulane, and LSU. He is a longtime advocate for safeguarding patients from \u201cassisted dying\u201d and notes that psychiatrists are meant to stop people from committing suicide, not help them to end their lives.<\/p>\n
He says legalization is becoming a \u201cpathway\u201d by which psychiatric patients would enter into eligibility for assisted suicide.<\/p>\n
The legalization of assisted suicide is currently being debated in the House of Lords in the United Kingdom.<\/p>\n
Psychiatrists in Great Britain are concerned that people with intellectual disabilities, who are more vulnerable to coercion and can find it difficult to fully understand the concept of death, will not be provided with the proper mental health care before being asked to make a decision on ending their life.<\/p>\n
Psychiatrists are medical doctors and have the most important medical role in the treatment of people with mental illness.<\/p>\n
Currently, fewer than one in five people in hospice care receive support from a psychiatrist.<\/p>\n
Crux Now spoke to Komrad online about assisted suicide and how it affects psychiatry.<\/p>\n
Crux Now: Why is the current debate on assisted suicide so important to the psychiatric field? How is psychiatry different than what people think of as \u201ctherapy?\u201d<\/p>\n
Komrad: The state of the art in psychiatry uses a large toolbox of interventions to help people who have distress and problems functioning in the domain of mental life, meaning thoughts, feelings, and behaviors.<\/p>\n
Inside that box are a variety of tools including medications, various methods of helping people change using \u201ctalk therapies,\u201d and the emerging use of neuromodulation technologies, such as magnetic and electric stimulation of the brain and central nervous system. A psychiatrist who has completed 4 years of medical school after college and at least 4 years of residency uses all those tools. Many go on to a 1\u20132-year fellowship in a subspecialty like child psychiatry, geriatric psychiatry, addiction medicine, et cetera.<\/p>\n
RELATED: Ethicist says psychiatrists should prevent suicide, not prescribe it<\/a><\/p>\n One of the most serious symptoms psychiatrists encounter is suicidal thinking and behavior. This arises in a number of psychiatric conditions and is not diagnostic of any one; just like fever is not a diagnosis of any somatic condition.<\/p>\n Psychiatrists encounter this potentially life-threatening symptom in outpatient offices, emergency rooms, hospitals, group homes, nursing facilities\u2014anywhere a psychiatrist\u2019s help is sought.\u00a0 Of all physicians, we have particular expertise in dealing with suicidality\u2014independent of what is the underlying diagnosis. Indeed, we have the capacity to help people see beyond the choice of death and find a better path to the future, even if they have no clear \u201cpsychiatric diagnosis\u201d at all. We specialize in ministering to helplessness, hopelessness, and demoralization, whatever the reason. This is our core skill set, the \u201cbread and butter\u201d of what psychiatrists encounter and work to ameliorate.<\/p>\n The emerging practices of legal \u201cassisted suicide\u201d (prescribing an oral medication to produce death) and \u201ceuthanasia\u201d (starting an IV to push a lethal medication) unfortunately establish two categories of suicide \u2014 the suicides that should be\u00a0prevented (as is the status quo of psychiatric practice), and the suicides that should be\u00a0provided \u2014 by doctors.\u00a0 Not only is there no clear way to distinguish for which patients should be prevented, and which provided, suicide, it inverts a fundamental ethos of psychiatry \u2014 especially when these procedures are made available to people with mental illness.<\/p>\n Besides colluding with patients\u2019 hopelessness, demoralization, and death wishes, medicalizing the provision of suicide puts psychiatrists in a paradoxical, indeed a subversive and rogue position of enabling suicide.<\/p>\n To consider suicide a potential treatment option is anathema to psychiatry. Besides creating an impossible position for psychiatrists to parse these two kinds of suicide for an individual patient, it interferes with psychiatry\u2019s public health agenda to reduce suicide rates in the population. It makes a form of suicide desirable, acceptable, even honorable, as a means of relieving others of a sick patient\u2019s burden (a very common motivation for the suicidal thinking we see in psychiatry).<\/p>\n It diminishes a very important feature of suicide prevention \u2014 taboo. Taboo is different from stigma. Taboo is not about shame and derision; it\u2019s a deterrent, a social value that simply asserts that it is \u201cnot cool,\u201d not desirable, to commit suicide.<\/p>\n We actually see\u00a0emerging data\u00a0<\/a>now that natural suicide rates have accelerated in jurisdictions that have legalized these procedures, suggesting that \u201csuicide contagion\u201d (a known phenomenon) may be occurring, likely thanks to reducing the suicide taboo.<\/p>\n What does \u201cfutility\u201d mean in the medical field \u2013 especially in hospitals?<\/p>\n The word \u201cfutility\u201d has not been a standard terminology in\u00a0any\u00a0field of clinical medicine until the advent of legalized physician administered death.<\/p>\n It is a term of art that emerged as a key designed to open the legal and clinical gates to these procedures in jurisdictions like the Benelux countries, or Canada, that moved beyond \u201cterminal illness\u201d as an eligibility criteria, to include the chronically ill and disabled.<\/p>\n Therefore, there are not commonly agreed upon definitions in clinical, scientific contexts. Related words that appear in legal statues regarding euthanasia are \u201cirremediable and \u201cuntreatable.\u201d Canada started with its own invented category constructed in 2016 with it\u2019s C-14 law: People whose \u201cdeath is in the reasonably foreseeable future.\u201d This was never defined, and seemed to hedge the space between \u201cterminal\u201d and \u201cuntreatable.\u201d<\/p>\n If you look up \u201cfutility\u201d in Websters, it is defined as \u201cuselessness,\u201d which is certainly an emotionally loaded definition.<\/p>\n RELATED: Assisted suicide increases rates of non-medical suicide, statistics show<\/a><\/p>\n What can look \u201cfutile\u201d to one clinician can look different to another, particularly a dedicated specialist in a particular condition.<\/p>\n However, not everyone has access to state-of-the-art specialists who might have additional approaches that local clinicians may either not have available, or sometimes even know about. Or they can\u2019t afford a more effective treatment. In Ontario, for example, the wait for one of the their few eating disorders subspecialty programs is over 400 days! In my own practice, high-end psychiatric residential treatment has completely turned around many \u201cfutile\u201d-looking cases.<\/p>\n Unfortunately, insurance rarely covers it, and the average family cannot afford the cost, which is upwards of $20,000 a month.<\/p>\n How does \u201cfutility\u201d work in the psychiatric field?<\/p>\n It doesn\u2019t.<\/p>\n Maria Nicolini, a prominent researcher in the area of psychiatric euthanasia, after reviewing the objective data\u00a0concludes<\/a>\u00a0\u201cClinicians cannot accurately predict long-term chances of recovery\u00a0in a particular patient.\u201d<\/p>\n The past president of the Canadian Psychiatric Association has\u00a0noted<\/a>: \u201cAn extensive review of the literature shows that we cannot predict irremediability [i.e. futility] when it comes to mental illness. There is a big difference between being able to predict the declining course of a well-known medical ailment with understood biology, even if not with 100 percent certainty, versus making unpredictable assessments about the course of mental illnesses.\u201d And we have so many different modalities of treatment, as I said earlier,\u00a0 not \u201cjust another medication.\u201d<\/p>\n Psychiatric conditions are among the most\u00a0human\u00a0forms of suffering, as they afflict higher consciousness. They can be some of the most difficult to bear, both for patients and for their treating clinicians. Absorbing a patient\u2019s hopelessness, struggling to bear the burden of a challenging patient, and wrestling with one\u2019s own values about what is a life worth living, are vulnerabilities for all specialists, but especially in the intensity of long term encounters with psychiatric conditions. Professional terms of art for these challenges are \u201ccounter-transference\u201d and \u201cprojective identification.\u201d<\/p>\n As the celebrated medical ethicist Dan Sulmasy\u00a0writes<\/a>: \u201cas a physician, I know that I can make\u00a0my\u00a0feelings of helplessness in the face of incurable disease seem like\u00a0your\u00a0independent judgement.\u201d<\/p>\n So, the lure of concluding that a patient\u2019s condition is \u201cfutile\u201d can be a path to relief\u00a0for the doctor\u00a0in euthanasia jurisdictions, meaning there is a highly subjective component to this. Christopher de Bellaigue\u00a0wrote<\/a>\u00a0of allowing one or two consulting doctors to open the gate of euthanasia for a patient: \u201dAs the most solemn and consequential intervention a physician can be asked to make . . .\u00a0 the decision to kill is oddly contingent on a single, mercurial human conscience.\u201d<\/p>\n You have said that futility is very proximate to the notion of \u201cterminality.\u201d Can you tell me what this means in layperson\u2019s terms and how this affects your field?<\/p>\n An ambiguity of \u201cfutility\u201d in this context is that it\u2019s often unclear whether it refers to the \u201cuselessness\u201d of\u00a0all possible treatments\u00a0for a condition (FDA approved, evidence based, anecdotally effective) or only the treatments that a patient will\u00a0accept.<\/p>\n For example, kidney dialysis is a highly effective treatment for end-stage kidney disease, that can maintain a person\u2019s life, often with very fair quality, for years. So, if a patient refuses dialysis, or kidney transplantation (they certainly have an ethical right to do so), does their condition now qualify as futile?<\/p>\n Very few statutes permitting medical administered death require patients to undergo any and all eligible, appropriate treatments for their condition. By refusing a treatment, a patient can\u00a0produce\u00a0a terminal situation by choice, in a condition that is not theoretically terminal.<\/p>\n In the U.S., we have physician assisted suicide in 12 states and DC (oral lethal pills, at the time of one\u2019s own choosing), not euthanasia (IV, scheduled, with the doctor at the bedside).<\/p>\n Also, the criterion for eligibility is having a \u201cterminal\u201d condition, a predicted 6 months life span \u2014 (whether with or without treatment is usually not statutorily specified).\u00a0So, in the U.S., to enter the gate of assisted suicide, one must be \u201cterminally\u201d ill. What about psychiatric conditions? We have NO established notion of a terminally ill psychiatric patient, since nobody can come close to predicting that any one patient is nearly certain to die within 6 months from their psychiatric illness.<\/p>\n Yet, one Colorado physician published\u00a0a paper in 2022<\/a>, utilizing the magic word \u201cterminal\u201d to describe 3 cases of anorexia nervosa. She prescribed lethal medications for assisted suicide to these patients, as there is a law permitting assisted suicide of the \u201cterminally ill\u201d in Colorado. So first, she controversially concluded these cases were \u201cfutile\u201d and then she transmuted that to \u201cterminal\u201d to open the legal gate to assisted suicide.<\/p>\n This paper is loaded with various assertions like this that are not standard practice in the eating disorders field. There is no such thing as \u201cterminal anorexia.\u201d Indeed, I and some other colleagues are endeavoring to get the publisher to retract this paper on ethical grounds, as it has had\u00a0pernicious influence on policy makers worldwide. It is analogous to the effect of the infamous paper that originally asserted vaccines cause autism, which was later retracted. If these cases were in Canada, where you don\u2019t have to be \u201cterminal,\u201d just \u201cfutile\u201d \u2014no prospect of further improvement\u2014that would be sufficient.<\/p>\n So, \u201cfutile\u201d if it\u2019s Canada, but in the U.S. that notion has to be rhetorically wrestled into \u201cterminal\u201d to open the assisted suicide option. That is how these notions are proximate.<\/p>\n The DHHS (HHS) is updating Section 504 of the Rehabilitation Act to prohibit disability-based discrimination in federally assisted programs. Why should ordinary people care?<\/p>\n \u201cAbleism\u201d is a common prejudice in society against disabled people. Those who are not disabled often feel that a significant disability would make \u201clife not worth living,\u201d and assume that disabled people would feel the same way.<\/p>\n This prejudice is even seen among some doctors, who were consciously or unconsciously motivated to proffer less assertive or innovative treatments for people who are disabled. Research has shown that the threshold for considering a patient\u2019s condition \u201cfutile\u201d is lower for the chronically disabled because of this prejudice.<\/p>\n This recent update to the Rehabilitation Act of 1973 strengthens prohibitions against disability discrimination in health and human services, including medical treatment, accessible equipment standards, and digital accessibility.<\/p>\n This fortification is particularly important in this era of spreading laws permitting physician assisted suicide and, I believe, the inevitable extension from the terminally ill to the chronically ill and disabled here in the United States.<\/p>\n Why do you think the push for assisted suicide is growing in many countries, and how does this affect the medical field?<\/p>\n There are multiple forces at play. In psychiatry we say that the causes are \u201coverdetermined.\u201d There is the \u201cold world\u201d ethos, which thrived in Judeo-Christian-Islamic soil, in which \u201csanctity of life\u201d was a key moral fulcrum.<\/p>\n Then there is the \u201cnew world\u201d ethos emerging from the Enlightenment and subsequent values that have ascended to high primacy in the post-modern world, such as fairness, autonomy, and justice. So, the old-world matrix is increasingly effete. In some countries, such as Canada and Belgium, the cultural urge to differentiate themselves from their heavy Catholic moral parentage is a real force. In Belgium, churches have very few attendees for services, and many have been turned into architectural and historical museums. Similarly in Canada. Self-determination, individualism, and entitlement are important dominant themes.<\/p>\n Relevant clues are that most people\u00a0 advocating for and choosing these procedures are \u201cthe 3 W\u2019s\u201d \u2014 wealthy, white, and well educated \u2014 a Western cohort that is used to living the way they wish, and therefore dying the way they wish.<\/p>\n Also, life extension due to medical advances and lifestyle improvements doesn\u2019t always mean more quality of life. The drive for euthanasia and assisted suicide is a counterpoint to the impetus to \u201cpull out all the stops\u201d medically, often excessively deployed beyond measure.\u00a0 Effective palliative care, if available, is of course the appropriate response to that\u2014getting out of the way of death, with comfort care and accompaniment\u2014not medically killing the sufferer, nor aiding and abetting their suicide.<\/p>\n What can ordinary people opposed to assisted suicide do to help stop this from growing?<\/p>\n I am a founder of the international organization\u00a0Doctors Say No<\/a>, in which doctors from all over the world have signed a manifesto stating that these are not \u201cmedical procedures.\u201d They should not be dressed in the white coat. These worldwide physicians advocate for more robustly available training and utilization of state-of-the-art palliative care for those who suffer chronically or terminally, rather than making the sufferer dead. Many leading professional medical organizations agree, notably the\u00a0American Medical Association<\/a>, and the\u00a0World Medical Association<\/a>.<\/p>\n Many are explicitly opposed to euthanasia for those with mental disorders, such as the\u00a0American Psychiatric Association<\/a>\u00a0and the\u00a0International Association for Suicide Prevention<\/a>.<\/p>\n But doctors alone can\u2019t check the metastasizing spread of this meme. All citizens who can influence the crafting of laws must participate. It is the effect of ordinary individuals\u2019 anecdotes to legislators, telling of their or their loved-ones\u2019 sufferings, which helped pass these laws in the first place. Legislators need to hear other kinds of stories \u2014 wrong diagnoses, prognostic errors, unavailable treatments due to finances, manpower, or\u00a0 insurance refusal.<\/p>\n Tales of ableism, ageism, and discrimination are critical. In places where these procedures are already legal, bring to hearings examples of poorly observed or ambiguous guardrails, and misadventures that occurred with prescribed poisons. Examples of all these are accumulating.<\/p>\n There is a growing\u00a0 coalition of organizations dedicated to preventing legalization of these procedures, or rolling them back.\u00a0 Anyone can donate to them, participate, or attend their numerous online seminars, which provide education and inspire advocacy.<\/p>\n Examples are:<\/p>\n The Euthansia Prevention Coalition<\/a>\u00a0and\u00a0Collectif Des Medicins Contre L\u2019Euthanasie in Canada<\/a>\u00a0in Canada<\/p>\n Patients Rights Action Fund\u00a0<\/a>and\u00a0Aging with Dignity\u00a0<\/a>in the U.S.<\/p>\n Caring Not Killing<\/a>\u00a0and\u00a0Our Duty of Care\u00a0<\/a>the UK<\/p>\n The Society of Supportive and Palliative Care<\/a>\u00a0in France<\/p>\n Many of my own presentations to these organizations are available at their websites. Don\u2019t think that, once passed, these laws are a done deal. Slovakia is a recent example of where a general referendum was able to\u00a0retract a previously passed euthanasia law<\/a>.<\/p>\n The forces promoting euthanasia and assisted suicide are coherent, strong, well organized, and well-funded. But, like David against Goliath, strategy, determination, and hope can redress an imbalance of strength against values.<\/p>\n Follow Charles Collins on X:\u00a0@CharlesinRome<\/a><\/p>\n