Dr. Mark S. Komrad has served on the Faculty of Psychiatry at several universities. He is a longtime advocate for safeguarding patients from assisted dying and says psychiatrists are meant to stop people from committing suicide, not helping them.
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As the legalization of “assisted dying” 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.
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.
In many jurisdictions, assisted suicide is already being offered to people suffering mental illness.
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 “assisted dying” and notes that psychiatrists are meant to stop people from committing suicide, not help them to end their lives.
He says legalization is becoming a “pathway” by which psychiatric patients would enter into eligibility for assisted suicide.
The legalization of assisted suicide is currently being debated in the House of Lords in the United Kingdom.
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.
Psychiatrists are medical doctors and have the most important medical role in the treatment of people with mental illness.
Currently, fewer than one in five people in hospice care receive support from a psychiatrist.
Crux Now spoke to Komrad online about assisted suicide and how it affects psychiatry.
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 “therapy?”
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.
Inside that box are a variety of tools including medications, various methods of helping people change using “talk therapies,” 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 1–2-year fellowship in a subspecialty like child psychiatry, geriatric psychiatry, addiction medicine, et cetera.
RELATED: Ethicist says psychiatrists should prevent suicide, not prescribe it
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.
Psychiatrists encounter this potentially life-threatening symptom in outpatient offices, emergency rooms, hospitals, group homes, nursing facilities—anywhere a psychiatrist’s help is sought. Of all physicians, we have particular expertise in dealing with suicidality—independent 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 “psychiatric diagnosis” at all. We specialize in ministering to helplessness, hopelessness, and demoralization, whatever the reason. This is our core skill set, the “bread and butter” of what psychiatrists encounter and work to ameliorate.
The emerging practices of legal “assisted suicide” (prescribing an oral medication to produce death) and “euthanasia” (starting an IV to push a lethal medication) unfortunately establish two categories of suicide — the suicides that should be prevented (as is the status quo of psychiatric practice), and the suicides that should be provided — by doctors. 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 — especially when these procedures are made available to people with mental illness.
Besides colluding with patients’ hopelessness, demoralization, and death wishes, medicalizing the provision of suicide puts psychiatrists in a paradoxical, indeed a subversive and rogue position of enabling suicide.
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’s 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’s burden (a very common motivation for the suicidal thinking we see in psychiatry).
It diminishes a very important feature of suicide prevention — taboo. Taboo is different from stigma. Taboo is not about shame and derision; it’s a deterrent, a social value that simply asserts that it is “not cool,” not desirable, to commit suicide.
We actually see emerging data now that natural suicide rates have accelerated in jurisdictions that have legalized these procedures, suggesting that “suicide contagion” (a known phenomenon) may be occurring, likely thanks to reducing the suicide taboo.
What does “futility” mean in the medical field – especially in hospitals?
The word “futility” has not been a standard terminology in any field of clinical medicine until the advent of legalized physician administered death.
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 “terminal illness” as an eligibility criteria, to include the chronically ill and disabled.
Therefore, there are not commonly agreed upon definitions in clinical, scientific contexts. Related words that appear in legal statues regarding euthanasia are “irremediable and “untreatable.” Canada started with its own invented category constructed in 2016 with it’s C-14 law: People whose “death is in the reasonably foreseeable future.” This was never defined, and seemed to hedge the space between “terminal” and “untreatable.”
If you look up “futility” in Websters, it is defined as “uselessness,” which is certainly an emotionally loaded definition.
RELATED: Assisted suicide increases rates of non-medical suicide, statistics show
What can look “futile” to one clinician can look different to another, particularly a dedicated specialist in a particular condition.
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’t 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 “futile”-looking cases.
Unfortunately, insurance rarely covers it, and the average family cannot afford the cost, which is upwards of $20,000 a month.
How does “futility” work in the psychiatric field?
It doesn’t.
Maria Nicolini, a prominent researcher in the area of psychiatric euthanasia, after reviewing the objective data concludes “Clinicians cannot accurately predict long-term chances of recovery in a particular patient.”
The past president of the Canadian Psychiatric Association has noted: “An 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.” And we have so many different modalities of treatment, as I said earlier, not “just another medication.”
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