Physician-Assisted Suicide for Mental Illness - It's Complicated, or Not

Two years ago, Mark Komrad attended and presented at a symposium in Belgium on physician-assisted suicide for people with mental illness. Komrad is a clinical psychiatrist, ethicist, and faculty member at Johns Hopkins. He just finished a 6-year tenure on the APA Ethics Committee and helped craft the current APA position on Medical Euthanasia for non-terminally ill patients. [That position joins the AMA to say, in a word, Don't.]

Komrad reported back on his experiences to You can read or listen to the his entire report here. This post quotes the parts that particularly struck me from a suicide prevention perspective.

In 2002 Belgium legalized euthanasia by physician (typically by injection) at the request of patients, and removed any distinctions between terminal vs. nonterminal illness, and physical vs. psychological suffering. As long as the condition is deemed "untreatable" and "insufferable," a psychiatric patient can be potentially eligible for euthanasia. There is a consultative process that basically needs a minimum of two doctors to agree about the patient's eligibility. Also, the patient gets to weigh-in on whether their condition is "treatable." Since the patient has the option to refuse treatments, this refusal may create an "untreatable" situation.

The medical associations of the rest of the world oppose this practice. Belgium and now the Netherlands are outliers on this position; they claim the high moral ground for acting with compassion and concern for patients' suffering and autonomy. Komrad provided context which included the recent anti-Catholic attitude of the country and the reluctance of opposition voices to resist, for fear of being dismissed as "Catholic."

But opposition does exist, and discussed the matter with Komrad privately. In Komrad's public comments, he made mention of the ways that the leading and most celebrated psychiatrists in Nazi Germany lost their ethical moorings, swept along by a powerful social movement, and participated with dedication and relish in the "T4" program to exterminate the mentally ill.

Wow. A cautionary note that Komrad believes went unheeded.

I keep writing about my ambivalence on the subject. I want a doc who doesn't give up on me, but I also want a doc who will not inflict more suffering on me in the effort to keep me alive. I want a doc who understands that some of the tools at his/her disposal to keep me alive make my life unlivable, and my refusal of such tools is not a refusal of his/her care. I also know that when I am suicidal, I may not be in "my right mind." On the other hand, I may understand quite well, better than the doc, what I am able to tolerate and for how much longer.

One issue that has us all stuck is the lack of options for care. In the US, there's hospitalization, frequently traumatizing and a bleak experience at best, ECT, stronger drugs. That's about it. Psychiatrist readers might object with a longer list. But fancier treatments are available to the privileged few, and a hypothetical treatment is not a treatment. So I'm sticking with it.

Another cautionary note is how many people commit suicide immediately upon discharge from the hospital.

That cautionary note also seems to go unheeded.

We suffer from a lack of imagination and anyway no way to fund whatever better solutions we might develop. What struck me was that Belgium itself has some imaginative solutions.

It turns out that there have been a couple of positive consequences of legalizing psychiatric euthanasia. One speaker, a psychologist, showed how she used the euthanasia law to introduce to Belgium the "Recovery" concept. She was able to build a peer support Recovery-oriented group of patients who have been approved for euthanasia but haven't yet implemented it. The purpose of the group is to use the Recovery model to help build more momentum, meaning, and support to 'live', an alternative to proceeding with the approved euthanasia. One of the most common motivations for psychiatric euthanasia in Belgium, according to data reported to review commissions, is being 'tired of living' or 'loneliness.' So that gives a compelling focus for a Recovery group.

How ironic, that somebody in the land of physician-assisted suicide has discovered there are other ways to prevent suicide than getting the person to a doctor's treatment. David Conroy is channeling here... Suicide is not a choice. It happens when pain exceeds resources for coping with pain. Ergo, suicide prevention is reducing pain, whatever that pain is, or increasing resources, whatever those resources are.

Komrad continues with a second option:

Another interesting development is a new specialty - psychiatric palliative care. The criteria for euthanasia -- a condition that is "insufferable and untreatable" - has called into existence a new category for the mentally ill who have those characteristics. As in the US, the notion of a truly "untreatable" condition in psychiatry really didn't exist in the Benelux countries, until their legislatures conjured that category into legal existence, thinking of the terminal somatic conditions with which physician administered euthanasia originally began. Once this category opened to "psychological suffering" it became a beckoning space which influenced how psychiatrists and their patients began to see some cases.

Oh my gosh, it's only the psychiatrists in the US who don't get an "untreatable condition" in psychiatry. Their patients who have quit them certainly understand the concept.

Suddenly "palliative care" for non-terminal psychiatric patients began to make sense. Without euthanasia, "palliative psychiatry" doesn't seem much different than ordinary psychiatry practiced with excellence (probably much more intensive than average). This new psychiatric specialty provides for the "hopeless and insufferable" cases a level of service intensity that can mitigate the need many patients feel to have euthanasia. Indeed, one of the psychiatric patients who attended this symposium told me that it is said in Belgium, "If you want better and more intensive psychiatric care, just say you want euthanasia."

With all those quotes around "palliative care" and "hopeless and insufferable," I fear Komrad may have missed the point.

Palliative care is not psychiatry practiced with excellence. It is a shift in relationship and in goals. It is the promise that nothing more will be done that will cause more pain. No more chemistry experiments - the patient is no longer a test tube. No threat of coercion - the patient can speak his/her truth. The psychiatrist relinquishes the "power over" relationship and relinquishes the threat of withdrawing from the relationship entirely.

Part of the pain of suicidality is the ongoing chemistry experiment, the "treatment" itself. The implicit threat of coercion removes resources from the patient who has to guard what s/he discloses. If these conditions were changed, this shift to palliative care may indeed relieve enough pain and provide enough resources that the patient can survive.

No, I don't want doctors handing out suicide methods. Komrad is right, the slippery slope is way too well greased in the US today. But I do long for psychiatrists to listen to oncologists about palliative care: What is it like to be a doctor who gives permission to your patients to die?

Talk among yourselves.

graphics in public domain
photo by Nevit Dilmen, used under terms of the GNU Documentation License
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