So far, other countries that have implemented physician-assisted suicide have not been able to constrain legal eligibility to the terminally ill. Inevitably, legal arguments based on equal access rights and challenges to distinctions between physical and mental suffering have resulted in slipping down a slope to eventually include non-terminal cases. Then, psychiatric patients have gotten in line to be included.
Many scholars, advocates, and legislators expect that this slippage is inevitable in the US. This is why the APA thought it critical to plant a flag in advance of that probability, protecting psychiatric patients from the likely elaboration of physician-assisted suicide, by declaring that a psychiatrist should not have a treatment plan with the goal of causing death. Focusing specifically on non-terminal patients was done deliberately, both to anticipate the future and to send a signal to countries where mentally ill patients are already being killed at their own request —often by their own psychiatrists. This focus was felt to be in the particular wheelhouse of the APA.
Several members of the APA Assembly are beginning to work on an action to formally censure this practice in those countries where physicians are colluding with psychiatric patients’ suicidality. They maintain that the fundamental ethos of psychiatry is the prevention of suicide, both on the individual level and in its public health message. Psychiatrists are trained to help people cope with such suffering, find a path to a better future —indeed, often to help people make meaning of suffering. There is concern that transforming the (long-acknowledged) freedom to commit suicide into a right engenders a duty to fulfill that right.
The APA position implies that, even where legal for the non-terminally ill, it is neither the duty of a psychiatrist to fulfill that right, nor is it ethically appropriate to do so. Some (in the Belgian press) have argued that an American association does not have a place in the discussion of medical and psychiatric practices, which make most sense when seen in the context of different cultures. However, there is an understanding in the domain of medical ethics that there are some principles that transcend cultures.
The Ethics Committee of the World Psychiatric Association (WPA) has crafted a position similar to that of the APA, which will be submitted for a membership vote at the 2017 World Congress in Berlin. If endorsed, the WPA would be acknowledging that, on this particular issue, the ethical proscription against helping psychiatric patients to commit suicide may be so antithetical to the fundamental ethos of psychiatry that it should indeed be applied worldwide.
With the growing number of states legalizing physician-assisted suicide, the time is coming when these requests will be initiated by psychiatric patients in the US. If legal trends in other countries are replicated here, psychiatrists will have to consider whether allying with non-terminally ill patients to fulfill their suicidal feelings and hopes is appropriate either ethically or clinically. The APA has anticipated this. Its Position Statement provides guidance for psychiatrists in the face of a rapidly changing landscape of social values and expectations of medical services.
MORE ABOUT Mark S. Komrad, MD
Dr. Komrad was the host of a call-in radio talk show about psychiatry that aired in 43 states. His most popular shows were open-phone hours, and a particularly common question was about how to convince a troubled loved one or friend to get a psychiatric evaluation. Brainstorming about this with numerous callers led him to develop these consultations as a specialty in his psychiatric practice and eventually led to the publication of the methods in You Need Help: A Step-by-Step Plan to Convince a Loved One to Get Counseling. He now travels the country speaking to many mental health organizations about these methods, and the National Alliance on Mental Illness uses the book in their Family-to-Family training program.
Another of his interests is addressing the stereotypes and negative depictions of psychiatrists and psychiatric treatment in the media. To clarify the role of psychiatry for a public that is often reluctant to consult psychiatrists, he’s taken part on radio and televisions forums and consulted on several Hollywood movies.
As a professional ethicist, he teaches about ethical issues in psychiatry, often using movie portrayals of both ethical and unethical psychiatric treatments. He also speaks widely to colleagues about the emerging trends in Europe and Canada of providing euthanasia to some psychiatric patients who request it, concerned that this practice will eventually reach the US. He was instrumental in crafting the American Psychiatric Association’s Position Statement on this matter.
Dr. Komrad is Ethicist-in-Residence for the Sheppard Pratt Health System and a Member of the APA Ethics Committee; he is also on the Faculty of Psychiatry at Johns Hopkins and the University of Maryland. Dr. Komrad’s opinions are his own, and he is not officially representing the APA in this article, nor Sheppard Pratt.
Dr. Komrad reports no conflicts of interest concerning the subject matter of this article. Dr. Komrad’s opinions are his own, and he is not officially representing the APA in this article, nor Sheppard Pratt.
For further reading
• Blake J. Man seeks euthanasia to end his sexuality struggle. June 9, 2016. http://www.bbc.com/news/world-europe-36489090. Accessed January 11, 2017.
• Emanuel E. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316:79-90.
• Groenewoud J, van der Heide A, Onwuteaka-Philipsen BD, et al. Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands. N Engl J Med. 2000;342:551-556.
• Heneghan T. Catholic nursing home fined thousands in euthanasia case. The Tablet. July 5, 2016.
• Kim S, De Vries RG, Peteet JR. Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016;73:362-368.
• Lemmens W, Lemmens T, Caplan A. The dangers of euthanasia on demand. Chicago Tribute. October 17, 2016.
• PBS. The Suicide Plan. http://www.pbs.org/wgbh/frontline/film/suicide-plan/. Frontline. Accessed January 11, 2017.
• Pies RW. Physician-assisted dying for adolescents with intractable mental illness? Psychiatric Times. May 2016;1,27-31.
• Pies RW. Physician-assisted suicide and the rise of the consumer movement. Psychiatric Times. August 2016;40-43.
• Schmidt S. Anorexic woman weighing 69 lbs has right to starve, court rules. Washington Post. November 22, 2016.
• Snijdewind M, Willems DL, Deliens L, et al. A study of the first year of the end-of-life clinic for physician-assisted dying in the Netherlands. JAMA Int Med. 2015;175:1633-1640.
• Thienpont L, Verhofstadt M, Van Loon T, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open. 2015;5.
• Winter M. Deaf Belgian twins going blind choose to be euthanized. USA Today. January 14, 2013.