Mark S. Komrad, MD

We would like to respond to the article "

 Their article in turn addresses an earlier essay on 

Strouse et al place forms of actively hastening death under the rubric of medical aid in dying (MAID), noting that 10 states and the District of Columbia have now legalized MAID, and that “all current state laws explicitly stipulate that such deaths are not suicide.” Their letter argued for a distinction between decisions to “directly hasten one’s own death” in the context of terminal illness, and what they called “conventional suicides.” Citing work including a statement from the American Association of Suicidology (AAS), Strouse et al argued that suicide is not the same as physician aid in dying, and that—allowing for some overlap—the 2 acts differ on the level of psychopathology. They further suggested clinicians distinguish between conventional suicide and MAID, so that they may “work skillfully and humanely with cancer patients, especially those who are expressing doubts about proposed treatment, or articulating a preference for hastened death.”

We respect Strouse and his colleagues’ clinical experience and humane intentions. However, as psychiatrists, medical ethicists and a palliative care physician (Dr Geppert), we find this thesis deeply troubling. In particular, the focus on state laws ignores the central ethical question of whether physicians’ helping patients kill themselves is ever justified in the context of terminal illness or in any other circumstance.

The notion that 22% of the US population live in a state where MAID is legal is a demographic fact, not a value claim. As Daniel P. Sulmasy, MD, has observed, “data cannot tell a society or a profession what ought to be done” and neither can legislation. This is a consequence of what philosophers call the 

. Sulmasy has said, “Whether just 1 person or 100,000 persons legally avail themselves of lethal prescriptions cannot tell us whether the practice is right or wrong.”

The mere fact that some state legislatures have passed statutes redefining suicide, such that MAID is not suicide, does not prove that this redefinition is conceptually or ethically justified; in fact, several judicial decisions have held this opinion. In 2017, the New York Court of Appeals held that “suicide has long been understood as ‘the act or an instance of taking one’s own life voluntarily and intentionally’ ... Aid-in-dying falls squarely within the ordinary meaning of the statutory prohibition on assisting a suicide.”

 Similarly, in 2016, the New Mexico Supreme Court held that the prohibition against assisted suicide unambiguously covered self-induced death in situations such as those described by Strouse et al.

 (521 US 702, 1997), the US Supreme Court permitted laws prohibiting assisted suicide because of the states’ compelling interest in suicide prevention, effectively equating assisted suicide with suicide.

While redefining suicide averts legal liability for physicians providing MAID, it does not change the essentially unethical nature of the act itself. The term 

 fundamentally means helping patients kill themselves. This is why the American College of Physicians rejects the term and explicitly endorses the term 

 Perhaps even more significant, following a comprehensive evaluation by the Council on Ethical and Judicial Affairs, the American Medical Association (AMA) House of Delegates rejected the term 

 Indeed, the process typically described as MAID in no sense aids dying; on the contrary, it rapidly converts an ill individual into a dead one. This is substantively different than the withdrawal of heroic but nonbeneficial or inappropriate measures, such as the use of ventilators that merely prolong the dying process in the final stages of a terminal illness.

Finally, statutorily declaring that self-induced death via a physician’s assistance is not suicide may soothe the consciences of legislators and allow payouts on life insurance policies; but, perversely, it may also incentivize some terminally ill patients to kill themselves. Furthermore, as Sulmasy

 notes, preliminary reports suggest increased rates of suicide in the general population of states that have legalized PAS. Specifically, “legalizing PAS has been associated with an increased rate of total suicides relative to other [non-PAS] states, and no decrease in non-assisted suicides.”

 Similarly, suicide rates in the Netherlands (where medical euthanasia is legal) have accelerated, compared to neighboring countries that have not legalized medical euthanasia.

Redefining suicide to exclude PAS in the context of terminal illness represents a radical linguistic maneuver that flies in the face of ordinary language, expressed over thousands of years. The Latin 

from which the English word suicide is derived—means the act of killing oneself intentionally or voluntarily. To be clear: we do not deny that there are often psychological and motivational differences between those with terminal illnesses who take their own lives and those who do so in the context of severe psychiatric illness, as the AAS statement details. But in both instances, the act is that of suicide

[A] s a philosopher, I feel an obligation to point out that, as a conceptual matter, there is nothing inaccurate or false about stating that a person who takes a drug, knowing that it will cause her death, and takes it because it will cause her death, is committing suicide on any reasonable conceptual analysis of what suicide is.

The hijacking of ordinary language is becoming increasingly common, such that comforting euphemisms like 

 have replaced the more troubling ordinary language term 

 Accordingly, one might reasonably wonder if the insistence that MAID not be described as suicide betrays some cognitive dissonance regarding the practice, especially on the part of psychiatrists whose duty is to prevent suffering patients from taking their own lives. The 

of many physicians who carry out MAID has been well-documented.

Cognitive Distortions, but No Mandated Treatment

Furthermore, most MAID laws do not require treatment for serious medical conditions, even when it is available to the patient. For example, a patient whose metastatic cancer stands a reasonably good chance of remission with aggressive treatment, but who nevertheless 

, is not required by state laws to undergo the treatment.

 Choosing assisted suicide in such a scenario may superficially appear to be a rational choice; but may instead represent a decision grounded in certain cognitive distortions that also characterize so-called conventional suicide. Importantly, this may be so, even in the absence of a diagnosed psychiatric disorder.

For example, Tomer T. Levin, MD, and Allison J. Applebaum, PhD, noted that some cancer patients may make erroneous assumptions, like, “No one can help me” or “No one understands what I am going through.”

 Such cognitive distortions may respond favorably to cognitive behavioral interventions and potentially avert or abort a request for PAS. Indeed, it has been found that “Requests for physician-assisted suicide are unlikely to persist when compassionate supportive care is provided.”

Unfortunately, in almost every US jurisdiction where PAS is allowed, no attempt to offer treatment by a mental health professional is required by law; and the psychiatrist’s role is typically relegated to ruling out mental illness and 

The Issue Is Not Intractable Pain and Suffering

As Daniel P. Sulmasy, MD, PhD, noted, “Despite public arguments that PAS is needed to avoid excruciating pain and other symptoms, the reasons attributed to patients who seek PAS are not uncontrolled symptoms but lost autonomy, independence, and control.”

 These are forms of psychological distress which, in our view, are best managed with supportive and empathic counseling and/or cognitive behavioral interventions, provided to patients and their families—not by prescribing lethal drugs. Indeed, as Levin and Applebaum pointed out

[T]he root of many patients’ desire for a hastened death may reside in dysfunctional thoughts such as, ‘I get claustrophobic in small spaces like coffins’ and ‘I deserve to die.’ Exploring such cognitions by asking, ‘What are your biggest fears about death and dying?’ will allow the cognitive therapist to reframe dysfunctional thoughts. For example, if the patient worries that death is always painful based his perception of his grandfather’s death in 1975, the therapist might explore how good pain management can facilitate a more peaceful death and contrast the state of palliative care in 1975 versus the advances of the present day.

Even the AAS acknowledges that there is an “undetermined amount of overlap” between the 2 categories of physician aid in dying and conventional suicide.

 Accordingly, we believe that the same precautionary principle that governs public health ought to apply to MAID requests.

This means erring on the side of caution and treating MAID requests from patients with terminal illnesses with the same degree of psychiatric scrutiny and concern that we would bring to any patient’s expressed wish to die. However, in most states, psychiatric assessment is not mandated in the MAID process and does not occur unless specifically requested by the evaluating physician who has initiated the MAID process.. This rarely happens. For example, in Oregon in 2020, only 0.8% of patients who were 

 were referred for psychiatric evaluation.

Moreover, the fairly subtle cognitive distortions described by Levin and Applebaum are unlikely to be detected in a superficial assessment of mental competence. It is no contradiction or paradox to argue, as we have, that pronouncing a patient qualified or competent for MAID is a violation of psychiatric ethics, since this unethically colludes with the process of aiding a patient’s suicide. Psychiatric involvement in end-of-life care is indeed essential, but it should remain well outside the procedures and processes involved in MAID deliberations.

Reducing Stigma vs Shifting it to the Other

Strouse et al emphasized that, “Most importantly, they [MAID laws] are intended by lawmakers to help avoid the stigma of suicide.” we agree that there is societal stigma associated with suicide, as the AAS recognizes. This, the AAS asserts, is in contrast to attitudes surrounding physician aid in dying

: “Death by suicide is often associated with substantial social stigma... [whereas] where it is legal, PAD is typically well accepted within the community and society at large.”

We infer from their commentary that Strouse et al would agree with the AAS claim (and co-author Margaret Battin, PhD, is a signatory to the AAS statement). Although well-intentioned, the AAS position and that of Strouse et al may have the unintended effect of increasing stigma directed toward those who attempt or complete a non-MAID suicide. In our view, creating a binary distinction between MAID and conventional suicide tends to marginalize individuals in the conventional group as “the Other.” This position may suggest to the general public that suicidal individuals with mental illness value their lives less than those with terminal physical illnesses—a claim we reject.

Indeed, as numerous suicide prevention websites 

: “Most suicidal people do not want to die. They are experiencing severe emotional pain, and are desperate for the pain to go away.”

 We would suggest that the same may be said of at least some individuals with cancer who seek MAID. Whenever complex ethical dilemmas are formulated as black-and-white categories, the many grey instances are often misclassified, with tragic consequences.

In short, the AAS position may have the perverse effect of merely shifting societal stigma from one group—those with terminal medical conditions—to those whose suicidal behavior occurs in the context of psychiatric disorders. We do not need such a 2-tiered classification, in which there are good and bad methods of taking one’s own life.

Moreover, we believe that such a dichotomy would likely magnify disparities in end-of-life care in resource-poor areas, where MAID would be far less expensive than sustaining palliative care. The AAS position may also weaken the motivation and rationale for suicide prevention, during a period when suicide rates have been rising in the US.

 We believe that efforts to promote MAID would be better directed toward destigmatizing the mental illnesses that underlie the majority of suicides and toward bolstering the availability of state-of-the-art palliative care.

The American College of Physicians has said

Physician-assisted suicide is neither a therapy nor a solution to difficult questions raised at the end of life. On the basis of substantive ethics, clinical practice, policy, and other concerns, the ACP does not support legalization of physician-assisted suicide. … However, through high-quality care, effective communication, compassionate support, and the right resources, physicians can help patients control many aspects of how they live out life's last chapter.

Like the ACP, we reject the implication that merely legalizing MAID somehow means that it is consistent with ethical medical practice. Quite the contrary. As physician and ethicist 

, MD, has pointedly cautioned: “We must care for the dying, not make them dead.”

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of 

is a psychiatrist on the clinical and teaching staff of Sheppard Pratt Hospital and the Johns Hopkins Hospital in Baltimore, Maryland; a clinical assistant professor of psychiatry at the University of Maryland; and a member of the teaching faculty at Tulane University in New Orleans, Louisiana. 

is a professor in the Department of Psychiatry and Internal Medicine and director of ethics education at the University of New Mexico School of Medicine in Albuquerque. She is also a health care ethicist with the Ethics Consultation Service of the Veterans Administration National Center for Ethics in Health Care, and an adjunct professor of bioethics at the Alden March Bioethics Institute of Albany Medical College, and serves as the Ethics Editor for 

is Director, Forensic Psychiatry Fellowship, University of Maryland, Baltimore, MD.

1. Strouse T, Battin MP, Bostwick MJ, et al. A new question in end-of-life ethics. 

. June 11, 2021. Accessed June 20, 2021. 

2. Myers CJ, Retamero C. Suicidal ideation and behaviors in oncology patients. 

3. Sulmasy DP. Physician-assisted suicide and the perils of empirical ethical research. 

6. Sulmasy LS, Mueller PS. Ethics and the legalization of physician-assisted suicide. 

7. Sabin J. Opinion of the council on ethical and judicial affairs. Proceedings of the 2019 Annual Meeting of the American Medical Association. 2019:235. Accessed June 23, 2021. 

8. Jones DA, Paton D. How does legalization of physician-assisted suicide affect rates of suicide? 

9. Boer T. Does euthanasia have a dampening effect on suicide rates? Recent experiences from The Netherlands. 

10. Dworkin G. Suicide, strictly speaking. 3 Quarks Daily. July 22, 2019. Accessed June 23, 2021. 

11. Koch T. The ethicist as language czar, or cop: "end of life" v. "ending life". 

12. Pies RW. How does assisting with suicide affect physicians? 

. January 7, 2018. Accessed June 20, 2021. 

13. To live each day with dignity: a statement on physician-assisted suicide. United States Conference of Catholic Bishops. June 16, 2011. Accessed June 23, 2021. 

14. Levin TT, Applebaum AJ. Acute cancer cognitive therapy. 

15. Public Health Division, Center for Health Statistics. Oregon Death with Dignity Act: 2019 Data Summary. February 25, 2020. Accessed June 23, 2021. 

16. Loggers ET, Starks H, Shannon-Dudley M, et al. Implementing a death with dignity program at a comprehensive cancer center. 

17. Cerel J, Battin MP. Statement of the American Association of Suicidology: “Suicide” is not the same as “physician aid in dying.” American Association of Suicidology. October 30, 2017.

18. Martuzzi M, Bertollini R. The precautionary principle, science and human health protection. 

19. Public Health Division, Center for Health Statistics. Oregon Death with Dignity Act: 2020 Data Summary. February 26, 2021. Accessed June 23, 2021.

20. Komrad MS, Pies RW, Hanson AL, Geppert CMA. Assessing competency for physician-assisted suicide is unethical. 

21. Macomb County Suicide Prevention Coalition. Holding onto life toolkit. Accessed June 23, 2021. 

22. Hedegaard H, Curtin SC, Warner M. Increase in suicide mortality in the United States, 1999-2018. 

23. Snyder Sulmasy L, Mueller PS, Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the legalization of physician-assisted suicide: an American College of Physicians Position Paper. 

A comparison of physician-assisted/Death-with-Dignity death and suicide patterns in older adult women and men

Are physicians who assist in suicide betraying their professional values?

. June 15, 2021. Accessed June 23, 2021. 

Pies RW, Hanson A. Twelve myths about physician assisted suicide and medical aid in dying. 

https://www.hcplive.com/view/twelve-myths-concerning-medical-aid-in-dying-or-physicianassisted-suicide

Articles

Should psychiatrists help patients end their own lives, even if it is technically legal? 

Against Assisted Suicide 

In Belgium, the Netherlands, and Luxemburg over a hundred psychiatric patients a year receive medical aid in dying (MAID). They do not need to have a terminal condition, only a degree of suffering that they find intolerable. This could include mental suffering, brought on, for instance, by depression.

MAID laws are now passing in the United States, and psychiatrists may soon face a difficult question. Should they help patients, who say their psychiatric conditions are unbearable, end their lives? In this Mental Health Minute, Mark S. Komrad, MD, discusses the various forms of MAID and makes a case against them, especially for psychiatric patients.

Read Komrad’s full feature article on MAID 

is a psychiatrist on the clinical and teaching staff of Sheppard Pratt Hospital and the Johns Hopkins Hospital in Baltimore, Maryland, clinical assistant professor of Psychiatry at the University of Maryland, and Teaching Faculty of Psychiatry at Tulane University in New Orleans.

Should psychiatrists ever assist in suicide? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

Videos

Medical aid in dying is available for psychiatric patients in European countries and Canada. Will the United States be next? 

Are Psychiatrists who Assist in Suicide Betraying Their Professional Values?

Dr Komrad has made a video to accompany this article. You can watch the video 

Canada just passed a law that radically changes the boundary between acceptable and unacceptable medical practice and has opened a path to euthanasia for patients with psychiatric illness who find their conditions unbearable.

Unfortunately, this is not a new phenomenon. Several countries allow psychiatric patients who are suicidal to voluntarily receive death by lethal injection (euthanasia) or a self-administered prescription for lethal medication (assisted suicide) from physicians. In Belgium, the Netherlands, and Luxembourg (collectively known as the Benelux nations) these practices first emerged in 2002, after laws were passed permitting medically assisted death for patients whose physical or psychological suffering was unbearable and 

could not be effectively treated by acceptable means

 A terminal condition was not a necessary criterion. This opened the door for some psychiatric patients in those countries to have suicide provided for them rather than prevented. It is documented that between 100 and 200 psychiatric patients are euthanized upon request annually between Belgium and the Netherlands (

TABLE 1. Belgian Patients Euthanized for Primary Psychiatric Disorders

In concerned response to these developments, the American Psychiatric Association issued a 

 in 2016: “A psychiatrist should not prescribe or administer any intervention to a non–terminally ill person for the purpose of causing death.”

TABLE 2. Patients Euthanized in the Netherlands for Primary Psychiatric Disorders

permitting medical euthanasia and physician-assisted suicide

, together known as Medical Aid In Dying (MAID).

 By November 2020, more than 13,000 individuals nearing the end of life had been voluntarily euthanized 

To be eligible, a patient’s natural death must be predicted to be reasonably foreseeable. This uniquely Canadian term was not statutorily defined, but it was understood to be associated with the end of life—how close was undetermined. Because death from mental disorders was not considered to be strongly predictable, mental illnesses were not eligible conditions. This feature of the law essentially prevented the kind of psychiatric euthanasia practiced in the Benelux countries.

 challenged the constitutionality of the reasonably foreseeable restriction.

 As a result, a new federal bill was introduced to extend euthanasia eligibility, without the previous restriction. This new initiative, 

, followed the Benelux model; it removed the prior exclusion of those who have with nonterminal chronic illnesses and permitted euthanasia for those whose psychological or physical suffering is deemed intolerable and untreatable.

Initially, Bill C-7 clearly excluded psychiatric disorders, which was at least implicit in the original C-14 law. However, there was ambiguity in this proscription, because psychological suffering (which is not defined in either legislation) continued to be a criterion for eligibility. In addition, many protested that C-14’s scope discriminated against those with mental illnesses. Ironically, in its efforts to promote parity, the Canadian Psychiatric Association was such a voice. As an organization, it declared: “Patients with a psychiatric illness 

should not be discriminated against solely on the basis of their disability

, and should have available the same options regarding MAID as available to all patients.”

This led to a dramatic turn of events in the (unelected) Canadian Senate, which considered Bill C-7 this February. In an unprecedented move, Senator Stan Kutcher, MD, who is also a psychiatrist, declared that the exclusion of individuals with psychiatric disabilities would be discriminatory. He introduced an 

amendment allowing MAID for mental illness

 available within 18 months of the bill passing.

 When the modified legislation was returned to the House of Commons, the discussion was quickly shut down by a liberal coalition and the bloc party from Quebec (a province that promotes euthanasia and aims to restrict conscientious objection to euthanasia by health care professionals). A vote was forced, and on March 17, 2021, the C-7 expansion of euthanasia in Canada 

, complete with the last-minute amendment to sunset the mental illness exclusion after 2 years.

This 2-year interval is to be used to create an expert panel to establish standards for evaluating patients and procedures to distinguish between patients with psychiatric disorders whose suicide should be prevented from those whose for whom it could be provided. However, as Alex Schadenberg, the executive director of the Euthanasia Prevention Coalition, noted in response to a query, “There isn’t a prosecutor in the land who would prosecute someone for doing euthanasia for mental illness before the 24-month time frame has passed because it is technically legal.”

Objections to Psychiatrist-Assisted Suicide

This is a profound change in the trajectory of the euthanasia law, and the practice of psychiatry for Canada, which is now the largest nation that will soon allow MAID for psychiatric conditions. It has rocked the professional mental health community in Canada, which fought to forestall the inclusion of psychiatric disorders for euthanasia.

The latest law is disappointing but unsurprising considering the huge pushes for parity and nondiscrimination at all costs. Unlike the in United States, health care in Canada is considered a charter (constitutional) right. Thus, once MAID became a medical procedure, excluding patients with psychiatric illness from this right was nearly impossible.

Countries that have allowed MAID in a limited number of cases have quickly found themselves descending a slippery slope. Prominent critic Wesley J. Smith, JD, noted, “Once a society embraces doctor-prescribed death as an acceptable answer to human suffering or as some kind of fundamental liberty right, there are no brakes. We need only look at European countries that have gone down the Euthanasia Highway to see how society is impacted deleteriously by 

 Indeed, Belgium and the Netherlands are now debating the 

extension of euthanasia beyond medical conditions

 to include those who feel they have a completed life

There is even discussion of de-medicalizing euthanasia by 

 Pegasos, a self-proclaimed “voluntary assisted dying association” based in Basel, Switzerland, 

Many psychiatrists in Canada are deeply concerned by the recent developments. In the face of C-7, the psychiatrist editor of the 

A few days ago, a 30-year-old patient with very treatable mental illness asked me to end her life. Her distraught parents came to the appointment with her because they were afraid that I might support her request and that they would be helpless to do anything about it. It’s horrific they have to worry that by going to a psychiatrist, their daughter might be killed by that very psychiatrist.

Similar significant objection comes from the 

 They are concerned that permitting euthanasia for nonterminal, disabled individuals implies that their lives may be not worth living. Furthermore, they recognize that individuals with disabilities may not have adequate access to state-of-the-art treatment, and that euthanasia could become a cost-saving alternative to suffering when adequate solutions are not available or affordable.

 also expressed strong worry about how Bill C-7 impacts individuals with chronic disabilities

We are deeply concerned that the eligibility criteria set out in Bill C-7 to access medical assistance in dying may be of a discriminatory nature, or have a discriminatory impact. By singling out the suffering associated with disabilities being of a different quality and kind than any other suffering, they potentially subject persons with disability to discrimination on account of such a disability.

strong objection among Canada’s First Peoples

, due to conflicts with cultural values, their limited access to state-of-the-art treatments, and staggering suicide rates in that population.

 Similarly, the Canadian Catholic Bishops, who are always opposed to euthanasia, have been left 

Bill C-7 also sets up a 2-tier system, abolishing some of the original C-14 safeguards. For instance, patients who are terminally ill can be evaluated for euthanasia and possibly receive it on the same day, with no waiting period, unlike the 10-day waiting period in the previous C-14 law. However, patients who are not terminally ill must wait 90 days. Ironically, it is not unusual to have to wait much longer than that in Canada to get psychiatric consultation, treatment, and other resources.

Moreover, there is no requirement that additional, evidenced-based treatments be implemented, although patients are urged to give all treatments serious consideration. Even Belgium, which is known for its liberal approach, recently added guidelines that individuals applying for euthanasia for a mental disorder should not have refused any evidenced-based treatments.

C-7 will allow physicians to end the life of people with disabilities or chronic illnesses at their request and will require the system to ensure it happens even when physicians are convinced, based on their expert knowledge, that medicine offers options and even when the patient may have years or decades to live with a good quality of life if other options are explored and tried first.

 that MAID practices are “fundamentally incompatible with the physician’s role as a healer,”

 and the World Medical Association “is 

 Nevertheless, these types of laws have been adopted around the world, most recently in New Zealand, Spain, Portugal, and several states in Australia. In US states, as in Canada, attempts have been made to 

 The justifications made in debate for euthanasia and assisted suicide (eg, autonomy, self-determination, and intolerable suffering) are now being applied to psychiatric disorders, despite lack of any agreement that treatment for psychiatric disorders are ever futile or that suffering is truly irremediable.

Bill C-7 and similar laws would represent a remarkable shift in the deep ethos of psychiatry, in which psychiatrists would have to decide which suicides should be prevented and which should be abetted.

Karandeep Sonu Gaind, MD, past president of the Canadian Psychiatric Association and a fierce critic of the MAID expansion to psychiatric patients, noted that less privileged patients have a much harder time accessing medical care in general, especially psychiatric treatment. He lamented the passing of C-7 in a 

So thank you Canada, powers that be,
For ensuring that our smooth passings
Will reflect the privilege of our life trappings.
I will soon be free, without anxiety, knowing
That with ease I can choose the time of my going.
And any poor souls sacrificed on this altar
Of my choice, my voice,
There will be no way of knowing.

is a psychiatrist on the clinical and teaching staff of Sheppard Pratt Hospital and the Johns Hopkins Hospital in Baltimore, Maryland; a clinical assistant professor of psychiatry at the University of Maryland; and a member of the teaching faculty at Tulane University in New Orleans, Louisiana.

1. Komrad MS. A psychiatrist visits Belgium: the epicenter of psychiatric euthanasia. 

. June 21, 2018. Accessed April 28, 2021. 

https://www.psychiatrictimes.com/view/psychiatrist-visits-belgium-epicenter-psychiatric-euthanasia#

2. du Bus C. Euthanasia in Belgium: analysis of the 2020 Commission Report. 

. November 16, 2020. Accessed April 28, 2021. 

https://www.ieb-eib.org/en/news/end-of-life/euthanasia-and-assisted-suicide/euthanasia-in-belgium-analysis-of-the-2020-commission-report-1921.html

3. Annual Report 2019. Regional Euthanasia Review Committees. April 2020. Accessed April 28, 2021. 

https://www.euthanasiecommissie.nl/binaries/euthanasiecommissie/documenten/jaarverslagen/2019/april/17/index/RTE_jv2019_ENGELS_gecorrigeerd.pdf

4. Komrad MS. APA position on medical euthanasia. 

. February 25, 2017. Accessed April 28, 2021. 

https://www.psychiatrictimes.com/view/apa-position-medical-euthanasia

5. Komrad MS. Medical euthanasia in Canada: current issues and potential future expansion. 

. June 29, 2018. Accessed April 28, 2021. 

https://www.psychiatrictimes.com/view/medical-euthanasia-canada-current-issues-and-potential-future-expansion

6. Schadenberg A. There have been approximately 19,000 euthanasia deaths in Canada. Euthanasia Prevention Coalition. October 20, 2020. Accessed April 28, 2021. 

http://alexschadenberg.blogspot.com/2020/10/there-have-been-approximately-19000.html

7. Health Canada. First annual report on medical assistance in dying in Canada, 2019. July 2020. Accessed May 10, 2021. 

https://www.canada.ca/en/health-canada/services/medical-assistance-dying-annual-report-2019.html

8. Rousseau S, Turner S, Chochinov HM, et al. A national survey of Canadian psychiatrists’ attitudes toward medical assistance in death. 

9. Marin S. Quebec court invalidates parts of medical aid in dying laws as too restrictive. 

. September 11, 2019. Accessed April 28, 2021. 

https://www.thestar.com/news/canada/2019/09/11/quebec-court-invalidates-portions-of-medical-aid-in-dying-laws-as-too-restrictive.html

10. First session, forty-third Parliament, House of Commons of Canada. Bill C-7: an act to amend the Criminal Code (medical assistance in dying). first reading February 24, 2020. Parliament of Canada. Accessed April 28, 2021. 

https://parl.ca/DocumentViewer/en/43-1/bill/C-7/first-reading

11. Chaimowitz G, Freeland A, Neilson GE, et al. Medical assistance in dying. Canadian Psychiatric Association. February 10, 2020. Accessed April 28, 2021. 

https://www.cpa-apc.org/wp-content/uploads/2020-CPA-Position-Statement-MAID-EN-web-Final.pdf

12. Bryden J. Senators amend MAID bill to put 18-month time limit on mental illness exclusion. 

. February 9, 2021. Accessed April 28, 2021. 

https://www.ctvnews.ca/politics/senators-amend-maid-bill-to-put-18-month-time-limit-on-mental-illness-exclusion-1.5302151

13. Bryden J. Canadian Senate passes Bill C-7, expanding assisted dying to include mental illness. 

. March 17, 2021. Updated March 19, 2021. Accessed April 28, 2021. 

https://globalnews.ca/news/7703262/canada-senate-passes-bill-c-7/

14. Smith W. Euthanasia spreads in Europe: several nations find themselves far down the slippery slope. 

. October 26, 2011. Accessed April 28, 2021. 

https://www.nationalreview.com/2011/10/euthanasia-spreads-europe-wesley-j-smith/

15. Boztas S. Euthanasia law proposed for healthy over-75s who feel their lives are complete. 

. July 19, 2020. Accessed April 28, 2021. 

https://www.dutchnews.nl/news/2020/07/euthanasia-law-proposed-for-healthy-over-75s-who-feel-their-lives-are-complete/

16. Cohen-Almagor R. Euthanizing people who are “tired of life.” In: Jones DA, Gastmans C, MacKellar C, eds. 

Euthanasia and Assisted Suicide: Lessons from Belgium

. Cambridge University Press; 2017:188-201.

17. Clusky P. Euthanasia debate in Netherlands takes an unwelcome twist. 

. September 10, 2019. Accessed April 28, 2021. 

https://www.irishtimes.com/news/world/europe/euthanasia-debate-in-netherlands-takes-an-unwelcome-twist-1.4013718

18. Cook M. A new Swiss group caters for Dutch who are eligible for euthanasia. 

. January 24, 2021. Accessed April 28, 2021. 

https://www.bioedge.org/mobile/view/a-new-swiss-group-caters-for-dutch-who-are-not-eligible-for-euthanasia/13673

19. Maher J. Why legalizing medically assisted dying for people with mental illness is misguided. Canadian Broadcasting Corporation. February 11, 2020. Accessed April 28, 2021. 

Mark S. Komrad, MD

Articles

Against Assisted Suicide

Are Psychiatrists who Assist in Suicide Betraying Their Professional Values?

First, Do No Harm: New Canadian Law Allows for Assisted Suicide for Patients with Psychiatric Disorders

Oh, Canada! Your New Law Will Provide, Not Prevent, Suicide for Some Psychiatric Patients

Psychiatrists Must Prevent Suicide, Not Provide It

PAS Versus Involuntary Commitment: Is There a Moral Dilemma?

A Second Country Practicing Medical Euthanasia Drops a Bomb

Euthanasia Versus Plagiarism: A Strange International Drama

An Open Letter to Representatives of the World Medical Association

Medical Euthanasia in Canada: Current Issues and Potential Future Expansion