Mark S. Komrad, MD

I appreciate the opportunity to respond to the comments from Kious and colleagues’ letter, “

Let’s Ask the Right Questions About Medical Aid in Dying

.” I certainly concur that psychiatrists are in the business of preventing suicide, not abetting or providing it, which also means not participating in a chain of culpability, the end product of which is the provision of suicide. This chain includes even competency evaluations for euthanasia, as I have argued.

 The letter says that there are distinctions between medical aid in dying (MAID) deaths and ordinary suicide. I disagree: There is no way to make a logically coherent argument distinguishing these 

 To endorse MAID is to endorse suicide for some.

The letter objects to my use of a slippery slope argument. Unfortunately, the slope is very real. We have chilling observations of these practices outside the halls of political debate and philosophical discourse. When MAID laws are first passed, they initially have limited conceptions and eligibility, but the eligibility always expands over scope and time. Even now, many US states with legalized assisted suicide are trying to expand eligibility criteria and decrease waiting times. These creeping thresholds of acceptability, propagating the emerging new tier of supposedly good and noble suicide —celebrated with goodbye parties and lauded by the press

—may be having the effect of suicide contagion. For example, the success of the Netflix television series 

 led to a marked increase in googling methods of suicide.

 By 2012, Oregon’s suicide rate rose 41% higher than the national rate.

 In Canada, children and teenagers are starting to ask their pediatricians about receiving euthanasia, though this option is not available for minors, for now.

 So, references to slippery slopes are not philosophical casuistry. The reality is that such slopes lessen the traction of suicide prevention. A taboo (not stigma) against suicide is an instrumental piece of suicide prevention.

Of course, the absence of evidence is not evidence of absence. Though many disability organizations have strongly objected to MAID practices (and provided disturbing anecdotal evidence of how a euthanasia option may short circuit the care of the disabled

) no one has systematically studied the effects of euthanasia on individuals with disabilities. We have very few data regarding 

 outcomes of this practice, although we know that suicide loss survivors have profound secondary trauma.

Furthermore, there is no validated empirical method or agreed-upon standard for determining that any psychiatric illness is 

; or when it would be reasonable to so conclude. There is tremendous controversy over 

 in psychiatry and prognostication regarding psychiatric illness is highly unreliable.

 An absence of response to treatments already provided is in no sense, and by no stretch of logic, a demonstration that the patient’s condition is irremediable. Canada will be struggling mightily to figure this out in the next 2 years.

When we lower the threshold for killing other human beings, disaster can follow. The celebrated psychiatrist, Robert J. Lifton, MD, author of 

The Nazi Doctors: Medical Killing and the Psychology of Genocide

, warned of “malignant normality,” times when what we put forward as self-evident and normal may be deeply dangerous and destructive. “When normality becomes malignant, professionals can be all too ready to serve that version of it as well. Indeed professionals are required for maintaining that malignant normality and bringing others into it.”

Finally, the critical question for readers of 

 is whether psychiatrists and related professionals, who are deeply trained to accompany patients in their suffering while trying to ameliorate it, should now be participating in killing some of the sufferers as a new means of helping them cope.

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

1. Komrad M, Pies R, Hanson A, Geppert C. Assessing competency for physician-assisted suicide is unethical. 

. 2018;79(6):18;r12566. Accessed August 19, 2021. 

2. Pies R, Komrad S, Geppert C, Hanson A. Against assisted suicide. 

3. Porter C. At his own wake, celebrating life and the gift of death. 

. May 25, 2017. Accessed August 19, 2021.

4. Ayers JW, Althouse BM, Leas EC, et al. Internet searches for suicide following the release of 13 Reasons Why. 

5. Valko N. Why are suicide rates climbing after years of decline? 

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

7. Baum, KB. Children, teens, parents asking Canadian pediatricians about assisted suicide. 

October 26, 2017. Accessed August 19, 2021. 

8. ‘The solution is assisted life’: offered death, terminally ill Ont. Man files lawsuit. CTV News. March 15, 2018. Accessed August 19, 2021.

9. Cerel J, Brown MM, Maple M, et al. How many people are exposed to suicide? Not six. 

10. Fusar-Poli P, Hijazi Z, Stahl D, Steyerberg EW. The science of prognosis in psychiatry: a review. 

Articles

Once a medical aid in dying laws is passed, eligibility for assisted suicide inevitably expands, putting more patients at risk. 

Medical Aid in Dying: A Slippery Slope

I am grateful for Michael von Poelnitz, MD’s letter “

A Psychiatrist’s Personal Perspective on Medical Aid in Dying

 on assisted suicide. I feel great compassion for him and his mother. I also appreciate his proper use of the word 

 in this context, referring to the procedure used with his mother in Switzerland, as opposed to many of the other euphemisms that are often deployed, particularly by proponents of assisted suicide and euthanasia. Language plays a very important role in this conversation. Indeed, as George Orwell famously said, “If thought corrupts language, language can also corrupt thought.”

The letter seems to imply that the medical killing discussed in my article about developments in Canada is 

in contrast to the voluntary and cooperative nature of the process in his mother’s case. I note in my opening paragraph, however, that all these laws involve voluntary participation by patients in these procedures. Typically, a patient makes the initial request. However, some Canadian colleagues tell me 

 to inform potentially eligible patients of the euthanasia option, even if patients do not bring it up. Even some physicians who are conscientious objectors are 

 to do this. However, there is also evidence that euthanasia is provided without request for some incompetent patients in the 

 (Belgium, the Netherlands, and Luxembourg) who have no family members available for proxy consent, nor advanced directives for 

 does the killing. In some cases, it is indeed a patient’s psychiatrist. In one Dutch series, Scott Kim, MD, PhD and his team found that 73% of psychiatric euthanasias in 66 patients were performed by doctors who were already caring for the patient.

 Specifically in cases involving euthanasia for personality disorders, 30% of the euthanizing physicians were psychiatrists.

 As psychiatric euthanasia becomes available in 2 years in the large nation of Canada, numerous psychiatrists will have to confront euthanasia as a legal option for their suicidal patients, and they will increasingly be in positions to possibly approve it, and even provide the service.

Finally, a standard canard of those favoring euthanasia and assisted suicide is to portray those opposed to it as lacking empathy for patients’ agonies. I would turn that charge around. A core competency in psychiatry is to have a deep immersion and empathic understanding for such feelings, to have what Karl Jaspers, MD, PhD called 

— a sense of standing in a patient’s shoes. What the letter calls “a willingness to go beyond one’s own limitations in order to sense and perceive more broadly” should not mean transcending empathic understanding to aid and abet suicide. Rather, it should give us a deeper standpoint from which to deploy support and advocacy, to help patients find a path into the future, to help mobilize their support systems and state-of-the-art palliative care, and to attend to them devotedly in their suffering—demonstrating the true meaning of compassion: 

. To provide or facilitate their suicide is a betrayal of a fundamental ethos of psychiatry.

1. Orwell G. Politics and the English language. 

. Houghton Mifflin Harcourt Publishing Company; 1981.

2. Pike G. Euthanasia and assisted suicide: when choice is an illusion and Informed consent fails. BiosCenter. November 26, 2020. Accessed August 4, 2021. 

3. Pereira J. Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls. 

4. Kim SYH, Conwell Y, Caine ED. Suicide and physician-assisted death for persons with psychiatric disorders: how much overlap? 

5. Nicolini ME, Peteet JR, Donovan GK, Kim SYH. Euthanasia and assisted suicide of persons with psychiatric disorders: the challenge of personality disorders. 

Proponents of medical aid in dying often accuse their opponents of lacking compassion. But what does that word really mean? 

The Meaning of Compassion

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 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

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 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.