A clinical psychiatrist and medical ethicist reviews some of the history, the data, the emerging reality of a remarkable slippery slope, and some profound ethical concerns raised by these practices.
Mark S. Komrad, MD
IN THIS PODCAST, Dr Mark Komrad provides an overview of the emerging practice, since 2002, of allowing psychiatric patients to access medical euthanasia in Belgium and the Netherlands. Remarkably, several hundred psychiatric patients in those countries whose cases have been deemed by the patient to be “unbearable” and by clinicians to be “untreatable,” have been euthanized on their own request, sometimes by their own treating psychiatrists. Dr Komrad reviews some of the history, the data, the emerging reality of a remarkable slippery slope, and some profound ethical concerns raised by these practices, proposing how they invert the fundamental ethos of what it means to be a psychiatrist.
Dr Komrad is a clinical psychiatrist and an ethicist. He just finished a 6-year tenure on the APA Ethics Committee and also serves on the APA Assembly. In those contexts, he helped to craft the current current APA position on Medical Euthanasia for non-terminally ill patients [PDF]. He is also on the teaching Faculty of Psychiatry at Johns Hopkins, Sheppard Pratt, and the University of Maryland. Dr Komrad’s opinions are his own, and he is not officially representing the APA in this article, nor any of the institutions where he is on the faculty. He is the author of You Need Help: A Step-by-Step Plan to Convince a Loved One to Get Counseling. He reports no conflicts of interest concerning the subject matter of this article.
Also see Dr. Komrad's podcast on Medical Euthanasia in Canada: Current Issues and Potential Future Expansion.
An Ethicist’s Experience in Belgium
On Sept 8, 2017, I was invited to give the opening lecture in a fairly remarkable symposium in Belgium on their 15-year-old practice of the voluntarily euthanasia of psychiatric patients. I spoke to an audience of Belgian mental health professionals and administrators. My charge was to present to them something of “the outside world’s view” of this issue and to touch on the recently issued Position Statement1[PDF] by the American Psychiatric Association (APA) regarding medical euthanasia: “. . . a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.”
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 evaluation pathway even makes it possible for a psychiatric patient to be euthanized with only a single psychiatrist in support. Once approved, some patients are euthanized by their own treating psychiatrist. Alternatively, there are other physicians who will perform euthanasia; though the number of such euthanizers is small (in fact, a large proportion of psychiatric euthanasias are performed by one particularly zealous Belgian psychiatrist, Dr Lieve Thienpont).
About 5000 inpatient psychiatric beds and a number of outpatient clinics in Belgium are run by the Catholic Order, The Brothers of Charity. Since the 2002 Belgian law was passed permitting psychiatric patients to access euthanasia, like those with other qualifying medical conditions, the Brothers would not allow the procedure or evaluation process in their facilities. However, in April 2017 they announced a change in policy: they would be providing euthanasia consultations and lethal injections for their psychiatric patients, much to the chagrin of Rome and the entire Catholic world.
In fact, the Pope warned them to stand down. Since the hospital sponsoring the symposium to which I was invited, the Alexianan Institute, in Tienen, is one of the Brothers’ hospitals, many members of the Board of the Brothers of Charity were present at the symposium. They were imminently preparing a response to the Pope’s objection. They had engaged a professional ethicist, who spoke on the program with me, who had helped them develop the theologically based ethical rationale for their astonishing shift in policy. He explained that their approach now is to strongly encourage the patient to live and engage in treatment, but The Brothers are now open to providing euthanasia as a “last resort.” A lecturer who was a Jesuit priest and an oncologist made reference to Jesus’ example of choosing his own death for the greater good of mankind.
It was made clear to me on my arrival that the majority of Belgians and their mass media support this practice. I learned that although a number of psychiatrists feel very negatively about this, they are reluctant to speak out for fear of being vilified in the press. Though back in 2002 several individual psychiatrists lobbied against the proposed law, medical organizations did not, and have not expressed objections. Organized medicine has not articulated a stance on this because there isn’t a strong enough consensus among doctors, not even psychiatrists, I was told. Also, I learned there isn’t a strong tradition of ethics activities at the organizational level, or significant focus on an ethics code. The Belgian professionals were quite aware that the majority of the world ’s medical associations disagree with the medical euthanasia in general. It seemed almost a point of honor that they differed in this way, as if they are on higher moral ground in a bold new era of medical ethics. Someone pointed to the fact that Belgium and the Netherlands (which also has a robust program of psychiatric euthanasia) after all, were the first nations to legalize gay marriage. They are claiming a similar, higher moral ground in the matter of psychiatric euthanasia.
In conversations with scholars, I ascertained that the background of religion is vital to understanding some of the vectors influencing the development of euthanasia in Belgium, and its slipping down the slope from terminal medical patients to psychiatric patients, and even those not medically ill at all, but simply “tired of living.” For centuries Belgium has been a deeply Catholic culture. However, in the latter part of the 20th century, the country became extremely secularized. They refer to their culture now as “post-Catholic.” In that sense, there is a pushback (conscious and unconscious) against values for which the Catholic Church traditionally stands.
One of those core values is the absolute value of life. “Post-Catholic” Belgians, rather, see the value of upholding life as something to be balanced against other values, which sometimes might supersede it (eg, autonomy, compassion, etc). Indeed, I heard that when a Belgian person asserts negative feelings about euthanasia, they are sometimes assumed to be “Catholic,” and that is used to invalidate their opinion. It will be interesting to see how that kind of ad hominem invalidation might change if The Brothers continue to sustain their position in defiance of Rome.
My presentation was titled “Voluntary Euthanasia of Patients with Mental Illnesses: An Inversion of Psychiatry’s Fundamental Clinical and Ethical Values.” I reviewed a great deal of data about psychiatric euthanasias in The Netherlands and Belgium, demonstrating how there has been a profound “mission creep” in both countries, with an ever-widening diameter of eligibility, leading to an appalling slippery slope. I did make 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.
The lesson is how physicians are vulnerable to a social tsunami, which can detach us from core medical ethics with enthusiasm, convinced we are pioneering a virtuous new moral frontier. I reviewed the positions of several international medical and psychiatric bodies that are against some of these practices, including that of the APA. I then addressed a variety of social, clinical, financial, and ethical concerns about psychiatric euthanasia. I particularly emphasized what I called the “fundamental ethos of psychiatry” to prevent suicide and its special skill set to address hopelessness, helplessness, desire to die, and inability to see a better future. Human suffering is our core focus, and we have a skill set to accompany a patient in their suffering, no matter what the diagnosis. Our approach is to address that suffering in various ways, but not by snuffing out the life of the sufferer. We prevent suicide, not provide it.
I went with an open mind to try and grasp the arguments in support of psychiatric euthanasia from the people and clinicians immersed in it as a “treatment” option. What I heard from several other speakers (philosopher, psychiatrist, psychologist, Jesuit priest who was also a physician) was actually very disturbing to me. I was powerfully struck that these professionals, who had been living with this as the law of the land, a fait accompli, were starting with the accepted conclusion that it was OK, and reasoning backwards to create an a postiori justification. The conclusions are a given, so arguments were sought specifically to justify the conclusion, and ideas that would lead to a contradictory conclusion were filtered out. It was a powerful kind of sophistry. Indeed, there was even an apologetic tone by some speakers; they seemed to be apologizing to themselves as many were uncomfortable with the conclusion.
The speaker who represented the new ethical stance of The Brothers seemed to convey in his apologetic tone-“we really don’t want to do this, but the society we live in wants it.” They were justifying literally killing (on request) the very kinds of patients to whose hopelessness and helplessness psychiatrists are devoted to address. My reaction was visceral; I found myself eyeing the exits to bolt out and get some fresh air. It wasn’t hard to imagine that I was at a psychiatric conference in pre-war Germany, listening to learned speakers intellectualize uses of psychiatry that were trying to topple the millennia-old gyroscope of medical ethics in service of radical progressive shifts in social mores.
Euphemisms abounded that permitted a disengagement from the prior, traditional moral baseline. There was talk of “compassion,” “listening to and respecting the patient’s wishes,” “the end of doctor-knows best,” and an apotheosis of autonomy to the point where it actually seemed fetishized. It was certainly easy to follow the arguments for compassion, not abandoning the patient, taking the patient’s suicidal wishes seriously, exploring the extensive underlying reasons for wanting to die, etc. All of these penultimate approaches sounded like good, solid psychiatry.
What was not presented at all was justification for taking the very last step- killing the patient, for the physician him or herself to engage in killing. I had hoped at the very least to hear the Belgian health care establishment support euthanasia, but protest that it should not be occurring in the House of Medicine, by the hand of a physician, and unhappiness that society had come to expect that of them. It was quite clear to me that these professionals who spoke have been living with this for far too long. They are too far down the rabbit hole at this point. Those who became mental health professionals 15 years ago were professionally born into this paradigm, and it’s all they have known their entire careers. The youngest physicians have grown up in this paradigm since childhood.
I don’t want to say that nobody had problems with it. There were some calls for modification of the law, extending the wait between approval and administration of euthanasia for psychiatric patients to at least a year. The sense was the system needed some “fine tuning” but was fundamentally acceptable. Outrageous cases are “exceptions to an otherwise good system.” There was, however, a small group of professionals who saw the whole situation as very negative, dire, and deeply disturbing. On two different nights they invited me to dinner to ventilate their concerns in a more private setting.
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.
Another interesting development is a new speciality -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 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.
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.”
Sadly, I left without much hope for Belgium to reverse its stance on psychiatric euthanasia. It has been too many years, there is too much widespread buy-in, the professional societies cannot get sufficient coherence to express a viewpoint or take a stand, and psychiatrists fear being seen as cruel, or retrogressive, or “crypto-Catholic” if they speak out too loudly as individuals. The press will flock to their door with unpleasantly critical, challenging interviews. As of the publication of this article, The Belgian Brothers of Charity remain open to performing euthanasia in their facilities.
The influences of the APA and WPA as prominent voices of organized psychiatry are important. But, unless the medical and psychiatric establishment in Belgium can get its act together and speak coherently against this appalling practice, objecting psychiatrists will have to continue to whisper their worries to each other, and little Belgium will likely continue to convince themselves that they are virtuously righteous in letting their doctors provide suicide to certain non-terminal suicidal patients who are “untreatable” and request death.
1. APA Joint Reference Committee. Position Statement on Medical Euthanasia. American Psychiatric Association. December 2016. https://psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-2016-Medical-Euthanasia.pdf. Accessed June 19, 2018.