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As the legalization of “assisted dying” increases around the world, there are risks the practice could be expanded beyond the terminally ill to people suffering different kinds of non-terminal illness. There are at least 12 U.S. states that have legalized assisted suicide, as well as several countries that have legalized the practice, including Austria, Belgium, Canada, Germany, Luxembourg, parts of Australia, the Netherlands, Portugal, Spain and Switzerland. In many jurisdictions, assisted suicide is already being offered to people suffering mental illness. Dr. Mark S. Komrad, M.D. has served on the Faculty of Psychiatry at Johns Hopkins, University of Maryland, Tulane, and LSU. He is a longtime advocate for safeguarding patients from “assisted dying” and notes that psychiatrists are meant to stop people from committing suicide, not help them to end their lives. He says legalization is becoming a “pathway” by which psychiatric patients would enter into eligibility for assisted suicide. The legalization of assisted suicide is currently being debated in the House of Lords in the United Kingdom. Psychiatrists in Great Britain are concerned that people with intellectual disabilities, who are more vulnerable to coercion and can find it difficult to fully understand the concept of death, will not be provided with the proper mental health care before being asked to make a decision on ending their life. Psychiatrists are medical doctors and have the most important medical role in the treatment of people with mental illness. Currently, fewer than one in five people in hospice care receive support from a psychiatrist. Crux Now spoke to Komrad online about assisted suicide and how it affects psychiatry. Crux Now: Why is the current debate on assisted suicide so important to the psychiatric field? How is psychiatry different than what people think of as “therapy?” Komrad: The state of the art in psychiatry uses a large toolbox of interventions to help people who have distress and problems functioning in the domain of mental life, meaning thoughts, feelings, and behaviors. Inside that box are a variety of tools including medications, various methods of helping people change using “talk therapies,” and the emerging use of neuromodulation technologies, such as magnetic and electric stimulation of the brain and central nervous system. A psychiatrist who has completed 4 years of medical school after college and at least 4 years of residency uses all those tools. Many go on to a 1–2-year fellowship in a subspecialty like child psychiatry, geriatric psychiatry, addiction medicine, et cetera. RELATED: Ethicist says psychiatrists should prevent suicide, not prescribe it One of the most serious symptoms psychiatrists encounter is suicidal thinking and behavior. This arises in a number of psychiatric conditions and is not diagnostic of any one; just like fever is not a diagnosis of any somatic condition. Psychiatrists encounter this potentially life-threatening symptom in outpatient offices, emergency rooms, hospitals, group homes, nursing facilities—anywhere a psychiatrist’s help is sought. Of all physicians, we have particular expertise in dealing with suicidality—independent of what is the underlying diagnosis. Indeed, we have the capacity to help people see beyond the choice of death and find a better path to the future, even if they have no clear “psychiatric diagnosis” at all. We specialize in ministering to helplessness, hopelessness, and demoralization, whatever the reason. This is our core skill set, the “bread and butter” of what psychiatrists encounter and work to ameliorate. The emerging practices of legal “assisted suicide” (prescribing an oral medication to produce death) and “euthanasia” (starting an IV to push a lethal medication) unfortunately establish two categories of suicide — the suicides that should be prevented (as is the status quo of psychiatric practice), and the suicides that should be provided — by doctors. Not only is there no clear way to distinguish for which patients should be prevented, and which provided, suicide, it inverts a fundamental ethos of psychiatry — especially when these procedures are made available to people with mental illness. Besides colluding with patients’ hopelessness, demoralization, and death wishes, medicalizing the provision of suicide puts psychiatrists in a paradoxical, indeed a subversive and rogue position of enabling suicide. To consider suicide a potential treatment option is anathema to psychiatry. Besides creating an impossible position for psychiatrists to parse these two kinds of suicide for an individual patient, it interferes with psychiatry’s public health agenda to reduce suicide rates in the population. It makes a form of suicide desirable, acceptable, even honorable, as a means of relieving others of a sick patient’s burden (a very common motivation for the suicidal thinking we see in psychiatry). It diminishes a very important feature of suicide prevention — taboo. Taboo is different from stigma. Taboo is not about shame and derision; it’s a deterrent, a social value that simply asserts that it is “not cool,” not desirable, to commit suicide. We actually see emerging data now that natural suicide rates have accelerated in jurisdictions that have legalized these procedures, suggesting that “suicide contagion” (a known phenomenon) may be occurring, likely thanks to reducing the suicide taboo. What does “futility” mean in the medical field – especially in hospitals? The word “futility” has not been a standard terminology in any field of clinical medicine until the advent of legalized physician administered death. It is a term of art that emerged as a key designed to open the legal and clinical gates to these procedures in jurisdictions like the Benelux countries, or Canada, that moved beyond “terminal illness” as an eligibility criteria, to include the chronically ill and disabled. Therefore, there are not commonly agreed upon definitions in clinical, scientific contexts. Related words that appear in legal statues regarding euthanasia are “irremediable and “untreatable.” Canada started with its own invented category constructed in 2016 with it’s C-14 law: People whose “death is in the reasonably foreseeable future.” This was never defined, and seemed to hedge the space between “terminal” and “untreatable.” If you look up “futility” in Websters, it is defined as “uselessness,” which is certainly an emotionally loaded definition. RELATED: Assisted suicide increases rates of non-medical suicide, statistics show What can look “futile” to one clinician can look different to another, particularly a dedicated specialist in a particular condition. However, not everyone has access to state-of-the-art specialists who might have additional approaches that local clinicians may either not have available, or sometimes even know about. Or they can’t afford a more effective treatment. In Ontario, for example, the wait for one of the their few eating disorders subspecialty programs is over 400 days! In my own practice, high-end psychiatric residential treatment has completely turned around many “futile”-looking cases. Unfortunately, insurance rarely covers it, and the average family cannot afford the cost, which is upwards of $20,000 a month. How does “futility” work in the psychiatric field? It doesn’t. Maria Nicolini, a prominent researcher in the area of psychiatric euthanasia, after reviewing the objective data concludes “Clinicians cannot accurately predict long-term chances of recovery in a particular patient.” The past president of the Canadian Psychiatric Association has noted: “An extensive review of the literature shows that we cannot predict irremediability [i.e. futility] when it comes to mental illness. There is a big difference between being able to predict the declining course of a well-known medical ailment with understood biology, even if not with 100 percent certainty, versus making unpredictable assessments about the course of mental illnesses.” And we have so many different modalities of treatment, as I said earlier, not “just another medication.” Psychiatric conditions are among the most human forms of suffering, as they afflict higher consciousness. They can be some of the most difficult to bear, both for patients and for their treating clinicians. Absorbing a patient’s hopelessness, struggling to bear the burden of a challenging patient, and wrestling with one’s own values about what is a life worth living, are vulnerabilities for all specialists, but especially in the intensity of long term encounters with psychiatric conditions. Professional terms of art for these challenges are “counter-transference” and “projective identification.” As the celebrated medical ethicist Dan Sulmasy writes: “as a physician, I know that I can make my feelings of helplessness in the face of incurable disease seem like your independent judgement.” So, the lure of concluding that a patient’s condition is “futile” can be a path to relief for the doctor in euthanasia jurisdictions, meaning there is a highly subjective component to this. Christopher de Bellaigue wrote of allowing one or two consulting doctors to open the gate of euthanasia for a patient: ”As the most solemn and consequential intervention a physician can be asked to make . . . the decision to kill is oddly contingent on a single, mercurial human conscience.” You have said that futility is very proximate to the notion of “terminality.” Can you tell me what this means in layperson’s terms and how this affects your field? An ambiguity of “futility” in this context is that it’s often unclear whether it refers to the “uselessness” of all possible treatments for a condition (FDA approved, evidence based, anecdotally effective) or only the treatments that a patient will accept. For example, kidney dialysis is a highly effective treatment for end-stage kidney disease, that can maintain a person’s life, often with very fair quality, for years. So, if a patient refuses dialysis, or kidney transplantation (they certainly have an ethical right to do so), does their condition now qualify as futile? Very few statutes permitting medical administered death require patients to undergo any and all eligible, appropriate treatments for their condition. By refusing a treatment, a patient can produce a terminal situation by choice, in a condition that is not theoretically terminal. In the U.S., we have physician assisted suicide in 12 states and DC (oral lethal pills, at the time of one’s own choosing), not euthanasia (IV, scheduled, with the doctor at the bedside). Also, the criterion for eligibility is having a “terminal” condition, a predicted 6 months life span — (whether with or without treatment is usually not statutorily specified). So, in the U.S., to enter the gate of assisted suicide, one must be “terminally” ill. What about psychiatric conditions? We have NO established notion of a terminally ill psychiatric patient, since nobody can come close to predicting that any one patient is nearly certain to die within 6 months from their psychiatric illness. Yet, one Colorado physician published a paper in 2022, utilizing the magic word “terminal” to describe 3 cases of anorexia nervosa. She prescribed lethal medications for assisted suicide to these patients, as there is a law permitting assisted suicide of the “terminally ill” in Colorado. So first, she controversially concluded these cases were “futile” and then she transmuted that to “terminal” to open the legal gate to assisted suicide. This paper is loaded with various assertions like this that are not standard practice in the eating disorders field. There is no such thing as “terminal anorexia.” Indeed, I and some other colleagues are endeavoring to get the publisher to retract this paper on ethical grounds, as it has had pernicious influence on policy makers worldwide. It is analogous to the effect of the infamous paper that originally asserted vaccines cause autism, which was later retracted. If these cases were in Canada, where you don’t have to be “terminal,” just “futile” —no prospect of further improvement—that would be sufficient. So, “futile” if it’s Canada, but in the U.S. that notion has to be rhetorically wrestled into “terminal” to open the assisted suicide option. That is how these notions are proximate. The DHHS (HHS) is updating Section 504 of the Rehabilitation Act to prohibit disability-based discrimination in federally assisted programs. Why should ordinary people care? “Ableism” is a common prejudice in society against disabled people. Those who are not disabled often feel that a significant disability would make “life not worth living,” and assume that disabled people would feel the same way. This prejudice is even seen among some doctors, who were consciously or unconsciously motivated to proffer less assertive or innovative treatments for people who are disabled. Research has shown that the threshold for considering a patient’s condition “futile” is lower for the chronically disabled because of this prejudice. This recent update to the Rehabilitation Act of 1973 strengthens prohibitions against disability discrimination in health and human services, including medical treatment, accessible equipment standards, and digital accessibility. This fortification is particularly important in this era of spreading laws permitting physician assisted suicide and, I believe, the inevitable extension from the terminally ill to the chronically ill and disabled here in the United States. Why do you think the push for assisted suicide is growing in many countries, and how does this affect the medical field? There are multiple forces at play. In psychiatry we say that the causes are “overdetermined.” There is the “old world” ethos, which thrived in Judeo-Christian-Islamic soil, in which “sanctity of life” was a key moral fulcrum. Then there is the “new world” ethos emerging from the Enlightenment and subsequent values that have ascended to high primacy in the post-modern world, such as fairness, autonomy, and justice. So, the old-world matrix is increasingly effete. In some countries, such as Canada and Belgium, the cultural urge to differentiate themselves from their heavy Catholic moral parentage is a real force. In Belgium, churches have very few attendees for services, and many have been turned into architectural and historical museums. Similarly in Canada. Self-determination, individualism, and entitlement are important dominant themes. Relevant clues are that most people advocating for and choosing these procedures are “the 3 W’s” — wealthy, white, and well educated — a Western cohort that is used to living the way they wish, and therefore dying the way they wish. Also, life extension due to medical advances and lifestyle improvements doesn’t always mean more quality of life. The drive for euthanasia and assisted suicide is a counterpoint to the impetus to “pull out all the stops” medically, often excessively deployed beyond measure. Effective palliative care, if available, is of course the appropriate response to that—getting out of the way of death, with comfort care and accompaniment—not medically killing the sufferer, nor aiding and abetting their suicide. What can ordinary people opposed to assisted suicide do to help stop this from growing? I am a founder of the international organization Doctors Say No, in which doctors from all over the world have signed a manifesto stating that these are not “medical procedures.” They should not be dressed in the white coat. These worldwide physicians advocate for more robustly available training and utilization of state-of-the-art palliative care for those who suffer chronically or terminally, rather than making the sufferer dead. Many leading professional medical organizations agree, notably the American Medical Association, and the World Medical Association. Many are explicitly opposed to euthanasia for those with mental disorders, such as the American Psychiatric Association and the International Association for Suicide Prevention. But doctors alone can’t check the metastasizing spread of this meme. All citizens who can influence the crafting of laws must participate. It is the effect of ordinary individuals’ anecdotes to legislators, telling of their or their loved-ones’ sufferings, which helped pass these laws in the first place. Legislators need to hear other kinds of stories — wrong diagnoses, prognostic errors, unavailable treatments due to finances, manpower, or insurance refusal. Tales of ableism, ageism, and discrimination are critical. In places where these procedures are already legal, bring to hearings examples of poorly observed or ambiguous guardrails, and misadventures that occurred with prescribed poisons. Examples of all these are accumulating. There is a growing coalition of organizations dedicated to preventing legalization of these procedures, or rolling them back. Anyone can donate to them, participate, or attend their numerous online seminars, which provide education and inspire advocacy. Examples are: The Euthansia Prevention Coalition and Collectif Des Medicins Contre L’Euthanasie in Canada in Canada Patients Rights Action Fund and Aging with Dignity in the U.S. Caring Not Killing and Our Duty of Care the UK The Society of Supportive and Palliative Care in France Many of my own presentations to these organizations are available at their websites. Don’t think that, once passed, these laws are a done deal. Slovakia is a recent example of where a general referendum was able to retract a previously passed euthanasia law. The forces promoting euthanasia and assisted suicide are coherent, strong, well organized, and well-funded. But, like David against Goliath, strategy, determination, and hope can redress an imbalance of strength against values. Follow Charles Collins on X: @CharlesinRome

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