Wednesday, May 22, 2019

Psychiatrists—we prevent suicide, not provide it!

Text from the debate between Dr Mark Komrad, Faculty of Psychiatry Johns Hopkins and the University of Maryland and Dr David Pollack, Department of Psychiatry, Oregon Health and Sciences University sponsored by the American Psychiatric Association (APA). Dr Komrad believes that doctors should care for their patients and never kill.

Mark Komrad
The 2300-year-old history of medical ethics is grounded in a covenant-based set of values that our profession “professes.” The Hippocratic Oath originally captured those covenantal values. It says: “I will give no one a poison, nor counsel any others to do so.” This is the root of the mighty tree from which the House of Medicine was built—forbidding killing—persisting as societies and their demands have come and gone. Hippocratic ethics have not been relegated to the trashbin of history. On the contrary, to this day, the WMA, the AMA, the APA, and many major medical organizations worldwide continue this ethical stance, without any Orwellian redefinitions of the word “suicide” which defy common sense.

The profound changes to a civilized society produced by even limited suicide-on-demand, are unnecessary and undesirable. Suffering and dying should have more access to the latest, state-of-the art palliative care, without being economically or morally short-circuited by institutional killing, promoted as a seductive virtue — referring to it as “dying with dignity.” It is unjust and impossible, in a democratic society, to permit suicide for some — like the terminally ill — but refuse it to others — like those with chronic physical and psychiatric disabilities. The signal that there are “lives not worth living,” is a dangerous one. Autonomy is precious, but shouldn’t crush other values that are necessary for the common good. Medicalizing suicide out-sources to physicians the moral responsibility for transgressing a taboo about taking one’s own life, reducing the moral deterrence to suicide, lowering the threshold of acceptability for all suicide. These practices overturn our Covenant to be providers of hope and healing, preventers of suicide. After two millennia of getting out of death’s way, providing palliative comforts— we now become providers of death? No.

Opening Statement

Thank you to Drs. Winchell and Bernanke and the APA for inviting me to participate in this critical debate in which we are considering profound changes to the ethical momentum, established over 2 millennia, regarding what it means to be a physician, especially a psychiatrist. Changing that venerable ethos is neither good medical ethics, nor desirable public policy.

This afternoon, please expect me to use language that reveals the nature of these activities, employing the ordinary use of English words. Suicide, for example, is defined by the CDC and well understood by psychiatrists as— “death caused by self directed behavior with an intent to die.” Also, “Killing,” defined by Websters as “actively terminating the life of a living creature.” Orwell described the consequences of hijacking ordinary language: 

“if thought can corrupt language, language can corrupt thought.”
Rather than using this opening statement to make arguments from principle, I want to share information with you about facts-on-the-ground, data from the living laboratories where assisted suicide and medical euthanasia have actually been deployed. Let’s see what happens when physicians are legally permitted to have a chemical gun with which to shoot eligible patients on demand, or give to patients to shoot themselves.

Let’s start with Oregon, the first to legalize assisted suicide for the terminally Ill in 1998. Several U.S. states have modeled their laws on Oregon’s With the exception of Hawaii, no state mandates any formal mental health evaluation or treatment to become eligible. In legalized states, though evaluators can refer if they suspect psychiatric problems, they are mostly non-psychiatrists, and we know the extensive research on the low pickup rate of mental disorders by non-psychiatrists. [ In Hawaii, the mandated psychological evaluation can be done by any mental health professional, not just psychiatrists]. Patients have to be competent. However, capacity assessment is a special skill set, not even possessed by all psychiatrists, yet no special training in those skills is required by evaluators. Second opinions are required, but they can be by any physician, and there are no criteria for independence—even a doc in the same practice is OK. No palliative care evaluation or treatment is required. Potential heirs to the soon-to-be deceased can be witnesses to signing consent forms. Although, coercion is forbidden, there is no statutory definition of coercion, and no way to distinguish the subtle differences between supportive encouragement and coercion. Nor are any witnesses required to ensure there isn’t coercion when the lethal pills are taken,. There is no required minimal length of a doctor-patient relationship for the evaluation. In the 2018 report of activities in Oregon, one new encounter was as brief as 4 days. Nothing in the law prevents a patient from converting a well maintained chronic illness into a terminal illness; for example, a diabetic deciding to stop insulin. Also, once the lethal meds are dispensed, there is no tracking what happens to them. They could be stored indefinitely in a shoebox, unless a suicidal relative finds them first! In Oregon, one batch of meds sat for over 800 days before being used.

This slide shows the growth of the practice in Oregon since 1998. Note about 1/3 of the scripts aren’t used. Nobody knows what happened to them! Most of the time, physicians are not present to prevent complications; and they do occur: 6 failed to die, 1 took 4 days to die. Worldwide experience, demonstrates that there is an inevitable evolution of these laws, so too in Oregon. What began as assisted suicide for the terminally ill, is now expanding via 2 current bills: one, to permit IV methods, taking a step towards euthanasia, and the other to be more like the Canadian euthanasia law: rather than terminal illness, “death at some point in the future.”

In 2002 the Netherlands and Belgium passed laws permitting euthanasia, untethering it from terminal illness . Eligible there is any condition that a patient finds“unbearable” and is considered “untreatable” (which is partially defined by what treatments a patient will accept). Also, respecting parity, any distinction was removed between physical and mental suffering. This paradigm allowed some with psychiatric disorders to have euthanasia, even those with dementia. Netherlands has had a growth in the number of psychiatric-only euthanasias, shown split here into those with dementia, and non-dementia. The latter have included a wide range of psychiatric diagnoses, mostly depression and borderline disorder. BTW, Scott Kim recently published that 28% of those euthanatized with personality disorders never had any psychotherapy.

In Belgium, you can see an exponential rise in psychiatric euthanasia, 22% between 2015 and 16. In a series of 100 psychiatric cases, you can see the wide range of diagnoses, again mostly depression and personality disorders, half of which were borderline; even some were psychotic but considered competent.

In Benelux the euthanasia is sometimes administered by the treating psychiatrist— the same one previously working to prevent the patient’s suicide, who then succumbs to providing it. Medical and psychiatric societies support it; even publish how-to manuals.

A “slippery slope” is not just theoretical, but demonstrated in the living laboratories of the U.S., Canada and Benelux These are actual developments! It always starts with the terminally ill but progresses to the non-terminal. Then the parity of mental suffering is embraced. Then, the laws have expanded to include children, and allow advance directives, including for dementia. Then, as we see in Canada—affirmed by a high court just last week—even conscientious objectors are legally mandated to discuss these options and refer. Then, our psychiatric patients are included, first the major mental illnesses, then conditions like personality disorders, alcoholism, and gender dysphoria. Then, prisoners with life sentences become eligible for euthanasia. Then proxy consent becomes possible for those who are not competent, and, legal constraints not withstanding, doctors start euthanizing incompetent end stage patients where family can’t be found. Finally, legislators push to de-medicalize the criteria as in the Netherlands, where now proposals are afoot to allow those who are simply “tired of living” or feel their life is “complete” to have access to euthanasia, possibly through self-administered, over the counter means. In Orwellian newspeak: “rational suicide.”

Colleagues, There are other ways to be compassionate and minister to our suffering and dying patients.

To this way, I personally believe we must stand up— as a profession. 

Caring not killing belongs in the House of Medicine. Let us sustain our core ethos, especially as psychiatrists—we prevent suicide, not provide it!

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