A Psychiatrist who visited Belgium comments on euthanasia for psychological reasons.

Alex Schadenberg
Executive Director - Euthanasia Prevention Coalition

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Dr Mark Komrad

r Mark Komrad, a clinical psychiatrist and ethicist, visited Belgium in 2017 to participate in a debate on psychiatric euthanasia. On June 21, the Psychiatric Times published his article uncovering the issues related to euthanasia for psychiatric reasons.

Komrad writes about what led him to become an expert on euthanasia for psychological suffering:

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 Statement 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.”

Komrad then establishes the current situation concerning psychiatric euthanasia in Belgium:

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 euthanasia's are performed by one particularly zealous Belgian psychiatrist, Dr Lieve Thienpont). 

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.

Komrad then writes about his presentation he gave in Belium on psychiatric euthanasia:

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.

Komrad then commented on the justification that was made for psychiatric euthanasia:

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 (Christian) 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.

Komrad states that Belgium has developed two new areas of psychiatry, that may have positive outcomes. The Belgium Recovery Model uses peer support among psychiatric patients approved for euthanasia. They have also developed "palliative psychiatry" which is a form of intensive psychiatric treatment for psychiatric patients who have requested euthanasia.

I am not an expert but I would suggest that the Belgium Recovery Model may have the opposite effect, meaning, peer support among psychiatric patients approved for euthanasia may in fact create a greater desire to die by lethal injection.

Komrad completed his article by expressing little to no hope for change in the Benelux countries:

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. 

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. 

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.

I am not so negative about the prospects for Belgium. Similar to any social change, once people come to understand the horrific outcome of permitting euthanasia, overtime they will also come to reject the killing. If not, someday, they will uncover the deception of euthanasia and decide that the killing must stop.