Is assisted suicide a suicide?

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Psychiatric Times has published several back and forth articles from Psychiatrist and ethicist Dr Mark Komrad (Article 1) (Article 2) and long-time euthanasia and assisted suicide activists, Margaret Battin PhD and associates (Article 1) (Article 2).

One of the key issues that separate psychiatrists and ethicists concerning assisted death is should psychiatrists prevent suicide or provide it? Komrad argues that assisted suicide constitutes a form of suicide and psychiatrists are trained to prevent suicide not provide it while Battin argues that assisted suicide does hasten death but it is not a suicide.

For instance Komrad et al stated in one of their article titled - Against Assisted Suicide:

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. Furthermore, in Washington v. Glucksberg (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 medical aid in dying fundamentally means helping patients kill themselves. This is why the American College of Physicians rejects the term and explicitly endorses the term physician-assisted suicide/PAS. 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 aid in dying and elected to retain the term physician assisted suicide in all AMA documents and references. 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.

Whereas Battin was a key force in the development of the AAS statement on suicide and physician-assisted suicide which proclaims that they are different acts. The AAS statement says:

The American Association of Suicidology (AAS) recognizes that the practice of physician aid in dying is distinct from the behavior that has been traditionally and ordinarily described as “suicide,” the tragic event our organization works so hard to prevent. This recognition does not assume that there cannot be “overlap” cases, but only that the two practices can in principle be conceptually distinguished and that the professional obligations of those involved in suicide prevention may differ.

How can there be such diverging views?

First of all, the AAS statement is philosophically based while the position of Komrad and his colleagues has a scientific, experiential and data basis. Battin recognized that the research by Dr Scott Kim found that some people who died by euthanasia for psychiatric reasons in the Netherlands were not treated for their psychiatric conditions, and furthermore some of these psychiatric conditions are associated with suicidal ideation. 

Komrad and colleagues recognize that: 

“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.

I have spoken to many people who called me concerning a family member or friend who was seeking an assisted death. The further our discussions go the more it appears that the person seeking an assisted death is experiencing suicidal ideation or often a fear of future suffering.

Canadian Psychiatrist Dr John Maher responded to CTV news on how Bill C-7 will affect his psychiatric patients, he said:

that the upcoming rules that could allow medical assistance in dying solely because of a mental illness don't take into account that those suffering from severe illness may not be capable of making the best decision for themselves.

"Last week I had a patient in her 30s who refused treatment who wants MAID. This is a young woman, who will get better who literal has --she's in her 30s -- she has at least 50 years of life left,"

In his concern about Canada's Bill C-7 expanding assisted death to people with mental illness, Psychiatrist Dr Sonu Gaind stated:

We are poised to provide death for mental illness to potentially suicidal, non-dying marginalized people suffering from life distress who have the potential to recover — all based on less evidence than is required for the approval of any sleeping pill. Given the ubiquity of mental illness, no family needs to look very far to appreciate the implications.

Battin argues philosophically that suicide is different than assisted suicide. In reality, psychiatrists who treat patients experience a different paradigm.

It is disconcerting that Battin, who was instrumental in developing the argument that suicide and assisted death are distinctly different, now defends her thesis with researchers, psychiatrists who are actively providing treatment and ethicists who are researching the actual facts.

My experience does not compare to the training and experience of Dr Komrad et al, but I am convinced that the reasons people ask for assisted death are the as the reasons people die by suicide, even though the circumstances may be different.