Physician Assisted Suicide: Clinical, Legal, and Ethical Implications for Psychiatry with Dr. Mark Komrad

Mark Mullen: [00:00:00] Welcome back to Psychiatry Bootcamp. Today we are talking about a controversial topic, even for this podcast, physician assisted Suicide. And I have to say, I did an incredible amount of prep for this episode, and I think that comes through both in terms of the depth and the breadth of the information that we're able to cover.

That said we had to limit ourselves to about an hour, and I want to lead with a couple of key points so that we can dive right in. First of all, the human suffering at the heart of this topic is immense. People who are considering suicide as an alternative to being alive are virtually by definition, experiencing life's most difficult situations and deepest forms of suffering.

One area where physician-assisted suicide often comes up is in patients with severe dementia. Alzheimer's runs in my family. It's not lost on me how much suffering dementia causes not only for a patient, but for [00:01:00] their entire support system. My heart goes out to people who find themselves in situations where they are considering physician-assisted suicide, and my intention with this episode is not at all to discount the severity of this suffering.

Or the sanctity of this very personal choice. I chose my guest carefully for this episode. I needed a guest with a wealth of experience and qualifications in medical ethics, and someone who would be able to articulate the complexities of this topic Well, I also didn't wanna sterilize the topic. I'm bringing you a guest who is a talented orator and who delivers information with passion, authenticity, and emotion.

This is intentional and I'm proud to be standing for something that I believe in. Throughout this conversation, I did step out of the unbiased host role and let my cards show a bit on this episode, so I hope the authenticity makes for a compelling listening experience. Finally, I want to name what I perceive to be the knifes edge of the argument that I've heard Dr.

Komrad make and the content that I studied to prep for this episode. There is an argument here [00:02:00] that can accept a person's right to bodily autonomy up to and including suicide. But what Dr. Komrad does not accept, and what I do not accept is the argument that physician-assisted suicide should be brought into the house of medicine as a valid medical treatment.

Dr. Komrad sees our role as psychiatrists, as people who can prevent suicide, people who have a specialized skillset to help people find meaning in life, and people who should not aid a bet or provide suicide, and we should be leaders, teachers, and exemplars of that ethos in the house of medicine. Komrad, welcome to Psychiatry Bootcamp, and I will ask you to introduce yourself to our audience.

Mark Komrad: I'd be glad to, and thank you very much for inviting me. My name is Dr. Mark Komrad. I am a psychiatrist, based in Baltimore. I did my training here at Johns Hopkins, and I spent many, years helping to run the treatment-resistant psychotic disorders unit at [00:03:00] Shepherd Pratt Hospital, which is the largest nonprofit hospital system, in Maryland and actually really in the tri-state area here.

Mark Mullen: Thank you for that introduction, and you have been very prolific on this topic of physician-assisted suicide. I've had the opportunity to review a lot of your work on the topic. You're a very gifted orator, so I did not know that you had a radio show, but it does not surprise me. I'm gonna start here with an Orwell quote that you actually presented in one of your previous, works on this topic.

The Orwell quote, if thought corrupts language. Language can also corrupt thought. So I think that, the words we use and the particular words that we use to describe certain phenomena can inform the way we conceptualize those phenomena. And I start with this because it's immediately clear to me when encountering the topic of physician-assisted suicide, that there's a range of different phrases that people use to describe similar phenomena.

Physician assisted suicide is one phrase people use, but also physician aid in dying medical [00:04:00] aid in dying death with dignity and euthanasia. Can you compare and contrast these terms for us? 

Mark Komrad: Yes, indeed. I think that's a very poignant quote. You know, so many topics these days, it's about how you language it and, particularly those in power may want to, both deploy certain languages as well as censor other kinds of languages.

Certainly seeing that in the terms of the US government today. so language is quite important, not just in terms of how we talk about it, but also, How we educate people about it. it turns out the language that you use when you do polls about these things, depending on how you, what terms you use, can create very significant differences in the outcome of those polls.

There's actually been some interesting research studies, so let's talk about some of the fundamental terms here that have become terms of art. First of all, let's simply start with the term palliative care, which has to do [00:05:00] with people who are suffering at the end of life, not necessarily strictly at the end of life is about trying to bring to bear the state of the art for relief and comfort, and even to help people find meaning with their suffering.

but especially when it comes to terminal illness, to get out of the way of death while providing those things. and that has, for some time now been a state of the art ethical. Ethically understood and, utilized practice in medicine. then the next, level that we should talk about is called physician-assisted suicide.

And in that a physician, although in some jurisdictions, a nurse practitioner and other mid-level interestingly, provides under certain conditions, a written prescription that a patient takes to the pharmacy and gets [00:06:00] a, collection of lethal medications, that are designed for the purpose of creating death.

and they self-administer those orally at the time. The place of their own choosing typically, with or without witnesses. because most jurisdictions that permit this don't require any witnesses at the time or even the presence of a physician. Those medications often are tucked away in the closet, hopefully not discovered by your suicidal granddaughter someday.

Sometimes they may sit around for several years, as has been documented. But this is a self-administered oral regimen. often involves, a box of barbiturates and digitalists and tricyclics, and a number of other things. So that's physician-assisted suicide. Now, I wanna say that term, which actually covers, the techniques that are allowed in some [00:07:00] states of the US which we can get to, has been challenged.

But the American Medical Association on five separate occasions has considered whether alternative words besides suicide should be used. And we should talk a little bit about why it might be important, but just to say at this juncture that the a MA has five times said that should be the preferred term.

It should not be called aid and dying. It shouldn't be called death with dignity. The, preferred term and the a MA uses and suggests be used is assisted suicide. And then the most ethically difficult and controversial method is called euthanasia. And I want to tell you that outside the United States, euthanasia is, I'm about to describe it, is the most commonly used procedure.

euthanasia is where the clinician starts an intravenous line and administers a lethal injection at the bedside of the patient, [00:08:00] just like a lethal objection in the, in, in jail, you know, for people with the death penalty. So that's euthanasia in most countries of the WOR world. Outside the us, as I've said, typically both physician-assisted suicide and euthanasia are available when it's legalized.

But in the vast majority of cases, given an opportunity to outsource the suicide to a physician, almost everybody prefers to do that. And we typically see a ratio of 99% of the cases are euthanasia and 1% assisted suicide in those places where both are an option. So those are the basic terms of art. 

Mark Mullen: So much you said that.

I wanna tug on those little threads. there's a lot to unpack here. I've covered this topic a few times throughout my education. So I remember in my social justice class, in medical school, we talked about euthanasia, physician [00:09:00] assisted suicide. I remember in my bioethics class in undergrad, we talked about this.

We talked about it in medical school again, in bioethics. Really interestingly, this topic didn't come up at one time in my four years of psychiatry residency, but I've always sort of enjoyed discussing it from an abstract academic lens. And this topic always seemed somewhere else. It seemed like it was in a fictional, futuristic novel or something that some particularly progressive folks were doing in Denmark, but not something that was gonna happen right here in the state of Missouri 

Mark Komrad: or out of movies like, Soylent Green.

Mark Mullen: That's right. That's exactly right. How common is this practice? How widespread is it? Is it getting more popular or is it getting less popular? 

Mark Komrad: It's, getting increasingly popular. In fact, I would go so far as to use the metaphor, a metastatic spread of this idea and its legalization. The countries that have been at this the longest, I would say the living laboratories in which [00:10:00] this experiment is running, where there's so much to be, learned from are the, Benelux country, Belgium, Netherlands, and Luxembourg, particularly Netherlands and Belgium.

They opened this in 2003. These procedures, and interestingly from the get go in those countries, they basically got out of the domain of terminal illness. And rather than focusing the eligibility for these procedures on terminal illness, they focused it on suffering, suffering. So in those countries, you do not need to be terminally ill.

You just need to have a condition that you, yourself. Can convince your physician that you, are unable to suffer it, that it is insufferable, and that you and your physician have agreed that there are no appropriate, acceptable means [00:11:00] of further relieving your suffering. So that opened it from the get go to chronically disabled people, not people necessarily who are terminally ill.

And because as we psychiatrists have long been trying to, to achieve parody, we, have long said that our patients should be considered like any other medical patients. And that psychiatric suffering should not necessarily be considered necessarily inferior or different, or of a different kind to physical suffering.

So once you have the formula of irremediable suffering. Rather than terminal illness. as the criteria for eligibility that opened, its opens it up to people with psychiatric disorders only. So in the Netherlands and Belgium, there have been, quite a few patients with psychiatric illness who have been euthanized in both these countries have [00:12:00] euthanasia, as their PR predominant thing.

So at this point, as of the end of 2024, the 2025 data isn't in. There have been over 107,000 people in the Netherlands who have died this way, and over 37,000 people in Belgium, a smaller country in the Netherlands, between six and 10%. So between six and 10 out of every human being who dies in that country dies at the sharp end of a doctor's needle.

Deliberately in Belgium, it's about 4% of all deaths. Are by euthanasia. Now Canada comes along a much bigger country. in 2016, Canada opens it up to people and they came up with a unique Canadian term, people whose death is quote in the reasonable for foreseeable future that was not [00:13:00] statutorily defined.

So you can imagine how wide one can interpret reasonably foreseeable, but it was felt to be tethered somehow to the end of life. that was until three years later when they widened it and they took on the same model. And then as the Netherlands and Belgium, rather than talking about death in the foreseeable or terminal illness, they too decided suffering would be the key to the opening the gate.

And the same criteria that you saw in the Netherlands at Belgium opened to. in Canada so that chronically disabled people. And what's interesting is if you were terminally ill, once they changed, they widened it. If you were terminally ill, you could get your euthanasia the same day you requested it.

If you were chronically ill and not terminally ill, now you have to wait 90 days to get it. [00:14:00] But they explicitly said no psychiatric patients until March of 2027. And in March of 2027, Canada intends statute by law has told psychiatrists to get ready, get your criteria going because we will let people with psychiatric disorders only be eligible for euthanasia.

It's predominantly euthanasia in March of 2027. So because Canada. Is so large, it's been really taken off. So basically there have now been in the merely, in the first eight years, they have had nearly as many cases as the Netherlands took 20 years to have. So Canada is up now between 90 and a hundred thousand deaths.

And [00:15:00] again, in Canada, b about between five and seven out of every 100 people in Canada now die by euthanasia. In fact, euthanasia is now the fourth leading cause of death in Canada. And then finally here in the United States, we had 12 jurisdictions, until this year when Delaware became the 13th.

And just in the last week, New York and Illinois. Just had their governors sign their statutes into law. So we've been having it. The first one was Oregon, back in, actually in, 1998. California, you know, came on around 2018. And here in the United States we only have physician-assisted suicide and we only have it for terminal illness.

However, let me say a word about terminal [00:16:00] illness. what's fascinating is that these laws have effectively changed the definition of what terminal illness means in the context of these procedures. We physicians have long come to understand and utilized in our common parlance, the term terminal illness, to mean an illness that somebody will probably die from within six months, given, Even in the face of state-of-the-art treatments, 

Mark Mullen: agree, 

Mark Komrad: right? These laws, however, here in the us, basically have changed that. They said terminal illness for the purpose of being eligible for your box of barbiturates means simply that you'll die within six months, not just if state-of-the-art treatment doesn't work, [00:17:00] but you can refuse whatever you want.

So within treatments that you find acceptable. So for example, if you have end stage renal disease and you do not want to have dialysis, or you don't wanna get on the transplant list, you have now created for yourself a terminal condition. And that's fine according to the laws. So terminal illness becomes not something that is futile in terms of what the state-of-the-art medicine has to offer.

But terminal illness is now in, in these statutes, basically becomes whatever the patient is willing or un unwilling to do. So it's a full autonomy paradigm. It's not about so much medical criteria because in the end, the patient themselves can produce a [00:18:00] terminal condition. 

Mark Mullen: Yeah, I mean that, that seems like it's a common thread through every country and every.

Set of language, every system that you just walked through. I'm seeing a lot of strategic ambiguity here on behalf of policymakers in insufferable condition with no acceptable means for remedying it. That's gonna mean different things to different people. And I guess how can you know what someone's internal experience is like?

You probably just have to take their word for it in most cases. And what's acceptable to one person might not be acceptable to another, so I definitely appreciate that strategic ambiguity. That being said, these seem like really important decisions and ones around which we should have certainty that the person is in the situation that is prescribed by law and has the full capacity to make that decision.

Tell me about who it is that is making these determinations as to whether or not someone has an insufferable condition. How they go about deciding if there is an acceptable model for remedying it, how this [00:19:00] person decides if this person does have a, if the patient does have a disease that will, lead to the end of their life in the reasonably foreseeable future.

What do these evaluations look like? 

Mark Komrad: Yeah, I wish I could tell you that there was a standard, a universal standard that was followed by all physicians or indeed standards that have been articulated bys scientific research by agreed upon medical societies and organizations, and point of fact there's been a widespread failure to systematize and figure out exactly what those criteria should be, and as a result, it is left to the discretion.

Of the individual physician who's evaluating. Now, in all these jurisdictions, there's typically two people who evaluate, by the way, those two people could be in practice together, not necessarily, [00:20:00] independent, you know, it could be partners. in the same practice, at least one of those two people can have as their specialty, administering these either prescriptions or injections, and has attracted, an enormous amount of zealotry.

I mean, the interesting thing is that, I have here some data from Oregon. So in Oregon there are about 6,500 doctors in Oregon. This is for 2022, only 146 doctors, 2% wrote the legal, all the lethal prescriptions. State. Most of those doctors only wrote one or two and found it actually traumatic and difficult and stopped writing it.

However, one doctor wrote 51 of those prescriptions that year, 

Mark Mullen: 51% or 51 

Mark Komrad: prescriptions, 50 prescriptions 12%, and one third of all the [00:21:00] prescriptions were written by only four doctors. we see the same thing in Canada. I have, this this guy here is in Ontario. a, Dr. Eric Thomas, I think he holds the record in Canada as of April of this year.

He euthanized and remember it's euthanasia there. So, started an IV and pushed a lethal injection on 577 people. In Canada, there are over 19,000 doctors. In 2023, only 361 actually prescribed euthanasia. 

Mark Mullen: Yeah, gotcha. So where I come from working on a CL service with this is I think about decisional capacity.

And my listeners are really generally pretty comfortable with this. We've had two episodes on decisional capacity. We have a third planned. We talk about the ABARES criteria, et cetera, et cetera. One thing we talk about is the sliding scale of capacity. That decisions with a higher risk benefit [00:22:00] ratio require a greater command at the ABARES criteria.

And so when I think about this decision, the decision to end your life, I can't think of a decision that would fall further on the sliding scale toward really needing to demonstrate firm command of whatever criteria you're using. So I would think there's a pretty standardized capacity assessment that would be done in these patients.

Mark Komrad: There's not 

Mark Mullen: to ensure, 

Mark Komrad: in fact, you know, the American Academy of Forensic Psychology has a 16 page. For capacity assessment. Of course that was developed in the context of things like capacity to stand trial, the right to refuse, surgical treatment, to write a will and so forth. Nobody has ever articulated capacity assessment under these circumstances.

If you look at the Oregon form that physicians fill out, there's a little checkbox that says, I have found that this person has capacity to consent to this procedure. Check, no [00:23:00] guidelines, no template, for the evaluation of that. And moreover, lemme just say, mark, that I consider capacity to be a highly specialized skillset.

In fact, I think it's a skillset that most psychiatrists are actually not experienced with. Even necessarily trained with, I think that it's a subspecialty skillset that is typically deployed by two subspecialties in psychiatry, forensic psychiatry, and CNL psychiatry. Right? The vast majority of people who are doing capacity assessments out there in the world of euthanasia assisted suicide are primary care physicians, oncologists, surgeons, who, as I say, have no training in this.

I am neither a CNL psychiatrist nor a forensic psychiatrist, even though I'm a, I have 35 years of experience as a [00:24:00] clinician. I personally do not feel qualified to do an ordinary capacity assessment for one of these other applications that we discussed, let alone for a procedure that I can't even give appropriate, informed consent about because I can't tell them what's on the other side of this intervention.

Mark Mullen: So there's no tracking of how thorough the decisional capacity assessments are for these patients. 

Mark Komrad: right. And in fact, studies that have been done in Europe, in Belgium, for example, have shown that when you actually review the criteria that were used in a select cases that were studied, that less than half of them had what a capacity trained psychiatrist would have considered an adequate assessment of capacity, but good enough because it's left to the discretion.

So we're back to the original question, which is how are they deciding? And the fact of the matter is, the bottom [00:25:00] line answer to that is, doctor, whatever your training has given you to evaluate whether a person understands what you're saying to them, whatever you usually do to do that, just do that. 

Mark Mullen: And it's basically straight from policy makers.

Yeah. Before the break, I am gonna ask you, you're clearly an advocate in this space, and I'm gonna ask you to slip on the role of devil's advocate just ever. So briefly, even if it's uncomfortable for you. I think this practice is pretty foreign to most mental health practitioners in the United States. I think preventing suicide is central to the ethos of being a psychiatrist, and so talking about inducing suicide or promoting suicide.

Mark Komrad: Providing suicide. 

Mark Mullen: Providing 

Mark Komrad: suicide, or even in the cases of euthanasia, administering suicide, or giving a patient a chemical gun with which to implement it. 

Mark Mullen: So some of our listeners might even be bored by this because it's so clearly a bad idea in their opinion, but how are [00:26:00] the psychiatrists who are providing euthanasia or promoting suicide, rationalizing this themselves?

What would they say about why they feel this is an ethical practice? 

Mark Komrad: Right. and I do wanna point that there are actual psychiatrists who are doing this in Belgium and the Netherlands. Psychiatrists don't usually get involved in non-psychiatric cases anywhere, but with the, in those jurisdictions where they do allow psychiatric patients, turns about 8% of psychiatrists are willing to do this.

In fact, are 

Mark Mullen: not just doing the assessment, but actually killing the patient. 

Mark Komrad: Right. Given the shot indeed. There is a specialized clinic in the Netherlands called the Euthanasia Expertise Center, or in Dutch, the Zy, the clinic, that does the majority of psychiatric cases because a lot of people just don't wanna touch psychiatric cases, and the people who are working in those clinics are to do the psychiatric are [00:27:00] psychiatrists.

So, it remarkably speaking, but by the way, more psychiatrists. Approve of this then are willing to do it. I have one colleague who Riley says, you know, a lot of people want hamburger, but, very few people are willing to kill the cow. the, but the fact of the matter is, that, even where psychiatrists support this idea, they're not willing to do it themselves.

And so what are the arguments in favor of it? Arguments fundamental argue as follows. First of all, they argue from the position of parody, which we talked about before. Right? And that is if indeed your society decides that somebody who's not necessarily terminally ill. And we do need to talk about the issue of terminality in psychiatry, because that's coming up, especially here in the US now where you have to be terminal.

But in Belgium, Netherlands, soon, in Canada, our [00:28:00] patients basically deserve the same. Privileges and opportunities. Indeed, the Canadian Psychiatric Association who supports this eventuality in Canada has said that it is unjust and discriminatory to not include psychiatric patients, but whether they're psychiatric patients or not, the idea is that, this is about the right to self-determination, and that if a person wants to do this, they should and say, those who argue in favor of this, including those psychiatrists that do, they say that under these circumstances we should not call this suicide.

So we're not actually providing and administering suicide. They're saying, this is something else. This is not suicide. As we have traditionally understood it, these people don't really want to die. Instead, [00:29:00] they just wanna end their suffering. And that in the interest of, which I think is a misinterpretation of the hippocratic dictum do no harm.

That if the only thing we can do to end suffering is to end the sufferer, that we should basically provide an end to the sufferer to end the suffering. So that's one aspect of the argument. by the way, I ju I wanna say on that point that for a while the American Association of Suicidology maintained this separate two, these two different kinds of suicide, right?

The one thing that we traditionally call suicide and the other, that's not suicide. That's, you know, aid in dying the suicide that we should prevent and the suicide we should provide. And the assumption was that it's possible to distinguish those two. Well, as it turns out, [00:30:00] the more one looks into this, the more ones encounters this.

It's actually not possible to distinguish those two different kinds of suicide, one, which we call a pathology, that we should intervene with and prevent, and the other that we should call a right, that a patient has and provide a medical procedure to administer it. So it, after maintaining this separateness for a couple of years, even that organization decided, you know what, we can't, we, can't make an adequate case for that.

And they retired that position that said, these two things should be separate and, you know, we'll get back to you once we figure out how we can distinguish those two. So that was a very significant reversal. Again, those who believe this, say, no. We shouldn't be using the word suicide. We, this isn't suicide.

This [00:31:00] isn't a pathology that we are basically, giving patients the relief that they are seeking. 

Mark Mullen: So we're looking at autonomy, we're looking at parity, we're looking at patient choice, we're looking at freedom, sort of would be the main principles. 

Mark Komrad: Yeah. but here's the thing is that, you know, it, it's initially promulgated as a right or a freedom that, you know, you should be free to choose this.

But what happens is what starts off as a freedom becomes converted into a right. And whenever you have a right, then there's a duty for somebody to fulfill that right. Not just the duty to fulfill it. Not just the possibility, but the obligation to institutionalize it. To regularize it. To 

Mark Mullen: facilitate it.

Yeah. 

Mark Komrad: Right. Let's set up systems, let's set up trainings. 

Mark Mullen: It's a dirty job, but someone's gotta do it. 

Mark Komrad: Let's have the National Organization of Aid and dying physicians, which there are now several. Let's have specialties. Let's [00:32:00] have places like in Canada that have the maid house, the medical aid and dying house, and the euthanasia expertise center in Netherlands.

So that once something be, moves from being a freedom to a right and then the duty becomes assigned to who, it becomes assigned to physicians. And when it's assigned to physicians. I mean, this is, when you think about this is a very fundamental change in the nature of civilization to basically designate, not in wartime, but one group of human beings.

Who are authorized to kill another set of human beings and of all people given that privilege, physicians, this is anathema to the venerable history. Medical ethics. 

Mark Mullen: Dr. Komrad, I'm gonna stop you right there. We need to take a quick break. I think you're on a roll here. When we come back, we're gonna talk about [00:33:00] specifically psychiatry patients and what diagnoses are most often used.

We'll talk about the idea of, terminality in psychiatric illnesses and many more, cogent points from Dr. Komrad ahead after this quick break.

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All right. Welcome back to Psychiatry Bootcamp with Dr. Mark Komrad. We're talking about physician-assisted suicide. Dr. Komrad, in my mind, physician-assisted suicide in euthanasia are really more of an extension of palliative care, right? The state of the art and hospice is really to get out of the way of the dying process, not to accelerate the dying process, but I see this as sort of one step further and actually accelerating the dying process to alleviate suffering.

to me it kind of belongs in palliative care, but it sounds like it's creeping into psychiatry. 

Mark Komrad: Mark. I just wanna say in response to that, most of the world's major hospice and palliative care organizations [00:37:00] disavow this as part of palliative care. I mean, there's enough trouble getting people to convince people to get into those kind of services without them thinking the doctor's gonna kill them or offering them death.

So, and in fact, there's quite a trove of palliative ca care nurses in Belgium who have left the field because of the attempt to shoehorn euthanasia into palliative care. So most palliative care professionals actually reject that this is part of palliative care. 

Mark Mullen: And I'm not even gonna get you started on organ donation yet.

So let's talk about psychiatric diagnoses. What psychiatric diagnoses do you think are most commonly used for this psychiatric, for the psychiatric diagnoses that are being used to justify this procedure and Dr. Komrad, since we have a psychiatric audience. I'm gonna ask you to dive a little bit into how countertransference and projective identification might play a role in these decisions.

Mark Komrad: Oh, good. Thank you. 'cause that's, something very important and typically having to [00:38:00] define those things for most, non psychiatric one is difficult. First about psychiatric diagnosis. So if you look in Belgium, we've had about, 750 and in Netherlands, a total of 1100 psychiatric patients now over the course of their time who have received euthanasia.

So the most common, diagnoses, are mood disorders. Okay. but a variety of other things, including psychotic disorders, which actually boggles my mind about how people with psychosis could be considered to have, you know, capacity to consent to this. But also eating disorders, autistic spectrum disorders, PTSD.

But here's the thing, I'll tell you the most common. Psychiatric diagnosis are often in comorbidity with others, sometimes by itself, personality disorders. And this audience, I'm sure will not at all be surprised to learn that the most common type of personality disorders is borderline personality disorder.[00:39:00] 

That which carries chronic suicidality is a way of coping with distress. And in both Belgium and the Netherlands, 50% of cases have a personality disorder, either solely or in comorbidity. And here's the amazing thing, only one third of those patients who've had personality disorders have ever had any psychotherapy.

I think we could all agree that psychotherapy is a cynical non of treatment for the, for personality disorders, and yet only one third of them have actually had psychotherapy. So that's really quite it. It's, both amazing and at the same time, not entirely surprising. So that's who's, getting.

I also wanna say that eating disorders is an emerging thing. and this actually is has been stirred up quite a bit of controversy. And let's start here in the US with this. So in Colorado there was [00:40:00] a now infamous paper, a paper that a lar, a group of us, including Paul Applebound by the way, are trying to urge the journal to retract.

But three patients in Colorado were deemed terminally ill. 'cause remember here in the US gotta be terminally ill. So three patients were deemed to have terminal anorexia, which is not a accepted construct, that their condition was considered futile. And that since the patients were resisting treatment and frankly why were they resisting treatment?

'cause the illness itself, '

Mark Mullen: cause they have anorexia, 

Mark Komrad: was impeding the treatment. They were considered to have full capacity and that because they wouldn't cooperate with treatment terminally, I, all three were given lethal medications to end their lives by their treating physician, and two of them used it, and one of them died before she could use it.

Meanwhile, [00:41:00] since those cases have come up, I've co had colleagues said that now some defense attorneys and involuntary commitment hearings for. Anorectic patients are citing that paper and saying that assisted suicide is the least restrictive alternative. Remember, that's always a criteria for involuntary hospitalization, that it's a lesser restrictive alternative than involuntary hospitalization.

And we've now documented 66 cases around the world of, terminal anorexia that have been euthanized or given assisted suicide. And there may be a lot more because there are cases both in, in Oregon, Washington, and Colorado, where the diagnosis at the time of death was listed as severe protein calorie malnutrition.

And we believe C can't get [00:42:00] access to those records 'cause of hipaa. But we believe that many of those cases, the real. The diagnosis was anorexia and instead of putting a psychiatric diagnosis, they put a medical diagnosis. 

Mark Mullen: Dr. Komrad, tell me, so first of all, I have never dropped an F-bomb on psychiatry bootcamp.

I considered unprofessional, but what I will say is that having the primary, the most popular psychiatric diagnosis used for euthanasia being borderline personality disorder and knowing that was it, only a third of those patients have even tried any form of psychotherapy before they're killed.

Mark Komrad: That's with the data from Scott Kim shows. 

Mark Mullen: Yeah. That's fucked. Can you tell me about the counter transference and the projective identification? 

Mark Komrad: Right. I'm glad. Thank you for coming back to that. So, as we know as psychiatrists, there's a complex dynamic that happens between doctor and patient, right? So that the doctor's own issues.

First of all, countertransference, the doctor's [00:43:00] own issues and discomfort with the patient. The doctor's own exhaustion. I mean, if you haven't yet been exhausted by a patient with chronic suicidality or self-harm or any one of an, any, a number of other symptoms, if you haven't been exhausted by a patient, then you haven't been a psychiatrist long enough, right?

it'll eventually happen. And imagine if you now live in a jurisdiction where one potential treatment plan is that we can put on the treatment plan suicide as something that I can aid and abbet you with. So my own discomfort with you. You a difficult patient, you an exhausting patient. You a patient who's constantly calling me and keeping me up in the middle of the night.

Okay. not to mention my own personal experience with perhaps a mentally ill parent that I grew up with, [00:44:00] right? all that background material that goes into countertransference now, projective identification. So projective identification, which is, you know, a dynamic that adheres to some extent in all relationships, but particularly in highly emotionally charged relationships is where a patient basically works unconsciously on the treater to produce in the treater the very feelings that the patient is having trouble coping with.

So that's the projection part, okay? Then the identification part is seeing how you, the treater cope with it. Okay, so I'm feeling hopeless as the patient. I'm working on you unconsciously and producing. You're feeling hopeless with me. Now, your hopelessness at this point is my hopelessness. That's where it comes from.

Okay? [00:45:00] And now I need to see how you deal with the hopelessness about my case, right? So if you're giving in to the hopelessness, it's basically my hopelessness. You are colluding in this dance of projective identification. You are colluding with my hopelessness, right? And rather than trying to accompany me on the journey out of hopelessness and help me find that path.

You are actually feeding my hopelessness, not just acknowledging my hopelessness, but you are satisfying my sense that it is hopeless and fruitless by providing me a chemical gun or approving me getting that iv. 

Mark Mullen: Thank you. I think that was extremely concise for us and very compelling. I heard you talk about that somewhere else when I was prepping for this episode, and [00:46:00] I have to say, I've never heard it put so bluntly that sometimes you're sitting with a patient that you know very well, that you care about so deeply and they're telling you for the 200th time how suicidal they are.

And you might have a straight thought that says. If you're so suicidal, why haven't you done it yet? Why don't you just go do it? You know? and to say that thought isn't crossing your mind, first of all, if that thought isn't crossing your mind at some point, you're not working hard enough. You're not trying hard enough.

Mark Komrad: Right. or you haven't had enough experience yet. 

Mark Mullen: Right. Patients. Right. Let's be honest. Right? And if you're in a position to be treating these patients, you should have seen other patients where you've had this counter transference, and I just can't imagine if that option were on the table and your patient were begging you for it, and your goal is to alleviate suffering.

it just twists my gut and knots. can you walk me through, I know you've been involved in policy on this issue, a lot of advocacy, but specifically position statements and, votes that have happened with organized medicine organizations. Can you tell me about the policy standpoint from the [00:47:00] American Medical Association and the American Psychiatric Association on this issue?

Mark Komrad: Right. So, the, American Medical Association, the a m. I think I alluded to this earlier, has, met on, five separate occasions, with their House of Delegates. and they have a statement that says physician-assisted suicide in euthanasia is fundamentally incompatible with the physician's role as a healer, would be difficult or impossible to control and would pose serious societal risks.

That was first crafted in 1994, reaffirmed in 2009, 2019, 2023, and again, just this past June in 2025. And again, as I said before, they also affirmed that the, appropriate term should remain assisted suicide and not other terms. So remember that the original [00:48:00] foundation of medical ethics was the hippocratic.

You know, in ancient Greece, euthanasia was not that unusual. There wasn't that much that you could, often do for people. But what differed the escape of Hippocrates was it was the only place where, first of all, in order to become a student there and to practice there, you actually had to events a set of values.

The only, only, in fact, you had to take an oath. And one of the key phrases of that oath, why key, because it would distinguished that value from all other, was I will not give any man a poison, nor instruct others how to do so. And that was the root. From which the Mighty Tree of Medicine has grown over the millennia, the boards of which have built the house of medicine.

So that dictum has been a through line. As civilizations have come and gone, governments [00:49:00] have come and gone wanting various things from physicians. So the A MA is and the World Medical Association, which also, has a very strong statement against these procedures, they say we're firmly opposed to euthanasia and physician assistants suicide have been the contemporary keepers of that code.

Now, the American Psychiatric Association, our code is built on top of the a MA code. In fact, the formal name of the code of ethics of the a PA and remember I was on the ethics committee for six years is the a MA code of ethics. Special annotations for psychiatrists. 

Mark Mullen: I'm a big fan of the Goldwater rule.

I've done a lot of work on that, so I'm familiar with the code 

Mark Komrad: and I was on the ethics committee at the height of the recent controversy in recent years about this. So we follow the a MA, however, we have, we, crafted and I helped to [00:50:00] craft this with a colleague, Anne Hansen, the, position statement that was written, especially for Belgium and the Netherlands and Canada, and any other jurisdiction that wants to consider our folks, and in general, those who are not terminally ill.

So the a PA statement, which was by the way, voted on unanimously by the assembly, not a single dissenting vote, not a single abstention, the a PA position. On this, is that the a PA opposes legislation that permits physicians to prescribe or administer an intervention for causing death to persons seeking assisted death solely for mental illness.

It's the position of the a PA that psychiatrists should not prescribe or administer such interventions. So we wanted to [00:51:00] just be heard loud and clear. On the, for the benefit of our particular patients, 

Mark Mullen: not permitting it in other cases, but just being especially specific that we have thought through this issue.

We have discussed it as a committee. We have voted on it and our, there is no universe in which the A PA would support physician assisted suicide for patients with a primary diagnosis of a psychiatric disorder. 

Mark Komrad: It wasn't just the ethics committee voter tonight. It's the entire a PA assembly and the board of directors.

I mean, that's how position statements, you know, are made. So, right. So we shouldn't be used to imply that we're okay with other ones, but we want you to hear us about our guys. 

Mark Mullen: Gotcha. Okay. So let's talk about. If this is, and this is becoming much more widespread, it is spreading across the United States.

Even now, I imagine there's some listeners that are confused about, or maybe con I should say, concerned about how this will affect them or how they will be expected to behave if that this is legalized in their jurisdiction, or if it already is legalized in their jurisdiction. Tell us about conscientious [00:52:00] objection in this realm.

How have conscientious objectors been handled in other countries, in the countries where this is a longstanding practice? How have conscientious objectors been dealt with in the United States? Any guidance you can give us there? 

Mark Komrad: Well, let's start off with the country that's, had the most difficulty with this, which is Canada, right?

In Canada, which now is the most active euthanasia regime in the world. We're talking, you know, last year, over 16,000 people euthanized, although they purport to have conscientious objection. Nevertheless, a doctor must be. At least part of the change chain of culpability. So there it is both unethical and actually illegal for you to not engage in two things.

One is letting a patient know, give informed consent that you might be [00:53:00] eligible for this because you know, gotta talk about all the medical procedures you might be eligible for. That's 

Mark Mullen: a, your legal duty as a 

Mark Komrad: physician. Your legal duty is to say, is to inform you might be eligible for them. Yes. 

Mark Mullen: Wow.

Mark Komrad: And secondly, if you don't wanna do it yourself, that's fine. If you don't wanna evaluate them or administer it, that's okay, but you must point them in the direction of somebody who would be willing to do that. 

Mark Mullen: It's too bad. I've used up all my f-bombs for the day, 

Mark Komrad: so now they do have an 800 number that's trying to get around that and their advertising for, so patients can call the 800 number.

You know, 

Mark Mullen: I think one of your points here too is their advertising. This is big business actually, but that's probably a separate topic in and of itself. 

Mark Komrad: Right. 

Mark Mullen: Okay. So you're talking about conscientious objectors. So you're telling me that in Canada it is a legal obligation of a physician to let a patient know if they might be eligible for this and if they don't want, if the physician is not willing to [00:54:00] participate in this chain of moral culpability, the physician is legally obligated to point the patient in the direction of someone who is likely to participate in this.

Is that correct? 

Mark Komrad: That's correct. 

Mark Mullen: Wow. 

Mark Komrad: Then in the Netherlands, they have dealt with that by setting up these specialty clinics. Right? So you can go to the specialty clinics, you don't even have to ask your doctor. You can just go knock on the door of the euthanasia expertise center. 

Mark Mullen: So they're actually okay with conscientious objectives because it's so common.

That doesn't matter. 

Mark Komrad: So they've created, you know, p plenty of enthusiastic, and as a matter of fact, even the psychiatrist in particular who are doing psychiatric euthanasia in these c specialty clinics in, Netherlands, I think one of them said, we're doing God's work. they're, you know, again, very proud.

They feel that they are on their vanguards of the cutting edge of, you know, a new and, [00:55:00] highly virtuous, moral structure there. Just 

Mark Mullen: like the lobotomy. 

Mark Komrad: Yeah. Yeah. In, America, you know, especially, certainly we've had plenty of experience here with other controversies like abortion and gender affirming care and so forth.

I think that we have much more rigorous, protections and effect are government protections for some of those things. And those are now applying where assisted suicide is legalized to that as well, that protect physicians' rights. But I will tell you that, it's become, in many countries, it's become a litmus test of whether or not you could be hired, whether or not your contract.

can be renewed. I mean, here is testimony, before, the Canadian Parliament, from a physician who said, at my institution, physicians are being [00:56:00] bullied into accepting the role of being involved with maid, which is what they call it, their medical aid and dying. This forces physicians to be legally responsible for the maid, even when it goes against their conscience or religious beliefs.

If they wanna keep their jobs, it gets worse. At one of our staff meetings, a psychiatrist actually stood up and announced that any physician who didn't actively support maid. Shouldn't be working at our hospital. There's horrendous stress at our hospital. Physicians are afraid to speak up, afraid they'll lose their jobs if they say anything.

Even just speaking to colleagues about this, we use alternative email addresses and speak in code. We feel sometimes like we're in some sort of dystopian novel. That's the atmosphere, the cultural change, and the pressures that are developing in these euthanasia friendly and active regimes. 

Mark Mullen: I might set you up for a story here.

So I work at a Catholic hospital, so I would think that [00:57:00] I as a Catholic hospital especially, right, the Catholic church has not been unclear on their stance on this issue over the centuries. Surely at a Catholic hospital, I would be very protected from this sort of government interference, right? 

Mark Komrad: No. So here's the story one, perhaps the one that you were fishing for.

the, a hospice in, British Columbia, I believe, basically said, you know, we are not gonna provide euthanasia. It's against our religious beliefs at our hospice. It's not gonna be an alternative. And the government said, well, in that case, we're gonna take away your government funding. So the Delta Hospice, it was called, said, fine, take away our funding.

And they turned to private donors, and they raised the money to make up for the difference. Government said, huh, in that case, we're gonna take you over by imminent domain. And, they nationalize the hospice. And now euthanasia [00:58:00] is an option at that hospice. So they couldn't escape. 

Mark Mullen: Similar situation with Christian brothers over in, was it the Netherlands?

Mark Komrad: It was in Belgium. Yeah. The brothers of Charity, the brothers of charity in Belgium run the majority of psychiatric hospitals. That's their mission. Their mission is, you know, psychiatric care. So they run both inpatient and outpatient units. And after living for 20 years with these procedures, I mean this is what happens, you know, this, the culture begins to change.

You have a whole generation that grows up where this is normative. You have physicians who are new to the profession, who is have never known a practice of medicine in which killing the patient on request was not an option. The hospitals are run by a board of directors and half the members of the board of directors are lay.

And they decided a, after some years of the brothers hospital saying, we're not gonna provide psychiatric euthanasia. The majority lay board [00:59:00] ruled, we're gonna go ahead and do that. And we're gonna open our Catholic psychiatric hospitals. We'll have the ECT suite and across the hall we'll have the euthanasia suite down in the basement and we're gonna provide them.

Well, that sent the Pope up the Z axis, and he said, no, you're not. And interestingly, just as that was occurring, I had been the invited guests to give the keynote address to the Brothers of Charity hospitals in their annual meeting where they were all ag, a ga, a GOG about this. And ultimately, the Pope said, if you're going to do that, then you're gonna need to take the name of the Catholic Church off your hospitals, that we don't want you to have any association, with the Catholic Hospital.

We're gonna have to rename your Catholic hospitals as something else, because if you're gonna do that, we want you to dissociate from us. And that's what they did. [01:00:00] 

Mark Mullen: One of my family held beliefs is that culture eats religion for breakfast. And I think this is a really good example of that. 

Mark Komrad: by the way, that's new.

I think for many millennia, religion ate culture. 

Mark Mullen: I think that's a fair take. I think that's a fair take. And I think that this, that, yeah, that's a fair take. so you have talked a lot about sort of the slippery slope of euthanasia, right? So one example there would be that where physician-assisted suicide is available, euthanasia is sort of the natural next step.

And then once that's allowed, everybody seems to choose that. You've mentioned that due to the ethical principle of parody, if we're going to allow physician-assisted suicide and euthanasia for patients with medical disorders, it's not much of a jump to include patients with psychiatric disorders. Do you think that we're nearing the bottom of this slippery slope?

Another way to ask this is this season is all about the future of psychiatry for us. So what is the [01:01:00] future of physician-assisted suicide in euthanasia? 

Mark Komrad: Right. I, we are not at all at the bottom of the slippery slope. And by the way, I hope that I've made it. Clear in our remarks, and I'm prepared to actually address this perhaps in the future, very specifically, how the slippery slope is not a theoretical concept.

It's not a, a fear that we're seeing this in the living laboratories, step by step, beginning with the low hanging fruit, people who are gonna die by the end of the week, eventually going to, you know, the disabled. So where else can it go from here? Well, it, it is going, we are already seeing in the Netherlands, the largest political party.

D 66 is now pushing, and it's been pushing for a while, but it's now hot on the trail of expanding this further and actually de medicalizing it, and making these procedures available for those who are, feel they have completed life [01:02:00] or are tired of living. and then what begins to happen is people begin to get to the point where.

It becomes not just an option, but increasingly an expectation and a duty. 

Mark Mullen: Right? 

Mark Komrad: I have a colleague in the Netherlands who tells me that his, elderly father who's had a chronic condition, has ceased to be able to complain about it, about his, suffering and his pain, because whenever he does, his friends say, we don't understand.

Why are you complaining? You could have euthanasia, you know, quit your belly aching. you could have euthanasia two poles. So it's reproducible, it's been produced in a separate poll, of Belgians who've now lived with this for a quarter century. Like I say, an entire generation, 40% of Belgians now say that, no [01:03:00] Belgian citizen should be given expensive medical treatment over the age of 80.

Mark Mullen: Wow. 

Mark Komrad: because we have another alternative now. So just expensive medical treatment. S so you know that to the normalization of, and indeed the expectation that you will avail yourself of this is what happens if this percolates for a generation. Let us learn from these living laboratories about where it goes.

And you know, people say, oh, that's their culture. You know, this is our culture. You know, the America is different. I mean, yeah, it's western culture, but human beings are human beings. And again, in all these different jurisdictions, we're seeing the same pattern of moving the guardrails, changing the goalpost, changing, expanding the criteria.

It may go at d at different rates. [01:04:00] But the trajectory is always in the same direction, albeit at various degrees of acceleration. 

Mark Mullen: I will. Self-disclose here that I have an, I don't know, I probably have kind of a little bit of an annoying libertarian streak in me. Kind of an abstract, not very pragmatic.

Everybody should be able to do what they want streak. I think probably every psychiatrist has that streak in them a little bit. But where my major moral, objection to this practice comes is I just don't think there's any way to safeguard volunteerism. And I think that's a big part of what you're talking about is once this cat is outta the bag, there is no way to ensure that this is a legitimate free choice that is free from any external persuasion.

Because as it turns out, caring for an 81-year-old with severe Alzheimer's disease is really expensive and very time consuming and does place a burden on a family and a society. And when just, 

Mark Komrad: and the care and the doctors, they're [01:05:00] caring for them. 

Mark Mullen: Exactly. And when just killing that person is seen as a valid and reasonable option.

You know what, Dr. Komrad, just tell me the story about the patient who had a advanced directive that said when they had, if they were to develop late stage dementia, they would wanna be euthanized. this is the 

Mark Komrad: Netherlands. 

Mark Mullen: Yeah. There's an interesting story about what happens when that actually comes into practice.

I'm gonna give you an open mic on that. 

Mark Komrad: Yeah. and by the way, not just that it's available, but that it would be a virtue. A virtue. 

Mark Mullen: You must do it. 

Mark Komrad: Yeah. Because look at, how you can relieve us of burdens, how you can give money for your grandkids, college education and so forth. 

Mark Mullen: Don't you love your family?

Right. Right. 

Mark Komrad: So, so th this, where advanced directives for dementia are allowed in the Netherlands, so. One woman who had this by whatever criteria she had set up, it was deemed that she had now reached the point. Of course, when they went to explain it to her, she didn't [01:06:00] understand what it was. And when they tried to, you know, bring her in and, you know, start the iv, she struggled, and didn't want it and said, no.

They tried to, sedate her by putting a sedative in her coffee and it didn't work. so ultimately the family gathered around with one family member on each limb and held her down. While the doctor started an IV and pushed the lethal injection. I mean, such an ugly scene. And that's one of the problems with advanced directives.

Something, which by the way now Canada is now considering the implementation of advanced directives for dementia. 'cause you know, at the moment, if you don't have advanced directives, then you have to have capacity at the time of the euthanasia. By the way, that capacity is a, is an interesting issue with the assisted suicide, right?

'cause if you can give [01:07:00] somebody a box of lethal medications to take whenever they want, and again, in Oregon, in one case, it sat around for over four years. Sure. You can evaluate their capacity at the ti if it's hopefully more than just a finger raise, at the time of prescribing. But what about at the time of taking 

Mark Mullen: Right?

Mark Komrad: And unfortunately there's no, the monitoring. Of, what's actually happening out there on that field is minimal. It's absolutely minimal. And the questionable cases, none of them are coming up for any serious review or prosecution. 

Mark Mullen: Copy that. Dr. Komrad, this has been a wide ranging conversation. We haven't covered.

I think we've probably only covered about half of the territory that I had hoped to just because it's so intricate and such a complex topic. But Dr. Komrad, it's been a pleasure to speak with you and I'd like to give you an open mic here briefly, if you have any final thoughts for our audience. 

Mark Komrad: Yes. So I wanna remind our audience that we are physicians.[01:08:00] 

and that, the venerable history of medical ethics has allowed us to accompany patients. Accompaniment is very important. We walk with them men in psychiatry in particular. We have particular experience, a skillset set and expertise to take that journey with patients and to deal with complicated, difficult suffering people.

We can lead them to the edge, but we do not push them over the edge, particularly with regard to suicide. And all of these procedures, amount to suicide and should not be distinguished from other forms of suicide. Cannot be, and indeed may even add to suicide contagion a whole separate session on that.

But the fact is that, we. Prevent suicide. We help people find a path to a better future. We do not provide suicide, and we have the skillset, especially a psychiatrist, [01:09:00] to help people find that path. Independent of any diagnosis, doesn't matter what or if there's a DSM diagnoses, we know how to minister to suffering, how to make meaning of suffering, how to garner support systems and resources, and to continue to accompany patients without, providing aiding or abetting suicide.

Which if we do, I think is a corruption of the fundamental meaning of what it means to be a, physician, but particularly what it means to be a psychiatrist. 

Mark Mullen: Thank you for that, and thanks for coming on Dr. Komrad.

Thanks for listening to this episode of Psychiatry Bootcamp. If you're enjoying the show, we'd love to know what you think. You can connect with us on TikTok or Instagram at Psych Bootcamp, or you can email me mark@psychiatrybootcamp.com. Visit psychiatry [01:10:00] bootcamp.com to sign up for our newsletter, and you can connect with the rest of the Human Content Podcast family on Instagram and TikTok at Human Content Pods.

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Our YouTube handle is at Psychiatry Bootcamp. Thanks for listening. I'm your host, Dr. Mark Mullen. Our executive producers are Aron Korney, Rob Goldman, Shahnti Brook, and me Mark Mullen. Season four is produced by Matthew Braddock, who also wrote this episode. Outline. Our editor and engineer is Jason Portizo.

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