de Nicola Center for Ethics and Culture  0:00  
This is Episode 41 of ethics and culture cast from Notre Dame's de Nicola Center for Ethics and Culture.

Welcome to Episode 41 of Ethics and Culture Cast from the de Nicola Center for Ethics and Culture. I'm Ken Hallenius, the communication specialist at the center. In this episode, we chat with Dr. Mark Komrad, a practicing psychiatrist and ethicist in residence for the Shepherd Pratt Health Systems in Maryland. He was with us last December to speak about physician assisted suicide and euthanasia for patients with non terminal mental disorders. In our conversation, we talk about the history and the spread of government approved euthanasia and the ethical crisis that this creates within the practice of medicine. Let's sit down for this important conversation.

Dr. Mark Komrad, thank you very much for coming to be with us today.

Mark Komrad  1:15  
Thank you for inviting me.

de Nicola Center for Ethics and Culture  1:17  
Well, we're excited that you're here to speak with us about your talk is called, "Physician Assisted Suicide and Euthanasia for People with Psychiatric Disorders, and Emerging Ethical Crisis." Now, you've described this as already happening in several European countries. Can you explain the current situation and where is it exactly legal? And what do the laws in the various countries allow?

Mark Komrad  1:43  
Sure. I think this is very important because frankly, I'm an ethicist as well as a practicing psychiatrist. So I approach this from the point of departure of an ethically and philosophically informed clinician who deals with people who have psychiatric disorders. So, here I am at the intersection of those two fields. And frankly, I did not know about this until about 2015. Even though, specifically, in Belgium and the Netherlands since 2002, both countries have indeed been practicing as part of their national policy and law physician administered euthanasia for people that have a wide variety of conditions, including psychiatric conditions, because in that year, 2002, both Belgium and the Netherlands developed a law permitting euthanasia without distinction between a terminal and a non-terminal illness or between physical and mental suffering. So unlike where we see the situation here in the United States,--which is confined to those who are clearly at the end of life and are considered terminally ill, although that term is a little squirrely in its own right, not entirely reliable--in these European countries--the Benelux countries could include Luxembourg as well--they decided that one shouldn't limit it, just to those at the end of life. And that instead, the criteria should be that you have a condition for which the suffering is unbearable--and that is up to the patient to declare that--and in which the condition is untreatable. And that is something that actually is not up to the medical team solely because the laws retain the status quo in medical ethics of people's right to refuse treatments. 

So if you have some treatments that you think can ameliorate the tradition, excuse me, the condition and patients don't want to participate in that, for example, in psychiatry, a particularly effective treatment that we have is electroconvulsive therapy, despite movie distortions to the contrary, and we can talk about that if you're interested. But, if a patient says, "No, I do not want to have that treatment, if that's what you got, if that's all that stands between me and untreated ability, I guess I'm untreatable." So the patient has a right to weigh in on that. And, they embraced actually something that we have long been promoting here in the United States, which is the idea that mental disorders should be treated no differently than other kinds of medical problems. And that suffering is suffering, whether the suffering is mental suffering or physical pain. And so the kind of suffering that you have shouldn't matter. 

So once they remove the distinction between physical and mental conditions, and the difference and remove the differences between physical and mental suffering and remove the differences between terminal conditions and non terminal conditions, that's when psychiatric patients began to get in line for these procedures and now, in those two countries combined, between one and 200 psychiatric patients have, who have been deemed to have insufferable and untreatable conditions are being euthanized on request. And often, actually, the majority of the time, by their own treating psychiatrists, the very psychiatrist who heretofore had been trying to prevent their suicide, had been dedicated to one of those fundamental missions and ethos of psychiatry, which is suicide prevention that we deploy both on a social level with our social messages of suicide prevention and an individual level with our individual patients. Psychiatrists are now, have become providers of suicide not just preventers in those countries. 

If you include dementia as a psychiatric condition--which many people would want to include, that is one of the things that are in our wheelhouse--the numbers in those countries rise to the several hundred a year. And those countries also do allow advanced directives so that people years in advance prior to their dementia can events an advanced directive to say when I become in dementia end stage I would like to be euthanized. That can lead to some pretty bizarre outcomes. So last year, there was a terrible case of a woman who had had an advanced directive for dementia. And so the family declared and the doctor decided, okay, now she's sufficiently advanced that we can implement her advanced directive. And they asked her, you know about it, and she said she didn't want it. But they determined that the advanced directive was her true authentic wish, and that her current refusal was an inauthentic wish. So they tried to euthanize her and she struggled. So they had to put a sedative in her coffee to try to calm her down. And even that was insufficient. And so the family and the doctor had to literally hold her down while they started the IV and euthanized her. I bring up that case, because just this month, that case finally has actually come to public attention once again, because it is now being the very first case in the Netherlands that has been prosecuted. 

de Nicola Center for Ethics and Culture  7:43  
Since 2002. 

Mark Komrad  7:45  
Since 2002, the very first case. 

de Nicola Center for Ethics and Culture  7:47  
Wow. 

Mark Komrad  7:47  
So now the doctor is being investigated as possibly guilty of poisoning the patient, that's what it would be called. And by the way, I do want to make the notes I've been using the word euthanasia and I just want distinguish the difference between euthanasia and physician assisted suicide. 

de Nicola Center for Ethics and Culture  8:03  
Please. 

Mark Komrad  8:04  
Right. So these are two different terms that are often in circulation and they are distinct. Physician assisted suicide is where a doctor writes a prescription for the patient to take and fill at the local pharmacy typically a box of barbituates. It's a box Box O' Barbs as its affectionately known, or dis-affectionately.

de Nicola Center for Ethics and Culture  8:27  
Dis-affectionately, yeah. 

Mark Komrad  8:28  
And then, you know, puts it in the shoe box in the closet to take at the time and place of his or her own choosing, assuming your suicidal granddaughter doesn't discover it first, of course. And it doesn't have to be supervised. It doesn't have to be monitored. There's no guarantees against coercion and so forth. So the doctor basically gives a paper version of a loaded gun to the patient and the patient uses that chemical gun at the time and place of their own choosing. That's physician assisted suicide.

de Nicola Center for Ethics and Culture  8:59  
And that's what's legal in certain states in America.

That's legal eight jurisdictions in the United States.

Mark Komrad  9:05  
In contrast to that is euthanasia. Euthanasia is where a physician starts an IV and pushes a lethal injection just like in an execution and kills the patient directly with his or her own hands in a matter of minutes. That practice, euthanasia, is 99% of the practice in Belgium, in the Netherlands, and in Canada. Canada, developed its own euthanasia national federal law that applies to all provinces in 2016, their so called C-14 Law. So, euthanasia is the rule in countries around the world that have been doing this for a while that are ahead of us. If you want to say ahead or behind? I don't know. But euthanasia is the typical approach in the United States. There is no jurisdiction that permits euthanasia by injection. And as a result, you know, the Europeans you know, are able to euthanize people who are unable to self administer the medication. And they actually feel more honorable like, you know, they're taking full responsibility, whereas they claim that we here in the United States, who employ assisted suicide, that doctors are kind of sanitizing themselves from it by being removed from proximate responsibility by just giving the prescription and then you know, letting the patient carry it on from there, or the patient's family if the family wants to be in a somewhat coercive situation and there are many ways to make coercion look like compassion. We actually have seen some examples of that, some heinous examples in Oregon and Washington where this is legal. But anyhow, those are the important distinctions between assisted suicide and euthanasia.

de Nicola Center for Ethics and Culture  11:04  
Excellent. How did the movement to allow physician assisted suicide and euthanasia. How did it gain traction? I mean, and is it growing?

Mark Komrad  11:13  
It is growing very much. So, certainly by the numbers. In Canada, as I said a moment ago, we've had the national federal law in Canada that the parliament struck two years ago. They're already up to about 3000 euthanasias in the second half of 2017, and that is up 35% from the first half of 2017. 

So it's growing by leaps and bounds. It's growing exponentially in Europe. Now, about four out of every 100 human beings who die in the Netherlands and in Belgium, die at the hands of a physician. They're killed by a physician. So 4% of the population now dies by euthanasia. In certain regions, it's even higher, such as the Flanders region, which is the northern region of Belgium. Over 6% of deaths in the Flanders region, are by the hands of a physician. So once the barn doors are open to this, it starts to take off and really accelerate and accelerates in a variety of ways, not just the numbers of people that are utilizing this new right, for which the medical profession has been given the duty to fulfill, but also in terms of the criteria. So originally, it really did start with end of life cases and in Belgium and the Netherlands, but then it quickly, because the law was written to allow the emergence of non terminally ill people and then of course, that includes people in my domain as a psychiatrist with mental disorders, but then it progresses even further. I mean, there are examples of people euthanized because they were unhappy with their homosexuality. People, I mean again, euthanize meaning voluntarily euthanized, on request, because they were going blind because they had tinnitus or ringing in their ears, because of gender reassignment surgery that did not give a satisfying result. I'm talking about actual cases in the news. And indeed, there was recently in Belgium a case of a rapist in prison who was serving a life sentence, who was able to argue that he was suffering in prison unbearably and there was no prospect for amelioration because he has a life sentence without parole. And so even though that wasn't a medical condition, he had mental suffering, with no prospect of relief, and he was allowed to be euthanized.

In the Netherlands now, the Minister of Justice and the Minister of Health and the one of the leading political parties, the D66 party, is pushing for really de-medicalizing the criteria for euthanasia to allow people to declare their lives complete or simply announce that they are tired of living, and are trying to open the law wider so that you don't even have to have a medical condition at all, in order to be able to ask your doctor to kill you. And moreover, there is an another movement that's especially popular among young people, and being particularly promoted by a large grassroots movement in the Netherlands called the Dutch Voluntary Euthanasia Society, which has over a quarter million members, to push for an over the counter suicide pill that you don't have to go to the doctor for. Their retired Supreme Court Justice, whose name is Huib Drion, wrote a famous essay promoting this and so it is called, in the Netherlands, the Pill of Drion and there's a movement afoot now to try to acquire and develop a pill of Drion. 

And you know, frankly as a physician, we can talk a little bit now about medical ethics. As a physician, I'm about one nanogram more comfortable with the Pill of Drion than I am knocking on the door of the house of medicine asking your doctor to kill you. Now, I wouldn't want to promote this as public policy and I actually think that it's extremely misguided in a society that on the one hand tries to prevent suicides, but declares a certain class of people to have the privilege of not only committing suicide, but being given suicide by the medical profession. I think that's bad public policy. But in terms of the fundamental ethos of what it means to be a physician in the Hippocratic tradition, and especially what it means to be a psychiatrist, where our very core ethos is to prevent suicide to help people find some path to a better future, to suffer along with them if that is going to happen, because that's what compassion means, right to suffer with, to try to mitigate, of course, the suffering that we can. And indeed we even have a skill set in the mental health professions. Something that I think Catholic audiences would especially be sensitive to, which is to make meaning of suffering, of which you know, much meaning can be made. And, of course, the state of the art of palliative care really is way more developed than most people realize, although not as accessible, as many people would like. So, I think that killing does not belong in the house of medicine. 

And so, if society wants to make, what I consider, the misguided step of transforming suicide--because that's what we're talking about here, folks, suicide--from a freedom, which it is now, into a right, then society will have a duty to fulfill that right because right comes within a company and duty. Right? A freedom, you know, we all have the freedom to own private property, but it's not a right so the government doesn't have to provide private property for us, right. But if we have a right, like the right to vote, then the government has to provide a mechanism like voting machines and elections to be able to do that. So, if we're going to transform suicide, from a freedom to a right then somebody is going to have to have the duty. And I would expect that society if they want to make that radical step, it provide that duty in some new way, some different way than the house of medicine. Where that has been clear that at least as a matter of principle, ethics, that basic respect for life and stewardship over life and yes, to try to ameliorate suffering as best we can, that duty does not belong in the house of medicine. 

You know, there were five generations of royal executioners in the French court prior to Lous XIV. So let society stand up, you know, a new class of thanatologists, royal executioners. Actually Virginia, had a Virginia State executioner until 1983. You know I'm not happy about that I really hope my patients don't want to do that. I am available for my patients and my prospective patients should they want to come and knock on my door and on the door of the whole house of medicine and especially the house of psychiatry. I'm available. I'm going to do what I do, which is to try to help you find meaning in your suffering, stay alive, find a path to a better future, help to maximize your psycho social supports, at to administered state of the art treatments where I can. Where especially--by the way--that's a big problem in mental health because in mental health a lot of our patients don't have access to the state of the art treatments in mental health the way that they're given free access to in other domains of medicine. So I'll do all of those things if you come knocking at my door, right? But I'm not going to kill you. Go knock on a different profession's door if you want to be killed. 

So that that's where I'm coming from as a practicing clinician. And as an ethicist. I do want to say one more thing about this lack of access. 

de Nicola Center for Ethics and Culture  20:12  
Yeah. 

Mark Komrad  20:12  
Because it's a big deal in psychiatry, mental health. And as a matter of fact, you know, I wrote a whole book trying to encourage, to give people techniques whereby they can help convince a loved one to get psychiatric treatment. The book, "You Need Help: A Step By Step Plan to Convince a Loved One to Get Counseling". And so and I talk a lot in that book, I have a whole chapter as to why you even need a book like that. You know, why don't people show up for mental health treatment? You know, you don't, see a lot of books trying to convince people to show up to see an orthopedic for their knee. But we need a book to convince people to show up for treatment and there are many, many obstacles to treatment, not just stigma of course that's a big one, but lack of insurance coverage, lack of finances, and so forth. 

By the way, lack of access to good state of the art treatment is true even in those societies that have socialized medicine, like Canada, like Belgium, like the Netherlands, these countries that we're talking about. So it's not you can get anything you want in those countries. You have to get it approved, you have to jump through a lot of hoops. Matter of fact, when I was lecturing over in Belgium, there was a patient in the audience who came up to me on the break and said, look, let me tell you something, do you know how you get the best psychiatric care around here is you say you want euthanasia? And then they're all over with you all over, you know, trying to see what are you lacking and what are you not getting? And so forth. So you know, euthanasia has sort of become a trump card for some patients to start to wave to say, okay, you need to give me the help that I need. 

So, but in mental health, the state of the art help is incredibly elusive. I have one colleague who told me that she had two patients. One was a person with chronic schizophrenia and she wanted that person to get a really great high-end residential treatment program of which they exist here in the United States. Really top end places that cost about $20,000 a month, at least in the first month, the price goes down. And the insurance wouldn't pay for that. She had another patient that she was consulting on who have liver failure, who had a liver transplant. And in fact, the first liver transplant failed, so had to have a second liver transplant, at the total cost between the two liver liver transplants of $2.8 million and her insurance paid every single penny of it. 

de Nicola Center for Ethics and Culture  22:49  
Wow. 

Mark Komrad  22:50  
So I will never forget her side by side example. 

de Nicola Center for Ethics and Culture  22:53  
Yeah. 

Mark Komrad  22:54  
You know, she wanted a couple of hundred thousand dollars to treat this person with mental illness in a kind of a healing wraparound residential situation, that was really a very celebrated place for that kind of thing for chronic mental illness. And she couldn't get a dime out of the insurance company to do that. And unfortunately, the family couldn't afford it. But she got $2.8 million out of the insurance company for two liver transplants on another patient. So, that's just a striking anecdote about the incredible inequity that we have in terms of access to resources for the mentally ill. So of all people who are vulnerable to not being able to get appropriate state of the art treatment, it's the mentaly ill and that we should short circuit them with having, you know, a fast path to providing the very suicide that is actually epiphenomenal of the illness that they have, seems to me a terrible social injustice.

de Nicola Center for Ethics and Culture  23:56  
Yeah. Wow. Well, so this lecture that you're giving here--and we'll have a link to it in the show notes--you've given several times already in various venues across the United States. How is the talk received? And what are some questions that people ask and objections that they may raise?

Mark Komrad  24:14  
Well, you know, my most common audience is colleagues. So my most common venue is what's called grand rounds, which is a tradition in medicine that departments will have a weekly or monthly lecture and they often bring in an outside guests to talk about a topic relevant to the field, whether it's medicine or surgery or obgyn or psychiatry. So, a lot of the venues that I appear at are psychiatry grand rounds, sometimes medical grand rounds, and almost invariably, my audience is shocked. People who at least understand that when you have euthanasia and assisted suicide, I guess there's you know, a potential for it to kind of spill over the edge and to psych patients. But when they learn from me some of the statistics that I'll be showing in the talk tonight, that it's not just theoretical, that as a matter of fact, actual patients are being euthanized, on request by their own treating psychiatrists to the tune of over 100 a year between these two countries, it's a tremendous eye opener to them. As, by the way, it was to me. You know, it's been hiding in plain sight remarkably. Though it's been going on since 2002, I actually didn't tune into it and wasn't aware of it till 2015. I had really missed the memo.  

It was really hiding in plain sight as it continues to. So, one of the things that I'm trying to do is to go around the country, talking to my colleagues, getting them ready. I actually call it my Paul Revere tour. Sounding out the alarm, "The Dutch are coming, the Dutch are coming." It's something ominous is coming from across the Atlantic and also for Canadian north that is metastasizing, especially in Western societies where there is the apotheosis of autonomy and self determination as now the predominant values, everybody has the right to self determination, the right to see, you know, to determine how they're going to die. And where especially here in the United States and Canada as well, there's a certain consumerism in medicine, where, you know, the whole covenantal relationship between doctors and patients has given way more to a contractual relationship. And we're called providers and patients are called, you know, clients or consumers in many areas so that it's become much more horizontal in which and patients are much more educated than they used to be obviously, through the internet, Dr. Internet. And so there's an increasing expectation that if the patient says jump, the doctor should say how high. 

And frankly, it was that medical consumerism that is very much the emotional and social psychological force that is responsible for the opioid epidemic. Those same forces that catalyzed the opioid epidemic are now at work in the, what I consider, an epidemic expansion of assisted suicide in this country. And no country that has been experimenting with this, as some of these countries have been, as I've explained, no country has been able to hold it to just the extreme end stage, end of life patients. In every country it precesses down a slippery slope from that to people who are non-terminal from major illnesses to more minor illnesses and things about lifestyle like homosexuality and, and tenderness to involve children. Several children now have been euthanized in Belgium to proxy consent where people who are incompetent have others make the decision for them. Gee, it's my thought that they probably don't want to live like this. I wouldn't want to live like this either. By the way, this is a big issue in the disability community because disability community feels like there's a embedded message here for disabled people that you know, your life isn't worth living. And by the way, lives not worth living is a very important catchphrase because it was the phrase of the Nazi Holocaust. 

That motivated you know, the extermination of millions that began with, as I will talk about in a lecture I'm giving here tomorrow, began with the mentally ill. Began with psychiatric patients. And in fact, the methods that were later spun up in the concentration camps were invented by and developed by psychiatrists in the so called Nazi T4 program which was the program dedicated to killing the mentally disabled and mentally ill first starting with children. And in fact, it was very difficult to do and the psychiatrists who ran this program, actually psychiatrists, and some of them, psychiatric leaders, head of the German Psychiatric Association heads of departments of Psychiatry at the medical schools at Berlin and Wurzburg, they created the killing techniques for lives not worth living. 

So the disabled community now is understandably aflame and of course, they're of two minds, right? So one mind is well, we deserve to be able to have access to this too, if we want, and some of us are too disabled to even give it to ourselves. So the U.S. needs to get on board and open it up to euthanasia, not just assisted suicide. Just some of us can't put a Box O' Barbs in our mouth. And law doesn't allow our relatives to open our mouths and put it in, although it may eventually come to that. So they're wanting euthanasia. But another segment of the disabled community are saying, you're now designating a whole concept of lives not worth living. And these are lives of people that are chronically impaired. These are people who are disabled. And we're going down a very ominous, slippery slope with that. So it progresses then to tired of living and completed life, as we discussed, and then the pill of Drion and over the counter suicide pills and suicide tourism. And so it goes and that the actual experiment I mean, we're I'm not talking here theory. I'm talking about the observation of what we can learn from these societies about where they've been going. And those of us who are are not there, those countries that are not there those states like Indiana, that are not there yet, with legalizing assisted suicide, need to pay close attention, not just to the lessons of distant history, but to the lessons of just the last 15 years.  

de Nicola Center for Ethics and Culture  30:54  
Well, Dr. Mark Komrad, thank you kindly for coming and being with us and for calling our attention to this and we will have links to your talk tonight in the show notes. And also we'll have a link to "You Need Help: Your Step By Step Plan to Convince a Loved One to Get Counseling". Thank you very much for your time.

Mark Komrad  31:38  
Thank you for the privilege.

de Nicola Center for Ethics and Culture  31:45  
Thank you to Dr. Mark Komrad. You will find links to the video of his presentation as well as his book "You Need Help" in the show notes. Subscribe to ethics and culture cast so that you can always get the latest episodes by visiting ethicscenter.nd.edu/podcast. We would love your feedback. Please review the show on iTunes, Google Play or wherever you get your podcasts, and email your suggestions to cecpodcast@nd.edu. Our theme music is, "I Dunno" by grapes, licensed under the Creative Commons Attribution license. We'll see you next time on ethics and culture cast. Until then, make good decisions.

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