Slippery Slope or Compassionate Care?

Psychiatric Perspectives on Physician-Assisted Suicide/Medical Aid in Dying

The plenary debate at this year’s ACLP Annual Meeting will support the Academy as it establishes its position on legal physician-assisted suicide and informing C-L Psychiatry best practice:

Saturday, 8:30 AM-10:15 AM, Grand Oaks Ballroom G-J (Ballroom Level)

Two presenters will take to the stage: Mark Komrad, MD, Johns Hopkins Hospital, University of Maryland, and Carly Zapata, University of California.

Dr. Komrad is a practicing psychiatrist and medical ethicist on the teaching faculty of Johns Hopkins. For more than 20 years he chaired the Ethics Committee for Sheppard Pratt, the largest non-profit psychiatric health care system in the US.

Previously host of a national radio talkshow about Psychiatry, and appearing widely in the media for 30 years, he treats patients and advises people on how to convince an emotionally or behaviorally troubled loved-one to accept psychiatric evaluation and treatment.  He has served as consultant in the development of both a major Hollywood film and a TV drama about psychiatrists, and even played the part of a psychiatrist in a movie—all in an attempt to  create  more accurate portrayals of psychiatrists and the mentally ill.

For six years he served on the American Psychiatric Association (APA) Ethics Committee and the APA Assembly. In these capacities, he helped craft the APA Position Statement, opposing euthanasia of the non-terminally ill, particularly for psychiatric patients. He is a founder of ‘Doctors Say No,’ physicians who maintain that physician-assisted suicide should not be considered ‘medical’ practices.

Dr. Komrad has spoken widely to make the case about why physician assisted suicide and medical euthanasia are neither good medical ethics nor good public policy, while raising ethical concerns about procedures—especially the paradox of psychiatrists participating in providing, rather than preventing, suicide.

“There are now at least 12 jurisdictions in the US that have legalized physician assisted suicide. Since initial legalization, many states have gradually expanded those laws: shortening waiting periods between evaluation and lethal prescribing, dropping residency requirements, liberalizing the clinical criteria for eligibility, allowing mid-level clinicians to evaluate and prescribe lethal medications, and permitting evaluation by telemedicine,” says Dr. Komrad. “There have also been cases of assisted suicide for psychiatric patients with anorexia nervosa, advancing the controversial notion of ‘terminal anorexia.’

“In some states, C-L psychiatrists are finding themselves on the front lines of these cases. They are being called upon to evaluate patients requesting assisted suicide for capacity, and to rule out potentially treatable psychiatric conditions that may underlie their suicidal wish.

“What is the ethically appropriate role for the C-L psychiatrist in these consultations? Are doing such evaluations aiding and abetting suicide? Should psychiatrists be helping to mitigate suicidal wishes and use their skills to guide patients into alternative paths like palliative care, or existential therapies? Is there room for conscientious objection, and how could that be ethically deployed? Should hospitals have a policy requiring all requests for assisted suicide to be evaluated by a C-L specialist?”

Dr. Zapata is a palliative care physician at UCSF, where she provides interdisciplinary care to patients in the outpatient setting for cancer patients and for those with other serious illnesses. As a bilingual Spanish-speaking physician, she cares for many patients from Latinx communities with limited English proficiency and co-facilitates psycho-oncology group medical visits with Spanish-speaking patients with cancer.

As program director for the UCSF Hospice and Palliative Medicine Fellowship, Dr. Zapata has led efforts to enhance holistic recruitment practices, new educational programming, and mentorship initiatives for learners underrepresented in medicine. Her scholarly work focuses on improving palliative care for patients with limited English proficiency and incarcerated individuals. She has led and contributed to research initiatives aimed at transforming the palliative care workforce and advancing care quality and access for structurally marginalized populations.

Dr. Zapata uses the term Medical Aid in Dying (MAID)—the practice, she says, of providing a terminally ill adult with a prescription for medication they may choose to ingest to end their life. “MAID evokes a wide range of perspectives among physicians around its medical and ethical implications,” says Dr. Zapata. Her presentation explores reasons informing the perspective of physicians who support MAID, while recognizing the nuanced and sensitive nature of the practice.

She will present four key reasons why physicians may support MAID:

• Some physicians view it as a fundamental expression of patient autonomy and the right to make informed decisions about one’s medical care and body. They may consider MAID a way to honor a patient’s wishes at the end of life.
• MAID is viewed by some physicians as a tool, among many others, to ameliorate suffering, which cannot always be relieved even with high quality palliative and other medical care.
• Some physicians perceive MAID to be part of the same spectrum with other accepted end-of-life practices, such as withdrawing life-sustaining treatment or initiating palliative sedation.
• Many physicians base their support on personal clinical experience after witnessing what they perceived to be unnecessary or prolonged suffering at the end of life.

Discussion will clarify the legal and clinical definition of MAID and how it is carried out, outlining its strict eligibility criteria.

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