A Response to Mark S. Komrad, MD, DFAPA: My Main Concern Was With Personal Autonomy and Dignity, Not Physician-Assisted Suicide

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

There is an old saying that goes “be careful what you wish for.” I thought of that when I wrote the column “Deciding How to Die” on April 15. Given how controversial physician involvement in euthanasia and assisted suicide has been, I had to assume that we would get some response from our readership. That it would come from Mark S. Komrad, MD, DFAPA, was not surprising, given his continued and convincing concern about physician, and especially psychiatric, involvement in such processes of inducing death. As he rightfully emphasizes in his response to me, “Assisted Suicide Should Not Be Provided by Physicians,” psychiatrists are devoted to life and preventing suicide. Probably the most painful and traumatic career clinical situation for me was my one and only patient suicide back when I was a psychiatric residence in training.

Nevertheless, even with strong arguments like his around, there are 11 states now with legal assisted dying procedures, with no evidence of the laws being abused.¹ Moreover, many more are currently considering similar laws, and widespread acceptance of the process has been increasing among the public, physicians, and lawyers. The current consideration of the Medical Aid in Dying Act in New York (and note the term “medical aid” here) has been endorsed by the Medical Society of the State of New York, the New York State Psychiatric Association, and the New York Bar Association. Like others, it overtly involves psychiatrists and other physicians.

The Swiss System of Assisted Dying

But all that was not at all the point of the column. The column presented my reaction to the planned death, a death of what can be called life completion, of Daniel Kahneman over a year ago in Switzerland. This was not an assisted death with severe suffering with a terminal illness. By all the reports which were recently released, he correctly used the Swiss legal process to die. Given that he was relatively healthy at 90, he added enjoyable time with family beforehand.

In all the assisted dying processes to date, both medical ethical and legal standards are involved. The more general medical ethical principle involved depends on how much medical intervention was—and is—involved. He met all their legal criteria about having a sound mind, that the death was put in motion by the person only, and that no one was to receive any personal gain from it. The Swiss system of assisted death covers the spectrum of those seemingly healthy on up to those severely suffering from terminal illness.²

The Swiss process is also much different than Dr Komrad’s point of ending one’s life that does not necessarily involve a physician, such as by voluntarily stopping eating and drinking. In practicality, those situations are generally part of the process of dying from the suffering of terminal medical illness, but often very distressing for the participant and for family members. As we all too well know, there are much quicker lethal ways to commit suicide, especially with our gun availability. Perhaps the most effective thing we can do to prevent treatable suicides is to reduce gun availability.

Two Medical Ethical Frameworks

Dr Komrad calls upon the “mighty” 2500 year old tree of the medical Hippocratic ethical oath for an overriding medical ethics guideline. In so doing, he invokes the well-known clause: “I will not give poison to anyone though asked to do so, nor will I suggest such a plan.”

Notwithstanding how different medicine and society were back in Greece, that the average lifespan was much less, and that the oath is recited less and less by current medical students, the Hippocratic principles have still sustained some tests of time.

However, that poison point is surrounded by others. One of the other points comes right before it, and I would suggest even more important: “With regard to healing the sick, . . . I will take care that they suffer no hurt or damage.”

That conveys a different medical ethical responsibility to reduce suffering and disease damage, the what to do in contrast to the what not to do as far as the poison. I cannot emphasize enough that it is what takes ethical priority, the physician putting the needs of the patient first as designated as our primary ethical responsibility in the Preface of the American Medical Association ethical principles.

The law that would apply here is whether the physician followed community medical standards and did not commit malpractice, a consideration when Jack Kevorkian, MD, who was a focus of Dr Komrad’s last paragraph, was involved in physician-assisted dying. After assisting over 130 patients in dying, Dr Kevorkian was eventually convicted of murder in 1999 in a voluntary euthanasia—and not assisted dying—of a patient with amyotrophic lateral sclerosis. Euthanasia—where the physician directly gives the lethal medication and could be considered more of a homicide than suicide—is now very rare.

Dr Komrad notes that “the Swiss approach is slightly better” in the sense that physicians do not have to participate in the places and organizations that are available to help, which are outside of formal medicine, such as Dignitas. Still, he also points out that physicians are an involved accessory, “as they must certify that people have the capacity to consent to suicide.”

It is here in his response that I am filled with puzzlement, concern, and anguish. If I understand it correctly, Dr Komrad conveys that he has received numerous calls from individuals in the United States asking for his help in evaluating them for having the required qualifying sound mind. I wonder, given his clear opposition to the physician-assisted death process, why they would even ask him. No wonder he refused. And then, what happens to those requestors after his refusal? Are they referred anywhere else or did they change their mind after talking to Dr Komrad? As he so rightly emphasized, we can and should accompany people and patients on their medical journeys. I would emphasize accompanying and helping people to prepare psychologically for death.

To be surer, I once again reviewed the Swiss process. As far as I can tell, the individuals must be of “sound mind,” but nowhere in the law as I read about it does that have to be verified by a physician. In our own legal systems in the United States, “sound mind” is difficult to define, but is a legal term to try to ensure individuals are mentally fit to make important decisions about lives and deaths, such as making a will. That can be determined not just by physicians, but also psychologists and even lawyers themselves.

The Swiss system, subject to legal changes after being put into motion in 1942, interestingly enough, the time of World War II and the Holocaust, has also been inclining closer to eliminating physicians from prescribing “poison”—that is, lethal drugs, which the person is supposed to take all on their own. An invented pod called Sarco has been used once, whereby the person puts themselves in the pod and turns on the lethal nitrogen. Those who helped this test case last year were accused of being accomplices, but the court has yet to decide on whether something like the Sarco can be used legally in the future.

Bioethical Ethics Beyond the Hippocratic Oath

Most importantly in this debate, there is another set of ethical principles in medicine to contend with besides the Hippocratic oath and its derivatives. Biomedical ethics is much newer than the Hippocratic oath, about 50 years old. However, as evidence of its acceptance and importance, one of the main texts is now in its eighth edition.³ Developed as much by ethicists from the fields of philosophy and ethics as from physicians, it emphasizes 4 main ethical principles: beneficence, nonmaleficence, autonomy, and justice. Each principle can stand on its own, though they can also overlap and be in conflict. Nonmaleficence seems to fit the Hippocratic oath of not using a “poison” to cause death, a confirming justification of Dr Komrad’s concern. However, it is autonomy that fits the point I was trying to make in my first column. Autonomy gives the person and patient much more power to decide their medical care and what should be done with their body if they are of sound mind. It is also a crucial ethical and moral consideration in our abortion debates. To meet that biomedical ethical standard, the physician must provide adequate informed consent and truth.

Medical ethical principles are also not the same in all countries. Neither are a society’s views about death and dying.⁴ In the United States, death has been generally psychologically denied and not adequately discussed in advance, though that is improving somewhat.⁵ For undue death anxiety, psychedelics are being researched.

The Role of Physicians in Assisting Death

Now back to where I started. It would seem unreasonable to conclude that Daniel Kahneman was a patient in a medical system in Switzerland. He certainly seemed to be a person of sound mind. Another colleague wrote me that his death was “the ultimate letting go . . . truly radical acceptance of mortality.” I could hardly think of a more psychologically sound, healthy, and knowledgeable person, even at the age 90, to have the right to arrange for his own aided death.

Kahneman’s example can be the beginning of a slippery slope for death, just like severe psychiatric disorders and dementia have become another justifiable reason for physician-assisted suicide in some countries. Here, sound mind cannot be met.

Inevitably, though, it seems like the Swiss process is headed toward eliminating physicians from the process for healthy individuals and that should be called assisted suicide (without the physician part). Or, better yet, called assisted death to remove any specific medical reference.

My Personal and Professional Assisted Dying Conclusions

For myself, now that I have reached a time of obviously limited life and increasing medical problems, I personally value that the Swiss “completion” option that Dr Kahneman took is available. Perhaps it is the reassurance of the availability itself that is of most general importance. I do not think we psychiatrists should turn away from the suffering and wishes that so many have, which will likely increase with our aging populations. Some call this process “suicide tourism,” given the large numbers of participants, though when completed, a tour without any return package. There are checks and balances in a required Swiss review process since it is a nonnatural death.

In the most general and comprehensive sense, I would conclude that the desired legal and ethical role of all physicians, including psychiatrists, is, when the opportunity arises, to help the person or patient achieve as painless and therapeutic a closure to life as possible without causing the death unless practically necessary.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He presented the third Rabbi Jeffrey B. Stiffman lecture at Congregation Shaare Emeth in St. Louis on Sunday, May 19, 2024. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.

References

1. Perlman BB. Commentary: will this be the year the terminally ill get the right to choose death with dignity? Albany Times Union. April 23, 2025. Accessed April 24, 2025. https://www.timesunion.com/opinion/article/give-terminally-ill-right-choose-death-dignity-20287157.php

2. Hurst SA, Maureen A. Assisted suicide in Switzerland: clarifying liberties and claims. Bioethics. 2017;31(3):199-208.

3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th edition. Oxford University Press; 2019.

4. Moffic HS. Social psychiatry: death and dying. In: Gogineni RR, Pumariega AJ, Kalivayalil, R, et al, eds. The WASP Textbook on Social Psychiatry. Oxford University Press; 2023.

5. Becker E. The Denial of Death. Simon and Schuster; 1973.