Note: The French National Assembly may vote on a 3rd and final reading of a terrible euthanasia bill, perhaps the worst in the world
By Mark Komrad (Le Figaro vox op-ed)
OPINION–
Editor: By including “psychological suffering” among the eligibility criteria for euthanasia, the end-of-life bill — back before the National Assembly since Monday — places psychiatrists in an untenable situation: they must simultaneously prevent suicides and, in certain cases, facilitate them, warns the American psychiatrist.
Mark Komrad is a psychiatrist on the faculty of Johns Hopkins and a clinical adjunct professor of psychiatry at the University of Maryland and Tulane. He contributes to parliamentary debates in numerous countries on the issues of suicide and assisted suicide (most recently in Norway, Ireland, and the United Kingdom).
France now finds itself at the heart of a contentious debate between advocates and opponents of assisted suicide and euthanasia. This debate is by no means unique to France; rather, it regularly resurfaces across many Western nations. As an expert in Psychiatry and Ethics, I have been called upon to share my clinical insights with the British Parliament—currently grappling with similar issues—as well as with authorities in Canada, New Zealand, Sweden, Norway, Ireland, Australia, Brazil, and my own country, the United States.
In this broad democratic discourse, one aspect in particular deserves deeper reflection and analysis: the psychiatric dimension of any request to administer death, and the implications for our discipline when society considers responding affirmatively to such a request. Some countries have already included psychiatric disorders among the qualifying conditions for access to assisted suicide. This is the case in the Netherlands, Belgium, and Canada—when the psychiatric illness is deemed irremediable. In Quebec, however, beginning in 2027, mental illness alone will suffice as an independent condition, regardless of other comorbidities. In France, the proposed legislation under debate closely mirrors the framework adopted in Canada and Belgium. As it stands, this bill plunges psychiatrists into a profound state of confusion: Does a psychiatric condition automatically preclude access to assisted suicide?What if the illness is present but does not seem to impair the patient’s capacity for informed, autonomous decision-making? What about depressive disorders?
Yet more broadly, it is illusory to believe that the psychiatric question begins and ends with whether mental illness is included in the eligibility criteria for assisted dying. This dimension is inherently intertwined with the issue, given the undeniable connection to suicide. In the United States, the CDC defines suicide as “a death caused by self-directed injurious behavior with intent to die as a result of the behavior.” In 2014, the American Foundation for Suicide Prevention attempted to draw a distinction between suicide and assisted suicide, stating that assisted suicide “cannot be considered suicide because the individual’s intent is not to die but to end suffering.”
However, this distinction presents a major challenge to clinicians: is a suicide attempt driven by a desire to die, or by the desire to end unbearable suffering?
The legalization of assisted suicide and euthanasia thus imposes an untenable binary upon clinicians: on the one hand, there are “bad” suicides that must be prevented and treated; on the other, there are “good” suicides, redefined as medical procedures meant to alleviate suffering. Such laws put psychiatrists and other physicians in the position of both providing suicide as well as preventing it.
Confronted with this impasse, the American Foundation for Suicide Prevention rescinded its 2014 clarification in March 2023, and in 2024, the American Medical Association reaffirmed that “assisted suicide and euthanasia are fundamentally incompatible with the physician’s role, are difficult or impossible to control, and pose numerous societal risks.” The World Medical Association, to which France belongs, remains “firmly opposed to euthanasia and physician assisted suicide.” They further stipulate “no physicians should be obliged to make referral decisions to this end.”
Indeed, a request for assisted dying closely resembles a suicidal ideation, with no truly reliable way to distinguish an “acceptable” suicide from an “unacceptable” one. In both cases, we must question the adequacy of psychological and psychiatric care. For instance, among patients in the Netherlands who sought assisted death for psychiatric reasons, only one in three had undergone psychotherapy, and half had refused treatment for their condition. In Canada, the wait for psychiatric care can be as long as 8-12 months [MK1]. Yet, when a person’s behavior endangers their own life or that of others, the law obliges us, as psychiatrists, to impose treatment, even against the patient’s will. What, then, should we do? What if there are two patients in the emergency department who are suicidal, and one of them has been previously authorized to have assisted suicide? Should we hospitalize the one, and send the other home, or send them to the “euthanasia suite?” instead of the treatment ward?
When treating suicidal syndromes, clinicians must also explore the patient’s sense of meaning in life and death. However, the option of donating organs after an assisted death may introduce a new form of meaning—one that potentially heightens the appeal of death, especially for psychiatric patients who often feel their lives are unworthy. Moreover, psychiatric patients often have the most intact organs, the most eligible for transplant. This seems inherently coercive. How can we respond to someone who argues that they would be more useful dead than alive?
In suicide prevention, assessing the pressure exerted by family or others is a core element of psychiatric evaluation. But is this any different in cases of assisted suicide?
Every psychiatrist knows there is a progression from suicidal ideation to intent, to attempt, and to completion—and that this gradation often provides critical intervention points that prevent death. But what becomes of this natural safeguard when the act is carried out by a third party in a context of assisted suicide? The externalization of the act brings with it an externalization of moral agency and a transfer of responsibility to the practitioner. To what extent does this mechanism facilitate suicide? It may decrease a taboo about suicide, which is actually a critical aspect of suicide prevention, and quite different from stigma.
As the former Chair of Psychiatry at Johns Hopkins, Paul McHugh, wrote, “Our patients tend to isolate themselves, to nurture their despair, to reject alternatives, to focus on those who have taken their own lives, and to sweeten their deadly poison by speaking of dying with dignity. But if even the psychiatrist becomes complicit with death, what hope remains?”
Before ruling on these grave questions of euthanasia and assisted suicide, I urge French lawmakers not to brush aside the psychiatric issue too hastily under the assumption that such conditions will be excluded—at least initially—from eligibility criteria. For in the end, is it truly normal for a human being to ask for death as a service?
Note: This is an English translation of a French article. The original article can be found here. 