Response to the APA on Physician Assisted Suicide

This article immediately raised red flags.

Dr. Karl Benzio, MD, founder and director of Lighthouse Network, has responded thoughtfully and with wisdom to the APA’s position on Physician Assisted Suicide.


       Recently, the American Psychiatric Association announced:


The American Psychiatric Association, in concert with the American Medical Association’s position on Medical Euthanasia, holds that a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.


As a psychiatrist, let me present some of my thoughts when I read this position.


               Those of us opposed to PAS/Euthanasia have continuously asserted that PAS and Euthanasia, if not stopped, will continue to be increasingly dangerous to not just terminal patients, but also to non-terminal patients, physicians, healthcare workers, the healthcare system, and our society. The slippery slope we predicted is significantly evidenced in both the need for the APA to produce a statement and position as well as some of the details in the statement.


               First, PAS easily and eventually evolves into euthanasia, for if you really think PAS is a rational and compassionate action, then all the same misinformation also informs or guides the position for euthanasia. Kevorkian, Belgium, the Netherlands, and Canada all slid down the slope to that rationalization. We have seen the progression of PAS to probably involuntary PAS to voluntary euthanasia, then non-voluntary euthanasia, and then involuntary euthanasia.


               Second, the initial designation of terminal meaning only having 6 months to live with medical intervention, has been expanded to mean 6 months without medical intervention. Now terminal is being defined as an illness that would kill someone if medications were not taken. So, situations like diabetes, cardiac conditions, post stroke, cancers, or appendicitis, where a person could easily live for 40-75 years with either medical intervention, medications, or surgeries, are now being considered terminal for purposes of PAS/Euthanasia.


               Third, in Belgium and Netherlands, the slippery slope of criteria regarding terminal has now expanded to include non-terminal illnesses which are accompanied by “unbearable suffering.” This suffering is judged by the patent, not a clinician. With this slippery slope expansion, now all the Behavioral Health (Mental Health and addictions) disorders would be fair game for PAS and Euthanasia. Most of these BH issues are curable, and the rest can certainly be addressed medically, psychologically, and spiritually to dramatically limit suffering and improve quality of life.


               It is this 3rd slippery slope issue the APA seems to be immediately responding to in stating they are opposed to a psychiatrist taking part in prescribing (PAS) or administering (Euthanasia) any intervention to lead to death in a non-terminal (BH patient) with self-proclaimed unbearable suffering.


               While nothing is overtly amiss in this statement, in my opinion, it falls woefully short, falling into the category of public policy malpractice, of where the organization representing the professional and highly trained suicidology experts, who are called in as the specialist when a patient with suicidal thoughts or an attempt presents to other medical professionals or first responders.


               Based on my role as a psychiatrist and healer, I would have liked the APA to authoritatively state they are opposed to PAS and Euthanasia in ALL forms and for ANY patient, terminal or non-terminal, regardless of level of suffering. Further, the APA should not just prohibit doctors from being part of the death march process, but also advocate for all doctors to be healers by protecting and always advocating for life regardless of circumstances, but especially when a patient is dealing with a life-threatening illness or one causing significant distress and suffering.


               Looking at the criteria for PAS/Euthanasia, most of the laws suggest the evaluating doctor consider a psychiatric evaluation to determine the patient’s clarity and ability to give informed consent to choose PAS/Euthanasia. Sadly, even though non-psychiatrists are woefully inadequate at diagnosing psychiatric illness, referring a PAS interested patient to psychiatry for evaluation is rare (only a couple percent in Oregon). Receiving a life-threatening diagnosis is a traumatic experience and depressing. This increases a person’s emotional volume, thus interfering with processing or information and judgment. In my medical opinion, those choosing to die are suffering from PTSD (or Acute Stress Disorder) and depression and are not “competent” to process the information and make an informed long-term decision that is in their best interests.   


               When looking at the looser criteria of “unbearable suffering,” almost by definition, the individual’s judgment will be compromised due to the intensity of their suffering.


               I would have liked to see the APA take the position of mandating the PAS/Euthanasia laws to be re-written to mandate a psychiatric evaluation as part of the screening criteria, then mandate the psychiatrists to clearly diagnose PTSD and/or depression for all those who want to die. This would be consistent with how we diagnose, protect, and treat everyone else who is suicidal to avoid a permanent solution to a temporary problem. These struggling patients need significant psychiatric treatment and spiritual care to help in this hopeless and despairing state.


               I believe, due to the intentional or incompetent incompleteness of the APA’s statement, many will interpret the APA’s statement to be endorsing of PAS and Euthanasia in terminal patient’s and even non-terminal patients, and probably even those with unbearable suffering (BH patients). The only element the APA specifically prohibits is the psychiatrist prescribing or administering lethal intervention causing death. Since it is rare (I do not know of any instance) that psychiatrists are the prescriber or euthanizer in the U.S., I believe it is rare in Europe or Canada, so I believe this is a diplomatic straddling of the fence without much real teeth. Maybe other organizations will take heart in the APA making a statement with some opposition to strengthen their positions as well.


               Doctors are called and vow to protect life. We are all taught to stop someone from suicide and commit them against their will if necessary. Suicide and all BH conditions are very treatable to either cure or dramatically improve the quality of life. We should not lower human life to the level of a pet and accelerate their death. Human life is sacred, unique, impossible to replicate and should be honored and protected at all costs. We are terrible fortune-tellers and cannot predict the future, so we should not play God and permanently interfere with a person’s future playing out for them.


               I have treated many patients who attempted suicide because all was bleak with no hope. After their suicide attempt and resultant permanent physical damage and disability, they were so glad their life was spared and they enjoyed many life activities and impacted others in positive ways.


               For our Healthcare system, to work well, it needs to be based on trust. The patient needs to trust their physician, knowing the doctor will help save them, so the patient can divulge any and all problems to the doctor. When the patient doesn’t know if the doctor will heal them or kill them, the patient will be less open and vulnerable and withhold information that increases the burden they are on society. How can a physician adequately treat someone when you don’t have all the information, especially the most harmful symptoms?


This very scenario of mistrust was prevalent in Hippocrates’ day, thus prompting Hippocrates to construct his famous creed to assure patients their information is confidential and would be used only to save their life and not kill them or the baby inside them. The people then voted with their feet and pursued those practicing medicine according to the principles outlined in the sacred Hippocratic Oath. This 2500 year old oath is what the APA should be endorsing as its position as well as mandating all psychiatry residencies recite at their graduation ceremony, while recommending all medical schools do the same.


Dr. Benzio can be reached:


Karl Benzio, MD
Founder and Clinical Director, Lighthouse Network

Pennsylvania Director, American Academy of Medical Ethics

Addiction and Counseling HELPLINE: 844-Life-Change (844-543-3242)