Advanced Directives and Dementia Cases

In this episode of Psychiatry Boot Camp, Dr. Mark Mullen speaks with psychiatrist and medical ethicist Dr. Mark Komrad about physician-assisted suicide and euthanasia, focusing particularly on their implications for psychiatric practice.

The discussion reviews the terminology, legal frameworks, and international trends surrounding assisted death, including developments in Belgium, the Netherlands, Canada, and multiple U.S. states. Dr. Komrad outlines concerns regarding capacity assessments, the expansion from terminal illness to psychiatric suffering, and the ethical tensions between autonomy and the physician’s role as healer.
The episode also examines countertransference, projective identification, and the clinical dynamics that arise when treating chronically suicidal patients in jurisdictions where assisted death is permitted. Position statements from the American Medical Association and the American Psychiatric Association are reviewed, along with questions of conscientious objection

Takeaways:

Terminology matters. Major professional organizations continue to prefer the term “physician-assisted suicide,” reflecting ongoing ethical debate about whether these practices are distinct from suicide prevention work.
Capacity assessment standards remain variable. In many jurisdictions, evaluations are left largely to physician (or provider) discretion without standardized psychiatric frameworks.
Expansion beyond terminal illness is occurring internationally. Countries that initially limited eligibility to end-of-life conditions have broadened criteria to include chronic disability and, in some regions, primary psychiatric diagnoses.

Borderline personality disorder and mood disorders are disproportionately represented in psychiatric assisted death cases in some European jurisdictions.
Countertransference and projective identification are clinically relevant. Physicians must remain vigilant about how therapeutic fatigue and induced hopelessness can influence decision-making in chronically suicidal patients.
Key professional organizations in the United States maintain opposition to physician assisted suicide. The AMA and APA have articulated clear ethical boundaries regarding the role of physicians and psychiatrists in assisted death. 

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