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Medical Assistance in Dying Should Not Exclude Mental Illness

By Clancy Martin

Mr. Martin is professor of philosophy at the University of Missouri in Kansas City and Ashoka University in New Delhi, and the author of “How Not to Kill Yourself.”

My first attempt to kill myself was when I was a child. I tried again as a teenager; as an adult, I’ve attempted suicide repeatedly and in a variety of ways. And yet, as a 55-year-old white man (a member of one of the groups at the highest risk for suicide in America) and the happily married father of five children, I am thankful that I am incompetent at killing myself.

I believe that almost every suicide can be prevented, including my own, with access to good behavioral health systems . I have talked many, many people “off the ledge.”

I am a Canadian, where eligible adults have had the legal right to request medical assistance in dying (MAID) since June 2016. Acceptance of MAID has been spreading, and it is now legal in almost a dozen countries and 10 U.S. states and Washington, D.C. To my mind, this is moral progress: When a person is in unbearable physical agony, suffering from a terminal disease, and death is near, surely it is compassionate to help end the pain, if the person so chooses.

But a debate has arisen in Canada because the law was written to include those living with severe, incurable mental illness. This part of the law was meant to take effect this year but was recently postponed until 2024.

Many people who want to end their lives because of intense mental suffering find themselves grateful for their lives once the suicidal moment or attempt has passed. As Ken Baldwin, who survived a suicide attempt by leaping off the Golden Gate Bridge, famously remarked , “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable — except for having just jumped.”

One might expect that as someone who has repeatedly attempted suicide and yet is happy to be alive, I am opposed to euthanasia on psychiatric grounds. But it is because of my intimacy with suicide that I believe people must have this right.

It’s true that policymakers, psychiatrists and medical ethicists must treat requests for euthanasia on psychiatric grounds with particular care, because we don’t understand mental illness as well as we do physical illness. However, the difficulty of understanding extreme psychological suffering is in fact a reason to endorse a prudent policy of assisted suicide for at least some psychiatric cases. When people are desperate for relief from torment that we do not understand well enough to effectively treat, giving them the right and the expert medical assistance to end that misery is caring for them.

Canada’s MAID law recognizes that people suffering from extreme depression, for example, may find no other means to end their agony. Approximately one-third of people coping with major depressive disorder have symptoms that do not reliably respond to available treatments. If you know there is no medically sanctioned way out of your mental pain, you may be likely to take matters into your own hands. Major depression is one of the psychiatric diagnoses most common to suicidal people, and approximately two-thirds of people who die by suicide are depressed at the time of their death. Yet any of us can commit suicide — and currently it is an epidemic.

A panel of experts has recommended safeguards and protocols for requests for aid in dying made by people with mental illness. Should MAID’s extension to those suffering acute mental pain follow the Canadian model, patients will be able to make their case to two health care practitioners, who must agree that their illness is “grievous and irremediable.” This is far preferable to the messy, difficult, terrifying job of trying to do it yourself. The suicidal person’s involvement in a behavioral health setting that can give a variety of kinds of help might result in rethinking the desire to die. Suicidal ideation can consume the lives of those who live with it. By interrupting or complicating the habitual patterns of chronic suicidal ideation, the prospect of relief through MAID could, paradoxically, ease the need for ending one’s own life.

As Dese’Rae L. Stage, a therapist and suicide-awareness advocate, told me, “This is one time that bureaucracy might actually save lives.” While the Canadian application for physician-assisted suicide is being reviewed, treatment and reflection can take place. Also, the knowledge that there is a way out may alleviate the terrifying claustrophobia so common to suicidal people like me and to people in acute suffering more generally. Pain can make anyone panic.

When people are granted the right to end their lives with medical help, they may opt not to use it. People should be granted the right to this assistance. It does not follow they will exercise that right.

I agree entirely with Andrew Solomon when he writes, “It is up to each man to set limits on his own tortures.” That is the compassionate wisdom informing every law permitting medical assistance in dying. If we are willing to help people end their physical suffering by assisting their death, can we in good conscience deny them that help for their mental suffering? As psychiatrists like Dr. Justine Dembo of the University of Toronto have argued, excluding mental suffering from MAID would “discriminate against individuals suffering intolerably from mental illness.”

Yes, we need wise regulation; we need expert advice; we need the best medical information: This is precisely why physicians who specialize in this must be involved, and Canada has these experts. Must Canada, and other countries with similar policies permitting MAID on psychiatric grounds, like Belgium and the Netherlands, continue to proceed with the utmost care, with the advice of appropriate behavioral health and ethical experts? Of course. Should we be especially cautious when it comes to cases involving anyone about whose informed consent we have concerns, such as minors or the disabled? Of course. But this is how any enlightened health care policy must proceed.

Suicidal people suffering from psychological torture should have the right to consult a medical expert about medical assistance in taking their own lives and be given that assistance if their need is justified. Having terrified or anguished people in acute mental suffering ending their pain by the many means available to them, often resulting not in death but in terrible physical injury, is much worse, and it’s happening every day.

If you are having thoughts of suicide, call or text 988 to reach the National Suicide Prevention Lifeline or go to SpeakingOfSuicide.com/resources for a list of additional resources.

Clancy Martin is professor of philosophy at the University of Missouri in Kansas City and Ashoka University in New Delhi. His latest book is “How Not to Kill Yourself.”

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Reflections on Medical Assistance in Dying (MAID)

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• Published: 02 November 2023
• Volume 48 , pages 199–200, ( 2024 )

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• Hannah Samuels   ORCID: orcid.org/0000-0002-0903-9839 1  

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This is not a typical essay on suicide. There is nothing typical about this story or the woman whom the story is about. For confidentiality reasons, identifying information has been altered and I will refer to her as Mrs. L.

Mrs. L was a 68-year-old woman admitted to hospital in Toronto, Canada, for pain secondary to a spinal cord tumor, which caused loss of bowel and bladder function and muscle weakness. She had been living with this condition for approximately 2 years, during which time, her symptoms had worsened. She was no longer able to ambulate, and by the time I first met her, was completely bed-bound.

Her pain was severe. The first day I met her, she grimaced in agony, her smooth skin folding into a thousand tiny wrinkles. She never cried out and wasn’t always in pain, but when the pain started, the loud, animated conversation would stop suddenly and leave in its place a tangible silence.

Her request to me was simple. “I want to die,” she said, “help me to die.”

As a psychiatry resident, these are words I hear far too often. The World Health Organization estimates that more than 700,000 people die by suicide each year, 4500 in Canada alone [ 1 , 2 ]. In the USA, suicide is the 11 th leading cause of death, and 48,183 Americans died by suicide in 2021 [ 3 ].

In my work, I am often asked to urgently assess individuals with suicidal ideation. During these encounters, I assess for a treatable mood or psychotic disorder to “cure” the suicidal ideation and prevent death by suicide.

In the case of Mrs. L, however, the story was different. I completed a full diagnostic assessment. Mrs. L was not clearly depressed and there was no evidence of psychosis. She had never experienced suicidal ideation up until her diagnosis. She cited the pain and the inability to ambulate as the primary reason to end her life.

Not only had Mrs. L never experienced suicidal ideation, but she had a fiery enthusiasm for life. She was a poet and master wordsmith who spoke in a compelling and intense way. Her hands would gesture in emphasis of her speech, and she had fuzzy salt-and-pepper hair, never quite combed back, which gave her the appearance of an eccentric, yet distinguished, professor.

While there was room for optimization of Mrs. L’s pain medication, her goal was medical assistance in dying (MAID). In Canada, MAID is a government-approved procedure in which a person with a serious and incurable illness may be found eligible to end their suffering by physician-assisted death. Eligibility requirements are strict and necessitate that a person be in an advanced state of irreversible decline and experience intolerable physical or mental suffering that cannot be alleviated under conditions the person considers acceptable [ 4 ].

I wondered if the current eligibility criteria truly applied to Mrs. L. She was certainly suffering, but in my opinion, she did not appear close to death and there was more that we could do to help.

I struggled with her request and continued to examine her capacity to make the decision for MAID. I asked her why she preferred to die instead of optimizing her pain control. She told me that she feared cognitive dulling, a potential side effect from strong pain medication. To Mrs. L, without her mind, there was no meaning to her life.

When I was told that Mrs. L was indeed eligible for MAID and would be undergoing the procedure later that week, I was unsettled. Was I wrong to think of her desire for MAID as suicidal ideation that needed to be treated?

I parted from Mrs. L the day before the MAID procedure with tears welling up in my eyes. “Take care,” I said, and she reached out to hold my gloved hand. I never saw her again.

The finality of Mrs. L’s death by MAID left me with more questions than answers. I felt sad, confused, and morally conflicted. Mrs. L never faltered in her confidence that this was the right decision for her, but I could not understand it.

I wondered about the responsibility of physicians in making life-and-death decisions, and how we can determine the extent of another’s suffering. Did Mrs. L’s decision to end her life qualify as “suicidal ideation?” If so, how could we have let Mrs. L go through with MAID when we try so hard to protect our patients from seeking death?

I have been trained to think of any request to die as another symptom of depression or other mental illness that can and needs to be cured. However, the story of Mrs. L made me think: When does suicidal ideation, with all its negative connotations, become an accepted MAID procedure in which doctors agree to help end another’s suffering in the most final of ways?

From a legislative perspective, the Canadian MAID law is more recently making headlines due to proposed changes which would allow for people with sole mental health issues to request MAID. A decision on this matter has been postponed until 2024 due to the ethical complexity of the issue [ 5 ].

I wonder what will happen if MAID becomes an option for those suffering with mental health conditions. How would we as practitioners who choose to guard life above all else, cope? When does the best care mean no longer trying new treatments but instead approving and aiding in death?

My conflicting feelings surrounding Mrs. L’s death remain, and this essay is an attempt to reflect on my experience with Mrs. L and honour her unique character. She prompted me to think deeply about the intricacies of our responsibility as physicians to do no harm. While I write perplexed about her death, what I remember clearly is her life. Ultimately, she lived in the same way she chose to die, with freedom, dignity, and a strong sense of meaning.

Suicide. World Health Organization. 2023. https://www.who.int/news-room/fact-sheets/detail/suicide . Accessed 14 Jul 2023.

Impact of suicide in Canada. In: Suicide in Canada. Government of Canada. 2023. https://www.canada.ca/en/public-health/services/suicide-prevention/suicide-canada.html . Accessed 14 Jul 2023.

Suicide Statistics. American Foundation for Suicide Prevention. 2023. https://afsp.org/suicide-statistics#:~:text=Additional%20facts%20about%20suicide%20in,are%20132%20suicides%20per%20day . Accessed 28 Jul 2023.

Medical assistance in dying: overview. Government of Canada. 2023. https://www.canada.ca/en/health-canada/services/health-services-benefits/medical-assistance-dying.html . Accessed 14 Jul 2023.

Eligibility for persons suffering from mental illness. In: Canada’s medical assistance in dying (MAID) law. Government of Canada. 2023. https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html . Accessed 14 Jul 2023.

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Acknowledgements

This essay was selected as the winner of the Centre for Addiction and Mental Health (CAMH) Isaac Sakinofsky Essay Prize in Suicidology and was awarded a $1000 prize. A sincere thank you to Dr. Deanna Chaukos, Dr. Lesley Wiesenfeld, and Dr. Sanjeev Sockalingam without whose advice and encouragement, this essay would not be possible.

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Samuels, H. Reflections on Medical Assistance in Dying (MAID). Acad Psychiatry 48 , 199–200 (2024). https://doi.org/10.1007/s40596-023-01893-4

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Arguments for and Against Physician-Assisted Suicide

The right to legally end your own life is a heavily debated issue..

Posted September 16, 2020 | Reviewed by Gary Drevitch

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Although September is designated National Suicide Awareness Month, there are those who think about suicide 12 months of the year. They may be survivors of suicide loss—the family and friends of those who have taken their own lives—or they may be people who often contemplate suicide or have already made attempts. Articles and anecdotes of suicide published during the month of September and at other times most often focus on prevention. But there’s another side to the story.

Many people believe that ending one’s own life is a human right, particularly for those who are terminally ill and suffering from indescribable pain or impairment. In the United States, however, it is only a right for those in the nine places where physician-assisted death is now legal when strict guidelines are followed. In Oregon, Washington, Vermont, Maine, Hawaii, California, Colorado, New Jersey, or the District of Columbia, eligible, terminally ill patients can legally seek medical assistance in dying from a licensed physician. In all of these places, a physician can decide whether or not to provide that assistance. At the same time, other states—Alabama, Arizona, Georgia, Idaho, Louisiana, New Mexico, Ohio, South Dakota, and Utah—have, in recent years, strengthened their laws against assisted suicide. In 2018, for instance, Utah amended its manslaughter statute to include assisted suicide.

In a nutshell, it works like this: The patient orally requests legal medical assistance in dying from a qualified physician. That physician must assess and confirm the patient’s eligibility and also inform the patient of alternative treatments that provide pain relief or hospice care. At that point, a second physician must confirm the patient’s diagnosis and mental competence to make such a decision. If deemed necessary, either physician can require the patient to undergo a psychological evaluation. The patient must then make a second oral request for assistance. Once approved, the original physician writes a prescription for lethal medication (usually a high-dose barbiturate powder that must be mixed with water) that the patient can self-administer when and where they choose, as long as it is not in a public place. Some people never fill the prescription or fill the prescription but never take the medication. Those who do generally fall asleep within minutes and die peacefully within a few hours.

Several organizations have been formed to both support and oppose physician-assisted dying for moral, ethical, and legal reasons. Groups such as Death with Dignity and Compassion and Choices are in favor of what they call “medical aid in dying” and work to provide assistance and lobbying efforts to initiate legal “right to die” programs in every state. They support patient autonomy and choice, particularly in the case of terminal illness. To these groups and their supporters, most of whom come to this side of the issue as a result of agonizing personal experience, death with dignity is a human rights issue and those who are suffering are entitled to a peaceful death.

On the other side of the debate, groups like the Patients Rights Council and Choice Is an Illusion work to tighten laws against euthanasia and medical aid in dying. They fear a complete lack of oversight at the moment of death, as well as normalization of the process to the degree that patients will feel they must relieve their families of the burden they are inflicting by living with their illness. They are concerned that decisions will be made by others on behalf of those too ill to speak for themselves. These groups believe the job of a physician is to find ways to eliminate patients’ suffering, not the patients themselves. They do not believe a physician is qualified to make the decision to assist in ending a life.

In the end, no group really wants assisted suicide to be the final answer, but those who favor medical aid in dying see little recourse for those living with unbearable chronic pain , who are terminally ill, and who have no hope of improving the quality of their lives because medical science has not yet caught up with our modern potential for longevity.

Compassion and Choices: https://compassionandchoices.org/

Death with Dignity: https://www.deathwithdignity.org/

Patients Rights Council: http://www.patientsrightscouncil.org/site/

Choice is An Illusion: https://www.choiceillusion.org/2019/04/in-last-ten-years-at-least-nine-…

Susan McQuillan is a food, health, and lifestyle writer.

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Medical Assistance in Dying Essay Example

In June 2016 Canada became one of the first law systems to legalize physician-assisted dying. Medical assisted dying is often seen as a form of suicide, which at the end of the day is in the hands of the person who has requested the procedure. To this day, euthanasia continues to be a topic of controversy. As a result, today most countries have decided to not legalize assisted dying. The three main issues that are affected because of euthanasia are the misinterpretations of Bill C-14, the ethical view of the mentally ill receiving euthanasia, and the view on medical assisted dying in care homes. There have been debates and controversial opinions if medical assisted dying can apply to individuals who have mental illnesses. This means that euthanasia would be legal for those individuals who are not necessarily in crucial pain, but rather to those that their way of living is limited and hindered because of their disability. 

To begin, this legal issue has led to an increase in legal controversies, according to Bill C-14, medically assisted dying is only eligible for adults who are in an irremediable condition. Bill C-14 is an “act to amend the criminal code and to make related amendments to other Acts”, as medical assistance in dying (McMorrow, 2018). For example, individuals with psychiatric disorders are technically eligible to proceed with medical assistance in dying. With saying that, they need to have specific requirements which are described in more detail further on. An individual is eligible if they have a medical condition that has no possible cure, if their suffering is intolerable and if “their natural death has become reasonably foreseeable” (Omar Ha-Redeye, 2016). Therefore, if the individual cannot identify with any of the previous requirements, then they are unable to receive the treatment. The main controversial topic of discussion that is had is with the last requirement, having the individual’s death reasonably foreseeable. While this is a little debatable since no one truly knows the date and time for someone’s death. At the same time, one can argue that their natural death is coming near regarding how the state of their health is.

Professor Montero argues that “Once euthanasia is allowed, it becomes very difficult to maintain a strict interpretation of the statuary conditions” (Omar Ha-Redeye, 2016). In other words, once it is legalized people can find a way around the rules and make a case for their situation. Individuals will interpret the statuary conditions in a different way than Bill C-14 establishes. This will be led to misinterpretation with courts and the rights of the individual. According to Bill C-14, the individuals eligible for medical assistance in dying are those who have a “grievous and irremediable medical” condition. This is readdressing the severity of the conditions of the individuals that can receive the assistance. This means that those individuals who have a medical condition that has a cure, or a treatment are not eligible. There have been some controversies for this reason even while the individual might be in extreme pain. 

On the other hand, individuals who have mental illnesses are not taken seriously on their thoughts or request to consider them as candidates for medical assistance dying. An issue that arises that goes against people with mental illnesses is that one of their symptoms may include failure to reason. This can lead to higher authorities refusing their request since in their eyes the individuals are not choosing with a proper and adequate mind. The right for the individual to proceed with euthanasia “includes those that are not terminal or life-threatening” (Omar Ha-Redeye, 2016). As a result of misinterpretation, certain individuals can bring reasoning behind their “illness”. For example, people who have disabilities and who do not have a strong support team might be led to believe in their eligibility for medically assisted dying. In saying this, individuals who might feel lonely are more prone to request this procedure because of their loneliness. Therefore, not necessarily having to do with anything with their health condition. This has led courts to be seen as unfair since they might give favoritism to certain individuals, while their intentions might not be to neglect certain groups intentionally. A clearer definition of suffering is “any enduring experience of pain or distress that significantly impairs a person’s subjective satisfaction with his or her quality of life” (Ryan Tanner, 2018). This can be both physical pain and emotional pain, mental illness can be as dangerous as physical pain. To this day, there is still a different view on mental health, and it is seen as to not be as crucial as physical pain. This can be a dangerous slope and theory to have since it can lead to a more delicate approach for those individuals that require assistance. 

Legal controversies on medical assistance dying have become a legal issue in a lot of care homes for the final days of their lives. This legal issue can defer if the organization is either religious or has set rules beforehand if an individual can apply for the home. In care homes, specific organizations have regulations where medical assistance dying is not supported, and if the individual requests euthanasia treatment, then they would have to be transferred to a different organization that supports it and can attend to their needs. 

In conclusion, a couple of legal issues that physician-assisted dying carries are misinterpretations of Bill C-14, ethical analysis, and view for the mentally ill, and controversies on care homes. According to an analysis report by Professor Montero, it is hard to maintain a rigid interpretation of the conditions and requirements to be eligible for euthanasia. This leads to misinterpretation of official documents of medical assistance dying and creating legal controversies.  Thus, having understood the ethical reasons behind the view on individuals with mentally ill helps paint a picture of why there are set requirements to proceed with medical assistance in dying.

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Have Arguments For and Against Medical Aid in Dying Stood the Test of Time?

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It has been 26 years since medical aid in dying (“MAiD”) was first legalized in Oregon, and today, about 20 percent of people in the US live in jurisdictions that permit MAiD. The New York State legislature is currently considering a bill that would permit Medical Aid in Dying for terminally ill patients in certain defined circumstances. Those states now benefit from decades of experience, evidence, and reporting from MAiD jurisdictions. This demonstrates that legislation can simultaneously grant terminally ill citizens the civil right to access MAiD while also aggressively protecting all patients from coercion, manipulation, and harm. Given the copious evidence gathered in the past decades, concerns about abuse can no longer be credited as grounds for opposing the passage of legislation that is demonstrably both effective and safe.

INTRODUCTION

It has been 26 years since medical aid in dying (“MAiD”) was first legalized in Oregon, [1]   and today, about 20 percent of people in the US live in jurisdictions that permit MAiD. [2] Other jurisdictions, including New York, are actively considering adopting MAiD laws. Those states now benefit from decades of experience, evidence, and reporting from MAiD jurisdictions, demonstrating that legislation can permit MAiD while also aggressively protecting all patients from coercion, manipulation, and harm. The data should allay the concerns of those who oppose MAiD due to the risk of abuse, coercion, and a hypothetical slippery slope. We, as a society, as clinicians, and as ethicists, must remain vigilant and prevent abuse of MAiD, given the potential risks in the community and in congregate care settings and the risk of patient exploitation by family members. However, given the copious evidence, concerns about abuse do not justify opposition to legislation that is effective and safe.

I.     New York’s MAiD Bill

The New York State legislature is currently considering a bill that would permit MAiD for terminally ill patients in defined circumstances. [3] The bill applies only to adults with a terminal illness or condition that is “incurable and irreversible” and “will, within reasonable medical judgment, produce death within six months.” The bill contains numerous protective requirements:

• MAiD requests can only be made by the patient themself; requests cannot be made by healthcare agents, surrogates, or anyone else;
• MAiD requests must be made both orally and in writing to the patient’s attending physician;
• No person is eligible for MAiD solely because of age or disability;
• The patient’s attending physician must determine the patient has a qualifying terminal illness, has decision-making capacity, and has made a voluntary, informed decision to request MAiD, in the absence of coercion;
• These determinations must be confirmed by a second consulting physician in writing;
• If the attending physician has any concern that the patient may not have decision-making capacity, the patient must be referred to a mental health professional;
• The attending physician has additional duties to the patient, including ensuring the decision is informed, by discussing the patient’s condition and prognosis; discussing the MAiD process, and treatment alternatives like palliative and hospice care; offering referrals to other appropriate treatment, like palliative and hospice care; and educating the patient that their request can be rescinded at any time and offering them an opportunity to do so;
• The written request must be witnessed by at least two adults who cannot be (i) related to the patient, (ii) entitled to any portion of the patient’s estate, (iii) employed by a healthcare facility where the patient is receiving treatment or residing, (iv) or the attending physician, consulting physician, or mental health professional determining decision-making capacity; and
• MAiD medication must be self-administered by the patient, and it must be voluntarily ingested. [4]

ARGUMENTS FOR AND AGAINST MAiD

II.     No Evidence of Abuse of Existing MAiD Laws

MAiD supporters and critics alike have a concern about the abuse of MAiD. For this reason, MAiD laws throughout the US incorporate strict eligibility criteria and protective procedural requirements. For instance, patients are eligible only if they are terminally ill with six months or less to live, more than one physician must be involved, and requests must be witnessed (by individuals unrelated to the patient who will not profit from the patient’s estate). MAiD requests have been closely examined in the 27 years since Oregon became the first state to legalize the practice. The results show that these compassionate and protective measures have worked .

There have been no documented or substantiated incidents of MAiD abuse since Oregon became the first to implement a MAiD law in 1997. [5] In 2019, the executive director of Disability Rights Oregon (DRO), an organization mandated by federal law to investigate complaints of abuse or neglect of people with disabilities, reported that DRO has never received a complaint that a person with disabilities was coerced into obtaining a prescription for MAiD drugs. [6]

A recent study of aggregated data from all nine of the US jurisdictions with publicly available MAiD records from 1998 to 2002 found that 95.6 percent of those who died by MAiD were non-Hispanic white individuals, and 53.1 percent were male. [7] 72.2 percent of these individuals had at least some college education, 74 percent had a cancer diagnosis, and the median age of MAiD death was 74 years old. Only 11 percent of patients were uninsured. MAiD users tend to be white, older, educated, diagnosed with cancer, and insured. Fears that MAiD would overwhelmingly be used by (or on) the poor, the uninsured, the uneducated, or racial and ethnic minorities have not materialized. This data has actually raised a converse concern: that MAiD may, inequitably, not be readily available to less privileged populations or those with a diagnosis other than cancer. [8]

Opponents of MAiD may argue that the recent relaxation of certain legal restrictions in some jurisdictions is evidence that the slippery slope to unrestricted euthanasia has begun. This is a mischaracterization. Certain restrictions have been adjusted. For instance, Oregon and Vermont removed the residency restriction that previously excluded non-residents from eligibility. [9] Both states changed the residency requirement due to lawsuits challenging the constitutionality of requiring residence. [10] New Jersey’s law will likely change soon, as well. [11] Initial MAiD laws were drafted to be highly restrictive out of concern about unintended and unforeseeable consequences. Given the gravity of the subject, decades ago, it was better to err on the side of caution, even if that meant excluding from eligibility people who ought to, ethically or legally, be included. Now, with nearly 30 years of experience and data, we can better determine which requirements are necessary to appropriately protect patients, clinicians, and society. Restrictions proven to be unnecessary can now be modified. The core purposes of MAiD laws and the rights and protections they provide are not changing. Rather, a few aspects of the regulations are being adjusted so they are not more restrictive than necessary to achieve their purpose. 

The ever-growing body of evidence that MAiD laws can adequately protect against abuse and the mythic slippery slope has assured many that their fears will not materialize. [12] For example, NYU bioethicist Arthur Caplan was once a vigorous opponent of MAiD. He worried that MAiD laws would lead to the abuse of the poor, uninsured, and disabled in service of cost-saving or the convenience of others. [13] But, after closely following the empirical evidence from MAiD early-adopters, Oregon and Washington, Caplan changed his mind . In 2018, he argued in favor of the NY MAiD bill before the New York State Assembly Standing Committee on Health. [14] Discussing his review of evidence from these states, Caplan stated:

I found no cause for my concerns, none with respect to the slippery slope. There isn’t solid evidence of coercion or duplicity being exercised with respect to people who choose assistance in dying in either state. The police, government officials, families of those who have chosen to use the legislation and the general citizenry find no causes or basis for changing the laws due to abuse or misapplication . . . These slippery slope arguments are just not true . . . there is no current factual support for this slippery slope argument that vulnerable individuals are at risk for being coerced into using the law. [15]

Decades of evidence has shown that legislation can simultaneously grant terminally ill patients access to MAiD while also protecting against coercion and abuse. In the face of this evidence, continuing to deny access to MAiD because of hypothetical abuse is unjust and unethical.

III.     Views of Opponents are Neither Grounded in Fact nor Consistent with Current End-of-Life Practices

           a.     Risk of coercion

One common argument heard today from some disability advocates who oppose MAiD goes something like this: Everybody who would qualify for and use MAiD is (or will become) a disabled person, so MAiD only kills people with disabilities. The most common reasons people choose to end their lives via MAiD are disability issues, like loss of autonomy, less ability to engage in activities, and loss of dignity. They argue that, instead of making it easier for disabled people to die, we should make sure that proper services and support exist so that disabled people do not choose to die. Such disability-rights-based arguments tend to assert that to avoid abuse, we must prohibit MAiD altogether.

They argue that legalizing MAiD will inexorably lead to abuse and coercion, and disabled people will be pressured into suicide. Some even argue that MAiD laws are the first step to euthanasia, noting the path in other jurisdictions. [16]

As an initial matter, people with disabilities deserve adequate support and services, and these are not always available to them. People with disabilities have faced tremendous discrimination in the healthcare system and have been historically prevented from accessing proper care and asserting their autonomy. Ensuring that all can access adequate end-of-life care, like palliative or hospice care, is an ongoing battle that ought not be abandoned. But fighting for adequate end-of-life care and legalizing MAiD are not mutually exclusive. In Oregon, 90 percent of those who access MAiD are enrolled in hospice and states with MAiD laws tend to have better access to palliative care than states without. [17] MAiD proponents seek only to add another choice for the dying, not to diminish any other options. This is reflected in the text of New York’s pending bill, which explicitly requires patient education and referrals to appropriate end-of-life services, like palliative care and hospice. [18] No one has openly argued that society should hold terminally ill patients hostage in order to obtain broader support and funding for palliative care, but that is the practical effect.

Beyond the need for supportive services and proper access to the full range of end-of-life care options, the disability argument fails. First, the assertion that MAiD laws will be abused and disabled people will be coerced into suicide is not grounded in fact. To the contrary, real-life evidence gathered in over two decades of legal MAiD has shown no documented or substantiated incidents of abuse, as discussed above. [19] The slippery slope has simply not materialized.

Advocates for people with disabilities who are opposed to MAiD have not clearly articulated exactly who is vulnerable to being coerced into obtaining a MAiD prescription or even how such coercion could logistically occur. Most people with disabilities are not vulnerable to MAiD abuse, as they do not have a qualifying terminal illness or lack decisional capacity due to a developmental disability and are therefore not eligible.

MAiD opponents appear to be claiming that all those who qualify for MAiD are vulnerable and seek protection from MAiD laws. But this would include many of the people that, over the past decades, have aggressively and publicly advocated for access to MAiD – terminally ill people, like Brittany Maynard, [20] many of whom lobbied hard for the passage of MAiD laws while knowing that they themselves would die before the laws passed. Opponents of MAiD from a segment of the disability rights community are telling individuals who they claim, without permission, as members of the MAiD opposition community, that they must all endure unimaginable suffering without a MAiD option because they must be protected from theoretical coercive harm . People with disabilities should be allowed to make their own choices. No one, not even the most well-meaning advocate, should be allowed to obstruct a patient’s end-of-life choices – those choices belong to the patient alone.

           b.     Argument That the Demand for MAID is a Result of Poor Disability Services

Second, the argument that terminally ill patients would decline MAiD if only they had better disability services or support is disingenuous to the extent that it ignores the fact that people choosing MAiD are actively dying . No provision of supportive services can change this. And it is perfectly reasonable for someone who knows that they will die in less than six months to want some control over the manner of their death and to avoid the deterioration, indignity, and suffering that could come with it. The argument construes a MAiD death as a choice to die rather than live with a disability. But individuals choosing MAiD are not choosing death – death is coming and coming quickly. MAiD simply offers some control over this reality, giving patients an option that is safe, certain, and painless. Certainly, supportive hospice services should be available for these individuals. But there is no evidence demonstrating that any amount of service would eliminate the need and desire for the MAiD option.

          c.     Inconsistent Positions on MAID and Other Ending Life Care Options: Palliative Sedation and VSED

MAiD opponents who are concerned about abuse and coercion often hold inconsistent views on other currently available ending life care options. [21] For example, some argue that palliative sedation [22] renders MAiD unnecessary and does not present the same ethical problems. [23] However, whereas MAiD can only be chosen by the patient themself (and the patient must have decision-making capacity), the same is not true for palliative sedation. Palliative sedation, a valuable modality of end-of-life care, does not have to be initiated by the patient. If the patient is deemed not to have decision-making capacity to make that decision, their healthcare proxy can decide to initiate the process and continue it until the patient dies. Individuals other than patients often choose to begin palliative sedation and continue it to its inevitable conclusion. And because palliative sedation does not require enabling legislation, none of the protective safeguards incorporated in MAiD legislation are available to protect those who receive palliative sedation.

Some may try to differentiate between palliative sedation and MAiD by saying that once started, palliative sedation can always be discontinued – it need not end in the patient’s death. This is true, but the very process of palliative sedation will inevitably make the patient insensible or unconscious or otherwise unable to exercise a choice to stop sedation. With MAiD, the patient must self-administer and ingest the medication on their own, with death following quickly. The patient can choose to forgo MAID up until the very moment of self-administration. Considering MAiD’s procedural safeguards, including that only the patient may choose and administer MAiD, MAiD patients are offered more protection from potential abuse than patients who receive palliative sedation.

While some have vocally opposed MAiD for decades, there has not been similar opposition to the option of voluntarily stopping eating and drinking (VSED). With VSED, adults with decision-making capacity make a voluntary decision to refuse nutrition and hydration to die more quickly. People choosing VSED are, essentially, making the same choice that people choosing MAiD do. But VSED is a less predictable process that takes much longer to complete. Unfortunately, the process also carries a risk of unpleasant side-effects, though proper care can help mitigate them. Additionally, the practice of VSED is not constrained by statutorily defined protective measures, as is the case with MAiD – one does not even need to have a terminal illness to choose VSED. [24]

It is logically inconsistent for those who oppose MAiD because of the perceived potential of abuse to hold different views about VSED. [25] If malevolent actors can unethically pressure or coerce patients into MAiD, they can also coerce them to stop eating and drinking. As with palliative sedation, it could be argued that an important difference is that VSED can be stopped, unlike MAiD. This argument fails clinically and ethically. As with palliative sedation, the VSED process eventually results in the patient losing consciousness and decision-making capacity. The patient generally becomes unarousable for a period that could last for days or even weeks. For this reason, it is crucial for VSED patients to express their choice in writing (or preferably in video recording) [26] to ensure that they will not be given nutrition or hydration when they are no longer able to enforce their refusal (or if they begin asking for nutrition or hydration). Therefore, there is a period in which the patient cannot decide to end the process, just as with palliative sedation. To the extent that someone is so concerned with potential abuse of MAiD that they seek to ban it but have not expressed similar concerns with VSED, these positions are inconsistent.

At a NYS Bar Association-sponsored conference on MAiD in 2019, David Hoffman asked a MAiD opponent whether, “as someone who is looking out for the interests of a segment of the disability population,” she supports palliative sedation and VSED.” [27] Kathryn Carroll, who represented the Center for Disability Rights (“CDR”), confirmed that CDR did not oppose palliative sedation and did not offer a position on VSED. She noted the subtle difference in intention:

I don’t believe the Center for Disability Rights has taken issue with palliative sedation. And my understanding is that there is a key difference between palliative sedation and assisted suicide, particularly in that palliative sedation, the point is not to bring about the death of the person, but to relieve the pain that they are experiencing. And so the death is more of a side effect rather than the intended outcome. [28]

During the questioning, she provided no explanation as to why the potential for abuse would be different among palliative sedation, VSED, and MAiD. [29]

The other MAiD opponent on the panel, Dennis Vacco, of Vacco v. Quill [30] fame, interjected but could not explain any ethically significant difference between VSED and MAiD. Instead, he focused solely on palliative sedation, stating that the relevant difference is that palliative sedation can be stopped:

. . . treating the pain including what you referred to as terminal sedation, is not moral and legally and ethnically the same as physician-assisted suicide . . . The fact of the matter is – the difference is you can terminate that treatment, and it’s the permanent aspect of physician-assisted suicide that goes back to what I said 20 minutes ago. You can’t put the bright line anyplace else other than where it is. [31]

But, as discussed above, that difference is of little import, given that palliative sedation results in patients without the ability or capacity to make the choice to stop treatment. Vacco then reverted to his concerns about the potential for coercion and the elusive slippery slope, referencing his primary argument that the only way to ensure there is no abuse of a MAiD law is not to have one at all:

The bright line that is created by the law in the state of New York, which makes physician-assisted suicide a manslaughter in the second-degree, or assisting suicide by anybody, manslaughter in the second degree . . . is unfortunately the only place that line can be. That line should not move further toward accommodation. And we see here in the context of . . . all of the so-called protections in the statute. With every protection that is not prohibition, with every protection, you raise the possibility of abuse. You raise the possibility with every protection. [32]

Neither Vacco nor Carroll addressed the fact that many common practices today can be the result of coerced decisions. These practices have none of the safeguards contained in MAiD legislation. As another panelist, David Leven, stated:

consider that people who want to have life-sustaining treatment withdrawn, whether it’s a ventilator or feeding tube, they can also be coerced by family members. That can happen even more often, of course, because that process takes place more and more often, and there are none of the safeguards that we’re talking about here . . . there are risks involved in any process which might result in a hastened death. But there seems to be very little risk involved with medical aid in dying based on the experience in 40 years and the nine states which now permit medical aid in dying. [33]

There is an inescapable inconsistency within the disability argument: one cannot logically be so concerned about the abuse of legalized access to MAiD to justify opposing all MAiD legislation while simultaneously supporting options like palliative sedation or VSED as abuse-free alternatives.

           d.     Argument Against Speaking for a Community with Diverse Views

Finally, while some disability advocates opposing MAiD will claim terminally ill patients as part of their community, they have no right or authorization to speak for the extremely heterogeneous group of terminally ill patients or the disability community [34] as a whole. The disability community is not homogenous; while some members oppose MAiD, others support it. [35] Recent polling indicates that MAiD may have broad support across the disability community. [36]

          e.     MAiD Opponents Hold the Rights of the Terminally Ill Subordinate to Their Personal Morality and Unsubstantiated Theoretical Concerns

The argument that does not get much attention, the one that is the simplest and perhaps even the most compelling, is that all killing is wrong, and the government ought not to be in the business of enabling it. That is certainly a compelling religious and moral argument against individuals engaging in any form of acts that result in ending a human life. But such an ethical or theological position does not dictate that individuals who hold different views on personal morality should be precluded by the state from accessing the most safe, certain, and painless means of addressing an invariably terminal illness.

Arguments like the one described above by Vacco (that the only way to completely avoid potential MAiD abuse is to prohibit MAiD) are essentially claiming that the safest thing to do is to subordinate the suffering of the terminally ill to avoid the more subtle task of balancing the interests of two different groups of New York state citizens. But surely, that is the role of the legislature every day. And we should expect no less from the legislature on this issue. The best way to ensure no one dies in car accidents is to prohibit driving. But instead of doing so, we implement safety regulations (like speed limits) to balance the right to travel with the right of everyone else not to be killed in the process. Evidence demonstrates that MAiD legislation can also strike a balance between the rights of the terminally ill and the need to prevent harm. It is not justifiable to support a blanket prohibition of MAiD.

Opponents of MAiD have had decades to cite problematic case studies or formulate a compelling moral argument against it that is grounded in data rather than an assertion of their personal morality. Plainly, no one on either side of the MAiD legislative discussion wants to see anyone subjected to involuntary euthanasia or coerced into MAiD as a better alternative to palliative care when such a plan of care is a viable alternative to “ending life care.” However, enough time has passed, and the risk of coercion has been given sufficient study and debate that we can now conclude, as a society, that the rights of the terminally ill and the rights of persons committed to living their best and longest life with a disability are wholly compatible. It is time for the legislature to strike the appropriate balance and give the terminally ill a well-regulated, responsible pathway to obtaining medication that can relieve their suffering in a manner that is safe, certain, and painless.

[1] Oregon’s Death with Dignity Act, Oregon Health Authority, https://www.oregon.gov/oha/ph/providerpartnerresources/evaluationresearch/deathwithdignityact/pages/index.aspx

[2] Elissa Kozlov et al., Aggregating 23 Years of Data on Medical Aid in Dying in the United States , 70 Journal of the American Geriatrics Society 3040 (2022). https://doi.org/10.1111/jgs.17925

[3] Medical Aid in Dying Act, A.995-A, N.Y. St. Assemb. (2023), available at https://legislation.nysenate.gov/pdf/bills/2023/A995A ; see also , Medical Aid in Dying Act, S.2445-A, N.Y. St. Senate (2023), available at https://legislation.nysenate.gov/pdf/bills/2023/S2445A .

[5] Ronald A. Lindsay, Oregon’s Experience: Evaluating the Record , 9 The American Journal of Bioethics 19 (2009), https://doi.org/10.1080/15265160802654137; Christopher A. Riddle, Medical Aid in Dying: The Case of Disability , in New Directions in the Ethics of Assisted Suicide and Euthanasia 234 (Michael Cholbi & Jukka Varelius eds., 2nd ed. 2023), https://doi.org/10.1007/978-3-031-25315-7; Health Law Section: Duties, Rights & the Law at the End of Life (2019) , NY ST. BAR ASSOC. (Nov. 8, 2019), https://nysba.org/products/health-law-section-duties-rights-the-law-at-the-end-of-life-2019/ ; Medical Aid in Dying: Hearing on A.2383-A Before the New York State Assembly Standing Committee on Health (2018) (testimony of Arthur Caplan), transcript available at https://nystateassembly.granicus.com/DocumentViewer.php?file=nystateassembly_bc5bd4afc9fd8b9021781bc9e35e15ae.pdf&view=1 ; Fact: Medical Aid in Dying Laws Work to Protect Patients . (n.d.). Compassion & Choices. Retrieved September 5, 2023, from https://compassionandchoices.org/resource/fact-medical-aid-in-dying-laws-work-to-protect-patients ; Frequently Asked Questions . (2021, December 7). Death With Dignity. https://deathwithdignity.org/resources/faqs/ .

[6] Bob Joondeph, Letter from Disability Rights Oregon (DRO) , Compassion & Choices (Feb. 14, 2019), https://www.compassionandchoices.org/docs/default-source/default-document-library/disability-rights-oregon-dwd-letter-2-14-19.pdf.

[7] Elissa Kozlov et al., Aggregating 23 Years of Data on Medical Aid in Dying in the United States , 70 Journal of the American Geriatrics Society 3040 (2022). https://doi.org/10.1111/jgs.17925

[9] Medical Aid in Dying: Act 39: Patient Choice and Control at the End of Life, Vermont Ethics Network, https://vtethicsnetwork.org/palliative-and-end-of-life-care/medical-aid-in-dying-act-39 (last visited Sept. 21, 2023).

[10] Gideonse v. Brown , No. 3:21-cv-01568-AC (D. Or.); Bluestein v. Scott , No. 2:22-cv-00160 (D. Vt.).

[11] Govatos v. Murphy , No. 2:23-cv-12601(D.N.J.).

[12] Medical associations, historically opponents of MAiD, have begun adopting neutral positions, reflecting changing attitudes of the medical community. E.g., California Medical Association removes opposition to physician aid in dying bill , California Medical Association (May 20, 2015), https://www.cmadocs.org/newsroom/news/view/ArticleId/27210/California-Medical-Association-removes-opposition-to-physician-aid-in-dying-bill ; Board directs CMS to develop and distribute “End-of-Life Act” education to members , Colorado Medical Society (November 22, 2016), https://www.cms.org/articles/board-directs-cms-to-develop-and-distribute-end-of-life-act-education-to-me ; Vermont Medical Society Policy on End-of-life-Care , Vermont Medical Society (2017), https://vtmd.org/client_media/files/vms_resolutions/2017End-of-Life-Care.pdf (last accessed Sept. 21, 2023); but see Physician-Assisted Suicide , AMA Code of Ethics, https://code-medical-ethics.ama-assn.org/ethics-opinions/physician-assisted-suicide . (5.7 provides opinion opposing MAiD; opinion 1.1.7 provides opinion on conscientious objection.); The American Medical Association could vote to change its stance on medical aid in dying , Death with Dignity (Nov. 10, 2023), https://deathwithdignity.org/news/2023/11/ama-could-vote-to-change-stance-on-maid/ (Update notes that the AMA did not change its stance from opposed to neutral at its November 2023 interim meeting in Baltimore, but referred the resolutions for further study).

[13] Medical Aid in Dying: Hearing on A.2383-A Before the New York State Assembly Standing Committee on Health (2018) (testimony of Arthur Caplan), transcript available at https://nystateassembly.granicus.com/DocumentViewer.php?file=nystateassembly_bc5bd4afc9fd8b9021781bc9e35e15ae.pdf&view=1 .

[16] Id . (noting the laws in Netherlands, Belgium and Canada.); see also National Council on Disability, The danger of assisted suicide laws: Part of the Bioethics and Disability series (2019). https://ncd.gov/sites/default/files/NCD_Assisted_Suicide_Report_508.pdf.

[17] Sean Riley & Ben Sarbey, The unexamined benefits of the expansive legalization of medical assistance-in-dying , 19 J. Bioethical Inquiry 4, 663 (2022) (citing Oregon Health Authority Center for Health Statistics, Oregon Death with Dignity Act: 2018 Data Summary (2019), https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year21.pdf   and R. Sean Morrison, et al., America’s care of serious illness: A state-by-state report card on access to palliative care in our nation’s hospitals , 14 J. Palliat. Med. 10, 1094–1096 (2011)).

[18] Medical Aid in Dying Act, A.995-A, N.Y. St. Assembly. (2023), available at https://legislation.nysenate.gov/pdf/bills/2023/A995A

[19] See also , Ben Colburn, Disability‐based Arguments against Assisted Dying Laws , 36 Bioethics 680 (2022) (cataloging research in multiple countries and concluding that “there is no evidence that assisted dying laws have a disproportionate effect on people with disabilities”). https://doi.org/10.1111/bioe.13036

[20] Eyder Peralta, As Planned, Right-To-Die Advocate Brittany Maynard Ends Her Life, NPR (Apr. 3, 2014), https://www.npr.org/sections/thetwo-way/2014/11/03/361094919/as-planned-right-to-die-advocate-brittany-maynard-ends-her-life (Activist Brittany Maynard moved to Oregon after she was diagnosed with a malignant brain tumor, because her home state did not permit MAiD at the time).

[21] Ending life care is defined as the final stage of the end-of-life care continuum, where the patient chooses to end their life as a means to end their suffering or unacceptable quality of life.

[22] Palliative sedation is defined as “the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life,” and it carries a risk of hastening death. Molly L. Olsen, Keith M. Swetz & Paul S. Mueller, Ethical Decision Making With End-of-Life Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatments , 85 Mayo Clin Proc 949 (2010). https://doi.org/10.4065/mcp.2010.0201

[23] E.g. Disability Rights Toolkit for Advocacy Against Legalization of Assisted Suicide , Not Dead Yet, https://notdeadyet.org/disability-rights-toolkit-for-advocacy-against-legalization-of-assisted-suicide (last visited Dec. 8, 2023) (describing palliative sedation as “a legal solution to any remaining painful and uncomfortable deaths; one that does not raise the very serious hazards of legalizing assisted suicide”); Testimony of CDR’s Kathryn Carroll, Esq. Opposing NY Assisted Suicide Bill A2383A , Not Dead Yet (Apr. 23, 2018), https://notdeadyet.org/testimony-of-cdrs-kathryn-carroll-esq-opposing-ny-assisted-suicide-bill-a2383a.

[24] Voluntarily Stopping Eating and Drinking: A Compassionate, Widely-Available Option for Hastening Death, (Timothy E. Quill et al. eds., 2021). https://doi.org/10.1093/med/9780190080730.001.0001

[25] This is not to say that MAiD and VSED are ethically identical. Different writers have articulated various reasons why MAiD and VSED are meaningfully different and meaningfully similar. Here we distinguish the potential for abuse, as this is the argument that persists among MAiD opponents, For a broader discussion on the ethics of VSED and how it compares to MAiD, see Voluntarily Stopping Eating and Drinking: A Compassionate, Widely-Available Option for Hastening Death, (Timothy E. Quill et al. eds., 2021). https://doi.org/10.1093/med/9780190080730.001.0001

[26] Id.; see also David N. Hoffman and Judy Schwarz, Can Patients Choose to Stop Eating–Even If They

Have Dementia–and Can Health Care Facilities Get Paid for Taking Care of Them? Ethics and Reimbursement at the End of Life (Am. Health L. Ass’n Conf. on Long Term Care and the Law 2020).

[27] Health Law Section: Duties, Rights & the Law at the End of Life (2019) , NY St. Bar Assoc. (Nov. 8, 2019), https://nysba.org/products/health-law-section-duties-rights-the-law-at-the-end-of-life-2019/.

[29] CDR still does not appear to have articulated a position on VSED. CDR is a major and vocal opponent of MAiD legislation in NY with considerable resources (they state their projected 2010 budget was approximately $29,000,000). About Us , Center for Disability Rights, https://cdrnys.org/about/ .

[30] Vacco v. Quill , 521 U.S. 793 (1997) (holding that there is no equal protection violation when N.Y. law criminalized assisted-suicide but permitted removal of life-support systems).

[31] Health Law Section: Duties, Rights & the Law at the End of Life (2019) , supra note 5.

[34] Ben Colburn, Disability‐based Arguments against Assisted Dying Laws , 36 Bioethics 680 (2022) (providing evidence that “that people with disabilities, and disability rights organizations, have diverse views on the question of whether assisted dying should be legal”). https://doi.org/10.1111/bioe.13036

[35] Us for Autonomy, https://www.usforautonomy.org (last visited Sep 10, 2023); see also , Kathryn L. Tucker, Building Bridges Between the Civil Rights Movements of People with Disabilities and Those with Terminal Illness , 78 U. of Pitt. L. Rev. 329 (2017) (collecting and describing amici participation by disability advocates supporting end-of-life liberty). https://doi.org/10.5195/lawreview.2017.473

[36] E.g. , USA/National Public Opinion Survey , Susquehanna Polling & Research, Inc. (Feb. 2023), https://d31hzlhk6di2h5.cloudfront.net/20230307/2e/9e/21/14/d37db7887f3f349202ae6f31/Raben_Crosstabulation_Report_2023.FINAL%20(1).pdf ).

David N. Hoffman

JD University of Buffalo School of Law, Professor Columbia University

JD Cornell University, MS Columbia University

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• http://orcid.org/0000-0001-9800-1308 John Richard Attia 1 , 2 ,
• Christine Jorm 3 and
• Brian Kelly 1
• 1 Division of Medicine , Hunter New England Local Health District , New Lambton , New South Wales , Australia
• 2 Faculty of Health and Medicine , The University of Newcastle , Callaghan , New South Wales , Australia
• 3 NSW Regional Health Partners , Hunter New England Local Health Network - HNELHN , New Lambton , New South Wales , Australia
• Correspondence to Professor John Richard Attia, SMPH, The University of Newcastle, New Lambton Heights, NSW 2305, Australia; john.attia{at}newcastle.edu.au

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• end of life care
• psychological care
• spiritual care
• terminal care

Euthanasia is the deliberate administration of medications with the explicit intention of ending life, whereas physician assisted dying is the prescription or supply of drugs to enable the patient to end their own life. 1 We use the term ‘medical assistance in dying’ (MAID) to refer to both. The rationale for MAID is usually based on two principles:

Compassion, that is, to relieve unbearable suffering.

Autonomy, that is, the right to self-determination.

Such individual rights however exist within a broader community, familial and societal context. Philosopher Daniel Callaghan stated: “Euthanasia is not a private matter of self-determination. It is an act that requires two people to make it possible and a complicit society to make it acceptable”. 2 We present our perspective on the (often unacknowledged) implications of MAID for the family, physician and the healthcare system. A MEDLINE review was done with snowballing that is, following up reference lists from papers identified.

Why patients might request MAID

Several factors drive patient requests for MAID, including the fear of becoming a burden to others, depression and feelings of hopelessness, loss of identity or dignity, feeling isolated, being tired of existence, and fear of uncertainty; it is of interest that the fear of pain more than pain itself was also a driver. 3–5 These studies explored the concerns of those with a terminal illness who usually did not have access to MAID and were considering a hypothetical situation. Initial experience from the Dying with Dignity programme in the USA 6 and the Medical Assistance in Dying programme in Canada 7 find that those dying through MAID are predominantly motivated by fear of the loss of control and autonomy. Interestingly, most were educated, higher socioeconomic level Caucasians (>90%). 7 It has been suggested that ‘Being in control has become the ultimate moral virtue of Western citizens. We desire full control not only of our life but of our death as well’. 8

Effects of MAID on the family

Systematic studies on the possible effects on family members are few. One major study of over 500 Dutch patients with cancer found that that family and friends of those who died by euthanasia had less traumatic grief symptoms, post-traumatic stress reactions and current grief than those who died of natural causes. 12 However, this study was carried out 2–8 years after the death and the two family/friend groups were significantly different; those in the euthanasia group were less religious, more educated and more distant from the deceased. A thematic synthesis of studies 13 found numerous negative consequences of MAID. Families were often involved in the MAID decision making, with the potential for creation or aggravation of family conflict when opinions differ. Even when they support the decedent’s wish for MAID, family members can feel conflicted, torn between hastening death and wishing for more time. This leads to regret, ethical questions, and fear of being judged or disapproved of. Consequently family members are unwilling to share their experiences, with further isolation and in some studies, higher rates of post-traumatic stress than those involved in natural deaths. Some family members admitted secretly hoping that MAID would be delayed and expressed gratitude when it was refused or a natural death supervened. 13

The potential for family division, misunderstandings and conflict is heightened by the recent Voluntary Assisted Dying legislation in the State of Victoria. Unlike the Dutch legislation, the Victorian legislation does not require the individual’s family to be notified of a MAID request. This elevates the autonomy of the individual above any other consideration and ignores their identity within the community of friends and family; there is the potential to make their grief even more complex. 4

Effects of MAID on physicians

Studies of physicians who participate in MAID consistently show detrimental effects. There is a conflict between respect for patient autonomy and wishes, and the call to preserve and value life. 14 A systematic review demonstrated that among physicians who participated in MAID, 30%–50% were left conflicted, uneasy, and uncomfortable with their role; 15%–20% reported significant ongoing adverse personal impact. 15 One felt it had left ‘an indelible mark’ on his soul and that something was ‘broken’ in his spirit. Another study 1 showed that although 52% of physicians had feelings of comfort with euthanasia, 75% also had feelings of discomfort, testifying to mixed emotions and inner conflict. It is noteworthy that this was in a group of practitioners who had voluntarily elected to participate in MAID. Experience in Quebec found that although ~66% of physicians had initially indicated willingness to participate,~60% were refusing to participate when resurveyed 18 months after legalisation, largely due to the emotional and clinical burden. 16 Another study discovered adverse effects even in other non-physicians indirectly involved through housekeeping, transportation, and medical records departments. 7

Effects of MAID on the healthcare system

MAID does not fit with the WHO definition of palliative care and is misaligned with the ethos of medical care and its Judeo-Christian roots. Indeed, it is significant that all major governance bodies have position statements explicitly stating MAID should not be part of palliative care practice; this includes the European Association for Palliative Care, 17 the International Association for Hospice and Palliative Care, 18 the Royal Australasian College of Physicians, 19 and the Australian and New Zealand Society of Palliative Medicine. 20

Canadian physicians warn of the risks of increasing government intervention in the nature of palliative care. When hospices in Quebec and British Columbia opted out of MAID, funding was threatened. 21 Such interventions would fundamentally change the practice of palliative care. The potential exists to open it up to financial pressures from an already overburdened healthcare system, for example to ‘expedite’ discharges. This reinforces the risk identified by one systematic review that MAID might become a less costly and less time-consuming substitute for optimal palliative care. 22 Such uncertainties in the nature of what is palliative care may also influence career choices; for example, the number of registrars entering palliative care in Quebec dropped after MAID legalisation. 21

Legislative requirements have proved ineffective in ensuring governance of MAID in the medical system. For example, despite the requirement for written consent in the Netherlands over 20% of MAID deaths had none. Similarity, despite reporting requirements, nearly half of all MAID deaths in Belgium were improperly recorded. 23

The request for MAID may represent a complex dynamic within the patient, their family and his/her social structures. It also has complex ramifications for the physician and the wider medical community. Our aim should be to elicit the underlying causes driving any request and undertake the necessary steps to address them. This requires clinicians to discuss patient concerns, particularly the dimensions of psychological distress at the end of life including existential dilemmas and anxieties. 19

A prime driver for MAID requests is the effort to exert control. The reality is we are not in control of all our circumstances during life; why pretend this is so in death? In the same way physical pain is a signal to the body to pay attention to something, the psychic pain of existential distress is a prompt to the individual to face transcendent eternal questions: What did it all mean? What I am leaving behind? Is there anything more? We do a greater service to our patients by helping them tackle these important questions rather than ignore them.

Considering the real (and potential) adverse effects of MAID on families, physicians and the palliative and healthcare systems, our vocation rather should stimulate us to have the time and courage to open these potentially difficult and challenging conversations.

• Haverkate I ,
• van der Heide A ,
• Onwuteaka-Philipsen BD , et al
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• Balaguer A ,
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• Rehmann-Sutter C
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• Gamondi C ,
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• Kissane D , et al
• Bouthillier M-E ,
• Radbruch L ,
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• De Lima L ,
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• The Royal Australasian College of Physicians
• The Australian & New Zealand Society of Palliative Medicine Inc
• Ferrier C , et al

Contributors JRA drafted the manuscript; CJ and BK critically reviewed it. All authors take responsibility for the content.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Commissioned; internally peer reviewed.

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Medical assistance in dying: Overview

What medical assistance in dying is, who is eligible, how to make a request, the process, and who can provide medical assistance in dying.

• Legislation in Canada
• Monitoring and reporting
• Independent reviews
• For health professionals and regulators
• Support and resources

Eligibility for MAID for persons suffering solely from a mental illness has been delayed until March 17, 2027.

In collaboration with Indigenous Peoples, Health Canada has begun a multi-pillar engagement process on MAID, supporting both Indigenous-led engagement and federally-led activities, including an online engagement tool that is open until June 30, 2024. Learn more:

• Join the discussion!

On this page

Eligibility, making a request, medical practitioners.

Medical assistance in dying (MAID) is a process that allows someone who is found eligible to be able to receive assistance from a medical practitioner in ending their life. The federal Criminal Code of Canada permits this to take place only under very specific circumstances and rules. Anyone requesting this service must meet specific eligibility criteria to receive medical assistance in dying. Any medical practitioner who administers an assisted death to someone must satisfy certain safeguards first.

Only medical practitioners are permitted to conduct assessments and to provide medical assistance in dying. This can be a physician or a nurse practitioner, where provinces and territories allow.

Learn more:

There are 2 methods of medical assistance in dying available in Canada.

Method 1: a physician or nurse practitioner directly administers a substance that causes death, such as an injection of a drug. This is sometimes called clinician-administered medical assistance in dying.

Method 2: a physician or nurse practitioner provides or prescribes a drug that the eligible person takes themselves, in order to bring about their own death. This is sometimes called self-administered medical assistance in dying.

Clinical guidelines and practices outline which drugs to use, and are established by:

• provinces and territories
• organizations that regulate the practice of medicine

Many of the drugs commonly used for this procedure are already available in Canada. Health care providers usually prescribe them at lower dosages for common purposes, such as:

• pain control
• anaesthesia

As the regulator of drug products, Health Canada is working with partners to help support access to drugs for medical assistance in dying.

To be eligible for medical assistance in dying, you must meet all the following criteria. You must :

• You may also be eligible if you meet your province or territory's minimum period of residence or waiting period.
• This means being capable of making health care decisions for yourself.
• have a grievous and irremediable medical condition
• The request cannot be the result of outside pressure or influence.
• give informed consent to receive medical assistance in dying

Generally, visitors to Canada are not eligible for medical assistance in dying.

Grievous and irremediable medical condition

To be considered as having a grievous and irremediable medical condition, you must meet  all  of the following criteria. You must:

• have a serious illness, disease or disability
• be in an advanced state of decline that  cannot  be reversed
• experience unbearable physical or mental suffering from your illness, disease, disability or state of decline that  cannot  be relieved under conditions that you consider acceptable

You do  not  need to have a fatal or terminal condition to be eligible for medical assistance in dying.

If your only medical condition is a mental illness, you are not eligible for medical assistance in dying until March 17, 2027.

If you have a mental illness along with other medical conditions, you may be eligible for medical assistance in dying.

Eligibility is always assessed on an individual basis and takes all relevant circumstances into account. However, you must meet all the criteria to be eligible.

Updates to legislation

Informed consent

Informed consent is when you give permission to receive medical assistance in dying  after  you receive all of the information you need to make your decision. This includes:

• your medical diagnosis
• available forms of treatment
• available options to relieve suffering, including palliative care

You must be able to give informed consent both:

• at the time of your request
• immediately before receiving medical assistance in dying, unless special circumstances apply

You can withdraw your consent at any time and in any way.

Regardless of location, you can request medical assistance in dying if you're eligible.

If you're experiencing a lot of pain and suffering due to your medical situation, talk to your physician or nurse practitioner. You can discuss options related to your circumstances and your possible interest in medical assistance in dying.

How and where this service will be offered is determined by:

• medical institutions
• the organizations that regulate health professionals

You may have to meet other requirements. Your health care provider can tell you more.

If you don't have a regular practitioner, your province or territory may have a central coordination service that can help you.

The role of provinces and territories

Policies and procedures may vary depending on where you live. Provinces and territories can create health-related laws or rules that may affect medical assistance in dying services. However, they cannot permit actions that are prohibited under the Criminal Code.

Rules that can affect medical assistance in dying can include:

• data and information collection
• the use of specific forms to fill out
• special medical training for providers of the service
• rules or requirements for either type of medical assistance in dying

If you have questions about the law and policies in your specific location, contact your province or territory.

Procedural safeguards

Before a medical practitioner administers medical assistance in dying, they must satisfy certain safeguards. These include making sure that you :

• have 2 independent medical assessments
• make a written request signed by an independent witness
• know that you can withdraw your request at any time
• provide final consent before receiving medical assistance in dying
• give advance consent, if applicable

They must also meet extra safeguards in the event that your death is not naturally foreseeable.

Medical assessments

When you make your request for medical assistance in dying, 2 independent medical practitioners (physicians or nurse practitioners) must assess it.

Your medical practitioner must make sure that you meet all of the listed eligibility criteria. The second practitioner must also provide a written opinion confirming that you're eligible.

The medical practitioner providing the original assessment and the one giving the second opinion  must  be independent. This means they cannot:

• knowingly benefit from your death
• hold a position of authority over the other
• be connected to the other or to you in a way that could affect their objectivity

Making a written request

You must sign a written request that says you want to have a medically assisted death. The request must include your:

• be at least 18 years of age
• understand what it means to request medical assistance in dying
• not benefit from your death (for example, they must not be an heir to your estate)
• written request must be signed and dated before  1 independent witness , who must also sign and date the request

Some provinces and territories may have a specific request form for you to complete. You can get this form from your health care provider or your provincial or territorial government website.

Independent witness

The role of the independent witness is to confirm:

• the signing and dating of the request by the person requesting medical assistance in dying
• that the person requesting medical assistance in dying understands what they're signing

An independent witness:

• must be at least 18 years of age
• can be a paid professional personal or health care worker
• must understand what it means to request medical assistance in dying

To be considered independent means that the witness  cannot :

• benefit from your death
• be an unpaid caregiver
• be an owner or operator of a health care facility where you live or are receiving care

Withdrawing your request

You must be informed of your right to withdraw your request for medical assistance in dying at  any  time and in any manner.

You do not have to proceed even if you're found eligible for the service.

Final consent

Immediately before receiving medical assistance in dying, you must:

• be given the opportunity to withdraw consent
• affirm your consent if you do not wish to withdraw it

An exception to this requirement is possible if you have a waiver of final consent. You can waive the requirement to provide consent just before you receive medical assistance in dying,  only if :

• your natural death is reasonably foreseeable and
• you were assessed and approved to receive medical assistance in dying
• your practitioner advised that you are at risk of losing capacity to provide final consent
• you made a written arrangement with your practitioner to provide consent in advance on your chosen date, if you no longer have capacity to consent on that date

Any arrangement for the waiver of final consent will be considered  invalid  if, at the time that you are to receive medical assistance in dying, you:

• no longer have capacity  and
• demonstrate refusal or resistance to the administration of MAID by words, sounds or gestures

Reflexes and other types of involuntary movements do not constitute refusal or resistance. Examples of involuntary movements include responses to touch or the insertion of a needle.

Advance consent in cases of self-administered medical assistance in dying

You can make a written arrangement with your practitioner so that they can administer medical assistance in dying in the event of failed self-administration.

This arrangement allows for clinician-administered medical assistance in dying if there are complications during self-administration that cause your loss of decision-making capacity but not your death. This means that your medical practitioner must be present at the time that you self-administer the medications.

Requests where your natural death is not reasonably foreseeable

If the medical practitioners assessing your request for MAID determine that your death is not reasonably foreseeable, there are extra safeguards that  must  be met before medical assistance in dying can be provided:

• If neither of them have this expertise, they must consult another practitioner with expertise in the medical condition during the assessment process.
• palliative care
• community services
• counselling services
• mental health and disability support services
• You and your practitioners must have discussed reasonable and available means to relieve your suffering, and  all  agree that you have seriously considered those means.
• Your eligibility assessment must take a minimum of 90 days, unless the assessments have been completed sooner and you are at immediate risk of losing your capacity to consent.
• give you an opportunity to withdraw your request
• ensure that you give express consent to receive medical assistance in dying

Those who can conduct assessments and provide medical assistance in dying are:

• nurse practitioners (in provinces where this is allowed)

Those who can help provide medical assistance in dying include:

• pharmacists, pharmacy technicians and assistants
• family members or other people that you ask to help
• health care providers who help physicians or nurse practitioners

These people can assist in the process without being charged under criminal law. However, physicians, nurse practitioners and other people who are directly involved must follow:

• the rules set out in the  Criminal Code
• applicable provincial and territorial health-related laws, rules and policies
• Criminal Code  provisions on Medical Assistance in Dying legislation (effective March 17, 2021)

Provider's rights

Not all health care providers are comfortable with medical assistance in dying. Federal legislation does not force  anyone  to provide or help to provide medical assistance in dying.

Provincial and territorial governments are responsible for determining how and where to provide health care services. They may also make policies around where medical assistance in dying can take place. However, they cannot permit actions that are prohibited under the  Criminal Code .

Supporting access

We understand that these provider rights could create challenges if you want to access medical assistance in dying. Contact your health care provider for questions about access. You can also contact your province or territory for information on the procedure and other care options.

If you're a health care provider, contact your provincial or territorial professional regulatory body for information about:

• your reporting obligations
• specific practice guidelines

Related links

• Canada's Medical Assistance in Dying Law

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• Volume 45, Issue 1
• Medical Assistance in Dying at a paediatric hospital
• Article Text
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• Carey DeMichelis 1 ,
• Randi Zlotnik Shaul 2 , 3 ,
• Adam Rapoport 4 , 5 , 6
• 1 Applied Psychology and Human Development, Joint Centre for Bioethics , University of Toronto , Toronto , Ontario , Canada
• 2 Bioethics Department , The Hospital for Sick Children , Toronto , Ontario , Canada
• 3 Department of Paediatrics , University of Toronto , Toronto , Ontario , Canada
• 4 Paediatric Advanced Care Team , The Hospital for Sick Children , Toronto , Ontario , Canada
• 5 Emily’s House Children’s Hospice , Toronto , Ontario , Canada
• 6 Departments of Paediatrics and Family & Community Medicine , University of Toronto , Toronto , Ontario , Canada
• Correspondence to Carey DeMichelis, Applied Psychology and Human Development, Joint Centre for Bieothics, University of Toronto, Toronto, ON M5S 1V6, Canada; carey.demichelis{at}mail.utoronto.ca

This article explores the ethical challenges of providing Medical Assistance in Dying (MAID) in a paediatric setting. More specifically, we focus on the theoretical questions that came to light when we were asked to develop a policy for responding to MAID requests at our tertiary paediatric institution. We illuminate a central point of conceptual confusion about the nature of MAID that emerges at the level of practice, and explore the various entailments for clinicians and patients that would flow from different understandings. Finally, we consider the ethical challenges of building policy on what is still an extremely controversial social practice. While MAID is currently available to capable patients in Canada who are 18 years or older—a small but important subsection of the population our hospital serves—we write our policy with an eye to the near future when capable young people may gain access to MAID. We propose that an opportunity exists for MAID-providing institutions to reduce social stigma surrounding this practice, but not without potentially serious consequences for practitioners and institutions themselves. Thus, this paper is intended as a road map through the still-emerging legal and ethical landscape of paediatric MAID. We offer a view of the roads taken and considered along the way, and our justifications for travelling the paths we chose. By providing a record of our in-progress thinking, we hope to stimulate wider discussion about the issues and questions encountered in this work.

• suicide/assisted suicide
• care of dying minors
• paediatrics

https://doi.org/10.1136/medethics-2018-104896

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Three years after the Supreme Court of Canada decriminalised Medical Assistance in Dying (MAID), the decision remains highly controversial. As healthcare providers across the country have begun providing MAID, the dense tangle of questions surrounding who should be assisted in ending their life and under what circumstances has become, if anything, more complex. This article explores the journey of one paediatric tertiary/quaternary care academic hospital, The Hospital for Sick Children in Toronto, Ontario, as it built a policy for providing MAID in a paediatric setting. In this article, we—several members of the small group charged with developing this policy—illuminate the conceptual, procedural and institutional questions that emerged during this ongoing process. i We focus in particular on the ethical challenges of managing MAID requests in a paediatric setting, as well as our experience of planning for future action from within contemporary conditions of social controversy and legal uncertainty.

This article proceeds in three steps. We begin with a brief summary of the legal infrastructure that currently regulates the provision of MAID in Ontario. We focus on how this legislation extends to young people, and the likelihood that the legal picture may change for capable minors ii in the near future. Next, we turn to the ongoing process of policy creation, focusing in particular on the theoretical and pragmatic difficulties that come to light when MAID is considered in a paediatric setting. We illuminate a central point of conceptual confusion about the nature of MAID (ie, what MAID is and what MAID is for) that emerges at the level of practice, and explore the various entailments for clinicians and patients that would flow from different understandings. Finally, we consider the institutional challenges of building policy concerning what is still an extremely controversial social practice. We argue that a rare opportunity may exist for MAID-providing institutions to reduce social stigma associated with MAID, but not without potentially serious consequences for healthcare providers and MAID-providing institutions themselves.

Thus, this article is intended as a road map through the still-emerging legal and ethical landscape of paediatric MAID. We offer a view of the roads taken and considered along the way, and our justifications for travelling the paths we chose. By providing a record of our in-progress thinking, we hope to stimulate wider discussion about the rich issues and questions encountered in this work.

MAID and minors in Canada

In February 2015, the Supreme Court of Canada issued a unanimous decision decriminalising MAID across the country. In the case of Carter v Canada , the court determined that capable adults who clearly consent to the termination of life and are suffering intolerably from a ‘grievous and irremediable’ medical condition (including an illness, disease or disability) should be able to gain medical assistance in ending their life. While the Carter decision specified that MAID should be available only to ‘capable adults’, the term ‘adult’ was not defined in the ruling, and a vigorous debate quickly emerged regarding whether the term should be interpreted in a way that would allow capable young people to access MAID. iii In response to these concerns, parliament directed the issue of extending MAID access to capable minors to an independent research group—the Canadian Council of Academies (CCA)—for a 2-year period of research and exploration. iv Results from the CCA working group are due back to Parliament by the end of 2018, at which time the age restriction for capable young people will be reconsidered. For the time being, MAID access is limited to patients who are 18 years and older. It is within this emergent, controversial and rapidly evolving landscape that our group was charged with developing a policy for managing MAID requests at our paediatric research institution.

Policy development

Given current federal legislation on MAID, at this moment our drafted hospital policy applies exclusively to patients who are 18 years or older—a small but important subsection of the patient population at The Hospital for Sick Children. As a paediatric hospital, it would of course be possible to refer patients aged 18 years who request MAID into an adult care setting. However, our working group felt that it would be antithetical to our philosophy of care to transfer patients—most of whom have long-standing relationships with our hospital—into a new and unfamiliar care setting for a procedure that could be safely and effectively performed at this institution. For this reason, and with an eye to a future when MAID may well become accessible to capable minors, the hospital undertook the process of developing a policy for managing MAID in our paediatric setting.

The policy is being developed by a working group, co-chaired by the director of the Department of Bioethics and the medical director of Palliative Care and is composed of experts from nursing, pharmacy, psychiatry, quality and risk management, oncology, intensive care, paediatric rehabilitation and public affairs. Feedback is being solicited from external and internal stakeholders as well as from the Family-Centred Care Advisory Committee—a group of family members of current and former patients who volunteer to advise the hospital on matters related to patient care. In selecting this working group and guiding its process, we looked to Eva Winkler’s work on the ethics of policy writing on controversial social issues, both to guide group composition (p. 563) 1 and in our efforts to make the rationale for the policy publicly available (p. 565). 1 We write this article documenting our in-progress thinking in an effort to make our aims and deliberative process clear, and to invite discussion of the ethical issues that were surfaced during the policy creation process.

The nature of MAID

The central theoretical question that emerged during the process of policy creation was whether MAID should be conceptualised as a medical intervention like others that result in the end of life (eg, palliative sedation and withdrawing or withholding life-sustaining interventions), v or whether MAID is practically and ethically distinct from these practices. Different ways of answering this question lead to very different ethical obligations at the level of practice. Indeed, it was in attempting to nail down practical questions about patient communication, confidentiality and capacity assessment that these conflicting theorisations of MAID became legible to our group.

We begin by outlining two competing conceptualisations of MAID. The first is the view that MAID is meaningfully distinct from other medical practices that result in the end of life. We begin here because this position is standard in the literature on MAID and is foundational to nearly all assisted dying policies and guides we have encountered. We then outline the opposing view: that MAID should be understood as practically and ethically equivalent to other medical practices that result in the end of life. We explore the entailments of each conceptualisation at the level of practice, and describe our group’s attempts to find ground between these competing theorisations.

Position A: MAID is practically and ethically distinct from other medical procedures that result in the end of life

It is frequently asserted or assumed that MAID is distinct in its nature and in its ethical implications from other consensual medical procedures that result in the end of life. This claim can rest on a variety of philosophical foundations, but a common approach relies on a moral distinction between killing and letting die. There are two broadly deontological arguments that could support this claim. First, in deontological ethics, killing is seen as a violation of a universally binding moral law. According to this way of thinking, there are certain things that humans simply should not do, regardless of the benefit to themselves or to others. The act of one person consciously ending another person’s life is one of those things that ought not be done under any circumstances. 2 3 , vi

Another articulation of the same deontological intuition, offered by Velleman, is grounded in a Kantian idea of human dignity—the idea that there is an inviolable value that a person possesses in themselves by virtue of their rational nature (p. 611). 4 Causing a person to die violates their inherent value. This violation cannot be justified by appeals to helping the person realise their goals or shielding them from harms, since the importance of the person’s good rests on a prior assumption about the fundamental value of the person themselves(p. 615). 4 The deontological objection to MAID, when it is justified on the basis of preventing harm or helping a patient realise their good, is that it denigrates human dignity by prioritising goods for the person over the value that inheres in the person.

Another means of distinguishing MAID from other medical procedures that result in the end of life concerns the intentions of clinicians. This argument, advanced most frequently by medical associations and particularly associations of palliative care providers, rests on the assumption that, in the case of MAID, the clinician intends for the patient to die while in the case of palliative sedation or withdrawing life-sustaining medical treatment death may be a foreseeable outcome but is not the primary intention of the clinician. 5–7 This empirical claim is frequently made in the absence of evidence and also without explicit theorisation of why and how intention matters. This is problematic since it is both plausible that a MAID provider’s primary intention could be something other than causing death, for example, ameliorating suffering and simultaneously implausible to suggest that causing death is nowhere in the intentional landscape of a physician who withdraws life-sustaining treatment.

Our working group considered these arguments for the distinctiveness of MAID from other medical procedures that result in the end of life. We found it striking that these deontological arguments and arguments from intention focus ethical consideration primarily on the clinician who is providing MAID rather than the patient who is receiving it. That is, they attend to the intentions, actions and experiences of clinicians, rather than on what is ethically at stake for the patient who is requesting MAID. It is understandable that clinicians and patients may, on the basis of their personal commitments, experience MAID as morally distinct from other procedures that result in the end of life. For this reason, no clinicians or patients are required to pursue MAID if doing so is contrary to their commitments. However, we were not convinced that there is a meaningful practical or ethical difference for the patient between being consensually assisted in dying (in the case of MAID) and being consensually allowed to die (in the case of refusing life-sustaining interventions). In fact, we felt that there are compelling reasons to consider these practices as ethically equivalent from the patient’s perspective.

Position B: MAID is practically and ethically equivalent to other medical procedures that result in the end of life

This position shifts attention away from the ethical obligations of the clinician and, instead, towards what is morally at stake for the person who is requesting MAID. Seen in this way, an important point of similarity emerges between MAID and other medical practices that result in the end of life: namely, that they alleviate unendurable suffering and facilitate the patient dying on their own terms. Rather than seeing the primary goal of MAID as ending life, this position sees the primary goal as ameliorating suffering, honouring the patient’s wishes or giving the patient agency over the way their life will end. Indeed, a recent survey of Canadian medical students indicates that the primary factors influencing the students’ stance on MAID were considerations relating to patient autonomy and responding compassionately to the patient’s diagnosis. On these grounds, the survey found that 88% of medical students surveyed support the provision of MAID (p. 5). 8

Additional support is found in the Supreme Court’s Carter decision, which argues that the MAID cases should be managed in a way that is consistent with other medical procedures that result in the end of life. The court writes:

Decisional capacity and vulnerability arise in all end of life medical decision making. Logically speaking, there is no reason to think that the injured, ill, and disabled who have the option to refuse or to request withdrawal of lifesaving or life sustaining treatment, or who seek palliative sedation, are less vulnerable or less susceptible to biased decision making than those who might seek more active assistance in dying. The risks [of coercing vulnerable patients] that Canada describes are already part and parcel of our medical system (par. 115). 9

Thus, the Supreme Court seems to support a view of MAID as practically and ethically similar to other medical interventions that result in the end of life and advocates for an approach to practice that is consistent with this understanding.

In ‘position B’, then, the underlying ethical commitment that unifies MAID and other medical procedures that result in the end of life is the conviction that (a) it is wrong to force a person to live in circumstances of unendurable and irremediable suffering and (b) that the wishes of capable patients should be respected within legal limits, especially in such an intimate matter as how they choose to die. Persons, in other words, have a right to life, not a duty to live (par. 63). 9 Refusing life-sustaining treatment and choosing to end suffering via MAID are ethically equivalent from the patients' perspective in that they allow capable patients to choose what they will and will not tolerate. The ends of alleviating suffering and giving capable patients agency in their end of life decision-making is prioritised over the means by which these goals are achieved.

Practical entailments

These different ways of understanding the nature of MAID lead to very different entailments and obligations at the level of practice. Indeed, our working group came to appreciate the importance of this conceptual distinction only as we attempted to pin down practical questions about patient communication, confidentiality and capacity assessment. When MAID is constructed as practically and ethically distinct from other medical practices that result in the end of life, it follows that it is appropriate to develop special procedures for managing communication, confidentiality and capacity assessment in MAID cases. When MAID is constructed as practically and ethically equivalent to other medical practices that result in the end of life, it follows that the same procedures surrounding confidentiality, communication and capacity assessment should apply in MAID cases. This may sound straightforward—our working group should simply pick a side and stick to it—but this became difficult to maintain in practice, as we found that national laws, standards of professional practice, the Supreme Court’s decision and our group’s own ethical intuitions about the nature of MAID all seemed to waver and equivocate as different dimensions of the practice were considered. Three examples will serve to illuminate this challenge.

The first example has to do with patient communication. Specifically, our working group wondered: who should initiate conversations about MAID? The patient? The healthcare provider? How, when and in whose presence, should these conversations take place? These questions apply in adult care settings as well, but they take on a different quality when they are considered in a paediatric setting in which the dominant discursive frame is ‘Child and Family-Centred Care’ 10 —a model that requires balancing respect for the autonomous decision-making of capable young people with an acknowledgement of their deep relational embeddedness within family systems (p. 6). 11 , vii In such a paediatric setting, how should conversations about MAID proceed?

Scholarly and applied literatures are united in their presumption that conversations about MAID will begin with a patient request. viii This is diametrically opposed to the way virtually all other medical communication is structured, in which the onus is on healthcare providers to inform patients of the full range of medical options that are available to treat a particular condition. The positive ethical and legal obligation for clinicians to inform patients is important because it is a foundational building block of informed consent and autonomous decision-making. ix In order for patients to make autonomous choices about their medical care, they must know the full range of options that are available to them. Healthcare providers are expected to be the medical experts, not patients.

This question of communication is the focus of a recent article by medical anthropologist Mara Buchbinder, who argues compellingly that a prima facie case may hold for physicians to inform their patients about the existence of MAID. 12 , x Buchbinder points out that public knowledge may lag behind legislative developments and, therefore, some patients may not know enough about assistance in dying to request it (p. 2). 12 , xi She adds that the people who are most likely to be uninformed about the existence of MAID are those who are already socially marginalised in other ways (linguistically, educationally, etc), and that this may potentially lead to an untenable situation in which patients who are already socially vulnerable receive a different range of care options at the end of life than those who are otherwise socially located (p. 3). 12 A positive obligation on clinicians to discuss MAID with their patients is a mechanism that levels the playing field, ensuring that all capable patients have access to information that will allow them to make autonomous medical decisions about how their life will end. Our working group was deeply influenced by Buchbinder’s arguments and came to feel uneasy with the seemingly universal practice of relying exclusively on patients to initiate requests for MAID.

The second set of questions that illuminated this conceptual confusion about the nature of MAID had to do with the process of determining capacity. More specifically our working group asked: how should capacity to consent be assessed in MAID cases? Again, this is a question that also applies to the practice of MAID in adult populations, but it takes on a special urgency in a paediatric setting, where young people’s capacity to contribute to medical decision-making remains controversial in some contexts. xii The Hospital for Sick Children is located in Ontario, a province that does not rely on age as a heuristic for capacity (ie, there is no ‘age of consent’ for medical treatment), but rather operates on the presumption of capacity for all patients regardless of their age (HCCA, section 4 (2)). 13 This means that young people can be and are found capable of making their own medical decisions, even when those decisions may result in their death. xiii The question facing our working group, then, was: should the same procedures and protections that govern capacity assessment for other medical practices that result in the end of life also apply to MAID?

The Supreme Court’s Carter decision indicates that the same procedures that apply to capacity assessment in other cases should also apply to MAID. They write: ’vulnerability can be assessed on an individual basis, using the procedures that physicians apply in their assessment of informed consent and decisional capacity in the context of medical decisions more generally’ (par. 115). 9 This guided our working group towards recommending the maintenance of consistent standards of capacity assessment and an underlying theorisation of MAID as practically and ethically equivalent to other medical interventions that result in the end of life.

However, clinical guides to MAID in Ontario contradict this mandate in several ways. First, as noted previously, current federal legislation restricts MAID access to persons who are over the age of 18 contra to provincial legislation that does not use age as a heuristic for capacity. Second, patients in Ontario who are found to be incapable of making their own medical decisions are usually permitted to appeal this finding to an independent body of medical and legal experts—the Consent and Capacity Board—who have the ability to make legally binding capacity determinations (section 32). 13 However the Consent and Capacity Board has pre-emptively declared that they will not hear MAID cases. 14 This means that, at present if a patient is found to be ineligible for MAID on the basis of incapacity, the patient does not have the usual recourse to appeal this decision as is guaranteed by provincial legislation.

Again, our working group found ourselves in a bind. The Supreme Court of Canada’s Carter decision seems to point us towards assessing capacity for MAID in the same way we would for other medical treatment decisions, thus supporting an underlying conceptualisation of MAID as ethically equivalent to other medical practices that result in the end of life. However, federal legislation restricting MAID access to patients who are aged over 18 years and current professional practice of the Consent and Capacity Board points towards treating MAID as exceptional.

A final example illustrating conceptual confusion about the nature of MAID is related to patient confidentiality. Specifically, our working group wondered about a hypothetical scenario: how should healthcare providers respond if a capable patient requests MAID, xiv but their parents clearly oppose this request? Are there situations in which MAID requests and administration would be kept secret from parents and other family members, for example, if a capable patient were to indicate that they do not want family members involved? Again, these questions are relevant to the adult care setting, but they are excruciatingly delicate when considered in paediatric care.

We found no literature or guides to practice on this particular issue, and so we looked to other circumstances in which capable young people make medical decisions that result in the end of their life. As discussed previously, Ontario is a jurisdiction in which capable young people can and do make the decision to refuse or discontinue life-sustaining treatment. It is our institution’s practice to discuss these decisions with the capable patient themselves, and to involve family members to the extent requested by the capable patient. Usually, the family is intimately involved in this decision-making process. If, however, a capable patient explicitly indicates that they do not want their family members involved in their decision-making, although healthcare providers may encourage the patient to reconsider and involve their family, ultimately the wishes of capable patients with respect to confidentiality must be respected. If we regard MAID as practically and ethically equivalent to other medical decisions that result in the end of life, then confidentiality regarding MAID should be managed in this same way.

This conclusion set our working group distinctly on edge. Would we really allow a capable patient receiving care in our paediatric hospital to receive MAID without the knowledge or consent of their parents? In other circumstances in which capable young people make medical decisions that result in the end of life, the answer is ‘yes’, although, again, clinicians would strongly encourage the patient to discuss this decision with their family. Is MAID meaningfully different from these practices? Is it sufficiently different to justify violating existing confidentiality standards? Again our working group found itself uncertain about the nature of MAID with legal, professional and scholarly sources all pointing in different directions or remaining silent.

Our policy and the search for middle ground

Our drafted policy seeks a middle ground between these competing theorisations—treating MAID in a manner that is consistent with other medical interventions that result in the end of life, while still acknowledging that MAID may be experienced as distinct by some patients and clinicians. The centrepiece of our current drafted policy is a flow chart, which is intended to guide clinical management of MAID cases ( figures 1-3 ).

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Flow chart draft of phase I medical assistance in dying. CCB, Consent and Capacity Board; HCP, heath care provider; MAID, medical assistance in dying; PACT, Paediatric Advanced Care Team.

Flow chart draft of phase II and III medical assistance in dying. CCB, Consent and Capacity Board; MAID, medical assistance in dying; MRP, most responsible physician; PACT, Paediatric Advanced Care Team.

Flow chart draft of phase IV medical assistance in dying. MAID, Medical Assistance in Dying.

Regarding issues of communication, we suggest that MAID will be initiated by the patient, although we note that patient initiation can take multiple forms including an explicit request for MAID, an explicit request for information about MAID or an expression of suffering and a request for help ending life. This request does not need to be made directly to the MRP, but rather can be made to any healthcare provider, in order to account for situations in which a patient may feel particularly close to a different member of their healthcare team.

We hope that this more nuanced position regarding what constitutes patient initiation may allow healthcare providers to engage conversations about MAID in a wider variety of circumstances; however, we stop short of asserting a positive obligation to inform patients about MAID. Although our working group found Buchbinder’s arguments regarding informed consent and the importance of ensuring equitable access to information about MAID extremely persuasive, we were also simultaneously keenly attuned to the discomfort expressed by members of our group at the idea of a prima facie obligation to routinely initiate conversations about MAID. Clinicians in our working group were concerned that the mere suggestion that clinicians may initiate conversations about MAID would be alienating to their coworkers who may (a) object to MAID on ideological or moral grounds, (b) feel unsure or uncomfortable about how to initiate these conversations or (c) resent this incursion into their practice. Continued discussions across hospital roles signalled that departing from this aspect of adult policy on MAID was not welcome at a time when the idea of providing MAID in a paediatric setting is already controversial. In light of these concerns, our drafted policy makes discussing MAID permissible when patients express suffering and request information about ending their life, but stops short of a prima facie obligation to inform patients about the existence of MAID. xv We plan to revisit this issue in future iterations of the policy when some of the contemporary social controversy and uncertainty around the practice of MAID has become more settled.

In all other regards, our working group has, at present, elected to conceptualise MAID as practically and ethically equivalent to other medical practices that result in the end of life. This theorisation of MAID is justified on the grounds that these practices share a common purpose of alleviating unendurable suffering and facilitate the patient dying on their own terms. We feel that this theorisation is consistent with the Supreme Court of Canada’s Carter decision, and is reflective of our concern that the conceptualisation of MAID should not place additional burdens on the patient or function to limit the rights and freedoms to which patients are typically entitled. In this regard, we note in box 12b that patients who are found ineligible for MAID on the basis of incapacity have a right to appeal the finding of incapacity to the Consent and Capacity Board. As a matter of hospital policy, then, our usual practices concerning communication, confidentiality and capacity assessment will also apply to MAID cases.

In the final section, we briefly consider the institutional challenges that arise in constructing polices concerning what is still an extremely controversial social practice. We argue that a rare opportunity may exist for MAID-providing institutions to reduce social stigma, but not without potentially serious consequences for healthcare providers and MAID-providing institutions themselves.

Messaging MAID

In addition to questions related to patient care, our working group considered the question of how the hospital would approach MAID as a matter of public relations. Should institutional conversations about MAID happen behind closed doors with an undisclosed list of participants or should conversations about MAID happen in the public sphere? Should the policy be accessible only by personnel at The Hospital for Sick Children or should the policy be made available to other institutions and members of the public? These questions are weighty, owing to the socially controversial nature of MAID and the potential for sensational media coverage. Two models were considered to guide us through this public relations challenge.

First, there is the ‘abortion model’. When restrictions on abortion were declared unconstitutional in Canada, 15 physicians who provided abortions and independent abortion-providing clinics were the target of violent attacks. 16 Hospitals that provide abortions (particularly late term abortions) still do not advertise the fact, instituting aggressive secrecy policies at a personal and institutional level. In her research on the effects of these regimes of silence on abortion workers, social worker Cherilyn van Berkel argues that this has negative consequences both for hospital workers (p. 7) 17 and for the public (p. 11). 17 If we take the abortion model as our strategy for publicly messaging MAID, we would proceed with great caution and secrecy in an effort to protect MAID providers and to avoid social controversy about this practice.

An alternative model for messaging MAID are the institutional responses to the HIV/AIDS epidemic. When the AIDS crisis hit in the 1980s, hospitals participated in destigmatising the disease by discussing it openly in the public sphere (pp. 5–7). 18 There is now a large body of research on the role of hospitals in reducing HIV stigma, which recommends institutional transparency and explicit conversations about the causes of HIV/AIDS. 18–20 In other words, healthcare institutions sought to leverage their social capital and prestige on behalf of their patients who are vulnerable to social marginalisation. If we take the HIV model as our strategy for publicly messaging MAID, we would proceed by providing MAID in a matter-of-fact way that may, over time, reduce the social burden both on patients seeking this procedure and clinicians providing it.

As may be obvious, based on our decision to write such a public article about this process, our working group has decided to cautiously follow the ‘HIV model’ and move carefully into discussing MAID in the public sphere. In this, we follow the lead of our international colleagues who have also chosen to write publicly about MAID implementation in their healthcare settings. 21 22 In order to protect staff members from potential violence and social harassment, we will not make public the names of the healthcare providers at The Hospital for Sick Children who have volunteered to provide MAID, nor will we disclose a full list of persons who comprised our working group. We will, however, as an institution, publicly discuss the provision of MAID in an effort to normalise this procedure and reduce social stigma for everyone involved. It is right and appropriate for this duty to fall to a well-resourced institution rather than rest on the shoulders of individual patients and providers. We hope that by facilitating frank and sincere conversations about paediatric MAID while still maintaining protections for MAID providers, we will protect those who are most socially vulnerable.

This article has explored the dense tangle of conceptual, procedural and institutional questions that emerged as our hospital works to build a policy to regulate MAID provision in a paediatric setting. We illuminated a central point of conceptual confusion about the nature of MAID that emerged at the level of practice: whether MAID should be theorised as ethically equivalent to other medical procedures that result in the end of life or whether it should be conceptualised as ethically distinct. We explore the various entailments for clinicians and patients that would flow from these different understandings and unpack our working group’s decision to conceptualise MAID as practically and ethically equivalent to other medical interventions that result in the end of life. Finally, we argue that MAID providing institutions should take advantage of the opportunities that exists to reduce social stigma associated with MAID, while simultaneously ensuring the safety of healthcare providers. Speaking openly about the provision of MAID is important because it signals respect for patient rights (as discussed in the Carter decision and under Bill C-14), and may help to ease the social burdens, both on patients seeking MAID and on the healthcare professionals providing it.

Acknowledgments

The authors would like to acknowledge the interdisciplinary MAID working group (comprising healthcare professionals in palliative care, bioethics, pharmacy, nursing, intensive medicine, risk management, critical care, psychology and rehabilitation) that advised and oversaw the policy creation process. The authors would also like to thank Virginia McLaughlin for her review of materials and two blind reviewers for their helpful comments.

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• ↵ Canadian Medical Association , 2014 . CMA Policy: Euthanasia and Assisted Death . https://www.cma.ca/Assets/assets-library/document/en/advocacy/EOL/CMA_Policy_Euthanasia_Assisted_Death_PD15-02-e.pdf
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• ↵ Ontario Ministry of Health and Long Term Care and Ministry of the Attorney General , 2016 . Stakeholder Presentation: Medical Assistance in Dying Update . http://ocfp.on.ca/docs/default-source/default-document-library/mohltc_maid_august2016_presentation1c78984a146060099dafff0000832dca.pdf?sfvrsn=fc18f889_0
• ↵ R. v. Morgentaler, [1988] 1 SCR 30, 1988 (SCC) . Retrieved 5 Apr 2018 .
• ↵ Abortion Rights Coalition of Canada , 2017 . The history of abortion in Canada. Position paper #60 . http://www.arcc-cdac.ca/postionpapers/60-History-Abortion-Canada.pdf .
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• ↵ University of Toronto Joint Centre for Bioethics , 2016 . MAID Implementation Task Force: Medical Assistance in Dying Draft Policy Template . http://www.jcb.utoronto.ca/news/documents/JCB-MAID-Policy-Template-DRAFT_June52016.pdf
• ↵ Oregon Death With Dignity Act: A Guidebook for Healthcare Professionals . 2008 . https://www.ohsu.edu/xd/education/continuing-education/center-for-ethics/ethics-outreach/upload/Oregon-Death-with-Dignity-Act-Guidebook.pdf .
• ↵ College of Physicians and Surgeons of Ontario , 2016 . Policy Statement: Medical Assistance in Dying . http://www.cpso.on.ca/Policies-Publications/Policy/Medical-Assistance-in-Dying
• ↵ Canadian Medical Association , 2005 . CMA Policy: Code of Ethics . https://www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Code_of_ethics_of_the_Canadian_Medical_Association_Update_2004_PD04-06-e.pdf
• ↵ American Medical Association , 2016 . Principles of Medical Ethics . https://www.ama-assn.org/sites/default/files/media-browser/principles-of-medical-ethics.pdf

↵ i The views and opinions expressed by the authors of this article are solely their own, and may not reflect the views and opinions of the hospital administration or other staff members.

↵ ii Capable minors are patients who are under the age of majority and are found to be capable of making their own medical decisions. In Ontario, patients are presumed to be capable regardless of their age, meaning that the burden is on physicians to show that young patients are not capable rather than on young patients to prove their capacity (HCCA, section 4). 13

↵ iii On one side of the debate was the Canadian Paediatric Society, which issued a parliamentary submission arguing that MAID should be accessible only to people who are 18 years or older. 23 On the other side of the debate were scholars and advisory groups who argued that MAID ought to be available to all persons who are capable of autonomous medical decision-making, regardless of their age. Three arguments were voiced against age restrictions as a proxy for capacity to make these medical decision: first that age restrictions are inconsistent with existing legislation, 25 second, that they do not adequately safeguard MAID access, 26 and third that they cruelly abandon capable young people to grievous and irremediable suffering that has been declared intolerable for adults. 25

↵ iv The question of extending MAID access to incapable minors, referred to elsewhere as ‘non-voluntary euthanasia’ 5 is not being considered in Canada or by this policy.

↵ v Palliative sedation involves the use of medications for patients who are terminally ill and near end of life with the intent of alleviating suffering and the management of symptoms that have been refractory to other treatments. Withdrawing or withholding life-sustaining interventions means discontinuing interventions such as artificial ventilation or nutrition, that are keeping the patient alive but are no longer wanted or medically indicated. 7

↵ vi There are some exceptions to this as often deontologists have provisos for duelling, warfare and capital punishment.

↵ vii Of course, all people are embedded in webs of interpersonal, social and cultural relation, dependent young people just more obviously so. 27 28

↵ viii In the scholarly literature see, for example, Quill  et al , Denier  et al and Meier et al . 29–31 For institutional policies and guidance documents that assume conversations about MAID will begin with patient-initiated requests, see the 2016 ‘MAID Policy Template’ created by the University of Toronto’s Joint Centre for Bioethics’ ( http://jcb.utoronto.ca/news/documents/JCB-MAID-Policy-Template_October112016.pdf ) 32 ; the 2008 ‘Oregon Death With Dignity Act: A Guidebook for Healthcare Professionals’ ( https://www.ohsu.edu/xd/education/continuing-education/center-for-ethics/ethics-outreach/upload/Oregon-Death-with-Dignity-Act-Guidebook.pdf ) 33 and the College of Physicians and Surgeons of Ontario’s Policy Statement on MAID ( http://www.cpso.on.ca/Policies-Publications/Policy/Medical-Assistance-in-Dying ). 34

↵ ix This is noted in the codes of ethics of both the American Medical Association and the Canadian Medical Association, which direct clinicians to ‘provide your patients with the information they need to make informed decisions about their medical care’ (p. 2) 35 including ‘the burdens, risks and expected benefits of all options including forgoing treatment’ (par. 2.1.1). 36

↵ x Buchbinder notes that this requirement may justifiably not hold in situations in which (a) the patient’s underlying condition would impede the ability to ingest the medication, (b) patients who have indicated they are already well informed about MAID and (c) patients have clearly indicated that MAID is contrary to their personal or religious beliefs (p. 2). 12

↵ xi In fact, during our consultation process for our policy, a palliative care physician who is currently providing MAID in the adult population shared a story to this effect: a patient who he had been following for months came to him one day and declared that he intended to go to Belgium to receive assistance in dying. The patient was completely unaware that MAID was available in Canada, although he had been receiving high-quality palliative care in Toronto for weeks.

↵ xii The question of whether and in what circumstances young people should be permitted to consent to medical treatment on their own behalf remains controversial in the field of paediatric bioethics generally and in MAID cases in particular.

↵ xiii This fact is not widely understood or appreciated and, at times, conflicts with the discursive environment of Child and Family Centred Care, which can be understood as giving families more rights than they actually enjoy according to the Healthcare Consent Act. 13

↵ xiv For the moment, we are only considering patients who are 18 years or older, but with an eye to the future where this may apply more broadly.

↵ xv This decision reflects uncertain legal waters. The Ontario Healthcare Consent Act indicates that physicians have an obligation to inform their patients of their treatment options and alternatives. If MAID is considered a treatment, an organisation would want to be clear about the rational for not expecting clinicians to raise this option when a patient seemed likely to meet the strict criteria for access.

Contributors RZS, Director of the Department of Bioethics, and AR, Medical Director of Palliative Care/Paediatric Advanced Care Team, were asked to assemble and co-chair an interdisciplinary working group that would develop a policy for responding to requests for MAID at The Hospital for Sick Children in Toronto, Ontario. They invited CD, a PhD Candidate at the University of Toronto’s Joint Centre for Bioethics, to participate in the working group and to draft the hospital’s policy. Conversations with the interdisciplinary MAID Working Group brought important normative questions to light. These theoretical questions and their practical entailments were drafted into the present paper by CD. All authors provided substantial contributions to the conception of the article. While CD drafted, RZS and AR revised critically for important intellectual content, and all provided final approval of the version being published and agreed to be accountable for all aspects of the work.

Funding Funding for this project was provided by The Hospital for Sick Children.

Competing interests None declared.

Patient consent Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement There is no additional unpublished data from the study.

Linked Articles

• Response To die, to sleep, perchance to dream? A response to DeMichelis, Shaul and Rapoport Joel L Gamble Nathan K Gamble Michal Pruski Journal of Medical Ethics 2019; 45 832-834 Published Online First: 18 Jul 2019. doi: 10.1136/medethics-2019-105393

Read the full text or download the PDF:

Other content recommended for you.

• Canadian French and English newspapers’ portrayals of physicians’ role and medical assistance in dying (MAiD) from 1972 to 2016: a qualitative textual analysis Ellen T Crumley et al., BMJ Open, 2019
• Organ donation after medical assistance in dying or cessation of life-sustaining treatment requested by conscious patients: the Canadian context Julie Allard et al., Journal of Medical Ethics, 2017
• Continuing the conversation about medical assistance in dying Carey DeMichelis et al., Journal of Medical Ethics, 2019
• Impact of medical assistance in dying (MAiD) on family caregivers Rachel Goldberg et al., BMJ Supportive & Palliative Care, 2019
• How is the medical assistance in dying (MAID) process carried out in Nova Scotia, Canada? A qualitative process model flowchart study Ellen T Crumley et al., BMJ Open, 2021
• Making a case for the inclusion of refractory and severe mental illness as a sole criterion for Canadians requesting medical assistance in dying (MAiD): a review Anees Bahji et al., Journal of Medical Ethics, 2021
• Social determinants of health and slippery slopes in assisted dying debates: lessons from Canada Jocelyn Downie et al., Journal of Medical Ethics, 2021
• Canadian neurosurgeons’ views on medical assistance in dying (MAID): a cross-sectional survey of Canadian Neurosurgical Society (CNSS) members Alwalaa Althagafi et al., Journal of Medical Ethics, 2019
• Clinician responses to legal requests for hastened death: a systematic review and meta-synthesis of qualitative research Tejal Patel et al., BMJ Supportive & Palliative Care, 2020
• Exploring key stakeholders’ attitudes and opinions on medical assistance in dying and palliative care in Canada: a qualitative study protocol Gilla K Shapiro et al., BMJ Open, 2021

Home — Essay Samples — Social Issues — Assisted Suicide — Medical Assistance In Dying In Canada

Medical Assistance in Dying in Canada

• Categories: Assisted Suicide Canada

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Words: 1046 |

Published: Jun 17, 2020

Words: 1046 | Pages: 2 | 6 min read

Works Cited

• Ireland, K. J. (2016). A History of Assisted Suicide in Canada. Canadian Journal of Disability Studies, 5(3), 61-80.
• Schuklenk, U., Van Delden, J. J. M., Downie, J., McLean, S., Upshur, R., & Weinstock, D. (2017). Report of the Royal Society of Canada Expert Panel on End-of-Life Decision Making (November 2011). Bioethics, 31(3), 191-201.
• Griffiths, J., Weyers, H., Adams, M., & Steenkamp, M. (2008). Euthanasia and assisted suicide: a survey of attitudes in Switzerland. Swiss Medical Weekly, 138(23-24), 345-352.
• Thienpont, L., Verhofstadt, M., Van Loon, T., Distelmans, W., & Audenaert, K. (2015). Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ open, 5(7), e007454.
• Ganzini, L., Goy, E. R., Dobscha, S. K., & Prigerson, H. (2009). Mental health outcomes of family members of Oregonians who request physician aid in dying. Journal of Pain and Symptom Management, 38(6), 807-815.
• Hendry, M., Pasterfield, D., Lewis, R., Carter, B., Hodgson, D., & Wilkinson, C. (2013). Why do we want the right to assisted suicide?. A qualitative study of the views of people with motor neurone disease. Palliative Medicine, 27(8), 747-754.
• Cohen-Almagor, R. (2016). Belgian euthanasia law: a critical analysis. Journal of Medical Ethics , 42(5), 323-327.
• Nilstun, T., Melltorp, G., & Hermerén, G. (2007). End-of-life decisions and the use of intensive care. The Lancet, 369(9565), 1949-1950.
• Braverman, B., Eysenbach, L. M., & Goldberger, J. (2018). Exploring Physician Attitudes Toward Medical Aid in Dying. Journal of Palliative Medicine, 21(3), 316-319.
• Battin, M. P. (2015). Physician-assisted death: What can we learn from the Dutch experience?. The Hastings Center Report, 45(4), 14-23.

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Medical Assistance in Dying and Mental Health: A Legal, Ethical, and Clinical Analysis

L’aide médicale à mourir et la santé mentale: une analyse légale, éthique et clinique, alexander i. f. simpson.

1 Complex Care and Recovery Program, Forensic Division, Centre for Addiction and Mental Health, Toronto, Ontario

2 Division of Forensic Psychiatry, University of Toronto, Toronto, Ontario

Medical assistance in dying (MAiD) legislation is now over a year old in Canada, and consideration is turning to whether MAiD should be extended to include serious mental illness as the sole qualifying condition for being eligible for MAiD. This article considers this question from ethical and clinical perspectives. It argues that extending the eligibility for MAiD to include those with a serious mental illness as the sole eligibility criterion is not ethical, necessary, or supported current psychiatric practice or opinion.

La loi sur l’aide médicale à mourir (AMAM) a un peu plus d’un an au Canada, et l’on examine maintenant si l’AMAM ne devrait pas être élargie pour inclure la maladie mentale grave comme seul état de santé qui rend admissible à l’AMAM. Cet article se penche sur la question d’un point de vue éthique et clinique. Il allègue qu’étendre l’admissibilité à l’AMAM pour inclure les personnes qui souffrent d’une maladie mentale comme étant le seul critère d’admissibilité n’est ni éthique, ni nécessaire, ni soutenu par la pratique ou l’opinion psychiatrique actuelle.

In February 2015, the Supreme Court of Canada struck down the Criminal Code prohibition on physician-assisted suicide under certain circumstances. 1 The federal government passed Bill C-14, which was enacted on June 17, 2016. Bill C-14 provides the legal structure for what has now been called medical assistance in dying, or MAiD, embracing both physician-assisted suicide (where the doctor prescribes medication for the person to take at some future time) and voluntary euthanasia (where the doctor administers medication to cause death). 2 The cases before the Supreme Court were ones of terminal illness and severe disabling physical illness. The Court ruled that persons facing grievous and irremediable suffering on the basis of a serious medical condition (one of the index cases was a terminal condition and one a degenerative neurological disorder) should be able to seek MAiD. The Court’s decision did not limit the scope of MAiD to terminal illness, however, but left the door open for a number of other medical conditions and concerns to qualify for MAiD. The Court also found that persons whose condition is so disabling that they are unable to exercise their own right to end their own life have a right to seek assistance to do so. The Joint Parliamentary Committee recommended including nonterminal disorders, 3 but Bill C-14 restricts MAiD to situations where death is ‘reasonably foreseeable’. This places MAiD largely in the area of end-of-life decision making, were MAiD is provided to a person whose death is ‘reasonably foreseeable’. Parliament further required independent review of whether the legislation should in future be extended to requests where mental illness is the sole underlying medical condition, consultation for which is currently under way.

MAiD has been quickly adopted. For the time period from June 2016 to June 2017 inclusive, 1981 persons have died using medical assistance, all bar 5 by voluntary euthanasia with 95.7% by physician and 4.3% by nurse practitioner. 4

The purpose of this article is to consider the issue of whether serious mental illness might be a condition that would allow a person to seek MAiD. The approach taken is to examine the fundamental ethical and clinical issues involved. For almost all situations where serious mental illness is the sole qualifying disorder, death is not reasonably foreseeable, nor is the person’s physical state so disabled that he or she is unable to exercise the right to end his or her own life. The exception is severe anorexia nervosa, which may meet the criteria in Bill C-14. 5 In the Netherlands, where mental illness is a sole eligibility criterion, only 3% of people with mental illness receiving voluntary euthanasia did so because of an eating disorder. 6 The clinical and ethical issues for extending MAiD to serious mental illness as a sole condition takes MAiD from end-of-life clinical care or assistance to those unable to make their own act of suicide into a much broader situation. This requires careful ethical attention.

Legal Argument

In some other jurisdictions, notably Belgium and the Netherlands, mental illness may qualify for MAiD. 7 The Court in Carter heard evidence about this but did not consider it, saying at paragraph 111, ‘Professor Montero’s affidavit reviews a number of recent, controversial, and high-profile cases of assistance in dying in Belgium which would not fall within the parameters suggested in these reasons, such as euthanasia for minors or persons with psychiatric disorders or minor medical conditions’. 1 It is unclear if the constitutional arguments that were found to apply for terminal illness and for those so gravely disabled as to be unable to exercise their right to end their own life hold in these other situations. Paragraph 111 does suggest that the parameters of Carter do not include persons with psychiatric disorders alone. 8 , 9

The specific cases before the Supreme Court in Carter did not require a ruling in relation to ‘psychiatric disorders’. However, in deciding that the appellants’ charter rights were violated by the prohibition on assisted suicide, the Court noted that section 7 of the charter protects the right to make fundamental personal choices free from state interference. This included a notion of personal autonomy involving control over one’s bodily integrity. The Court found that the prohibition on assisted suicide interfered with the applicants’ ability to make decisions about their bodily integrity and thus encroached on their liberty. It also found that to the extent that the prohibition left people like the appellants to endure what for them was intolerable suffering, it impugned their security of the person.

The Court argued that if a medical condition robs a person of the physical ability to take his or her own life, section 7 of the charter protects the right of those individuals to seek MAiD so that they are not forced to end their lives earlier than they otherwise would out of knowledge that they could not do so later when they would be too incapacitated. As the Court opined,

The trial judge found that the prohibition on physician-assisted dying had the effect of forcing some individuals to take their own lives prematurely, for fear that they would be incapable of doing so when they reached the point where suffering was intolerable. On that basis, she found that the right to life was engaged.…The sanctity of life is one of our most fundamental societal values. Section 7 is rooted in a profound respect for the value of human life. But s. 7 also encompasses life, liberty and security of the person during the passage to death. It is for this reason that the sanctity of [page 368] life “is no longer seen to require that all human life be preserved at all costs” (Rodriguez, at p. 595, per Sopinka J.). And it is for this reason that the law has come to recognize that, in certain circumstances, an individual’s choice about the end of her life is entitled to respect. (1, paragraphs 57-63)

For terminal illnesses and severe disabling disorders, this line of argument has considerable support from other jurisdictions. This type of argument is part of the foundation for MAiD in terminal conditions in Quebec and 6 US states. 10 In the legislation in Quebec, MAiD is seen as extending from a physician’s duty of care in end-of-life care and thus bounded by the clinical ethics of end-of-life decision making whilst specifically excluding psychiatric conditions. 11 Most psychiatrists in Canada appear to support MAiD at end of life but are much more reticent about extending MAiD to persons only with a serious mental illness. 12 Australasian 13 and American 14 psychiatric bodies have come out against such extension.

The proposal to extend MAiD to include someone with a serious mental illness who retains the physical and mental ability to end his or her own life and who is not dying takes MAiD into a different ethical and constitutional framework than argued in Carter . The arguments from end-of-life care and from a right to life and bodily integrity perspectives no longer hold. These are not end-of-life decisions, nor is the person unable to end his or her own life should he or she so choose. 15 So why should the prohibition on assisted suicide be lifted here?

Status of Mental Illness

Mental illness is not, generally, a terminal disease. Mental illness alone does not, generally, deprive people of their own ability to end their life. Suffering from a mental illness can be immensely difficult and painful. It can be life threatening. But the possibility of recovery is never lost. 16 The severity of mental illness waxes and wanes. New treatments are possible, new types of therapy can assist, and new ways of thinking about being someone living in recovery are always available from many sources. We do not yet know enough about when or if someone will recover or if the severity of their disorder will remit in time. 12 , 17 But clinicians must at all times remain engaged and try to help as best they can. Giving up on hope for some patients may be dangerous for mental health services.

Clinicians know only too tragically that there are times when people with mental illness may take their own life; most of us in clinical practice have lost at least one patient to suicide. Depression can lead a person to feel hopeless, worthless, and unable to change his or her life situation. Psychosis can grossly distort the nature of how the person experiences the world and people in it. Decisions made in the grip of illness deny the possibility of seeing the world differently, or a person can feel ground down by years of problems that all feel too much. But people with mental illness usually retain the capacity to look at their life situation competently, at times hopeful, at other times not, as they try to determine how best to live, thrive, and manage the ebb and flow of psychiatric disability. Suicide under these situations is an understandable answer to the problems of living with mental illness, although, we hope, never the best alternative. 18 The task of living with serious mental illness can be overwhelming and painful, and contemporary mental health care remains of limited effectiveness for many.

It is not for carers and clinicians to lose our hope. 16 We must always seek the possibility of finding ways to help people with their suffering and help them see their ongoing life as valuable and vital, for themselves and for others who know them and love them. In my view, the role of psychiatrists in the mental health system is to assist people in recovery, including relief of suffering, and enhance their ability to find ‘a life worth living’ as they define it. All people are worthy of our service, most importantly at the times when they struggle with whether they can bear to continue to live. To expect clinicians to participate in a person’s decision to take his or her own life adds a fundamentally different and conflicting mission to that commitment. 15

The next complicating factor for people with mental illness is that socioeconomic factors can be major ones in making someone’s life difficult, such as inadequate income support, poverty, and poor or unavailable housing. People with mental illness frequently have poor social conditions and a lack of good housing and income support. Social inclusion is often frustrated by major barriers of stigma and discrimination. These factors can be very significant in how people judge the value of their life or whether they feel valued and have a place in the wider community. The task of reducing stigma and promoting social inclusion is vital, including ensuring there are adequate clinical and community supports for people with mental illness. It would be tragic if societal inadequacies increase people’s sense of hopelessness so that they seek death by MAiD.

The Ethical Nature of a Request for Assistance to End One’s Life

There is another dimension that is rarely discussed but remains vitally important: when is it ethical for one person to ask another person to kill him or her or to be party to that person’s death? This is, in ethics and relationships, what MAiD is: a request of a physician to participate in suicide (physician-assisted suicide) or euthanasia (physician-caused death of a consenting person). In both situations, a physician has become involved in and party to the patient’s death. It involves other health care professionals also: nurse practitioners, pharmacists, and other members of the health care team. Bill C-14 defines that if a person’s death is reasonably foreseeable and his or her suffering is irremediable, then it is legal to ask someone to assist, 2 and Quebec has agreed that this is part of the ethics of end-of-life care. 11 But beyond those narrow limits, we must be careful. Is it ethical for a person to ask someone else to kill him or her? What ethical burden does that place on the other person?

And there are broader questions about the practice of psychiatry itself. Accepting MAiD for mental illness risks that despite our values of protecting and upholding life, we will also do the opposite and end life in some situations. Defining those situations is essentially one of individual value judgements by each psychiatrist about which lives are worth living and which are not. Will we progressively expand our definition of what life no longer has purpose or value? And are we sufficiently confident that we have the ability to do this, cognizant of the involvement of psychiatry in the eugenics movements of the past? What does it say to others who may be vulnerable and struggle to find meaning of a life with suffering?

Involving others in one’s death places an ethical burden upon them that may of itself be harmful. Evidence from the countries that have this legislation suggests the burden of participation in physician-assisted suicide is not insignificant. 19 It is so against the core values and training of physicians to be involved in causing the death of other people. It seems reasonable to expect that being party to some of our patients’ deaths would bring significant ethical fallout for physicians as practitioners and as people.

There is no argument from liberty that one has a right to engage someone else in the act to end one’s life. This argument only holds if one is physically incapable of doing so oneself and then only under certain circumstances. It is not the right to take one’s life that is being sought; it is the right to involve others in one’s suicide. Suicide is not illegal. It is available to all of us who have the physical ability to end our own lives. MAiD, however, is getting the help of a doctor in one’s suicide and, for serious mental illness, getting help when one has the physical capability of doing so oneself. Assistance of a health care professional is not generally required to commit suicide.

It is worth reflecting that suicide must be the only legal act that is illegal to assist. This speaks to society’s concern that we must not condemn a person for feeling suicidal or for taking his or her own life. But neither do we want to encourage or facilitate suicide, and we may condemn anyone who does so. We see people feeling suicidal as vulnerable and worthy of our support at times of crisis. Allowing MAiD for persons with mental illness overturns these core commitments.

Liberty defends the right to decide if and when we die. The Court has found that if one loses physical capability, then liberty argues for the ability to ask others to assist in one’s death. But the Court was also aware of the need to protect vulnerable others, for all our decisions in this area will affect others: family, friends, people suffering in similar ways, and others who may experience negative impacts on the sense of value of our shared lives. There is reference throughout Carter of this being a limited liberty and of the need to protect ‘vulnerable populations’ without enunciating what MAiD protection needs to be or why. As Callahan 20 has stated, respect for autonomy is vital but not determinative, and relief of suffering is not the only human good that physicians must respect. The current law wisely limits MAiD to end-of-life care to achieve this balance; extending to include serious mental illness alone would not.

Concluding Remarks

Those of us who work in mental health are only too aware of our limitations. There are people for whom it seems all we can do is inadequate to help them find a way to live. We need to be humble in the face of that limitation and keep striving to improve our care and practice. To introduce MAiD as an ‘option’ in this great struggle will only undermine our ability to help people who are suffering greatly with mental illness and burden clinicians with profoundly difficult ethical conflicts between hope, life, and assisted suicide. People may choose to take their own lives; that is understood and respected. But acting as a partner in helping people recover as well as acting as an agent in a patient’s death is an impossible burden that is not ethically justifiable or legally necessary.

MAiD should be confined to terminal illnesses and situations where a person is physically incapable of enacting his or her own wish to commit suicide and not to serious mental illness alone.

Acknowledgement

I thank Scott Kim, Trudo Lemmens, and Michelle Warner for their helpful comments on earlier drafts of this article and my Centre for Addiction and Mental Health colleagues for their discussion in helping define these issues. The views are my own.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

The Ethical Issues in Medical Assistance in Dying

Introduction, the definition of medical assistance in dying, the ethical debate surrounding medical assistance in dying, the arguments for and against medical assistance in dying, the potential risks and complications of medical assistance in dying, the role of the physician in medical assistance in dying, the role of the patient in medical assistance in dying, the impact of medical assistance in dying on society, the legal landscape of medical assistance in dying.

The Ethical Issues in medical assistance in Dying is a blog that discusses the ethical implications of Medical Assistance in dying.

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Euthanasia and physician-assisted suicide (PAS) are highly controversial topics. The two practices are often confused, but there are important distinctions between them. Euthanasia is defined as the act of deliberately ending a person’s life in order to relieve their suffering. PAS, on the other hand, is defined as the act of providing a person with the means to end their own life.

The ethical issues surrounding euthanasia and PAS are complex and sensitive. There is no easy answer as to whether or not these practices should be legalized. Those who support euthanasia and PAS argue that terminally ill patients should have the right to end their suffering if they so choose. Those who oppose euthanasia and PAS argue that these practices would cheapen human life and could lead to abuse.

The debate surrounding euthanasia and PAS is ongoing, and there is no easy resolution in sight. However, it is important to continue to have open dialogue about these issues in order to ensure that everyone’s voices are heard and respected.

Medical assistance in dying is a topic of much controversy and ethical debate. It is defined as “the voluntary provision of lethal medication, at the request of a competent adult patient, to end that person’s life” (1). The patient must be terminally ill and suffering from an incurable condition that causes intolerable suffering. They must be competent, which means they must be able to make an informed decision about their own medical care. And they must have made a voluntary request for Medical Assistance in dying.

There are many ethical issues surrounding medical assistance in dying. One of the most controversial is the definition of “terminally ill.” Some people argue that it should only be used for people who are imminently dying, while others believe it should be available for people with chronic conditions that cause them great suffering. Another issue is whether or not medical assistance in dying should be available to people with mental illness. Some argue that it could be used as a way to alleviate suffering in mentally ill patients, while others worry that it could be misused in cases of non-terminal mental illness.

There are also concerns about potential abuse and misuse of medical assistance in dying. Some worry that it could be used as a way to hasten death in cases where patients are not actually suffering from an incurable condition. Others worry that it could be used as a way to pressure vulnerable people into ending their lives.

There are no easy answers to these ethical questions. But as medical assistance in dying becomes more widely available, it is important to continue to have these debates and to try to find solutions that respect the autonomy of individual patients while also protecting vulnerable people from abuse and misuse.

The ethical debate surrounding medical assistance in dying is one that has been ongoing for many years. There are a number of different arguments for and against the practice, and it is an issue that divided opinion. In recent years, there have been a number of high-profile cases in which people have sought medical assistance to die, and this has brought the issue back into the public eye.

Those who are in favor of medical assistance in dying argue that it is a fundamental right of every individual to have control over their own body and life. They argue that people should be able to make the decision to end their life if they are suffering from a terminal illness or facing an unbearable amount of pain. They also argue that medical assistance in dying can be safeguard against people being coerced into ending their lives if they become unable to make the decision themselves.

Those who are opposed to medical assistance in dying argue that it is a slippery slope that could lead to euthanasia becoming more widespread. They argue that it is impossible to guarantee that people who request medical assistance to die are doing so voluntarily and without coercion. They also raise concerns about the potential for abuse, if people who are not terminally ill or in pain could request medical assistance to die for non-medical reasons.

The ethical debate surrounding medical assistance in dying is one that is likely to continue for many years to come. It is an issue that raises complex ethical questions with no easy answers.

The topic of medical assistance in dying is one that raises ethical issues for many people. The arguments for and against medical assistance in dying can be complex, but there are some key points to consider.

Those who are in favor of medical assistance in dying argue that it is a way to respect the autonomy of patients who are suffering from terminal illnesses. They may also argue that medical assistance in dying is a way to reduce the burden on families and friends who would otherwise have to watch a loved one suffer.

Those who are opposed to medical assistance in dying may argue that it is a form of suicide and that it goes against the Hippocratic Oath, which states that doctors should do no harm. They may also argue that medical assistance in dying could be abused by families or doctors who want to hasten the death of a patient for financial gain or other reasons.

Ultimately, the decision about whether or not to support medical assistance in dying is a personal one. It is important to weigh all of the arguments before making a decision.

Medical assistance in dying (MAiD) is a complex and sensitive issue, with a number of potential risks and complications. These need to be considered carefully before MAiD is undertaken.

One of the most serious risks is that of compromised patient care. MAiD may result in patients not receiving the best possible care, as resources are diverted to those who choose to end their lives. This could lead to a two-tier system, with MAiD patients receiving lower-quality care than those who do not opt for this course of action.

Another risk is that of coercion. MAiD could be used to pressure vulnerable people into ending their lives, especially if they feel that they are a burden on others. This could happen within families, where relatives may feel pressured to agree to MAiD in order to relieve the financial or emotional strain that caring for a terminally ill family member can cause. It could also happen in hospitals or other care settings, where staff members may unwittingly coerce patients into choosing MAiD rather than continuing with treatment or palliative care.

There is also a risk that MAiD could be used as a way of avoiding difficult conversations about death and dying. If people know that they can opt for MAiD at any time, they may be less likely to plan ahead for their own death or have difficult conversations with loved ones about end-of-life wishes. This could lead to people making hasty decisions about MAiD without fully considering the implications, or denied the opportunity to change their minds after starting the process.

Finally, there is a risk that MAiD could normalise suicide and devalue human life. IfMAiD becomes widely accepted, it could send the message that suicide is an acceptable solution to difficult life circumstances. This could lead to an increase in suicides among vulnerable groups such as young people and those with mental health problems. It could also devalue human life by making it seem like ending one’s life is an acceptable solution when things get tough.

The role of the physician in medical assistance in dying is a complex and controversial issue. There are a number of ethical issues that need to be considered when determining the role of the physician in medical assistance in dying. These ethical issues include the following:

– The autonomy of the patient: The patient should be autonomous in making the decision to end their life. The physician should respect the patient’s right to self-determination.

– The beneficence of the physician: The physician should act in the best interests of the patient. This includes ensuring that the patient is competent to make the decision to end their life, and that they understand the consequences of their decision.

– The non-maleficence of the physician: The physician should do no harm. This includes ensuring that the patient is not suffering from undue psychological or physical pain, and that they are not at risk of harming themselves or others.

– The duty of confidentiality: The physician should respect the confidentiality of the patient’s medical information.

– The duty of care: The physician has a duty of care to their patients. This includes ensuring that they provide competent medical care, and that they do not abandon or neglect their patients

When it comes to medical assistance in dying, the role of the patient is often considered to be of paramount importance. After all, it is the patient who is requesting medical assistance in dying, and it is the patient who will ultimately be the one to receive the lethal injection or take the life-ending medication.

However, the role of the patient is not always as clear-cut as it may seem. For example, in some cases, patients may not be able to make their own decisions about whether or not to receive medical assistance in dying. In other cases, patients may be pressured into requesting medical assistance in dying by their families or friends.

Moreover, even when patients do have a clear and unambiguous desire to receive medical assistance in dying, there are still ethical issues that must be considered. For instance, should patients be required to undergo a psychological assessment before they can receive medical assistance in dying? Should doctors be allowed to refuse to provide medical assistance in dying on the basis of conscience?

These are just some of the ethical issues that need to be considered when thinking about the role of the patient in medical assistance in dying.

Medical assistance in dying is a highly controversial topic that has divided society. Proponents of medical assistance in dying argue that it is a compassionate way to end the sufferings of terminally ill patients. Critics, on the other hand, argue that medical assistance in dying is a slippery slope that could lead to non-voluntary euthanasia.

There are a number of ethical issues that need to be considered when it comes to medical assistance in dying. One key issue is whether or not medical assistance in dying should be available to non-terminally ill patients who are suffering from intractable pain. Another key issue is whether or not medical assistance in dying should be available to minors.

There are strong arguments on both sides of the debate and there is no easy answer. Ultimately, the decision of whether or not to allow medical assistance in dying is a complex moral question that each individual must answer for themselves.

In recent years, a number of countries have changed their laws to allow medical assistance in dying (MAID), commonly known as euthanasia. This has been a controversial issue, with strong arguments on both sides. In this article, we will take a look at the legal landscape of MAID around the world.

MAID is currently legal in Belgium, Canada, Colombia, Luxembourg, the Netherlands, and Switzerland. In the United States it is legal in the states ofColorado, Montana, Oregon, Vermont, and Washington. Washington D.C. also allows MAID.

Arguments for and against MAID often center on ethical issues. Those who are in favor of MAID argue that it is a humane way to end the suffering of terminally ill patients. They also point out that MAID is always done with the consent of the patient and under strict medical supervision.

Opponents of MAID argue that it is a form of euthanasia and that it goes against the Hippocratic Oath taken by doctors to do no harm. They also worry that allowing MAID could lead to abuse, with vulnerable people being pressured into ending their lives.

The legal landscape of MAID is complex and ever-changing. It is an issue that is sure to continue to be debated in the years to come.

In conclusion, medical assistance in dying is a complex and sensitive issue with many ethical considerations. The decision to provide or withhold medical assistance in dying must be made on a case-by-case basis, taking into account the individual’s circumstances, values, and wishes.

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Opinion: Should treatment for severe mental illness include medical assistance in dying?

C anada is on the threshold of enacting a law that would make medical assistance in dying (MAiD) accessible to people whose only medical condition is mental illness. If this were to pass, Canada would be one of only a handful of countries to extend that process for patients with serious mental illness.

It will apply to conditions that are primarily within the domain of psychiatry like depression and personality disorders. Political leaders have accused the Trudeau government of promoting a “culture of death;” others see this as a sign of gross underfunding of high demand mental health services. 

In the United States, Oregon was the first state to enact the Death With Dignity Act, in 1997 . The measure allowed terminally ill adults to end their lives by voluntarily self-administering lethal doses of medication prescribed by a physician for that purpose, with key caveats that included a physician’s diagnosis of terminal illness leading to death within six months. Since then, the District of Columbia and nine additional states have enacted laws that facilitate medication assisted death along the lines of the Oregon model. 

Societal expectations regarding MAiD evolved over time. Several European countries have broadened the scope beyond terminal illness and imminent death to include suffering, functional decline and unbearable circumstances with no prospect of improving with treatment, thereby incorporating quality of life metrics into the process. 

In a potentially dangerous expansion, countries including Switzerland, the Netherlands, Belgium and Luxembourg currently permit medical assistance in dying for patients characterized as having severe and persistent mental illness (SPMI) — defined as conditions resistant to evidence-based treatments — provided they meet additional criteria that include intolerable suffering with preserved decision-making capacity. By expanding into the realm of mental illness, we change the fundamental nature of the discussion. 

Serious mental disorders are in essence brain disorders that are influenced by psychosocial factors. Unlike neurologic diseases, mental disorders cannot be localized to specific regions of the brain. Neuroimaging studies of patients diagnosed with SPMI, including bipolar disorder, the schizophrenia spectrum, anorexia, and post-traumatic disorder, for example, demonstrate that multiple brain regions are involved in the development of these illnesses. These disorders are mediated by impaired brain circuits — interconnected brain regions — rather than any specific part of the brain. The region most consistently involved in these circuits is the prefrontal cortex, which mediates executive functions.  

Executive functions include judgment, abstract thinking, planning, integrating information from all brain regions and insight. These domains are therefore compromised in patients with SPMI, with important downstream behavioral consequences that include impaired insight into the nature of their illness and loss of the ability to objectively consider the pros and cons of intervention. 

This is not to suggest that all patients with SPMI have minimal insight or are incapable of making rational decisions about their health care. Far from it. But it must be acknowledged that not all diseases, not even all brain disorders, are the same, and some of them do adversely impact cognitive domains germane to consequential decision-making. 

There are effective treatments, both pharmacological and psychotherapeutic, that can reduce the burden of disease and improve the quality of life for patients with mental illness. Some of them require long treatment trials using traditional approaches or with newer neuromodulation techniques, such as transcranial magnetic stimulation.   

A major compounding factor for patients with SPMI is the lack of adequate access to psychiatric care. Insurance companies frequently use a ‘business model’ approach that maximizes profit; for those with insurance, especially publicly funded insurance that is increasingly privatized, payment is often denied or limited. Denial of care exacerbates the challenges patients face as they navigate our health care system and potentiates the desire for an “exit plan.” Like the current debate in Canada, adequate mental health services and access to care will serve as mitigating factors favoring life in a subgroup of patients. 

The notion that there is a right dose and combination of medications for all patients that will eventually result in symptom remission is more folklore than science. We must be intellectually honest and acknowledge that not all forms of SPMI are curable with appropriate therapy and that some patients remain refractory to treatment even after repeated attempts. Patients may also be overwhelmed by long medication trials and experience hopelessness about clinical remission, which is difficult to disentangle from the very symptoms of these illnesses. Perseverance is often a long game in clinical medicine.  

An option for this group would be palliative psychiatry . Palliative medicine — that is, the absence of active medical interventions while providing basic sustenance and support — is more widely appreciated in cases of cancer and other near terminal illnesses where the patient makes an informed decision that quality of life, brief as it may be, is more important than measures to extend life, especially when they cause undue discomfort. Palliative approaches in psychiatry are conceptually comparable and include accepting that severe mental illness can be incurable, avoiding direct treatments with challenging side effects and questionable impact, and offering a support system that helps patients live impactful lives until death. 

The American Medical Association’s Code of Ethics maintains that assisting in death violates a fundamental code for medical practitioners. The American Psychiatric Association adopted the same position as the AMA in 2016, stating “a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing deaths. Suicide prevention is the bedrock of mental health care throughout the country.” 

The debate is clearly a difficult one, fraught with emotions; it needs to incorporate not only new scientific information but also the cultural values and principles of the society in which we live. The relationship between patients with mental illness and the practice of medical assistance in dying is a slippery slope that is likely to get even more slippery over time. We will require great caution and a thoughtful national debate as we move forward. 

Anand Kumar, MD, MHA, is a professor and head of the department of psychiatry at the University of Illinois in Chicago, where Sally Weinstein, Ph.D., is an associate professor. They are director and associate director, respectively, of the University of Illinois Center on Depression and Resilience.  

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