Ethical Issues of MAID Current and Future Controversies

Ethical Issues of MAID: Current and Future Controversies David Campbell, Ph. D Ethicist, KHSC Palliative Care Working Group Education Day Nov 13, 2018

The Carter Ruling � Feb. 6, 2015 Supreme Court struck down Criminal Code prohibitions on assisted suicide and will no longer apply to a “competent adult person who clearly consents to the termination of life and has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition. ”

SC Ruling on MAID � SC found Charter right to life doesn’t require absolute prohibition on assistance in dying (no “duty to live”) � MAID supported by principles of autonomy and dignity � Physicians not compelled to provide MAID � MAID will include assisted suicide and euthanasia

Fundamental Questions � Carter ruling open to broad interpretation. Does it include depression? Quadriplegia? MS? Elderly tired of living? Existential despair? � Should facilities with religious affiliations be forced to provide MAID? � What if not enough practitioners are prepared to participate in MAID? How can we guarantee equity of access?

Bill C-14: June 17 MAID Legislation � Limits access of MAID to those “suffering intolerably” and whose death is “reasonably foreseeable” � Limited to competent adults entitled to receive public health care � Includes mandatory 10 day “reflection period” after pt makes initial request � Allows for NPs to administer MAID as well as MDs � Protects HC professionals and family members who assist in MAID

Ethical Arguments for MAID � Autonomy: Overriding value in our culture, fundamental ethical principle within medical ethics � Compassion: fundamental duty to relieve suffering (beneficence/non-maleficence) � Justice: Able-bodied can end their lives but disabled cannot without assistance

Ethical Arguments Against MAID � Harms to Patients: danger of coercion, misdiagnosis, pt’s “giving up” to early � Harms to Society: weakens social taboo against suicide (“slippery slope”), clinical answer to complex issues (e. g. loneliness) � Harms to Physicians and Health Care System: fundamentally inconsistent with goals of medicine, could cause moral distress and trauma

The Logic of Expanding MAID � Once assistance in dying becomes legal, it is interpreted as a right � Rights by their nature are expansive � Providing MAID becomes a duty � If right is based on choice and intolerable suffering, there can be no grounds of limiting this right to some but not others � Discriminatory not to allow MAID for those currently excluded

MAID and Mature Minors � Will be reviewed by Parliament in future � Previous SC rulings involving mature minor’s right to refuse life sustaining medical treatment has set legal precedent � Jurisdictions with liberal MAID legislation later expanded it to minors (Belgium and Netherlands) � Autonomy, compassion and justice all support it

Why the discomfort? � Studies show adolescents lack insight, are impulsive and susceptible to peer pressure � Societal view that death for elderly is natural but unnatural among the young, therefore more tragic � Professional difficulty of purposely ending life of a minor versus adult (could I do this to my own child? ) � Ageism

MAID and the Mentally Illness � Logic of Carter ruling and SC rulings support it � Not all mental health conditions can be managed by medication/therapy � Mentally ill suffer as much (more? ) than physically ill � Mentally ill already suffer from stigma and discrimination

Philosophical and Ethical Concerns � How can we justify suicide prevention? Which mental illness qualifies for MAID vs suicide? � Mentally ill especially vulnerable, MAID would be an easy solution to complex existential and social problems � We lack understanding of mental health; new psych treatments might exist in future

MAID and Advance Care Plans � Purpose of ACP to guide clinical decisions for incapable pts � As MAID is a clinical intervention, it should be respected in an ACP � If MAID requests are not respected in ACP, what is the point of an ACP? Why respect other requests mentioned in an advance directive? � Dementia pts have catch 22 of waiting too long for MAID or choosing it too soon

Legal and Ethical Issues directives not legally valid � Severely demented cannot consent � Danger of abuse � Open to interpretation � Qo. L changes over time � Demented not the same person; ethical conflict between past and future selves � Advance

Conscientious Objection: Fundamental Questions � How do we balance rights of health care professionals with rights of patients? � If we allow for conscientious objection, how do we best manage it? � Should health care professionals even have the right to conscientiously object to legal clinically indicated health care services?

MAID Faith Based Institutions � Can organizations have rights or a conscience? � If a faith based organization receives public funding, doesn’t it have to provide all the services Canadians are entitled to? � Shouldn’t all religions be able to have publically funded hospitals? � Should faith based organizations be able to provide controversial treatments (e. g. FGM, conversion therapy, enforced gender-specific care, spirit healing, etc. ? )

The Myth of MAID � Loss of dignity and autonomy main reasons for MAID requests, not physical pain � Bad memories of family members suffering with dementia can haunt those who request MAID � Fear of dementia and concern of being burden on loved ones behind desire for advance requests for MAID � Good palliative care not solution; most MAID pts receive palliative care

MAID: A Proper Perspective � MAID will be expanded in the future � Vast majority of public support it � MAID extremely rare (0. 39% deaths in Oregon vs 3. 7% deaths in Netherlands in 2015) � Need to address role of religion in publically funded health care (freedom of religion includes freedom from religion…) � Need to stop offering non-beneficial treatments which merely prolong dying process

Thank you! If you have any ethics related questions, comments or quandaries, please feel free to contact me at: david. campbell@Kingston. HSC. ca