By Lori Seller and Veronique Fraser
As ethicists working in university health centers, many of our consultations revolve around decision making at the end of life. We know from academic literature, as well as from experience, that end of life discussions tend to come late in the illness trajectory and that the quality of these discussions is not always optimal. Health care professionals as well as patients can be reluctant to talk about death and dying for a variety of reasons. Patients sometimes receive what appears to be disproportionately burdensome treatment with little benefit at the end of life which can compromise quality of life. Late discussions can also result in patients being ill-prepared to consider the full gamut of end of life care options; this potentially robs them of an opportunity to exert some control over their illness by making fully informed choices.
Medical aid in dying (MAiD) was introduced as an end-of-life care option in Quebec in 2015. MAiD consists of a physician administering medication to a person at the end of life upon their request with the goal of relieving their suffering by hastening their death. The introduction of MAiD raises ethical questions and considerations in the context of end of life care discussions. We were curious: how does MAiD fit into the broader context of end of life care? Do MAiD requests prompt discussions about end of life care and referral to palliative care? Or will patients who request MAiD do so only after prolonged discussions about their goals at the end of life and after all care options to relieve their suffering have been exhausted? Are patients who request MAiD still receiving life prolonging interventions at the time of their request? If so, what does it mean that a patient who is requesting a medically hastened death is still receiving life-prolonging treatment? While there has been considerable discussion about the ethics of MAiD, little is known about the answers to these questions.
In our article, we examine how requests for MAiD fit into the broader context of end of life care. Our results suggest that many requests for MAiD occur late in the illness trajectory and do not appear to come after a documented evolution of goals of care towards a palliative approach. Rather, they may occur suddenly with little time spent with palliative care. We believe that how MAiD is approached in practice hinges on the critical question of whether MAiD is considered morally distinct from other end of life options. Some may feel that the legalization of MAiD has by default made MAiD an end of life care option like any other for which there are no particular ethical considerations. Others believe that the long-standing moral distinction between allowing death to occur and “killing” still stands; if so, the issue of timing potentially raises new and significant moral questions.
The Canadian parliament has appointed an expert panel to explore the possibility of broadening access to MAiD to include mature minors, incompetent adults who previously completed an advance directive and requests where mental illness is the sole underlying medical condition. However, before broadening access, we believe it would be helpful to establish how society and physicians currently approach MAiD in practice and reflect on the current moral status of MAiD in light of its recent legalization. If MAiD is still worthy of additional ethical considerations, we should consider on what grounds we defend this and how these considerations might inform decisions about broadening access to new, and historically more vulnerable groups of patients, in a principled way.
Authors: Lori Seller1,2, Marie-Ève Bouthillier3, Veronique Fraser1
Affiliations:
1 Centre for Applied Ethics, McGill University Health Centre
2 Biomedical Ethics Unit, McGill University
3 Centre Intégré de Santé et de Services Sociaux de Laval
Competing interests: None declared.