Bioethics in Aid in Dying

Ethical issues surrounding Medical Assistance in Dying (MAID) typically center around the principles of autonomy, beneficence, justice, and non-maleficence. Although MAID is legal in certain jurisdictions within the United States, it remains a topic of debate, particularly regarding its potential impact on individuals with mental illnesses. In jurisdictions such as Canada, MAID has been approved for patients with mental illness, but its implementation is currently delayed until March 2024 to allow for the development of practice standards and appropriate training. Since the practice of MAID largely depends on the patient’s legal capacity to make an informed choice, it has prompted numerous ethical dilemmas, some of which are discussed here.

Autonomy is generally defined as an individual’s ability to make decisions that will affect their lives, including decisions regarding their care. In the context of autonomy, if a patient with a mental illness has the capacity and competence to make an informed decision regarding their care, they can request that their physician evaluate their suitability for MAID. It can be argued, however, that some patients may experience impaired judgment or decision-making due to the symptoms of their mental illness, raising questions about their mental competence. Some studies have found that although depression can influence decision-making capacity, it does not necessarily reflect patient incompetence. As many as 75% of patients with mental illnesses may possess the capacity to make their own healthcare decisions. 

Mental illnesses can be episodic in nature, which means that symptoms can improve over time if the patient receives suitable treatment. Symptoms can also worsen if the patient is exposed to traumatic experiences, stress, or other triggering factors. The principles of non-maleficence and beneficence, which address the duty to do no harm and to promote good, can be viewed as conflicting positions when considering patients who have requested MAID. If there is a chance that the patient’s mental status could improve with treatment, consenting to provide MAID could violate these principles since the practice affirms the patient’s decision to die. Another ethical consideration is that denying the patient’s request for MAID can be harmful if the patient genuinely believes that this is the only way to relieve their suffering. 

Another ethical dilemma can arise when considering the principle of justice, which emphasizes the importance of equality and fairness to all people. In the context of MAID, justice could mean that if MAID is accessible to patients who are terminally ill, the decision to withhold MAID from patients with treatment-resistant mental illness would be unjust. Conversely, some have argued that approving MAID for patients with mental illness might inadvertently perpetuate the misconception that mental illness cannot be effectively treated. Given the wide variety of ethical dilemmas surrounding MAID, debate among patients, policymakers, and caregivers will only continue as the landscape of this practice continues to evolve.

Sources 

“Your Questions on MAiD and Mental Illness”. CAMH. https://www.camh.ca/en/camh-news-and-stories/maid-and-mental-illness-faqs 

“Suffering is not enough: Assisted dying for people with mental illness”. Bioethics. https://pmc.ncbi.nlm.nih.gov/articles/PMC9306695/ 

“Medical Assistance in Dying Should Not Exclude Mental Illness”. New York Times. https://www.nytimes.com/2023/04/21/opinion/medical-assistance-dying-mental-illness-maid.html 

“Medical Assistance in Dying: Challenges for Psychiatry”. Frontiers in Psychiatry. https://pmc.ncbi.nlm.nih.gov/articles/PMC6295549/ 

VSED is an acronym for voluntarily stopping eating and drinking as a means of hastening one’s death. It is most often chosen by persons who are terminally ill and experiencing increasing suffering but who do not qualify for medical aid in dying either because they are expected to live beyond the requisite 6 months or because they live in a state where medical aid in dying is prohibited by law. In some instances, an elderly person may choose VSED because they are simply “done” with living and are ready to die. 

Proponents of VSED cite it as a compassionate, relatively painless means to end one’s life, and for many people who choose the option, this is true. Depending on the person’s physical health, level of commitment and the amount of support available, the process can take as few as several days or as long as several weeks to complete. According to Compassion & Choices, the factors that most often impact the length of time it takes a person to die in this way include their:

• Age 
• Underlying illness
• Physical condition, including nutritional and hydration status
• Kidney function
• Ability to avoid all fluids, even ice chips
• Readiness to die

During VSED, the person undergoing the process usually needs a significant amount of support to maintain their fast. Hospice or a physician who is willing to provide symptom management are often, but not always required. Some people will require medications to alleviate anxiety or restlessness that comes from extreme thirst. Others can manage their discomfort with distractions such as reading, engaging with friends and family, or in spiritual pursuits. Again, the amount of time it takes for the person to succumb to starvation and dehydration varies greatly. Some people become unconscious in a matter of days while others remain alert and, in some cases uncomfortable for a considerable period of time. The latter scenario can be quite difficult for family members and caregivers, so it’s important to have adequate supports in place

It should be noted here that because VSED is voluntary, it does not require a doctor’s order and is completely legal in every state. Nevertheless, if you are contemplating VSED you may wish to spell out your wishes in your advance directive and, of course, let your health care proxy know what you plan to do. Additionally, you may create an advance directive that specifies that you do not want “assisted feeding” if you develop dementia and are unable to take in food on your own. These “dementia directives” are somewhat controversial, however. Those who oppose them argue that a person with capacity cannot impose that decision on their future self, who, despite being incapacitated, may very well wish to continue to eat and drink. For this reason, they are not legal in every state and, practically speaking, are often ignored.

Another ethical objection to VSED that has been raised by some is that it is tantamount to suicide, which an ethical society cannot support. However, this objection is generally considered unsustainable by the bioethics community, since in the vast majority of cases the person choosing VSED is already dying. They are simply taking control of the timing and manner of their death. 

Sources

“Washington Post Boosts Suicide by Self-Starvation”. National Review. https://www.nationalreview.com/corner/washington-post-boosts-suicide-by-self-starvation/ 

Patients who opt for Medical Aid in Dying (MAID) are provided with specific prescription medications that will be self-administered when the patient is ready to die, whereas euthanasia is differentiated by these medications being administered by a physician or healthcare staff. Euthanasia is illegal in the United States, and as of 2023, MAID is currently legal in 11 states and continues to receive advocacy in states where access is restricted. Another distinguishing factor is that there is only one type of MAID, but there are many different types of euthanasia and practices that are categorized as euthanasia. 

It is important to understand that the decision to withhold or withdraw life-sustaining interventions is not the same as euthanasia or MAID. Deciding to stop treatment is a common occurrence in healthcare, but the element of life-sustaining interventions is often unique to emergencies or end-of-life care scenarios. If the intervention no longer benefits the patient, doesn’t improve the patient’s quality of life, or no longer meets care goals, it is deemed appropriate to withdraw. If the patient has decision-making capacity, understands the outcome of their decision, and states that they no longer wish to receive the intervention, this also justifies the decision to withdraw. However, if the patient doesn’t have decision-making capacity, the decision may be made according to indications in an advance directive or transitioned to the patient’s surrogate in the absence of these documents. 

In contrast, specific criteria must be met to be eligible for MAID. Individuals must be at least 18 years of age or older, terminally ill with a prognosis of six months or less to live, have the capacity to make their own healthcare decisions and have the ability to self-administer the prescribed medication. If someone does not meet all four of these criteria, they are deemed ineligible and exceptions cannot be made. Since euthanasia is illegal in the United States, criteria are not used to determine eligibility, but rather to discern whether a patient’s death resulted from an illegal practice rather than natural causes. In other countries, euthanasia is only legal if physicians have fully adhered to the laws pertaining to the termination of life within the region.

MAID and euthanasia differ fundamentally in method, legality, and the level of involvement between the patient and the physician. Despite these differences, most people become interested in MAID or euthanasia for similar reasons. Many people fear the dying process and have concerns surrounding reduced quality of life, poor pain management, loss of bodily function, or lack of dignity as they become more reliant on others for care. Some individuals request MAID or euthanasia because it provides them with a sense of control regarding when and how they will die. Rationale varies based on each person’s values, preferences, and concerns pertaining to the end of life.  

As the societal conversation around end-of-life care continues to evolve, it’s crucial to understand the differences regarding MAID, euthanasia, and their implications in order to maintain informed and respectful discussions about these deeply personal decisions. Legislation and policies pertaining to MAID will continue to change as advocacy and the landscape surrounding end-of-life care continue to evolve and shift with the healthcare sector. Maintaining awareness of these changes and engaging in more open dialogues to reduce stigma can have a significant role in ensuring that patients with these wishes are understood, respected, and acknowledged appropriately. 

Sources 

“Reasons for requesting medical assistance in dying”. Canadian Family Physician. https://pmc.ncbi.nlm.nih.gov/articles/PMC6135145/ 

“Medical Aid in Dying”. Compassion & Choices. https://compassionandchoices.org/our-issues/medical-aid-in-dying/ 

Medical aid in dying or physician-assisted death is one of the most fervently debated topics in healthcare today. Although most Americans believe that physicians should have the right to help mentally competent, terminally ill adults end their lives, many religious groups and health care professionals are vehemently opposed. Nevertheless, as of this writing, nine states and the District of Columbia have legalized the practice either through legislation or the courts.

The ethical debate over medical aid in dying is, for the most part, divided between those who support the practice and those who oppose it on religious, moral or ethical grounds.

Ethical Arguments in Support of MAID

Those who support the practice of medical aid in dying do so based on the concepts of autonomy, justice, compassion, individual liberty, and honesty and transparency. 

Specifically, they include:

• Respect for autonomy: Competent human beings ought to have the right to decide when and under what circumstances they die. 

• Justice: Justice requires that we “treat all cases alike.” A person who is terminally ill has the right to refuse life-prolonging treatments, such as mechanical ventilation or dialysis. So, in cases where a terminally ill person is experiencing unbearable suffering but does not require life-saving treatments to prolong life, helping them end their lives is a just act. 

• Compassion: Suffering is much more than physical pain. A person may experience horrible suffering due to loss of independence, mobility, control of bodily functions and personal dignity. Sometimes, even the most compassionate care cannot relieve this kind of suffering. In that case, medical aid in dying is the most compassionate act.

• Honesty and transparency: By legalizing and legitimizing medical aid in dying, society encourages open and honest communication between patients and their doctors about end-of-life goals. This may ultimately lead to more compassionate end-of-life care. 

• Individual liberty: Although society has an interest in preserving and protecting life, that interest becomes less compelling when a person is terminally ill and wants to choose when and how they die. In these cases, personal liberty rightfully ought to supersede state interest. 

Ethical Arguments Against MAID

Many of those who object to medical aid in dying do so on moral or religious grounds. Others believe that allowing medical aid in dying is a “slippery slope” that puts vulnerable populations at risk. For physicians, objections may rest on professional integrity and the concept of “do no harm.” 

Specifically, some arguments against medical aid in dying include;

• Sanctity of life: Historically, both religious and secular traditions hold that life is sacred and that deliberately taking a life, even one’s own, is morally wrong. 

• Passive versus active: Although most people agree that withholding life-saving treatment is ethically defensible when a person is terminally ill, it can be argued that withholding treatment and allowing a person to die is not the same as actively helping a person to die. 

• Potential for abuse: Some believe that legitimizing medical aid in dying puts vulnerable populations, such as the poor, the disabled and the elderly, at risk of being pressured to end their lives either to ease the burden on caregivers or to cut costs. (Note: In Oregon, where medical aid in dying has been legal for 20 years, neither of these scenarios has come to pass.) 

• Professional integrity: The Hippocratic Oath, which many (but not all) medical school graduates take upon becoming a doctor, says in part, “I will not administer poison to anyone where asked,” and I will “be of benefit, or at least do no harm.” Many physicians believe this is a proscription against assisting a patient in ending their lives. What’s more, even physicians who support medical aid in dying in theory have expressed reservations about participating in the practice themselves.

• Fallibility: This argument contends that no physician is infallible, and prognoses are often wrong. Lapses in medical care can also occur, which, if rectified, might significantly improve a person’s quality of life. Doctors may also miss a diagnosis of depression in a terminally ill person who wants to end their life. 

Sources

“Assemblymember & NY Alliance for Medical Aid in Dying Question Medical Society of State of New York “Survey”. Compassion & Choices. https://compassionandchoices.org/news/assemblymember-ny-alliance-medical-aid-dying-question-medical-society-state-new-york-survey/