Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations

Lori Seller, Marie Eve-Bouthillier, Veronique Fraser

Journal of Medical Ethics

Abstract

Background Medical aid in dying (MAiD) was introduced in Quebec in 2015. Quebec clinical guidelines recommend that MAiD be approached as a last resort when other care options are insufficient; however, the law sets no such requirement. To date, little is known about when and how requests for MAiD are situated in the broader context of decision-making in end-of-life care; the timing of MAiD raises potential ethical issues.

Methods A retrospective chart review of all MAiD requests between December 2015 and June 2017 at two Quebec hospitals and one long-term care centre was conducted to explore the relationship between routine end-of-life care practices and the timing of MAiD requests.

Results Of 80 patients requesting MAiD, 54% (43) received the intervention. The median number of days between the request for MAiD and the patient’s death was 6 days. The majority of palliative care consults (32%) came less than 7 days prior to the MAiD request and in another 25% of cases occurred the day of or after MAiD was requested. 35% of patients had no level of intervention form, or it was documented as 1 or 2 (prolongation of life remains a priority) at the time of the MAiD request and 19% were receiving life-prolonging interventions.

Interpretation We highlight ethical considerations relating to the timing of MAiD requests within the broader context of end-of-life care. Whether or not MAiD is conceptualised as morally distinct from other end-of-life options is likely to influence clinicians’ approach to requests for MAiD as well as the ethical importance of our findings. We suggest that in the wake of the 2015 legislation, requests for MAiD have not always appeared to come after an exploration of other options as professional practice guidelines recommend.

Seller L, Bouthillier M, Fraser V. Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations. J Med Ethics. 2019;45:106-111 .

Canadian ethicists prepare for the worst

Bioedge

 Michael Cook

Conscientious objection seems like the paradigmatic ethical choice between right and wrong. An ethicist, of all people, ought to have this option, just as mathematicians count or sopranos sing.

Not so fast, write two healthcare ethicists at the Centre for Applied Ethics at McGill University Health Centre, in Montreal, in the blog Impact Ethics. Now that the Canadian Supreme Court has declared that euthanasia is a human right, it is time to focus on who is entitled to conscientious objection to participating in euthanasia. And perhaps ethicists are not.

We found ourselves asking the following questions: Should a clinical ethicist have the right to conscientious objection in cases of medical aid in dying? Can the role of the clinical ethicist to provide ethics analysis in matters of moral ambiguity be reconciled with a right to opt-out on the basis of personal convictions?

The nub of the question is this: when an ethicist is asked for advice, is she involved as a human being or is she merely a database of ethical choices? The ethicists write:

On the other hand, there is a growing consensus that clinical ethics expertise is grounded in the competence of the clinical ethicist to facilitate a robust process aimed at ensuring fair and transparent healthcare decisions. The clinical ethicist is expected to adopt a stance of neutrality which allows her to facilitate discussion of competing values without allowing her own beliefs to influence the discussion.

On this view, it is not the “rightness” or “wrongness” of the final outcome by which the clinical ethicist is professionally judged, but rather her skill in guiding various stakeholders through a reasonable process; a clinical ethicist’s personal convictions should not impact on her ability to facilitate this process. In this sense, perhaps the right to conscientious objection is antithetical to the provision of clinical ethics consultation, as it seems to call into question the profession’s ability to remain neutral on morally contentious issues.

There is an urgent need, the authors write, to articulate the rights and duties of healthcare ethicists, as in the wake of Carter v Canada, the euthanasia case, the boundaries will be tested.

It would be interesting indeed if Canadian ethicists who oppose euthanasia are told to pack their bags and look elsewhere for jobs. What do unemployed ethicists do? Work in Starbucks? Become an Uber driver? There are some great ideas at the website of the Unemployed Philsophers Guild — making coffee mugs, finger puppets, and scented soap.


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