Ethics Debated in Raising Idea of Assisted Death

In recent years, open and frank discussions about end of life have become more normalized, and a growing number of older adults and people with terminal illnesses have been empowered to express their wishes for a “good death”.  While there are often unforeseen challenges, palliative care has adapted and grown to become an essential component of providing support and quality of life for patients and their families.  New guidance for Canadian doctors goes one step further, suggesting that when assisted death is a “medically relevant” option, doctors should bring up the subject as part of the informed consent process. 

According to a recent London Free Press article, the Canadian Association of MAID (Medical Assistance in Dying) Assessors and Providers says there is no legal restriction on who can raise the matter of MAID with someone who meets the criteria for assisted death.   But because of the power dynamic between doctor and patient, most jurisdictions with legalized euthanasia prohibit or strongly discourage doctors from bringing up the subject of assisted dying.  The request must come from the individual, without prompting, to be sure there is no ethical dilemma concerning whether or not the patient has chosen to end their life without the influence of their doctor. 

If the topic of assisted death is raised by a doctor first, ethicists argue that patients would infer the “treatment option” as a suggestion, no matter how carefully worded the conversation.  Patients would also realize they meet the criteria for a medically assisted death or the topic would not be raised – a concern for patients who are depressed, are living in poverty, or feel they are a burden to their family.  The line between informed treatment and undue influence can blur under these circumstances. 

On the other side of the argument, not informing patients of all their options may lead to unnecessary suffering or missing the window of opportunity when conversations about end-of-life goals and values can be clarified.  Patients may not even be aware that assisted death is legal in their country if they are newer citizens, or lived a more isolated life. 

The timing of the discussion disclosing the availability of MAID, according to CAMAP, should be at the discretion of the doctor once all treatment options, or stopping treatment, have been presented and discussed.   Bringing up MAID while giving a patient a terminal diagnosis would not be appropriate, but rather should be discussed later within the context of establishing goals of care and wishes based on individual values. 

Read more about raising Medical Assistance in Dying as a clinical care option by following this link to a recent CAMAP document that guides doctors and nurse practitioners in navigating MAID as the eligibility criteria expand.