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Lyon C. Canada's Medical Assistance in Dying System can Enable Healthcare Serial Killing. HEC Forum 2024:10.1007/s10730-024-09528-3. [PMID: 39093520 DOI: 10.1007/s10730-024-09528-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 08/04/2024]
Abstract
The Canadian approach to assisted dying, Medical Assistance in Dying (MAiD), as of early 2024, is assessed for its ability to protect patients from criminal healthcare serial killing (HSK) to evaluate the strength of its safeguards. MAiD occurs through euthanasia or self-administered assisted suicide (EAS) and is legal or considered in many countries and jurisdictions. Clinicians involved in HSK typically target patients with the same clinical features as MAiD-eligible patients. They may draw on similar rationales, e.g., to end perceived patient suffering and provide pleasure for the clinician. HSK can remain undetected or unconfirmed for considerable periods owing to a lack of staff background checks, poor surveillance and oversight, and a failure by authorities to act on concerns from colleagues, patients, or witnesses. The Canadian MAiD system, effectively euthanasia-based, has similar features with added opportunities for killing afforded by clinicians' exemption from criminal culpability for homicide and assisted suicide offences amid broad patient eligibility criteria. An assessment of the Canadian model offers insights for enhancing safeguards and detecting abuses in there and other jurisdictions with or considering legal EAS. Short of an unlikely recriminalization of EAS, better clinical safeguarding measures, standards, vetting and training of those involved in MAiD, and a radical restructuring of its oversight and delivery can help mitigate the possibility of abuses in a system mandated to accommodate homicidal clinicians.
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Affiliation(s)
- Christopher Lyon
- Department of Environment and Geography, University of York, York, YO10 5DD, UK.
- Leverhulme Centre for Anthropocene Biodiversity, University of York, York, YO10 5DD, UK.
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Choi WJW, Astrachan IM, Sinaii N, Kim SYH. When medical assistance in dying is not a last resort option: survey of the Canadian public. BMJ Open 2024; 14:e087736. [PMID: 38910003 DOI: 10.1136/bmjopen-2024-087736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
OBJECTIVES What are the Canadian public's understanding of and views toward medical assistance in dying (MAID) in persons refusing recommended treatment or lacking access to standard treatment or resources? DESIGN/SETTING An online survey assessed knowledge of and support for Canadian MAID law, and views about four specific scenarios in a two (medical or psychiatric) by two (treatment refusal or lack of access) design. PARTICIPANTS A quota sample (N=2140) matched to the 2021 Canadian census by age, gender, income, education and province. MAIN OUTCOMES Participants' level of support for MAID in general and in the four specific scenarios. RESULTS Only 12.1% correctly answered ≥4 of 5 knowledge questions about the MAID law; only 19.2% knew terminal illness is not required and 20.2% knew treatment refusal is compatible with eligibility. 73.3% of participants expressed support for the MAID law in general, matching a nationally representative poll that used the same question. 40.4% of respondents supported MAID for mental illnesses. Support for MAID in the scenarios depicting refusal or lack of access to treatment ranged from 23.2% (lack of access in medical condition) to 32.0% (treatment refusal in medical illness). Older age, more education, higher income, lower religious attendance or being white was associated with greater support for MAID in general but was either negatively associated or not associated with support for MAID in the four refusal or lack of access scenarios. CONCLUSIONS Most Canadians support the current MAID law but appear unaware that MAID cases they do not support are compatible with that law. The lower support for MAID in the four scenarios cuts across sociodemographics. The gap between current policy and public opinion warrants further study. For jurisdictions debating MAID, opinion surveys may need to go beyond assessing general attitudes, and target knowledge and views regarding implications of legalisation.
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Affiliation(s)
- William J W Choi
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, NIH Clinical Center, Bethesda, Maryland, USA
| | - Scott Yung Ho Kim
- Department of Bioethics, NIH Clinical Center, Bethesda, Maryland, USA
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Shenouda J, Blaber M, George R, Haslam J. The debate rages on: physician-assisted suicide in an ethical light. Br J Anaesth 2024; 132:1179-1183. [PMID: 38290905 DOI: 10.1016/j.bja.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 12/22/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
The British Medical Association and some Royal Colleges have recently changed their stance on physician-assisted suicide from 'opposed' to forms of 'neutral'. The Royal College of Anaesthetists will poll members soon on whether to follow suit. Elsewhere neutrality amongst professional bodies has preceded legalisation of physician-assisted suicide. We examine the arguments relevant to the anaesthesia community and its potential impact in the UK.
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Affiliation(s)
- John Shenouda
- Anaesthetics, Perioperative Medicine and Pain Department, The Royal Marsden Hospital, London, UK.
| | - Michael Blaber
- Connected Palliative Care, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Robert George
- Department of Palliative Care and Policy, Cicely Saunders' Institute, King's College London, London, UK
| | - James Haslam
- Radnor Intensive Care Unit, Salisbury NHS Foundation Trust, Salisbury, UK
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DiDanieli M. Autonomy is not a sufficient basis for analysing the choice for medical assistance in dying in unjust conditions: in favour of a dignity-based approach. JOURNAL OF MEDICAL ETHICS 2024; 50:421-422. [PMID: 37414540 DOI: 10.1136/jme-2023-109284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 06/09/2023] [Indexed: 07/08/2023]
Abstract
In their paper titled Choosing death in unjust conditions: hope, autonomy and harm reduction, Wiebe and Mullin argue against the stance of diminished autonomy in chronically ill, disabled patients living in unjust sociopolitical environments who pursue medical assistance in dying (MAiD). They suggest that it would be paternalistic to deny these people this choice and conclude that MAiD should actually be seen as a form of harm reduction for them.This response to their article argues that basing discussions surrounding this important topic on a single bioethical concept does not address the needs of this cohort and is restrictively siloed. The discussion should include considerations of human rights and the need for legislative reforms to address social conditions, in addition to traditional bioethical principles. Work in this area needs to become interdisciplinary and collaborative as well as integrate input from the patients themselves. The concept of the dignity of these patients, in its broadest sense, needs to be infused into the discussion in order to optimise the exploration for solutions for this cohort.The stance of MAiD as harm reduction, in this context, does not meet the definition of harm reduction, nor does it represent a commitment to the best interests of these patients.
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Affiliation(s)
- Maria DiDanieli
- Burlington Family Health Team, Burlington Ontario Health Team, Burlington, Ontario, Canada
- Edinburgh School of Law, The University of Edinburgh, Edinburgh, UK
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Christie T, Li M. Medically assisted dying in Canada and unjust social conditions: a response to Wiebe and Mullin. JOURNAL OF MEDICAL ETHICS 2024; 50:423-424. [PMID: 37451856 DOI: 10.1136/jme-2023-109327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
In the paper, titled 'Choosing death in unjust conditions: hope, autonomy and harm reduction,' Wiebe and Mullin argue that people living in unjust social conditions are sufficiently autonomous to request medical assistance in dying (MAiD). The ethical issue is that some people may request MAiD primarily because of unjust social conditions, not their illness, disease, disability or decline in capability. It is easily agreed that people living in unjust social conditions can be autonomous. Nevertheless, Wiebe and Mullin fail to appreciate that autonomy is only a necessary condition for MAiD. In addition to autonomy, one must decide that providing assisted dying to a patient because they are living in unjust social conditions is ethical. Central to making this ethical decision is the principle of non-maleficence, famously articulated as 'do no harm.' The authors admit that performing MAiD in response to unjust social circumstances is harmful, but they justify this harmful action by appealing to the principle of harm reduction. A fundamental flaw of their approach is that it relies on the legislative definition of intolerable suffering, which is based on circular reasoning and given that 99.2% of patients that have applied for MAiD satisfied this criterion, it is essentially equivalent to no standard/criterion. Canadian society is struggling with the ethical implications of its permissive MAiD programme, and, fundamental to this debate, will be determining the proper balance between autonomy and non-maleficence for people living in unjust social conditions.
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Affiliation(s)
- Timothy Christie
- Ethics Services, Horizon Health Network, Saint John, New Brunswick, Canada
- Adjunct Professor of Bioethics, Dalhousie University, Halifax, Nova Scotia, Canada
- Adjunct Professor of Philosophy, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Madeline Li
- Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Clinician Scientist, Department of Supportive Care, Princess Margaret Cancer Center, Toronto, Ontario, Canada
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Lyon C. Words matter: 'enduring intolerable suffering' and the provider-side peril of Medical Assistance in Dying in Canada. JOURNAL OF MEDICAL ETHICS 2024:jme-2023-109555. [PMID: 38443165 DOI: 10.1136/jme-2023-109555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
Enduring intolerable suffering, an essential eligibility criterion in Medical Assistance in Dying (MAiD) in Canada and elsewhere, is a contradiction in terms, in that suffering must be tolerable to be endured. Cases of people who were approved for MAiD but who elected to die naturally, thus tolerating their suffering, bear out the unreliability of this central safeguard. The clinical assessment of intolerable suffering may be strengthened by adopting a definition of intolerable suffering centred on clinically evidenced physical and psychological decompensation. This argument also raises important questions about the risks of MAiD clinicians subjectively defining, approving and providing MAiD in ways that deviate from accepted legal and clinical concepts and ethics. Examples show some prolific clinicians describe MAiD in terminology that differs from such norms, as a personal mission, as personally pleasurable, and as a rights-based service. These alternative views are explored for their risks in assessing and providing MAiD for intolerable suffering. This further demonstrates the need for conceptual clarity in legislation, improved vetting and monitoring of clinicians, and a different assessment process to protect patients and clinicians.
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Affiliation(s)
- Christopher Lyon
- Leverhulme Centre for Anthropocene Biodiversity, University of York, York, UK
- Department of Environment and Geography, University of York, York, UK
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Stergiopoulos V, Bastidas-Bilbao H, Gupta M, Buchman DZ, Stewart DE, Rajji T, Simpson AIF, van Kesteren MR, Cappe V, Castle D, Shields R, Hawke LD. Care considerations in medical assistance in dying for persons with mental illness as the sole underlying medical condition: a qualitative study of patient and family perspectives. BMC Psychiatry 2024; 24:120. [PMID: 38355467 PMCID: PMC10865571 DOI: 10.1186/s12888-024-05541-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 01/19/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Persons with mental illness as their sole underlying medical condition are eligible to access medical assistance in dying (MAiD) in a small number of countries, including Belgium, the Netherlands, Luxemburg and Switzerland. In Canada, it is anticipated that people experiencing mental illness as their sole underlying medical condition (MI-SUMC) will be eligible to request MAiD as of March 17th 2024. To date, few studies have addressed patient and family perspectives on MAiD MI-SUMC care processes. This study aimed to address this gap and qualitatively explore the perspectives of persons with lived experience of mental illness and family members on care considerations during MI-SUMC implementation. METHODS Thirty adults with lived experience of mental illness and 25 adult family members residing in Ontario participated in this study. To facilitate participant engagement, the semi-structured interview used a persona-scenario exercise to discuss perspectives on MAiD MI-SUMC acceptability and care considerations. Framework analysis was used to inductively analyze data using NVivo 12 Pro. Steps, processes, or other care considerations suggested by the participants were charted in a framework matrix after familiarization with the narratives. Key themes were further identified. A lived-experience advisory group participated in every aspect of this study. RESULTS Six themes were developed from the patient and family narratives: (1) Raising MAiD MI-SUMC awareness; (2) Sensitive Introduction of MAiD MI-SUMC in goals of care discussions; (3) Asking for MAiD MI-SUMC: a person-focused response; (4) A comprehensive circle of MAiD MI-SUMC care; (5) A holistic, person-centered assessment process; and (6) Need for support in the aftermath of the decision. These themes highlighted a congruence of views between patient and family members and described key desired process ingredients, including a person-centred non-judgmental stance by care providers, inter-professional holistic care, shared decision making, and the primacy of patient autonomy in healthcare decision making. CONCLUSIONS Family and patient perspectives on the implementation of MAiD MI-SUMC offer important considerations for service planning that could complement existing and emerging professional practice standards. These stakeholders' perspectives will continue to be essential in MAiD MI-SUMC implementation efforts, to better address the needs of diverse communities and inform improvement efforts.
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Affiliation(s)
- Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
- University of Toronto, Toronto, Ontario, Canada.
| | | | - Mona Gupta
- Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Daniel Z Buchman
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Donna E Stewart
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Tarek Rajji
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Alexander I F Simpson
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Vivien Cappe
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - David Castle
- University of Tasmania, Hobart, Tasmania, Australia
- Statewide Mental Health Service, Hobart, Tasmania, Australia
| | - Roslyn Shields
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Lisa D Hawke
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
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Related Developments and Debates in Canada: Time Line and Publications. Hastings Cent Rep 2024; 54 Suppl 1:S49-S50. [PMID: 38382039 DOI: 10.1002/hast.1556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
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Triviño R, Rueda J, Rodríguez-Arias D. A Slippery Argument: Ableism in the Debate on Medical Assistance in Dying. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:99-102. [PMID: 37879033 DOI: 10.1080/15265161.2023.2256263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Affiliation(s)
| | - Jon Rueda
- University of California, San Diego
- University of Granada
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Güth U, Weitkunat R, McMillan S, Schneeberger AR, Battegay E. When the cause of death does not exist: time for the WHO to close the ICD classification gap for Medical Aid in Dying. EClinicalMedicine 2023; 65:102301. [PMID: 38021370 PMCID: PMC10660015 DOI: 10.1016/j.eclinm.2023.102301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Medical aid in dying (MAID) is a highly controversial ethical issue in the global medical community. Unfortunately, the International Classification of Diseases (ICD) of the World Health Organization (WHO) lacks coding for MAID. Therefore, no robust data adequately monitors worldwide trends that include information on diseases and conditions underlying the patients' request for assisted dying ("MAID gap"). Countries with legalised MAID observe substantial increases in cases, and likely additional countries will allow MAID in the near future. Hence, we encourage the WHO to create specific ICD codes for MAID. According to internationally established practices, a revised classification would require separate MAID-codes for (1) assisted suicide and (2) voluntary active euthanasia including supplemental codings of diseases, clusters of symptoms and function-oriented categories. By addressing these concerns, the WHO could close the "MAID gap" with new codes providing urgently necessary insights to society, public health decision-makers and regulators on this comparatively new social and medical ethical phenomenon. Search strategy and selection criteria Data for this Viewpoint were identified by searches of MEDLINE, PubMed, and references from relevant articles using the search terms "Medical Aid in Dying", "Assisted Dying", "Assisted suicide", "Voluntary active euthanasia", "End of life decisions" and "Cause of death statistics". Only articles and sources published in English between 1997 and 2023 were included."
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Affiliation(s)
- Uwe Güth
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, CH-4056 Basel, Switzerland
- Department of Breast Surgery, Brust-Zentrum Zürich, Seefeldstrasse 214, CH-8008 Zurich, Switzerland
| | - Rolf Weitkunat
- Federal Statistical Office, Espace de l'Europe 10, CH-2010 Neuchâtel, Switzerland
| | - Shaun McMillan
- Department of Breast Surgery, Brust-Zentrum Zürich, Seefeldstrasse 214, CH-8008 Zurich, Switzerland
| | - Andres R. Schneeberger
- Department of Psychiatry, University of California San Diego, 8950 Villa La Jolla Drive, La Jolla, CA 92037, USA
| | - Edouard Battegay
- International Center for Multimorbidity and Complexity in Medicine (ICMC), University of Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
- Department of Psychosomatic Medicine, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- Merian Iselin Klinik Basel, Föhrenstrasse 2; CH-4054 Basel, Switzerland
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Kim SYH. Canadian Medical Assistance in Dying and the Hegemony of Privilege. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:1-6. [PMID: 37930942 PMCID: PMC11146200 DOI: 10.1080/15265161.2023.2264096] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
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Coelho R, Maher J, Gaind KS, Lemmens T. The realities of Medical Assistance in Dying in Canada. Palliat Support Care 2023; 21:871-878. [PMID: 37462416 DOI: 10.1017/s1478951523001025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
OBJECTIVES To examine the impact of the Canadian MAiD program and analyze its safeguards. METHODS A working group of physicians from diverse practice backgrounds and a legal expert, several with bioethics expertise, reviewed Canadian MAiD data and case reports. Grey literature was also considered, including fact-checked and reliable Canadian mainstream newspapers and parliamentary committee hearings considering the expansion of MAiD. RESULTS Several scientific studies and reviews, provincial and correctional system authorities have identified issues with MAiD practice. As well, there is a growing accumulation of narrative accounts detailing people getting MAiD due to suffering associated with a lack of access to medical, disability, and social support. SIGNIFICANCE OF RESULTS The Canadian MAiD regime is lacking the safeguards, data collection, and oversight necessary to protect Canadians against premature death. The authors have identified these policy gaps and used MAiD cases to illustrate these findings.
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Affiliation(s)
| | - John Maher
- Ontario Association for ACT & FACT, Barrie, ON, Canada
| | - K Sonu Gaind
- Temerty Faculty of Medicine, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Trudo Lemmens
- Faculty of Law and Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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