Downie and Schuklenk1 provide a clear narrative of the development of Canadian policy on medically assisted dying. This is very helpful for considering specific aspects of the continuing deliberations in Canada. This commentary presents an alternative perspective on the authors’ argument that narrow eligibility criteria for medical assistance in dying are discriminatory and unjustified. I argue that disability or mental illness as sole reason for accessing MAiD removes protections for all people who have times in their life when they have (...) mental illness or disability combined with intolerable suffering. I claim that individuals do not make their best, self-actualising decisions at those times and the supposed protections of vague terms such as incurable, advanced and decline are not clinically useful for evaluating eligibility for individuals with chronic health conditions. Within discussion of the impact of social determinants of health on access to MAiD, the authors present the argument that decisionally capable people with mental illness or disabilities as their sole underlying condition should be allowed to access MAiD. The authors state that opposing this access sacrifices patient rights and strips people of their agency. To support their argument, they embrace the idea that people with mental illness or disabilities belong to an identifiable cohort. They claim that …. (shrink)

In this commentary, we criticize the argument that allowing euthanasia for people with disabilities is ableist. We analyze the distinction between facts and values in medical assistance in dying, the expressivist objection, and the problem of crypwashing.

In their contribution, Kok et al raise a relevant, though often underestimated, issue: clinical ethics support services are often assumed to lead to an improvement of quality of care at the organisational level, but evidence in support of this claim is weak, if not completely lacking.1 Therefore, the authors propose a complex theoretical model connecting a specific kind of CESS, moral case deliberation, with mechanisms for quality of care improvement at the individual and the organisational level. The proposal is original, (...) and the topic discussed of great interest not only to practitioners and researchers dealing with CESS, but also to health policy-makers and managers of healthcare system, for all of whom it is indeed crucial to understand whether and how ethics support can positively impact quality of care. However, despite its undoubtful merits, we feel that some claims and model’s underlying assumptions might require in-depth scrutiny and more solid justification. i. First, the authors discuss two different approaches to understanding quality of care: the first approach, which they define as reductionist, interprets quality as an outcome-oriented, quantitative, and therefore, measurable function. The second approach defines quality …. (shrink)

The purpose of this paper is to identify a kind of discrimination that has hitherto gone unrecognised. ‘Terminalism’ is discrimination against the dying, or treating the terminally ill worse than they would expect to be treated if they were not dying. I provide four examples from healthcare settings of this kind of discrimination: hospice eligibility requirements, allocation protocols for scarce medical resources, right to try laws and right to die laws. I conclude by offering some reflections on why discrimination against (...) the dying has been hard to identify, how it differs from ageism and ableism, and its significance for end-of-life care. (shrink)

Daryl Pullman (2023) highlights a striking statistic—while aid in dying constitutes less than one percent of deaths in the U.S. states that have legalized the practice,1 around three percent of dea...

In the Australian state of Victoria, legislation allowing voluntary assisted dying (VAD) passed through parliament in November 2017. There was then an eighteen-month period before the start date for patient access to VAD, referred to as the “implementation period.” The implementation period was intended to allow time for the relevant government department and affected organizations to develop processes before the Act came into effect in June 2019. This qualitative interview study investigates the perspectives of a multidisciplinary sample of twelve clinicians (...) from a single metropolitan hospital during this implementation period. Maximum variation sampling was utilized to ensure breadth across discipline (medical, nursing, allied health), speciality, and stated level of support for the VAD legislation. Four key themes were identified from the interview data: preparing for the unknown, ethical diversity within the organization, building a respectful culture, and concerns about the inability of the legislated approach to capture clinical nuances. Overall, these clinicians’ workplace experiences during the implementation period were shaped by the ethical diversity within their organization and a sense of uncertainty about how the VAD legislation would integrate with the practical realities of their clinical setting. The concept of “ethical diversity” could be a useful one for supporting staff in an organization during a VAD implementation period. (shrink)

Canada’s new medical assistance in dying law is ethically superior to the previous version. I agree with Udo Shuklenk and Jocelyn Downie1 that both social determinants of health and slippery slope objections to the recent amendments are unsuccessful.[1] Despite this broad agreement, I worry that the authors’ argument against the slippery slope objection is too focused on the current amendments at the expense of future changes. Before I address that argument, I have one point about the social determinants of health. (...) Any treatment that goes against a patient’s values is wrong. Critics of expanding MAiD criteria are concerned that expanded access will mean that persons with disabilities, among others, will be more likely to be pressured into getting an assisted death. Were there is evidence for this worry, it ought to be taken seriously. However, in my work as a clinical ethicist, it is overwhelmingly more common for me to be consulted about clinical situations where patient values are disregarded for the sake of invasive life-sustaining treatment, rather than concerns about hastened death. This takes different forms. In some cases, a healthcare provider or a family member will pressure a patient who has decision-making capacity. This is why patients occasionally ask that their request for MAiD be kept private from their family: the patient is worried about being pressured out of it. In non-MAiD cases, a patient’s substitute decision-maker will request treatment with the aim of maximising length of life, despite knowledge that the patient did not want life-sustaining treatment …. (shrink)

Canadian ethicists Jocelyn Downie and Udo Schuklenk seek to assess the effect of Canada’s decriminalisation of ‘medical assistance in dying’ ‘to inform Canada’s ongoing discussions and because other countries will confront the same questions if they contemplate changing their assisted dying law.’1 Their assessment focuses on two arguments earlier levied against expansion of these procedures. The first is that of a ‘slippery slope’ and the second is what they disingenuously call, ‘social determinants of health’. They conclude that, in both cases, (...) the effect of legislation permitting first limited and then expanded options for medical termination has been benign. The argument in this brief commentary is that the ‘slippery slope’ is clearly evident and support for those with chronic, progressive diagnoses a clear contributor to the ever increasing number of persons seeking MAID. Downie and Schuklenk first review the legal and legislative history of MAID. In Carter v Canada, the courts found …. (shrink)

This article seeks to assess the results of legislation legalizing medical termination, known in Canada as "medical aide in dying" in 2016. Its focus, like that of previous authors, is to ask if the concerns of skeptics opposed to legalization have been realized or were they unfounded. These include the likelihood of a “slippery slope” with an expanding definition of eligibility and of MAiD deaths. Of similar concern at least since 1995 was the likelihood that, in the absence of the (...) provision of palliative, rehabilitative, psychological and social services that medical termination would be a substitute for good medical care. These and other concerns are the basis for the review of MAiD in Canada clinically, legally and as an ethical construct. (shrink)

BackgroundWith the enactment of Bill C-7 in Canada in March 2021, people who are eligible for medical assistance in dying (MAiD), whose death is reasonably foreseeable and are at risk of losing decision-making capacity, may enter into a written agreement with their healthcare provider to waive the final consent requirement at the time of provision. This study explored healthcare providers’ perspectives on honouring eligible patients’ request for MAiD in the absence of a contemporaneous consent following their loss of decision-making capacity. (...) MethodA critical qualitative methodology, using a feminist ethics theoretical lens with its focus on power and relationality, was used to examine how socio-political and environmental contexts influenced healthcare providers' moral agency and perspectives. Semi-structured interviews were conducted with 30 healthcare providers (13 physicians, six nurse practitioners, nine nurses and two social workers) from across Canada who provide MAiD-related care.ResultsThemes identified include; (1) balancing personal values and professional responsibilities, (2) anticipating strengths and limitations of the proposed waiver of final consent amendment, (3) experiencing ethical influences on decisions to enter into written agreements with eligible patients, (4) recognizing barriers to the enactment of MAiD in the absence of a contemporaneous consent and (5) navigating the potential for increased risks and burden.DiscussionTo our knowledge, this is the first study in Canada to explore healthcare providers’ perspectives on waiving the final consent for MAiD using a written agreement. Most participants supported expanding eligible people’s access to MAiD following loss of capacity, as they believed it would improve the patients’ comfort and minimize suffering. However, the lack of patients’ input at the time of provision and related ethical and legal challenges may impact healthcare providers’ moral agency and reduce some patients’ access to MAiD. Providers indicated they would enter into written agreements to waive final consent for MAiD on a case-by-case basis. This study highlights the importance of organizational, legal and professional support, adequate resources, clear policies and guidelines for the safety and wellbeing of healthcare providers and to ensure equitable access to MAiD. (shrink)

BackgroundNo laws or official guidelines govern voluntary assisted dying (VAD) in Japan. A legislative bill on the termination of life-sustaining measures has yet to be sent to deliberations for legislation, due to strong opposition that has prevented it from being submitted to the Diet. However, Japan has recently witnessed several cases involving VAD.Main textAgainst this backdrop, we argue that Japan should begin discussion on VAD legislation, referring to the Voluntary Assisted Dying Act 2017 (VADA2017), which was established in 2017 in (...) Victoria, Australia. VADA2017 puts in place a wide range of stringent safeguards and is considered worldwide to be the safest and most conservative policy on a physician offering assisted dying based on the patient’s premeditated request. We consider what opposing opinions from society would arise in response to the VADA2017. Among these will include arguments against VAD itself, those against the validation of this act, and opinions that oppose even the initiation of the dialogue on VAD.ConclusionsWe conclude that to protect the right to life among those placed in vulnerable positions and, at the same time, to respect decision-making of those who wish for immediate death due to unbearable suffering, the dialogue must immediately begin with that on introducing a policy more conservative than that of the VADA2017, which solidly considers arguments against VAD. (shrink)

Background Medical assistance in dying (MAiD) sparks debate in several countries, some of which allow or plan to allow MAiD where a mental disorder is the sole underlying medical condition (MAiD-MD). Since MAiD-MD is becoming permissible in a growing number of jurisdictions, there is a need to better understand the moral concerns related to this option. Gaining a better understanding of the moral concerns at stake is a first step towards identifying ways of addressing them so that MAiD-MD can be (...) successfully introduced and implemented, where legislations allow it. Methods Thus, this article aims (1) to better understand the moral concerns regarding MAiD-MD, and (2) to identify potential solutions to promote stakeholders’ well-being. A qualitative thematic review was undertaken, which used systematic keyword-driven search and thematic analysis of content. Seventy-four publications met the inclusion criteria. Results Various moral concerns and proposed solutions were identified and are related to how MAiD-MD is introduced in 5 contexts: (1) Societal context, (2) Healthcare system, (3) Continuum of care, (4) Discussions on the option of MAiD-MD, (5) MAiD-MD practices. We propose this classification of the identified moral concerns because it helps to better understand the various facets of discomfort experienced with MAiD-MD. In so doing, it also directs the various actions to be taken to alleviate these discomforts and promote the well-being of stakeholders. Conclusion The assessment of MAiD-MD applications, which is part of the context of MAiD-MD practices, emerges as the most widespread source of concern. Addressing the moral concerns arising in the five contexts identified could help ease concerns regarding the assessment of MAiD-MD. (shrink)