Ethical tensions emerge over dying with dignity

Medical assistance in dying (MAID) has received lots of media attention over the past few years. This is especially true as the Canadian government considers expanding eligibility for people whose sole underlying condition is a mental illness.

Even in its present form, MAID is fraught with ethical tensions. As scholars engaged in research on MAID, we have heard about these tensions firsthand through interviews with physicians and nurses who provide MAID-related care, clinical ethicists who perform MAID-related consults, family members of patients who have received MAID and patients who have requested MAID.

Tensions can contribute to unpredictability in health service provision, strained relationships, moral distress, harm for prospective patients and the erosion of public trust.

There is debate about whether a health-care worker can participate in both palliative care and the MAID program.

Palliative care involves efforts to improve the quality of life of patients facing serious or life-threatening illness by preventing or relieving suffering.

MAID, on the other hand, provides patients experiencing intolerable suffering the option to end their lives with the assistance.

Some people see the two services as coexisting within end-of-life care. Others view them as having incompatible intentions and goals, and being in conflict.

For instance, as one medical professional informed us, pharmaceuticals that might be provided to relieve pain during palliative care could undermine cognitive capacity and limit a patient’s ability to consent to MAID.

“It was brutal. I knew at that time we wouldn’t be able to do the provision because we would have to medicate her so much … then we’d have to reverse it to get consent, and that was really hard.”

Examples like this reveal the tensions that medical professionals might face if they seek to provide both palliative care and MAID. We also heard that some palliative care professionals perceive MAID requests as a failure of their efforts to provide palliative care.

This can potentially place strain on professional relationships between MAID providers and palliative care teams, or cause moral distress for palliative care providers.

The federal government notes the importance of transparency for the improvement of MAID and maintenance of public trust.

However, patients and care providers sometimes have strict privacy concerns, wanting their participation in MAID kept confidential because of disapproving family, colleagues or community members.

This is particularly true in smaller communities where privacy may be more limited, health-care professionals are highly visible and people may be concerned about MAIDrelated stigma.

When medical providers are asked to assist patients in secrecy, transparency may become compromised.

“Staff had to really balance transparency with confidentiality … One of those transparency pieces, very clearly from the government, was accurate recording, so that there was nothing secret … [But] we’ve had patients who have said, ‘I don’t want my family to know.’ But they’re going to find out what the cause of death was; the death certificate is very clear.”

In cases like this, medical professionals are placed in the difficult position of not being able to accommodate privacy requests of patients or family members, as doing so could undermine ethical obligations of transparency and professional accountability.

MAID is often celebrated for supporting suffering patients to exercise control and die with dignity.

With the passage of Bill C-7, which removed the requirement of a reasonably foreseeable death, Canadians are now applying for MAID when suffering is impacted by socioeconomic factors such as inadequate housing, medical care, food security or income supports.

Tensions surrounding MAID place staff in complex ethical predicaments and are deserving of greater attention. We encourage the federal government to reconsider its role in improving the quality of life of its citizens.

In many situations, Bill C-7 has made “dying with dignity” easier than “living with dignity.” It is ethically problematic if a state is more willing to facilitate death than to provide the necessities of life.