Deceased organ and tissue donation after medical assistance in dying and other conscious and competent donors: guidance for policy

James Downar, Sam D. Shemie, Clay Gillrie, Marie-Chantal Fortin, Amber Appleby, Daniel Z. Buchman, Christen Shoesmith, Aviva Goldberg, Vanessa Gruben, Jehan Lalani, Dirk Ysebaert, Lindsay Wilson and Michael D. Sharpe

Canadian Medical Association Journal


  • First-person consent for organ donation after medical assistance in dying (MAiD) or withdrawal of life-sustaining measures (WLSM) should be an option in jurisdictions that allow MAiD or WLSM and donation after circulatory determination of death.
  • The most important ethical concern — that the decision for MAiD or WLSM is being driven by a desire to donate organs — should be managed by ensuring that any discussion about organ donation takes place only after the decision for MAiD or WLSM is made.
  • If indications for MAiD change, this guidance for policies and the practice of organ donation after MAiD should be reviewed to ensure that the changes have not created new ethical or practical concerns. . .
  • [Full text]

Downar J, Shemie SD, Gillrie C, Fortin M-C, Amber Appleby A, Buchman DZ, Shoesmith C, Goldberg A, Gruben V, Lalani J, Ysebaert D, Wilson L, Sharpe MD.  Deceased organ and tissue donation after medical assistance in dying and other conscious and competent donors: guidance for policy. CMAJ. 2019 Jun 3;191(22):E604-E613. doi: 10.1503/cmaj.181648.

U.S. Public Health Service STD Experiments in Guatemala (1946–1948) and Their Aftermath

Kayte Spector-Bagdady, Paul A. Lombardo

Ethics and Human Research


The U.S. Public Health Service’s sexually transmitted disease (STD) experiments in Guatemala are an important case study not only in human subjects research transgressions but also in the response to serious lapses in research ethics. This case study describes how individuals in the STD experiments were tested, exposed to STDs, and exploited as the source of biological specimens—all without informed consent and often with active deceit. It also explores and evaluates governmental and professional responses that followed the public revelation of these experiments, including by academic institutions, professional organizations, and the U.S. federal government, pushing us to reconsider both how we prevent such lapses in the future and how we respond when they are first revealed.

SpectorBagdady K, Lombardo PA. U.S. Public Health Service STD Experiments in Guatemala (1946–1948) and Their Aftermath. Ethics & Human Research. 2019 Apr; 41(2): 29-34.

A right to be unconscious

Julian Savulescu, Janet Radcliffe-Richards


[Referring to Sinmyee et al] This seems to us to be an important, landmark paper. This is because the issues it addresses are important in their own right: how to ensure death without suffering in jurisdictions where assisted dying (including assisted suicide or euthanasia) is allowed, and also, because the technicalities are the same, in cases of capital punishment by lethal injection. Moreover, the paper shows the potential for the use of anaesthesia in contexts beyond surgery. Anaesthesia in its ordinary uses is intended to facilitate surgery designed to restore a patient to improved health and functioning. In assisted dying, however, there is no question of restoring health. The proposition is to use anaesthesia primarily to prevent suffering in a patient who is about to die and, in this sense, places anaesthesia on a new footing as a primary medical intervention, serving a purpose in its own right.

Savulescu J, Radcliffe-Richards J.  A right to be unconscious. Anaesthesia. 2019 May; 74(5): 557-559

Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying

S. Sinmyee V. J. Pandit J. M. Pascual A. Dahan T. Heidegger G. Kreienbühl D. A. Lubarsky J. J. Pandit



A decision by a society to sanction assisted dying in any form should logically go hand-in-hand with defining the acceptable method(s). Assisted dying is legal in several countries and we have reviewed the methods commonly used, contrasting these with an analysis of capital punishment in the USA. We expected that, since a common humane aim is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress, there might be a single technique being used.

However, the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined. In voluntary assisted dying (in some US states and European countries), the common method to induce unconsciousness appears to be self-administered barbiturate ingestion, with death resulting slowly from asphyxia due to cardiorespiratory depression. Physician-administered injections (a combination of general anaesthetic and neuromuscular blockade) are an option in Dutch guidelines. Hypoxic methods involving helium rebreathing have also been reported.

The method of capital punishment (USA) resembles the Dutch injection technique, but specific drugs, doses and monitoring employed vary. However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness. This raises a concern that some deaths may be inhumane, and we have used lessons from the most recent studies of accidental awareness during anaesthesia to describe an optimal means that could better achieve unconsciousness. We found that the very act of defining an ‘optimum’ itself has important implications for ethics and the law.

Sinmyee S, Pandit VJ, Pascual JM, Dahan A, Heidegger T, Kreienbühl G, Lubarsky DA, Pandit JJ. Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying. Anaesthesia. 2019 May;74(5): 630-637.

Not here: Catholic Hospital Systems and the Restriction Against Transgender Healthcare

Eric Plemons

Not here: Catholic Hospital Systems and the Restriction Against Transgender Healthcare

. . . Over the past five years, however, public and
private health insurance coverage for transition-related surgery has increased exponentially.2 As available funds have increased, so has demand for services.3 American institutions are now struggling to meet a growing demand for competent, efficient, and effective transgender
healthcare that they had denied for decades. . . . The rapid expansion of Catholic hospitals is a concern for transgender people, their advocates, and the insurers who provide their health coverage because Catholic hospitals do not provide transition-related care. . .

Plemons E. Not here: Catholic Hospital Systems and the Restriction Against Transgender Healthcare. Crosscurrents. 2018 Dec; 68(4): 533-549.

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


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 .

Drawing the line on physician-assisted death

Lynn A. Jansen, Steven Wall, Franklin G. Miller

Journal of Medical Ethics


Drawing the line on physician assistance in physician-assisted death (PAD) continues to be a contentious issue in many legal jurisdictions across the USA, Canada and Europe. PAD is a medical practice that occurs when physicians either prescribe or administer lethal medication to their patients. As more legal jurisdictions establish PAD for at least some class of patients, the question of the proper scope of this practice has become pressing. This paper presents an argument for restricting PAD to the terminally ill that can be accepted by defenders as well as critics of PAD for the terminally ill. The argument appeals to fairness-based paternalism and the social meaning of medical practice. These two considerations interact in various ways, as the paper explains. The right way to think about the social meaning of medical practice bears on fair paternalism as it relates to PAD and vice versa. The paper contends that these considerations have substantial force when directed against proposals to extend PAD to non-terminally ill patients, but considerably less force when directed against PAD for the terminally ill. The paper pays special attention to the case of non-terminally ill patients who suffer from treatment-resistant depression, as these patients present a potentially strong case for extending PAD beyond the terminally ill.

Jansen LA, Wall S, Miller FG. Drawing the line on physician-assisted death. J Med Ethics. 2019;45:190-197.

Rawls, Reasonableness, and Conscientious Objection in Health Care

Xavier Symons

Rawls, Reasonableness, and Conscientious Objection in Health Care

Much ink has been spilled in recent years over the controversial topic of conscientious objection in health care. In particular, commentators have proposed various ways with which we might distinguish legitimate conscience claims from those that are poorly reasoned or based on prejudice. The aim of this chapter is to argue in favor of the “reasonableness” approach to conscientious objection, viz., the view that we should develop an account of “reasonableness” and “reasonable disagreement” and use this as a way of distinguishing licit and illicit conscience claims. The author discusses Rawls’ account of “reasonableness” and “reasonable disagreement,” and consider how this might guide us in regulating conscientious objection in health care. The author analyzes the “public reason” account offered in Card (2007, 2014), and argue that we should modify Card’s account to include a consensus among regulators about what counts as “basic medical care.” The author suggests that Medical Conscientious Objection Review boards should consider whether conscience-based refusals are based on defensible ethical foundations.

Symons X. Rawls, Reasonableness, and Conscientious Objection in Health Care. In: Grant B, Drew J, Christensen H, editors. Applied Ethics in the Fractured State (Research in Ethical Issues in Organizations, Vol. 20). Bingley, UK: Emerald Publishing Limited; 2018. p. 45-54.

Nurses’ use of conscientious objection and the implications for conscience

Christina Lamb, Marilyn Evans, Yolanad Babenko-Mould, Carol Wong, Ken Kirkwood

Journal of Advanced Nursing


Aims: To explore the meaning of conscience for nurses in the context of conscientious objection (CO) in clinical practice. Design: Interpretive phenomenology was used to guide this study.

Data sources: Data were collected from 2016 ‐ 2017 through one‐on‐one interviews from eight nurses in Ontario. Iterative analysis was conducted consistent with interpretive phenomenology and resulted in thematic findings. Review methods: Iterative, phased analysis using line‐by‐line and sentence highlighting identified key words and phrases. Cumulative summaries of narratives thematic analysis revealed how nurses made meaning of conscience in the context of making a CO.

Impact: This is the first study to explore what conscience means to nurses, as shared by nurses themselves and in the context of CO. Nurse participants expressed that support from leadership, regulatory bodies, and policy for nurses’ conscience rights are indicated to address nurses’ conscience issues in practice settings.

Results: Conscience issues and CO are current, critical issues for nurses. For Canadian nurses this need has been recently heightened by the national legalization of euthanasia, known as Medical Assistance in Dying in Canada. Ethics education, awareness, and respect for nurses’ conscience are needed in Canada and across the profession to support nurses to address their issues of conscience in professional practice.

Conclusion: Ethical meaning emerges for nurses in their lived experiences of encountering serious ethical issues that they need to professionally address, by way of conscience‐based COs.

Lamb C, Evans M, Babenko-Mould Y, Wong C, Kirkwood Ken. Nurses’ use of conscientious objection and the implications for conscience. J Adv Nurs 2018 Oct 16. doi: 10.1111/jan.13869

Is Euthanasia Psychiatric Treatment? The Struggle With Death on Request in the Netherlands

Damiaan Denys

The American Journal of Psychiatry

A 42-year-old married woman with three children was referred to our department for treatment of treatment-resistant depression. Pharmacotherapy, psychotherapy, and ECT were unsuccessful. We applied deep brain stimulation, which was partially effective and reduced depressive symptoms by 30%, but the patient still suffered. During our struggle to find optimal deep brain stimulation parameters in the course of treatment, the patient requested that her general physician provide euthanasia. Following guidelines in the Netherlands, our team was consulted, but we disapproved because her suffering was not prospectless and there still were treatment options with deep brain stimulation. Although we had treated her intensively for 2 years, our advice was disregarded. Eight weeks later we received the obituary of the patient.

Denys D. Is Euthanasia Psychiatric Treatment? The Struggle With Death on Request in the Netherlands. Am J Psychiatry. 2018 Sep 1;175(9):822-823. doi: 10.1176/appi.ajp.2018.18060725.