Medical Assistance in Dying — Implementing a Hospital-Based Program in Canada

Madeline Li, Sarah Watt, Marnie Escaf, Michael Gardam, Ann Heesters, Gerald O’Leary, and Gary Rodin

NEJM

Abstract
After Canada legalized medical assistance in dying (MAiD), the University Health Network in Toronto implemented a hospital-based MAiD program. UHN offers a framework for assessing patients for and providing MAiD while respecting the rights of patients and staff.


Li M, Watt S, Escaf M, Gardam M, Heesters A, O’Leary G, M.B., Rodin G. Medical Assistance in Dying — Implementing a Hospital-Based Program in Canada. N Engl J Med 2017; 376:2082-2088 May 25, 2017 DOI: 10.1056/NEJMms1700606

Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception

Julian Savulescu, Udo Schuklenk

Bioethics

Abstract:  In an article in this journal, Christopher Cowley argues that we have ‘misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors’. We have not. It is Cowley who has misunderstood the role of personal values in the profession of medicine. We argue that there should be better protections for patients from doctors’ personal values and there should be more severe restrictions on the right to conscientious objection, particularly in relation to assisted dying. We argue that eligible patients could be guaranteed access to medical services that are subject to conscientious objections by: (1) removing a right to conscientious objection; (2) selecting candidates into relevant medical specialities or general practice who do not have objections; (3) demonopolizing the provision of these services away from the medical profession.

Savulescu J, Schuklenk U.  (2016) Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception. Bioethics. doi:10.1111/bioe.12288

Why Are Religious Reasons Dismissed? Euthanasia, Basic Goods, and Gratuitous Evil

Stephen Napier

Christian Bioethics

Abstract:  Many proponents of euthanasia eschew appeals to religious premises as good reasons for thinking that human life has intrinsic worth. The reasons offered are that religious reasons do not meet some theory-neutral epistemic standard. My first argument is to show that pro-euthanasia arguments fail to meet those same standards. In order to avoid this incoherence, the rejection of religious reasons is a function of thinking that such reasons are simply false. Arguing against religious belief has typically fallen to the evidential argument from evil. My second argument is to show that the argument from evil must hold to a basic goods account of human life. Such an account is contrary to the view of human life held by most euthanasia proponents. So, euthanasia proponents who reject religious belief on the basis of an argument from evil must hold to a contradictory view of human worth. One cannot both be a euthanasia proponent and reject arguments against euthanasia (that are based in part on religious premises). I explore ways to resolve this tension, but none save pro-euthanasia arguments.

Napier S.  Why Are Religious Reasons Dismissed? Euthanasia, Basic Goods, and Gratuitous Evil. Christ Bioeth (2016) 22 (3): 276-300 doi:10.1093/cb/cbw012

Medical Assistance in Dying in Canada: An Ethical Analysis of Conscientious and Religious Objections

Dylan Dahlgren, Fred Koning, John Sloan, Timothy Christie

Bioethique Online

Abstract

Background: The Supreme Court of Canada (SCC) has ruled that the federal government is required to remove the provisions of the Criminal Code of Canada that prohibit medical assistance in dying (MAID). The SCC has stipulated that individual physicians will not be required to provide MAID should they have a religious or conscientious objection. Therefore, the pending legislative response will have to balance the rights of the patients with the rights of physicians, other health care professionals, and objecting institutions.

Objective: The objective of this paper is to critically assess, within the Canadian context, the moral probity of individual or institutional objections to MAID that are for either religious or conscientious reasons.

Methods: Deontological ethics and the Doctrine of Double Effect.

Results: The religious or conscientious objector has conflicting duties, i.e., a duty to respect the “right to life” (section 7 of the Charter) and a duty to respect the tenets of his or her religious or conscientious beliefs (protected by section 2 of the Charter).

Conclusion: The discussion of religious or conscientious objections to MAID has not explicitly considered the competing duties of the conscientious objector. It has focussed on the fact that a conscientious objection exists and has ignored the normative question of whether the duty to respect one’s conscience or religion supersedes the duty to respect the patient’s right to life.

Christie T, Sloan J, Dahlgren D, Konging F.  Medical Assistance in Dying in Canada: An Ethical Analysis of Conscientious and Religious Objections.  BioéthiqueOnLine, 2016, 5/14

Emerging assault on freedom of conscience

Stephen J. Genuis

Canadian Family Physician

Discussion on physician autonomy at the 2014 and 2015 Canadian Medical Association (CMA) annual meetings highlighted an emerging issue of enormous importance: the contentious matter of freedom of conscience (FOC) within clinical practice. In 2014, a motion was passed by delegates to CMA’s General Council,and affirmed by the Board of Directors, supporting the right of all physicians, within the bounds of existing legislation, to follow their conscience with regard to providing medical aid in dying. The overwhelming sentiment among those in attendance was that physicians should retain the right to choose when it comes to matters of conscience related to end-of-life intervention. Support for doctors refusing to engage in care that clashes with their beliefs was reaffirmed in 2015. However, a registrar from a provincial college of physicians and surgeons is reported to have a differing perspective, stating “Patient rights trump our rights. Patient needs trump our needs.1

So, do the personal wishes of doctors hold much sway in Canadian society, where physicians are increasingly perceived as publicly funded service providers? Should the colleges of physicians and surgeons have the power to remove competent physicians who refuse to violate their own conscience?

And what about FOC in a range of other thorny medical situations unrelated to physician-assisted dying?

Genuis SJ. Emerging assault on freedom of conscience.  Canadian Family Physician April 2016 vol. 62 no. 4 293-296  [Full text]

Legal and ethical aspects of organ donation after euthanasia in Belgium and the Netherlands

Jan Bollen,Rankie Ten Hoopen, Dirk Ysebaert, Walther van Mook, Ernst van Heurn

Journal of Medical Ethics

Abstract

Organ donation after euthanasia has been performed more than 40 times in Belgium and the Netherlands together. Preliminary results of procedures that have been performed until now demonstrate that this leads to good medical results in the recipient of the organs. Several legal aspects could be changed to further facilitate the combination of organ donation and euthanasia. On the ethical side, several controversies remain, giving rise to an ongoing, but necessary and useful debate. Further experiences will clarify whether both procedures should be strictly separated and whether the dead donor rule should be strictly applied. Opinions still differ on whether the patient’s physician should address the possibility of organ donation after euthanasia, which laws should be adapted and which preparatory acts should be performed. These and other procedural issues potentially conflict with the patient’s request for organ donation or the circumstances in which euthanasia (without subsequent organ donation) traditionally occurs.


Bollen J, Ten Hoopen R, Ysebaert D, van Mook W, van Heurn E. Legal and ethical aspects of organ donation after euthanasia in Belgium and the Netherlands. J Med Ethics. 2016 Aug;42(8):486-9. doi: 10.1136/medethics-2015-102898. Epub 2016 Mar 24.

Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living?

Eva Elizabeth Bolt, Marianne C Snijdewind, Dick L Willems, Agnes van der Heide, Bregje D Onwuteaka-Philipsen

Journal of Medical Ethics

Abstract

Background Euthanasia and physician-assisted suicide (EAS) in patients with psychiatric disease, dementia or patients who are tired of living (without severe morbidity) is highly controversial. Although such cases can fall under the Dutch Euthanasia Act, Dutch physicians seem reluctant to perform EAS, and it is not clear whether or not physicians reject the possibility of EAS in these cases.

Aim To determine whether physicians can conceive of granting requests for EAS in patients with cancer, another physical disease, psychiatric disease, dementia or patients who are tired of living, and to evaluate whether physician characteristics are associated with conceivability. A cross-sectional study (survey) was conducted among 2269 Dutch general practitioners, elderly care physicians and clinical specialists.

Results The response rate was 64% (n=1456). Most physicians found it conceivable that they would grant a request for EAS in a patient with cancer or another physical disease (85% and 82%). Less than half of the physicians found this conceivable in patients with psychiatric disease (34%), early-stage dementia (40%), advanced dementia (29–33%) or tired of living (27%). General practitioners were most likely to find it conceivable that they would perform EAS.

Conclusions This study shows that a minority of Dutch physicians find it conceivable that they would grant a request for EAS from a patient with psychiatric disease, dementia or a patient who is tired of living. For physicians who find EAS inconceivable in these cases, legal arguments and personal moral objections both probably play a role.


Bolt EE, Snijdewind MC, Willems DL, van der Heide A, Onwuteaka-Philipsen BD. Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living? J Med Ethics doi:10.1136/medethics-2014-102150

Medical students’ attitudes towards conscientious objection: a survey

Sven Jakob Nordstrand, Magnus Andreas Nordstrand, Per Nortvedt, Morten Magelssen

Journal of Medical Ethics

Objective: To examine medical students’ views on conscientious objection and controversial medical procedures.

Methods: Questionnaire study among Norwegian 5th and 6th year medical students.

Results: Five hundred and thirty-one of 893 students (59%) responded. Respondents object to a range of procedures not limited to abortion (up to 19%)—notably euthanasia (62%), ritual circumcision for boys (52%), assisted reproduction for same-sex couples (9.7%) and ultrasound in the setting of prenatal diagnosis (5.0%). A small minority (4.9%) would object to referrals for abortion. In the case of abortion, up to 55% would tolerate conscientious refusals, whereas 42% would not. Higher proportions would tolerate refusals for euthanasia (89%) or ritual circumcision for boys (72%).

Discussion: A majority of Norwegian medical students would object to participation in euthanasia or ritual circumcision for boys. However, in most settings, many medical students think doctors should not be able to refuse participation on grounds of conscience. A minority would accept conscientious refusals for procedures they themselves do not object to personally. Most students would not accept conscientious refusals for referrals.

Conclusions: Conscientious objection remains a live issue in the context of several medical procedures not limited to abortion. Although most would want a right to object to participation in euthanasia, tolerance towards conscientious objectors in general was moderate or low.


Nordstrand SJ, Nordstrand MA, Nortvedt P, Magelssen M. Medical students’ attitudes towards conscientious objection: a survey. J Med Ethics 2014;40:609-612 doi:10.1136/medethics-2013-101482

Canadian physicians warned to get ready for euthanasia and assisted suicide

Sean Murphy*

Canadian physicians warned to get ready for euthanasia and assisted suicide

Three physicians and a lawyer have written an article published in the May issue of the Canadian Medical Association Journal.[1] The lead author, Dr. James Downar, is co-chair of a euthanasia/assisted suicide advocacy group.

Anticipating a change in the law, the authors warn that “well-rehearsed debates” about sanctity of life and personal autonomy “may become obsolete.”

“We need to start to answer some challenging questions in preparation for the possibility that physician-assisted death will be available in Canada soon,” they write.

Among the questions they pose, one raises two particularly sensitive issues:

Will physicians who are conscientious objectors be obliged to present physician-assisted death as an option to patients and facilitate transfers of patients to other physicians or facilities?

As a matter of law and ethics, physicians are expected to advise patients of all reasonable legal options for treatment so that patients can provide informed consent to it.  However, many physicians who are strongly opposed to euthanasia and assisted suicide may view the “presentation of an option” for either procedure as inherently abusive of vulnerable patients.  This problem does not usually arise with respect to other morally contested procedures, like abortion or contraception.

A requirement to “facilitate transfers” of patients would probably be acceptable if it involved only the kind of  cooperation normally involved in the transfer of records when a patient is taken on by a different physician; this is all that is required in Belgium, Oregon and Washington State.  However, a demand that objecting physicians refer patients or actively initiate transfers would be resisted by those who would consider such actions to involve unacceptable complicity in killing.  The Supreme Court of the Philippines recognized this issue when it struck down a mandatory referral requirement in the country’s Reproductive Health Law as an unconstitutional violation of freedom of conscience.

Murphy S. Canadian physicians warned to get ready for euthanasia and assisted suicide [Internet]. Powell River, BC: Protection of Conscience Project; 2014 May 13 [Updated 2021 Mar 09].

Notes

1. Downar J, Bailey TM, Kagan J, Librach SL.  Physician-assisted death: time to move beyond Yes or No.  CMAJ 2014 May 13;186(8):567-8. doi: 10.1503/cmaj.140204. Epub 2014 Apr 7.

Rethinking Voluntary Euthanasia

Byron J. Stoyles and  Sorin Costreie

The Journal of Medicine and Philosophy

Abstract

Our goal in this article is to explicate the way, and the extent to which, euthanasia can be voluntary from both the perspective of the patient and the perspective of the health care providers involved in the patient’s care. More significantly, we aim to challenge the way in which those engaged in ongoing philosophical debates regarding the morality of euthanasia draw distinctions between voluntary, involuntary, and nonvoluntary euthanasia on the grounds that drawing the distinctions in the traditional manner (1) fails to reflect what is important from the patient’s perspective and (2) fails to reflect the significance of health care providers’ interests, including their autonomy and integrity.


Stoyles BJ, Costreie S. Rethinking Voluntary Euthanasia. J Med Philos (2013) 38 (6): 674-695. doi: 10.1093/jmp/jht045