10/27 Medical Aid in Dying (MAID) + Palliative Care

medical aid in dying (MAID)

a clinician provides the patient w a prescription for meds to end their own life, which are self-administered

euthanasia

a clinician directly causes a patient to die, such as thru injecting a lethal substance

palliative care

the provision of treatments meant to ease discomfort and manage symptoms of any serious illness, such as heart failure or cancer, but not to cure or aggressively intervene in a disease

hospice care

specialized palliative care provided for terminal physical illnesses

MAID or Other End-of-Life/Palliative Care:

Withholding life-sustaining treatment (like mechanical ventilation) or not resuscitating a patient

Palliative care; not considered MAID, even if patients die due to the lack of intervention

T/F: patients can document their wishes to withhold life-sustaining treatment in a living will or DNR

true

MAID or Other End-of-Life/Palliative Care:

providing medications that hasten death due to their effects (like slowing respiration) but aren’t intended to cause death directly

palliative care

MAID or Other End-of-Life/Palliative Care:

sedating a severely ill patient until they die of their illness

palliative care

key ethical issues in MAID

the four principles

does MAID honor people’s autonomy and reduce suffering, or does it cause harm? under what conditions?

key ethical issues in MAID

professional role

are clinicians ethically obligated to end all forms of suffering, even if it means facilitating someone’s death?

key ethical issues in MAID

criteria

do we allow MAID for some conditions and not others? how can we compare forms of suffering, if at all?

key ethical issues in MAID

vulnerability

vulnerable people, especially w limited access to quality healthcare, may feel compelled to seek MAID

where is MAID legal?

• several (but not all) U.S. states

• Netherlands, Belgium, Canada, Colombia, Luxembourg, New Zealand, Switzerland, Spain, Germany, Austria

  • however, international laws differ

  • as of jan 2025, some countries allow ppl w serious psychiatric conditions to access MAID w/o a terminal physical illness (Netherlands), while others do not (USA)

American Medical Association position on MAID

as of 2022, AMA states that physicians in the USA can facilitate MAID where it’s legal, but individual physicians still hv the right not to provide MAID services based on their personal beliefs + values

T/F: while physicians can participate in MAID, “Euthanasia is fundamentally incompatible w the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks”

true

what are the religious beliefs related to MAID (Pew 2013)?

many Christian/Catholic, Jewish, Islamic, Hindu, and Buddhist communities OPPOSE MAID as violating the sanctity of life

T/F: Many religions allow withdrawing life-sustaining treatment, considering this a natural end to life

true

Which faith endorses MAID?

Unitarian Universalism

T/F: Individual ppl’s ideas about MAID must correspond to prevailing ideas in their faith

False; Individual people may have their own ideas about MAID that don’t necessarily correspond to prevailing ideas in their faith

What are the common steps to accessing MAID?

1. be a legal adult (over 18) who receives a diagnosis that qualifies for MAID

2. make a formal written request to physician for MAID

3. be assessed by at least two different physicians to review prognosis + informed patient of any other available options, whether active treatments/interventions or palliative care

4. complete formal capacity evaluation if necessary

5. some cases: complete a mandatory waiting period before the prescription for life-ending meds r given

what are some questions regarding psychiatric MAID?

• should we allow medical aid in dying for patients whose only or primary diagnosis is a serious mental health condition that causes intense distress and isn’t responding to treatment?

• if the condition is that serious, would they have the capacity to freely agree to MAID?

Canada passed a psychiatric MAID law but its implementation has been repeatedly delayed, why?

Partly due to concerns that a lack of access to mental health services must be addressed so that ppl don’t seek out MAID due to inadequate available care

palliative care ethical questions

• how do we communicate to patients about the limits of what biomedicine can do to heal them?

• how do we balance making someone comfortable with minimizing further harm of certain interventions?

• do we have a moral obligation to patients + society not to offer aggressive, expensive medical interventions when someone is in their last weeks or months of life, and would die regardless, or is this unjust?

palliative psychiatry for anorexia (carter and mizelle 2023)

what can we do to help patients with severe, treatment-resistant anorexia nervosa (AN), which has a high mortality rate amongst psychiatric diagnoses?

• patients may be highly distressed by repeated hospitalization

• there’s debate about palliation for anorexia or deeming it “terminal,” suggesting recovery isn’t possible

• advocates of palliation say it honors respect for persons and non-maleficence, and suggest that for at least 1/3 of patients, less invasive palliative treatments are appropriate (ex: dietary supplements versus invasive feeding tubes)

what are important ethical questions for end-of-life care?

• medical aid in dying differs from palliative care, but they are both shaped by what patients value and the type or extent of the care they want at the end of life and what is legal, ethical, and medically appropriate

• ethics at the beginning and end of life are often especially fraught, as they relate to broader philosophical and societal questions about who lives and how we die

• ethical principles can guide us, even if different patients might make different end-of-life choices

discussion

All of the patients in the cases below wish to pursue MAID. How

would you weigh the ethical considerations in these cases? How do

they compare?

• An older woman with mild dementia who has occasional memory loss and confusion, and who is suffering from ALS

• A man in his 30s who has debilitating depression that has failed to respond to aggressive treatment including ECT and TMS

• A teenager who has incurable terminal cancer that causes intense pain, but whose parents oppose MAID

• ALS + Mild Dementia: Autonomy vs. Declining Capacity. The core risk is capturing truly informed, valid consent before progressive cognitive decline strips away the patient's decision-making capacity.

• Treatment-Resistant Depression: Beneficence vs. Vulnerability. The core risk is non-maleficence (doing harm). It is incredibly difficult to distinguish a rational desire to end psychological pain from a symptom of the illness driving hopelessness.

• Terminal Teenager + Parental Opposition: Mature Minor Autonomy vs. Parental Authority. The core friction is forcing a competent youth to endure agonizing, terminal physical pain against their will versus violating familial structures and proxy rights.