Physician assisted suicide: the great Canadian euthanasia debate

The Discourse of Medical Assistance in Dying and Its Relationship With Hospice Palliative Care in Canada: An Integrative Literature Review

AIM

To explore how the legalisation of medical assistance in dying (MAiD) has shaped the discourse of MAiD and its relationship with hospice palliative care (HPC) in Canada.

BACKGROUND

There is perceived tension in the discourse between the goals of MAiD and HPC, but little literature examines this relationship and the effect it has on healthcare providers such as nurses.

DESIGN

Integrative review following Whittemore and Knafl's and Toronto and Remington's methodology.

REVIEW METHODS

A search was conducted to identify literature discussing MAiD and HPC in Canada. Articles were critically appraised for methodological quality. Data from each article were abstracted, thematically analysed, and synthesised.

DATA SOURCES

Initial searches were conducted in CINAHL, PubMed, and professional association and government websites in September 2018 and updated in May 2023.

RESULTS

A total of 457 records were screened for inclusion, and 83 articles were included. Articles included healthcare provider, patient, public, and institutional perspectives. Three themes identified from the data were the relationship between MAiD and HPC, suffering in the context of MAiD, and moral distress and moral uncertainty in providing or not providing MAiD.

CONCLUSIONS

The discourse around the relationship between MAiD and HPC is complex and contextual. Personal and professional understandings of end-of-life care differ and influence perspectives on how and whether MAiD and hospice palliative care can be reconciled. More exploration of this topic is recommended, given the changing legislation and beliefs around MAiD.

IMPACT

Findings consider how the concepts of end of life, MAiD, HPC, suffering, and moral distress influence and are influenced by the discourse of dying. This review provides direction for healthcare professionals working in end-of-life care and future ethical and moral areas for consideration.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was necessary for this literature review.

Moral psychological exploration of the asymmetry effect in AI-assisted euthanasia decisions

A recurring discrepancy in attitudes toward decisions made by human versus artificial agents, termed the Human-Robot moral judgment asymmetry, has been documented in moral psychology of AI. Across a wide range of contexts, AI agents are subject to greater moral scrutiny than humans for the same actions and decisions. In eight experiments (total N = 5837), we investigated whether the asymmetry effect arises in end-of-life care contexts and explored the mechanisms underlying this effect. Our studies documented reduced approval of an AI doctor's decision to withdraw life support relative to a human doctor (Studies 1a and 1b). This effect persisted regardless of whether the AI assumed a recommender role or made the final medical decision (Studies 2a and 2b and 3), but, importantly, disappeared under two conditions: when doctors kept on rather than withdraw life support (Studies 1a, 1b and 3), and when they carried out active euthanasia (e.g., providing a lethal injection or removing a respirator on the patient's demand) rather than passive euthanasia (Study 4). These findings highlight two contextual factors-the level of automation and the patient's autonomy-that influence the presence of the asymmetry effect, neither of which is not predicted by existing theories. Finally, we found that the asymmetry effect was partly explained by perceptions of AI incompetence (Study 5) and limited explainability (Study 6). As the role of AI in medicine continues to expand, our findings help to outline the conditions under which stakeholders disfavor AI over human doctors in clinical settings.

Palliative sedation and medical assistance in dying: Distinctly different or simply semantics?

Medical assistance in dying (MAiD) and palliative sedation (PS) are both legal options in Canada that may be considered by patients experiencing intolerable and unmanageable suffering. A contentious, lively debate has been ongoing in the literature regarding the similarities and differences between MAiD and PS. The aim of this paper is to explore the propositions that MAiD and PS are essentially similar and conversely that MAiD and PS are distinctly different. The relevance of such a debate is apparent for clinicians and patients alike. Understanding the complex and multi‐faceted nuances between PS and MAiD allows patients and caregivers to make more informed decisions pertaining to end‐of‐life care. It is hoped that this paper will also serve to foster further debate and consideration of the issues associated with PS and MAiD with a view to improve patient care and the quality of both living and dying in Canada.

Continuous Deep Sedation and Euthanasia in Pediatrics: Does One Really Exclude the Other for Terminally Ill Patients?

Debates on morally acceptable and lawful end-of-life (EOL) practices in pediatrics were reignited by the recent amendment in Belgian law to allow euthanasia for minors of any age who meet the criteria for capacity. Euthanasia and its legalization in pediatrics are often opposed based on the availability of aggressive palliative sedation. For terminally ill patients, this type of sedation is often identified as continuous and deep sedation until death (CDS). We demonstrate that this reasoning is based on flawed assumptions: (1) CDS is a morally preferable alternative to euthanasia; (2) CDS can meet the same patient needs as euthanasia; (3) children lack the capacity and experience to make EOL decisions; (4) unlike euthanasia, CDS does not raise capacity issues. Our aim is not to reject CDS as a valid option at the EOL, nor to offer a clear-cut defense of euthanasia for minors, but to emphasize the ethical issues with both practices.

Nurse leaders' role in medical assistance in dying: A relational ethics approach

Recent changes to the Criminal Code of Canada have resulted in the right of competent adult Canadians to request medical assistance in dying (MAID). Healthcare professionals now can participate if the individual meets specific outlined criteria. There remains confusion and lack of knowledge about the specific role of nurses in MAID. MAID is a controversial topic and nurses may be faced with the challenge of balancing the duty to provide routine care, with moral reservations about MAID. The role of a nursing leader is to support nurses by ensuring they have the knowledge they require to care for patients requesting the service, whether or not the nurse is directly involved in the MAID process. The moral dilemmas raised by MAID provide an opportunity to look at a relational ethics approach to nursing leadership both for MAID and other difficult situations that arise in nursing practice. Relational ethics is a framework that proposes that the ethical moments in healthcare are based on relationships and fostering growth, healing, and health through the foundational concepts of mutual respect, engagement, embodiment, and environment. This article will use a relational ethics framework to examine how nursing leadership can support nurses who care for patients requesting MAID.

Physician-Assisted Suicide and Euthanasia in the ICU: A Dialogue on Core Ethical Issues

OBJECTIVE

Many patients are admitted to the ICU at or near the end of their lives. Consequently, the increasingly common debate regarding physician-assisted suicide and euthanasia holds implications for the practice of critical care medicine. The objective of this article is to explore core ethical issues related to physician-assisted suicide and euthanasia from the perspective of healthcare professionals and ethicists on both sides of the debate.

SYNTHESIS

We identified four issues highlighting the key areas of ethical tension central to evaluating physician-assisted suicide and euthanasia in medical practice: 1) the benefit or harm of death itself, 2) the relationship between physician-assisted suicide and euthanasia and withholding or withdrawing life support, 3) the morality of a physician deliberately causing death, and 4) the management of conscientious objection related to physician-assisted suicide and euthanasia in the critical care setting. We present areas of common ground and important unresolved differences.

CONCLUSIONS

We reached differing positions on the first three core ethical questions and achieved unanimity on how critical care clinicians should manage conscientious objections related to physician-assisted suicide and euthanasia. The alternative positions presented in this article may serve to promote open and informed dialogue within the critical care community.

Physicians and euthanasia: a Canadian print-media discourse analysis of physician perspectives

BACKGROUND

Recent events in Canada have mobilized public debate concerning the controversial issue of euthanasia. Physicians represent an essential stakeholder group with respect to the ethics and practice of euthanasia. Further, their opinions can hold sway with the public, and their public views about this issue may further reflect back upon the medical profession itself.

METHODS

We conducted a discourse analysis of print media on physicians' perspectives about end-of-life care. Print media, in English and French, that appeared in Canadian newspapers from 2008 to 2012 were retrieved through a systematic database search. We analyzed the content of 285 articles either authored by a physician or directly referencing a physician's perspective.

RESULTS

We identified 3 predominant discourses about physicians' public views toward euthanasia: 1) contentions about integrating euthanasia within the basic mission of medicine, 2) assertions about whether euthanasia can be distinguished from other end-of-life medical practices and 3) palliative care advocacy.

INTERPRETATION

Our data showed that although some medical professional bodies appear to be supportive in the media of a movement toward the legalization of euthanasia, individual physicians are represented as mostly opposed. Professional physician organizations and the few physicians who have engaged with the media are de facto representing physicians in public contemporary debates on medical aid in dying, in general, and euthanasia, in particular. It is vital for physicians to be aware of this public debate, how they are being portrayed within it and its potential effects on impending changes to provincial and national policies.

Trends of psychology-related research on euthanasia: a qualitative software-based thematic analysis of journal abstracts

Euthanasia has received increasing attention in both academic and public debates as one of the most controversial issues. However, the contribution of psychology-related themes to the topic has had little role on these ongoing debates. The aim of the present study is twofold: (1) to explore the main themes relating to euthanasia as provided by psychology-related research; (2) to analyze the temporal trends of psychology-related research on euthanasia over the last decades. A comprehensive search of academic literature was conducted on PsychINFO database. A qualitative software-based thematic analysis was carried out on 602 journal abstracts published from 1935 to 2014. This study highlighted four different thematic areas which characterized the scientific discourse on euthanasia: (1) moral values, in terms of religious, philosophical, and social implications concerning the individual's decision to die; (2) professional ethics, in terms of health and social workers' legal responsibility in death assistance; (3) end-of-life care, with regard to medical options provided to support individuals nearing death; and (4) patient's right to healthcare, in terms of access to palliative care and better quality of dying. Euthanasia discourse over the last decades seems to be overall characterized by two main dimensions: (1) the increasing trend of social legitimacy and acceptability of euthanasia over time, which moved from ethical to healthcare issues; and (2) the curvilinear temporal trend about the request/provision process in euthanasia, which moved from patient's decision for ending life (mainly characterizing the most past and recent research) to the role of health professionals (with a peak in the 1990s). The results suggest palliative care as a potential future research area which can provide healthcare providers with skills to 'connect' with patients, understand patients' hidden agendas, and grant a good quality of life and dying process.