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van den Besselaar BN, Sewnaik A, Hoesseini A, Dorr MC, Baatenburg de Jong RJ, Offerman MPJ. Causes and Ways of Death in Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2024; 150:303-310. [PMID: 38358760 PMCID: PMC10870226 DOI: 10.1001/jamaoto.2023.4694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/15/2023] [Indexed: 02/16/2024]
Abstract
Importance There is limited literature on the exact causes and ways of death in patients with head and neck cancer. To provide optimal care, especially in the palliative phase, more information on this is needed. Objective To provide insights into the causes and ways of death among patients with head and neck cancer. Design, Setting, and Participants This retrospective cohort study included a consecutive population of patients who received a diagnosis of primary squamous cell carcinoma of the head and neck between January 2006 and December 2013 who were treated in the Erasmus MC. Patient data were merged with nonpublic microdata from Statistics Netherlands. Follow-up time was specified as the date of diagnosis until death or December 3, 2019, whichever came first. The data were checked and reanalyzed in November 2023. Main outcomes and Measures Causes (eg, head and neck cancer, other cancer) and ways (eg, natural death, suicide) of death. Results A total of 1291 patients (59.2%; 342 women [26.5%]) died during follow-up (median [IQR] follow-up, 2.7 [1.2-5.6] years). The main cause of death was head and neck cancer (557 [43.1%]), followed by the competing cause of other cancers (344 [26.6%]). In total, 240 patients (18.6%) received palliative sedation and 70 patients (5.4%) euthanasia. Compared with patients with head and neck cancer as the underlying cause of death, lower odds ratios (ORs) were observed for receiving palliative sedation (OR, 0.32 vs 0.07; 95% CI, 0.22-0.46 vs 0.03-0.12) and euthanasia (OR, 0.22 vs 0.01; 95% CI, 0.11-0.41 vs 0-0.107) in patients with other causes of death. Patients with a middle and high income had higher ORs for receiving palliative sedation (OR, 1.46 vs 1.86; 95% CI, 1.05-2.04 vs 1.22-2.85) or euthanasia (OR, 2.25 vs 3.37; 95% CI, 1.18-4.3, 1.6-7.12) compared with low-income patients. Retired patients had lower ORs for receiving palliative sedation or euthanasia compared with employed patients (OR, 0.56 vs 0.44; 95% CI, 0.39-0.8 vs 0.24-0.82). Conclusion and Relevance The results of this cohort study suggest that more than half of the patients died of competing causes and palliative sedation and euthanasia were more common in patients with head and neck cancer as the underlying cause of death. Patients with a higher socioeconomic status had higher odds of receiving palliative sedation and euthanasia. These insights may support health care professionals in providing patient-centered care, especially for patients in the palliative phase.
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Affiliation(s)
- Boyd N. van den Besselaar
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Arta Hoesseini
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Maarten C. Dorr
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Robert. J Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Marinella P. J. Offerman
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
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Redelmeier DA, Wang J, Drover SSM. COVID Vaccine Hesitancy and Long-Term Traffic Risks. Am J Med 2024; 137:227-235.e6. [PMID: 37890570 DOI: 10.1016/j.amjmed.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND COVID vaccine hesitancy identifies a discrepancy between personal decisions and public guidelines. We tested whether COVID vaccine hesitancy was associated with the long-term risks of a traffic crash. METHODS We conducted a population-based longitudinal cohort analysis of adults by determining COVID vaccination status through linkages to electronic medical records. Traffic crashes requiring emergency medical care were defined by multicenter outcome ascertainment of all hospitals throughout the region over the subsequent year. RESULTS We identified 11,598,549 total individuals, of whom 1,210,754 had not received a COVID vaccine. A total of 54,558 were subsequently injured in traffic crashes during the 1-year follow-up interval, equal to a risk of 4704 per million. Those who had not received a COVID vaccine had a 58% higher risk than those who had received a COVID vaccine (6983 vs 4438 per million, P < .001). The increased traffic risks among unvaccinated individuals included diverse subgroups, were accentuated for single-vehicle crashes, extended to fatal outcomes, exceeded the risks associated with sleep apnea, and persisted after adjustment for baseline characteristics. The increased risks were validated in analyses using Artificial Intelligence techniques and generally larger than the risks of other adverse events frequently ascribed to COVID vaccination. CONCLUSIONS COVID vaccine hesitancy is associated with significant increased long-term risks of a traffic crash. A greater awareness of traffic risks might encourage patients to take protective actions for personal safety.
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Affiliation(s)
- Donald A Redelmeier
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ont, Canada; Department of Medicine, University of Toronto, Ont, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ont, Canada; Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ont, Canada; Center for Leading Injury Prevention Practice Education & Research, Sunnybrook Research Institute, Toronto, Ont, Canada.
| | - Jonathan Wang
- Department of Medicine, University of Toronto, Ont, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ont, Canada
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White BP, Jeanneret R, Willmott L. Barriers to connecting with the voluntary assisted dying system in Victoria, Australia: A qualitative mixed method study. Health Expect 2023; 26:2695-2708. [PMID: 37694553 PMCID: PMC10632633 DOI: 10.1111/hex.13867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/24/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023] Open
Abstract
INTRODUCTION Voluntary assisted dying (VAD) is increasingly being legalised internationally. In Australia, all six states have now passed such laws, with Victoria being the first in 2019. However, early research in Victoria on the patient experience of seeking VAD shows that finding a connection to the VAD system is challenging. This study analyses the causes of this 'point of access' barrier. METHODS We conducted semi-structured qualitative interviews with family caregivers and a person seeking VAD, with participants recruited via social media and patient interest groups. Data were thematically analysed. We also undertook documentary analysis (content and thematic) of publicly available reports from the oversight body, the Voluntary Assisted Dying Review Board. RESULTS We interviewed 32 family caregivers and one patient across 28 interviews and analysed six Board reports. Finding a point of access to the VAD system was reported as challenging in both interviews and reports. Four specific barriers to connecting with the system were identified: (1) not knowing VAD exists as a legal option; (2) not recognising a person is potentially eligible for VAD; (3) not knowing next steps or not being able to achieve them in practice; and (4) challenges with patients being required to raise the topic of VAD because doctors are legally prohibited from doing so. CONCLUSION Legal, policy and practice changes are needed to facilitate patients being able to find a connection to the VAD system. The legal prohibition on doctors raising the topic of VAD should be repealed, and doctors and institutions who do not wish to be involved in VAD should be required to connect patients with appropriate contacts within the system. Community awareness initiatives are needed to enhance awareness of VAD, especially given it is relatively new in Victoria. PATIENT OR PUBLIC CONTRIBUTION Families and a patient were the focus of this research and interviews with them about the experience of seeking VAD were the primary source of data analysed. This article includes their solutions to address the identified point of access barriers. Patient interest groups also supported the recruitment of participants.
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Affiliation(s)
- Ben P. White
- Australian Centre for Health Law Research, Faculty of Business and LawQueensland University of TechnologyBrisbaneQueenslandAustralia
| | - Ruthie Jeanneret
- Australian Centre for Health Law Research, Faculty of Business and LawQueensland University of TechnologyBrisbaneQueenslandAustralia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Business and LawQueensland University of TechnologyBrisbaneQueenslandAustralia
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Galmiche P, Mesnage V, Spranzi M. The Slippery Slope Argument and Assisted Death: Which Approach to MAiD Does It Really Support? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:110-112. [PMID: 37879011 DOI: 10.1080/15265161.2023.2256270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Affiliation(s)
- Perrine Galmiche
- Center for Clinical Ethics (Assistance Publique - Hôpitaux de Paris), Paris, France
| | - Valerie Mesnage
- Center for Clinical Ethics (Assistance Publique - Hôpitaux de Paris), Paris, France
- Hospital Foch, Suresnes, France
| | - Marta Spranzi
- Center for Clinical Ethics (Assistance Publique - Hôpitaux de Paris), Paris, France
- UVSQ - UFR Simone Veil - Santé, Montigny-le-Bretonneux, France
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Knox M, Wagg A. Contemplating the Impacts of Canadian Healthcare Institutions That Refuse to Provide Medical Assistance in Dying: A Framework-Based Discussion of Potential Health Access Implications. Am J Hosp Palliat Care 2023; 40:1154-1162. [PMID: 36802722 PMCID: PMC10571375 DOI: 10.1177/10499091231155854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
INTRODUCTION Following the historic Canadian legislation on medical assistance in dying (MAiD) in 2016, many implementation challenges and ethical quandaries have formed the focus of further scholarly investigation and policy revisions. Of these, conscientious objections held by some healthcare institutions have involved relatively less scrutiny, despite indicating possible hurdles to the universal availability of MAiD services in Canada. METHODS In this paper, we contemplate potential accessibility concerns that pertain specifically to service access, with the hope to trigger further systematic research and policy analysis on this frequently overlooked aspect of MAiD implementation. We organize our discussion using two important health access frameworks: Levesque and colleagues' Conceptual Framework for Access to Health and the Provisional Framework for MAiD System Information Needs (Canadian Institute for Health Information). RESULTS Our discussion is organized along five framework dimensions through which institutional non-participation may generate or exacerbate inequities in MAiD utilization. Considerable overlaps are revealed across framework domains, indicating the complexity of the problem and the need for further investigation. CONCLUSION Conscientious dissensions on the part of healthcare institutions form a likely barrier to ethical, equitable, and patient-oriented MAiD service provision. Comprehensive, systematic evidence is urgently needed to understand the nature and scope of resulting impacts. We urge Canadian healthcare professionals, policymakers, ethicists, and legislators to attend to this crucial issue in future research and in policy discussions.
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Affiliation(s)
- Michelle Knox
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Adrian Wagg
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Orentlicher D. Aid in Dying in Canada and the United States: Are U.S. States Too Cautious? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:73-75. [PMID: 37879018 DOI: 10.1080/15265161.2023.2256617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
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Downar J, MacDonald S, Buchman S. Medical Assistance in Dying, Palliative Care, Safety, and Structural Vulnerability. J Palliat Med 2023; 26:1175-1179. [PMID: 37404196 DOI: 10.1089/jpm.2023.0210] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
As more jurisdictions consider legalizing medical assistance in dying or assisted death (AD), there is an ongoing debate about whether AD is driven by socioeconomic deprivation or inadequate supportive services. Attention has shifted away from population studies that refute this narrative, and focused on individual cases reported in the media that would appear to support these concerns. In this editorial, the authors address these concerns using recent experience in Canada, and argue that even if we accept these stories at face value, the logical policy response would be to address the root causes of structural vulnerability rather than attempt to restrict access to AD. In terms of concerns about safety, the authors go on to point out the parallels between media reports about the misuse of AD and reports of wrongful deaths due to the misuse of palliative care (PC) in jurisdictions where AD was not legal. Ultimately, we cannot justify having a different response to these reports when they apply to AD instead of PC, and nobody has argued that PC should be criminalized in response to such reports. If we are skeptical of the oversight mechanisms used for AD in Canada, we must be equally skeptical of the oversight mechanisms used for end-of-life care in every jurisdiction where AD is not legal, and ask whether prohibiting AD protects the lives of the vulnerable any better than legalization of AD with safeguards.
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Affiliation(s)
- James Downar
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Susan MacDonald
- Departments of Medicine and Family Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Sandy Buchman
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Freeman Centre for The Advancement of Palliative Care, North York General Hospital, Toronto, Ontario, Canada
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Rosenbaum D, Hales S, Buchman DZ. Commentary: Access to Psychedelics for Psychological Suffering at the End of Life - Prioritizing Our Priorities. Healthc Policy 2023; 18:143-148. [PMID: 37486819 PMCID: PMC10370398 DOI: 10.12927/hcpol.2023.27047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
We agree with Kratina et al. (2023) that the problem of psychological suffering at the end of life deserves attention from a policy standpoint and that psychedelic therapies show promise in this clinical context. However, we argue the following in this rejoinder: (1) disproportionate attention to psychedelics may overstate the current evidence base, potentially diverting resources away from existing evidence-based programs; (2) a more pressing policy priority related to this public health problem is to address population-level inequities in accessing high-quality, early and holistic palliative care, including psychosocial care; and (3) discussions about expanded access to psychedelics must also foreground equity issues.
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Affiliation(s)
- Daniel Rosenbaum
- Psychiatrist and Clinician Investigator, Nikean Psychedelic Psychotherapy Research Centre, University Health Network, Lecturer, Department of Psychiatry, University of Toronto, Toronto, ON
| | - Sarah Hales
- Psychiatrist and Clinician Investigator, Department of Supportive Care and Centre for Mental Health, University Health Network, Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, ON
| | - Daniel Z Buchman
- Bioethicist and Independent Scientist, Centre for Addiction and Mental Health, Assistant Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
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Redelmeier DA, Wang J, Thiruchelvam D. COVID Vaccine Hesitancy and Risk of a Traffic Crash. Am J Med 2023; 136:153-162.e5. [PMID: 36470796 PMCID: PMC9716428 DOI: 10.1016/j.amjmed.2022.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 10/27/2022] [Accepted: 11/02/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Coronavirus disease (COVID) vaccine hesitancy is a reflection of psychology that might also contribute to traffic safety. We tested whether COVID vaccination was associated with the risks of a traffic crash. METHODS We conducted a population-based longitudinal cohort analysis of adults and determined COVID vaccination status through linkages to individual electronic medical records. Traffic crashes requiring emergency medical care were subsequently identified by multicenter outcome ascertainment of all hospitals in the region over a 1-month follow-up interval (178 separate centers). RESULTS A total of 11,270,763 individuals were included, of whom 16% had not received a COVID vaccine and 84% had received a COVID vaccine. The cohort accounted for 6682 traffic crashes during follow-up. Unvaccinated individuals accounted for 1682 traffic crashes (25%), equal to a 72% increased relative risk compared with those vaccinated (95% confidence interval, 63-82; P < 0.001). The increased traffic risks among unvaccinated individuals extended to diverse subgroups, was similar to the relative risk associated with sleep apnea, and was equal to a 48% increase after adjustment for age, sex, home location, socioeconomic status, and medical diagnoses (95% confidence interval, 40-57; P < 0.001). The increased risks extended across the spectrum of crash severity, appeared similar for Pfizer, Moderna, or other vaccines, and were validated in supplementary analyses of crossover cases, propensity scores, and additional controls. CONCLUSIONS These data suggest that COVID vaccine hesitancy is associated with significant increased risks of a traffic crash. An awareness of these risks might help to encourage more COVID vaccination.
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Affiliation(s)
- Donald A Redelmeier
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ont, Canada; Department of Medicine, University of Toronto, Ont, Canada; Institute for Clinical Evaluative Sciences (ICES), Toronto, Ont, Canada; Division of General Internal Medicine; Center for Leading Injury Prevention Practice Education & Research, Sunnybrook Health Sciences Centre, Toronto, Ont, Canada.
| | - Jonathan Wang
- Department of Medicine, University of Toronto, Ont, Canada; Institute for Clinical Evaluative Sciences (ICES), Toronto, Ont, Canada
| | - Deva Thiruchelvam
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ont, Canada; Institute for Clinical Evaluative Sciences (ICES), Toronto, Ont, Canada
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Auret K, Pikora T, Gersbach K. Being a safe place: a qualitative study exploring perceptions as to how a rural community hospice could respond to enactment of voluntary assisted dying legislation. BMC Palliat Care 2022; 21:2. [PMID: 34980093 PMCID: PMC8725330 DOI: 10.1186/s12904-021-00891-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/01/2021] [Indexed: 11/21/2022] Open
Abstract
Background There is a lack of research to guide the implementation of voluntary assisted dying legislation within a hospice setting. Furthermore, there is limited published information related to the expectations of the community and staff to assist decision making regarding voluntary assisted dying in a community hospice. The aim of this study was to explore the expectations of staff, volunteers and members of the community as how a rural Australian community hospice could respond in relation to imminent enactment of Voluntary Assisted Dying legislation. Methods A total of 63 Hospice staff and volunteers and community members participated in 11 workshops. This qualitative study used the interpretive description method to analyse the workshop transcripts. Results While there was not a consensus view on community expectation, there was agreement among the participants for respect for a patient’s individuality and choices. Furthermore, care offered in hospice needs to remain non-judgemental and patient focused regardless of whether voluntary assisted dying policy was implemented or not. Both opportunities and risks associated with implementation were identified by the participants. Conclusion There was common ground around the respect for the dying person and the ideal of a “safe place” despite opposing views on what this may mean in practice. There is a need for clarity in organisational responses around policy, risk management, education, and staff support.
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Affiliation(s)
- Kirsten Auret
- Rural Clinical School of Western Australia, University of Western Australia, M701 31 Stirling Terrace, Albany, Western Australia, 6330, Australia.
| | - Terri Pikora
- Rural Clinical School of Western Australia, University of Western Australia, M701 31 Stirling Terrace, Albany, Western Australia, 6330, Australia
| | - Kate Gersbach
- Albany Community Hospice, Diprose Crescent, Albany, Western Australia, 6330, Australia
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Downie J, Schuklenk U. Social determinants of health and slippery slopes in assisted dying debates: lessons from Canada. JOURNAL OF MEDICAL ETHICS 2021; 47:662-669. [PMID: 34349029 PMCID: PMC8479744 DOI: 10.1136/medethics-2021-107493] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 07/01/2021] [Indexed: 05/09/2023]
Abstract
The question of whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying has recently come to the fore in debates about the legalisation of assisted dying. For example, it was central to critiques of the 2021 amendments made to Canada's assisted dying law. The question of whether changes to a country's assisted dying legislation lead to descents down slippery slopes has also come to the fore-as it does any time a jurisdiction changes its laws. We explore these two questions through the lens of Canada's experience both to inform Canada's ongoing discussions and because other countries will confront the same questions if they contemplate changing their assisted dying law. Canada's Medical Assistance in Dying (MAiD) law has evolved through a journey from the courts to Parliament, back to the courts, and then back to Parliament. Along this journey the eligibility criteria, the procedural safeguards, and the monitoring regime have changed. In this article, we focus on the eligibility criteria. First, we explain the evolution of the law and what the eligibility criteria were at the various stops along the way. We then explore the ethical justifications for Canada's new criteria by looking at two elements of the often-corrosive debate. First, we ask whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying of decisionally capable people with mental illnesses and people with disabilities as their sole underlying medical conditions. Second, we ask whether Canada's journey supports slippery slope arguments against permitting assisted dying.
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Affiliation(s)
- Jocelyn Downie
- School of Law, Dalhousie University Schulich School of Law, Halifax, Nova Scotia, Canada
| | - Udo Schuklenk
- Department of Philosophy, Queen's University, Kingston, Ontario, Canada
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