Attitudes and Arguments for and against Medical Aid in Dying

by Mark Hughes, MD, MA

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    00:01 So the attitudes about medical aid in dying are buried.

    00:05 This is a controversial topic, it's unsettled.

    00:09 Really something that each clinician is going to have to decide for themselves, whether this is appropriate.

    00:15 There are professional societies that have various standpoints about this.

    00:19 Some are neutral, some are against it, some are in favor of it.

    00:23 So that professional level, you really need to consider what are the implications of considering medical aid and dying.

    00:31 It's probably clear that, at least in several countries, that public attitudes towards legalization of medical aid and dying appear to be shifting in favor of its permissibility.

    00:43 At least for those patients who wish to use it.

    00:45 So giving this as an option for certain people.

    00:49 And it's been around now for a few decades, in certain countries.

    00:53 There are about a dozen countries now where medical aid and dying is available.

    00:57 And when you actually look at it, it's sort of rarely used less than 5% of deaths in those countries are the result of medical aid and dying.

    01:08 So let's walk through the arguments for and the arguments against medical aid and dying so you can again, make up your own mind about these issues.

    01:17 So some of the main arguments for medical aid and dying are, first of all, it promotes patient autonomy.

    01:22 So this idea that the patient should be able to choose their own treatments or choose to refuse treatments or choose to end their life, this is a manifestation of their autonomous decision making, and medical aid and dying is just one other demonstration of their autonomy.

    01:38 There could be an argument that it preserves patient defined dignity.

    01:42 So again, people might think that being functional and in control and independent is a manifestation of their dignity.

    01:51 And if they are bed bound or incontinent, that is some way you know, undignified, so how they define their dignity, if they don't want to be in that condition, that state of being, they may choose medical aid and dying to they may preserve what they view as a dignified life.

    02:10 It's a means of having that person address their suffering.

    02:13 So if they really have intractable suffering, or envision that they're going to be suffering more in the future, with their terminal illness, this option of medically denying is a way to address the suffering.

    02:26 When it's the involvement of a physician or clinician, the other argument for medical aid in dying is that having the physician be available for these, these means of assistance is a way to uphold non-abandonment.

    02:41 So if you're supposed to be there for your patient, being there through the end, whatever decisions they make, if it's for assistance in dying, that's part of the role of the physician in that circumstance.

    02:54 So those are arguments for medical assistance in dying.

    03:01 Their arguments against medical aid and dying, the first would be well, some people would say that killing another person or assistance in the killing of another person is wrong.

    03:12 So that is intrinsically against the role of the physician who is supposed to preserve life or promote healing.

    03:18 So there's the wrongness of killing or assistance in killing.

    03:23 Is it really true to the role of healers.

    03:26 So if healer is supposed to make a person whole, so even when they're suffering, there is still the opportunity to make them whole, despite their natural progression of their illness.

    03:38 Is this assistance actually counter to that role? There may be concerns that this undermines trust in the physician, especially those looking, you know, from the public into this involvement by physicians, how do we know that we can trust the physician is not going to go to involuntary euthanasia? How do we know that in that one on one relationship with a patient that the physician was in some way, unduly influencing the patient to choose this option and medical aid in dying? How do we know that it was truly voluntary? Another concern is well, we really haven't done an adequate job of providing palliative care resources.

    04:23 The state of the world might be that, you know, we need more palliative care clinicians, we need all clinicians to be better trained in primary palliative care.

    04:31 We haven't achieved that yet.

    04:33 So when patients are faced with intractable symptoms, these other means of suffering, and we haven't provided them adequate palliative care, they might see medical aid and dying as the option to consider because we haven't done a good enough job of relieving their symptoms or their suffering.

    04:55 There's also concerns well, you know, maybe there are patients where they're desiring this hasten death because they have inadequately treated mental illness.

    05:03 So similar to the physical symptoms or the existential suffering, that might exist for certain patients.

    05:09 There might be mental illness that if it were adequately treated, that desire for hasten death might go away.

    05:15 And there have been studies to show that if you give adequate psychiatric support, things where you're really trying to help them work through their existential suffering, help them with their mental illness, that desire for hasten death may go away.

    05:32 Other arguments against the use of medical aid in dying are, well, there's a risk of abuse without regulatory oversight.

    05:40 So you need to have some means of a legal system, regulatory system to oversee this, so that, there aren't abuses and how it's being implemented.

    05:54 There may be times and it's perhaps rare, but it can happen, so if a patient that decides on physician assisted suicide, if they take that dose of lethal medication, maybe they can't swallow it completely.

    06:08 Maybe they get nauseous as a result.

    06:11 Maybe that actually leads to other complications.

    06:13 That enhances their distress, they're having more suffering, because their action to end their life actually wasn't successful.

    06:25 A big concern, especially from people with disability is, this is a concern that vulnerable patients might be pressured into ending their lives.

    06:37 And there might be, you know, feelings of indifference towards people that are vulnerable or prejudiced towards people that need assistance in terms of their daily care.

    06:47 You know, they're bathing, they're dressing, they're being bed bound.

    06:52 There might be patients that feel compelled to consider medical aid and dying because of psychological or financial pressure.

    06:58 So for any of those reasons, they would say, well, that's taking advantage of their vulnerability and pushing them into this decision, whereas if we had actually not been indifferent to their suffering, have not been prejudiced against people with disabilities, had made sure that there aren't these financial pressures, maybe they wouldn't desire the hasten death.

    07:20 And then lastly, there's this concern that it might lead you down a slippery slope.

    07:24 So if you make it permissible for terminally ill patients, what's to say that you couldn't make it available for other patients with other kinds of suffering? Maybe they're, they're not near the end-of-life, but they just can't envision, you know, years or decades of living with their current condition.

    07:40 And there have been movements in certain countries to permit medical aid and dying for things like intractable depression.

    07:49 Is that something that we really should be considering? Again, a controversial debatable topic about who should be able to pursue medical aid and dying.

    About the Lecture

    The lecture Attitudes and Arguments for and against Medical Aid in Dying by Mark Hughes, MD, MA is from the course Ethical Considerations in Palliative Care.

    Included Quiz Questions

    1. Public and professional attitudes are shifting in favor of permissibility.
    2. Public and professional attitudes are not shifting.
    3. Public and professional attitudes are shifting in favor of disallowing.
    4. Only professional attitudes are shifting in favor of permissibility.
    5. Only professional attitudes are shifting in favor of disallowing.
    1. Over 12
    2. Over 100
    3. Less than 5
    4. Between 5 and 10
    5. 11
    1. Promotes patient autonomy
    2. Preserves patient-defined dignity
    3. Addresses suffering
    4. Wrongness of killing
    5. Counters the role of a healer
    1. Undermines trust in the physician
    2. Preserves patient autonomy
    3. Preserves patient-defined dignity
    4. Addresses suffering
    5. Upholds nonabandonment

    Author of lecture Attitudes and Arguments for and against Medical Aid in Dying

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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