Physician-assisted dying is legal in Canada, due to legislation passed in June 2016. Ethicists are among those providing multidisciplinary education in the hospital setting. Ethicists are seeing the following issues:
- Many physicians and other team members are uncomfortable with physician-assisted dying.
- It is unclear as to the clinical meaning of some of the terminology in the legislation.
- Conscientious objectors are required to make a referral, but some are uncomfortable doing so.
As of June 2016, physician-assisted dying can be legally practiced in Canada. Recently passed legislation allowing the practice of “medical assistance in dying” (MAID), “has engendered spirited dialogue and deep moral reflection across the nation,” says Ruby Rajendra Shanker, MBBS, MHSc (Bioethics), the bioethicist for Toronto General Hospital & Women’s College Hospital.
At Ontario hospitals where MAID services are available, there is wide consensus that all staff and clinicians need a “high-level understanding” of the process, says Shanker, in order to respond to patient requests for information.
“Ethicists have been involved with providing education sessions for interprofessional teams, as well as sessions with a disciplinary focus,” adds Shanker. These sessions cover logistical and procedural information, but also tend to elicit emotional responses or reflective silence. “These reactions speak to the varying levels of comfort that healthcare providers feel in the context of MAID,” says Shanker.
University of Toronto’s Joint Centre for Bioethics convened a task force in 2015, including ethicists, clinicians, lawyers, health policy analysts, and representatives from professional colleges and the Ontario Health Association. “The goal has been to operationalize the ethical principles of accountability, collaboration, dignity, equity, respect, transparency, fidelity, and compassion in the context of MAID,” says Shanker, a member of the task force.
The group has produced a MAID policy template for healthcare organizations, an algorithm to map out the MAID process, and FAQs for patients and families, and staff and physicians. “Interprofessionally focused educational modules have been developed,” adds Shanker.
Bob Parke, BA, BSW, MSW, MHSc (Bioethics), bioethicist at Humber River Hospital in Toronto, says, “The ethical issues which I have had in my experience of working in a secular hospital which permits MAID are several.” The following are some ethical issues encountered by Canadian ethicists since the legislation:
- Many physicians expressed that the issue is morally challenging for them.
“What has been important, in legislation and in practice, is that conscientious objection rights of physicians are protected,” says Parke.
In Parke’s experience, the majority of doctors do not wish to participate in physician-assisted dying. “What I have found is that physicians’ willingness to participate falls along a continuum from being opponents to proponents of physician-assisted death,” he says.
Few fall at either extreme of the continuum. “Most are willing to explore why a person is making a request — but can’t cross the moral divide into causing a person’s death,” says Parke. This stance often stems from faith-based values, or in the physician’s interpretation of “doing no harm.”
“Not uncommonly I have heard, ‘I did not get into medicine for this’ — to cause someone to die,” says Parke. This point of view typically comes from physicians who do not espouse a religious tradition, whereas physicians coming from a religious perspective usually place their conscientious objection within the context of their faith.
Some physicians wanted reassurance that they had the right to conscientious objection, since they’d concluded that their personal and professional values cannot be reconciled with MAID. Shanker notes, “The rights of professionals, however, come with obligations to not abandon their patients.” There is a concomitant duty to ensure continuity of care by making an effective referral to another provider who can address the patient’s request.
Ethicists themselves may be conscientious objectors. “While the thought of an ethicist conscientiously objecting to discussing MAID may be seen as perplexing for some, it is important to remind ourselves that ethicists come with varied experiences, values, and cultural backgrounds,” says Shanker.
Thus, ethical challenges can arise for ethicists both in institutions that permit MAID, and in those that prohibit it. “An ethicist may feel that they are unable to act in alignment with their values if they are barred from even engaging in the subject,” Shanker explains.
- A few physicians questioned whether their safety would be at risk if they participated.
“There were concerns that there might be threats to their lives and well-being, as was experienced by some physicians who are known for doing abortions,” explains Parke. In both policy and practice, ethicists keep the names of participants as private as possible. “We want to avoid participating staff being negatively labelled for participating in physician-assisted deaths,” says Parke.
- Conscientious objectors still have to provide care to a patient, while the process for assisted dying works through the assessment stages through to its completion.
“It is hoped that a physician can transfer care,” says Parke. “But this might not be possible contingent on their specialty, role, and relationship to the patient.”
In Ontario, the College of Physicians and Surgeons requires that a physician who conscientiously objects make an “effective referral.” “The challenge is: What does it mean for a physician to make an ‘effective’ referral?” asks Parke.
For most conscientious objectors, directly referring to another physician who is willing to assist a patient in their death would make them complicit in an immoral act. “What needs to be done is to find ways to distance the objecting physician from a direct referral,” says Parke. A possible solution: Having a third party, such as a chief of the department or a coordinating group, take on the various roles related to physician-assisted death, including facilitating referrals.
- There is a concern that some people will request MAID due to lack of regularly available palliative care.
Insufficient palliative care remains an ethical challenge, says Parke. “Across Canada, there is a patchwork quilt of excellent to non-existent palliative care.”
- Some non-clinical team members feel morally uncomfortable with physician-assisted death, yet are asked to participate.
This includes nurses, pharmacists, social workers, chaplains, and even bioethicists. “For the most part, the law and hospital policies permit staff to identify their conscientious objection and have their values respected,” says Parke.
“Behind-the-scenes” healthcare providers, such as professional interpreters or the IT team, aren’t typically included in discussions when a person is moving forward with physician-assisted death, though. Professional interpreters may be called in to translate, for instance.
“Informing them ahead of time allows them the choice of whether they will participate or not — and to find an alternative person if they are morally uncomfortable in providing their services,” says Parke.
At Humber River Hospital, the IT team designed the EMR screens used to document the process of physician-assisted dying. “When a case is proceeding, IT staff can be called in to ensure that the EMR is properly completed for each component of the physician-assisted death,” Parke explains. The IT team is asked to be available during cases to ensure clinicians document appropriately.
“Our experience in Canada is that all staff want to make sure that they have done all steps of the process very well,” says Parke. This is important, since physician-assisted deaths do not occur frequently. “We want this assurance, as MAID is an exemption from a criminal act, and we know that the EMR will be reviewed by our coroners,” Parke explains. Not all IT team members are comfortable participating, however. “We had a situation when members of our IT team did not want to be involved, which I understood and supported,” says Parke. “Fortunately, they had an alternative person available.”
- Some families have asked for MAID on behalf of incapable persons with dementia.
“In all cases, I have empathized with their request — but informed them that the law does not permit a substitute decision-maker to request MAID on behalf of an incapable person,” says Parke.
- The language of the legislation is open to interpretation.
The legislation sets out eligibility criteria and additional safeguards. “Yet translating these into standards for clinical practice has been, at times, challenging. The language of the law and that of healthcare are often not shared,” explains Shanker.
The legislation includes terms such as “death is reasonably foreseeable.” “This has created problems when trying to assess if a person is eligible for MAID,” says Parke.
One of the criteria for eligibility is that a person must have a “grievous and irremediable” condition. “This terminology is unfamiliar to clinicians,” says Shanker. “While the legislation elaborates on it to some degree, its meaning and application are not obvious to non-lawyers.”
The legislation seems to have been written in a manner which invites a range of interpretations, so as to leave room for clinical judgment. “However, in clinical practice, this introduces additional layers of complexities,” says Shanker.
- There is no consensus on a standardized clinical tool to assess capacity for MAID.
“Capacity assessments in the context of MAID give one pause for ethical reflection,” says Shanker.
In Canada, the test for capacity to consent to MAID follows the same legal standard as those for other healthcare decisions. Shanker recently conducted a review of capacity assessment tools within mental health, and concluded there is no consensus on the best tool for evaluating the capacity to make complex treatment decisions.
“Capacity assessments for MAID thus represent one aspect of the evolving landscape of practice,” says Shanker. “Clinicians must learn from experience and support others as they continue to build skills and enhance competency.”
- Bob Parke, BA, BSW, MSW, MHSc (Bioethics), Bioethicist, Humber River Hospital, Toronto, Ontario, Canada. Phone: (416) 242-1000 ext. 82808. Email: BParke@hrh.ca.
- Ruby Rajendra Shanker, MBBS, MHSc (Bioethics), Bioethicist, Toronto General Hospital/Women’s College Hospital, Toronto, Ontario, Canada. Phone: (416) 340-4800 ext. 8750. Email: Ruby.Shanker@uhn.ca.