The Complicated Ethics of Medical Aid in Dying
One researcher has been studying medical aid in dying (MAID) through the lens of Canadian nurses’ experiences since it was legalized in 2016.1-3 Based on this work, Sally Thorne, RN, PhD, FAAN, and colleagues developed guidance for nurses to work through some of their ethical questions regarding MAID.4
“This is a rapidly evolving issue, and one that has attracted wide attention,” says Thorne, a professor at the School of Nursing at the University of British Columbia.
In Canada, MAID is handled primarily by physicians or nurse practitioners, although self-administration is allowed. “There is much in the Canadian context that will be helpful to U.S. nurses in trying to understand how this end-of-life option may affect their practice,” Thorne asserts.
Additional ethical questions involving MAID and nursing are arising, as Canadian legislation removes some of the current exemptions to eligibility.
“We will continue to reflect on what we learn from the nursing perspective as this process evolves,” Thorne says. Consider these ethical issues involving nursing and MAID:
• Not all patients know about MAID. Nurses were not named in the original Canadian legislation as playing a role in provision of MAID. “However, it quickly became apparent that nurses were very often the most likely healthcare professional to be involved in the initial conversations that could potentially lead to MAID,” Thorne says.
Early on, healthcare providers assumed the MAID-seeking patient had to initiate such conversations. “But nurses began to understand that the capacity to initiate such conversations was different among various members of the population,” Thorne says.
People with social privilege might find it easy to ask about MAID, while those who are disadvantaged might be unaware of MAID or less likely to ask about it. Nurses noticed some patients asked about the topic indirectly, with questions such as, “Is there anything that can be done to make this go faster?” or “How long does this have to go on?”
“Before MAID was legalized, there truly was nothing nurses could offer, morally or legally. Now, nurses need to interpret such signals and decide how to respond,” Thorne says.
Nurses might bring up the topic indirectly by asking a patient, “Are you thinking about whether there are any options for you in how the end of your life plays out?” More directly, nurses might ask, “Are you asking about whether you might be eligible for MAID?”
“Managing these delicate conversations becomes an ethical challenge for many nurses,” Thorne notes.
• Some nurses object to MAID on moral grounds. When MAID became legal, many nurses reflected on whether they were a “conscientious objector.”
“We have found that hard distinction has softened over time,” Thorne reports. A small proportion of nurses do have sufficient moral objection, meaning they cannot participate at all in the care of a patient choosing MAID. However, many Canadian nurses who initially thought they would have a moral problem with the MAID provision felt differently when confronted with a real patient and family. “Many nurses have come to prioritize their ethical responsibility to support the best death possible for their patients,” Thorne reports.
• Nurses can help the patient experience a “good” MAID death. “When a patient has been deemed eligible for MAID, there is often considerable planning toward all of the issues that arise,” Thorne says.
Nurses might help patients determine who will be told about the MAID decision, how to communicate with family members, and who will be present in the room. Nurses also consider how they can support the family afterward. “Nurses become fiercely committed to doing what they can in support of their patients under such circumstances,” Thorne says.
1. Pesut B, Thorne S, Storch J, et al. Riding an elephant: A qualitative study of nurses’ moral journeys in the context of medical assistance in dying (MAiD). J Clin Nurs 2020;29:
2. Pesut B, Thorne S, Schiller CJ, et al. The rocks and hard places of MAiD: A qualitative study of nursing practice in the context of legislated assisted death. BMC Nurs 2020;19:12.
3. Pesut B, Thorne S, Schiller C, et al. Constructing good nursing practice for medical assistance in dying in Canada: An interpretive descriptive study. Glob Qual Nurs Res 2020;7:2333393620938686.
Some patients and staff alike do not know what the process is, which can lead to misconceptions. Others might not want to ask about it, while some might object on moral grounds. Researchers are working on better education.
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