Professor, Department of Bioethics Faculty of Medicine, Dalhousie - - PowerPoint PPT Presentation

Jeff Kirby Professor, Department of Bioethics Faculty of Medicine, Dalhousie University

 Two case studies to help ‘ground’ the

presentation and discussion

 Clarification of some assisted dying terminology  Relevant ethical values and principles  Two distinct sets of assisted dying circumstances  Other ethical assisted dying issues and

considerations

 What’s been happening in Canada?  Interactive dialogue

 Normal critical/acute care practice

• Withholding of potentially life-sustaining treatment
• Withdrawal of potentially life-sustaining treatment

 Integrated palliative care practices

• Potentially life-shortening use of pain/opioid

medication

• Proportionate, distress-relieving sedation
• Continuous deep sedation until death
•  Assisted dying practices
• Physician-assisted suicide
• Voluntary euthanasia

 The intentional administration of an intravenous

• r subcutaneous sedative medication at the end-
• f-life to induce and maintain a deep coma state

until the patient dies

 Usual length of CDS when artificial hydration and

nutrition have been discontinued: 1 to 4 days

 Either the patient or the patient’s legitimate

substitute decision maker (if the patient lacks capacity) may consent to the use of CDS

 The intentional ending of the life of the patient by

(the hand of) the patient who consumes/drinks a lethal dosage of a barbiturate sedative medication; usually preceded by the use of an anti-nausea drug

 The patient must be capable of consenting to an

assisted death

 One of the physician’s roles is to prescribe the

sedative medication; the pharmacist’s role is to fill the prescription

 The direct, intentional ending of the patient’s

life by the physician’s intravenous administration of two medications:

• Initially, a lethal dosage of a potent sedative

barbiturate

• Subsequently, after achievement of a coma state, a

large dosage of a paralyzing (muscle-blocking) agent

 Requirement for fully-informed, direct consent

• f the patient

 Individual autonomy: foundational basis of

‘right to die (with dignity)’ and ‘choice in dying’ claims:

• A person has the right, and should have the
• pportunity, to choose his/her ‘life plan’ and to make

meaningful decisions about her/his health care and treatment, including decisions that are made at the end-of-life

• This principle is actualized in health care through: 1)

the informed consent/choice process, and 2) health care providers’ and organizations’ commitment to patient-centered care

 Patient welfare principles

• Beneficence – the obligation of health care

providers and organizations to provide therapeutic benefits to patients with legitimate health care needs

• Nonmaleficence – the obligation of health care

providers and organizations to do as little as possible harm to patients

 ‘Do as little as possible harm’ – what is the

relevant harm in the assisted dying context?

• Version 1: profound/unbearable suffering

experienced by a patient (primary perspective of supporters of assisted dying)

• Version 2: hastened death of the patient (primary

perspective of those who are opposed to assisted dying)

 Social justice

• The responsibility of individuals and societies to

prioritize, and pay particular attention to, the interests and needs of members of historically marginalized and otherwise disadvantaged social groups

• It could be argued that individuals with a terminal

illness who are experiencing profound distress/ suffering constitute a disadvantaged social group (for the purposes of eliciting the above obligation)

 Concept of a ‘relevant difference’ – what makes it

morally permissible (ok) to provide continuous deep sedation, assisted suicide or voluntary euthanasia to some patients (when it wouldn’t be

• k to provide these practices to others):
• ‘3i’ paradigm circumstances:

 Intoler

• lerabl

able/unbearable suffering/distress  Distress/suffering is refractory to standard acute and palliative care treatments/interventions (intra racta ctabl ble)  Death is predicted to be ‘near’/imm mminent nent – a few days to a few weeks

 It is anticipated that death will occur ‘naturally’

within days to a few weeks

 Current presence of profound suffering which is

experienced as unbearable/intolerable by the person

 The suffering is either primarily physical, e.g.,

shortness of breath, agitated delirium (confusion) or mixed physical and psychoexistential in nature

 Intractable/refractory medical condition – realizable

treatment modalities have failed or are anticipated to result in more burdens than benefits or (?) an informed decision to forgo further treatment been made by the patient

 There are other circumstances in which persons

seek out an assisted death when their death is not anticipated to be ‘near’

• Presence of a significant health condition that, from

the perspective of the individual, makes the prospect of further life ‘not worth living’ because of

• ne or more person-specific, quality-of-life factors
• Affected individuals in these circumstances tend to

be highly-actualized in educational, occupational and economic domains

 Typically, the distress in these non-paradigm

circumstances is primarily of a psychoexistential nature

 Examples of some negatively-perceived, quality-of-life

factors in these circumstances:

• Inability to participate in activities that formerly made life

meaningful and/or enjoyable

• Perception of current or anticipated, progressive loss of

‘self’, dignity, independence and/or social significance

• Preference for control over one’s destiny, including one’s

‘final exit’

• Desire to not become, or continue to be, a burden to loved
• nes
• Hopelessness

 Recent high-profile Canadian examples:

• Kim

m Teske ke – 52 woman with mid-stage Huntington’s disease made a decision to permanently stop eating and drinking Kim’s Choice: A death on her own terms

(Globe & Mail article and photojournal July 2014)

• Gil

illi lian an Be Bennett nett - 84 year old, retired clinical psychotherapist in early to mid stage dementia committed suicide by drinking a sedative barbiturate in liquid form (with a “draught of good whiskey”)

 Recent high-profile Canadian examples, cont’d:

• Don
• nna

a Delorm lorme e – Calgary-based advocate for assisted dying (who was living with longstanding, progressive multiple sclerosis) committed suicide at home

• Elizab

izabet eth Fisch scher er – 68 year old artist, musician and writer with terminal lung cancer chose to end her life in a Dignitas Clinic; her trip to Switzerland and her assisted death (via a vacation in Iceland) are largely funded by a “fun(d)raising wake” held in September 2015

 Often used in an attempt to justify potentially life-

shortening use of pain/opioid medication and continuous deep sedation

 Essentially states that it’s morally permissible (ok)

to deeply sedate patients or escalate dosages of their pain medication if the healthcare provider’s sole intention ntion is to relieve profound suffering (in ‘3i’ circumstances) even though the risks – loss of consciousness and hastening of death – are foreseeable

 Given the ‘exceptionally bad’ alternative – the

continued profound suffering/distress of patients, the use of pain medications or sedatives in these atypical ways and in these particular circumstances is morally ‘good’, a proportionately beneficial response

 Assisted dying practices are viewed as constituting

discrimination against, and abuse of, persons with disabilities

 Related concerns about: 1) reinforcement of existing

negative stereotypes, 2) devaluation of the lived experiences

• f persons with disabilities, and 3) engenderment of a ‘duty

to die’

 American ‘Not Yet Dead’ grassroots disability rights activists

view ADPs as “deadly forms of discrimination”, while the Council of Canadians with Disabilities opposes decriminalization of assisted dying and characterizes these practices as “killing with state sanction”

 Dr. Catherine Frazee, a prominent Canadian

disability rights activist, commented in 2014…

• “See me as anything but your equal in human worth

and, at that moment, in that glance, with that sorrowful sigh, you have robbed me of dignity. Speak

• f willful death as a reasonable choice for persons

afflicted with the presumed indignity of physical incapacity, and my dignity is undermined. This is not some trivial conceit. For my my dignity is utterly bound up with your respect for my way of life. It is not abstract, and it is not a solitary attribute. Dignity is social.”

• http://ottawacitizen.com/news/national/catherine-

frazee-there-can-be-dignity-in-all-states-of-life

 A ‘paradox’ that many individuals who request an assisted

death in non-paradigm circumstances are persons living- with-disabilities

 Margaret Battin and colleagues failed to demonstrate a

disproportionate impact of legally-available physician- assisted suicide on ten “vulnerable” social groups, including persons with non-terminal physical disabilities or chronic non-terminal illnesses (other than HIV disease) in a systematic analysis of physician-assisted suicide practice experiences in the early to mid 2000s in Oregon and the Netherlands

Battin MP, van der Heide A, Ganzini L, van der Wal G, Onwuteaka-Philipsen BD. Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impacts

• n patients in “vulnerable” groups. J Med Ethics. 2007 Oct; 33(10): 591 – 97.

 They are needed to:

• Comprehensively assess and treat patients who are

approaching death due to illness(es)/injury(ies)

• Help establish when necessary conditions are met
• Perform certain actions, e.g.:

 Prescribe an oral sedative barbiturate for the patient to take (physician-assisted suicide)  Prescribe and administer a ‘lethal cocktail’ directly by intravenous injection (voluntary euthanasia)  Determine and declare death

 What supports professional autonomy and the

(partial) authority of physicians in end-of-life, clinical circumstances:

• Generally-accepted principle of respect for

professional judgment

• Their accepted ‘legitimate stakeholder role’ in

shared decision making about their patients’ health care and treatment

• Principle of conscientious objection: healthcare

providers are not required to participate in all legal medical practices (under certain conditions)

 Claim that the use of assisted dying practices

in non-paradigm circumstances in Belgium and the Netherlands has opened-up an ‘imaginative public space for doubt and fear’ about assisted death practices

 Recent sensationalist media attention paid to a

number of provocative euthanasia cases in Belgium:

• 45 y.o. twins with congenital deafness who were progressively

losing their vision due to glaucoma

• A transgendered person
• A person with an eating disorder
• Planned euthanizing of a convicted murderer-rapist (Frank Van

Den Bleeken)

 Provocative cases in the Netherlands

• Recent assisted suicide of a 47 y.o. person with tinnitus where
• std. treatment trials had not been performed
• Recent assisted suicide of a pre-retirement individual who was

concerned about being lonely when he retired in the future

 Also contributing to the public’s doubt and fear

about assisted dying practices…

• Highlighting of past-actual and alarming future-

theoretical non-paradigm circumstances by articulate disability rights activists who have understandable concerns about possible, related devaluation of the lived experiences of persons with disabilities, given the long history of conscious and unconscious discrimination directed against them and members of other historically-marginalized and otherwise disadvantaged social groups in the health care domain



 2009 - Canadian Society of Palliative Care Physicians

indicated that it did not support assisted suicide and voluntary euthanasia – “they are not a part of quality end of life [palliative] care”; the CSPCP reiterated its

• pposition to euthanasia in a statement on Quebec’s

Bill 52 and stated after the SCC decision that… “while not endorsing the act of physician assisted death, we will work actively … in partnership with … to develop those system guidelines that will seek to minimize potential harm for the majority and respect the rights

• f the minority who seek this mode of death.”

Canadian Society of Palliative Care Physicians. Position statement following supreme court judgment re. Carter [Internet]. Surrey: Canadian Society of Palliative Care Physicians; 2015 Feb 12 [cited 2016 Jan 8]. Available from: http://www.cspcp.ca/wp-content/uploads/2014/10/CSPCP-Position-Following-SCC- Judgment-12-Feb-2015.pdf

 2013 Canadian Medical Association poll: 4 out of

5 Canadian physicians would be unwilling to participate in (legalized) assisted dying practices

https://www.cma.ca/Assets/assets- library/document/en/advocacy/Canadian-Approach-Assisted- Dying-e.pdf

 June 2014 - Quebec National Assembly passes

Bill 52 which ‘legalizes’ voluntary euthanasia in near-death paradigm circumstances in Quebec; to be implemented in December 2015

 Aug 2014 - recent change in position of Canadian

Medical Association: an advisory resolution adopted during the Annual General Council Meeting supported the right of Canadian physicians to follow their consciences when deciding whether to engage in (legalized) assisted dying practices

 Oct 2014 – Supreme Court of Canada heard an

appeal of the decision by the BC Court of Appeal to

• verturn an earlier decision by the BC Supreme Court

that ruled that the existing ban on assisted dying was unconstitutional

 2015 SCC Carter v. Canada decision:

• Created an exemption to the Criminal Code

prohibition against assisted dying that will become effective in early February 2016

• After that, physicians will not be criminally

prosecuted if they assist their capable patients to die when they are experiencing…

 Enduri uring and intolerab lerable le sufferin ring g of a physical ical or psych cholo logical gical nature ture as a result of a grievo evous us and irremed emediab iable le medical cal condi ditio tion *Note: these criteria make no reference to whether or not the patient is near-death

 Interpretation challenge…

• Although it may be relatively easy for an attending

physician to determine/confirm whether her/his patient’s suffering is endur urin ing and intolerabl tolerable “to the individual in the circumstances of his/her condition”, it may be more difficult to discern whether the underlying medical condition(s) is gri rievous evous and irr rremediab emediable le in nature, particularly when this condition is a psychiatric disorder

 Traditionally, the assessment of irremediability (refractoriness; intractability) is jointly-informed by the patient and her/his attending physician

 Three-person panel appointed by the Harper

Government to explore assisted dying legislative

• ptions

 Provincial/territorial (- Quebec & BC) expert advisory

group appointed by the Ontario Government to advise re. development of assisted dying guidelines/regulations

 CMA developed ‘principles-based recommendations

for a Canadian approach to medical aid in dying’

 College of Physicians and Surgeons of Nova Scotia

• Federation of Medical Regulatory Authorities of Canada

 NS Health Authority & NS Department of Health and

Wellness (?)