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 or subcutaneous sedative medication at the end- of-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 of 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 opportunity, 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 ok to provide these practices to others): ◦ ‘3i’ paradigm circumstances: Intoler olerabl 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 one 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 ones ◦ 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 onna 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 of 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 of 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
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