Summary
Medical assistance in dying (MAID) is a process where cognitively competent adults suffering from a terminal illness, yet alive in the final six months of life expectancy and capable of making their own healthcare decisions, may choose to end their lives with assistance from their doctors. They may request prescriptions for medications that they can ingest at a time and place of their choosing to end their life, on their own terms. In his previous commentary, Dan Cohen, an international consultant in patient safety and clinical risk management, and a Trustee for Patient Safety Learning, discussed how MAID aligns with the principles of biomedical ethics. In this commentary, he discusses why MAID is not 'suicide' in the traditional sense of how this word is used.
*Content warning* Some of the themes included in this blog people might find upsetting.
Content
What is suicide, or perhaps… what is it not?
Suicide is a terribly sad and tragic event for people desperately driven to end their lives, often because of various traumatic life events and/or mental illnesses. In many instances, if suicides are prevented then those individuals may go on to live normal lives.
Some have posited that MAID is a form of assisted suicide. In my view, that is a dangerous and narrow interpretation of the word 'suicide' that is frankly disingenuous, insincere and inappropriate. In the analysis below I will explain my view that MAID is not assisted suicide as the term 'suicide' is generally applied.[1]
Suicide, self-inflicted death, is a tragic consequence that may occur in people of all ages but is more common in older people. The frequency of suicide for people aged 25–75 years is approximately 14–19+/100,000, with an increasing trend associated with aging where the frequency of suicides in 80–85+ year olds is approximately 22+/100,000.[2]
The factors contributing to suicide also vary by age, with acute life-altering circumstances more predominant in younger and middle-aged people. These include mental health conditions, interpersonal/family conflicts, spouse or friend trauma and abuse, substance abuse and previous attempts at suicide. If these suicides are prevented, then individuals may, with appropriate clinical and sociological interventions, live long and productive lives.
In older people, the factors differ and are more likely to include chronic physical illnesses, chronic pain, disabilities affecting lifestyle and enjoyment of life, loss of independence, death of a spouse or lifelong friends or siblings, social isolation, late-onset depression, feelings of despair and perceived lack of purpose or value in later life. There also may be financial factors, including fixed-incomes, medical expenses and retirement poverty. The burden of a terminal illness or progression of a chronic illness to a terminal phase also plays an increasing role. [3][4]
Regardless of age or circumstances, self-ending of life is a sad outcome. However, the self-ending of life by someone living and suffering with a terminal illness may be viewed as not so tragic. Rather, life’s ending in someone with a terminal illness can be viewed with a sense of relief. Some may consider that a friend or relative remained in control of their life as long as possible and then chose to die by their own hand when the suffering became intolerable and death’s door was within arm’s reach. Patients suffering from a terminal illness in the final six months of life expectancy are, metaphorically speaking, walking down a progressively darkening corridor and slowly approaching a door labelled “End of your life, please pass through”.
For patients suffering with a terminal illness, ending their lives on their own terms may be viewed as their choice of a caring option. They may define benefit as ending their suffering, pain, disability and even humiliation, in instances where control of bodily functions has been compromised. Finally, they avoid harm (maleficence) as each patient defines harm, in this case the harm of suffering until natural death occurs.
MAID is a compassionate effort to enable terminally ill patients to control the timing and terms of their own death by their own hand. These patients will die within a few months, at most, anyway. They cannot be saved and the quality of their lives cannot be substantially improved.
How does MAID align with other healthcare options for desperately ill patients?
Providing MAID resides within a continuum of caring options that patients with serious, often terminal illnesses should be able to take advantage of. This is in keeping with and supported by two other well-established and legally accepted caring options: 1) Advanced Directives, authored by cognitively competent patients and expressing their perspectives on their care and caring, especially when encumbered with potentially life-ending illnesses; and 2) Healthcare Powers of Attorney, authored by cognitively competent patients and granting individuals, often family members, the authority to make decisions regarding healthcare options for the patient when the patient is no longer able to make their own decisions due to physical, psychological and/or neurological incapacitation.
These two caring options are used to advise doctors of the scope and range of treatment options that their patients would, if not incapacitated, choose or not choose to receive, such as cardiopulmonary resuscitation, respiratory ventilation, renal dialysis, tube feedings, etc. Doctors and other clinicians are generally bound by these legal caring options, though there are exceptions based upon religious beliefs or moral perspectives.
Respect for patient choice and autonomy, the first principle of biomedical ethics, is thus retained for patients approaching the end of their lives.
The primary difference between these two options and MAID is that the choice to utilise MAID must be expressed verbally and in writing by cognitively competent patients capable of making their own healthcare decisions and living with terminal illnesses with less than six months life expectancy. The other two options involve documents authored when patients are cognitively competent, but do not come into effect until the patients are no longer cognitively competent and capable of making healthcare decisions.
All three of these treatment options are impacted by the interpretation of the word 'suicide', which has been grossly distorted by individuals who do not understand, or choose to deny, the nuanced meaning of 'suicide'.
If a patient chooses to refuse cardiopulmonary resuscitation, when successful resuscitation may temporarily prolong life for some period of time, then that patient is asking for assistance in ending their life. The patient is invoking their right to refuse treatment and, thus dying, assisted or enabled by their doctor. If doctors are advised to withdraw care and/or to not intervene with measures felt to be inconsistent with the patient’s wishes and/or beliefs, extended by an individual retaining healthcare power of attorney responsibilities, then these processes should (and generally will) be respected. A patient’s life will end by not providing care that may prolong life for some period but will not reverse the inevitable demise of the patient.
The laws governing the provision of MAID generally require patients to be cognitively competent to make their own healthcare decisions and require the request for MAID to be done verbally and in writing before they may receive MAID. Doctors prescribing oral medications that the patient can take at a time of their own choosing to end their life, while suffering from a terminal illness and with less than six months life expectancy, are in compliance with the Principles of Biomedical Ethics (see previous commentary). From the patient’s perspective, the choice to receive MAID is an autonomous choice. MAID is a benefit as the patient defines benefit, and harm (maleficence) is avoided as the patient defines harm, i.e., the prolongation of the process of dying and suffering.
The Royal College of Physicians[5] and British Medical Association[6] have adopted neutral positions on MAID. These organisations neither support or oppose the current legislation and wish their members to make their own decisions regarding providing MAID once legislation is passed. Given the range of moral perspectives, theistic or non-theistic, this is understandable.
Conclusion
Suicide and MAID are vastly different concepts and to suggest that MAID is a form of a doctor’s assistance in 'suicidal death' is disingenuous, insincere and highly inappropriate given the context and circumstances leading to the desired death by patients living and suffering with terminal illnesses. The patients requesting MAID have less than six months to live, based on the best medical evidence and endorsed by two or more doctors who have assessed them. This is perhaps best summarised by the statement below, authored by the American Association of Suicidology.[7]
“The American Association of Suicidology recognizes that the practice of physician aid in dying, also called physician assisted suicide, death with dignity, and medical aid in dying, is distinct from the behavior that has been traditionally and ordinarily described as “suicide,” the tragic event our organization works so hard to prevent. Although there may be overlap between the two categories, legal physician assisted deaths should not be considered to be cases of suicide…”.
References
*The parameters discussed in this post relating to the processes of providing medical assistance in dying represents a compilation of requirements as commonly portrayed in various forms of international legislation and may not be applicable in all countries.
**The opinions expressed above are those of the author. Others may agree or disagree.
About the author
Daniel L Cohen is an international consultant in patient safety and clinical risk management, senior healthcare executive with extensive leadership experience, former US Department of Defense (DoD) physician executive with career culminating as Chief Medical Officer/Executive Medical Director for the DoD TRICARE health plan currently providing healthcare to over 9 million beneficiaries worldwide. Most recently served as Chief Medical Officer for Datix where he championed the company’s comprehensive patient safety thought leader efforts internationally through innumerable conference presentations, publications and commentaries.
Further reading on the hub from Dan:
Late night reflections on patient safety: commentaries from the frontline (2014)
Patient safe care as a moral imperative: The mandate of medical ethics
Diagnostic errors and delays: why quality investigations are key
Patient Safety Spotlight Interview with Dr Dan Cohen, Patient Safety Learning Trustee
Structures, processes and outcomes for better or worse: Personal responsibility in patient safe care
Providing patient-safe care begins with asking and listening... really listening!
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