By Stacey Kusterbeck
Clinicians face unique ethical questions with medical-aid-in-dying (MAID) cases, and ethicists soon may be seeing more consults involving this issue.
“Bills have been introduced in a number of additional states, and it is likely that MAID will become legal in more of them. As clinicians become more comfortable assessing and prescribing, calls to consultation teams might go down. However, as the number of patients requesting MAID increases, there may be more dilemmas posed to consultation services,” predicts Constance Holden, RN, MSN, an ethics consultant at Boulder Community Health.
The American Clinicians Academy on Medical Aid in Dying (ACAMAID) Ethics Consultation Service is available to assist with these concerns. “There is very little literature about the unique ethical dilemmas faced by professionals who participate in this kind of end-of-life assistance,” says Jean Abbott, MD, co-chair of the ACAMAID Ethics Consultation Service.
Currently, the ACAMAID Ethics Consultation Service has 13 members from diverse professions with expertise in medical ethics and MAID. “Some clinicians have limited or no access to an ethics consultation service with any experience in this field,” says Lynette Cederquist, MD, a member of the Ethics Consultation Service and director of clinical ethics and chair of the Hospital Ethics Committee at UC San Diego Health. The ACAMAID Consultation Service is available to ethicists in jurisdictions where MAID is allowed and has consulted on 14 cases to date. The service has addressed these ethically complex questions:
• Is it ethical for a hospice to have a policy requiring staff to leave the room during the patient’s ingestion of the lethal medication? In this case, the ethicists concluded that such policies were not ethical, because it forces nurses to violate the professional and ethical standard of not abandoning their patients.
• Can a person qualify for MAID by proceeding with voluntary stopping eating and drinking (VSED)? The committee noted that some clinicians would not offer MAID based on VSED. However, there may be ethical justification to support those clinicians who would be willing to offer this, recognizing that this is a legal gray zone.
“Our ethics committee uses the traditional process of ethics consultation. We gather information from the involved parties, synthesize that information to define the ethical dilemma, then deliberate broadly to formulate our conclusions and recommendations using ethics case analysis,” explains Cederquist. The ACAMAID Ethics Consultation Service team tries to understand the perspectives of stakeholders — potential patients, families, providers, and the institutions. Ethicists then articulate options and choices that would be ethically supportable. In some cases, the consult team also outlines options that would not be ethically supportable.
Some clinicians already have access to ethicists at their institutions who can assist with ethically complex MAID cases. “We suggest that clinicians take their difficult situation to their organization’s ethics committee first,” says Holden, a member of the ACAMAID Ethics Consultation Service.
Clinicians who work in outpatient settings or in hospices may not have any access to ethics consultation services at all. Even in the hospital setting, some ethics consultants are not familiar with the issues that come up in MAID cases. “The Consultation Service will collaborate with an institution’s own service, with the prescribing and consulting clinician, and with other members of the patient’s end-of-life care team,” says Holden.
The ACAMAID Ethics Consultation Service supports professionals, rather than potential patients directly. Therefore, the discussions and analysis are directed at providers and other professionals involved in supporting patients considering MAID.
“As with other clinical ethics consultations, the team does not adjudicate the ‘right’ answer to an ethical dilemma,” says Jeanne Kerwin, DMH, HEC-C, a clinical ethics and palliative care consultant at Atlantic Health System and co-chair of the ACAMAID Ethics Consultation Service.
Rather, the ethicists clarify the ethical values that are in tension. For example, there may be disagreements about whether a patient is eligible for MAID among providers. “Prognostication is not an exact science,” Holden explains. “Additionally, cardiac and neurological conditions pose particular challenges with prognostication.”
Rather, the ethicists clarify the ethical values that are in tension. For example, there may be disagreements about whether a patient is eligible for MAID among providers. “Prognostication is not an exact science,” Holden explains. “Additionally, cardiac and neurological conditions pose particular challenges with prognostication.”
