By Stacey Kusterbeck
Ethical controversy over medical aid in dying (MAiD) persists, despite the practice being legal in some jurisdictions. Researchers surveyed Colorado physicians who were likely to have participated in MAiD to learn about physicians’ attitudes toward ethical issues surrounding MAiD.1
“Our main motivation was to expand the ethical discourse around physician assisted suicide/medical aid in dying. We wanted to learn, at a more granular level, what physicians think about the practice,” says Matthew DeCamp, MD, PhD, director of the research ethics program at the Colorado Clinical and Translational Sciences Institute and associate professor in the Center for Bioethics and Humanities at University of Colorado Anschutz Medical Campus. Some key findings:
• The fact that physicians had participated in MAiD didn’t make those physicians more willing to expand eligibility for this practice.
• Many physicians (40%) had never disclosed their views on MAiD to patients. “The issue of whether, how, or when physicians should disclose their views is unsettled,” notes DeCamp. “The main concern on either side — disclosing or not — is whether doing so might create undue influence on a patient’s decision.”
• There was low reported use of ethics consultation.
“Few, if any, decisions around the end of life are straightforward,” says DeCamp. Just as with other complex medical decisions, having additional ethics support to clarify eligibility, patient values, and needs could be helpful in cases where the right thing to do is unclear.
Courtney S. Campbell, PhD, has been involved in few ethics consults involving MAiD in Oregon, where “death with dignity” was initiated in 1997. One reason is that most of the patients are enrolled in hospice care, which provides an informal ethics consult. “There are, however, some circumstances in which a more formal ethics consult or, in hospice, an ethics committee discussion or review, has been generated,” reports Campbell, director of the program in medical humanities at Oregon State University. Some examples:
• Occasionally, physicians are unaware that they are not required by the laws or professional statutes to participate in a patient’s request.
In these cases, ethics consults can help clarify the scope of a physician’s responsibilities, including the legal right and professional autonomy to decline to participate.
• Physicians may experience some moral distress regarding referring patients, if the physician is opposed to participation.
At the same time, physicians want to be sure the patient is not abandoned. “An ethics consult in these rare scenarios can be helpful for the physician,” says Campbell.
• The patient makes a request to the physician and the physician agrees to assist, but the patient exercises their legal option to not disclose the request to family members.
In one such case, a patient made a request, the physician concurred, and the hospice nurse was aware. However, the patient’s family did not know. “One day the family came for a visit and found their relative had taken the medication and ended their life. There were some difficult repercussions in that instance,” says Campbell. To prevent such cases, an ethics consult can be valuable in thinking through the ethical responsibilities of physicians for family caregivers, says Campbell.
• Physicians or nurses may question whether they can and should be present with the patient when they ingest the medication.
Since the “presence” issue can be a source of moral uncertainty and distress, an ethical consult can be helpful. “There is no legal requirement either way, and hospice programs have generally left this to the discretion of the physician or nurse or spiritual case advisor,” notes Campbell. Ethicists can help with MAiD cases in these ways, according to Campbell:
• Assist clinicians with thinking through the options that align with their professional values.
• Make a recommendation based on the values and interests of the patient and physician. “A consult is not the time to make a case for or against the law or policy. The consultant can provide general ethical principles, but must not engage in ethical micromanaging,” cautions Campbell.
• Identify moral distress or moral injury. “But the consultant is not a counselor. The consultant should recommend other persons best positioned to work with the person on their distress,” says Campbell.
MAiD can come up in ethics consults even in states where it is not legal. Several years ago, Hilary Mabel, JD, HEC-C, received a consult from a physician whose patient was seeking MAiD in a European country. It was part of that country’s process that the patient’s home physician provide a letter affirming decision-making capacity and that the patient’s decision was an informed one. As an ethicist, Mabel helped the physician reflect on whether they felt being part of the process of facilitating MAiD was aligned with their values and their duties as a physician. “My role was more as a sounding board and support for the physician’s moral reflection,” explains Mabel, core faculty and healthcare ethicist at Emory University’s Center for Ethics.
Mabel had two separate conversations with the physician. In the first, she laid out various ethical considerations and viewpoints. For example, she explained that some physicians view MAiD as honoring their patient’s self-determination, while others feel that MAiD violates the oath to “Do no harm.”
Mabel advised the physician to take a few days to reflect on their views and to read more about the practice of MAiD. In the second conversation, Mabel talked more about the physician’s personal views. “I tried to create a space of non-judgment and exploration,” Mabel says. “I do think medical aid in dying can be ethically supportable, but a physician’s involvement in the process depends on their conscientious views. I have physician mentors and colleagues who don’t support it.”
In the end, the physician philosophically agreed with MAiD and decided to write the letter for the patient. The physician also connected with the hospital’s legal team to discuss legal issues. “The physician seemed grateful for my role in highlighting the relevant ethical considerations and creating space to explore and validate the physician’s views,” observes Mabel.
- DeCamp M, Ressalam J, Lum HD, et al. Ethics and medical aid in dying: Physicians’ perspectives on disclosure, presence, and eligibility. J Law Med Ethics 2023;51:641-650.
