'Medical Assistance In Dying (MAID)'

CAERS SUBSTACK ARTICLE #64

‘Medical Assistance In Dying’ (MAID)’

CAERS Substack Article #64

I have read that a considerable percentage of the population fear public speaking more than they fear death. Although I sympathize with that sentiment, I suspect that many of those people have engaged in public speaking, but many fewer have experienced a near-death experience (NDE). Perhaps if they had, they would feel differently?

There is little doubt that death has troubled and mystified humanity for a very long time. Years ago, I attended a spiritual seminar for individuals with deep religious beliefs in an afterlife. When the presenter asked for a show of hands as to whether people felt comfortable with the idea of dying, all hands arose in unison. When asked how many would be ready to die that afternoon, nervous chuckles pervaded the room as all hands remained glued to their lap.

This is not surprising: all living things at some level realize the miraculous and fragile blessing called life. We are programmed with very powerful and instantaneous reflexes designed to keep us alive at all costs. With rare exceptions, such as protecting loved ones, we defer to them unquestioningly.

Which is what makes MAID, Medical Assistance In Dying, both exceptional and confusing. It seems to contradict this very life force within us, so it compels asking the question: under what circumstances, other than protecting someone for whom they care (altruism), would someone voluntarily choose to die?

The justification for MAID likely involves three underlying principles. One, a person has the right to control their life and there are legitimate circumstances under which an individual would rationally desire to end their own life. Two, there is a way to confidently confirm that such a desire is primarily based in rational thought, as opposed to irrational thinking or pure emotion. And three, given the finality of death, that such a desire is not temporary and will not change.

I have seen a fair number of people die during my career. Some have passed very peacefully, exiting silently in their sleep or gently slipping away with loved ones present. But I have also seen some prolonged and miserable ways to leave this world. Neurologic diseases strike me as some of the worst; ALS and supranuclear palsy come immediately to mind. Many think that pain is one of the worst symptoms, and of course it can be; but it is sometimes easier to manage than breathlessness or severe nausea, for example. So, I find it understandable that many do not relish some ways of perishing. Equally, I can see how it might be easier to reject the possibility of a rare moral justification for MAID for those who believe in the absolute sanctity of life if they are not familiar with such conditions or have not personally witnessed them.

Irrespective of one’s feelings about MAID, I suspect that most of us realize that it could be utilized inappropriately. Patients could request it in situations where the true prognosis might not be fully known, or they fear the worst scenario that is likely never to unfold. It might be requested for conditions that wax and wane over time, or are manageable but not necessarily curable. And it is not hard to imagine situations in which a person might not be capable of making the decision for themselves and instead it is made incorrectly by someone delegated to make decisions for them. There have been scenarios in other countries in which adults who have never had the capacity to make a decision regarding MAID have had it made for them using a rather utilitarian calculus (it’s best for all of us that this person’s life comes to an end).

There is a distinction made between pain and suffering. In Buddhism it is said that during life pain is mandatory but suffering is optional. In other words, we may experience unpleasant sensations (physical, psychological or spiritual) but still rise above them and find some degree of peace, comfort and meaning in our lives. I suspect, however, that most mere mortals have some kind of limit on the pain that they can endure before suffering becomes inevitable. Few of us want to see another person suffer, and most of us have compassion for those who cannot reach beyond their pain to avoid suffering.

We euthanize animals because we do not want to see them suffer. As much as humans have a level of consciousness greater than other species and may therefore have the capacity to rise above their pain, it is not infinite and sometimes it may not be enough to avoid horrific suffering. Where do we draw the line between what degree of suffering we can allow versus ethically justified intervention through MAID? And how many who choose MAID do so to spare their loved ones the distress of watching their demise if it is going to be prolonged and arduous? In such cases, the act of opting for MAID could be seen as a selfless one. Such decisions will likely always have a significant subjective element that varies depending on the unique circumstances of each individual. So, it seems to me that a broader discussion in our society about MAID is much needed. This should not be left to a few experts, lawyers or politicians to sort out, and it should be actively and transparently monitored in real time.

MAID is part of a bigger discussion regarding death and dying in general. Have these issues been relevant during the pandemic? Have we been able to engage in productive and compassionate dialogue about them? I have heard of individuals who have experienced what they consider to be severe side effects from the C-19 inoculations who have not been able to obtain medical recognition of this, nor the necessary assistance, and who have subsequently resorted to MAID. Irrespective on our feelings about the inoculations or MAID, this should concern us.

There are likely no simple or universally agreed upon answers to these morally challenging problems. And we will likely be left with considerable moral residue no matter what decisions we make. The next few articles in a week or so will explore some ethical principles and theories that might be of help.

J. Barry Engelhardt MD (retired) MHSc (bioethics)

CAERS Health Intake Facilitator