Should Assisted Dying be Medical?

Part One

Thanks to everyone who attended my virtual talk for the Joint Centre for Bioethics! If you missed it, you can watch the recording here. A reminder that the deadline to submit an abstract to the Toronto Bioethics Workshop is January 15th, which is next Monday. I can tell from here that you’re sitting on a paper idea. Here’s your chance to workshop it. The details are here. Even if you don’t submit, be sure to keep May 17th and 18th free for the event.

My goal in this series is to describe the pros and cons of the medical model of assisted dying, which is the system we currently have, then explore how a non-medical model might work and whether it could be ethically acceptable.

Country after country is legalizing assisted dying because people want control over how they die. It used to be—and still is in many places—that even if you were wracked with pain from a terminal illness, you would have to suffer until the disease killed you. Since the 1980s, if you were lucky enough to be on a ventilator in a hospital, you could demand the withdrawal of the ventilator and die quickly. Most people aren’t so lucky. Some aren’t even lucky enough to have a terminal illness. Instead of suffering for months, they have to endure years of pain, unable to do the things that used to make life worth living for them.

Assisted dying solves this by letting people decide for themselves when their lives are no longer worth living for them. They can look at the facts as they are and make up their own minds.

Almost every place where assisted dying is legal takes a medical approach. Multiple health providers must agree that the patient meets the stringent criteria, then a provider either prescribes the drugs for the patient to self-administer, or the provider administers the drugs for the patient. 

Despite what you’ve heard if you still read the news, this system works pretty well. Assisted dying is much more regulated than other end-of-life options. You don’t need two physicians to assess you before you switch to comfort care. No one is worried about the number of people dying because their ventilator was removed. Opponents of assisted dying haven’t realized that providers and families exist in these other cases, so, if pressure and coercion or lack of capacity are concerns, the sheer numbers mean that their attention is misdirected.

Even though the medical approach works well, there are legitimate criticisms, not from people who want more restrictions, but from those who want fewer. One is practical. The medical model is time-intensive. Healthcare providers involved in assisted dying have worked incredibly hard to get assisted dying where it is, and, even when an assessment and provision go smoothly, it takes a lot of time and pays poorly. On the whole, physicians, nurses, and pharmacists didn’t exactly welcome assisted dying with open arms. Even now, there’s plenty of opposition by providers who think their profession shouldn’t be involved in assisted dying, which puts the burden on the minority of providers willing to participate.

Another criticism is that the restrictive assisted death criteria cause suffering. The more requirements, the more people who are excluded from access, which means more suffering. In all the U.S. states where assisted dying is legal, you’re required to have a terminal illness which you’ll die from within six months. If you’re suffering from a condition that won’t cause your death in that timeframe, you’re out of luck. This isn’t a necessary consequence of the medical model, but it’s a predictable effect. The system is restrictive by design, and, as we’ve seen, attempts to expand the criteria lead to a whole lot of controversy.

Perhaps the most serious criticism of the medical model is that it requires someone’s approval to die. Philip Nitschke, who has been arguing against the medical model since before I was born, calls the current approach “beg and grovel laws”. If you want to die peacefully, you need a physician’s permission, otherwise you’re left to figure it out for yourself, with potentially horrific consequences for you and the people in your life.

I’ve joked that I should make a bot that scours the internet and comments whenever someone says there’s a right to assisted dying in Canada. There’s no such thing. Carter, the Supreme Court decision that struck down the prohibition on assisted dying, created a permission for healthcare providers to help people die. The laws passed after Carter did likewise. Currently, even if you meet all the requirements for medical assistance in dying in Canada, no one is obligated to help you. The system requires a high level of assistance but doesn’t guarantee it. If you can’t find a willing provider, you’re welcome to keep looking, but access to MAID isn’t a right. The case for a non-medical approach is that it removes the need for permission. 

In Patient, Heal Thyself, Robert Veatch argues that every medical decision involves a value judgment, and that healthcare providers lack both the training to make these judgments and the authority to impose them on their patients. As he puts it, “It is absurd for a man to ask his doctor, of all people, whether Viagra is right for him.” Similarly, if a woman wants to go on birth control and her doctor asks her why, she should have the right to say “it’s none of your business” and still receive the drug. The non-medical model goes further: it means she could get birth control without seeing a doctor at all.

Nitschke tells the following story about why he abandoned the medical model. A 76-year-old woman came to him when he was a physician in Australia. Assisted dying had recently become legal in the state where he worked, and she told him that she wanted to die when she turned eighty. He asked her why, and she said in response, “It’s got nothing to do with you. Don’t sit here trying to judge my reasons.”

Veatch and Nitschke argue for an approach that is neutral about the reasons people have for their decisions. According to their approach, a physician can say, “I don’t think that’s a good idea,” but that doesn’t mean the physician is ethically justified in stopping the person from making the decision.

Still, death isn’t Viagra or birth control. There’s more unpacking to do. In the next post, I’ll take a closer look at what it might mean to have a right to die.

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Quick Hits

• Matthew Yglesias over at Slow Boring is here to remind us that most dentistry isn’t evidence-based and that the regulations around it are bad for the public.

• For another excellent anti-dentist dive, see Ferris Jabr’s longform article in The Atlantic from 2019. Please, whatever you do, don’t assume that your dentist is correct when he says you need a root canal (or anything else).

• A lot of people died from hydroxychloroquine during the pandemic, which raises important gatekeeping questions.

• My running project for this semester is to run to all my classes from the end of the subway line, which is 22 kilometres round trip. This will help me prepare for an ambitious event in June, and it also means that I’m getting through a lot of audio books! I finished The War of Art in one trip yesterday. It’s a strange book with some strange metaphysical commitments, but I appreciate a good writing pep talk, and maybe you will too (even if you’re trying to do something other than writing).