Summary:

In The Atlantic article “How Canada’s Assisted-Suicide Law Went Wrong,” David Brooks explores the ramifications of extreme liberalism on healthcare and individuals by examining Canada’s MAID law. Liberalism celebrates freedom of choice, but this freedom can turn detrimental and contribute to societal breakdown when taken to the extreme. In 2016, Canada’s medical assisted in dying (MAID) law legalized physician-assisted death. The original qualifications for assisted dying were well-defined and reasonable, but in recent years, the qualifications have relaxed and the range of qualified people has increased and expanded. In autonomy-based liberalism, where individual autonomy rules above all, people become isolated and prone to suicide. Instead of autonomy-based liberalism, our society’s perspective should move towards gift-based liberalism in which each person is a receiver of gifts, and has the responsibility to recognize those gifts, use them to benefit the community, and pass them along to future generations. With gifts-based liberalism, people will find deeper purpose and meaning in life. Policymakers should value the good of the people over the will of the people.

Connections to Medical Philosophy:

Brooks’ article touches on several of the philosophical concepts described in Jacob Stegenga’s “Care and Cure” book, including what it means to be healthy (Chapter 1), the definition of disease (Chapter 2), and the definition of death and ethics of killing (Chapter 3).

According to chapter 1, the positive health view holds that being healthy involves something beyond mere freedom from disease; a patient’s overall well-being must be taken into account, which includes having meaningful relationships, achieving life goals, and being satisfied with life. A person may look physically healthy on the outside, but could be overall unhealthy if the person struggles with life circumstances or mental health. Physicians and policymakers need to be aware of the positive health view to help prevent situations like in Canada, where people see assisted suicide as an escape from misery and release of suffering. The Atlantic article revealed that some people cite poverty or housing uncertainty as the main reason for seeking assisted suicide. The positive health view would argue that people who struggle with poverty or housing uncertainty are unhealthy because they are not satisfied with their life, nor achieving their life goals. Patients who are not medically future but seek assisted suicide as a release from distressing life circumstances are looking for purpose in life.

In chapter 2, the definition of disease that relates the most to assisted suicide is normativism, which contends that diseases are disvalued states, and a person with that condition is harmed by it. Normativism holds that disease is directly related to values. Therefore, from the normativism perspective, being disabled is a disvalued state, and people with disabilities are less than people without disabilities. When MAID was created, administrators conformed to the idea that some lives are less valuable than others, in which people with disabilities have less fulfilling and worse lives than people without disabilities. However, people who find value and purpose in their lives can feel happy and fulfilled, despite their disabilities. In The Atlantic article, historian Wilfred McClay’s mother remarked that if she ever was left unable to read, write, or speak, then her life should not be prolonged because there would be no point in living. A couple years later, his mother suffered a near-fatal stroke, and she was unable to speak. Contrary to her statement a few years earlier, his mother found meaning in life: she became a warmer, more affectionate, and more generous person who communicated through gestures, facial expressions, and loved her grandchildren. Spending time with her family brought her joy in life, and her life was not any less full. Based on the normativism definition of disease, McClay’s mother was not diseased because she did not feel harmed by it and she found meaning in being a loving mother and grandmother.

Moving onto the topic of death in chapter 3, the concept of personhood applies to the ethics of assisted suicide. Personhood is a status in which a person has moral properties and cognitive capacities, like the capacity of consciousness. Personhood differs from biological death, which is the cessation of functioning of the physical body. From the personhood perspective, death is the loss of a soul and losing the capacity of consciousness. A person in a permanent vegetative state is alive as a biological organism, but dead in the sense of personhood with loss of consciousness and moral properties. In Canada’s MAID law, the requirement that natural death must be “reasonably foreseeable” was lifted in 2021. In the article, Brooks names patients who were granted access to assisted suicide even though death was not reasonably foreseeable, including 61-year-old Alan who had hearing loss and history of seizures, 37-year-old Tyler who was physically healthy but suffered from PTSD and schizoaffective disorder, and 23-year-old Kiano who had diabetes and lost vision in one eye. All three of these patients retained their personhood, but decided for themselves that life was not worth living anymore. When applying the personhood perspective to assisted suicide, administering lethal doses to these three cases would not be ethical because there was no death of personhood.

Applications:

Featured in a multi-platform, thought-provoking magazine, “How Canada’s Assisted-Suicide Law Went Wrong” is an opinion piece that harshly criticizes the implications of Canada’s MAID law. After reading this article, the average reader would be outraged by the liberalism and looseness of Canada’s MAID law and want to advocate for stricter qualifications and support groups to help people find meaning for life. However, there is a disconnect between the popular production of medical knowledge in the media, and how medical knowledge is discovered and produced in research. Although well-written, this article was opinion-based and did not thoroughly examine each qualification in the MAID law, choosing to focus more on how people who did not fit the original criteria were being granted access to assisted suicide. The article also did not explore whether people who cited poverty and housing uncertainty as reasons to seek assisted suicide actually got their request granted.

News media can exaggerate and omit parts that do not tell the readers the entire story. When people consume medical knowledge from news media instead of research journals, they might emerge with a perspective that is not completely accurate. To navigate an atmosphere in which patients are consuming medical information through the news, public health advocates and healthcare workers should be responsible for communicating both sides of medical issues and should be well-versed in how medical information is portrayed in the media compared to in research. When patients come to practitioners with misinformation about medications or treatment plans, practitioners should respond in a thoughtful and respectful way that clears up any misconceptions that the patient has.

References

Brooks, D. (2023, May 19). Canada legalized assisted suicide-and exposed the limits of liberalism. The Atlantic. https://www.theatlantic.com/magazine/archive/2023/06/canada-legalized-medical-assisted-suicide-euthanasia-death-maid/673790/

By Anna Chong

Brief Summary of Reading:

Physician-assisted death is when a physician provides a patient with the means and information necessary to end his or her life. Only six countries and ten U.S. states have legalized the procedure. In the Hippocratic Oath, doctors explicitly promise to not administer a poison to anyone. As a healer, physicians want to promote the patient’s good (beneficence principle), and also avoid harming the patient (nonmaleficence principle).

The concept of medical futility refers to cases in which there is no reasonable way for the patient to be helped. Quantitative futility and qualitative futility are tools that set standards for when interventions become futile, when likelihood and quality of benefit fall below a minimal threshold. Futile interventions can give patients false hope and cause the physician moral distress. The justice principle is about allocating resources and treatments to patients who can benefit instead of wasting resources on patients who will not.

Physician-assisted dying relates to physicians, morality, and dignity. The “significant responsibility argument” and “significant relationship argument” assert that physicians bear some responsibility for the situation of their dying patients and have built up a relationship of trust, so physicians be the ones to carry out the assisted dying procedure. The “dignified lives argument” is that protecting dignity for terminally ill patients may involve giving them the ability to control when and how they die. The concept of action vs. omission is whether taking action to end a life is different from omitting life sustaining treatment.

Discussion Questions:

1. Is there a difference between withholding/withdrawing life-sustaining treatment (omission) and prescribing a lethal dose (action)? (consider moral and conceptual perspectives, outcomes, and intentions)
2. What circumstances can euthanasia be justifiable under, if at all?
3. Should doctors be required to give euthanasia to patients who demand the procedure (autonomy principle)?
4. Should doctors be able to suggest euthanasia as a recommended medical procedure?
5. Should doctors be required to notify family members if a patient requests euthanasia? And if a family member or friend of the patient objects, should doctors carry out the wishes of the patient or the family?

Class Discussion:

Our class agreed that withholding/withdrawing LST and prescribing a lethal dose were conceptually different, but looking at the situation from a moral standpoint is more complex. Some patients want to die with dignity. In Canada, euthanasia is allowed for some psychiatric patients (MAiD).

Then, we started to talk about how a physician’s intentions matter. One argument is that withdrawing or withholding life-sustaining treatment (LST) allows the patient to live their lives and leaves room for a miracle, whereas prescribing a lethal dose is giving patients exactly what they need to kill themselves. However, a counterargument is that omission itself is an action. When LST is withdrawn, the physician knows that the patient will die. The intention and knowledge – knowing that the patient will die – is the same. Whether a physician withdraws LST or prescribes a lethal dose, both options mean that a physician is admitting the patient is going to die.

Our class agreed that if someone wants euthanasia, there should be multiple steps completed before the euthanasia is administered. The patient should have to sign paperwork, get their request approved by a council, and also have a conversation with the doctor and someone that the patient loves and trusts. A patient might not be in the best state of mind, so someone that the patient trusts should be there before the patient makes a rash decision. The physician should let the patient know euthanasia is an option and lay all cards on the table in a medically futile case.

Although patient autonomy is important, physician autonomy should also be taken into consideration. If a physician feels that administering euthanasia conflicts with their moral values or ethics, then the physician should not be forced to do the treatment. The physician should refer the patient to another physician who will do the treatment.

At the same time, physician autonomy is a slippery slope. Can a physician deny a patient of any treatment just because the physician does not believe in it? What if a physician denies a patient based on a patient’s identity, or because the physician does not believe in the procedure?

Doctors are there to serve. If doctors are not treating their patients to the extent they need help, then perhaps doctors are not doing their jobs.

Some terminally ill patients cannot do much with their lives; treatment can extend life, but cause quality of life to suffer.  A patient could be on so many pills that their body lives but the person inside deteriorates so much that they are unrecognizable. One perspective is that euthanasia ends suffering. Perhaps we should be asking ourselves, from the physical, mental, and spiritual perspectives, what is death, and what is life?

For example, if a physician unplugs someone from life support, the physician is withdrawing treatment but also killing the patient. If you take away the very thing that keeps someone alive, you are still killing them.

When we discussed how much a patient’s family should know, we agreed that although physicians should notify family members, but patient autonomy rules – the patient should still be allowed to get euthanasia even if the family members object. Also, there is the possibility that physicians cannot legally tell anyone that their patient is considering euthanasia. HIPPA protects patients and their health information from being disclosed, and requires the patient to give permission before a physician can share health information with someone else.

Reflection:

Physician-assisted death is a complicated topic with no objective correct answer. Medically futile patients have to ask themselves: at what point is life not worth living anymore? And what does it mean to live a fulfilling life? Patients who have to face these difficult existential questions are conflicted with a roller coaster of emotions, and the physician should be there to help guide them through this emotional thought process.

Death can be defined in multiple ways. We should all ponder the meaning of death. Death can be defined from the physical perspective and the physical body giving up. Death can also be defined as the death of personhood and soul, where one’s mind deteriorates until they are a ghost of who they used to be, such as patients who are in a permanent vegetative state.

During the end of the discussion, we explored the idea that the omission vs. action debate is not really a debate at all: not doing anything is an action. When one chooses to not do anything, they are choosing to stick with the status quo. If we view omission as an action, then perhaps pulling the plug for life support is not really that different from euthanasia.

Finally, we need to take into account the responsibility of physicians. Physicians brought upon the treatment, and so medicine should bear some responsibility for the pain that patients experience.

We can strive for a particular ideal of ethics in the realm of medicine, but the boundaries and ends of medicine are evolving. We as humans need to ponder and meditate on these difficult and personal questions on what it means to live, to die, and medical ethics.