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To die, to sleep, perchance to dream? A response to DeMichelis, Shaul and Rapoport
  1. Joel L Gamble1,
  2. Nathan K Gamble1,
  3. Michal Pruski2,3
  1. 1 Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2 Manchester Metropolitan University, Manchester, UK
  3. 3 Manchester University NHS Foundation Trust, Manchester, UK
  1. Correspondence to Mr Joel L Gamble, University of Toronto, Toronto, ON M5S 1A8, Canada; joel.gamble{at}


In developing their policy on paediatric medical assistance in dying (MAID), DeMichelis, Shaul and Rapoport decide to treat euthanasia and physician-assisted suicide as ethically and practically equivalent to other end-of-life interventions, particularly palliative sedation and withdrawal of care (WOC). We highlight several flaws in the authors’ reasoning. Their argument depends on too cursory a dismissal of intention, which remains fundamental to medical ethics and law. Furthermore, they have not fairly presented the ethical analyses justifying other end-of-life decisions, analyses and decisions that were generally accepted long before MAID was legal or considered ethical. Forgetting or misunderstanding the analyses would naturally lead one to think MAID and other end-of-life decisions are morally equivalent. Yet as we recall these well-developed analyses, it becomes clear that approving of some forms of sedation and WOC does not commit one to MAID. Paediatric patients and their families can rationally and coherently reject MAID while choosing palliative care and WOC. Finally, the authors do not substantiate their claim that MAID is like palliative care in that it alleviates suffering. It is thus unreasonable to use this supposition as a warrant for their proposed policy.

  • euthanasia
  • end of life care
  • palliative care
  • care of dying minors
  • right to refuse treatment

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  • Contributors JLG wrote and revised the manuscript. NKG assisted with writing and editing. MP contributed to early drafts of the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.

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