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• Kevorkian’s ghost: A response to Wiebe and Mullin’s argument for MAiD for the oppressed
  Christopher Lyon
  Published on: 16 May 2023
• Hopeless hope, autonomy, and anthropology: a response to Wiebe and Mullin
  Quentin IT Genuis
  Published on: 12 May 2023
• "harm reduction" for harmful ethics.
  Thomas Koch
  Published on: 12 May 2023

• Published on: 16 May 2023

  Kevorkian’s ghost: A response to Wiebe and Mullin’s argument for MAiD for the oppressed

  • Christopher Lyon, Environental social scientist University of York

  Philosophical arguments about autonomy and Medical Assistance in Dying (MAiD), such as those recently espoused by Wiebe and Mullin [1] in the BMJ Journal of Medical Ethics are deeply troubling in their implications and flawed in their considerations.

  In a nutshell, Wiebe and Mullin argue that MAiD can be a ‘harm-reducing’ embrace of individual autonomy to avoid prolonging suffering in oppressed people who cannot access adequate socioeconomic resources. They speak specifically to the application of Bill C-7 MAiD, also known as not-reasonably-foreseeable-natural-death or Track 2, which is for people with chronic physical conditions causing suffering but not death. They argue that even though a person may be poor or have limited options, they can still hold and express autonomy to request and receive death. Death, in their formulation, is the least bad option for people suffering social inequality in an unjust world.
  Theirs appears as the latest in a series of recent papers attempting to use autonomy arguments to justify MAiD access under an expanding range of circumstances. Davis and Mathison [2], for example, argue that a person's ‘welfare condition’ is irrelevant to the ‘moral permissibility’ of MAiD. Braun similarly argues for the ‘provision of assisted suicide (but not euthanasia) as justified when it is autonomously requested by a person, irrespective of whether this is in her best interests’ [3].

  These are not new arguments.

  Thirty year...

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  Philosophical arguments about autonomy and Medical Assistance in Dying (MAiD), such as those recently espoused by Wiebe and Mullin [1] in the BMJ Journal of Medical Ethics are deeply troubling in their implications and flawed in their considerations.

  In a nutshell, Wiebe and Mullin argue that MAiD can be a ‘harm-reducing’ embrace of individual autonomy to avoid prolonging suffering in oppressed people who cannot access adequate socioeconomic resources. They speak specifically to the application of Bill C-7 MAiD, also known as not-reasonably-foreseeable-natural-death or Track 2, which is for people with chronic physical conditions causing suffering but not death. They argue that even though a person may be poor or have limited options, they can still hold and express autonomy to request and receive death. Death, in their formulation, is the least bad option for people suffering social inequality in an unjust world.
  Theirs appears as the latest in a series of recent papers attempting to use autonomy arguments to justify MAiD access under an expanding range of circumstances. Davis and Mathison [2], for example, argue that a person's ‘welfare condition’ is irrelevant to the ‘moral permissibility’ of MAiD. Braun similarly argues for the ‘provision of assisted suicide (but not euthanasia) as justified when it is autonomously requested by a person, irrespective of whether this is in her best interests’ [3].

  These are not new arguments.

  Thirty years ago, the American murderer Dr MJ ‘Jack’ Kevorkian [4], a euthanasia and assisted suicide advocate and illicit provider, expressed cruder versions of the same positions, claiming that ‘autonomy always, always should be respected, even if it is absolutely contrary, the decision is contrary to best medical advice and what the physician wants…’ and that a mere request for death is justification alone for provision, regardless of circumstance [5]. He rationalised this idea through an instrumental view of life, arguing like Patrick Henry in the American Revolution [6], that death is an acceptable solution to any perceived loss of personal liberty (i.e., oppression).

  ‘Listen, when you take my liberty away, you've taken away more-something more precious than life. I mean, what good is a life without liberty? Huh? None.’ [7]

  ‘If you don't have liberty and self-determination, you've got nothing, that's what this is what this country is built on. And this is the ultimate self-determination, when you determine how and when you're going to die when you're suffering.’ [8]

  It is also worth noting that Kevorkian disproportionately killed or assisted death for women, many of whom may not have had any physical illness [9] and claimed ‘that only medical men should decide’ on MAiD [7]. Aside from his blatant misogyny, his statements highlight a central but unacknowledged problem in Wiebe and Mullin’s and similar individualised formulations of MAiD: the tension between the patient's autonomy, the clinician's autonomy, and society.

  Dying with Dignity, Canada's 43-year-old MAiD lobby group is organised around an autonomy rationale [10,11]. Autonomy likewise appears in the final report of the Canadian parliamentary joint committee on MAiD as part of the package of justifications and recommendations [12]. Current Canadian MAiD providers also frequently cite autonomy rationales that echo Kevorkian, Wiebe and Mullin, and others, suggesting that together with reported cases [13], some assessors and providers may already operationalise such arguments, including senior members of the Canadian Association of MAiD Assessors and Providers [14], who make statements such as:

  ‘My job is to help them have a good life and a good death by their standards, not by mine or anybody else’s’[15]

  ‘I believe very, very strongly in patient autonomy, what we call patient centred care…’[16]

  Importantly, in Canada, MAiD is 99.9 % euthanasia. Still, the autonomy of the clinicians who decide how to present MAiD to the patient, how to assess the request, and finally, whether to still proceed with lethal injection (or issuing lethal doses of pharmaceuticals for the sporadic self-administration cases) after asking the patient for their final consent, are ignored by Wiebe and Mullin. By enlisting euthanasia, patients might be better said to be surrendering, not embracing, much of their autonomy, indeed their lives, to their assessors and providers. Certainly, there are already published accounts of shackled and guarded prisoners being assessed and euthanised by paired MAID assessors and providers, yet apparently still considered to have enough coercion-free autonomy for death [17].
  Providers are not Kevorkian’s Thanatron death machine [18], but human ‘agents ‘ themselves who must have the same autonomy as their patients, albeit with wealth, health, privilege, and decision-making power, including a legal exemption to criminal culpability for murder, that leaves them in a much more advantageous ‘welfare condition’ than Wiebe and Mullin’s impoverished or oppressed requestors. Wiebe and Mullin, however, call it ‘paternalistic’ to prevent people from accessing MAiD but make no comment on the brutal paternalism of a privileged and empowered actor representing the state who judges someone’s eligibility for death and then may kill them. Why is clinician autonomy discounted? The privilege and power of assessors and providers is a major persistently unaddressed flaw in the reasoning of these kinds of patient autonomy-based arguments.
  Wiebe and Mullin also attempt to criticise ‘relational autonomy’ perspectives, arguing that restricted options do not limit a person’s autonomy because they can still exercise,

  ‘the ability to understand, appreciate the consequences of their choice, the capacity to value, the ability to reflect on the values guiding their decision, as well as the attitudes of engaged hope, self-worth and self-trust.’[1]

  However, their definition of autonomy appears to be a repackaging of the obsolete ‘homo economicus’ model human actor from neoclassical economic theory, where people are understood to be ‘unswervingly rational, completely selfish, and can effortlessly solve even the most difficult optimization problem’ [19]. However, research in neuroscience, biology, psychology, public health, sociology, and other disciplines has long since established that our relative autonomy and agency are products of myriad internal and external biophysical and social experiences, relationships, circumstances, and systems. None of us exists in hermetic vacuums of rational reason.
  Among these relationships are loved ones, friends, and others impacted by a MAiD death, who might also be sources of support otherwise unknown to the assessor. No consideration is given to them, yet it is well established that suicide and homicide (euthanasia is a form of the latter), in addition to MAiD, can lead to diagnosed prolonged grief disorder, trauma, and other health problems in those who knew the deceased or witnessed the death [20–22]. MAiD clinicians, however, are not legally required to seek information from such people (including other healthcare providers) or enlist them to help identify supports that might relieve oppression and improve conditions. Nor are they required to facilitate grief support, even when the patient does not ban them from contacting others. In fact, the recently released but optional Model Practice Standard for MAiD strongly advises assessors to take every step to seek ‘collateral information’ from other sources [23], suggesting this is not routinely happening. However, suppose a MAiD assessor strongly believes in the individual rather than relational autonomy. In that case, they have no ideological reason to seek such information from others or mitigate harm to them through engagement and grief support.
  By voiding a person’s relational context, the impact of their death on others, and the autonomy of the people who must assess and approve death from consideration, Wiebe and Mullin and their ideological colleagues idealise patient autonomy. Like Kevorkian, they construct euthanasia or assisted suicide (non-culpable homicide and suicide assistance under Canadian MAiD law [24]) as virtuous though ‘tragic’ expressions of self-determination and ‘harm reduction’. Do they consider the harm to others from MAiD deaths as illegitimate or irrelevant? There is a prospect, for example, of an otherwise healthy person grieving or traumatised by a MAiD death and diagnosed with PTSD or a grief disorder receiving MAiD for such mental illnesses in 2024 when this becomes available. Would such begotten MAiD also be a tragic but laudable act of ‘harm reduction’ because grief is suffering, regardless of its origin?
  Finally, Wiebe and Mullin claim that the cases they describe ‘will be few relative to the proportion of patients who can and will access MAiD due to Bill C-7’ (MAiD for disabled people who are not dying). However, according to federal reporting, there were 221 C-7 deaths in 2021 after Bill C-7 became law [25], which is not a ‘few’. Note here that Health Canada reporting obscures this number in a mixed format of a percentage of a fraction (2.2 %/10 064 deaths), so the reader must convert that percentage to get the number of C-7 deaths [25]. Given the significant yearly increases in MAiD deaths, there will likely be more than 221 for 2022 when data become available. Those 221 people were real people with names and authentic lives (not merely dehumanised ‘agents’) and will likely amount to thousands of deaths in a very short time, given the annual increases in deaths we have already seen [25].
  Societies that find intellectual ‘reasons’ to euthanise or kill the poor, sick, disabled, or socially oppressed groups commit atrocities. A former MAiD provider has even sounded this alarm in the wake of eligibility expansions [26]. Despite claims that a lack of support for people is a ‘deep injustice’, the vision of society painted by Wiebe and Mullins is dystopian, where injustice may be morally permitted to flourish so long as others with greater autonomy judge oppressed people to have enough autonomy and ‘engaged hope’ to kill themselves or have themselves killed. Indeed, they seem to argue that medically provided suicide-for-oppression is a suitable and just response ‘to a world that currently does not exist and is unlikely to emerge in the near future’. Thus, in addition to MAiD for both chronic and terminal physical illness and disability, and official consideration or arguments for mental illness [27], children (‘mature minors’) [12] and infants [28], we now see Kevorkian’s old argument re-emerge as a new slip on the expansionist slope as an argument for MAiD for people whose sole condition is the experience of forms of deprived liberty. Wiebe and Mullin’s and allied proposals, perhaps unwittingly, thus serve the construction of an intellectual foundation for eliminating rather than emancipating the poor and oppressed by an empowered (medical) elite. MAiD, in this way, is ultimately a political, not a medical, project. We have seen versions of this before and we know how it ends.

  References

  1 Wiebe K, Mullin A. Choosing death in unjust conditions: hope, autonomy and harm reduction. J Med Ethics 2023;:jme-2022-108871. doi:10.1136/jme-2022-108871
  2 Davis J, Mathison E. The Case for an Autonomy-Centred View of Physician-Assisted Death. J Bioethical Inq 2020;17:345–56. doi:10.1007/s11673-020-09977-8
  3 Braun E. An autonomy-based approach to assisted suicide: a way to avoid the expressivist objection against assisted dying laws. J Med Ethics 2022;:medethics-2022-108375. doi:10.1136/jme-2022-108375
  4 Charatan F. Dr Kevorkian found guilty of second degree murder. Br Med J 1999;318:962.
  5 The Kevorkian Verdict. Frontline. 1996.http://www.pbs.org/wgbh/pages/frontline/kevorkian/ (accessed 18 Mar 2023).
  6 Henry P. Give Me Liberty Or Give Me Death. 1775.https://avalon.law.yale.edu/18th_century/patrick.asp (accessed 14 May 2023).
  7 Lessenberry J. Jack Kevorkian: Defending Assisted Suicide Right Up to the End. Los Angel. Times. 1993.https://www.latimes.com/archives/la-xpm-1993-12-12-op-1235-story.html (accessed 12 May 2023).
  8 Kevorkian J. Dr. Jack Kevorkian’s ‘60 Minutes’ interview. 2011.https://www.cbsnews.com/news/dr-jack-kevorkians-60-minutes-interview/ (accessed 12 May 2023).
  9 Solomon LM, Noll RC. Physician-assisted suicide and euthanasia: Disproportionate prevalence of women among Kevorkian’s patients. Gend Med 2008;5:110–4. doi:10.1016/j.genm.2008.06.001
  10 Dying With Dignity Canada. You searched for autonomy. Dying Dign. Can. https://www.dyingwithdignity.ca/search/autonomy/ (accessed 12 May 2023).
  11 Godley E. Patients’ right to die becoming major issue for MDs and MPs. Can Med Assoc J 1992;146:608–10.
  12 Garneau M, Martin Y. Medical Assistance in Dying: Choices for Canadians Report of the Special Joint Committee on Medical Assistance in Dying. Ottawa: : Parliament of Canada 2023.
  13 Anderssen E. A complicated grief: Living in the aftermath of a family member’s death by MAID. Globe Mail. 2023.https://www.theglobeandmail.com/canada/article-maid-death-family-members... (accessed 20 Mar 2023).
  14 Governance – CAMAP. https://camapcanada.ca/about/governance/ (accessed 13 May 2023).
  15 The Canadian Press. Dr. Ellen Wiebe: ‘We should all have the right to die at our own choice’. Macleans.ca. 2016.https://macleans.ca/news/canada/dr-ellen-wiebe-we-should-all-have-the-ri... (accessed 18 Mar 2023).
  16 Stefanie Green: The ethics of assisted dying. HARDtalk. 2023.https://www.bbc.co.uk/programmes/w3ct32mr (accessed 18 Mar 2023).
  17 Driftmier P, Shaw J. Medical Assistance in Dying (MAiD) for Canadian Prisoners: A Case Series of Barriers to Care in Completed MAiD Deaths. Health Equity 2021;5:847–53. doi:10.1089/heq.2021.0117
  18 Beschizza R. The Thanatron, Jack Kevorkian’s Death Machine. Wiredhttps://www.wired.com/2007/06/the-thanatron-j/ (accessed 12 May 2023).
  19 Levitt SD, List JA. Homo economicus Evolves. Science 2008;319:909–10. doi:10.1126/science.1153640
  20 Wagner B, Müller J, Maercker A. Death by request in Switzerland: Posttraumatic stress disorder and complicated grief after witnessing assisted suicide. Eur Psychiatry 2012;27:542–6. doi:10.1016/j.eurpsy.2010.12.003
  21 Tal Young I, Iglewicz A, Glorioso D, et al. Suicide bereavement and complicated grief. Dialogues Clin Neurosci 2012;14:177–86. doi:10.31887/DCNS.2012.14.2/iyoung
  22 Yan H, Bytautas J, Isenberg SR, et al. Grief and bereavement of family and friends around medical assistance in dying: scoping review. BMJ Support Palliat Care Published Online First: 13 September 2022. doi:10.1136/spcare-2022-003715
  23 MAID Practice Standards Task Group. Model Practice Standard for Medical Assistance in Dying (MAID): Regulatory authority for [Physicians/Nurses] of [jurisdiction] Standard of Practice Medical Assistance in Dying (MAID). Health Canada 2023. https://www.canada.ca/en/health-canada/services/medical-assistance-dying...
  24 Criminal Code. 1985.
  25 Health Canada. Third annual report on Medical Assistance in Dying, 2021. Ottawa: : Government of Canada 2022. https://www.canada.ca/en/health-canada/services/medical-assistance-dying...
  26 Gaind KS. Nothing, nowhere, all at once: Canada’s courtship with assisted death. 2023.https://umanitoba.yuja.com/V/Video?v=847548&node=4129787&a=22215896&auto... (accessed 12 May 2023).
  27 Health Canada. Final Report of the expert panel on MAiD and mental illness. Ottawa: : Government of Canada 2022.
  28 Cullen C, Zabjek A. Federal minister says she’s ‘shocked’ by suggestion of assisted deaths for some babies. CBC News. 2022.https://www.cbc.ca/news/politics/assisted-dying-carla-qualtrough-1.6625412 (accessed 11 Apr 2023).

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  Conflict of Interest:
  None declared.

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• Published on: 12 May 2023

  Hopeless hope, autonomy, and anthropology: a response to Wiebe and Mullin

  • Quentin IT Genuis, Emergency Physician and Physician Ethicist St Paul's Hospital

  Wiebe and Mullin argue that autonomous individuals requesting MAiD because of “unjust social circumstances” or “oppression” should receive MAiD as part of a “harm reduction approach.”

  To successfully defend this thesis, one would be required to defend a particular understanding of autonomy and harm. As these authors note, these terms are notoriously difficult to define. The authors assert that “acting autonomously…requires hope,” the implication being that a truly hopeless person cannot be meaningfully autonomous. The authors subsequently argue, in seeming contradiction, that “people whose reduced opportunities have led them to lose all hope” are autonomous decision makers. Their attempt to resolve this tension involves asserting that the act of pursuing MAiD is, itself, evidence of “engaged hope.” This runs directly contrary to the witness of patients in these circumstances, who cite despair and hopelessness as their motivation. It is an idiosyncratic and paternalistic (and therefore ironic) understanding of hope that suggests that patients who report a desire for MAiD because of hopelessness are, contrary to their own feelings, hopeful and therefore autonomous.

  It may be helpful to think in particulars. In my work as a physician and ethicist in Canada, I have encountered the type of cases that Wiebe and Mullin allude to. In a representative case, a previously able-bodied individual experienced sudden, inexplicable neurological illness that caused significa...

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  Wiebe and Mullin argue that autonomous individuals requesting MAiD because of “unjust social circumstances” or “oppression” should receive MAiD as part of a “harm reduction approach.”

  To successfully defend this thesis, one would be required to defend a particular understanding of autonomy and harm. As these authors note, these terms are notoriously difficult to define. The authors assert that “acting autonomously…requires hope,” the implication being that a truly hopeless person cannot be meaningfully autonomous. The authors subsequently argue, in seeming contradiction, that “people whose reduced opportunities have led them to lose all hope” are autonomous decision makers. Their attempt to resolve this tension involves asserting that the act of pursuing MAiD is, itself, evidence of “engaged hope.” This runs directly contrary to the witness of patients in these circumstances, who cite despair and hopelessness as their motivation. It is an idiosyncratic and paternalistic (and therefore ironic) understanding of hope that suggests that patients who report a desire for MAiD because of hopelessness are, contrary to their own feelings, hopeful and therefore autonomous.

  It may be helpful to think in particulars. In my work as a physician and ethicist in Canada, I have encountered the type of cases that Wiebe and Mullin allude to. In a representative case, a previously able-bodied individual experienced sudden, inexplicable neurological illness that caused significant disability and chronic pain. He was no longer able to work or access his home, and the required mobility supports were initially denied. In this context, the patient requested MAiD, citing the unjust and ableist nature of the system as his sole motivation. He was clear that his ‘higher’ desire was to live; his request to die would be retracted if his circumstances changed. His request for MAiD was not the choosing of a preferred option. He requested MAiD because, in his unjust context, it seemed to be his only choice. He felt as if he had no choice. His circumstances were straightforwardly coercive.

  Wiebe and Mullin have said, in this kind of situation, that a physician like myself can (and should) both try to remedy the underlying injustice and also end the life of a patient who, regardless of any autonomy determination, has a higher desire to live. In a particular case, I cannot do both. In this case, his care team chose to advocate for him. He is alive today, grateful to a team that ‘paternalistically’ valued his higher desire and intrinsic value, over a desperate request driven by unjust circumstances. Would Wiebe and Mullin suggest that they harmed him by doing so?

  Finally, it is important to address the underlying assumptions that lie beneath Wiebe and Mullin’s understanding of autonomy and harm. Which understanding of anthropology suggests that it is less harmful to end a person’s life rather than to deny a request that is motivated by remediable social injustice? Certainly not the anthropology of Kant or Mill, who are originators of the modern idea of autonomy. Certainly not that of Beauchamp and Childress, who were the first to formulate ‘The Principle of Respect for Personal Autonomy’ as a “prima facie” principle of biomedical ethics (more on this here: https://academic.oup.com/jmp/article/46/3/330/6265006). Certainly not the classical medical view of the person, which defines harm in terms of health. I empathize with the discouragement that the authors express regarding the availability of equitable medical care in Canada. But I do not agree that such a context should lead us to hopelessness, abandoning vulnerable individuals who feel like they have no choice but to die. An ethical society would pursue the good for these individuals. Good medicine would pursue their health.

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  Conflict of Interest:
  None declared.

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• Published on: 12 May 2023

  "harm reduction" for harmful ethics.

  • Thomas Koch, medical geographer and ethicist University of British Columbia

  In a recent article two Canadian ethicist/philosophers argued the appropriateness of granting early medical termination (MAiD) to those requesting it because of poverty or a lack of socioeconomic or institutional resources. These are those who would prefer to live but only with unavailable support services ranging from housing to social or rehabilitative and housing resources.

  That the ethical focus should be on the a lack of resources so severe as to make life seem intolerable is not considered by these authors or most other ethicist/philosophers. They assume limited resources are fixed and institutionalized. This ignores the long history of medical and social activism begun in the mid-1800s--Rudolph Virchow being the most famous example--that focused on the failure of social support rather than the inevitable deaths that resulted. If one were to take ethics seriously, the issue would not be permissiveness but activist arguments in that earlier tradition for the care required by the fragile and vulnerable. It is thus that was lost--what Jane Adams called the 'guardianship function' when bioethicists sought successfully to disparage the ethical engagement of physicians involved in patient care.

  Alas, an ethics of 'least harm' that accepts the status quo driving individuals to seek an early death is really no ethic at all. It's simply an acceptance of an unacceptable status quo that in ethics, should be the focus.

  Conflict of Interest:
  None declared.

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