Showing posts with label assisted dying. Show all posts
Showing posts with label assisted dying. Show all posts

Sunday, November 11, 2018

Things I Don't Understand: objecting to assisted dying when you don't mind if people die

This post was inspired by, but is not directly related to, this op-ed outlining how the new provincial government's policies could kill people.

Policy can kill people.  Politicians who enact such policies and other proponents of these policies either don't care if people die, or see people's deaths as acceptable collateral damage.

What's weird is the intersection between not caring if one's policies kill people, but being opposed to medically-assisted death. If you don't care if people die, why would you object to people dying?

Some people hold the idea that people should contribute to society rather than being a burden to society.  Others refute argue against this idea, saying that your value comes from who you are as a person rather than what you can contribute.  (I actually don't hold either of these ideas - I don't feel it's my - or anyone's - jurisdiction to go around insisting others contribute to my satisfaction or accusing others of being a burden, but I also don't feel that every human being has intrinsic value for the simple reason that I can't perceive any intrinsic value in my own essential humanity.)

So I also find it weird when people who hold the "contribute to society or you're a burden" idea are opposed to assisted death. In a paradigm where it is possible for a person to be a burden, why would you be opposed to someone saying "I'm too much of a burden, so I'm going to get out of the way now.

One reason I have heard for objecting to medically-assisted death while not objecting to death itself is that if you can do it yourself, you don't need medical assistance.

But the benefit of medically-assisted death rather than suicide is it doesn't leave a mess for other people to clean up.  Currently, we don't have any non-medical method of suicide that doesn't leave a carcass in a place where it's inconvenient to others for there to be a carcass.

In contrast, in medical settings where people die, they're fully trained and prepared to move a dead body and hygienically clean up afterwards. (In my grandmother's long-term care home, they have whole procedures in place for this eventuality!) Until we have Suicide Place, medical contexts are our only option for people to die without being an undue burden upon others.

So it's really strange to me that people who don't mind that their policies might kill people are opposed to people choosing to die.

Sunday, October 14, 2018

The only requirement for assisted death should be wanting to die

I've always been thinking about medically-assisted dying from the point of view of not having access to it. I fear reaching the point where I can no longer have a quality of life that meets my minimum standards, but not being eligible to be put out of my misery.  I fear decades of being tube-fed against my will, or never being able to have privacy because I'm too far into my decline to be unsupervised but not permitted to die.

And I've been writing about assisted dying from this perspective. Recent attempts at assisted-dying legislation set out very specific medical prerequisites for qualifying for assisted death.  I see gaps in these criteria, so I'm trying to come up with policy ideas that would fill in the gaps while being sufficiently palatable to pass into law.

It recently came to my attention that some people think about it from the opposite perspective: they're concerned that the existence very specific medical criteria will create a situation where people who meet those criteria but want to continue living will be pressured or coerced to die.  I've noticed that, in particular, people with disabilities who have been through some shit are concerned about being seen as less worthy of living if they meet the assisted dying criteria.

As a proponent of assisted dying, this is not my intention!  My wanting death to be available to me and not wanting to have life inflicted upon me against my will doesn't mean that I don't want life to be available to others and want death to be inflicted upon others!

Fortunately, there is a simple solution to meet the needs of both sides.  One, and only one, medical prerequisite for assisted death: the patient wants to die.

If the patient wants to die, they meet the legal requirements for assisted death.  If the patient doesn't want to die, they don't meet the legal requirements for assisted death. Period.

The only problem is, I don't think they'll go for it.  Too many people are uncomfortable with the idea of death on demand that they feel it's morally imperative to put obstacles in the way. I don't like it, but right at this exact moment I think our options are assisted dying with obstacles, or no assisted dying whatsoever.

But those obstacles shouldn't be medical prerequisites for assisted death.  Instead, they should be part of the protocol that medical professionals follow.

For example, when a patient requests assisted death, protocol could dictate that medical professionals first conduct a quality of life analysis, and try to resolve the quality of life issues through less drastic means. Perhaps even a minimum amount of time would have to pass between the patient first requesting assisted death and assisted death being administered, during which time other, less drastic interventions are tried to resolve the patient's quality of life issues.  (There would have to be an exception in cases where this minimum amount of time is longer than the patient's life expectancy prognosis, or when the patient and their medical team have already tried everything.)

But ultimately, in order to meet the needs of vulnerable people who want death to be available to them and vulnerable people who don't want death inflicted upon them, the only legal requirement,  the only official medical criterion, and the sine qua non for assisted death must be wanting to die. Everything else is merely procedural.

In other words, the only requirement for whether to provide assisted dying is that the patient wants to die.  Everything else is about how.

Monday, October 10, 2016

Another way to improve any assisted dying legislation

A problem with attempts to legislate assisted dying is that they attempt to define in legislation what does and doesn't constitute a good enough reason to die, and thereby what does and doesn't constitute adequate quality of life. As life and death are infinite and complex, some things will almost certainly fall through the cracks.

At the same time, when legislation includes specific things that are considered acceptable reasons to want to die, some people who have those conditions or experiences but don't want to die sometimes take offence, as though society is telling them that they don't deserve to live.  And this push-back may lead legislators to be reluctant to include additional specific conditions, for fear of offending more constituents.

These problems could be mitigated with a single provision: if the patient wants to die because of the absence of a specific aspect of quality of life, and the patient does not have a reasonable chance of gaining or regaining that aspect of quality of life, the patient is permitted to die.

The advantage of this is it takes legislators out of the business of deciding what is and isn't deathworthy (or, depending on your perspective, lifeworthy). Each patient gets to set their own priorities.

In carrying this out, medical professionals should drill down and make sure they pinpoint the actual quality of life issue that's important to the patient, in case it could be addressed some other way.  For example, if a patient says "I want to die if I ever end up paralyzed," what exactly is it about being paralyzed that makes them feel it's deathworthy? Are they afraid of never having sex again? Are they afraid of being dependent on someone else to bathe them for the rest of their life? And are these things that actually happen if you're paralyzed, or are there workarounds that the patient doesn't know about?

If they pinpoint that what the patient actually fears is being dependent on someone else to bathe them for the rest of their life, the living will would be edited from "I want to die if I ever end up paralyzed" to "I want to die if I ever end up in a condition where I'm dependent on someone else to bathe me for the rest of my life," which not only addresses the actual problem, but also includes situations the patient didn't anticipate where they might end up unable to bathe themselves.  It would also tell the patient's medical team where to focus, so they can make a point of trying everything to enable the patient to bathe themselves.

In interviewing the patients to drill down and identify their actual concerns, medical professionals would need to be extremely careful not to be judgemental. They'd need to make very certain to treat every concern as completely valid, and not try to talk patients out of it or even react negatively if the concern sounds petty or shallow or superficial. I know this would be difficult for some corners of the medical profession where people see the direst aspects of the human experience every day and would feel inclined to laugh in the face of "I want to die if I can never again eat recreationally."

But if we can successfully legislate and implement a system where patients choose which aspects of quality of life they see as lifeworthy and deathworthy for themselves with the guidance and support of an empathetic and knowledgeable medical team, that will eliminate many potential problems of mislegislation.

Tuesday, May 17, 2016

How to improve assisted dying legislation with one simple rule

I've been reading about the various flaws in the current assisted dying legislation, and my shower gave me an idea of a simple way to improve it, or any other assisted dying legislation really.

I propose that, in addition to whatever categories of patients legislators deem acceptable candidates for assisted dying, any patient who has tried everything and still wants to die is permitted access to assisted death.

I don't think this is anywhere near a whole solution, but I do think it's a (relatively) easy rule that is unobjectionable to as many people as possible and achieves a number of things:

1. It catches the patients that legislators didn't think of. People generally want to impose restrictions on access to physician-assisted dying because they have various "What if?" scenarios in mind that they want to prevent, and they try to write restrictions that address those scenarios.  But, apart from people who don't want anyone to die at all ever, I doubt any of the scenarios people are thinking of preventing include cases where absolutely everything has been tried and the patient still can't bear to go on living.

2. It could create an additional path to help patients access treatments they haven't been offered yet. Sometimes you hear about situations where doctors simply rule out the possibility of certain potential treatments on grounds that the patient might not agree with (e.g. to protect the patient's fertility). But if applying for physician-assisted dying triggers a review of what has been tried so far and a protocol for trying everything else, when they say "We can't offer you death without first trying to remove your ovaries to see if it helps," you can say "Great, let's do that!"

3. It provides hope for all patients.  Even if you don't qualify for assisted dying right this second, you can get there just by following the standard protocol of trying, ruling out and refining treatments.  It will take time and difficulty, but you can get there. Every unsuccessful treatment you attempt is a step towards being put out of your misery.

4. It provides a built-in waiting period. Many people who are opposed to death at will cite first-hand or third-hand experiences of wanting to die but then, after some time passes, not wanting to die any more. Their concern that the desire to die might go away with time would be addressed by all the time it takes to proceed through all the treatments, which makes them less likely to oppose this rule.

***

At this point, you're probably wondering about the definition of "everything". Does that mean you have to try every single medication in existence, or just a representative sample? Do you have to try alternative medicine? What if it's unproven? Do you have to participate in clinical trials?

And what if you can't afford the prescriptions or alternative medicine treatment? What if you can't get into the clinical trials?

First of all, I think the Try Everything rule could be implemented immediately before these points are addressed, with the understanding that we will take the time to examine the nuances and refine the definition of "everything".  This will provide immediate  access for a (admittedly very small) number of people who may have otherwise slipped through the cracks but whose death by choice is as unobjectionable as possible, because they already have tried everything and have documented evidence of this.

Then, the process of working on refining the definition of "everything" could leverage the Anti-Death No Matter What lobby to improve access to medical care in general. Currently, they seem to be limited to saying "No death! Death is Bad!"  But this would give them positive things to lobby for that would serve as obstacles to death, but also help everyone in the meantime.  For example, it's not reasonable to expect people to try every prescription medication if the cost is prohibitive. So now the anti-death lobby is incentivized to lobby for pharmacare.  It's not reasonable to demand that people try alternative medicine that's unproven and not covered by OHIP, so now the anti-death lobby is incentivized to lobby for alternative medicine to undergo clinical testing, and for treatments that turn out to be proven by clinical testing to get covered by OHIP.

***

Of course, this comes nowhere near addressing all the problems with assisted dying legislation.  Notably, it does nothing about the lack of ability to provide an advance directive. But, nevertheless, expanding assisted death availability to include patients who have tried everything would fill in some gaps while being consistent with the spirit and intent of the legislation.

Thursday, August 20, 2015

A better approach to ethical objection by doctors

I've blogged before about the mystery of doctors who choose to practise in a certain field of medicine even though they morally object to an integral part of that field of medicine.  Surely they should have seen it coming that they'd be called upon to do the thing to which they morally object (in the case that inspired that blog post, prescribing contraception when working in a walk-in clinic) and surely they should have chosen a different field of medicine if they objected to this.

But with the eventual legalization of physician-assisted dying (as they seem to be calling it now) in the news, I see a situation where the doctors literally didn't sign up for this.  It's quite possible for someone to have become a doctor without having seen it coming that they could be called upon to deliberately end a life. 

So in the shower, I thought of a simple guideline that balances physicians' ethics, patients' rights, the "they should have seen it coming" factor, and the "they couldn't have seen it coming factor."

Doctors should be required to provide all procedures and services that were usual and customary in their field and their jurisdiction at the time when they begin practising.  However, doctors can be permitted to opt out of only those procedures or services introduced after they began practising. The time when they "began practising" can be defined as either the time when they began their medical training as a whole, when they began their training in that specialization, when they graduated, when they began (or completed) their internship or residency - whatever the medical profession considers the optimal point in time.

So if you became a general practitioner in 1951, you can opt out of prescribing birth control pills on moral grounds. If you became a general practitioner in 2015, you had fair warning that you'd be called upon to prescribe birth control pills, so if you'd find that prospect morally objectionable, you had plenty of time to plan your career in a different direction.

If you became a doctor in 2007, you can opt out of physician-assisted dying on moral grounds.  If you become a doctor in 2020, you'll have fair warning that you might be called upon to help people die in whatever specialties end up providing that service, so if you don't want to provide that service you can specialize in podiatry or obstetrics or something.

If a doctor changes specialization or changes jurisdictions, they're required to provide all the usual and customary procedures and services at the time of their transfer. The reasoning here is they have an opportunity to research what they're getting into and plan accordingly.

This will also make it easier for patients not to get stuck with doctors who won't provide the service they need.  Patients can simply look up the doctor in CPSO or their jurisdiction's equivalent, and see when they began practising.

This way, the proportion of doctors providing a potentially-controversial service or treatment will always increase and never decrease. The acceptance of services among doctors (and therefore their availability) should mirror the acceptance of services among society (and therefore demand).  After a transitional period, patients won't ever find themselves stuck with a doctor who is morally opposed to a usual and customary service or treatment in their field. But, at the same time, no doctor is required to provide any service or treatment that they didn't know they were getting into.