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Medical Aid in Dying

Overview | Clinical Scenarios | References
By Richard Martinez, MD, MH

OVERVIEW

Definitions

  • Medical Aid in Dying (MAiD): the activity whereby a qualified, ill person requests a life-ending medication to be provided by a physician and self-administers the medication. Outside of the U.S., MAiD includes voluntary active euthanasia.
  • Voluntary Active Euthanasia: the act or practice whereby a physician actively administers a life-ending medication to a patient, who is very sick or injured, with the permission and consent of the patient, to prevent any more suffering.
  • Suicide: the act of killing oneself because of a desire not to live.
  • Withdrawing/Withholding Life Sustaining Treatment: the process that involves taking away or not giving certain medical treatments, like ventilation, with the expectation that the patient will die.

 

General Considerations and Principles

  • Medical aid in dying (MAiD) in the United States, now legal for over 22% of the U.S. population in more than 10 states, allows certain competent adult patients with terminal illness to obtain a prescription from a physician to end their lives in a peaceful manner. 
  • While each state that has legalized MAiD has variations in the process to obtain prescriptions, all jurisdictions have established safeguards that protect the patient, the family, and the physicians. These safeguards include:
    • Two physicians confirming that the patient has a terminal illness.
    • A written request by the patient to participate in MAiD.
    • Waiting periods between requests and access to the procedure.
    • Referral to a mental health professional if there are concerns about mental illness or capacity to make an informed decision. 
  • While the U.S. has limited MAiD to those with “terminal illness,” some countries, including Canada, Belgium, Netherlands, and Switzerland, allow voluntary euthanasia and access to the procedure with criteria that are more subjective patient-centered judgments of suffering. In Canada, for example, a person must have a “grievous and irremediable” medical condition, and in March 2024, will include those suffering qualifying mental illnesses.
  • Controversy exists in the U.S. and other countries about whether some patients with mental illness should have access to MAiD. Some argue that the psychiatrist’s role is to help people create “a life worth living” and to relieve suffering, not to participate in assisting patients in taking their lives. These individuals believe that MAiD goes against a psychiatrist’s primary obligation to provide hope and relief from mental suffering. 
  • Studies have concluded that most patients who seek MAiD have cancer, followed by neurocognitive disorders.
  • From an ethical perspective, MAiD involves a dilemma in which respect for patient autonomy conflicts with the parens patriae duties of the medical profession and society to protect vulnerable individuals, to avoid harm, and to provide beneficial procedures and interventions. The historical role of the physician as healer and comforter is understandably challenged in MAiD. 
  • While rare, in some jurisdictions, psychiatrists or psychologists may be asked to assess whether a mental illness impacts decision-making capacity in patients requesting MAiD. The decision by a psychiatrist to participate in this type of evaluation must be voluntary as the AMA recognizes that different physicians may be on either side of the moral perspective about MAiD. As with other medical decision making, the psychiatrist or psychologist should assess whether the patient can make a competent, voluntary, and non-coerced decision to end their life. 

 

Jurisdictional Considerations

In 1990, the U.S. Supreme Court affirmed the right to refuse unwanted medical treatment in the Nancy Cruzan case. The U.S. Supreme Court ruled in 1997 that the Constitution does not guarantee a right to medical aid in dying. However, the Court left open the option for each state to decide whether to legalize the practice. Since 1997, some states have legalized MAiD. See https://deathwithdignity.org/states/

CLINICAL SCENARIOS

Scenario #1: You are asked as a psychiatrist or psychologist to evaluate depression in a 58-year-old man with pancreatic cancer who has been told he has less than six months to live unless he agrees to additional treatment. He has requested to participate in the hospital’s MAiD program. What are your obligations?

  • First, are you in support of MAiD and is it legal in your state or jurisdiction? If the answer is no to either or both questions, you should refer the patient to another professional. 
  • Assess the patient for decision-making capacity including his ability to understand and appreciate his medical condition and prognosis, as well as the consequences of taking a life ending prescription.
  • Assess the potential of treatment of his depression which could alter or change the patient’s request for MAiD. Is his depression an understandable consequence of his terminal illness? 
  • Involve family members in assessment of his mental state and decision to pursue MAiD.

 

Scenario #2: You are called by a 38-year-old female patient with severe anorexia nervosa. She asks if you, as a psychiatrist, would be willing to examine her and prepare an opinion letter stating that she is of “sound mind and judgment.” This “clearance evaluation” is required by the organization she has contacted in Switzerland for her to participate in their program to end her life. She tells you she is “done” with treatment for her eating disorder after 20 years of suffering, numerous hospitalizations that included forced treatment on more than one occasion. She adds that she has the support of her family in this decision.

  • First, are you in support of euthanasia in individuals with a primary mental illness, and what are your views about someone with a primary mental illness pursuing such an end-of-life procedure? The American Psychiatric Association (APA) has a position statement that is opposed to prescribing or administering a medication to a “non-terminal ill person for the purpose of causing death.” 
  • Assuming you would be willing to evaluate the patient, you have an ethical obligation to inform her that agreeing to meet with her is not a guarantee that you will write a report supporting her decision.
  • Assuming you meet with the patient, you would assess the patient for factors that might be contributing to her believing that her condition is intolerable, including the presence of treatable depression or other symptoms of mental illness that may be impacting her decision-making capacity, while assuring that she is fully informed and making a voluntary decision. 
  • You should review all medical and psychiatric records, and obtain consent to discuss her situation with previous healthcare professionals.
  • You may wish to meet with family members or a loved one to assess the support or lack of support for her decision.

 

Scenario #3: An oncologist calls you, a psychiatrist with expertise in consultative psychiatry. The patient is a 29-year-old female with an inoperable, terminable brain tumor. She and her husband have requested that her oncologist refer her to a MAiD program that will guide her through the end-of-life process including the option of obtaining a prescription if she and her husband decide to actively end her life. The oncologist is concerned that the patient is showing signs of neurological impairment with periods of irritability, memory loss, and occasional confusion.

  • First, determine if you are ethically in support of MAiD. If not, you should refer the patient to another professional who is favorable presupposed to the procedure. 
  • Meet with the patient and husband to assess the patient’s understanding of MAiD, along with her appreciation of her diagnosis and prognosis. 
  • Assuming there are signs of cognitive deficits, assess the extent of these deficits and their impact on her ability to comprehend her medical situation and the implications of her decisions.
  • Discuss with her and her husband the importance of utilizing MAiD while she is conscious and able to self-administer the medication. Emphasize as well, the risk that if her mental functioning further deteriorates, she may no longer qualify to self-administer the medication. 

 

REFERENCES

  1. AMA position in Code of Medical Ethics in E-5.7 (PAS) and E-1.1.7 (Physician Exercise of Conscience). Available from: https://code-medical-ethics.ama-assn.org/ethics-opinions/physician-assisted-suicide
  2. Canadian Psychiatric Association Committee on Professional Standards and Practice Position Paper “Capacity assessments and the assessment of voluntariness in the context of MAiD legislation: the role and responsibility of psychiatrists” approved by the CPA’s Board of Directors on August 28, 2023. Available from: https://www.cpa-apc.org/wp-content/uploads/2023-CPA-MAID-Capacity-Position-Paper-ENG-Final-V8.pdf
  3. CEJA Report 2-A.19. Available from: https://www.ama-assn.org/system/files/2019-05/a19-ceja2.pdf
  4. APA Resource Document on PAD approved by JRC in 2017. Available from: https://www.psychiatry.org/getattachment/4dea01a9-7e29-4c51-a29a-990cbdd6c194/Resource-Document-2017-on-Physician-Assisted-Death.pdf
  5. APA Position Statement on Medical Euthanasia (2016). Available from: https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-2016-Medical-Euthanasia.pdf
  6. Quill, Timothy E. and Sussman, Bernard. Medical Aid-in-Dying. The Hastings Center. Published June 30, 2023. Available from: https://www.thehastingscenter.org/briefingbook/physician-assisted-death/
  7. Nancy Beth Cruzan, by her parents and co-guardians, Lester L. Cruzan, et ux., Petitioners v. Director, Missouri Dept of Health, et al. 497 U.S. 261 (1990)
  8. Washington v. Glucksberg, 521 U.S. 702 (1997)
  9. Vacco v. Quill, 521 U.S. 793 (1997)

Additional Reading

  1. Simpson, Alexander I. F. Medical assistance in dying and mental health: a legal, ethical, and clinical analysis. The Canadian Journal of Psychiatry. 2018;63(2):80-84. https://doi.org/10.1177/0706743717746662
  2. Appelbaum, Paul S. Should mental disorders be a basis for physician-assisted death? Psychiatric Services. 2017 April;68(4):315-317. DOI: 10.1176/appi.ps.201700013
  3. van Veen, Sisco M.P.; Ruissen, Andrea M.; Beekman, Aartjan T.F.; Evans, N.; Widdershoven, Guy A.M. Establishing irremediable psychiatric suffering in the context of medical assistance in dying in the Netherlands: a qualitative study. Canadian Medical Association Journal. 2022;194(13):E485-91. Available from: https://www.cmaj.ca/content/194/13/e485
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