The Compulsion of Physicians to Assist Patients in Having Maid

The Compulsion of Physicians to Assist Patients in Having MAID

Nicholas Ferrara

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With the legalization of medical assistance in dying (MAID), in 2016, a physician’s role has been altered such that it may violate their conscience or religious beliefs because they are required to participate. This act directly violates the Hippocratic Oath which states: “I will use those dietary regimens which will benefit my patients according to my greatest ability and judgement, and I will do no harm or injustice to them. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan…” (North, 2002). The aim of this paper is not to debate the issue of whether MAID is a justified treatment, rather to discuss the role of the physician and whether they should be compelled to assist. According to The College of Physician and Surgeons for Ontario (CPSO), “Where a physician declines to provide medical assistance in dying for reasons of conscience or religion, the physician must not abandon the patient. An effective referral must be provided” (Cpso.on.ca, 2016), with this policy a physician could potentially lose their medical licence by not abiding by it. The purpose of this paper is to argue the fact that a physician who has moral objections to MAID should not be forced to participate in nor assist their patients to have medical assistance in dying on the grounds of it violating their human rights and autonomy. For most physicians the implementation of MAID also imposes a procedure which was not part of the profession when they initially pursued the field, this makes it unethical to force MAID on pre-existing physicians. Due to evident objections physicians may have towards MAID, a solution that not only aims to protect the physicians who have objections to MAID but also still provide the patient with this service is essential. With regards to alternatives, it is accurate to suggest that not all physicians need to be involved in the process in order for it to be offered to the patients; therefore, perhaps only those physicians willing, or implementing a separate career path that specifically revolves around MAID, is the solution to provide the patients access the service while respecting the moral objections of the physicians.

In order to defend the position that physicians should not be compelled to assist in medical assistance in dying, the degree of participation must first be addressed. As previously mentioned by the College of Physicians and Surgeons for Ontario, “Where a physician declines to provide medical assistance in dying for reasons of conscience or religion, the physician must not abandon the patient. An effective referral must be provided” (Cpso.on.ca, 2016). This means all physicians are not required to directly administer the medicine required to fulfil the assistance in dying. A common argument is that by making a referral it is not the same as directly administering the procedure. However, there are a significant number of doctors who consider the referral as unsettling as the procedure itself. For example, Dr. Natalia Novosedlik, a palliative care physician, of Scarborough was asked why she opposed providing a referral she said,

“I feel that providing a referral is participating. By providing a referral I'm opening a door through which the patient may or may not choose but certainly may go down a path that will lead to someone ending their life, and I'm the person opening that door. I do see that as a direct participation. And I don't think that's a totally new idea. I recall before this was legalized there were patients who would sometimes request referrals to the program in Switzerland that does physician-assisted suicide for people internationally, it's the only program in the world that does that. And I remember the advice that I was given at the time was that if you did make a referral that could potentially be abetting a suicide” (Janus, 2017).

Prior to legalization, this act of providing a referral could be seen as this illegal act, therefore, it is unethical to impose this procedure on physicians who hold strong objections to the process. Dr. Novosedlik proceeds to discuss her sole experience participating in medical assistance in dying saying, “I have had the experience of making a referral, I did make a referral for this, and I did it knowing that it was against my conscience, and I went against my conscience and I found that to be a really internally divisive experience” (Janus, 2017). By making it mandatory that physicians to play any role in this process in Ontario, infringes on their belief systems and threatens their ability to practice medicine.

Those who believe that physicians should be compelled to assist in MAID often address that if a physician refuses to participate in any part in the process, even referrals, they are obstructing the patient’s autonomy. Autonomy is, “The right to act and govern oneself in accordance with one’s own private beliefs, values, and choices without interference as long as one’s behavior does not harm others” (Salem, 1999, p.31).

The question then arises, if one's request to have physician assisted suicide does not harm others, and the individual is fully informed and understands the extent of the process, then why deny their request?

J.S. Mill said we should never interfere with a person’s freedom except in three situations, “he or she doesn’t know or understand what’s happening, he or she is going to harm you or he or she is going to harm another person” (Lacewing, 2018).

The explanation from Mill paired with the definition from Salem demonstrates that by compelling a physician to assist in this would be violating the autonomy of that physician. By definition autonomy for a person is respected, “…as long as one’s behaviour does not harm others” (Lacewing, 2018). It has been observed, that physicians who were initially willing to provide MAID have found the experience “emotionally distressing” and “overwhelming” to the point that they cannot continue the practice (Stevens, 2006). For the person who objects prior to being involved in the process, the moral distress of participating either directly or indirectly would be greater. Therefore, by requiring a physician to participate in MAID it is implying that the autonomy of the patient is more important than the autonomy and well-being of the physician.

There are individuals who would argue that a doctor’s objection due to their beliefs is not valid. In today’s society the thought is that a physician and all other health care professionals have the duty to carry out a patient’s requests (Janus, 2017). Consequently, this impedes again on the rights of the physician and is not justified. There are people who are willing to provide this procedure, and which is honorable but does not mean because some physicians are willing they should all be required. By compelling all physicians to participation in this process it will expose them to the emotional repercussions of it. The research offers some understanding of the emotional effects of assisting in a death. One of which was a 2006 review by Kenneth R. Stevens, Jr., MD., FACCR, which found that “the emotional and psychological effects on the participating physician can be substantial, including feeling powerless and isolated, and being shocked by the “suddenness” of the death (Stevens, 2006). Among other studies, Stevens looked at surveys from ’90s of US physicians who had performed MAID and found that “24% regretted it, and 16% said the emotional weight of having performed it had negative effects on their practice” (2006). In medicine, physicians are accustomed to death, however for most deaths, they are involved in a passive way thus, when it occurs, it’s inevitable. In the case of medical assistance in dying these physicians possess an active role in the death of the patient. The compulsion of physicians to participate in medical assistance in dying may have serious effects on their well-being and their ability to fulfil the duties of their practice.