Medically assisted dying in (MAiD) Ireland - mapping the ethical terrain

1. M E D I C A L L Y A S S I S T E D
D Y I N G I N D Y I N G ( M A i D )
I RE L A N D : M A P P I N G T H E
E T H I C A L T E RRA I N
Ghaiath Hussein, MBBS, MHSc, PhD
Assistant Prof. in Medical Ethics & Law,
Trinity College Dublin
@GhaiathHussein

2. OUTL I NE : WHAT MY PRESENTATION IS(NOT)
• Provide an ethically-oriented logical framework to guide a
conceptual discussion on MAiD, following this categorization:
▪ The decision
▪ The decisionmakers
▪ The outcome
• Using examples from some countries that legalized MAiD, with
focus on Canada.
• NOT an attempt to explain or endorse any ethical theory or
approach or any official or religious viewpoint

3. W H AT I S
E T H I C A L LY
R E L E VA N T / U N I Q U E
A B O U T M A I D ?
Irreversible decision
Contradicting morally-equivalent
values and duties
Death as a value-laden concept
(spiritual vs. clinical)
Death is a process not an event
Similarities and differences to other
EOL care decisions
Option, right or duty?

4. W HO IS W HO IN MAID?
MAiD
Patient
Family
HCPs
Public
W HICH E THICAL PATH?
Theories
as
lenses
Deontological
Teleological
Principlism
Contractarian

5. ETHICAL QUESTIONS ABOUT THE PATIE NTS?
Autonomy (& Informed Consent)
• How to define capacity to consent? How informed/manipulated/coerced they are?
• What are the limits of autonomy? Do they apply to MAiD?
• Does MAiD dignify autonomous choices or limit view to self?
• Can consent be delegated (children, unconscientious, etc.)?
• Why should 'autonomy' be privileged above other principles of medical ethics?
Concepts of life, death, suffering
• How about non-pain-related reason (loss of autonomy, losing dignity and the
intolerability of not being able to enjoy one’s life)?
• How to assess the impact of COVID-19 and the like on MAiD eligibility and choices?
Option, right or duty?
• Is there a duty to die? avoid burdening others (what is the role of family?)
• MAiD with(out) request: who decides? Blurring of criteria
• Is it ok to change my mind?
• Can MAiD candidate choose what happens after her death?

6. E T H I C A L Q U E S T I O N S A B O U T T H E H C P s ?
Conflicts of duties and roles
• Conflicting duties of not to harm, care, do good, alleviate pain?
• What are the limits of autonomy? Do they apply to MAiD? How about ‘Principle of Double Effect’?
• Role in MAiD? Consultant, assessor, informer, advocate, decisionmaker, implementer
• How would each of these roles affect the main duty to care?
Conscious-based objections
• On what basis can HCPs refuse to be involved (personal, religious, etc.)?
• Can faith-based healthcare facilities be ‘exempted’?
• How to manage uncertainties about the patient’s condition or the outcome of MAiD itself?
Moral habituation and erosion
• What kind of emotional support is available?
• From reflection and guilt to a habit and business as usual
Legal arguments and implications
• How safeguarding are the safeguards? Example of ‘foreseeable death’, used ‘wrong combination’
• Patient choice or physicians’ assessment?

7. ETHICAL QUESTIONS RELATED TO THE
COMMUNITY & WIDER P UBL IC
• Would legalizing MAiD affect perception/trust in HCPs?
• How MAiD may reorientate the focus/roles & priorities?
• Will legalizing MAiD abolish self-committed or unregulated suicide?
Pubic view of healthcare facilities and providers
• Who gets the ‘service’?
• Who pays for it?
• Questions on eligibility, accessibility, and affordability
Justice and access
• How MAiD will affect the reallocation of resources?
• How MAiD lead to view some patients as ‘burden’?
Impact on disabled and persons with special needs?

8. M A I D I N A C T I O N :
C A N A D A
https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html#s1

9. TRYING THE TRIED?
The Spectator (UK) Dr Joel Zivot,

10. O N A F I N A L N O T E / T H O U G H T
• We need evidence. From, with, and about all the
stakeholders.
• ‘Others did it, why not us’ is not a good argument.We
may be similar but not the same.
• Others did it, so let’s learn from them and see how they
ended up is a better prologue
• The majority rules only in politics. In ethics, we need to
hear from the minorities first.