What is Medical Aid in Dying?

Medical aid in dying (MAID) generally refers to a practice in which the physician provides a terminally ill patient with a prescription for a life-ending dose of medication, upon the patient’s voluntary, informed request.

The Medical Aid in Dying for the Terminally Ill Act provides a structured, legal process by which qualified patients may request and receive life-ending medication from their attending physician under specific circumstances.

Isn’t medical aid in dying the same as euthanasia?

No. Medical aid in dying refers to the physician providing the means for death with a prescription for lethal medication. The patient, not the physician, will ultimately self-administer the lethal medication. Euthanasia generally means that the physician would act directly, for instance by giving a lethal injection, to end the patient’s life. Some other practices that should be distinguished from medical aid in dying are:

  • Terminal sedation: This refers to the practice of sedating a terminally ill competent patient to the point of unconsciousness, then allowing the patient to die of their disease, starvation, or dehydration.

  • Withholding/withdrawing life-sustaining treatments: When a competent patient makes an informed decision to refuse life-sustaining treatment, there is virtual unanimity in state law and in the medical profession that this wish should be respected.

  • Pain medication that may hasten death: Often a terminally ill, suffering patient may require dosages of pain medication that impair respiration or have other effects that may hasten death. It is generally held by most professional societies, and supported in court decisions, that this is justifiable, as long as the primary intent is to relieve suffering.

Is medical aid in dying ethical?

The ethics of assisted death continue to be debated. Some often argue that medical aid in dying is ethical on the grounds that it may be a rational choice for a person who is choosing to die to escape unbearable suffering. Furthermore, the physician’s duty to alleviate suffering may, at times, justify the act of providing assistance with dying. These arguments rely a great deal on the notion of individual autonomy, recognizing the right of competent people to choose for themselves the course of their life, including how it will end.

Others have often argued that physician aid in dying is unethical because it runs directly counter to the traditional duty of the physician to preserve life. Furthermore, many argue if hastened death were legal, abuses would take place. For example, many opponents falsely claim the poor or elderly might be covertly pressured to choose medical aid in dying over more complex and expensive palliative care options. In the 20+ years that aid in dying has been legal in other states, including NJ, there has never been a documented case of coercion or undue influence related to medical aid in dying.

What are the arguments in favor of medical aid in dying?

Those who argue medical aid in dying is ethically justifiable offer the following arguments:

  • Respect for autonomy: Decisions about time and circumstances around death are very personal. Every competent person should have a right to choose death.

  • Justice: Justice requires that we “treat like cases alike.” Competent, terminally ill patients are allowed to hasten death by treatment refusal. For some patients, treatment refusal will lead to more suffering. Justice requires that we should allow assisted death for these patients.

  • Compassion: Suffering means more than pain; there are other physical and psychological burdens. It is not always possible to relieve suffering. Allowing terminally ill people to determine the timing and manner of their deaths is a compassionate response to unbearable suffering.

  • Individual liberty vs. state interest: Though society has strong interest in preserving life, that interest lessens when a person is terminally ill and has a strong desire to end life. A complete prohibition on assisted death excessively limits personal liberty.

  • Openness of discussion: Assisted death already occurs, albeit in secret. For example, morphine drips ostensibly used for pain relief may be a covert form of assisted death or euthanasia. Legalization in New Jersey has promoted more open discussions about end-of-life options.

What do patients and the general public think of medical aid in dying?

The vast majority think that medical aid in dying is ethically justifiable in certain cases, most often those cases involving unrelenting suffering.

What Does the Medical Profession Think of Medical Aid in Dying?

A December 2016 Medscape poll of more than 7,500 U.S. physicians from more than 25 specialties demonstrated a significant increase in support for medical aid in dying from 2010. 57% of the physicians surveyed endorse the idea of medical aid in dying, agreeing that “physician-assisted death should be allowed for terminally ill patients,” up from 46% in 2010. We also know that many physicians who support the end-of-life option are reluctant to declare so publicly for fear of repercussions in their workplace or medical community.

The American Medical Association opposes aid-in-dying laws. However, not only does the AMA represent a declining number of physicians (only about 1 in 3 doctors are AMA members), a 2011 survey of physicians conducted by Jackson & Coker found that 77% of physicians believe the AMA no longer reflects their views.

Many national organizations have affirmed their support or adopted a position of “engaged neutrality.” These are:

 

  • “RESOLVED, that the American Academy of Family Physicians adopt a position of engaged neutrality toward medical-aid-in-dying as a personal end-of-life decision in the context of the physician-patient relationship, and be it further

    “RESOLVED, that the American Academy of Family Physicians reject the use of the phrase ‘assisted suicide’ or ‘physician-assisted suicide’ in formal statements or documents and direct the AAFP’s American Medical Association (AMA) delegation to promote the same in the AMA House of Delegates.”

  • “1. AMWA supports the right of terminally ill patients to hasten what might otherwise be a protracted, undignified or extremely painful death. 2. AMWA believes the physician should have the right to engage in practice wherein they may provide a terminally ill patient with, but not administer, a lethal dose of medication and/or medical knowledge, so that the patient can, without further assistance, hasten his/her death. This practice is known as aid in dying. 11. AMWA supports the passage of aid-in-dying laws that empower mentally competent, terminally ill patients and protect participating physicians, such as that passed in Oregon, the Oregon Death With Dignity Act.”

  • “In consideration of the Ethics, Law and Humanities Committee recommendations, the AAN Board of Directors carefully deliberated this important issue, taking into account the evolving legal environment, all aspects of the ethical debate, the reported values of AAN members, and expectations of their adult patients dying of neurologic illness. Accordingly, the AAN has decided to retire its 1998 position on “Assisted suicide, euthanasia, and the neurologist” and to leave the decision of whether to practice or not to practice LPHD to the conscientious judgment of its members acting on behalf of their patients. The Ethics, Law and Humanities Committee and the AAN make no attempt to influence an individual member’s conscience in consideration of participation or nonparticipation in LPHD.”

  • “With the aging of the LGBT community, end-of-life concerns will continue as an important topic for the community and for GLMA’s work. Aging can be particularly difficult for members of the LGBT community due to estranged family situations, being single or not having dependents, and unequal treatment under the law. It is critical then that LGBT patients have a legal framework to discuss all healthcare options, including end-of-life options, with their physicians and healthcare providers.”

  • “BE IT RESOLVED: That the ACLM recognizes patient autonomy and the right of a mentally competent, though terminally ill, person to hasten what might otherwise be objectively considered a protracted, undignified or painful death, provided, however, that such person strictly complies with law specifically enacted to regulate and control such a right; and BE IT FURTHER RESOLVED: That the process initiated by a mentally competent, though terminally ill, person who wishes to end his or her suffering and hasten death according to law specifically enacted to regulate and control  such a process shall not be described using the word “suicide”, but, rather, as a process intended to hasten the end of life.”

  • “The American Public Health Association (APHA) has long recognized patients’ rights to self-determination at the end of life and that for some terminally ill people, death can sometimes be preferable to any alternative. Accordingly, the American Public Health Association:

    Supports allowing a mentally competent, terminally ill adult to obtain a prescription for medication that the person could self-administer to control the time, place and manner of his or her impending death, where safeguards equivalent to those in the Oregon DDA are in place. Rejects the use of inaccurate terms such as “suicide” and “assisted suicide” to refer to the choice of a mentally competent, terminally ill patient to seek medications to bring about a peaceful and dignified death.”

  • “Excellent medical care, including state-of-the-art palliative care, can control most symptoms and augment patients’ psychosocial and spiritual resources to relieve most suffering near the end of life. On occasion, however, severe suffering persists; in such a circumstance a patient may ask his physician for assistance in ending his life by providing physician-assisted death (PAD). PAD is defined as a physician providing, at the patient’s request, a lethal medication that the patient can take by his own hand to end otherwise intolerable suffering. The term PAD is utilized in this document with the belief that it captures the essence of the process in a more accurately descriptive fashion than the more emotionally charged designation physician-assisted suicide. AAHPM takes a position of ‘studied neutrality’ on the subject of whether PAD should be legally regulated or prohibited, believing its members should instead continue to strive to find the proper response to those patients whose suffering becomes intolerable despite the best possible palliative care. Whether or not legalization occurs, AAHPM supports intense efforts to alleviate suffering and to reduce any perceived need for PAD.”

  • “The American Medical Student Association: SUPPORTS passage of aid-in-dying laws that empower terminally ill patients who have decisional capacity to hasten what might otherwise be a protracted, undignified or extremely painful death. Aid in dying should not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide.”

  • Click here to view the resolution of the MSNJ Committee on Biomedical Ethics' resolution

    However, the final vote to end formal opposition was defeated.

If I am a Physician, What Should I Do if a Patient Asks Me for Assistance in Dying?

One of the most important aspects of responding to a request for medical aid in dying is to be respectful and caring. Virtually every request represents a profound event for the patient, who may have agonized over their situation and their possible options. The patient’s request should be explored, to better understand its origin, and to determine if there are other interventions that may help ameliorate the motive for the request. In particular, one should address:

  • motive and degree of suffering: are there physical or emotional symptoms that can be treated?

  • psychosocial support: does the patient have a system of psychosocial support, and have they discussed the plan with them?

  • accuracy of prognosis: every consideration should be given to acquiring a second opinion to verify the diagnosis and prognosis.

  • degree of patient understanding: the patient must understand the disease state and expected course of the disease. This is critical since the patient may misunderstand clinical information. For instance, it is common for patients to confuse “incurable” cancer with “terminal” cancer.

Sources for the above information: University of Washington School of Medicine (1998) – Clarence H. Braddock III, MD, MPH, Project Director, Bioethics Education Project; Faculty, Departments of Medicine and Medical History and Ethics, with Mark R. Tonelli, MD, MA, Assistant Professor, Pulmonary and Critical Care Medicine, and Death with Dignity https://deathwithdignity.org/learn/healthcare-providers/What if the patient persists?

What if I do not feel comfortable prescribing or am opposed to medical aid in dying?

You are under no obligation to agree to prescribe or consult on a patient seeking medical aid in dying.

However, since aid in dying has now become a standard of care option in end-of- life planning as it is stated in the law: 

“This State affirms the right of a qualified terminally ill patient, protected by appropriate safeguards, to obtain medication that the patient may choose to self-administer in order to bring about the patient’s humane and dignified death.”

You should be ready to provide that patient with information about the law,  a referral to a participating provider and to forward to that provider all of their relevant medical records. It is extremely important to document your conversation with the patient so that time is not lost in fulfilling their wishes (see more info and sample documentation)

This facilitation does not constitute participation in medical aid in dying as stated in the law:

“Participate in this act” means to perform the duties of a health care provider in accordance with the provisions of P.L.2019, c.59 (C.26:16-1 et al.), but does not include: making an initial determination that a patient is terminally ill and informing the patient of the medical prognosis; providing information about the provisions of P.L.2019, c.59 (C.26:16-1 et al.) to a patient upon the patient’s request; or providing a patient, upon the patient’s request, with a referral to another health care provider.

How do I provide medical aid in dying to my patients?

We are able to provide you with individualized mentorship. Reach out here.

The following is a brief outline to get you started:

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