Running head: MAID 1 Medical Assistance in Death Maegan Abad Seneca CollegeMAID 2 The Parliament of Canada has passed Bill C-14, which is a new law governing medical assistance in dying (Gamble, 2018). This law allows physicians and nurse practitioners to provide an assisted death for adult patients who have made a voluntary request to end their life (CNA, 2017). There are three stages that are involved in Medical Assistance in Dying also known as, MAiD, which are determining the eligibility, ensuring the safeguards are met, and providing medical assistance in dying whether it is provided by the Nurse Practitioner (NP) or physician or self administered by the client (CNA, 2017). The legalization of MAID has presented nurses with a complex array of ethical and moral decisions as they determine one’s level of involvement in this care option (Pesut, 2019). Advocating for Medical Assistance in Death is due to client choice, alleviate suffering and the nurse maintaining commitments to the client. As per the CNO, the ethical value of client choice is defined as self determination and includes the right to information necessary to make choices to consent or refuse care (CNO, 2019). The value of client choice and the ethical principle of autonomy can interrelate with one another. The law states that to be eligible for Medical Assistance in Death, the client must be at least 18 years of age, be capable of making decisions about their health and voluntarily request MAID after being informed of available treatments (CNO, 2018). From this definition, the client must be competent and be able to make their own choice regarding their own life if they choose MAID. Autonomy as a value refers to the interest people have in living their own lives according to their own conceptions of a good life (van Delden, 2012, p. 201). In a journal titled Nursing and Euthanasia, it stated, “There were also a number of authors that argued that upholding an individual’s right to die fosters human flourishing and in turn, facilitates a dignified andMAID 3 autonomous death (Pesut, 2019). By choosing MAID, the client has the right to die in anyway they choose. In an article Medical Assistance in Dying , it stated “The primary reason for MAiD requests was loss of autonomy — independent of being a burden on others or loss of dignity — and not symptom control” (Ritchie, 2017). Autonomy was the principle used most frequently in defense of nursing's participation in assisted death as an acceptable end-of-life option (Pesut, 2019, p. 224). Most often, arguments in favour of euthanasia were grounded in rights-based language; for example, the ‘right to die’, the ‘right to self-determination’, 48 or the ‘right to die with dignity’. (Pesut, 2019). One argument that advocated for MAID declared “Requests for euthanasia are not an indication of failure of healthcare professionals’ abilities to provide care, but rather an expression of autonomy or the right of an individual to make a ‘choice that they consider consistent with the person that they are and the life that they have led’ (Pesut, 2019). As a result of a lack of autonomy, the client would rather choose to die with dignity with the life they have led and are content with it than to continue on feeling like a burden on others. There are also counterarguments that are opposed to MAID. There were a number of authors that provided arguments that were opposed to it using the autonomy principle as their main view but also using beneficence and nonmaleficence (Pesut, 2019). An argument opposed to MAID argued that “individual autonomy is not a supreme ethical doctrine and does not deserve to be weighted more heavily than the physician’s duty to ‘above all do no harm’. (Pesut, 2019, p. 115) However, to be eligible for MAID the client has to be competent to make the choice to voluntarily request for MAID and therefore demonstrating autonomy. The act of caring (ethics) involves ‘feeling with’ the other requesting aid in dying are rational and do not infringe on the rights of others (Pesut, 2019). The act of caring is also putting the client’s needs first, respectingMAID 4 the client’s choice of choosing MAID, and not imposing the nurse’s values onto the client. A reason a client may have chosen MAID is as a result of intolerable and unbearable suffering. Alleviating suffering according to the Canadian Nurses Association states “When a person receiving care is terminally ill or dying, nurses foster comfort, alleviate suffering, advocate for adequate relief or discomfort and pain and support a dignified and peaceful death” (CNA, 2018). Nursing has always aspired to patient – centred care and alleviating suffering to the greatest extent possible. (Schiller, 2019). MAID is eligible for people who have a grievous and irremediable medical condition, which they have a serious and incurable illness, disease or disability (CNA, 2018). But, it is also important to note that suffering can only be defined as what the patient says it is. (Schiller, 2019). Clients who have chosen MAID as a result of intolerable suffering, is still their choice to make and for everyone to respect their choice. Many make the argument that patients in great suffering may be better off dead than alive (in the view of the patient and/or the physician) (Gamble, 2018). For MAID, one of the criteria is that the client has given informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care (CNA, 2017). An ethical value supporting MAID is patient well-being, or rather the absence of well-being (van Delden, 2012, p. 202). The person who requests MAID will not consider his or her life as a benefit but will see it as a burden (van Delden, 2012, p. 202). Client well being and alleviating the suffering of the client can co-exist with each other where by alleviating the suffering of the client from pain, it would be removing the harm through the process of MAID, with the voluntary request of the client. The Canadian Nurses Association (CNA) contains a statement of nursing values and responsibilities where one value and responsibility is to promoteMAID 5 health and well being for the client (CNA, 2017). Nurses can achieve this by supporting the client in acheiving their highest level of health in ways that are meaningful and acceptable to themselves and to strive for excellence in end of life care options which includes palliative care, natural death or MAID (CNA, 2017). Therefore, once MAID is chosen by the client, the nurse must promote health and well being up until the process of MAID has occurred. There are also arguments that point out that using Medical Assistance in Death could alleviate suffering, but it is the wrong way to do it. There is the deontological view that the deliberate killing of an innocent person is always wrong (van Delden, 2012, p. 202). However, alleviating the suffering of the client by Medically Assisting them in Death would only be up to client, but would not be a part of client well being by killing them. MAID might be provided by an act of utilitarianism – an ethical theory where the consequences of an action are weighed in the context of a particular situation (Pesut, 2019). The particular situation would be of the client’s suffering and that by using the process of MAID would alleviate that suffering and would be the better outcome for the client. By assisting and caring for the client for MAID is also maintaining a commitment to them. Another ethical value is maintaining commitments, especially to the client. Nurses are to provide safe, effective and ethical care (CNO, 2019). A behavioural directive for the nurse is identifying when their own values and beliefs conflict with the ability to keep implicit and explicit promises and taking appropriate action and putting the needs and wishes of clients first (CNO, 2019). When a client has chosen Medical Assistance in Dying, it is the nurse’s responsibility to identify their own values and to not let it interfere with caring for the client who has chosen it. Since the nursing codes of ethics require a duty of care and non-abandonment,MAID 6 nurses cannot simply stop providing care when they disagree with a person’s choices (Theile, 2019). The American Nurses Association supports recommendations that nurses: Never "abandon or refuse to provide comfort and safety measures to the patient" who has chosen medical aid in dying (Pesut, 2019). Once a patient makes an informed and autonomous decision to receive MAiD, then nurses become a means through which to realize that patient – centred choice (Schiller, 2019). Therefore, it is a part of the nurse’s behavioral directives that it is the nurse’s duty to put the needs of the client’s first from their choice to proceed with MAID. If the nurse is unable to provide care for the client who has chosen MAID and objects to it, the nurse should notify their employer in advance of their objection so that the nursing leaders could delegate MAID related responsibilities to another healthcare provider (CNA, 2017). However, the nurse that objected to caring for that client would not be maintaining their commitment to the client. Nurses are faced with difficult and ethical dilemmas when caring for a client who has chosen to end their life using Medical Assistance in Dying. It incorporates many ethical values and ethical principles towards not only the nurse but both the client and the health care team. Using the ethical decision making model by Toren and Wagner, you define the ethical dilemma which is Medical Assistance in Dying, clarifying the personal and professional values and laws involved, identify with the client possible alternatives, choosing an action and to generalize the solution (Kozier, 2018, p. 675). When choosing to support MAID and proceeding with it, it is due to the competent client’s choice and autonomy, choosing it to alleviate and relieve their suffering when it is no longer tolerable and having the nurse maintaining their commitments especially to the client.MAID 7 References Canadian Nurses Association (2018). Ethics in Practice: Respecting Choices in End-of-Life Care: Challenges and Opportunities for RNs. https://canadian-nurse.com/~/media/canadian-nurse/files/pdf%20en/respecting-choices-in-end-of-life-care.pdf Canadian Nurses Association (2017). National Nursing Framework on Medical Assistance in Dying in Canada. https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/cna-national-nursing-framework-on-maid.pdf College of Nurses of Ontario (2019). Practice Standards – Ethics http://www.cno.org/globalassets/docs/prac/41034_ethics.pdf Gamble, Nathan. (2018). CAN EUTHANASIA BE CLASSIFIED AS A MEDICALLY BENEFICIAL TREATMENT? Ethics & Medicine : A Christian Perspective on Issues in Bioethics., 34 (2), 103. Kozier, B. J., Erb, G., Berman, A., Snyder, S. J., Frandsen, G., Buck, M. …Stamler, L.L. (2018). Fundamentals of Canadian nursing: Concepts, process, and practice (4 th Cdn. ed.). Don Mills, ON: Pearson. Schiller, CJ, Pesut, B, Roussel, J, Greig, M. (2019). But it’s legal, isn’t it? Law and ethics in nursing practice related to medical assistance in dying. Nurs Philos . 2019; 20:e12277. https://doi-org.libaccess.senecacollege.ca/10.1111/nup.12277MAID 8 Pesut, B., Greig, M., Thorne, S., Storch, J., Burgess, M., Tishelman, C., … Janke, R. (2019). Nursing and euthanasia: A narrative review of the nursing ethics literature. Nursing Ethics . https://doi.org/ 10.1177/0969733019845127 Pesut, B., Thorne, S., Greig, M., Fulton, A., Janke, R., & Vis-Dunbar, M. (2019). Ethical, Policy, and Practice Implications of Nurses' Experiences With Assisted Death. Ans. Advances in Nursing Science, 42 (3), 216-230. Pesut, B., Thorne, S., Stager, M. L., Schiller, C. J., Penney, C., Hoffman, C., … Roussel, J. (2019). Medical Assistance in Dying: A Review of Canadian Nursing Regulatory Documents. Policy, Politics, & Nursing Practice. https://doi.org/10.1177/1527154419845407 Pesut, B., Thorne, S., Stager, M. L., Schiller, C. J., Penney, C., Hoffman, C., … Roussel, J. (2019). Medical Assistance in Dying: A Review of Canadian Nursing Regulatory Documents. Policy, Politics, & Nursing Practice . https://doi.org/10.1177/1527154419845407 Ritchie, K., Gérin-Lajoie Caroline, & Viren, N. (2017). Medical assistance in dying: Letter]. The New England Journal of Medicine, 377 (9), 896-898. doi: http://dx.doi.org.libaccess.senecacollege.ca/10.1056/NEJMc1708958 Thiele, T., & Dunsford, J. (2019). Nurse leaders’ role in medical assistance in dying: A relational ethics approach. Nursing Ethics , 26 (4), 993–999. https://doi.org/ 10.1177/0969733017730684 van Delden, JJJ (2012). Encyclopedia of Applied Ethics: Euthanasia (Physician Assisted Suicide) (2nd ed.). Retrieved from ScienceDirect.