Physicians’ Moral Distinctions Between MAiD and Withdrawing Life-Sustaining Treatment
New study shows they don't think there's a moral difference
Here’s a new study that interviewed 21 Canadian doctors about their thoughts on the distinction between assisted death and withdrawing life-sustaining treatment (WLT).
Key Excerpts
“Of physicians who had experience with MAiD, 14 were MAiD providers, 3 had assessed patients for MAiD eligibility but had not provided MAiD, and 4 had referred patients for MAiD but had neither assessed for nor provided MAiD themselves.”
“Just under half of participants were general practitioners (n = 8), with the remaining representing palliative care (n = 6), internal medicine (n = 5), psychiatry (n = 1), and obstetric (n = 1) specialties.”
“Our study found three overarching themes: (1) consensus on MAiD’s moral equivalence with WLT despite differences between the practice, (2) discord regarding the use of the term ‘killing’, and (3) disjuncture between bioethical debates and practice. Theme 1 sub-divided into three sub-themes: 1.1 no moral difference between MAiD and WLT, 1.2 physician versus underlying medical condition as cause of death, and 1.3 relief of suffering…”
“Despite significant variation in perspectives, most participants ultimately did not perceive a moral difference between the two practices, even as they differed on the underlying reasoning regarding causality and intent.”
“Participants exhibited considerable variation in views regarding whether it is the physician’s actions or the underlying illness that causes death in MAiD and WLT. Seven participants argued that MAiD directly causes death, while WLT does not. Among these, four participants opted not to engage in MAiD, citing the act of administering a lethal drug as a defining distinction.”
“Five participants saw both practices as causing death, asserting that the distinction is less meaningful due to the shared outcome”
“Nine participants contended that neither practice causes death, attributing it instead to the underlying illness.”
“Participants consistently emphasized relief of suffering as the primary intent in both MAiD and WLT, underscoring the centrality of patient-centred care. However, perspectives on the prevalence of this focus varied. Many participants described relief of suffering as their foremost goal when providing MAiD...Others highlighted the importance of patient autonomy in determining the path to relief”
“Despite these divergent views on causality and intent, the majority of participants (n = 16) did not perceive a moral difference between MAiD and WLT. Participants explained that both practices involve actions leading to an inevitable death, with distinctions largely concerning the mechanisms and timing rather than moral principles.”
“Some participants expressed offence at what they perceived as provocative or emotionally charged language, particularly regarding the term “killing.” Of the 10 interviewees who emphasized that neither MAiD nor WLT should be described as “killing,” 6 found the term offensive, arguing that it carries connotations of criminality and moral wrongdoing.”
“In contrast, fewer participants expressed strong opinions about the term “allowing to die.” Almost half of respondents (n = 10) preferred this terminology over “killing” if language had to be applied to both MAiD and WLT.”
“The final theme captures the clinical utility of bioethical debates. The majority of participants stated that they did not find practical utility from current distinctions. Most respondents (n = 18) found that the abstract bioethical debates comparing MAiD and WLT were not helpful because they are not grounded in the reality of patients’ lived experiences with pain, illness, and desire for control over their end-of-life circumstances.”
“An important limitation of this study is that recruitment for participation occurred through the CAMAP, a pan-Canadian pro-MAiD organization which supports clinicians involved in the practice, thus inclining the interview sample toward physicians who are involved in MAiD.”
Response
In general, I’m not sure what the value of studies like this is given the low number of participants (21) and given that most of them were likely already in favor of assisted death. Furthermore, I don’t see why knowing their intuitions is supposed to tell us anything about the moral permissibility of the option, which I assume is the point of the paper.
In the introduction, it states,
The judgment that MAiD is morally impermissible requires a meaningful difference between it and WLT. For these reasons it is imperative to understand how clinicians experience the similarities and differences between MAiD and WLT. Bioethical discussions of these subjects often fail to capture the lived experiences of healthcare providers who must navigate these ethically complex practices in their day-to-day work.
In general, to figure out what’s morally permissible, you have to engage in the philosophical arguments. Surveying people with relevant lived experience is important when they can provide insights or perspectives that would otherwise go undiscussed. But I just don’t see that here. Bioethicists are fully aware that assisted death is about autonomy in end-of-life circumstances and the reduction of suffering.
That said, I do sympathize with the participants denying the relevance of abstract bioethical debates, but I don’t think this is because the abstract debates are in themselves irrelevant. Rather, I suspect it’s because philosophers engage in technical puzzle-solving that’s hard for nonphilosophers to follow and because it’s hard to determine who’s ultimately right.
One thing I tell my students is that philosophy is unavoidable: you’re either doing philosophy or making philosophical assumptions. If so, then these abstract debates must be relevant because the philosophical assumptions are relevant; they may not be directly relevant, however. What philosophers are good at doing is analyzing the appropriateness of our assumptions that others take for granted. We do the necessary theoretical heavy lifting that others rely on.
Regarding causation, I find it odd to think that the cause of death in euthanasia isn’t the lethal injection administered by the healthcare provider. It seems obvious to me that it is. And in the case of assisted suicide, the cause of death is the patient’s act of taking the lethal drugs.
But just because one is causally responsible doesn’t mean one is blameworthy. Let’s say one day I decide to walk to the park and someone mugs me. Am I causally responsible for what happened? Yes, partially, because if I had stayed home instead, I wouldn’t have been mugged. But I’m not blameworthy because I didn’t do anything morally wrong.
What this highlights is a distinction between moral responsibility and causal responsibility. Moral responsibility entails causal responsibility, but causal responsibility doesn’t entail moral responsibility. With this in mind, I propose that in the context of assisted death, what we care about is moral responsibility, or more specifically, blameworthiness. So that’s what we should be focusing on.
Relatedly, I actually don’t have a problem with the word “killing” because I think euthanasia is clearly a type of killing. You’re intentionally ending someone’s life via an action. Whether or not it’s justified is another question. Generally, I think killing should be deemed a morally neutral term, which is consistent with most instances of killing being unjustified.
I feel the same about the word “suicide.” Assisted suicide is clearly a type of suicide because it’s intentional self-killing. I just think suicide should be a morally neutral term.