When Should a Doctor Speak to a Patient about MAID?
October 23, 2023
Medical Assistance in Dying (MAID) is when a doctor[1] assists a patient, at their request, in ending the patient’s life.[2] MAID is legal in Canada and will likely remain so. But it matters how and when doctors discuss MAID with patients.
My view is that when possible, doctors should not deliver bad news and discuss MAID in the same meeting. ‘Bad news’ means “any news that drastically and negatively alters the patient’s view of her or his future,” for example, when a doctor tells you that you have cancer or a terminal prognosis.
Here’s what happened when my doctor discussed MAID with me. I first learned that the tumour in my throat was growing again when I read the online biopsy report. The next day, I met with the surgeon who had performed the biopsy. The doctor confirmed that the cancer was back. Here is the gist of our conversation:
Surgeon: “I’ll review your options. First, there is palliative care.”
Me, silently: <What? Palliative care is intended to comfort the patient but not to cure her. Why are we talking about this?>
Surgeon: “Second, there is medical assistance in dying.”
It took me a moment to grasp that my doctor had just offered to help me take my own life. Then,
Me: “That’s not an option for religious reasons.”
Surgeon, kindly: “I understand. I mentioned these options first because we do not have much to offer regarding treatment.” He added—incorrectly, as it turned out--that I had “months, not years” to live.
In a few minutes, the surgeon delivered the bad news that the radiation treatment had failed, offered me MAID, and told me I had a terminal prognosis.
Why was this a problem?
As a group, cancer patients die by suicide at twice the rate that others do. There is also strong evidence that the risk of cancer patient suicide rises sharply following the delivery of bad news. Fang and his colleagues studied the health records of more than six million Swedes to examine the associations between a cancer diagnosis[3] and the risk of suicide from 1991 through 2006. They found that the risk of suicide increased twelve-fold during the week following the patient’s learning about their cancer diagnosis.
How could just hearing bad news have such a devastating effect? That delivering bad news can trigger suicide fits a theory of suicide from Shirley Wang and her colleagues. They propose that suicidal thoughts can emerge when people experience a surge of fear or other severely aversive internal states they cannot regulate. If no other means of escape are at hand, suicide may appear to be the only way out. This suggests that some suicides occur because a hopeless and panicked person acts impulsively.
The worry is that if MAID is offered in the context of devastating news, a patient may choose to end their life impulsively. This choice might be less likely if the patient had time to reflect. MAID may seem the only escape when bad news elicits great disappointment and fear. However, given time to reflect, some patients may be less likely to choose MAID.
So, if the patient wishes to discuss MAID, this should occur in a follow-up meeting. Delivering bad news and then giving patients time to think could save lives.
When the Supreme Court of Canada legalized MAID in the Carter decision, it sought to balance two concerns:
On the one hand stands the autonomy and dignity of a competent adult who seeks death as a response to a grievous and irremediable medical condition. On the other stands the sanctity of life and the need to protect the vulnerable. (emphasis added)
To support patient autonomy, doctors should do what they can to help patients make decisions that reflect their best interests. A patient receiving devastating news is unlikely to be in the best position to make a deliberate, rational choice.
I am also concerned that in the wake of bad news, patients will turn urgently to their doctors for solutions. A doctor may believe it is appropriate to discuss MAID at this time simply because it is a legal option. The patient, however, might interpret the doctor’s offer of MAID as the doctor’s recommendation that MAID is the patient’s best choice.
I do not believe MAID is healthcare. Therefore, doctors are not obligated to make unsolicited MAID offers. However, suppose the patient requests MAID in a bad news meeting. Then, the doctor should respond with information about this option. Still, even here, a physician can suggest that the patient take time to process the bad news before requesting MAID.
[1] I will discuss cancer throughout because about two-thirds of the Canadians who die by MAID are cancer patients. I will also speak about doctors delivering bad news and offering MAID. However, the clinician could also be a nurse practitioner.
[2] That is one way to describe MAID. You could also say that the clinician either helps the patient die by suicide or the clinician euthanizes the patient.
[3] I havhaven’tund comparable data for other forms of bad news, such as telling patients they have a terminal prognosis. However, I found that the terminal prognosis was more frightening than the initial cancer diagnosis.
I sometimes glean from statements from providers and bioethicists that the 'rational choice' perspective revolves around two positions.
1. Whatever is 'rational' to the patient 'in the moment' is all that matters. Prognosis, options for relief, distress, etc., future, past, do not matter. All the does is pure momentary 'choice' in the present.
2. Prioritise/triage the elimination of suffering through death above all other considerations or options. It follows that it is unethical to compel a person to wait for treatment or reflect on their condition and continue to suffer. This idea terrifies me because it ontologically unifies the person and their experience of suffering, so eliminating the person is the same as relieving suffering and vice versa. It's easy to fold time into this so that person-suffering-moment becomes an inseparable atomised trinity.
Christopher, thanks for these comments. I have never heard or read anyone say point #1 explicitly, but I agree that it probably describes how some people think.