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1 Stiening Erica Stiening M. Ed. Kuzuhara ENGL 215 / Rough Draft 19 March 2024 Rough Draft Medical aid in dying is not something new to the medical world, but there are still stigmas that surround it. “End-of-Life Care: Medical aid in dying” defines MAID as “a practice in which a physician provides a competent adult with a terminal illness with a prescription for a lethal dose of a drug at the request of the patient, which the patient intends to use to end his or her life” (VandeKieft 1). Medical aid in dying or MAID, may be referred to as “aid in dying, death with dignity, doctor-prescribed death, right to die, and physician-assisted death (PAD)” (Dugdale 1). Not everyone has access to aid in dying because there are specific requirements to be eligible. As Treem states, “Medical aid in dying is intended to be a thoroughly thought-out and planned decision, not a spontaneous one” (Treem 4). The eligibility process varies depending on location, the terminally ill patient with less than six months to live must request MAID twice, have a capacity elevation, have a witnessed written statement of understanding, and finally the patient will be prescribed their aid in dying medication (Treem 4). Medical aid in dying has negative connotations consisting of a lack of knowledge and access, being viewed as unethical, and there being a lack of understanding and compassion. This dearth of knowledge contributes to the biggest stigma related to medical aid in dying. With the current parameters set by the Supreme Court, each state can make their own decision on the legalization of medical aid in dying (Kusmaul 3). There are eleven states where physicians practice aid in dying, the remaining states leave a void in knowledge related to

2 Stiening physician assisted death. In states where physician assisted death is not available, their populations may have no knowledge of the practice. For many they may associate Jack Kevorkian, also known as Dr. Death with medical aid in dying, from his public case in the nineties. This association shows a lack of education because Kevorkian was preforming euthanasia, not to be confused with medical aid in dying. Physician assisted death is voluntary, whereas euthanasia is not always a choice the patient makes (Dugdale 2). This juxtaposition gives medical aid in dying a bad reputation, and “euthanasia is not permitted anywhere in the United States” (Haberman 2). Many people are unfamiliar with the process that is necessary to receive medical aid in dying. Kusmaul explains that the patient must be terminally ill with less than six months of life left, get a mental health evaluation, make two separate oral requests with the pre-specified time frame in between, a written request that has been witnessed, the patient must also be aware of all the different options available to them including hospice, and finally the patient must be able to self-administer the medication (Kusmaul 2). It is important to know that the determination of one’s life expectancy could come down the bias of the provider (Luterman 7). The steps that a patient must follow to receive MAID is lengthy, giving them time to be confident in their decision once it is time take the medication. There needs to be education for the population to allow for comprehension of doctor assisted death. The absence of access has also contributed to the substantial stigma concomitated with aid in dying. The current legislation allows for each state government to legalize medical aid in dying if they choose to (Kusmaul 3). As a result of this decision from the Supreme Court, not everyone in the United States has access to medical aid in dying. Out of the fifty states there are only eleven jurisdictions with legalized medical aid in dying, which are California, Colorado, Washington DC, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, and

3 Stiening Washington (Buchbinder 1, Right to Die 2, Singer 272, Treem 2). This leaves forty states with no access to aid in dying. Over the years there have been different bill proposals regarding medical aid in dying, however they have not been the been successful in the creation for more access. “Bills were initiated to block or limit patient access to MAID by restricting drugs, funds, health care services, legal assistance, policy, and research related to MAID” (Kusmaul 10,11). Physicians cannot discuss AID with any eligible patients, so unless they initiate the conversation, a patient may have no idea that AID even exists, let alone that they qualify. (Buchbinder 6). “Because more-educated patients are more likely to be informed about AID and initiate a conversation about it with a physician, access is stratified along socioeconomic lines” (Buchbinder 6). This shows that one’s ability to access medical aid in dying is not exclusive to just living in a state that allows for AID, but further restricted based on “cultural health capital, the tacit cultural knowledge, resources, and behaviors” (Buchbinder 7). Medical aid in dying is not available to everyone, and the process takes time which allows for the patient to be certain that this is what they want, and making this decision is not something one could do on a whim. Medical aid in dying has the controversial argument of being unethical and this has resulted in a stigma. The ethical debate surround aid in dying varies from person to person. The ethical discussion is persuaded by personal beliefs, religious views, family upbringing, and societal influences. “The government has an acute interest in preserving life” (“Right to Die” 2), which presents an ethical controversy. “Dr. Treem also noted several legal and ethical considerations surrounding medical aid in dying” (Treem 6). Treem looks at a case where a Catholic organization fired a doctor for prescribing MAID medication, because their organization does not support aid in dying (Treem 6). This case shows where religious beliefs impact what one may deem as ethical or unethical. Since not everyone has the same religious

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4 Stiening viewpoint, it is critical that this choice be left up to the individual, and them alone. The five to midnight problem also exists as an ethical issue, where a patient may decline faster than they are ready to utilize MAID (Treem 6). Some physicians may face the issue of determining whether one is using aid to end their terminal illness or act on a suicidal attempt and may want no part of MAID in these specific cases where their ethics may be challenged. “In cases where a patient has a history of suicide attempts and a terminal illness, the health-care provider must consider if they are treating the terminal illness or the suicidality” (Treem 6). Some may decide the most ethical choice is to deny the patient the MAID, to avoid any backlash. Some providers may try to find another solution, such as granting access but not give the script until their illness has gotten to the point, they are knocking on deaths door. (Treem 7). There is also concern that the elderly and disabled may be coerced to using MAID (Luterman 8,9). This risk can be mitigated because doctors are not allowed to advise patients about aid in dying, the patient must bring it up on their own. (Buchbinder 6) Some argue that the ethical problem is “the only wrong is being denied the ability to make your own choice” (“Right to Die” 10). Everyone has their own opinions and thoughts on the topic which are all related to ethics. There are set ethics for physicians in their practices, but those may vary from their own. “Neither church doctrine nor other theological objections to assisted suicide, advocates contend, ought to determine law. The views of particular religious groups should not be allowed to constrain the freedoms of those who do not share their faith” (“Right to Die” 10). On the other side of the ethical debate there are those who argue this is murder. “Right to Die” says that “when legalized, the practice is a little more than state- sanctioned killing” (“Right to Die” 10). The arguments for and against medical aid in dying are all influenced over the ethical views of each person. At the end of the day ultimately the state

5 Stiening government’s ethical views have the biggest influence on the tainted opinion for medical aid in dying. For some, they lack the understanding and compassion for the choice of medical aid in dying. Compassion is defined as “sympathetic consciousness of other’s distress together with the desire to alleviate it” (“Compassion Definition & Meaning” 1). People hear aid in dying, and immediately think suicide and begin judgement. The difference between medically assisted death and a suicide attempt is that death is guaranteed with PAD without pain and suffering. Suicide attempts do not always result with death, but possibly more health related issues. Suicide is not exclusive to the terminally ill either, some who are in perfect physical health may be suicidal due to mental health issues. Bills introduced to congress did not address the reasons for MAID, such as “avoiding physical pain, reducing the emotional costs of dealing with chronic illness by a patient, respecting autonomy, humanity, dignity, preventing suicide, or forgoing life-sustaining treatment” (Kusmaul 11). Those in society against medical aid in dying need to look at the why and then show compassion. One of the first things they need to understand surrounding medical aid in dying, is those who can utilize MAID. The people who are eligible for aid must be over the age of eighteen with a prognosis of less than six months, along with a more in-depth process following those first two requirements (Treem 4). Many who turn to aid are suffering from cancer (“Right to Die” 7). Patients who choose physician assisted death are not making the choice to be selfish and hurt their loved ones. A patient may consider medical aid in dying due to loss of autonomy, being a burden, unable to participate in activities, or losing their dignity (Dugdale 3). Preserving autonomy “refers to governance over one’s own actions. In the healthcare setting, this means the patient determines which medical interventions to elect or forgo” (Dugdale 3). Pet owners are often able to offer compassion to their pets when they

6 Stiening euthanize them due to pain, suffering, and a declining quality of life (Cruser). If someone is willing to kill their animal to offer compassion with their health, why wouldn’t they be open to their family member making a similar choice for themselves? Aid in dying is different from euthanasia, but the idea of offering compassion to someone who is suffering is the same. Others choose aid to relieve their suffering and lessen the burden for their family, because patients fear the idea of relying on others for their care when they lose the ability to perform basic tasks. “Advocates of aid argue that relief of suffering through lethal ingestion is humane and compassionate – if the patient is dying and suffering is refectory” (Dugdale 3). When a patient is suffering, the family wants to see that end, some may seek hospice while others are open to the use of aid because they know death is coming regardless of the treatment the patient receives. The patient does not want their family to watch them decline nor do they want to be remembered in such a way, rather the good times that they all shared together. Each patient who is partaking in aid, should be treated the same as those who are choosing to live out their terminal illness. “Terminally ill patients not only have the right to refuse treatment, but also have the right to ask for medical assistance in actively ending their lives” (“Right to Die” 3). “For many human beings, the value of their lives is inextricably linked to the quality of their lives, and life below a subjective threshold of quality is no longer worth living” (“Right to Die” 9). The quality of life versus the quantity of life carries a significant influence on the medical care one seeks. Those who believe that their quality of life is dwindling may seek to end their life in place of pain and suffering. Medical aid in dying is “when a medical doctor gives a terminally ill patient the information or means needed to end their own life” (Kusmaul 2). Medical aid in dying has multiple stigmas surrounding it due to a lack of education/knowledge, deemed unethical, and a lack of understanding and compassion. To lower or eliminate the

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7 Stiening negative associations of aid there first needs to be more education. With eleven jurisdictions already allowing the practice of medical aid in dying “approximately 22 percent of the U.S. population” (“Right to Die” 1) has access to the practice and can be used as an example to create acceptance. Reports show that the practice of medical aid in dying are working well (“Right to Die” 10) and therefore show medical aid in dying is not a negative practice. While there will always be different ethical views on the matter, society needs to agree to disagree, while only worrying about themselves. The population needs to leave the judgement behind and only worry about themselves and have compassion for those who are suffering and just want relief. Unless you have a terminal illness, you have no idea what they are going through physically, mentally, and emotionally. There needs to be more than just a population acceptance, but a legal acceptance as well. As more states begin to create legislation in support of medical aid in dying the stigmas will start to decline.

8 Stiening Works Cited Buchbinder, Mara. “Access to Aid-in-Dying in the United States: Shifting the Debate From Rights to Justice.” American journal of public health vol. 108,6 (2018): 754-759. doi: 10.2015/AJPH.2018.304352 “Compassion Definition & Meaning.” Merriam-Webster , Merriam-Webster, www.merriam webster.com/dictionary/compassion. Accessed 29 Sept. 2023. Cruser, Darrell. “EStiening Peer Response Professional Letter” 10.7.23. Ivy Tech Community College, Fort Wayne, IN Dugdale, Lydia S et al. “Pros and Cons of Physician Aid in Dying.” The Yale journal of biology and medicine vol. 92,4 747-750. 20 Dec. 2019 Haberman, Clyde. “Stigma around Physician-Assisted Dying Lingers.” The New York Times, The New York Times, 23 Mar. 2015, www.nytimes.com/2015/03/23/us/stigma-around- physician-assisted-dying-lingers.html. Kusmaul, Nancy, et al. “A Policy Mapping Analysis of the U.S. Congressional Approach to Medical Aid-in-Dying.” Omega , Sept. 2021, p. 302228211043694. EBSCOhost , https://doi.org/10.1177/00302228211043694. Luterman, Sara. “The Right to Live.” Nation , vol. 316, no. 12, June 2023, pp. 28– 33. EBSCOhost , research.ebsco.com/linkprocessor/plink?id=fda2803d-efba-31fa-a19c- c1bc7dd6dc82. “Right to Die.” Issues & Controversies, Infobase, 17 Sept. 2019, icof.infobase.com/articles/QXJ0aWNsZVRleHQ6MTYyNzM=. Accessed 2 Sept. 2023.

9 Stiening Singer, Jonathan, et al. “Examining Public Stigma and Expectations of Grief Following Medical Aid and Dying in the US: A Vignette-Based Experiment.” Palliative & Supportive Care , vol. 21, no. 2, 2023, pp. 270–276., doi:10.1017/S1478951522000852. Treem, Jonathan. “Medical Aid in Dying: Ethical and Practical Issues.” Journal of the advanced practitioner in oncology vol. 14,3 (2023): 207-211. doi:10.6004/jadpro.2023.14.3.5 VandeKieft, Gregg K. “End-of-Life Care: Medical Aid in Dying.” FP essentials vol. 498 (2020): 32-36.

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