By Monica Gill and Dr. Amrik Randhawa
In Part I of this series of blog posts, we presented the current interfaces of MAiD and hospice care in Canada and the US. Now, in Part II, we identify some ethical and legal challenges that arise from the interfaces and advocate for a reworking to better support patients.
As discussed in Part I, the practical interface between MAiD and hospice care is one of both connection and difficulty. Arguably, these difficulties exist because the ideological interface is one of opposition. This opposition can lead hospice and palliative care institutions to have less desire to provide training regarding MAiD or allow MAiD to be performed on-site. Hospice policy choices and a lack of training raise ethical concerns regarding patient autonomy and care providers’ fidelity, beneficence, and competence.
The autonomy of patients can be restricted through policies that do not allow MAiD to be performed at a hospice. Faced with the difficulty of having to leave a hospice facility to access MAiD, a patient may choose to forego either service despite desiring to access both. The fidelity and beneficence of care providers is challenged when a patient leaves to access MAiD, as the care provider is forced to sever the relationship abruptly and the patient must undergo the difficulty of leaving.A patient’s autonomy can also be restricted if they are not adequately supported in discussions about death and MAiD. If a patient feels like their decision to opt for MAiD is looked down upon because of a care provider’s lack of competence in managing discussions about death, they may feel reluctant to go through with their choice.
A legal challenge that arises out of the current interfaces of hospice care and MAiD concerns the right to health, one element of which is accessibility. As the legal interface provides that hospice care and MAiD are distinct but connected services, the implication is that both must be accessible for a patient’s right to health to be realized. However, the accessibility of both services is questionable. Approximately 12.5% of Canadians who received MAiD did not have access to palliative care, and around 10% of MAiD recipients in the US did not access palliative care. For access to MAiD, the lack of on-site availability that stems from the oppositional ideological interface leads to inaccessibility.
As the current interfaces of MAiD and hospice care present difficulties for patients and care providers, as well as produce ethical and legal challenges, it is necessary to rework the current system. We propose that the ideological interface be modified. It continues to be true that MAiD and hospice care are distinct in their stance on hastening death. Therefore, we do not advocate for considering MAiD to be part of palliative care. Instead, like the legal and practical interfaces, the ideological interface should be one that recognizes that the services are distinct but connected through the medium of a patient’s life.
Creation of a right to palliative care in Canadian and US law could help foster a reworked interface. The right would reinforce the distinctiveness of hospice care and palliative care. Should the right improve access to palliative care, it would also foster connectivity with MAiD as it would help ensure a patient’s request for MAiD is truly voluntary. Improvements in access could also support a patient’s right to health and allow patients to access palliative care at earlier stages of illness progression.
The reworked ideological interface could also be fostered by offering modified farewell ceremonies to patients that leave a hospice to access MAiD. Traditional farewell ceremonies involve families and care providers reminiscing about a deceased patient as the patient’s body is removed from the hospice. A modified ceremony could include an emotional goodbye between care providers and a patient leaving to access MAiD. While the process of leaving under the current interfaces may give rise to feelings of isolation in patients and guilt in care providers, a farewell ceremony could ease these harms by severing the care relationship less abruptly. Modified farewell ceremonies would still hold MAiD and hospice care as distinct services but help recognize the connectedness of them in a patient’s life
Finally, the reworked interface could be fostered through the implementation of training regarding MAiD for all care providers. While this training could make clear that hospice care and MAiD are distinct services, merely having training supports ideological connectivity. Training would help ensure that care providers are competent when conducting conversations about death with patients. In turn, patients may be better able to exercise their autonomy as they feel supported in their choice regarding MAiD.
The importance of a reworked interface of hospice care and MAiD cannot be overstated. Patients who elect for hospice care and MAiD are confronting the arguably most feared phase of life: death. These patients deserve the best quality of care and support that can possibly be provided. By reworking the ideological interface, we hope to better the experiences of patients.
About the authors
Monica Gill graduated from the University of Toronto with a Juris Doctor in June 2024. Prior to law school, Monica obtained an Honours Bachelor of Science from the University of Toronto. She has served as a patient support worker in a hospice for over five years and previously volunteered at both a hospital and women’s health centre. Monica has been published in the British Journal of Anaesthesia. The opinions expressed are solely her own.
Dr. Amrik Randhawa is in his third year of internal medicine residency at the University of Saskatchewan. Previously, he obtained a Doctor of Medicine from McMaster University and a Bachelor of Medical Sciences: Honors Specialization in Physiology and Pharmacology from the University of Western Ontario. He has been involved in research throughout his studies. Amrik is keenly interested in the governance of healthcare.
McGill Journal of Law and Health 
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