There shouldn’t be much more to say about this subject. The highly contentious and divisive issue of medical assistance in dying (MAID) has been widely and publicly discussed. From a legal perspective, the issue has been settled in Canada. Citizens can now opt to have their lives ended given they fulfill certain criteria. The medical profession and our hospitals have an obligation to support patients who qualify. Individual physicians who chose to actively end the lives of these patients will be legally protected in doing so. Those who conscientiously object are not required to provide MAID but are professionally and ethically required to support their patients in making the decision and seeking the service, which is now being provided, both in and out of our hospitals. There would seem to be no need for further debate or discussion.
However, little has been written about the impact on those involved in the care of patients opting for MAID.
I’ve recently been hearing from medical students who, in the course of clerkship rotations, became involved with patients who elected for medically assisted death. They have found the experience, to say the least, highly unsettling.
For those readers not familiar, senior medical students, in the course of their clinical placements, will become part of medical teams caring for groups of hospital in-patients. The medical student is the most junior member of that team, consisting of graduate physicians training in particular specialties and supervised by a fully qualified Attending Physician. The student is assigned a small number of patients who they are expected to assess and follow throughout their hospital stay. They report regularly on their patients to senior residents and the Attending Physician who review the patient with them and must approve all investigations, treatments and major decisions.
In the course of these rotations, medical students get to know their patients quite well. In fact, they may become the member of the team most familiar with all aspects of the patient’s history and current care, most familiar with the patient as an individual, often even meeting their family, and may become a source of support and information to the patient and family. In short, they “bond” with their patients. Because these are the first such experiences for medical students, these relationships can be quite significant for them, and very memorable. Most practicing physicians can recall with considerable detail and deep feeling patients they encountered as medical students.
When a patient assigned and followed by a medical student dies, it can therefore be quite an emotional experience for the student. They can experience a sense of very personal loss. They grieve. When that death occurs as a consequence of the medical illness under treatment, that loss and associated grief are difficult but valuable components of the learning experience. They understand that this is something that every physician must learn to deal with. Doing so is a part of professional development that must be experienced. In the learning context, senior members of the team can support them by sharing the sense of loss and their own experiences. Within the medical school environment, they can also seek help from knowledgeable and experienced advisors and counselors.
Medically assisted death brings new dynamics and challenges to physicians involved in the care of the patients.
Although always prepared intellectually for the eventuality of death as a consequence of illness, students (and qualified physicians) are not prepared either intellectually or emotionally for the concept of deliberately ending a patient’s life, even if they’re not directly involved in the final act. Coming to grips with this in the abstract is one thing, but encountering it in a person one has engaged as a patient and has gotten to know personally is quite another. No one engages medicine as a career with this purpose in mind.
We teach and practice that medical care should continue throughout a patient’s life, and that compassionate attention and care to a patient’s needs and comfort should not stop when cure is no longer possible. Participation in MAID seems, for many, very difficult to reconcile with that approach, even when carried out at the request of the patient.
Medical students on clinical rotations who have been involved with MAID situations, I’ve come to learn, are particularly vulnerable. There are a number of reasons for this. They may be reluctant to express and undertake “conscientious objection” out of fear of being seen as weak or inadequately trained. They may not be aware of that option. They may not yet be clear about their own perspectives on the issue or reactions to these situations. They are young, and for many these may be their first experiences with professional or personal loss. The playing field, therefore, is far from even.
Moreover, supervising physicians and residents who are themselves engaging MAID for the first time may be coming to grips with their own involvement and therefore uncomfortable and unprepared to counsel students involved in these situations.
For all these reasons, we need to give some consideration as to how we can best support students as they (and we) come to grips with MAID. This will involve ensuring:
- They understand the legislated rights of patients
- They understand the ethical/professional obligations of physicians
- They understand the procedures in place to provide MAID in their hospitals and communities
- They learn of the needs and how to best support patients with chronic pain and other end-of-life challenges
- They understand that when patients under their care die, they will experience a personal reaction they won’t be able to fully anticipate until it happens.
- That they know how to seek help to deal with these situations.
We also need to ensure our residents and faculty are aware and prepared to respond.
There is a danger that raising such concerns may be regarded as callous to the suffering of patients with terminal diseases, or opposition to their right to choose an option that is legally available to them. That is not the intention. The right to assisted death has been legally provided and should be honoured. However, the well-intentioned efforts to provide MAID has placed new and impactful demands on physicians and learners which were either unanticipated or ignored. We must consider these consequences as we come to grips with how this legislated right is to be provided.
In the end, there is something profoundly dissonant about expecting that those who have dedicated their lives to preserving life will also participate willingly in ending it, and without personal consequence. There is a price to be paid, and that toll may be falling on the most vulnerable among us.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education