Resuscitation theater ("slow codes"), and Medical Aid in Dying

 Here's an article pointing out that "slow codes" often constitute resuscitation theater, i.e. they are a way to follow bureaucratic directives requiring attempted resuscitation after cardiac arrest in hospitals, when the physicians don't think that would be in the patient's best interest, i.e. when resuscitation would only prolong dying and suffering.  I think this should be part of the discussion of the kinds of "covert" medical aid in dying that takes place even in jurisdictions that don't legally authorize physicians to help shorten the dying process.

McLennan S, Bak M, Knochel K. Slow Codes are symptomatic of ethically and legally inappropriate CPR policies. Bioethics. 2025 May;39(4):327-336. doi: 10.1111/bioe.13396.

Abstract: Although cardiopulmonary resuscitation (CPR) was initially used very selectively at the discretion of clinicians, the use of CPR rapidly expanded to the point that it was required to be performed on all patients having in‐hospital cardiac arrests, regardless of the underlying condition. This created problems with CPR being clearly inadvisable for many patients. Do Not Resuscitate (DNR) orders emerged as a means of providing a transparent process for making decisions in advance regarding resuscitation, initially by patients and later also by clinicians. Under hospital policies in many countries, however, CPR remains the default position for all patients having cardiac arrest in the hospital if there is no DNR order in place, regardless of whether CPR is medically indicated or in the patient's best interests. “Slow Codes” are the delayed or token efforts to provide CPR when clinicians feel CPR is futile or inappropriate. After giving a historical overview of the development and the changing use of CPR, we argue that more attention needs to be given to the cause of slow codes, namely, policies requiring CPR to be performed as the default action while simultaneously lacking implementing interventions such as advance care planning as a routine policy. This is ethically and legally inappropriate, and hospital policies should be modified to allow clinicians to consider whether CPR is appropriate at the time of arrest. Such a change requires a stronger emphasis on early recognition of patients for whom CPR is not in their best interests and to improve hospital emergency planning.

" Proponents of the ‘slow code’ find that intentionally delaying CPR might, in some cases, be a more compassionate alternative to aggressive and potentially futile interventions.

...

"Cardiopulmonary resuscitation is indicated for the patient who, at the time of cardiopulmonary arrest, is not in the terminal stage of an incurable disease. Resuscitative measures on terminal patients will, at best, return them to the dying state. The physician should concentrate on resuscitating patients who were in good health preceding the arrest, and who are likely to resume a normal existence"

Medical aid in dying: the continuing debate in England

In June, the British Parliament passed a law to permit medical aid in dying, which still needs further action before going into effect.

  The Guardian looks at the harrowing situations facing some proponents of MAID:

‘Bad deaths scar families for ever’: what terminally ill people want you to know about assisted dying

Here's the backstory:

From 20 Jun 2025

MPs vote to accept assisted dying bill

"MPs have voted to accept the assisted dying bill, with 314 votes in favour to 291 against, a majority of 23.

The bill will now go to the House of Lords for further scrutiny".

Informed consent and mortal sin, in the case of Medical Aid in Dying

 Studying morally contested transactions doesn't always suggest paths by which consensus might be reached. It often suggests that conflicting views may be irreconcilable. 

That seems to be the case for the growing legalization of Medical Aid in Dying (MAID, also called medically assisted suicide), about which I've recently blogged several times.  

MAID laws face determined religious opposition.  When Hawaii legalized MAID in 2018, the Catholic Diocese of Honolulu issued some guidance to clergy pointing out that the law's requirements for informed consent seemed to coincide with the requirements for a sin to be a mortal sin.

 Diocese of Honolulu November 5, 2018: Instruction Regarding Sacraments and Funerals In Situations Involving Physician Assisted Suicide for Clergy, Parish Staff and Ministers to the Sick and Homebound
“Everyone is responsible for his life before God who has given it to him. It is God who remains the sovereign Master of life. We are obliged to accept life gratefully and preserve it for his honor and the salvation of our souls. We are stewards, not owners, of the life God has entrusted to us. It is not ours to dispose of” (Catechism of the Catholic Church [CCC], no. 2280)

...

7."For a sin to be a mortal sin, three conditions must be fulfilled:

•  the matter must be grave,
•  the person must have knowledge of the gravity of the matter, and
•  the person must freely choose the matter after sufficient deliberation (see CCC, nos. 1857-1859).

8."The process required by the State of Hawaii for a person seeking medically assisted suicide is meant to guarantee that he or she is fully informed and has made a deliberate consent, thus likely fulfilling the requirements for mortal sin.

9." If a person dies in mortal sin without contrition, such final impenitence results in the “exclusion from Christ's kingdom and the eternal death of hell, for our freedom has the power to make choices for ever, with no turning back” (CCC, no. 1861; see no. 1864)

 

HT: Julio Elias

New York State senate passes medical aid in dying bill

 Yesterday the NY State Senate took the next step in making medical aid in dying legal in NY.  Now the bill goes to the governor...

The NYT has the story:

New York Moves to Allow Terminally Ill People to Die on Their Own Terms
A bill permitting so-called medical aid in dying passed the State Legislature and will now head to Gov. Kathy Hochul for her signature. by Grace Ashford

"Eleven states and the District of Columbia have passed laws permitting so-called medical aid in dying. The practice is also available in several European countries and in Canada, which recently broadened its criteria to extend the option to people with incurable chronic illnesses and disabilities.

The bill in New York is written more narrowly and would apply only to people who have an incurable and irreversible illness, with six months or less to live. Proponents say that distinction is key.

“It isn’t about ending a person’s life, but shortening their death,” said State Senator Brad Hoylman-Sigal, a Manhattan Democrat and one of the sponsors of the bill. It passed on Monday night by a vote of 35 to 27, mostly along partisan lines.

...

"The bill was first introduced a decade ago by Assemblywoman Amy Paulin, a Westchester Democrat who leads the body’s Health Committee, at a time when few states were considering such measures.

...

"The bill has earned the support of a range of powerful interest and advocacy groups, including the New York State Bar Association, the New York State Psychiatric Association, the Medical Society of the State of New York and the New York Civil Liberties Union.

"While it was also backed by some religious groups, including Congregation B’nai Yisrael, a Westchester synagogue, and Catholics Vote Common Good, it was staunchly opposed by the New York State Catholic Conference."

Medical aid in dying bill advances (controversially) in New York State

 A bill to legalize Medical Aid in Dying (MAID) in New York state has passed the Assembly and been referred to the Senate (after which it would go to the Governor for signature).  It's controversial, so I don't have a good sense of whether it will become law.

Here's the text of the bill itself, on the NY State Assembley page: "Medical Aid in Dying Act"

Here's a well written article summarizing the controversy, and ultimately opposing the bill in its present form.

Will New York Soon Make It Too Easy to Die?   By Madeleine Kearns

"In April, New York’s “Medical Aid in Dying Act” passed the state assembly by a vote of 81 to 67. It has until the end of the legislative session—June 12—to face a vote in the Senate. On Thursday, June 5, Senate majority leader Andrea Stewart-Cousins said she believed there were enough votes for the legislation to pass and “it is likely that it will come to the floor.” Perhaps as soon as Monday, June 9.

If the legislation passes, New York would join the 11 other states that have legalized assisted dying in various forms. (It is also legal in the District of Columbia.) For those who have seen difficult deaths or are daunted by the prospect, the kind of death Nancy describes—peaceful and pain-free—is what they are hoping the law will all but guarantee.

But those opposed to assisted suicide—their preferred term—warn that such laws endanger the vulnerable by reshaping social norms so that, for some, the right to die becomes a duty to die. Moreover, New York’s legislation, they argue, is on the “outer edge” of liberalization, eliminating safeguards that exist in other states where medical aid in dying (MAID) is legal."

Medical aid in dying in Canada doesn't require a terminal diagnosis--should it?

 Repugnance to medical aid in dying is sharpest when death isn't otherwise imminent.  Canada allows patients with irremediable pain to qualify for MAID (qualifying in this way is called Track 2).  Here's a thoughtful article in the NYT about some of the issues.

Do Patients Without a Terminal Illness Have the Right to Die?
Paula Ritchie wasn’t dying, but under Canada’s new rules, she qualified for a medically assisted death. Was that kindness or cruelty?   By Katie Engelhart 

"While a Track 1 patient could technically apply for and receive MAID within a day, the process for Track 2 was slower; there had to be at least 90 days from the start of the assessment to the patient’s death. Each patient was assessed by two independent clinicians, and if neither of the assessing clinicians had expertise in the patient’s medical condition, they had to consult with a clinician who did. The patient requesting assisted death also had to be informed of “the reasonable and available means” to relieve the suffering — and to give “serious consideration” to those means.

"By law, a MAID patient had to be suffering in some way. The suffering could come either directly from the medical condition or indirectly from the condition’s follow-on effects. It could be either physical or psychological, as long as it was “enduring.” The law did not define exactly what it meant to suffer, or exactly how a medical professional was meant to evaluate the suffering. It was up to individual clinicians to figure out, in conversation with their patients. In a “Model Practice Standard” published by Health Canada, the country’s federal health regulator, MAID assessors were instructed to “respect the subjectivity of suffering.”

"For other clinicians, the concern about Track 2 was more philosophical. Dr. Madeline Li, a cancer psychiatrist who developed the MAID program for Toronto’s University Health Network and who has personally overseen hundreds of Track 1 patients, told me that she was hesitant to involve herself in Track 2 because it didn’t fit with her larger understanding of medicine and its purpose. “If you want to allow people to end their lives when they want to, then put suicide kits in hardware stores, right?” Li told me. It was not “assistance in dying” if the patient was not actually dying.

...

"The most organized critique of Canada’s law came from disability rights advocates. In September 2024, two people with disabilities and several nonprofit organizations announced a legal challenge to Bill C-7. Their case argues that, by definition, all Track 2 MAID patients are disabled — people with medical conditions that limit daily functioning — and thus, that the law is discriminatory. If a nondisabled person is suffering and wants to die, her desire will be understood as pathological, and she will be offered suicide prevention. If a disabled person is suffering and wants to die, her doctor will hand her the proverbial gun.

...

“I’m certainly not going to argue that the system is in good shape,” Wonnacott said. He tended to receive criticism of MAID with equanimity. Of course the system was broken. Of course people ended up on the wrong side of it. And of course the government should work urgently to improve it. But then again, it was the system. There was no other system on offer. “And to force people to continue suffering as we wait an indefinite amount of time to fix it is unfair.” Sure, in any given MAID assessment, Wonnacott could allow himself to get caught up in the past conditional of what should have been done, what could have been. But there was the suffering patient sitting in front of him, here and now, wanting an answer.

"Wonnacott also disagreed with the solution that the critics offered: to shut it all down. Fundamentally, he didn’t think the best way to protect poor and marginalized patients was to force them to stay alive, because in some counterfactual version of events, in which the world was a better and more just place, they might have chosen differently. That wasn’t how anything in medicine worked; a doctor always treated the patient as she was. How could it be otherwise? If only those who were rich or well connected were recognized to have autonomy and allowed to choose?

...

"The critics seemed to imply that a few hundred Track 2 deaths each year were, together, taking the pressure off government officials to improve the system. And that, inversely, if enough people who wanted to die were instead forced to live, their suffering would create the moral imperative for a wide-reaching social-welfare revolution. Wonnacott and his colleagues thought this seemed unlikely. As it was, Canada had more publicly funded health care than many other countries."

Medical aid in dying advances in France

 The proposed French law has some familiar and some novel features.

Reuters has the story:

French lawmakers approve assisted dying bill, paving the way for approval
By Elizabeth Pineau May 27, 2025

"- French lower house lawmakers approved a bill on Tuesday to legalise assisted dying, paving the way for France to become the latest European nation to allow terminally ill people to end their lives.
 

"The final passage of the bill remains some way off, with the text now heading to the Senate. However, the legislation is expected to pass, with polls showing more than 90% of French people in favour of laws that give people with terminal diseases or interminable suffering the right to die.

...

"The bill, which was approved in parliament by 305 votes to 199, provides the right to assisted dying to any French person over the age of 18 suffering from a serious or incurable condition that is life-threatening, advanced or terminal.
 

"The person, who must freely make their decision, must also have constant physical or psychological suffering that cannot be alleviated. Lawmakers stipulated that psychological suffering alone would not be enough to end one's life.
 

"The patient can administer the lethal dose themselves or by an accredited medical professional if they are physically unable. Healthcare workers who object to doing so are free to opt out. Anyone found to have obstructed someone's right to die can face a two-year prison sentence and a 30,000 euro fine.

"Laws to enable assisted dying are gathering steam across Europe. In November, British lawmakers voted in favour of allowing assisted dying, paving the way for Britain to follow countries such as Australia, Canada and some U.S. states in what would be the biggest social reform in a generation.
 

"In March, the Isle of Man, a self-governing British Crown Dependency off northwest England, approved an assisted dying bill, potentially making the island the first place in the British Isles where terminally ill people could end their lives.
 

"France is one of the last countries in Western Europe to legislate on this issue," leftist lawmaker Olivier Falorni told Reuters. "We are in a global process ... France is behind, and I hope we will do it with our own model."

 

 

HT: Alex Chan

Palliative care involves hard conversations

 JAMA has a viewpoint by several palliative care physicians reflecting on why they are sometimes "fired" by their patients, i.e. why patients with (potentially) terminal illnesses may stop talking to them.  The reasons range from not necessarily agreeing that their illness is terminal (their other physicians may be conveying more optimistic messages), to finding that the patient's thoughts  about ending their lives are documented in their medical record.

Why Good Palliative Care Clinicians Get Fired  by Abby R. Rosenberg, MD, MS, MA1,2; Elliot Rabinowitz, MD1,2; Robert M. Arnold, MD  JAMA. Published online April 14, 2025. doi:10.1001/jama.2025.4353

 
"Even the most seasoned palliative care clinician gets fired. In the past year, one of us was fired after asking whether a patient endorsing suicidal ideation had access to a gun; the patient requested not to see the palliative care team because we asked intrusive questions and documented the encounter. One of us was fired after supporting a family’s decision to discontinue life-sustaining therapies for their loved one with multisystem organ failure; the primary intensivist suggested palliative care overstepped in discussing options for which the family (and clinical teams) was not ready. And one of us was fired after sharing the impression that a patient with cancer was dying; the family suggested they preferred the oncologist’s version of a more hopeful future.

Although many health care clinicians have been fired by a patient or family, palliative care clinicians may be at increased risk for dismissal.1,2 We invite difficult conversations, confront people with news they prefer to avoid, and encourage otherwise taboo topics such as human frailty and death. Our focus on what may go wrong differs from other clinicians’ optimism and may be unwelcome to patients and health care teams alike. We acknowledge emotional vulnerability, explore uncertainty, uncover fears, and describe a future in which patients make difficult choices about how they live and how they die."

Hospice care and its limitations

 I've recently posted about Medical Aid in Dying (MAID), which is quite controversial.  An alternative model of end of life care is a hospice, which offers palliative care to patients with terminal diagnoses.  But it turns out that Medicare only covers very limited hospice care, so that most patients who qualify medically have to be cared for by relatives at home.

Slate has the story, by a hospice doctor.

“But They Are Dying.”  Hospice physicians like me can’t usually offer patients the care they need.
By Charlotte Grinberg 

"A patient qualifies for hospice when they have a terminal illness with a prognosis of six months or less based on the natural progression of their disease. Hospice does not usually provide 24/7 private care or the physical place of residence for the dying; typically, people with a terminal diagnosis who opt against further medical interventions die at home, and with significant caregiving duties provided by someone in their family or hired privately. The only place where people receive 24/7 care by hospice-trained professionals are inpatient hospice facilities.

...

"I also work with patients who are under routine care at home or in an assisted living or a nursing facility. To me it’s clear that continuous attention provides a better experience, for patients and their loved ones. But most hospice patients will never be able to access inpatient hospice care. In fact, most hospices across America don’t even have inpatient hospice facilities because they are expensive to build, staff, and maintain, and ultimately depend heavily on philanthropy to both build and cover ongoing operations. Instead, dying patients only see a hospice nurse approximately once per week and are able to call a hospice triage nurse 24/7. They rarely—or never—see a hospice physician.

"The average cost of routine hospice at an inpatient hospice facility is $350 a day. Medicare will only cover inpatient hospice care under very specific circumstances. Families can request “respite care” for five days at a time to get temporary relief from serving as caregivers. Patients can also meet a General Inpatient Hospice level of care. The GIP level of care is intended to cover the time it takes to stabilize a crisis of acute symptoms that cannot be managed in any care setting other than a Medicare-certified inpatient hospice facility (or a contracted hospital or nursing facility). Once a patient’s symptoms are stabilized, the payment for room and board ceases, and the patient is considered to be in a routine level of care.

GIP is only approved when there is a crisis of physical symptoms such as pain, vomiting, seizures, or difficulty breathing. In 2021, only about 1 percent of all hospice days in the United States qualified for the GIP level. Medicare specifies that GIP is not appropriate for situations where a patient’s caregiver support has simply broken down. Complete caregiver breakdown would also not qualify someone for respite care, because respite care is specifically designed to be temporary relief. The primary burden still falls on the patient’s support system, if they have one, to simply figure out how to manage."

MAID in the Netherlands, together

 The Guardian publishes a moving photo, and an interview with the photographer about his parents' decision to avail themselves of medical aid in dying, together.

My parents holding hands after their assisted deaths: Martin Roemers’ most personal photograph Interview by Charlotte Jansen   16 Apr 2025

 

 

"They had a good life and a very happy marriage, but the last years were difficult. They were both sick and exhausted. Both had heart failure, my mother had a lot of pain. Both were in a really bad shape. They still lived in their own house but life was getting harder and harder, even with help. They did not want to go to a nursing home and neither wanted to live without the other – they wanted to step out of life together. They were afraid one would die naturally and the other would be left behind. They were very close, and did everything together, really everything – so it made sense they would leave this life together

 

"In the Netherlands, where assisted dying is legal, this is possible if you have a very good reason. My mother always said: ”We will stay with you as long as we can, until we can see no other way out.” Physicians have to be convinced that the patient is suffering unbearably and has no chance of recovery. My parents were independently evaluated by different doctors, and it was granted to both of them.

 

"It’s a very long process but once the decision was made, it all happened very fast. They picked a date, and it was a week later – much sooner than I had thought. My father wanted to go out to dinner somewhere, and on the last evening before they would die, we were able to do that. My father was a very optimistic and worry-free person who would always laugh at our jokes, until the end. He was visibly enjoying his dinner that evening – that was good".

Danny Kahneman's last interview, and its backstory

 Sometimes the backstory is more revealing than the story.

In yesterday's NYT, the philosophers Katarzyna de Lazari-Radek and Peter Singer published a piece that recalled their interview with Danny Kahneman, a week before he flew to Switzerland to end his life.

There’s a Lesson to Learn From Daniel Kahneman’s Death, by  Katarzyna de Lazari-Radek and Peter Singer  April 14, 2025

"On March 19, 2024, we emailed the psychologist and Nobel laureate Daniel Kahneman, inviting him to appear on our podcast, “Lives Well Lived,” and suggesting a date in May. He replied promptly, saying that he would not be available then because he was on his way to Switzerland, where, despite being relatively healthy at 90, he planned to die by assisted suicide on March 27.

"In explanation, Professor Kahneman included a letter that his friends would receive a few days later. “I have believed since I was a teenager,” he wrote, “that the miseries and indignities of the last years of life are superfluous, and I am acting on that belief. I am still active, enjoying many things in life (except the daily news) and will die a happy man. But my kidneys are on their last legs, the frequency of mental lapses is increasing, and I am 90 years old. It is time to go.”

 ...

"We did not try to dissuade Professor Kahneman, but we asked him to view the interview as a final opportunity to tell people what he thought they should know about living well. He accepted the invitation, though he did not wish to discuss his decision to end his life."

"The interview took place on March 23. Professor Kahneman was cheerful and lively, with no mental lapses."

######### 

They go on to think aloud about why Danny might have decided to end his life, and about medical aid in dying--i.e. physician assisted suicide--more generally.  But, as agreed, they didn't discuss this in the interview, which you can listen to below.  (I found it a little slow moving, almost as if they would have preferred to be talking about assisted suicide...)

 

A Canadian MAID doctor recalls her first time

 Yesterday's post was about medical aid in dying (MAID) in Switzerland, and the decision of a courageous scientist.  Below are some excerpts from a story in the Guardian about how MAID looks from a Canadian doctor's point of view.

‘We’re going to talk about death today – your death’: a doctor on what it’s like to end a life rather than extend one.  I used to focus on maternity and newborn care, but when Canada legalised assisted dying in 2016, I began helping people with a different transition  By Dr Stefanie Green 

"I get down to the essentials. “Why do you want to die?”

"Harvey smirks. “I don’t! I’d rather live. I’ve had a great life. But it seems I no longer have much say in the matter.”

...

“I’ve got great friends, great kids, we’re blessed with family all around us. I know I’m lucky. I’ve been married to this gal here for 52 years … ” He trails off, holds Norma’s hand, shakes it at me a bit and swallows some emotion before continuing. “I really wanted to make it to 52 years, and I did.” He’s quieter now, his energy already drained. “Now I’m ready.”

"Harvey is straightforward with me. He knows he is dying, that it will not be long, but he wants to control the how and the when.

“I want Norma and the kids with me at the end,” he says with a flash of spirit, “here, in my home, in my own bedroom … I want to do it my way. I want to have my friends over this weekend, have one last bash, maybe even sneak a sip of a beer.” He smiles at the thought. “I’ve seen friends linger on at the end … in bed … out of their minds. I’m not interested in putting myself or my family through that.”

"Harvey ticks every box of eligibility. He is capable of making his own decisions, he is making a voluntary request, and he has a grievous and irremediable condition. He will need to sign an official request form, and Norma assures me it will be completed by the end of the day, witnessed by two independent people. After that, a mandatory 10-day reflective period can begin. The law also requires a second clinical opinion, so I will call a local colleague to see if he is available.

"The next few days are busy. As is expected with his liver failure, Harvey continues to decline cognitively. If he declines too much, too quickly, he won’t be able to give his final consent immediately before the procedure, which is required. Because the second doctor and I agree this risk is imminent, we are allowed to shorten the waiting period. Harvey chooses a date three days out."

Danny Kahneman's final decision

Danny Kahneman spent his life thinking about how humans make decisions.  His final decision was to travel to Switzerland to avail himself of the medical aid in dying laws there. (A number of American states permit medical aid in dying, but only for those who have been diagnosed as very near death.)  Danny chose to depart on his own schedule.

 The WSJ has the story:

The Last Decision by the World’s Leading Thinker on Decisions
Shortly before Daniel Kahneman died last March, he emailed friends a message: He was choosing to end his own life in Switzerland. Some are still struggling with his choice.  By Jason Zweig, March 14, 2025 

"In mid-March 2024, Daniel Kahneman flew from New York to Paris with his partner, Barbara Tversky, to unite with his daughter and her family. They spent days walking around the city, going to museums and the ballet, and savoring soufflés and chocolate mousse. Around March 22, Kahneman, who had turned 90 that month, also started emailing a personal message to several dozen of the people he was closest to.

“On March 26, Kahneman left his family and flew to Switzerland. His email explained why:

“This is a goodbye letter I am sending friends to tell them that I am on my way to Switzerland, where my life will end on March 27.”

###########

I wasn't among the recipients of Danny's email, but I am not surprised.  Here is my blog post from a year ago, noting his passing:

Wednesday, March 27, 2024 Danny Kahneman (1934-2024)

"His death was confirmed by his stepdaughter Deborah Treisman, the fiction editor for the New Yorker. She did not say where or how he died."

Derek Humphry, Pivotal Figure in Right-to-Die Movement, (1930-2025)

 Here's the NYT obit:

Derek Humphry, Pivotal Figure in Right-to-Die Movement, Dies at 94
His own experience assisting his terminally ill wife in ending her life set him on a path to founding the Hemlock Society and writing a best-selling guide.  By Michael S. Rosenwald, NYT,  Jan. 24, 2025

"Derek Humphry, a British-born journalist whose experience helping his terminally ill wife end her life led him to become a crusading pioneer in the right-to-die movement and to publish “Final Exit,” a best-selling guide to suicide, died on Jan. 2 in Eugene, Ore. He was 94.

His death, at a hospice facility, was announced by his family

...

"In August 1980, he and his [second] wife rented the Los Angeles Press Club to announce the establishment of the Hemlock Society, which they ran out of the garage of their home in Santa Monica.

"The organization grew quickly. In 1981, it issued “Let Me Die Before I Wake,” a guide to medicines and dosages for inducing “peaceful self-deliverance.” The group also lobbied state legislatures to enact laws making assisted suicide legal. In 1990, the Hemlock Society moved to Eugene. By then it had more than 30,000 members, but the right-to-die conversation hadn’t yet reached most dinner tables in America. 

"That changed spectacularly in 1991, after Mr. Humphry published “Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying.” The book was a 192-page step-by-step guide that, in addition to explaining suicide methods, provided Miss Manners-like tips for exiting gracefully.

...

"“Final Exit” quickly shot to No. 1 in the hardcover advice category of The New York Times’s best-seller list.

“That is an indication of how large the issue of euthanasia looms in our society now,” the bioethicist Dr. Arthur Caplan told The Times in 1991. “It is frightening and disturbing, and that kind of sales figure is a shot across the bow. It is the loudest statement of protest of how medicine is dealing with terminal illness and dying.”

"Reactions to “Final Exit” were generally divided along ideological lines. Conservatives blasted it.

“What can one say about this new ‘book’? In one word: evil,” the University of Chicago bioethicist Leon R. Kass wrote in Commentary magazine, calling Mr. Humphry “the Lord High Executioner.”  

...

"But progressives embraced the book, even as public health experts expressed concern that the methods it laid out could be used by depressed people who weren’t terminally ill. "

Diane Coleman, Fierce Foe of the Right-to-Die Movement, (1953-2024)

 A courageous, long-lived disability-rights activist who made an eloquent case against medical aid in dying has died.

Diane Coleman, Fierce Foe of the Right-to-Die Movement, Dies at 71
Her fight for disability rights included founding a group called Not Dead Yet, which protested the work of Dr. Jack Kevorkian and others.   By Clay Risen

"At the core of her critique was the argument that the idea of a “right to die” was evidence of how little society valued people like her and a warning that the health care system was broken.

“It is already possible in some states for impoverished disabled, elderly and chronically ill people to get assistance to die,” she told the House Judiciary Committee in 1996, “but impossible for them to get shoes, eyeglasses and tooth repair.”

"Not Dead Yet showed up at Princeton University in 1999 after the university announced the hiring of Peter Singer, an Australian philosopher who had argued for voluntary euthanasia for people with disabilities.

...

“It’s the ultimate form of discrimination to offer people with disabilities help to die,” she told The New York Times in 2011, “without having offered real options to live.”

MAID in Canada,

 Medical Aid in Dying (MAID) in Canada is regulated more liberally than in many places, since it doesn't require the recipients to be terminally ill, but can be accessed by people whose diseases are incurable and intolerable.  Nevertheless, most patients who access it are terminally ill.

The Guardian has the story:

Canada’s rate of medically assisted deaths rises to record high. Roughly 96% of deaths by euthanasia in 2023 were for those with a terminal condition, as growth in overall cases slows 

"A growing share of deaths in Canada are from euthanasia, but the vast majority are for terminal illnesses, according to new government figures.

"More than 15,000 people received medical assistance in dying in Canada in 2023, the highest figure on record. But federal statistics show the growth in cases has slowed significantly, with assisted death making up 4.7% of deaths, compared to 4.1% the previous year.

"In both 2023 and 2022, roughly 96% of cases were those with a terminal condition, with cancer cited as the most common reason for accessing assisted death. The median age of someone requesting euthanasia is 78.

"Canada is among a few countries that have introduced assisted dying laws in recent years, alongside Austria, Australia and Spain. The United Kingdom recently passed legislation on the issue."

###########

Fifth Annual Report on Medical Assistance in Dying in Canada, 2023
 

Britain moves towards legalizing medical aid in dying

 The Guardian has the story:

MPs vote for bill to legalise assisted dying in England and Wales
Terminally ill adults with less than six months to live will be given right to die under proposed legislation, by Jessica Elgot, Eleni Courea and Rowena Mason 

"MPs have taken a historic step toward legalising assisted dying in England and Wales after backing a bill that would give some terminally ill people the right to end their lives.

"The Commons backed the bill by 330 votes in favour to 275 against, a majority of 55. Keir Starmer and Rachel Reeves both voted in favour, Labour MPs told the Guardian.

"The private member’s bill, brought by the Labour MP Kim Leadbeater, gives terminally ill adults with less than six months to live the right to die once the request has been signed off by two doctors and a high court judge.

"The change is unlikely to occur for three years as the bill must pass several more hurdles in parliament and will not be brought before MPs again until April. The government is likely to assign a minister to help work on the bill, without formally giving its support.

...

" Peter Prinsley, a Labour MP and surgeon, said he had changed his mind over his years in medicine after witnessing the “terrifying loss of dignity and control in the last days of life”.

“When I was a young doctor I thought it unconscionable. But now I’m an old doctor and I feel sure it’s the right change. I have seen uncontrollable pain, choking, and I’m sorry to say the frightful sight of a man bleeding to death whilst conscious as a cancer has eaten away at a carotid artery.”

"Opponents of the bill said it would fundamentally change the relationship between the state and its citizens, and between doctors and patients. They argued the bill was rushed and the safeguards for vulnerable people were insufficient."

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Earlier:

October 15, 2024 Medical aid in dying comes up for a vote in England

A medically aided death in New Jersey: Pat Koch Thaler

 Following a full life, a peaceful end.

Pat Koch Thaler, Sister to a Famed Mayor, Chose to Die on a Saturday
Ms. Thaler, a former dean at N.Y.U., used her last interview to reminisce about her brother, Ed, and to publicize the alternatives to prolonging pain and suffering. By Sam Roberts

"After 22 years of fending off cancer, Ms. Thaler had run out of miracles. Twice the disease had gone into remission, only to return. One kidney had been removed. She had been bombarded by radiation, chemotherapy and ablation. Finally, the tumors had been declared inoperable.

“My mother died in agony,” Ms. Thaler recalled. Her mother was 62, misdiagnosed and undergoing an operation to remove her gall bladder when surgeons found her body was riddled with cancer.

"Of her own experience, Ms. Thaler said she had been offered a drug that “would slow things down, but would have some serious side effects.”

“And I decided, I’m 92 and a half years old, I have lived a very, very rich life, a very happy life, and I didn’t want to torture myself anymore,” she said. “I did what I could, and knowing that the law is on my side, I decided to take advantage.”

"A New Jersey law that took effect in 2019 allows a mentally alert adult — whose prognosis of having less than six months to live has been certified by two doctors — to self-administer a lethal prescription. The powdery medication is mixed with three ounces of juice, must be consumed within two minutes, immediately induces sleep and, within hours, causes death.

...

"Ms. Thaler spent her last few days paying bills, disposing of her furniture, distributing her artwork to her children and grandchildren, and confirming the funeral arrangements

...

"She chose Saturday, she said, because her children worked, and she wanted a time that would be most convenient. Wearing a white long-sleeved shirt and loose black pants in her apartment, surrounded by her family, she took the powdered medication mixed in apple juice under a doctor’s supervision at 11 a.m.

"At 4:58 p.m., she was pronounced dead."

Medical aid in dying comes up for a vote in England

 The upcoming vote on legalizing medical aid in dying in England and Wales has attracted controversy along lines that will be familiar to readers of this blog, concerning both fundamental values and slippery slopes.  But a comment by British Cardinal Vincent Nichols introduces an argument that I hadn't heard stated so clearly before, about the religious significance of suffering.  But first, here's the background, from the BMJ.

MPs set for historic vote on bill to legalise assisted dying in England and Wales,  by Clare Dyer, 07 October 2024  BMJ 2024;387:q2191

"A bill to legalise assisted dying for terminally ill people in England and Wales is expected to be introduced in the House of Commons on 16 October.

...

"Hundreds of terminally ill people from the UK have travelled to the Swiss clinic Dignitas to end their lives. But friends and relatives who help them are at risk of prosecution for assisting a suicide, which carries a maximum prison sentence of 14 years.

...

"Surveys of public opinion show that about two thirds of the public support allowing assisted dying. The BMA dropped its opposition in 2021 to take a neutral position on a change in the law."

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And here is a story about objections from a religious point of view, from the senior Catholic official in England.

UK’s top Catholic bishop urges faithful to lobby MPs to oppose assisted dying  by Hayden Vernon Sat 12 Oct 2024 

"The archbishop of Westminster continued: “The suffering of a human being is not meaningless. It does not destroy that dignity. It is an intrinsic part of our human journey, a journey embraced by the eternal word of God, Christ Jesus himself. He brings our humanity to its full glory precisely through the gateway of suffering and death.”

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Earlier:

Friday, March 1, 2024

Medical aid in dying--the ongoing debate in Britain

Medical Aid in Dying Laws in the U.S.

 JAMA has a review of the current state of medical aid in dying in the 12 U.S. jurisdictions (if Delaware proceeds) that now allow it.

Medical Aid in Dying Laws: More Accessible in More States by Thaddeus Mason Pope, JD, PhD, JAMA. 2024;332(14):1139-1140. doi:10.1001/jama.2024.15925

"Delaware may soon become the 12th US jurisdiction to authorize medical aid in dying. The Ron Silverio/Heather Block End-of-Life Options Law1 becomes a statute as soon as the governor acts and takes effect once the Delaware Department of Health and Social Services promulgates regulations to implement the statute. Delaware could follow 11 other US jurisdictions that have authorized medical aid in dying; more than 15 000 patients have received prescriptions for medical aid in dying since 1998 in California, Colorado, Hawaiʻi, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, Washington, and Washington, DC.

...

"Medical aid in dying has become an increasingly prominent end-of-life option. More than 20 states considered new medical aid in dying legislation in 2024, and most of the 11 jurisdictions that previously authorized medical aid in dying have amended their original statutes during the past 5 years (eTable in the Supplement).2-6 When enacting or amending medical aid in dying statutes, state policymakers have been carefully recalibrating the balance between safety and access

...

"Medical aid in dying is only available to terminally ill adults with decision-making capacity. They must have an “incurable and irreversible illness” with a prognosis of 6 months or less. If patients can navigate the other eligibility requirements and safeguards, they can get a prescription for lethal medications that they might later self-ingest to hasten their death.6

"Hospice and palliative care are often sufficient to address the suffering of patients, and one-third of those who receive medical aid in dying prescriptions never obtain them from the pharmacy or ingest them.3,4 Most of the remaining patients administer the prescriptions by mixing the powdered drugs with 2 oz to 3 oz of apple juice or push a plunger on a feeding or rectal tube. The patients fall asleep within minutes and usually die within an hour. There is never intravenous administration of the prescriptions or clinician- or third-party administration of the prescriptions.

...

"The Delaware end-of-life options law would require the patient to make 3 requests, 2 of which must be separated by at least 15 days.1 A waiting period has been a requirement in all jurisdictions that have authorized medical aid in dying. However, significant evidence showed that many patients either died or lost decision-making capacity before expiration of the waiting period.4 Many states (California, Colorado, Hawaiʻi, New Mexico, Oregon, and Washington) have either shortened their waiting periods or permit the waiting period to be waived when the patient is likely to die or lose decision-making capacity.

"The Delaware end-of-life options law would be limited to residents of Delaware1; however, for nonresidents, Delaware residency can be established by renting an apartment in Delaware.4 Residency requirements remain an additional hurdle in a long list of obstacles that terminally ill patients must navigate to become eligible. Within the past 2 years, both Oregon and Vermont removed their residency requirements.2,4,6 And the constitutionality of New Jersey’s residency requirement is being challenged in federal court.6 Nationwide, many bills proposed in 2024 omitted residency preconditions.

...

"Commentators regularly express concerns about the use of medical aid in dying in Canada7 and in Europe. It is important to protect vulnerable populations from coercion, duress, and inadequately considered choices; patients should not be steered toward choosing to request medical aid in dying. In addition, the adverse effects of orally ingested medications must be mitigated.4 In California, SB 1196 would have probably solved that problem by permitting (self-administered) intravenous administration of the end-of-life prescriptions. However, any change that would allow intravenous administration and other new and imminent expansions for medical aid in dying raise their own set of novel challenges for US clinicians.

"Given the number of bills and other indicators of interest, medical aid in dying is likely to be authorized in more states over the next few years, and the use medical aid in dying is likely to increase with more accessible terms and conditions. Although medical aid in dying continues to be used by less than 1% of dying patients,2 it is becoming a more integral part of end-of-life care."