Does the possibility of misdiagnosis make the concept of brain death invalid?

Recently I read the detailed account of what has happened with Jahi McMath, titled “What Does It Mean to Die?” in the most recent issue of The New Yorker. It made me reassess what I think about the concept of brain death. Four years ago, Jahi McMath was a thirteen-year-old African American girl who had a tonsillectomy to treat severe sleep apnea. She had a cardiac arrest due to postoperative bleeding with a prolonged 2.5-hour resuscitation and ended up on a ventilator. She was later determined to meet the criteria for brain death, but her family refused to allow her to be taken off the ventilator. They had serious concerns that she had not received the care she should have received prior to her arrest and had little confidence in the doctors or hospital that were telling them that she was dead. Four years later her vital functions continue to be maintained on a ventilator and some medical experts are convinced that she no longer meets brain death criteria and may be in a minimally conscious state.

When I think about the concept of brain death, what is important in accepting it as a valid way to determine that a person is dead is that brain death involves both loss of function of the entire brain including the brain stem and that the loss of function is irreversible. Accepting that loss of cognitive function alone could define death puts anyone with impaired cognitive function at risk of being treated as if they were dead. Loss of brain stem function is more closely related to the functions of the brain that keep us alive and fit better with the determination of death. However, it is critical that this loss of entire brain function is irreversible. We do not consider a person in cardiac arrest who is able to be resuscitated to be dead, because that person’s loss of heart and lung function is reversible. This case calls into question whether we are able to determine that loss of complete brain function is irreversible.

It appears to be quite possible that this girl who was diagnosed as being brain dead did not have the irreversible loss of complete brain function that is essential for the definition of brain death. It is recognized that the criteria for diagnosing brain death are different in children and adults and that the diagnosis may be more difficult to make in children. Her case leaves us with some significant questions. Are the criteria that we have for determining a diagnosis of brain death accurate enough in predicting the irreversibility of loss of whole brain function to be reliable in making the diagnosis? Do we need absolute certainty in diagnosing brain death? Every decision we make in medicine involves some uncertainty. Diagnoses are seldom absolute. We make life or death decisions with limited information. People die due to inaccurate diagnoses even when everything has been done properly and the diagnosis has been made with all due care. Sometimes, despite our best efforts, we are wrong. Is diagnosing brain death any different from other life or death decisions we make? How much inaccuracy can we accept in the diagnosis of brain death?

What’s really happening with doctor-assisted suicide?

Recently, Wesley Smith posted on the National Review’s “Corner” blog new concerns that Oregon’s “Death With Dignity” law may not be as tightly regulated as advertised.  Specifically, a Swedish fellow named Fabian Stahle, who evidently is troubled by the prospect that his country might embrace doctor-assisted suicide, claims to have carried out an e-mail exchange with someone in the Oregon Health Authority to ask how the law is interpreted in that state.  The responses included a statement that, to qualify for assisted suicide, a patient must have a “terminal illness” but said illness could include a potentially treatable condition which, if allowed to take its course without treatment, would be expected to cause death within 6 months.  That suggests that assisted suicide might be legally employed in Oregon in cases in which the patient refused treatment or the patient’s insurance company refused to pay for effective treatment.  The Oregon official cited by Mr. Stahle is quoted by him as having written that “the law is best seen as a permissive law…[that] does not compel patients to have exhausted all treatment options first, or to continue current treatment.”

You can read Mr. Stahle’s entire account here.

I must say that, while I mention this for this blog, I have not attempted to confirm these assertions by contacting the Oregon officials myself, and my first reaction is skepticism that what Mr. Stahle reports is in fact the correct interpretation of the Oregon law.  Even I, a staunch opponent of assisted suicide, must allow that the intent of such laws seems to be that assisted suicide is intended for cases for which potentially effective treatment options HAVE been exhausted.  But I suppose that further investigation is in order.

While at it, Wesley Smith also cited a 2005 British House of Lords inquiry into the Oregon law, from which a group apparently opposed to assisted suicide posted some comments here.  The entire House of Lords transcript, BTW—all 744 pages of it!—is available here for interested parties.  I must confess I have not had time to read the whole thing.

The most recent data summary from the state of Oregon that I am aware of is for 2016.  It reports 133 deaths from taking drugs from 204 lethal prescriptions filled in the state in 2016.  These numbers were slightly down from 135 and 214 in 2015.  The 2016 “death with dignity” rate is cited as 37.2 per 10,000 deaths in Oregon.  Of the 133 people who died with medical assistance in Oregon in 2016, 96% were white, about 80% had cancer, nearly all had some form of insurance, and about 85% were age 65 or older.  The two most commonly-stated reasons for seeking assisted suicide were loss of autonomy and loss of enjoyment of life—about 90% in each case.  Inadequate pain control was listed for about one-third of the cases.  The median time the patient had been seeing his or her prescribing doctor was 18 weeks, and the prescribing doctor was present for 13 of the 133 deaths.

Of course, all of this assumes the reporting is complete and accurate.  I have no information that would lead me to believe otherwise.  I state the facts in the preceding paragraph without commentary or, in some cases, without the irony I feel in reading them.

I can’t conclude from the Oregon report that patients who availed themselves of assisted suicide there were foregoing potentially effective treatment for their disease, much less that an insurance company refused to pay for it.  Of course, there is the one famous case of a person there getting a “suggestive” note about PAS from his insurer, some years ago—I can’t locate it at the moment.

In general, I’d say that the concerns raised through the above-mentioned posts are ones we must keep in mind, but that the slope may not yet have gotten that slippery.

Finally: the National Academies of Science, Engineering, and Medicine will hold a conference in Washington DC on Monday and Tuesday, February 12 and 13.  Looks like a webcast is available.  You can find information about it, and sign up to attend in person or by the web, here.  I’m going to try to at least watch some of it. From the information at that site:

This workshop will include discussions, and background materials, that address:

  • What is known empirically about the access to and practice of physician-assisted death in the U.S. and in other countries?
  • What are potential approaches for physicians, including those practicing in states where it is legal, those who receive a request for access when the practice is legal in nearby states but not in the state of practice, and those who practice in a state where it is legal but are personally opposed to physician-assisted death.
  • What is known about how palliative care and hospice services have incorporated the practice of physician-assisted death in states where it is legal?

The DNR Tattoo

National media outlets have reported the fascinating account of the unconscious 70-year old brought into the Jackson Hospital (Miami) emergency room with a “Do Not Resuscitate” tattoo on his chest.

In correspondence to the New England Journal of Medicine, doctors involved in the case explain the process by which the medical team used to evaluate the case. At first, the team did not plan to honor the tattoo, but an ethics consultation “suggested that it was most reasonable to infer that the tattoo expressed an authentic preference . . . and that the law is sometimes not nimble enough to support patient-centered care and respect for patients’ best interests.” One wonders what facts were used to shed light on the accuracy of the tattoo, especially in view of another case, cited in the NEJM correspondence (“DNR tattoos: a cautionary tale”), when a DNR tattoo did not convey the wishes of the patient.

The accounts of this most recent case end on a positive note: “Subsequently, the social work department obtained a copy of his Florida Department of Health “out-of-hospital” DNR order, which was consistent with the tattoo . . . We were relieved to find his written DNR request…” I was happy to read this too, as tattoos are not necessarily the best way to communicate end of life issues.

Those who work with people thinking about advance directives know that what seems clear one day, could easily be less clear the next. Some patients change their mind on code status frequently, especially as they develop breathing problems and the like. It is, of course, their right to do so. Simply put, it would be hard to rescind (or even modify) a tattoo.

Those of us involved in chaplaincy speak of patients as being “living documents.” I am relatively sure this is not what is meant.

Giving people nearing the end of life the same protection we offer children

Tony Walter writing on the website The Conversation suggests an interesting perspective on how society ought to think about those of us who are at the end of life. He suggests that we need to provide the same protection for them that we offer to children. He is not suggesting that we take away the autonomy and independence of our parents and grandparents, but that if we focus solely on the autonomy of those who are at the end of life we run the risk of abandoning them. In early childhood, all of us live in a state of dependence and we recognize the responsibility that parents must provide for the needs of their children. We also recognize the societal responsibility when parents are unable to or for other reasons do not provide for the needs of their children. He is saying that there are many among us who enter into a state of dependence as they age and develop diminished capacity to provide for their own needs. When this occurs we as a society have a responsibility to see that those needs are provided for, while still recognizing and encouraging whatever autonomy those elderly persons in need still possess.

In my practice, I commonly see situations in which children begin to take on a parenting role toward an aging mother or father with diminished capacity to care for her his own needs. At times, this is awkward and may be resisted by either the parent or the child, but it can be done well with respect for the aging parent and gratitude on the part of the child for how the parent cared for him or her at the beginning of life. It would be good for us to recognize this symmetry of life with dependence at both its beginning and end, and embrace it rather than ignoring or avoiding it.

The focus on autonomy and self-reliance in our society can at times be productive but also can be destructive. Those of us who are Christians should be able to understand that no matter how capable we are we are all dependent. None of us is capable of being what God desires for us to be on our own. We are all dependent upon him to be transformed into the representation of his image that he desires for us to be. If we can recognize that dependence is something that we all share we can respond to the needs of the frail elderly among us in a way that both respects and protects them.

More about Charlie Gard

Dr. Robert Truog, the bioethicist and transplant physician who has pushed the envelope on the definition of death, has weighed in on the Charlie Gard case in a “Perspectives” piece that is generally available (i.e., without a subscription) from the Journal of the American Medical Association (JAMA).   By all means read it.

Dr. Truog approaches the case from the standpoint of limiting medical research—indeed, that’s in the title of his article.  He says the case is about “the best interest of the patient, financial interest, and scientific validity.”  On the first point, he is cautious about the British courts’ assertions that it can assess how much pain and suffering Charlie is experiencing, and whether the courts know this better than the baby’s patients.  This caution seems wise.  As I have reflected further on this case it strikes me that I may be missing a legal distinction between Britain and the US; frankly, I am not well-versed on British law in these cases.  I do tend to think of the Gard case in terms of substituted decision-making in the case of severe or terminal illness.  My thought process runs through the checkpoints.  First, the patient’s wishes are paramount.  In this case, the patient cannot express wishes and may not be able to form them.  In that case, second, a surrogate decision-maker should speak for the patient using “substituted judgment” or “substituted perspective” to express how the patient might have approached the case if able to express wishes.  Here, the parents are available to speak for the patient.  It would be only in the absence of a decision surrogate that “the best interests of the patient,” as judged by the physicians or the courts, would control.  Apparently British law grants rather more primacy to third parties, other than the patient and any surrogate decision-maker.  Under the rubric I’m used to, the parent’s wishes would control.  Here, the British authorities argue, they do not.

The columnist William McGurn took exception to this attitude in The Wall Street Journal earlier this week.  “This is our call, [the doctors and courts] say,” he writes.  And this is the necessary attitude of single-payer healthcare, he claims: “at the heart of single payer is single authority.”  The hospital, McGurn charges, “even wants the last word on love: ‘In one respect, Charlie is immensely fortunate” to have such loving parents, but that respect apparently has nothing to do with this decision, for which their love apparently disqualifies them.  (BTW, perhaps you have seen the report that the court-appointed “guardian” for Charlie chairs an organization that is a sister organization to one that promotes doctor-assisted suicide.)

Dr. Truog’s second point is that distributive justice trumps (my word, no political pun intended, honest) the money Charlie’s parents have raised for his experimental care.  In fact, justice demands we disqualify that fundraising effort, because to allow them to pay is to elevate their ability to pay over others who may be in need of scarce resources.  He says that public funds have stood up the hospital and British health system overall, so the Gard family does not, as it were, “own” it or lay privileged claim to access.  I find this argument of Dr. Truog’s specious.  There is no certainty at all that Charlie would block other needed care—unless, I suppose, it is allowed that Britian’s National Health Service already rations care to the point of extreme scarcity!—and they harm no one by possibly paying for experimental care.

That leaves the third issue—is treatment, admittedly experimental in this case, ethical?  Dr. Truog says no, because the chance of success is so low and “does not meet a threshold of scientific plausibility.”  He argues that the rationale is theoretical only, and complains that the proposed experimental treatment has not been tested in animals or humans before.  But again, this is at least partially specious.  Charlie suffers from an extremely rare condition, animal models may be lacking or entirely unpredictive (medical researchers operate with this general conceit that animal studies DO predict—boy can I tell you how often we are wrong about that!), and when a condition is rare, EVERY individual case provides the opportunity to learn something.  Medical history is replete with work based on the careful observation of clinicians, even apart from the randomized clinical trial, which could never be done in such a rare condition as Charlie’s.

It is of course possible to object that the risk-benefit ratio for giving Charlie the experimental treatment is a judgment call that should be made against treatment.  If the doctor is truly being reckless with the proposed treatment, is profiteering, or if there is no reasonable possibility, at acceptable risk, for direct benefit to Charlie or for useful knowledge to be gained, then the proposed treatment should be deemed unethical.  In the U.S., that would be a call for an IRB and the FDA.  And again, they might say “no,” in which they would be speaking more to the doctor than the patient’s parents.

But in this case I think the British courts should defer to the parents and allow them to pursue that question in the U.S.

The Prognosis for Whole Brain Death is…

Recent court proceedings bring the case of Jahi McMath back into the bioethical news. As you will recall, she had medical complications following a surgical procedure in 2013 and was declared brain dead. The family argued for continued life support, which the hospital denied (since she met the criteria for whole brain death). After much legal wrangling, she was transferred to New Jersey, where she remains alive on ventilator and nutritional support. This case has been reviewed in this blog (here and here). Professor Thaddeus Pope has followed this case from a medicolegalethical standpoint on his Medical Futility Blog, which is generally where I keep up with the case. His catalogue of the legal proceedings is complete, and while I disagree with many of his bioethical positions, I appreciate his rational discussion of those issues. For the remainder of this blog, I wish to focus upon the issue of brain death in the case of Jahi McMath and specifically our ability to accurately determine it.

No one, and as far as I can tell I mean absolutely no one, denies that Jahi met the criteria for whole brain death by late 2013. Her EEG was isoelectric (flatline – no brain electrical activity), radioisotope cranial blood flow studies showed no cortical blood flow (which normally results in cell ischemia, and, if not immediately corrected, brain cell death), brainstem auditory evoked responses (BAERs) were absent (usually indicating future inability to receive auditory input even if there were an otherwise healthy brain ready to receive that input) and somatosensory evoked potentials (SSEPs) were absent above the neck (usually indicating inability to receive sensory input from the body). As a result, she met the criteria for whole brain death in California and was issued a death certificate. Since that declaration, she has shown signs of entering puberty (which requires a minimally functioning portion of the brain called the hypothalamus), her heart rate has been noted to change when she hears her mother’s voice (which should not be possible given her BAER results) and she has moved her right arm to verbal command (an act that would require the ability to receive the auditory input, left hemisphere cortical brain processing of that input, signal transfer within the left hemisphere of the brain to the motor area that controls the right arm, and finally signal transfer down through the brainstem to the portion of the spinal cord that controls the right arm). If any of those are true, Jahi McMath fails to satisfy the criteria for whole brain death. Here is the testimony of Dr D.Alan Shewmon, emeritus professor of pediatric neurology at UCLA and an expert in pediatric brain death. His 26-page testimony provides an excellent discussion of the problems of determining whole brain death, particularly in the case of Jahi McMath.

The problem of potential reversibility after a determination of whole brain death hits home professionally for me. I have cared for patients in an inpatient rehabilitation hospital setting who suffered severe head injuries, as well as consulted on several more who never made it our rehabilitation hospital because of brain death. This included assisting in the discussion of whether to discontinue ventilator, nutrition and hydration support following a proper determination of whole brain death. And, while I think similar discussions are reasonable in individuals sustaining injuries leaving them in a persistent vegetative state (PVS, i.e. having brain function that only acts reflexively without awareness or capability for any cognition, perhaps a better description of Jahi McMath’s current status), no such discussion should happen until brain recovery has reached its maximal endpoint. With whole brain death, those discussions can happen immediately because that endpoint has been reached. Dead brains, by definition, do not recover.

Until now?

The initial determination of whole brain death in Jahi McMath appeared proper.

If the reports of her responsiveness are true, Jahi McMath clearly no longer meets the criterion for whole brain death. The very fact that she has remained alive over three years after the determination of whole brain death argues against whole brain death. Artificial life support has advanced but not to the degree that we can mimic all of the routine vegetative functions controlled by the brain necessary to keep the body alive. It is “easier” to keep an individual in PVS alive because the brain is still doing a large part of its bodily maintenance/regulation work.

At the very least, even if none of the above observations of Jahi McMath are true, the prognosis for whole brain death, while still very, very, very poor, is no longer zero.

Charlie Gard, the New England Journal of Medicine, and the Limits of “Conscience”

I would venture that most bioethicists would agree it would be ethically permissible to remove life support and active care from little Charlie Gard, and let him die.   The hospital in Britain where he has been receiving his care wants to do that, and the courts agree.  But why do they insist on this action when his parents want to transfer him for another try at experimental treatment, have raised the money, and reportedly have a center in the US willing to accept him for such an attempt?

I can think of two reasons.  One is a frank utilitarian insistence on limiting costs.  It has been publicly charged that is precisely the motive for this and similar recent cases in the U.S.

Or it could be that those caregivers who argue against the futility of such care do so on conscience grounds.  This is at least a more charitable reading.

But if that is the case, then might we not ask:  on what grounds do such conscience concerns mandate blocking the wishes of the baby’s parents—setting aside just how quickly the futility of further care would be evident?  It is commonly argued that practitioners who wish not to provide abortions or participate in assisted suicide retain a professional obligation to refer to someone who will perform the procedure in question.

So why don’t we demand that the British hospital actively refer Charlie’s parents to another facility?  Just wondering…

Maybe the parents in this case are the ones appealing to conscience, but, in the view of the medicolegal authorities, wrongly so.  In postings dated June 2 and June 6 of this year, this blog carried a 2-part rejoinder to an April 6 article in the New England Journal of Medicine that took the position that conscientious objection by medical practitioners should be considered unethical.

The NEJM has now published correspondence in response to that “Sounding Board” article.  Unlike the initial article, a subscription is not needed to read these letters and the responses of the authors.  Three letters were published.  One argues that the initial article relied on “reflective equilibrium” as the critical process by which medical practice standards are established, but to do so and reject conscientious objectors is wrongly to restrict that process, which in any case does not indubitably lead toward moral truth.  The second wondered aloud about whether construing the doctor-patient relationship as covenantal matters, whether doctors also have some degree of autonomy that commands respect, and whether the consensus of the medical profession is always ethical.  In the third, a clearly irritated correspondent complains that it is rich to offer, as the authors of the initial article stated, that potential practitioners just avoid moral issues by voluntarily excluding themselves from specialties in question; i.e., would-be OB-GYNs who consider it immoral to perform an abortion need not apply.  In response, the authors say that objectors need not be silenced but must comply, and that society expects physicians to act against their personal beliefs if necessary.

Most tellingly, the authors in question, Stahl and Emanuel, claim that the doctor-patient relationship is NOT a covenant precisely because it is not a relationship of equals; doctors hold immense power of different sorts.  Physicians must respect this inequality by avoiding specialties that pose moral conflicts to them.

I thought that the patient’s special need was precisely why a covenantal relationship is the only framework sufficient to guarantee that the patient as person is appropriately cared for.  Stahl and Emanuel are quite explicit; doctors may not stand in the way of societal calculations, on their patients’ behalf.  They have to get out of the way.

Can there be a new society of physicians dedicates to the categorical rejection of this thinking?  Could such a group possibly practice in today’s legal environment, and in the political-economic spirit that has turned medicine into a centrally-managed public utility?

Dr. Cheyn Onarecker, in the two posts in early June, addressed these points, in opposition to Stahl and Emanuel and, in fact, anticipating their responses in the new correspondence.  Read those again.

But we need to go further, and attempt to restore the covenantal view of medicine.  I’d like to hear more from Dr. Onarecker and other real doctors on this blog about that.

PAS in California: the first 6 months

In a 2016 data report, the California Department of Public Health says that in the first 6 months after California enacted the “End of Life Option Act,” 111 people committed suicide with the help of a doctor’s intentionally lethal prescription, as permitted under the terms of the law.  The time period reviewed was the last 6 months of 2016.

The people in question are understood to all have been terminally ill, as the law intends.  The majority of these 111 were white and college-educated.  The median age was 73.  They had a variety of diseases; a few more than half of the 111 had cancer. 

The report says 258 people asked their doctors about PAS.  Of these, 191 got prescriptions, and 111 took the drugs (orally) and died.  Another 21 did not take the drugs.  What happened to the remaining 59 of the 191 is not known.  The law calls for prescribing physicians to report outcomes after prescription, when known.

In the time period PAS accounted for 6 of every 10,000 deaths in California.  By comparison, the Associated Press reported that the figure for 2016 in Oregon was 37 of every 10,000.

84% had been enrolled in hospice or palliative care, suggesting to me the acceptance of PAS as a standard of care by specialists in palliative care.   Or perhaps the patients decided palliative care had failed them.  Details of the mindsets of the 111 are not part of the report.

Most pressing bioethics issue

In yesterday’s post Mark McQuain asked the readers of this blog what they consider to be the most pressing bioethics issue in the context of a call for our president to establish a bioethics council. He referred to my recent post on reproductive ethics and the manufacturing of children. I think that is important. I also think that abortion including the aborting of children with developmental abnormalities such as Down syndrome, euthanasia, and the treatment of children with gender dysphoria are very important. However, my most pressing concern related to bioethics in our society is freedom of conscience.

It is important that we express clearly the value of human life and how that impacts how we understand the ethics of things such as reproductive technology, abortion and euthanasia, but we are living in a time in which many do not listen to reasoned arguments about what is right. Much of our society believes that what is right is determined by how they feel and they desire to be free of any limits on what they can do. They also believe, somewhat contradictorily, that they should be affirmed in being able to do what they desire by having society help them do it; even if that means that others need to do things that they believe to be wrong. Our society is losing the concept of any objective moral values. Without objective moral values it does not make sense for someone to refuse another person’s request for help in fulfilling their desires based on conscience, particularly conscience informed by an objective understanding of right and wrong. If there is no objective standard on which to refuse such a request the refusal must involve some sort of personal rejection of the one making the request.

Thus we have ACOG saying their members must affirm patients who desire an abortion. Canadian physicians may soon be required to affirm their patients’ desire for euthanasia. There is a push for physicians, psychologists and others to be required to affirm the desire for a confused child to be identified as having a gender that is in conflict with the child’s biological sex. As Cheyn Onarecker has discussed in his posts yesterday and last week, there are some prominent ethicists who give reasoned, although faulty, arguments against rights of consciences for physicians.

The elimination of rights of conscience threatens the ability of not only Christian physicians but all people of strong moral conviction in all professions to practice their professions without violating their consciences. If allowed to go unchecked the demand to affirm every request by every person in the name of pluralism and personal liberty will leave every profession in our society without those who are most conscientious. It will also lead to the demise of ethics as a disciple. If our society really believes that there are no objective moral truths and everyone should be free to pursue his or her desires and enlist others in that pursuit, then any statement that an action is wrong will not be seen as a particular understanding of what is right and wrong which can be civilly discussed, but as an unfounded personal attack on someone who desires to do that action. Thus there will be reason to shut down all ethical discussion and the discipline of ethics will be forbidden.

Euthanasia in Canada: Early Returns

Last week’s New England Journal of Medicine carried a report from physicians in Toronto about early results implementing “Medical Assistance in Dying,” or “MAiD,” the preferred euphemism for doctor-assisted suicide or euthanasia, in Canada.

“MAiD” became legally sanctioned throughout Canada in 2016.  It includes not only assisted suicide—where a doctor provides a patient with a drug prescription intended to be lethal if taken as directed—but also euthanasia, in which a doctor actively kills a patient, at the latter’s request (at least for now).  The recounts provisions in Canadian law intended to limit “MAiD” to people whose medical condition is deteriorating from a serious, incurable disorder, and to ensure that people who receive “MAiD” do so after freely requesting it, and affirming that request after 10 days to think it over.

To keep things “controlled,” the Toronto program is entirely hospital based, limited to lethal IV injection for which recipients are evaluated and ultimately killed by dedicated physicians who have freely agreed to participate.  The specific hospital ward where a patient is euthanized is rotated, so that no ward gets the title of the “MAiD ward,” but the medical team is set.

Some noteworthy points:

  • MAiD was assigned to the Department of Supportive Care. Other clinical departments demurred out of concerns like “conscientious objections of staff” and “obscuring their specialty’s role in protecting life.”
  • As reported elsewhere, patients receiving MAiD sought it because of loss of autonomy, as well as inability to enjoy life, not because of uncontrolled physical symptoms. These people “tended to be white and relatively affluent.”
  • From March 2016 to March 2017:

o   74 MAiD inquiries in the region served by the Toronto investigators.

o   29 went from request to formal assessment for eligibility, under the terms of the law, by the physicians.

o   19 actually received the injection (i.e., were killed by their doctors at their request).

  • In all cases, death occurred within minutes.

o   People who were not assessed or who were but were not injected did not progress because they died too quickly, changed their minds, or lost decision-making capacity.

o   Some patients refused symptom-controlling treatment—notably, opioids—in an attempt to stay clear-headed enough to be deemed to have a valid request for euthanasia.  That is, they requested compromise of their palliative care to keep the “MAiD” option live.

The authors believe that the MAiD decision process should be moved earlier in care—to the point at which end-of-life care and advance directives are discussed more generally—to prevent discussions or decisions about MAiD from being rushed at the very end of life.

They conclude,

“Just as advocacy from outside mainstream medicine brought palliative care ‘from the margin to the center,’ so has it brought MAiD into the mainstream of medicine.  It is now clear that MAiD education must be included in undergraduate medical education curricula…and in the training for a variety of specialties…[It remains to be seen] whether the legalization of MAiD…this ‘brave new world’ will ultimately be regarded as enlightened or dystopian.”

I cast a Huxleyan vote for “dystopian.”