When the Supreme Court of Canada ruled the existing law against euthanasia as unconstitutional in February 2015, Canadians began to take notice of what would become a seismic shift in how death and dying would be viewed. A year later, when the proposed legislation changed from Physician Assistance in Dying to Medical Assistance in Dying shortly before Bill C-14 went to vote, Canadian nurses took notice as suddenly we were no longer on the sidelines, but nurse practitioners would participate directly in the prescription and administration of substances to cause death, without facing criminal charges. Even for nurses who are not nurse practitioners, facilitating requests of patients for MAiD and assisting physicians and NPs have become reality since Bill C-14 became law on June 17, 2016, even as our professional associations and regulatory colleges scramble to prepare policy guidelines. According to the CNA Senior Nurse Advisor, CNAs definition of MAiD includes administration of a substance by an authorized nurse practitioner (voluntary euthanasia). It also includes the prescription or provision of a substance that the person self-administers (assisted suicide). In other words, MAiD includes nurses.
From an international perspective, the inclusion of nurses in this legislation puts us in a situation quite apart from the traditional nursing stance on euthanasia. Nurses have held a longstanding position against euthanasia. For example, the American Nurses Association holds that active euthanasia is intrinsically incompatible with the ends that the profession seeks, and that it is a violation of the social contract that nursing has with society (Fowler, 1988). In the UK, the Royal College of Nurses in its submission of evidence to the House of Lords on the Assisted Dying Bill stated its position to be firmly against euthanasia (Holt, 2008). The empirical literature reveals a lack of consensus among nurses on euthanasia in general and their involvement in the process in particular. Their feelings are extremely complex and the descriptions given of personal conflict, moral uncertainty, frustration, fear, secrecy and guilt would seem to reflect a convoluted array of personal and professional values alongside a range of social, religious and legal considerations (Tamayo-Valzquez, Simon-Lorda, & Cruz-Piqueras, 2012).
Our provincial and national professional organizations have needed to respond quickly to develop the necessary policies and regulatory frameworks to guide nurses in this new reality. The guidelines being drafted by CNA, for example, are vital in providing a clear framework for nurses, nurse regulators, clinical nurse leaders, employers, and healthcare teams in developing policies, guidelines, processes, and services (CNA, 2016). Thus far, however, Canadian nursing responses have been predominantly technical, procedural, and “clinical”, rather than existential, interpretive, and contextual to take into account the range of ethical values that are relevant to MAiD (de Bal et al., 2006). Likewise, much of Canadian discourse—whether professional or lay—has been framed in an individualistic philosophy, where the autonomy and rights of the individual are emphasized over human relationships and community care.
At this point, as the only faith-based nursing program in Canada, faculty in the School of Nursing are thinking deeply about MAiD, especially in relation to how to appraise nursing students and novice nurses of the legal and ethical implications of this new legislation. In an upcoming Nursing Networking Café (November 22nd, 2016), we will offer a framing for how we are doing so and will engage nurses on the type of questions we must consider:
- Are there limits to autonomy and self-determination? How do we balance the rights of an individual in the context of community and relational ethics?
- How do we understand suffering? How does one’s view of suffering shape one’s view of MAiD? How might Bill C-14 influence societal views on suffering and death?
- What is the source of one’s dignity—one’s ability to be self-determining and independent, or one’s human existence? How can we enhance the dignity of those who are suffering or dying?
- How do we take an upstream approach to MAiD, particularly in light of vulnerable populations who might perceive themselves or be perceived as worthless?
- How can nurses enact their professional ethics that have them display solidarity and trust with those who are suffering while also supporting requests for MAiD?
- How can healthcare organizations ensure conscientious protection for their employees while meeting legislative requirements?
- What are the longer term effects of nurses and other healthcare providers’ involvement with MAiD on their moral resiliency and moral agency? What ethical tensions do they (and their leaders) face in the changing and complex moral landscape?
- It has been said that the social movement for MAiD is a predominantly White, secular movement. How might newcomers to Canada, members of minority religions, and indigenous populations view MAiD?
- What is the impact of framing nursing’s ethical obligation primarily as one of ensuring access to MAiD?
Bill C-14 has resulted in a watershed change for Canadians and Canadian nurses. Which ethical values are foregrounded has a profound influence on the response of individual nurses, patients and families who might consider MAiD, and our healthcare organizations and professional associations.
References
Canadian Nurses Association (2016). National Nursing framework on medical assistance in dying in Canada. Draft. Ottawa, ON: Author.
Fowler, M. (1988). Ethical issues in critical care. On killing patients. Heart & Lung, 17(3), 322-323.
Holt, J. (2008). Nurses' attitudes to euthanasia: the influence of empirical studies and methodological concerns on nursing practice. Nursing Philosophy, 9(4), 257-272.
Tamayo-Velázquez, M. I., Simón-Lorda, P., & Cruz-Piqueras, M. (2012). Euthanasia and physician-assisted suicide Knowledge, attitudes and experiences of nurses in Andalusia (Spain). Nursing Ethics, 19(5), 677-691.