This document outlines a presentation on mapping the ethical terrain of medically assisted dying (MAiD) in Ireland. It does not take a stance but provides a framework to guide conceptual discussion. It focuses on the decision, decision makers, and outcomes using Canada as an example country that has legalized MAiD. Key ethical questions are raised about patients' autonomy and consent, physicians' conflicting duties, and impacts on public perception and resource allocation. Data from Canada on MAiD providers and annual reported deaths is presented. The conclusion emphasizes the need for evidence from all stakeholders and learning from other jurisdictions' experiences before a decision is made.

1. M E D I C A L LY A S S I S T E D
D Y I N G I N D Y I N G ( M A i D )
I R E L A N D : M A P P I N G T H E
E T H I C A L T E R R A I N
Ghaiath Hussein, MBBS, MHSc,
PhD
Assistant Prof. in Medical Ethics &
Law,
Trinity College Dublin
husseing@tcd.ie
@GhaiathHussein

2. OUTLINE: WHAT MY PRESENTATION IS(NOT)
• Provide an ethically-oriented logical framework to guide
a conceptual discussion on MAiD, following this
categorization:
 The decision
 The decisionmakers
 The outcome
• Using examples from some countries that legalized
MAiD, with focus on Canada.
• NOT an attempt to explain or endorse any ethical theory
or approach or any official or religious viewpoint

3. W H AT I S E T H I C A L LY
R E L E VA N T / U N I Q U E
A B O U T M A I D ?
Irreversible decision
Contradict morally-equivalent values and
duties
Death as a value-laden concept (spiritual vs.
clinical)
Death is a process not an event
Similarities and differences to other EOL care
decisions
Option, right or duty?
Extended impact (patient, carers, public)

4. WHO IS WHO IN MAID?
MAiD
Patient
Family
HCPs
Public
WHICH ETHICAL PATH?
Theories
as
lenses
Deontological
Teleological
Principlism
Contractarian

5. ETHICAL QUESTIONS ABOUT THE PATIENTS?
Autonomy (& Informed Consent)
• How to define capacity to consent? How informed/manipulated/coerced they are?
• What are the conditions and limits of autonomy? Do they apply to MAiD?
• Does MAiD dignify autonomous choices or limit view to self? Is fear of stigma?
• Can consent be delegated or assisted (e.g. ADMCA 2015 3 tiers (DMA, CDM, DMR))?
• Why should 'autonomy' be privileged above other principles of medical ethics?
Concepts of life, death, suffering
• How about non-pain-related reason (loss of autonomy, losing dignity and the
intolerability of not being able to enjoy one’s life)?
• How to assess the impact of COVID-19 and the like on MAiD eligibility and choices?
Option, right or duty?
• Is there a duty to die? avoid burdening others (what is the role of family?)
• MAiD with(out) request: who decides? Blurring of criteria
• Is it ok to change my mind?
• Can MAiD candidate choose what happens after her death? (COI: organ donation,
inheritance)

6. E T H I C A L Q U E S T I O N S A B O U T T H E H C P s ?
Conflicts of duties and roles
• Conflicting duties of not to harm, care, do good, alleviate pain?
• What are the limits of autonomy? Do they apply to MAiD? How about ‘Principle of Double Effect’?
• Role in MAiD? Consultant, assessor, informer, advocate, decisionmaker, implementer
• How would each of these roles affect the main duty to care?
• How to define ‘independence’ from patients in smaller communities?
Conscious-based objections
• Is involvement opt-in or opt-out?
• On what basis can HCPs refuse to be involved (personal, religious, etc.)?
• Can faith-based healthcare facilities be ‘exempted’?
• How to manage uncertainties about the patient’s condition or the outcome of MAiD itself?
Moral habituation and erosion
• What kind of emotional support is available for families and HCPs alike?
• From reflection and guilt to a habit and business as usual
Legal arguments and implications
• How safeguarding are the safeguards? Example of ‘foreseeable death’, used ‘wrong combination’
• Patient choice vis-a-vis physicians’ assessment?

7. ETHICAL QUESTIONS RELATED TO THE PUBLIC
• Would legalizing MAiD affect perception of/trust in HCPs?
• How MAiD may reorientate the focus/roles & priorities?
• Will legalizing MAiD abolish self-committed or unregulated suicide?
• Is death the answer to ‘system-inflicted’ (iatrogenic) suffering?
Pubic view of healthcare facilities and providers
• Who gets the ‘service’? Who pays for it?
• Minorities (ethnic, religious, …)
• Role of faith-based healthcare institutions?
• Setting new societal norms and values
Justice and access
• How MAiD will affect the reallocation of resources?
• How MAiD can lead to view some patients as ‘burden’?
Impact on disabled and persons with special needs?

8. M A I D I N A C T I O N : C A N A D A
https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html#s1

9. S O M E F I G U R E S F R O M C A N A D A

10. Total Reported MAID Deaths in Canada, 2016 to
2020
Speciality of MAID Practitioner,

11. TRYING THE TRIED?
The Spectator (UK) Dr Joel Zivot,

12. O N A F I N A L N O T E / T H O U G H T
• We need evidence. From, with, and about all the
stakeholders.
• ‘Others did it, why not us’ is not a good argument.
We may be similar but not the same.
• Others did it, so let’s learn from them and see
how they ended up is a better prologue
• The majority rules only in politics. In ethics, we
need to hear from the minorities first.