Introduction and background

Medical Aid in Dying (MAiD) is the practice of painlessly and actively putting to death persons who are suffering from painful and incurable diseases or an incapacitating physical disorder, [1] and has remained a controversial debate while caring for patients who are at the end of life.

Medicine has come a long way in the past few decades, and the physician’s ability to prolong life is ever-increasing. However according to the proponents of physician-assisted dying, for the terminally ill patient, prolonging life may just mean the prolongation of suffering. The moral and social debate is further complicated by the appreciation of a terminally ill patient’s autonomy and right to decide regarding their treatment [2].

The concept of Medical aid in dying encompasses various terminologies. These include Physician-Assisted Death (PAD), Aid In Dying (AID), and Physician Assisted Suicide. Most authors acknowledge terminology variation but do not explain their choice of terms around this topic [3].

According to the Canadian Medical Association, medical aid in dying, physician-assisted dying and physician-assisted death are defined as a situation where a doctor intentionally participates in the death of a patient by directly administering a life-ending substance, or by providing the means where a patient can selfadminister a substance leading to their death [4].

Assisted suicide is defined as providing another with the knowledge or means to intentionally end his or her own life, rather than the physician actively ending their life, as in euthanasia [5].

According to the Death with Dignity Act, value-neutral language is preferred when dealing with physician-assisted death. Neutral terms include Assisted Death, Physician Assisted Dying, Aid in Dying, and Medical Aid in Dying. Terms such as Physician Assisted Suicide and Mercy Killing are deemed inaccurate, inappropriate, or biased, as they imply a value judgement [6].

Euthanasia, on the other hand, is generally defined as the practice of intentionally performing an act to end the life of another, to relieve their pain and suffering [7]. This term may be used in a context where the patient is unable to express their desire to die, and the decision may be made for them as an act of mercy, i.e. the patient may be in a long-standing coma.

Review

Many studies conducted globally reveal that attitudes towards euthanasia vary with sociocultural environment, religious beliefs, professions, age, and the liberty of one’s views, and the attitude towards the subject changes with time [8].

Medical aid in dying has gained legality in the Netherlands, given that the patient is enduring unbearable suffering and there is no prospect of improvement. There are several checks and balances, including doctors having to consult one another on whether the patient meets the necessary criteria. Belgium, Luxembourg, Canada, and Colombia also allow both euthanasia and assisted suicide, although there are differences. For example, only terminal patients can request MAiD in Colombia, while Belgium is unique in that it has no age restriction for children (although they must have a terminal illness).

Assisted suicide is more widely available than euthanasia. Among the places where people can choose to end their lives this way are Switzerland and several US states including California, Colorado, Hawaii, New Jersey, Oregon, Washington state, Vermont, and the District of Columbia. Laws permitting assisted suicide also came into force in the Australian state of Victoria [9].

Opponents of medical aid in dying argue that the role of a physician is that of a caregiver, which is irreconcilable with the practice of MAiD and therefore cannot be offered in good conscience. Others argue that the issue of a patient wanting to end their life is a shortcoming of the physician’s management of the patient in the first place, be it pain management or even psychological treatment [10]. Others argue that it is a slippery slope toward a suicide endemic at the core of medicine [11,12].

The role of MAiD in psychiatric disease is another issue. Cases of major depression or ‘tired of life’ elderly patients requesting physician-assisted death will inevitably come up in the future, as is already happening in the Netherlands, which opens a whole new chapter in this debate [13].

The issue of medical aid in dying is a pertinent ethical question that is becoming more and more relevant in health care, as it cuts across complex issues encompassing legal, ethical, human rights, health, religious, economic, spiritual, social, and cultural aspects [14]. The pros and cons of the MAiD debate are more along the lines of moral arguments rather than objective truths [15].

So far, most major medical bodies are withholding judgement on the matter, best illustrated by the Royal College of Medical Practitioners, which conducted its largest consultation on an issue of public policy both in terms of response rate and volume of respondents [16]. Previously having rejected the practice in 2014, the Royal College of Physicians has now adopted a neutral stance on legalizing assisted dying, after a survey of its members found that neither opposition nor support won more than a 60% supermajority [17].

The perceptions of Medical Aid in Dying and its morality and legality are generally not discussed in lower and middle-income countries. It was found that in India, 60% of physicians agreed with the practice of euthanasia, but these figures declined drastically in Islamic countries. In Malaysia, 52% of those interviewed approved of the practice, whereas in Sudan only 21% were in agreement [18]. Another study in New Delhi found that a majority of physicians found that the withholding or withdrawal of treatment was acceptable, whereas active euthanasia was generally opposed [19].

The Islamic Code of Medical Ethics, 1986 mentions that the concept of a life not worthy of living does not exist. Therefore, Medical Aid in Dying is forbidden and Islamic law prohibits euthanasia in all circumstances.

However, the wishes of a patient not to have his dying prolonged artificially in the presence of a hopeless prognosis are well preserved, even in Muslim countries. Such wishes are accepted as Do Not Resuscitate (DNR) orders in certain hopeless medical conditions [20].

Concurrently, there are many barriers to implementing the DNR orders effectively in developing countries such as Pakistan. The major barriers faced in terms of DNR orders are mainly family-related barriers such as low level of education or disagreement within the family, personal barriers such as lack of knowledge of the diagnosis, and hospital-related barriers such as time constraints and lack of administrative support [21]. Both patients and physicians would be stigmatized and legally prosecuted for participating in MAiD, as its legality is questionable in the light of Islam [22]. Even in the event of withdrawal of life support, there is much confusion regarding the definition of brain death, end-oflife recognition, and indications and processes of withdrawal of life support [23].

Pakistan which is a lower middle-income country, and also one that was established on a religious ideology, has so far had no discussion into the concept of medical aid in dying.

There is even no direct mention of MAiD or euthanasia in the Pakistan Penal Code [24].

Conclusion

Patients admitted in Pakistan have high rates of multi-morbidity, CVD risk, inefficient public health facilities, and an overall lack of resources. With rising multi-morbidity including cancers and an evergrowing elderly population, it would be useful to explore the understanding of the concept of Medical Aid in Dying at the end of life of patients. There has been no discussion along religious, political, sociological, or academic lines due to a range of factors, one of which is the questionable legality of the practice in Islam.

Healthcare professionals are generally not aware of nor trained to approach this concept, as MAiD is neither practiced nor researched in the country There is not enough literature regarding the practice, legality, consequences, or prospects of MAiD in the country. MAiD as an option for patients willing to seek alternative care abroad where MAiD may be legal is also not discussed.

Pakistan must work towards forming concrete parameters and regulations around the practice of MAiD, and to do so, must first conduct cross-sectional studies to find the general perceptions of physicians and the public towards MAiD, as has been done in some other developing countries. This will lead to further studies and the foundation of a discourse on MAiD in Pakistan.

Declarations

Conflicts of interest: All the authors declare no conflicts of interest.

Funding: None.

References

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