How to Get A Head in Life

Note: The Bioethics Program blog will be moving to its new home on April 1, 2015. Be sure to change your bookmarks to http://bioethics.uniongraduatecollege.edu/blog/

by Bonnie Steinbock, Bioethics Program Faculty

An Italian scientist, Sergio Canavero, claims that he is two years away from performing the world’s first human head transplant, in which the head of one person would be grafted onto the body of a newly deceased person

Canavero’s proposed procedure would involve cooling the patient’s head and the donor’s body so that their cells do not die during the operation. After the head is cut off the patient’s body, the blood vessels would be lined up, and the spinal cord cut with a very sharp knife to minimize nerve damage. The patient would have to be immobilized by being kept in a coma for several weeks. Canavero believes that the patient would be able to speak when he woke up, although a year or more of physical therapy would be necessary for him to be able to move his body.

The biggest technical obstacle is that no one knows how to reconnect spinal nerves and make them work again, although there has been some success with animals. In 1970, a team at Case Western Reserve transplanted the head of one monkey onto the body of another, although they did not attempt a full spinal cord transfer. The monkey was unable to move its body. In 2014, researchers at Harbin Medical University in China were able to preserve breathing and circulatory function in mice. However, as is well known, “everything works in mice.” Most neurosurgeons are skeptical that this would work in humans. Moreover, it seems unlikely that ethics review boards today would approve experiments to see if the procedure worked in non-human primates.

Technical challenges aside, there are a number of ethical questions to be considered. We know that some people have been unable to adjust to transplanted appendages and have even had them removed. The psychological impact of waking up with a new body is unknown: how would you get truly informed consent for that? Nevertheless, if the procedure would save the patient’s life, and the alternative is death, perhaps this is a risk we should let competent adults take.

But would the patient’s life be saved? This is not a medical or scientific question, but a conceptual or metaphysical one. It depends on one’s theory of personal identity. On one view, known as mind essentialism, we human persons are essentially embodied minds, that is, embodied beings with the capacity for consciousness. Since the capacity for consciousness resides in the brain, we are our functioning brains. If your brain could be transplanted onto someone else’s body and continue to function, you would continue to exist.Indeed, philosopher Jeff McMahan created the hypothetical example of a brain transplant as evidence for mind essentialism.

An opposing view of personal identity holds that we are not essentially minds, but human animals or organisms. Its primary supporter, David DeGrazia, holds this to be a matter of educated common sense, and its denial by mind essentialism to be a serious defect in the theory. But what about the plausible intuition that “you go where your mind goes”? Its plausibility stems from the conflation of two distinct senses of identity: numerical and narrative. Narrative identity is psychological. It involves our sense of who we are: our beliefs, memories, values, and intentions. By contrast, numerical identity refers to what makes me the same individual, over time. On the human organism view of identity, I would continue to exist as the same individual even if my narrative identity were lost, as it would be if I permanently lost consciousness, as in permanent vegetative state (PVS).

We care deeply about narrative identity, DeGrazia says. Indeed, it is “what matters in survival.” That is why most people would not want to be sustained in (reliably diagnosed) PVS. Nevertheless, the organism account allows us to say that we can become PVS. On the embodied mind view of identity, this is literally impossible. My organism could become permanently unconscious, but since I am not my organism, I would no longer be there.

Both are plausible metaphysical views: which one is correct? In my view, neither, because both rest on the questionable assumption that we are essentially something. Why insist that we must be either embodied minds or organisms? Why can’t we be both? As a person, Terri Schiavo, ceased to exist when her cerebral cortex permanently ceased functioning in 1992. As a human organism, she died in 2005. And if she has an immortal soul, she continues to exist today.

From a practical perspective, the view of identity one takes doesn’t really matter as regards head transplants, since it is narrative identity that matters in survival. But would narrative identity be preserved? This is not simply a matter of reconnecting the spinal nerves, enabling the reconstructed person to be awake and sentient. If the patient woke up and had none or few of the memories, beliefs, values, or concerns he had before the head transplant, his narrative identity would be lost. Unless there was a possibility of recovering many of the mental contents of his mind, it is hard to see what benefit there would be in even a successful head transplant.

[The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

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Will Ariadne Lead Us Through the Maze of End-of-Life Healthcare?

Note: The Bioethics Program blog will be moving to its new home on April 1, 2015. Be sure to change your bookmarks to http://bioethics.uniongraduatecollege.edu/blog/

 

by Richard Koo, Bioethics Program Alum (MSBioethics 2011) and Adjunct Faculty

About four years ago, Susan D. Block, M.D. posted a blog on Harvard Business Review’s website as part of a series of writings focusing on innovation in health care. In her blog, she bemoaned the “lousy job” doctors do in communicating with patients when it becomes apparent that additional treatment and technology will fail to stave off death. Among several other proposals, she suggested that standards for appropriate documentation of end of life discussions should be developed, promulgated, and used as reportable indicators of quality care. To carry out that innovation, she proposed that “all electronic medical record systems would be expected to support documentation of the patient’s health care proxy, values and goals” and “a broadly-agreed-upon definition of populations for whom these discussions and documentation are appropriate would be developed.”

Dr. Block is no stranger to the subject of end of life communications between doctors and patients. She participated in a number of panels and has authored articles on the subject since the 1990s. She also did not wait for the medical profession to follow through on her proposals. As Director of the Serious Illness Program at Ariadne Labs, Dr. Block spearheaded the development of a system (the “System”) to assure that doctors caring for seriously ill patients can develop competency in communicating with their patients so that the patients “can live with their serious illness and into the last stage of life with dignity, control and a sense of peace.” The System aims to train physicians in identifying appropriate patients for such communication, determining the right time to initiate the serious illness conversation, engaging in serious illness planning, helping patients discuss their end-of life preferences with their families, and documenting those plans and preferences in the patient’s electronic health record.

Presently, Ariadne Labs is evaluating the outcomes of the System through a series of clinical and implementation trials measuring outcomes in oncology, primary care, nephrology, chronic illness, surgical and emergency settings and adapting it to culturally diverse populations. The plan is to launch the System nationally in the fall of 2015 through a collaborative of approximately 20 health care networks to test it in different populations across the country.

Even before System launch, I’ve heard some potential concerns about the System from health care professionals who work with seriously ill patients day to day:

Pushback 1: “Discussions with patients with serious illness near the end of life are intensely personal and depend on an individual’s health care trajectory, views on life, death, and religion, financial situation as well as family dynamics. No standardized set of conversation guides, scripts, checklists and reminders can be practically useful.”

Counterpoint: “Standardized” doesn’t necessarily mean one size fits all. Though the System hasn’t yet been publicly released, based on Dr. Block’s body of work, my bet is that the System will direct physicians to take into account individualized variations in patient background, prognoses, situations and preferences. It should also help the physicians structure their communications according to those variations.

Pushback 2: “The reason why the medical profession does a “lousy job” in end of life communications is because many doctors have little motivation or interest to get good at it. Changes to the U.S. health care delivery system of a more fundamental nature have to be made before the medical profession current approach to communications with seriously ill patients will change.”

Counterpoint: So what are health care professionals supposed to do: sit on their hands until fundamental changes happen?   Communicating with patients is an integral part of the provision of health care. Health care professionals have an ethical imperative not to do a “lousy job” in that regard, whether or not these improvements are financially rewarded.

Pushback 3: “The medical profession would be better off leaving the task of difficult discussions near the end of life to those who presently deal with it best, namely palliative care physicians, nurses and nurse practitioners, hospice care specialists, social workers and patient advocates.

Counterpoint: One of the driving forces behind the development of the System is to raise the recognized standard of care of all physicians who treat seriously ill patients. Leaving the task of having appropriate end of life planning and communications in the hands of a cadre of specialists does nothing to address the “lousy job” physicians do that Dr. Block bemoaned. Any improvement in serious illness communications and the heightened sensitivities that the System might help bring about would also enhance the prospects that physicians will work collaboratively with the rest of the health care team to improve patient care near the end of life.

From a broader view, these potential concerns about the System seem symptomatic of the threat that innovative ideas present to the status quo. Personally, I’m excited about the possibilities of the System, in part because of my great respect for Ariadne Labs and its leaders, including Executive Director Atul Gawande, M.D.

[The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Understanding the Latino Patient with Cancer

by Beatriz Lorena Hurtado, Bioethics Program Alumna (MSBioethics 2014)

As a Latina working in healthcare I have always felt the responsibility to provide education about my culture, and to clarify cultural differences and misconceptions. It is always surprising to witness how eliminating misconceptions eventually translates into an increase in patient satisfaction, and less apprehension about cultural differences from the healthcare team. This is one of the reasons why, in my view, education on Cultural Competence in healthcare is probably the most appropriate way to avoid generalizations and achieve equality in healthcare.

Latinos currently constitute seventeen percent (17%) of the nation’s population, making them the largest racial and ethnic minority in the US. They are also amongst the fastest growing minorities the United States. Should current demographic trends continue, it is estimated there will be 41 million Latinos in the United States by 2020.

These numbers should not only indicate the rising presence of Latinos in the United States, but also highlight the need for developing pathways to improve language and cultural services in the healthcare arena.

This need is particularly in oncology: as the American Cancer Society notes, cancer is the second leading cause of death for Latinos. It is also important to add that the most common cancer diagnosis in Latino women is breast cancer, while prostate cancer is the most common diagnosis in Latino men (with colon, lung, melanoma, stomach, and liver cancer following closely behind).Therefore, as it happens with any chronic disease, the medical visits are usually recurrent and the treatments involve an extensive group of healthcare professionals.

As a Latina I believe there are three important characteristics of Latino cultural expressions, meanings, and value systems that warrant specific attention:

First, family is the foundation that supports life for Latinos in general. Medical decisions are in most cases a family affair. The presence of family signifies emotional support, empathy, and togetherness, and is always favored in a difficult medical situation. Moreover, if facing a difficult moment or vulnerability, like a cancer diagnosis, family support is at the top of the list of necessities of the Latino patient. Latinos place much of their identity and self-worth into the family structure and customs.

Although it is recognized that the Latin American family has undergone changes in its structure in recent decades, it is important to note that these changes haven’t shifted the sense of group, affective value, and financial support in the immigrant family. Latinos are gregarious, often moving in culturally-defined groups. They also identify themselves within their group and by the role they play in it. Failing to recognize the place family has in medical decisions for Latino patients could be viewed as a lack of acknowledgement of who they are as persons, and their position in the micro universe that is their family life.

Second, in the Latino culture, talking about death is commonly viewed as summoning it. Acknowledging death can be seen as giving up hope, limiting a patient’s chances of surviving and a threat to their recovery. This has obvious implications for conversations about death, end-of-life issues, living wills and advance directives. Also, because of the substantial Catholic background and deep religious roots, most Latinos believe that talking about the possibility of a negative outcome is an expression of limited faith in God. It can symbolize doubt on God’s abilities to heal the sick.

Third, even though Latinos share many characteristics, they are also a very diverse group. They are united in their diversity. For instance, a Latino patient from South America may have a specific cultural response towards the healthcare team (e.g., a more entitled behavior) that may be very different from the cultural response of a Latino patient from Central America (e.g. a more humble and unassuming attitude).

Despite all the similarities that unite Latinos (language, religion, family union, etc.), there are several particular cultural conventions that vary depending on the country from where the person comes. Identifying that the patient may speak Spanish or may come from Latin America represents merely the basic steps in beginning a successful communication, but it does not contribute significantly towards building a strong a fruitful rapport with a Latino patient. To achieve this, establishing a conversation free of narrowly defined cultural assumptions is crucial. Even though Latinos share many characteristics, like the general value placed on family and the inclination to avoid discussions of death, there is a rich diversity of Latino cultures and healthcare providers must make it a point to avoid generalizations.

In the context of the Latino culture, to achieve a culturally competent treatment is to understand their culture and demonstrate respect for their differentiating traits while they are in treatment. This means providing care that recognizes and caters to those cultural differences. By acknowledging their gregarious behavior towards family and group, by attributing their reluctance to plan for the worse to their unceasing hope in their interpretation of death and dying, and by respecting the differences among these common traits, the healthcare team can provide culturally competent care. In turn, this will help the patient feel acknowledged and less intimidated by the medical environment, resulting in a more effective relationship, better care, and better outcomes.

[The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

The Man Who Mistook His Life For A Hat

by Jacob Dahlke, Bioethics Program Alum (MSBioethics 2012)

Our society tends to put on pedestals the celebrities among us, particular upon their deaths. For author Oliver Sacks, it is no different except that he is not yet dead. He did, however, recently announce in the New York Times that metastasized tumors were found in his body. His diagnosis is terminal in the near future. There is an ease and confidence with which he declares, “It is up to me now to choose how to live out the months that remain to me”. These are not the words of a man who plans to rage against the dying of the light, he simply plans to confront (as Hume did) the difficulty “to be more detached from life than I am at present.”

We could certainly expect – from his own energetic accounts – Dr. Sacks to plunge aggressively into treatment. He describes himself in the NY Times piece with powerful, vivid words, a “man of vehement disposition, with violent enthusiasms, and extreme immoderation in all (his) passions.” One might presume that such a person, when faced with the prospect of a terminal illness such as Dr. Sacks’, he would opt for Thomas’ strategy. And yet, when given the opportunity to consider his path, he has chosen differently. Dr. Sacks decided to forgo aggressive treatments – choosing the quality of his life over its quantity. His path is not the one less traveled, but rather one recently reflected in the perspectives of healthcare providers and patient alike.

What is so striking about Dr. Sacks’ writing, then, is how he elucidates the transition from a life with one set of goals and purposes to another set, with goals and purposes all their own. People outside the shadow of a terminal illness may see this transition as a loss of will to live out their remaining days – hence the outcry over such stories as Brittany Maynard, or of the recent news in Canada about assisted suicide. But Dr. Sacks cut through such presumptions with surgical precision: “This is not indifference but detachment.” It is not a loss of the will to live, but instead a loss of the will to live as before. It’s not that issues like global warming are no longer important; they’re just not important to him individually anymore.

It is as though Dr. Sacks’ life as a public figure is a sort of hat. Something worn, but not entirely revealing. And now that he is nearing home, his hat has become less useful. It is, perhaps, time to take his hat off.

I am not sure we will hear much more, if anything, from Dr. Sacks from now until his death in the coming months. He decided to focus on those close in his life, and that is certainly to be respected and praised. But Oliver Sacks’ potential withdrawal from the public sphere is a loss for our society as a whole. It remains difficult to translate the thinking about end of life decisions well, and his experience and skill, his work does that with such clarity.

His accomplishments are many, but for health care professionals whose patients approach death’s door, this short piece will be perhaps the most useful. These health care professionals themselves wear many hats, and, increasingly, one of these pushes patients, families, and the public to confront what it means for their light to fade. Of course, they may choose to fight to the very end. But the brutal honesty of Olivers Sacks’ reflections opens a space for these patients to say (and for their families to hear) that they, like Dr. Sacks, have decided not to rage. Instead, they have chosen to look back and say: “Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure.”

[The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

The Carter v. Canada Conundrum: Next Steps for Implementing Physician Aid-in-Dying in Canada

by Sally Bean and Maxwell Smith (Bioethics Program Alum, 2010)

We applaud the February 6, 2015 Supreme Court of Canada’s (SCC) unanimous ruling in Carter v. Canada (Attorney General), 2015 SCC 5. The Court found the criminal prohibition of assisted death to be in violation of section 7 of the Canadian Charter of Rights and Freedoms, which guarantees the right to life, liberty and security of the person. The ruling has been suspended for 12 months to enable time for a Parliamentary response. In the wake of this landmark ruling, we identify and briefly discuss three issues that require serious attention prior to the implementation of Physician Aid-in-Dying (PAD) in Canada.

The legal prohibition on assisted dying in Canada dates back 22 years to the SCC’s 1993 ruling in Rodriguez v. British Columbia (Attorney General). In a 5-4 decision, the majority of the Court held that, although prohibiting aiding and abetting a person in committing suicide (section 241(b) of the Criminal Code) did deprive a patient (Rodriguez) of her security of person under section 7 of the Canadian Charter of Rights and Freedoms, this violation was justifiable because the infringement was in accordance with “the principles of fundamental justice.”

Reflecting a changing legal and moral landscape, the Carter v. Canada SCC ruling again addressed Criminal Code section 241(b), in addition to section 14 (prohibiting persons from consenting to death being inflicted on them). Specifically, the ruling held that these sections of the Criminal Code are void if they prohibit PAD for a competent adult who “(1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease, or disability) that causes enduring physical or psychological suffering that is intolerable to the individual in the circumstances of his or her condition.”

Competent Adults

The SCC Carter ruling will now require subsequent legislation or regulations to delineate who counts as a competent adult. Like most jurisdictions that permit PAD, the ruling limited it to competent adults. Importantly, this may preclude patients suffering from advanced dementia or other diseases that render a person incapable of making their own treatment decisions. The legal standing of an advance directive authorizing PAD, made while an individual possesses decision-making capacity, remains to be seen and warrants further consideration.

Some Canadian jurisdictions, such as Ontario, do not have a legal age of consent for healthcare treatment decisions. Rather, under Ontario’s Health Care Consent Act, decision-making capacity is based on an individual’s ability to both understand the relevant information and appreciate the reasonably foreseeable consequences of the decision. Therefore, in jurisdictions without an age of consent for treatment, the Carter ruling could potentially require clarification if a determination of being an “adult” is based on the legal age of majority as determined by each province or territory (and is either 18 or 19 years of age across Canada), or if it is based on a capacity to make treatment decisions.

PAD Application beyond Terminally Ill Patients

The SCC left open the possibility that PAD should not be confined only to the terminally ill but also “persons with a grievous and irremediable medical condition that causes enduring physical or psychological suffering.” As Sean Philpott-Jones notes, “[b]y including references to disability and psychological suffering, the Court potentially opened the doors not only to those with terminal illnesses, but also those with chronic but not life threatening illness or disabilities, as well as those suffering from mental illness.” Further thought will have to be given to how we determine that a person’s condition is in fact “grievous and irremediable.” For example, will someone with treatment resistant depression be required to have attempted all reasonable treatment options, regardless of associated side effects?

Physician Conscientious Objection

The ruling also broaches the issue of which physicians will provide PAD. Just one month before the ruling, a member survey by the Canadian Society of Palliative Care Physicians found that 74% of its members reported they would not provide PAD. Similarly, a member survey conducted by the Canadian Medical Association indicated that more than one-quarter would be willing to provide PAD. Jurisdictions with PAD legislation, such as Oregon’s Death with Dignity Act, recognize that physicians have the ability to conscientiously object to participating in PAD. As a harbinger to the Carter ruling, in August 2014, the Canadian Medical Association softened its stance on PAD and in a released statement noted that the CMA “supports the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding to provide medical aid in dying.” Before PAD is implemented in Canada the issue of who will provide assistance in dying must be addressed at the very least to avoid inequities in access.

Now that the ruling has been handed down, the more difficult task of defining the legal and ethical parameters of who can consent to PAD and what obligations physicians have to honor such requests must begin.

[The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

The Importance of History for Bioethics: It is What it Was

by Barry Shuster, Bioethics Program Alum (2013)

At a holiday social gathering last year, I sat with a former colleague, a physician, who inquired about my progress in bioethics. While he finds bioethics interesting and occasionally useful, he broached the familiar refrain: “It’s all relative”.

“We say this is ‘right’ or ‘wrong’ based on someone’s philosophy,” he said. “But there are always other perspectives. The Nazis thought what they were doing was ethical.”

My friend paused to take bite of his sandwich, and looked across the table, waiting for a response. I’m Jewish, so the comment was particularly provocative. If I’ve learned anything from being a lawyer and parenting teenagers, however, it is how not to flinch when provoked. I encouraged him to continue.

“The problem with bioethics is there are no clear standards,” he said. “There is no bar exam for bioethics. Ultimately, doesn’t the ‘who’s right or wrong’ question really get down to who won?

He raised an important question that challenges the validity of bioethics as a discipline, let alone a profession. That is, who is to say whose approach and philosophies are more valid?

I believe most reasonable people appreciate that bioethics – like the humanities, philosophy, and even social sciences – is not physics, whose theories can be explained with mathematical precision and repeated in a controlled setting. Yet bioethics aspires to provide firm moral guidance on matters of life and death.

When I try to explain medical ethics and its moral foundations, I follow the approach of Dr. Robert Baker, Director Emeritus of the Bioethics Program, and trace its historical roots from the Hippocratic tradition. This approach affirms that bioethics is not as much a fixed set of principles and rules, as it is a continually unfolding story of collective response to events. This approach has helped me many times.

In my participation on hospital ethics committees and IRBs, when encountering situations that lack clear guidance, I have noted that those who make the strongest cases often tell stories based on first- or second-hand experience, rather than recite principals and rules.

Once upon a time there was a situation. This approach was taken. These principals were applied. And they lived happily ever after – or not.

And when I find that my own collection of stories fail to provide direction, I tend to lean on history lessons to find my way. I recall a case of a severely disabled infant with a discouraging prognosis. The family wanted to take him home and care for him there. The team wondered if allowing the ventilator-dependent child to go home was ethical. One member of the team – a father of young healthy children – questioned the use of resources and the stress on the family. He wondered aloud if this was a “life worth living.”

Contemplating his provocative comments, I remember thinking back to the concept of “ballastexistenzen” and a case of Baby Doe.

You might also recall that ballastexistenz is a German term, which was used by the Nazis to describe “dead weight existences”, including individuals with psychological and intellectual disabilities, and extended to any group that did not reflect Arian ideals. Considered burdens to society, they were systematically “euthanized”.

In 1982, Baby Doe was born with Down’s syndrome and a correctable tracheoesophageal fistula. The doctor advised that baby’s life was not worth living and it was in the best interest of family to let the child die of starvation and dehydration. The parents agreed. C. Everett Koop, Surgeon General at the time, took efforts to educate Congress about this issue, which ultimately led to the Baby Doe Amendment that extended the laws defining child abuse to include the withholding of fluids, food, and medically indicated treatment from disabled children

My recollection of these events provided a foundation for my reasoning. And they can guide our reasoning going forward. The concept of ballastexistenz prompts us to continue exploring what it means to be “burdensome” in a 21st -century Western medical setting. Baby Doe reminds us to ask, analyze, and discuss what we mean when we say “quality of life”.

Last fall, I taught a graduate-level course titled “Ethical and Legal Issues in Health Care”. As the semester drew to an end, I came across a news item about a prominent cancer doctor in Michigan who admitted in court to intentionally and wrongfully diagnosing healthy people with cancer . He also admitted to giving them chemotherapy drugs for the purpose of making a profit.

My students included clinicians, hospital executives, and other professionals who were pursuing an MBA with a concentration in healthcare administration. They had spent weeks with me reviewing ethical concepts and codes; and legal theories, cases, regulations, and statutes. In the context of the news item on this doctor, they were versed in the laws of informed consent, common-law battery as applied to health care, statutes proscribing health care and insurance fraud, etc. In the first week of the course, I had also presented a lecture and materials on the historical evolution of medical ethics.

When I presented this case to the class, I was delighted when some of them started the discussion in the 5th century BCE. They reasoned the doctor had only to follow the original Hippocratic Oath, the origin of the trust modern physicians enjoy today, and which introduced the concept of nonmaleficence, one of the four pillars of principlism.

I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel …

It wasn’t a question of informed consent versus paternalism, or of the revenue streams that run through medical practice. If the Michigan doctor had faithfully followed the Hippocratic principles, he would have spared his patients misery, spared him society’s condemnation, and spared harm to society’s trust of physicians.

[The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

How to Die in Canada

by Sean Philpott-Jones, Director of the Center for Bioethics and Clinical Leadership

Last week, our neighbors to the north took a huge step towards legalizing physician aid-in-dying. On Friday, the Supreme Court of Canada unanimously struck down that country’s ban on the practice, suspending two sections of the Criminal Code that outlawed assisted suicide and euthanasia, and ordering the Canadian Parliament and the various provincial legislatures to draft new legislation that would allow physician aid-in-dying.

This is not the first time that Canada has dipped it toe into these treacherous waters. Earlier this year, the Canadian province of Quebec passed Bill 52, also known as ‘An Act Respecting End-of-Life Care’. That Act, which would have taken effect in December, would grant terminally ill Quebecers the right to request a physician’s aid in dying.

In order to qualify for medical assistance in ending their lives, however, these patients must have “an incurable illness that is causing unbearable suffering”. They would have to be in constant and unbearable pain that doctors couldn’t relieve with treatment. The request for aid-in-dying would also have to be made in writing, witnessed by the attending physician, and approved though consultation with a medical team after two doctors determine that the patient is competent to make this request.

The Supreme Court ruling went much further than what Quebec’s law would allow. The nine Canadian justices ruled that physician-assisted suicide should be made available to any competent adult who “clearly consents to the termination of life and has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.”

By including references to disability and psychological suffering, the Court potentially opened the doors not only to those with terminal illnesses, but also those with chronic but not life threatening illness or disabilities, as well as those suffering from mental illness.

It is unclear how Canadian legislators and medical professionals will respond to this ruling, but they will face a number of challenges in devising an aid-in-dying process that will allow seriously ill patients to end their lives peacefully while still protecting their rights and safety.

But this is a Canadian problem, right?. Why should we care what is happening in the Great White North? Rulings by that country’s Supreme Court have no bearing on US law. Moreover, any aid-in-dying process that our neighbors create is likely to be limited to the citizens and residents of Canada, preventing so-called ‘euthanasia tourism’.

But we should care about what’s happening in Canada because the aid-in-dying movement is also becoming an increasingly powerful voice in US medical practice (particularly following the death of Brittany Maynard, the terminally ill 29-year-old who spoke publicly about moving from California to Oregon in order to legally end her life). American policymakers and physicians can learn a lot from watching the Canadian experiment.

Currently, only five states allow physician aid-in-dying: Montana, New Mexico, Oregon, Vermont, and Washington. In three of those states, laws allowing terminally ill patients to request a doctor’s assistance in ending their own lives were passed by popular referendum or legislative votes. Similar legislative bills or public referendums have been proposed in other states, and popular support for physician aid-in-dying is increasing.

Just last November, for instance, Massachusetts’ voters narrowly defeated a referendum called Question 2 that would have legalized physician aid-in-dying in that state. That narrow 51-49 loss occurred only after well funded and politically savvy opponents were able to reframe discussion about the referendum. The public debate about Question 2 became less about the rights of the terminally ill and more about potential abuses of the disabled and the elderly. But recent polls suggest that nearly two-thirds of voters in the Bay State now support physician aid-in-dying, and a new bill to legalize the practice is currently winding its way through the Massachusetts legislature.

Those of us who live in the Empire State may never get a chance to vote on physician aid-in-dying as New York does not have a popular initiative and referendum process. Efforts have been made to introduce aid-in-dying bills in the state legislature, but these bills face an uphill battle due to strong opposition by religious groups, disability advocates and conservative lawmakers. But this doesn’t mean that physician-assisted suicide won’t soon be legal in New York.

As with Montana and New Mexico, physician aid-in-dying may become legal in New York via court ruling. Just last week, a group of terminally ill patients and clinicians filed a lawsuit asking the New York Supreme Court to invalidate the state’s current prohibition on assisted-suicide.

Currently, a doctor who prescribes a fatal dose of medication to a terminally ill patient can be prosecuted for manslaughter under New York’s Assisted Suicide Statute, which makes it a crime to “intentionally cause or aid another person to commit suicide.” To date, no doctor has ever been prosecuted under this statute. Despite this, the plaintiffs argue that current assisted suicide laws violate the equal protection clause of the State Constitution. For example, physicians are already help some terminally ill patients die (by removing life support) but they cannot help patients who do not rely on continuous medical intervention to live.

Whether or not the New York Supreme Court will rule for the plaintiffs in this case remains to be seen, but the tide of public opinion is clearly shifting in favor of physician aid-in-dying. Physician aid-in-dying may not become the law of the land in New York anytime soon (be it by legislative action or judicial fiat), we need to start talking about it.

No matter which side of the debate you are on — either for or against physician aid-in-dying — we need to have a thoughtful and respectful discussion about dying, about the rights of the terminally ill, and about the role that physicians should play in helping patients attain a peaceful death. And we should watch the Canadian experiment carefully (and the experience of Montana, New Mexico, Oregon, Vermont, and Washington), and learn from their success and mistakes.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on February 12, 2015, and is available on the WAMC website. The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]