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Feminist Approaches to Medical Aid in Dying: Identifying a Path Forward

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New Directions in the Ethics of Assisted Suicide and Euthanasia

Part of the book series: The International Library of Bioethics ((ILB,volume 103))

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Abstract

This essay addresses feminist approaches to medical aid in dying (MAID), considering whether it is a practice that should be supported for women and other marginalized groups. Some feminists have raised rights and justice-based arguments in support of MAID; others have taken a care-based approach to suggest that the practice violates relationships of care and only worsens distrust between marginalized groups and the medical establishment. I argue that we need to adopt both justice and care approaches to develop a robust feminist account of MAID. I defend a woman’s right to choose death in cases of terminal illness or suffering but argue that relational concerns of care, trust, and trustworthiness must be addressed at the same time to ensure that MAID is justly practiced and accessible to all those who want it.

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Notes

  1. 1.

    I will adopt the term medical aid in dying (MAID) as used by the group Compassion and Choices to refer to the practice in which terminally ill patients voluntarily take life-ending medications, thus accessing the means to end their own lives. By using this terminology, Compassion and Choices distinguishes medical aid in dying from euthanasia. On their website they note that “While both practices are designed to bring about a peaceful death, the distinction between the two comes down to who administers the means to that peaceful death. Euthanasia is an intentional act by which another person (not the dying person) administers the medication. By contrast, medical aid in dying requires the patient to be able to take the medication themselves and therefore always remain in control. Euthanasia is illegal throughout the United States” (https://compassionandchoices.org/resource/assisted-suicide/). This terminology is like Canada’s, which refers to medical assistance in dying (MAiD). Yet in Canada, MAiD includes the act by a physician or nurse practitioner of directly administering a substance that causes death, such as an injection of a drug. For the purposes of my argument, the person who applies the means of death is not a central concern, since my focus is on the grounds for supporting medical aid in dying for women, and not who fulfills it. In this paper I will adopt the acronym MAID to refer generally to the act of aiding or assisting terminally ill or suffering patients in achieving their death. My paper will limit itself to the current laws in the U.S. and Canada. However, my comments concerning MAID address general feminist concerns relating to the practice and its impact on women globally.

  2. 2.

    The article in this collection by Christopher Riddle specifically addresses concerns about disability in medical aid in dying. But as feminists like Kimberle Crenshaw have long observed, individuals have complex and multiple identity points such that they may experience discrimination based on more than just one identity (Crenshaw 1989). My feminist analysis in this paper will address concerns with race, disability, and other marginalized identities because they impact women’s use of (and perspective on) MAID in important ways.

  3. 3.

    Note that Laws’s terminology is inaccurate in the U.S. context, since as the Compassion and Choices website notes, “Medical aid-in-dying laws on the books in California, Colorado, the District of Columbia, Hawai’i, Maine, Oregon, Vermont and Washington expressly state: ‘Actions taken in accordance with [the Act] shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide.’ And in Montana, where assisted suicide is specifically illegal, the Montana Supreme Court ruled in Baxter v. Montana that medical aid in dying provided to terminally ill, mentally competent adult patients in no way violates established state law [including Montana’s assisted suicide statute] or the principles of public policy.” (https://compassionandchoices.org/resource/assisted-suicide/).

  4. 4.

    Note that even if these factors are in play to some degree when a patient invokes MAID, I do not think that should automatically eliminate MAID as an option if the patient is seriously ill and experiencing unremitting suffering. This will be addressed in more detail later in this paper.

  5. 5.

    Indeed, feminist bioethicists are concerned about these issues and much feminist literature addresses issues of access to health care for marginalized patients. See Sherwin (1992), Wendell (1996), and Rogers (2006) as examples of this literature.

  6. 6.

    This issue for elderly women of surviving their partners and living in isolation and loneliness was especially acute during the Covid-19 pandemic. The need to shut down nursing homes in order to contain the spread of the virus had seriously damaging physical, emotional, and psychological effects for the nursing home resident population. See Parks and Howard (2021) for more on this.

  7. 7.

    Studies have determined that in the clinical setting Black patients experience biases against their pain claims to a much higher degree than white patients. See Hoffman et al. (2016), Meghani et al. (2012), Mende-Siedlecki et al. (2019). Since Black women’s experiences intersect race and gender, commentators raise concerns about the way they may encounter unique forms of pain bias based on the combination of their race and gender. See Bassett (2021), Harrigan-Farrelly (2022), Omeish and Kiernan (2020). More studies are needed to address the intersections of race and gender where pain bias is concerned. Research has established that pain bias affects the care of women and Black patients, but little has been done to address how the intersecting identities of being Black and female may worsen the biases they experience.

  8. 8.

    In researching this paper, I could find no studies that address the impact that pain bias (or other factors, such as loneliness or greater longevity) might have on women’s access to or requests for MAID. The data on women and pain bias alone does not support the claim that women will be more likely to be assisted in dying. Since women experience a credibility deficit where pain is concerned, there is no reason to think their reports are more believable—and more likely to be given uptake—than men’s. One might still think that women’s un-treated or under-treated pain might drive them to request MAID. But “Multiple studies have shown that most patients who seek MAID do so not because of unrelieved symptoms, such as chronic pain, but because of more existential suffering, such as loss of autonomy and an inability to enjoy life” (Weiss 2018, 249).

  9. 9.

    Indeed, 2021 data reported from the Oregon Death With Dignity Act indicates that women are not over-represented in the number of patients who have died from ingesting a lethal dose of medication. On the contrary, in 2021 out of 238 cases of MAID, 133 (55.9%) were men and 105 (44.1%) were women. And in 2020, out of 259 cases 131 (50.6%) were men and 128 (49.4%) were women. In total, since the Death With Dignity Act began collecting data, 53% of deaths have been men and 47% have been women (Oregon Health Authority Public Health Division 2021).

  10. 10.

    Note that “testimony” in this case does not refer to an individual giving evidence in court; rather, it refers to the general practice of speaking, reporting and offering observations. In the case of women, I am arguing that testimonial injustice is committed because they are denied believability based partly on gender norms that depict women as flighty, unreliable, hypersensitive and demanding.

  11. 11.

    While some men suffer from chronic fatigue syndrome, the large proportion of CFS patients are women. Studies indicate that women are 3–4 times more likely than men to have the condition (US Institute of Medicine 2015; Faro et al. 2016) and that “patients do not know how to describe their condition to themselves or others” (Fennell et al. 2021).

  12. 12.

    Of course, addressing justice in health care requires ensuring that everyone has a substantive right to certain goods—like decent health care, access to palliative and hospice care, access to medical aid in dying, etc. Buchbinder’s account recognizes the connection between justice and rights, but she adopts an approach that rejects a “thin” formal approach to rights. Thus, the title of her article (“Access to Aid-in-Dying in the United States: Shifting the Debate from Rights to Justice”) is somewhat misleading because she is concerned with rights, and she doesn’t separate rights from justice; she just demands a more substantive view of rights in the context of MAID.

  13. 13.

    The problem is that there are a variety of reasons that could explain why few minorities are taking advantage of MAID (where legal) in the U.S. Minority groups might reject MAID for religious or cultural reasons, for reasons of distrust, or because they are not properly informed of the option. More research is required to determine which of these factors is impacting the use of MAID by minority groups to determine if there are equal access issues.

  14. 14.

    Indeed, Buchbinder acknowledges this concern and notes that “Some racial and ethnic minority groups, particularly African Americans, harbor deep mistrust of hospice and palliative care and prefer aggressive end-of-life treatment. Among patients holding such views, access to AID will not be desirable, and different patterns of access will not raise justice concerns” (2000, 757).

  15. 15.

    Not Dead Yet (NDY) represents a disability rights perspective on MAID, but not the perspective on this issue. Disability theorists who reject the claims of NDY claim that denying people with disabilities the right to make end of life decisions is unjustified paternalism that treats them in exactly the infantilizing ways to which NDY objects. See, for example, Silvers and Francis (2016) and Riddle (2017). Downie and Schuklenk (2021) also question whether vocal groups like NDY can speak for all persons with disabilities, given that two of the cases that prompted the revised Canadian law were patients with disabilities who were petitioning for MAID access using equal protection concerns.

  16. 16.

    See Kaiser Family Foundation report (2021): https://www.kff.org/racial-equity-and-health-policy/issue-brief/covid-19-cases-and-deaths-by-race-ethnicity-current-data-and-changes-over-time/ [Accessed December 3, 2021].

  17. 17.

    Pullman’s account of care ethics draws on Gilligan’s empirical claims about women’s different moral sensibilities to argue that pro-MAID feminists are failing to speak in that “different” voice. Yet Gilligan’s empirical claims regarding women’s moral orientation toward care and the care perspective have been roundly criticized by some scholars who see it as essentializing and reductive of women’s perspectives. See Pollit (1992) and Senchuk (1990) as examples of such criticisms. By contrast, when I appeal to care ethics in this paper I will be referring to it as a feminist stance that challenges rights-based approaches to MAID, one that emphasizes the relational nature of autonomy and the social and political value of care and caregiving relationships.

  18. 18.

    For excellent accounts of care in the social/political context, see Kittay (1999) and Tronto (2013).

  19. 19.

    This is a feminist issue because, within each marginalized group, women tend to represent the worst-off members of those groups. For example, Black and Hispanic women and women with disabilities tend to fare worse than men from those same groups when various factors are assessed, such as income, education, and other factors. According to the U.S. Bureau of Labor Statistics (2021), Black women’s average weekly salary in 2020 was $764 compared to Black men’s average of $830. And the Department of Labor Office of Disability Employment Policy (2021) reports that for 2021, 24.7% of disabled women between the ages of 25–54 lived below the federal poverty level versus 20.9% of disabled men.

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  1. Department of Philosophy, Loyola University Chicago, Chicago, IL, USA

    Jennifer A. Parks

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Correspondence to Jennifer A. Parks .

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  1. School of Philosophy, Psychology, and Language Science, University of Edinburgh, Edinburgh, UK

    Michael Cholbi

  2. Department of Philosophy, Contemporary History, and Political Science, University of Turku, Turku, Finland

    Jukka Varelius

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Parks, J.A. (2023). Feminist Approaches to Medical Aid in Dying: Identifying a Path Forward. In: Cholbi, M., Varelius, J. (eds) New Directions in the Ethics of Assisted Suicide and Euthanasia. The International Library of Bioethics, vol 103. Springer, Cham. https://doi.org/10.1007/978-3-031-25315-7_14

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