Social Science & Medicine 289 (2021) 114366

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

“Reflection and soul searching”: Negotiating nursing identity at the fault

lines of palliative care and medical assistance in dying
David Kenneth Wright a, *, Lisa S. Chan b, Jennifer R. Fishman c, Mary Ellen Macdonald d
a
School of Nursing, University of Ottawa, Roger Guindon Hall, 1480C-451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada
b
Palliative Care and Nursing Ethics Hub, Centre for Research on Health and Nursing, University of Ottawa, Roger Guindon Hall, 1118C-451, Smyth Rd, Ottawa,
Ontario, K1H 8M5, Canada
c
Biomedical Ethics Unit and Department of the Social Studies of Medicine, McGill University, 307-3647, Peel Street, Montréal, Québec, H3A 1X1, Canada
d
Faculty of Dentistry, McGill University, 530-2001 McGill College Avenue, Montréal, Québec, H3A 1G1, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: Authorities within the field of palliative care frequently espouse that assisted death is – and must remain –
Medical assistance in dying separate from palliative care. This fault line, between palliative care and assisted death, has important impli­
Euthanasia cations for how we enact end-of-life care, particularly in jurisdictions where assisted death is legal. And yet little
Palliative care
is known about how direct-care clinicians providing palliative care navigate this demarcation in everyday
Nursing
practice. This qualitative study reports on semi-structured interviews with 22 palliative care nurses from across
Feminist ethics
Qualitative research Canada, where assisted death was legalized in 2016. Although a minority of participants did express categorical
Canada opinions around the (non) legitimacy of assisted death as an ethical end-of-life care option, most engaged in an
ongoing and sometimes painful process of questioning and self-examination. Their ethical reflections were more
nuanced than simply dismissing MAiD as incompatible with palliative care philosophy; yet this idea of in­
compatibility weighed heavily as they reasoned through their experiences and questioned their own perspec­
tives. Nurses described grappling with the finality of assisted death, which contradicts their belief in the telos of
palliative care; when adequately resourced, palliative care should be available to support people to live well
before death. At the same time, commitment to important palliative care values such as the non-abandonment of
dying people and respecting peoples’ individual end-of-life choices reveal the possibility of overlap between the
ethos of assisted death and that of palliative care nursing. Drawing on scholarship in feminist ethics, our study
sheds light on the moral identity work that assisted dying catalyzes amongst palliative care nurses. We highlight
what is at stake for them as they navigate a delicate tension in responding ethically to patients whose suffering
motivates an interest in assisted death, from within a wider professional collective that upholds a master
narrative about the incompatibility of assisted death and palliative care.

1. Introduction different assisted death practices, such as voluntary euthanasia (assisted

Worldwide, the assisted death movement is growing. It is currently
legal to deliberately cause or facilitate the death of a person, at their
explicit request and under specific conditions, in an increasing number
of jurisdictions around the world, including in Belgium, the Netherlands,
Luxembourg, Switzerland, Columbia, New Zealand, and certain states
within the USA and Australia. In many other countries where assisted
death is not (yet) legal, it is an active topic of social and legislative
debate such as in the United Kingdom (Davis, 2019). Jurisdictions
around the world draw various legal and ethical distinctions between
death that is clinician administered) and assisted suicide (assisted death
that is self-administered). With the exception of Switzerland, which al­
lows non-clinicians to provide assistance in dying, the social and cultural
legitimacy of assisted death typically requires it to be located within a
medical framework (Karsoho et al., 2016). In Canada, assisted death was
legalized as a medical practice in 2016. Although Canada’s law allows
for both assisted death that is self-administered (via oral substance) or
clinician administered (via intravenous solution), the two modes in this
country are collapsed under one practice – medical assistance in dying
(MAiD). They share identical eligibility criteria, safeguards, and

* Corresponding author.
E-mail addresses: dk.wright@uottawa.ca (D.K. Wright), nursing@uottawa.ca (L.S. Chan), jennifer.fishman@mcgill.ca (J.R. Fishman), mary.macdonald@mcgill.ca
(M.E. Macdonald).

https://doi.org/10.1016/j.socscimed.2021.114366
Received 21 December 2020; Received in revised form 22 August 2021; Accepted 1 September 2021
Available online 3 September 2021
0277-9536/© 2021 Published by Elsevier Ltd.
D.K. Wright et al. Social Science & Medicine 289 (2021) 114366

reporting requirements. Further, although both modes are technically patient until the day of the procedure when the patient is transferred
permissible under one regulatory framework, in practice MAiD is almost off-site. (Mellett, 2020, p. 46)
always clinician administered (Government of Canada, 2020).
These demarcations have important consequences for palliative care
In their most recent position statement on assisted death, the Inter­
patients, their families, as well as for palliative care programs and health
national Association for Hospice and Palliative Care (IAHPC) provides
care professionals. For example, a palliative care provider’s individual
the following definitions for euthanasia: “A physician (or other person)
objection to MAiD may cause them to lose a patient’s trust (Mathews
intentionally ending the life of a person by the administration of drugs,
et al., 2020); and a freestanding hospice’s refusal to provide MAiD might
at that person’s voluntary and competent request”; and physician-
threaten the trust they hold of an entire community (e.g., Hamil­
assisted suicide (PAS): “A physician intentionally helping a person to
ton-McCharles, 2020). Meanwhile, many palliative care programs rely
terminate his or her life by providing drugs for self-administration, at
on charitable donations to operate, which in some cases may be
that person’s voluntary and competent request” (De Lima et al., 2017, p.
contingent on not practicing MAiD. In other designated settings, such as
3). MAiD in Canada is consistent with each of these definitions, with the
palliative care units within publicly funded hospitals, the boundaries
additional precision that in Canada, the clinician administering or
can be more subtle. While an outright refusal to provide MAiD may not
providing the life-ending drugs is either a physician or a nurse
be legally allowed in such settings, individual palliative care pro­
practitioner.
fessionals may nevertheless put limits on their involvement in MAiD
Working from these definitions, the position of the IAHPC is that “no
practices, if they feel that MAiD contradicts their philosophy of practice.
country or state should consider the legalization of euthanasia or PAS
In conversations with colleagues as we prepared this research study, a
until it ensures universal access to palliative care services” (De Lima
nursing leader told us about the first MAiD administered on the dedi­
et al., 2017, p. 1). In countries where these practices are already legal,
cated palliative care unit of their hospital. The unit nurses had provided
such as Canada, the position of the IAHPC is that “palliative care units
routine care to the patient throughout the morning of their death, and
should not be responsible for overseeing or administering these practices
they would be the ones to provide post-mortem care once the MAiD was
as doing so would place the professionals, their staff and, in some cases,
administered. But they did not want to be in the room during the MAiD
their patients and families, in untenable positions” (p. 5, emphasis added).
procedure itself, which would be administered by an outside practi­
The authors of this statement situate their position in reference to the
tioner. During the MAiD procedure, the unit nurses gathered together in
WHO definition of palliative care, which “regards dying as a normal
the nursing station. They supported and comforted each other during
process and emphasizes that palliative care never intends to hasten nor
what was described as a difficult and emotional moment.
postpone death. Euthanasia and PAS are in direct conflict with this
A recent interview study with nurses about their experiences with
definition” (p. 5).
MAiD (from a variety of settings, including but not specific to palliative
A recent systematic scoping review of the relationship between
care) confirms the relationship between palliative care and MAiD can be
assisted dying and palliative care, in jurisdictions where assisted dying is
a conflictual one (Pesut et al., 2020a). While nurses reported the tension
legal, expands understanding around the intricacies of this relationship
between palliative care and MAiD seemed to be easing over time, they
(Gerson et al., 2020). Belgium is the only jurisdiction where this rela­
remained disturbed by certain palliative care practitioners whom they
tionship is described as integrated and synergistic, but available litera­
perceived to directly interfere with patients’ access to MAiD, for
ture does not contain any detail about how this synergy is enacted in
example by ignoring patient requests, or alternatively, to withdraw
practice (Gerson et al., 2020). Studies from other jurisdictions (United
palliative care services once a decision for MAiD was made. Such
States, Switzerland, and a single Canadian study), “paint a more com­
withdrawal was unconscionable to nurses. In the words of one partici­
plex picture of shifting relationships between assisted dying and palli­
pant, “we have a serious practice issue here. I’m mad as hell.” (Pesut
ative care” (Gerson et al., 2020, p. 1299). In Canada, the leadup to
et al., 2020a, p. 5).
legalization saw many palliative care leaders publicly declare their op­
Palliative care nurses are nurses for whom palliative care philosophy
position. For example, the opening line of a 2015 news article, published
and practice are the primary focus of their role. In Canada, such nurses
by the Canadian Medical Association Journal, states that: “Dying Ca­
work in a variety of settings; they require specific and advanced
nadians should not assume palliative care doctors will assist them if they
knowledge in symptom assessment and management, end-of-life care,
choose to end their lives because the majority of those currently prac­
loss, grief, and bereavement, as well as in ethical and legal issues related
tising don’t want that role” (Eggertson, 2015). Since legalization, some
to death and dying (Canadian Nurses Association, 2019). As Canada and
designated palliative care settings in Canada, such as certain free­
other jurisdictions navigate new policies around assisted death, these
standing residential hospices, have refused to provide MAiD on the basis
nurses find themselves at the nexus of two opposing social forces: an
that it contradicts palliative care philosophy. A boundary is thus
increasing expectation amongst the general public and health policy
apparent, ideological as well as practical, between palliative care and
makers for MAiD to be recognized as a legitimate and necessary option
assisted death. Mellett (2020), for example, conducted a comparative
for end-of-life care, and a disciplinary discourse that rejects MAiD as
study of two Canadian hospices, one which allows MAiD to occur on site,
incompatible with the foundational values of palliative care philosophy.
and another that does not. Across Mellett’s descriptions of each of these
The knowledge and expertise that palliative care nurses embody through
two sites, sharp demarcations are evident:
their everyday work with dying patients and families suggests they hold
At Site 1, MAID is allowed on site, though both patient assessments important perspectives on the ethics of end-of-life care. These nurses’
for MAID and the procedure itself are carried out by an external team proximity to dying patients also indicates that irrespective of whether
operated by the provincial health authority. Except for a manager they choose to participate in MAiD administration, they will inevitably
who acts as a liaison between the [health authority] and hospice be involved more generally in caring for MAiD patients (Mathews et al.,
teams, hospice staff are not involved in the provision of MAID. 2020). It is therefore vital that we understand the perspectives of
Should a hospice patient request MAID, hospice staff direct the pa­ palliative care nurses, as they negotiate their moral identity in relation
tient to the [health authority’s] MAID website. Moreover, as per to MAiD.
hospice policy, hospice staff will not bring up the option of MAID
with a patient.
1.1. Moral identity and feminist ethics
Site 2 does not allow MAID on-site. Patients who request MAID are
transferred off-site to receive the procedure. Staff may help the pa­ Our use here of moral identity reflects a theoretical perspective of
tient start the paperwork, and will continue to provide care for the nursing scholars who study the ethical landscapes of nursing practice –
and the ethical lives of nurses themselves – from a perspective of

2
D.K. Wright et al. Social Science & Medicine 289 (2021) 114366

feminist ethics. According to Peter and Liaschenko (2013), moral agents, palliative care nurses will hold the identities of vulnerable patients and
including nurses, are: families who explore and potentially choose MAiD, and how the field of
palliative care will, in turn, hold the identities of its nurses, as they
… embodied beings whose identities are shaped by the historical
practice within this new landscape.
circumstances of their lives and the master narratives of those periods
that set boundaries on who can be what kind of person and why. As
2. Methods
such, identities are key in feminist ethics. (p. 339, emphasis added)

As assisted death becomes integrated into landscapes of end-of-life
care, palliative care nurses are challenged to determine whether, how,
and to what extent their field should take responsibility for the care of
patients requesting and/or receiving this option. These nurses’ moral
reasoning and actions will occur from within the multiple and poten­
tially conflicting positions that they occupy. For example, palliative care
nurses are both individual caregivers who develop unique insights about
their patients’ suffering, including patients contemplating MAiD, given
their close proximity to them and to their families over the course of a
24 h day (Malone, 2003; Wright and Brajtman, 2011). At the same time,
palliative care nurses belong to a wider professional community that
upholds a master narrative about the incompatibility of MAiD and
palliative care. As Lindemann (2019) writes in her Invitation to Feminist
Ethics, “Identities are social constructions. They are multiple; people
have more than one at a time. They are relational—that is, they are
always connected to other identities within a social web. They are often
unchosen” (p. 54).
Our feminist approach to research about MAiD aims to expose and
scrutinize the social and political power dynamics at play in palliative
nursing, which, in turn, aims to foster epistemic justice (Fricker, 2007).
For example, around the time that MAiD was just becoming legal, some
of us attended a meeting with an influential and well-respected pallia­
tive care leader, who flatly stated that upon legalization, any clinician
who might participate in MAiD would lose all credibility in calling
themselves a palliative care practitioner. Although this person had no
legal or professional authority over other providers, their cultural power
was clear. This statement caused us to wonder, and worry, about the
freedom that palliative care nurses would have to explore the ethics of
MAiD with openness and curiosity. Feminist ethics can be an avenue
toward such freedom by taking seriously the perspectives of nurses, who
might critically question the status quo, and by recognizing their
epistemic credibility within a community of knowers who, together,
constitute the wider landscape of end-of-life care (Lindemann, 2019;
Morley et al., 2021).
According to Peter et al. (2018), “Our identities are relational
because they are developed and maintained through interactions with
other people who ‘hold’ our identities” (Peter et al., 2018, p. 326,
emphasis added). Here, Peter and colleagues are speaking about all of us
(e.g., nurses, patients, families), and the ways in which our identities are
The purpose of our research is to understand how palliative care
nurses negotiate their moral identity in relation to MAiD. Our analysis in
this paper focuses on how nurses’ espoused moral commitments inter­
sect with a broader master narrative, that palliative care does not
include MAiD.
For this qualitative research study, we invited a sample of Canadian
palliative care nurses to discuss their ethical understandings of assisted
death in the aftermath of its becoming a legal end-of-life care option. We
recruited participants with announcements circulated through the Ca­
nadian Palliative Care Nursing Association and the Canadian Nurses
Association. Twenty-two palliative care nurses from across Canada
participated in individual semi-structured telephone interviews, ranging
in length from 46 to 122 min (average interview length was 83 min),
which were then transcribed verbatim for analysis. Our sample included
nurses from the Canadian provinces of British Columbia, Alberta,
Ontario, Québec, New Brunswick, Nova Scotia, and Prince-Edward Is­
land. Participants had worked in a dedicated palliative care role for an
approximate average of 14 years (range 3–33) and in nursing more
generally for an approximate average of 27 years (range 8–47). Most
participants worked full-time, were engaged in a primarily clinical role,
were university educated, and held specialty certification in hospice
palliative care nursing. The different settings of palliative care provision
represented in our sample were home care, acute care, long-term care,
hospital palliative care unit, and freestanding palliative care residence
(hospice). See Table 1 for a demographic overview of the sample.
Because of our theoretical focus on moral identity (Liaschenko and
Peter, 2016; Peter and Liaschenko, 2013; Peter et al., 2018), we began
our interviews by asking participants what being a palliative care nurse
means to them. We asked them to reflect on their values, as palliative
care nurses, and about the implications of these values for their feelings
about the legalization of MAiD in Canada. We asked them about how
Table 1
Participant demographics (n = 22).
Average age in years 52 (range 30–69)
Gender 21 Women; 1 man
Regions represented Western Canada (9)
Eastern Canada (8)
Atlantic Canada (5)

affirmed or damaged within the relationships that we inhabit. They

–
Urban/Suburban (10)
explain that when identities are held well, for example through mutual Rural (3)
recognition, people flourish; when they are held badly, for example by Both urban and rural (9)
being labelled as morally inferior, people are harmed. This ‘holding’ of Average years worked as a nurse 27 (range 8–47)
Average years worked in 14 (range 3–33)
identity is reciprocal – nurses hold the identities of their patients
palliative care
through the care they offer; and through their responses to this care, Highest education Diploma or Associate degree in Nursing (7)
patients hold the identities of their nurses. Nurses’ identities are also Bachelors in Nursing (9)
held by other people with whom they interact, such as colleagues, and Master’s or other postgraduate degree (6)
by master narratives about nurses and nursing practice. As Liaschenko National certification in hospice Yes (16)
palliative care nursing No (6)
and Peter (2016) explain:
Setting of palliative care practice Hospice or palliative care unit (8)
Acute care hospital (2)
Master narratives are cultural stories that function as summaries of
Community (7)
shared social understandings that represent the norms and expecta­ Works across settings (5)
tions we have of situations and groups we encounter. While not Type of role in palliative care Direct care nurse in community or hospital
necessarily negative, these become unconsciously internalized by the (5)
group, becoming prescriptive in that they come to direct the values Clinical nurse specialist (2)
Nursing administrator (6)
and practices of the group (p. S19). Other (e.g. palliative care consultant,
resource nurse, coordinator, educator) (9)
Applying these ideas to the context of MAiD and palliative care
Employment status Full time (17)
nursing raises important questions. At stake are whether and how Part time (5)

3
D.K. Wright et al.
MAiD had affected the context of their practice (including their own
workplace as well as the larger professional field of palliative care
nursing), and about any specific experiences caring for patients
requesting and/or receiving MAiD. Our interview guide was developed
and revised in consultation with a small group of palliative care nurses
from various Canadian provinces, with input from the Canadian Nurses
Association and the Canadian Palliative Care Nursing Association. It was
also pilot tested with a nurse researcher and palliative care program
administrator, outside of our research team.
Interviews were conducted by the second author and analyzed as a
team. Our analytic process was one of continuous dialogue about the
interview data within our team. We synthesized the interview text to
highlight any ethical arguments articulated, narrations around specific
nursing values, responsibilities, and relationships relevant to MAiD, and
the emotional tone of the interview. We moved back and forth between
these syntheses and the data as a whole, in order to ensure that our
emerging conceptualizations remained faithful to the ‘bigger picture’ of
what participants had shared with us. We focused on the ways that
participants spoke about MAiD in relation to their patients, their col­
leagues, the public, professional nursing, and the field of palliative care.
We kept track of specific ways that participants’ experiences of and
perspectives about MAiD appeared similar to or different from one
another, the extent to which individual participants appeared to claim
an ethical ‘stance’ in relation to MAiD, and the nuances apparent within
these stances.
As a team, we pushed each other to think both within and beyond our
original theoretical ideas that framed our entry to this topic, to even­
tually arrive at an understanding about how palliative care nurses
appeared to be negotiating their moral identity in relation to MAiD in
Canada.
Given the sensitivity of this topic, confidentiality was a key consid­
eration in this project. In writing our findings, we aimed for a balance
that would successfully engage the reader in coming to know the per­
spectives and experiences of our participants, but without compromising
their privacy by including more narrative detail than necessary. Here
too, the involvement of multiple authors in reviewing data and its pre­
sentation was helpful in striking this balance. Also to protect privacy, we
chose not to associate the individual passages that appear in this paper
with participants’ specific role or geographic location. The passages
presented below are from interviews with nurses from each of the seven
provinces that were included in our sample.
Nurses interested in the study contacted us via email for information.
At this point, they were sent study information including the consent
form. Once they confirmed their interest, a telephone interview was
scheduled. At the time of interview, verbal consent was obtained from
all participants. This study received ethical approval from the Research
Ethics Board of the University of Ottawa.
3. Results
3.1. Grappling with the finality of MAiD
All participants believed that the ultimate purpose of palliative care
is to promote quality of life and to alleviate suffering – this is its ‘raison
d’être’. Working toward these values means that nurses focus on life and
living, at least as much if not more than on dying and death. For many
participants, this focus feels subversive in the face of a wider healthcare
culture that dismisses the lives and circumstances of dying people who
are suffering as beyond help – an attitude that, as the quote below
suggests, can be internalized by patients themselves.
Our people come to live with us, they don’t come to die … I’ve seen
people with horrible illnesses … where they want MAiD … they’ve
come to us for pain and symptom control and after spending a few
days with us, completely reverse their decision [about MAiD],
because they had no idea that they could be helped.
4
Social Science & Medicine 289 (2021) 114366
This passage demonstrates a stance of resistance against wider social
discourses of helplessness that, in the opinion of the participant,
marginalize dying people. Other participants echoed such a resistant
stance, for example by countering prevalent attitudes that there is not “a
lot to do” for dying people.
The idea is that we want to promote quality of life, our focus is on life
and living. This is what we say all the time. It’s kind of like … our
mantra. … I’m sure if you ever worked in a hospital … people will
say something along the lines of like, ‘Oh they [patient] are “com­
fort” now … meaning like, we don’t have to do a lot for them. When
in actual fact, it’s the opposite … this is a time in that patient and
family’s life where they need the most care … From my perspective
as a palliative care nurse, [that] is when they’re the most vulnerable
… they’re requiring your best efforts … [we] need to talk about how
they’re feeling and how we can make things better.
For participants in our study, enacting a palliative care ethos means
recognizing the end of life as a valuable period filled with meaning.
Palliative care is about accompanying the dying … accompanying
the person, helping them through that, that whole process. I
personally believe there is great meaning to be derived from that part
of the journey … I see that time as valuable.
Participants explicated the ways that palliative care helps people to
take advantage of this time, for example by supporting patients to
“enjoy” their life before it ends, and by supporting grieving families to
gradually integrate the reality of their loved one’s forthcoming death.
From this standpoint, participants grappled with the finality of MAiD. At
issue here is not the permanency of death itself. Death is, after all, the
ultimate finality, which palliative care nurses are accustomed to and
comfortable with. Rather, participants expressed difficulty with the
irreversibility that MAiD introduces into dying trajectories that feel, to
them, unfinished.
… palliative care nurses … we’ve had many experiences of people
like this [where suffering improves as a result of palliative support]
… that was, that was our difficulty with it [MAiD] … it was very
difficult to accept.
One participant expressly used a language of grief to articulate this
difficulty, which led us to consider the wider relevance of this concept
for what other participants were experiencing. When attending forums
about end-of-life care, in which stories about MAiD are presented as an
ethical response to intolerable suffering, she noticed that a fulsome
representation of what palliative care is able to achieve, when
adequately resourced, was sorely lacking. This gap in wider narratives
about MAiD (i.e., outside of palliative care), was “heartbreaking” for this
participant:
I think I feel grieved that it [MAiD] is an opportunity missed, an
opportunity lost. … you heard story after story about nurses seeing
people like this [with intolerable suffering] and [you think] well,
MAID would be a good answer. Because I would never want to see
somebody suffer like that. And it was heartbreaking because … it was
heartbreaking because [those stories are] such a poor representation.
That was such a missed opportunity and a poor representation of
what palliative care could do if it was given the opportunity. I mean
my heart just broke when I heard those stories because I agree with
them, nobody should be put in that position. It’s one of the reasons
why I went into palliative care.
The caveat above, about the potential of palliative care to alleviate
suffering when adequately resourced, came through strongly in our in­
terviews. One participant, for example, suggested that patients’ interest
in MAiD sometimes arises from an unwillingness to burden family
caregivers, who are unsupported within the current system. For this
participant, this under-resourcing of services for family caregivers
D.K. Wright et al.
represents a failed promise of palliative care.
We wanted to encourage people to die at home, we created hospices,
we created a philosophy, and what we didn’t do was invest in the
resources required to actually carry out the philosophy that was
created. We promised the public that we would do that. So now …
people are suffering at the end of their life, and we didn’t give them
what they need … my patients have said … they want to end their life
because … their heart can’t handle watching their family suffer
because the family has now the burden of their total care.
Thus, grief provoked by the finality of MAiD is also, in part, grief over
inadequate end-of-life care. For palliative care nurses, improving access
to palliative care is an ongoing and unfinished project. Grappling with
the finality of MAiD requires nurses to accept a patient’s personal choice
to put an end to their own suffering by having their life ended, against a
spectre that such suffering may itself have resulted from the failed
promise of palliative care.
3.2. Dominant voices around MAiD
As MAiD was legalized, participants were working within teams that
needed to develop protocols and practices in response. Participants
described this period of adjustment as happening within a context of
strong normative messaging – both supportive of and oppositional to
MAiD – in their own professional and practice communities. One
participant worried about how others within palliative care would
perceive her, were she to ‘out’ herself as supportive of and available to
patients who pursue MAiD. In speaking about a specific palliative care
leader in her region, she reflected that:
[that person is] probably [the] voice for palliative care within our
[community]. So they’re going around … writing a letter … saying
they’re against [MAiD] having anything to do with [us]. And then
when you’re put in a situation where you’re present [with a patient
receiving MAiD], you know, you’re going against them.
This passage illustrates a recurring theme within our interviews, a
preoccupation with the social consequences that could result from
having or expressing dissenting perspectives about the ethics of MAiD
within palliative care.
I felt … very suppressed and very quiet initially, because the voices
were so loud in opposition that there didn’t feel like there was space
for people to say, you know maybe there is a role [for us] in this and
maybe we are part of it. Because we actually have the skills that
could be extremely helpful in going through this [MAiD] process
with people.
Importantly, discomfort over holding unpopular opinions manifest in
different directions, depending on the overarching attitude within the
local contexts of participants’ practice. The above-mentioned examples
describe participants who felt silenced from expressing support for
MAiD within a climate of opposition. Conversely, other participants felt
they were denied the opportunity to voice ethical misgivings about
MAiD. This diversity is not surprising, considering that palliative care
nursing is provided across a range of different settings, for example
within dedicated palliative care teams (e.g., hospices) in which a uni­
fying palliative care ethos may be present, and within more acute
medical teams, in which lone nurse specialists may be the only team
member with palliative care expertise. Further, as described earlier,
even within specialist palliative care, different settings adopt different
approaches to MAiD (e.g., some allow it on site, others do not). In the
following passage, a nurse describes feeling silenced in expressing an
ethical opposition to MAiD, while working with colleagues who are less
experienced in palliative care philosophy.
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Social Science & Medicine 289 (2021) 114366
On our team, I have the most experience as the palliative care
specialist … I have the most years of experience and the most specific
hospice palliative care training … In Canada you can practice in
palliative care but not have to have training behind that. And so I
work actually with a lot of professionals who don’t have the addi­
tional certification in hospice palliative care nursing or they don’t
have additional courses in palliative care … When MAID was
introduced … at least in my team, there was a large assumption that
we were all good with it … that this is client-centered care and that
this is what we should have been doing all along. That was the ma­
jority of voices. That was the voice and that was the message that was
coming from leadership. And when that’s the prevailing emphatic
voice coming through at your team meetings, you’re not really
feeling at liberty to have an alternate opinion.
In another example, a nurse described having a strong reaction to the
first MAiD that was permitted to occur in her dedicated palliative care
facility. She had supported this patient’s choice to receive MAiD and was
present for their death. This experience caused her a lot of uncertainty
and distress, and she explains how there was little space within her
workplace to work through these emotions.
I very much felt judged by my Administration. Many eyes were on
me. I was told that I shared too much, that I shouldn’t have cried in
front of my [colleagues] … I felt very judged and very alone. After a
little while in fact I was encouraged by my management to take time
off work. So that I could basically get my emotions in check and come
back to work with a smile.
3.3. Destabilization of identity
In response to our first question about what being a palliative care
nurse means, to them, participants used words such as “passionate” and
“fulfilling” when speaking about the privilege they experienced in being
able to meet and work with people during such a crucial time, and the
opportunity to make an important difference in peoples’ lives. They
spoke about working with patients to explore and achieve their own
vision for whatever a best quality of life might mean, and about helping
families through anticipatory grief so that they are “not quite so lost
when the person that they love dies.” Ultimately, palliative care was
described as an area of practice that is “very different than any other
nursing.” For the nurses in our study, this professional ethos was deeply
personal. Conventional distinctions between these two dimensions of
self – personal | professional – evaporate in this context where chosen
values about palliative care reflect larger values about life itself. This
was the case for all participants regardless of supporting or opposing
MAiD.
Being a palliative care nurse is something that made me really
examine … my own personal values, my life philosophy, how we
support people … for me it’s a way of being as well (expressed a
supportive attitude about MAiD)
[Being a palliative care nurse is] about my values about life, and
about caring for others, and I wouldn’t want to do anything else.
(expressed opposition to MAiD)
In the wake of MAiD becoming legal, and consistent with the idea
that for palliative care nurses, the professional is deeply personal, many
participants expressed feeling destabilized. They wrestled with their
own responses to MAiD (emotions, attitudes, experiences) and were
preoccupied by concerns that these responses might have adverse con­
sequences for their patients. Thus, although participants emphasized
that “personal” opinions should not affect their work, their narrations
revealed the tenuousness of such separation. This tenuousness was most
apparent for one participant, whose moral distress over MAiD caused
her to leave clinical practice. This nurse described two different
D.K. Wright et al.
instances of unresolvable moral conflict. First, while deeply uncom­
fortable with the prospect of MAiD happening within palliative care, she
was more disturbed at the prospect of denying hospice access to patients
seeking MAiD. Second, after MAiD became legal, some palliative care
colleagues were choosing to accompany patients through their MAiD
deaths, while others were refusing. She felt this variability exposed
patients to an unfair degree of uncertainty about what they could expect
from the palliative care team. Because of these tensions, she decided her
only way through was to resign. In her words, “it just got so horrible … I
just had to leave …. I just had to leave.”
Other nurses also spoke about how their values were challenged
since MAiD became legal. For example, one participant was disturbed by
the lack of responsiveness her palliative care colleagues demonstrated in
response to MAiD requests.
… [My colleagues will] wait until Monday to start the paperwork
[for MAiD], and it’s like, well, why? Does it have to wait until
Monday? … I feel like [for] other goals … we’re going to do every­
thing we can to make it happen now … people are much more likely
to not go the extra mile to help someone meet their goal [with
MAiD].
Another challenge stemmed from a perception that talking openly
with patients about MAiD might violate the legal and ethical boundaries
of their nursing role. Participants spoke of receiving the message, from
their regulators and other authorities within their own organizations,
that open dialogue with patients about MAiD carried a risk of unduly
influencing the patient’s decision. Thus, a new boundary to the rela­
tional aspects of palliative nursing practice was created, which
contributed to an intense degree of self-monitoring and ultimately a
hesitation in offering therapeutic support. As one participant described,
such hesitation is devastating for a palliative care nursing identity, the
crux of which is relational engagement through open dialogue about
dying and death.
The education and instruction that nurses have gotten was that we
aren’t to provide anybody with information on MAiD … I can’t be
perceived as either encouraging or not encouraging it … It’s unfor­
tunate that I have this restriction put on me … in terms of talking.
That’s the biggest part of palliative care, is talking and conversations,
and finding out what people know, and what they are afraid of and
what they’re hopeful for. And I can be that for every subject under
the sun. Except for MAiD.
Regardless of individual nurses’ feelings around whether they could
support MAiD, the identity implications described above were experi­
enced on a deeply personal level for all of our participants. As one nurse
described, reconciling MAiD with other concerns related to the ethics of
end-of-life care required an intensely personal process of critical self-
examination:
I have done a lot of reflection and soul searching … we do need to
provide patients and families with all of the options, and we need to
provide them with really good palliative care. And then if they still
feel that this [MAiD] is what their choice is, then I can feel I can
support that.
3.4. Not abandoning MAiD patients within palliative care
One of our participants, who supports MAiD, told us a story about a
hospice patient who feared that her palliative caregivers would not
support her end-of-life choice.
One patient I remember, who was scheduled to have MAID at hospice
… she said to me … “I’m dying in two days.” And I said, “I know, yes I
know,” and she said, “And what do you think of that?” And I just said
… “I’m glad that your, your choice is being honoured.” And she said,
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Social Science & Medicine 289 (2021) 114366
“Everybody here has been so nice to me about it. I was so worried
that people would be mad at me or try to talk me out of it.”
At first, this participant was surprised that her patient would feel
fearful in this way, but then realized that the opposition to MAiD as
expressed within palliative care had evidently been internalized by
palliative care patients.
Why would [she] think that? But then I was like well, there’s still a
lot of people in the palliative care community that have been very
vocally against it, [including] colleagues of mine.
Another participant, who expressed deep ethical misgivings about
MAiD, used evocative language in highlighting the risk that MAiD pa­
tients can be ostracized within palliative care: “I just think that it’s
important that they not be shunned, the patients not be shunned because
of that”. The reflections of each of these nurses, one who supports and
the other who opposes MAiD, demonstrate a shared ethical commitment
about not abandoning palliative care patients who choose MAiD. They
also demonstrate concern for the vulnerability of people who are close to
death and who need to feel support from their palliative care providers.
This vulnerability was exemplified in the story of one participant, who
spoke of a patient who was resolute in her choice to receive MAiD, but
was worried that her family and her faith community would not support
her. The nurse, who elsewhere in her interview told us about having
difficulty reconciling MAiD with the ethics of palliative care, encour­
aged this woman to talk openly with her significant others about her
choice.
And much to this person’s surprise, both the church and the family
was very accepting, and so it made this very okay for this lady. And in
fact I had a long chat with the reverend of the church and actually
attended the funeral service and she made mention of it [MAiD]
during the service, that this path had been chosen, and that it was
okay.
In this story, the nurse does not discuss whether the patient should or
should not have pursued MAiD. Instead, her concern was about whether
the patient would feel “okay” within the relationships that mattered to
her, before she died.
Some palliative care nurses we interviewed had chosen to accom­
pany their patients during MAiD-related procedures (e.g., eligibility
assessments), including the final administration. One of our partici­
pants, for example, was present during the deaths of two of her patients
who received MAiD. In both cases, she was already in relationship with
them; she had been their nurse, and she saw her presence during their
dying moment as a continuation of this relationship.
I don’t mind being present but I choose to be present for people that
I’m working with … if there is a different person like another nurse
or somebody that’s got a better relationship with them [the patient],
if they’re comfortable in it, I think it should be them. I don’t want to
be known as ‘the team’ [i.e., designated MAiD professional] … My
intention is to support my clients when they need support.
This passage indicates a primary ethical orientation toward the
nurse-patient relationship, rather than to a broader ideological stance
regarding MAiD. This relational orientation is what animates the
commitment to non-abandonment, described above. For some nurses,
their relationships with patients such as these provoked a period of self-
questioning and a shift in previously held opinions. This was a difficult
and emotionally intense process for palliative care nurses.
So much of my palliative care training centered so much on [MAiD]
not being part of it [palliative care] … But then she [a patient] asked
me if I would be with her when it [MAiD] actually occurred … she
wanted me there in particular. And I told her I would. And then I
went home and I cried. And I wondered, “How am I going to do
that?”
D.K. Wright et al.
The above passages exemplify how participants wrestled to reconcile
their discomfort with MAiD with their commitment to non-
abandonment. For some, this reconciliation was not fully possible. For
example, one of our participants practiced in a residential hospice that
requires patients to leave, if they are to receive MAiD. This policy did not
sit well with her.
It can be difficult of course to have to transfer people out … Do they
feel abandoned by us, that we should do that? And then they are also
having to choose to leave something that has become familiar. And a
familiar environment to go to an unfamiliar environment, to then
have the service provided for assisted death … that in itself is anxiety
producing right?
Yet this participant remained uncomfortable with the idea of
providing MAiD within her facility. Her hesitation was ultimately about
trust; she believes that patients and families need to know that palliative
care, by definition, does not intend to shorten life. She worried that
enacting MAiD from within a palliative care facility would undermine an
ability to gain this trust, which she describes as an ongoing and daily
challenge in palliative care practice.
There is this, always this fear … even use of opioids for relieving
dyspnea, pain, …symptom control, and there is still such a huge
education to be done. People often misperceive giving a little bit of
morphine to relieve their dyspnea as … very frightening … people
are often scared to have their loved ones relieved of symptoms.
Because they are scared that we will shorten their life. So how do
you, how do you deal with that while … you are actually providing
end of life? Like you are ending life.
4. Discussion
This study contributes to an emerging body of scholarship about
nursing perspectives on MAiD. While other studies have included some
palliative care nurses in their larger samples of nurses from diverse
practice contexts (Beuthin et al., 2018; Pesut et al., 2020a, 2020b), to
our knowledge this is the first Canadian MAiD study to look exclusively
at palliative care nurses. We interviewed each participant once, at a
single moment in time. Given how quickly the landscape of nursing
practice is shifting in response to relatively recent and ongoing legisla­
tive changes, our findings should not be read as representing a definitive
stance regarding the ethics of MAiD within palliative care nursing.
Rather, our analysis shows how thinking about MAiD in the context of
palliative care nursing practice is an instance of moral identity work;
involving a process of deep reflection and negotiation of values, re­
sponsibilities, and relationships (Liaschenko and Peter, 2016; Wright
et al., 2020). Across our interviews, we found that a commitment to
palliative care values, including not abandoning dying people, hon­
ouring peoples’ end-of-life choices, and promoting quality of life in
dying caused our participants to reflect deeply on the ethics of MAiD and
its place within their practice of palliative care nursing. Rather than
espouse categorical endorsement or rejection of MAiD as a legitimate
end-of-life care option (although this did sometimes occur) most of our
participants engaged in an ongoing and sometimes painful process of
questioning and self-examination. Their ethical navigations were far
more nuanced than simply dismissing MAiD as incompatible with
palliative care philosophy; yet this idea of incompatibility weighed
heavily as they reasoned through their experiences and questioned their
own perspectives.
In the short years since MAiD was legalized in Canada, scholars have
begun to analyze this practice from a nursing perspective. A recent study
of Canadian nurses’ experiences (Pesut et al., 2020a), from a variety of
practice contexts and not specific to palliative care, surfaced several
findings that resonate with our own. Some nurses in their study wrestled
with uncertain feelings about MAiD. They grappled with the ethics of
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Social Science & Medicine 289 (2021) 114366
introducing MAiD into a healthcare system that is woefully inadequate
with respect to the availability and accessibility of palliative care. In a
second paper reporting findings from the same study, Pesut et al.
(2020b) describe how nurses take very seriously an ethical commitment
to not impose their own values onto their patients. A dominant feature of
their participants’ moral reasoning around MAiD was to continuously
remind themselves that “it’s not about me.” Yet, their decisions around
participation in MAiD were influenced by their family and community
networks, with nurses considering what consequences these decisions
would have for their personal relationships, their reputation, and their
integrity. This influence reveals the limitations of trying to understand
moral experience in nursing through appeals to a conceptual separation
between personal and professional spheres of lived experience. For
example, in an interview study analyzing nurses’ emotional experiences
when caring for dying people in hospice, Ingebretsen and Sagbakken
(2016) show that nurses do strive to balance their ‘personal’ and ‘pro­
fessional’ worlds, and to create some distance between the two. Ulti­
mately however, “distinguishing their person fully from their
professional appearance was explained as impossible” (p. 7). Our find­
ings show how this impossibility is particularly salient for palliative care
nurses, as they negotiate moral identity in relation to MAiD. These are
nurses for whom values of palliative care philosophy are indissociable
from values about life itself, and for whom reputation and standing
within local palliative care communities of practice are at stake.
Beuthin et al. (2018) interviewed a sample of nurses – again not
specific to palliative care – working across Vancouver Island (a region in
the Canadian province of British Columbia) about their early experi­
ences of MAiD. While two of their participants were opposed to
participating in MAiD, most felt that participation in MAiD was
consistent with their wider nursing values. MAiD provided an oppor­
tunity to enact holistic and non-judgemental care, advocate for and
respect patient choice, and to broaden their understanding of what a
good death could mean, as defined by the patient. Both of these prior
studies (Beuthin et al., 2018; Pesut et al., 2020a, 2020b) with nurses
who did not necessarily identify as ‘palliative care nurses’, demonstrate
that nurses are engaged in reflective processes about MAiD and its
impact on themselves and their practice. Each study surfaces similar
language describing the depths of this reflectiveness: “soul searching”
(Beuthin et al., 2018, p. 516); “soul struggle” (Pesut et al., 2020b, p. 9).
Overall, however, participants in these studies appeared more enthusi­
astic about the advent of MAiD as an end-of-life care option than the
palliative care nurses we interviewed. Beuthin and colleagues charac­
terize many of their participants as “early adopters” and “pioneers,”
because of their willingness to take responsibility for MAiD care despite
much uncertainty during a period of legislative and practice change.
Pesut et al. (2020b) describe how for some nurses, participating in MAiD
reinforces their moral identity of nursing: “Nurses who participated in
MAiD believed they were making a real difference in the lives of
suffering patients and families, and in doing so, experienced new
meaning and purpose in nursing” (Pesut et al., 2020b, p. 11).
These are important departures from our findings. While some of our
participants expressed agreement with MAiD as a valid end-of-life care
choice, none were as enthusiastic as the participants in these previous
studies. Further, Beuthin et al. (2018) found that the small minority of
their participants who objected to MAiD did so on religious grounds.
When we asked our participants about how their spiritual beliefs influ­
enced their perspectives on MAiD, several emphasized that their moral
hesitations originated not from any religious worldview, but rather from a
perceived threat to their professional identity. This distinction was pre­
viously reported in a qualitative interview study from Québec about
palliative care physicians’ positions on assisted death. In that study, all
participants expressed discomfort with assisted death as an aspect of
ethical end-of-life care, and all but one explicitly denied the influence of
religious positions in shaping these views (Belanger et al., 2019). Thus,
while nurses working in various contexts may experience MAiD as a good
“fit with the grand moral narratives of nursing” (Pesut et al., 2020b, p. 10),
D.K. Wright et al.
our study suggests that the fit with the grand moral narrative of palliative
care, which sees death as a natural event that should not be intentionally
precipitated, is more difficult.
The uniqueness of palliative care nurses’ experiences is also apparent
at the level of their emotional experiences. Beuthin et al. (2018) describe
a range of nurses’ emotional responses to MAiD, from sadness at seeing
families say goodbye to their loved one, to feelings of peace and
amazement at participating in a good death. What these authors
describe as the “paradoxical experience of witnessing death that is both
‘sad’ and ‘beautiful’” (p. 518) is, arguably, a familiar and everyday re­
ality for palliative care nurses. Conversely, the emotional intensity we
observed in our study was more in response to a threatened professional
ethos, which one participant expressly identified as grief. For several of
the palliative care nurses we spoke to, the legalization of MAiD had
destabilized a value system that heretofore had defined their entire
nursing role: that no matter how ‘hopeless’ a situation appears to be,
there is always something that can be done to help a dying person to
experience better quality of life and less suffering. Further, several of our
participants described experiences of unprecedented moral conflict.
Such conflict was perhaps most consequential for the one nurse who
resigned from clinical practice, but in different ways was also apparent
in the stories that participants told about experiencing new difficulties in
their relationships, with patients and with colleagues, in the aftermath
of legalization. Thus, while nurses inside and outside of palliative care
are experiencing emotional intensity in response to MAiD – consistent
with international studies of nursing and assisted death (Denier et al.,
2010; Elmore et al., 2018) – the underlying explanations for this
emotional intensity appear to be different for palliative care nurses.
While palliative care nurses are familiar and comfortable with death as
part of their everyday work, they may struggle with MAiD if they
perceive it as disrupting the ethos of helping people to live well until their
(natural) death. This ethos is a strong source of meaning and purpose in
palliative nursing practice.
4.1. Returning to moral identity and feminist ethics: a reflection on
reciprocal holding
In their review of how feminist thought influences nursing ethics,
Peter and Liaschenko (2020) take the example of midwifery to argue
that:
Feminist ethics has been especially valuable for midwifery as it is
possible to articulate a relational approach to midwifery that is more
consistent with its core values and practices, unlike principle-based
bioethics and traditional codes of ethics (p. 29).
Likewise, approaching the topic of MAiD from a perspective of
feminist ethics can open space for critical reflections about its relational
dimensions. Narrow and procedural conceptualizations of assisted
death, as merely the administration of a life-ending substance, obscure
the intricate dynamics involved as patients, families, and care providers
navigate this choice. In a now classic ethnographic study of euthanasia
in the Netherlands, Norwood (2007) shows how euthanasia is a
communicative process, a series of back and forth interactions between
physicians and patients that may be stopped and re-initiated multiple
times. Understood as a relational care process that occurs over time,
‘euthanasia’ does not even necessarily result in the deaths of patients,
who might withdraw their requests or die before being able to fulfill
them. In a more recent ethnography of assisted dying in the USA,
Buchbinder (2018) shows how people who pursue an assisted death do
so in ways that are highly dependent on support from other people, who
are themselves profoundly affected, at deep emotional and existential
levels, as a result of their involvement. Through multiple case studies
chronicling the ways that assisted death is co-navigated by patients,
their families, and their providers, Buchbinder argues that assisted death
“fosters distinctive forms of sociality that challenge its public image as a
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Social Science & Medicine 289 (2021) 114366
radically independent practice” (p. 485). A strong ethic for MAiD care,
then, requires recognition of this practice as a form of relational
engagement, not merely a discrete procedural act. Such an ethic attri­
butes moral significance to how willing and able providers are to
respond to peoples’ uncertainties and fears, to help them to understand,
explore, and enact their options, and to facilitate communicative in­
teractions that enable people to feel supported before death and in grief.
Consideration of potential tensions and compatibility between the
core values and practices of palliative care nursing, and the relationality
of assisted dying, is deepened when we invite direct care practitioners,
such as the palliative care nurse participants in our study, to talk about
their work. An ethic of relationality has always been more consistent
with the ethos of palliative care nursing than principle-based ap­
proaches. Palliative care nursing rejects a one-size-fits-all approach,
focusing instead on the particularities of individual situations. It rec­
ognizes and honours the inherent uniqueness of all people, as well as
their families and communities. It seeks to safeguard and promote the
wellbeing and dignity of those facing life threatening illness, respecting
their own values and on their own terms.
We began this paper by asking whether and how palliative care
nurses are able to hold the identities of vulnerable patients and families
who explore and potentially choose MAiD, and whether and how the
field of palliative care will, in turn, hold the identities of its nurses, as
they practice within this new landscape. As Peter and Liaschenko (2020,
p. 28) make clear, “caring work and caring relationships are only
possible in sociopolitical contexts that foster them”. A feminist analysis
brings into sharper view the power dynamics that operate between
palliative care nurses, their patients, and those who hold authority over
their practice (at the level of local organizations as well as the wider
professional culture) - and the ways in which these dynamics influence
the reciprocal holding of identity.
A recent position statement on palliative care and MAiD, jointly
released by the national group of palliative care physicians together with
the wider Canadian Hospice Palliative Care Association, reaffirms the
boundary between the two: “Provision of MAiD is a practice distinct from
palliative care” (Canadian Society of Palliative Care Physicians, 2019).
Broad and influential statements such as these transform palliative care
into a binary landscape, within which some patients and families will
inevitably contemplate and/or choose MAiD and in so doing, will risk
being cast outside the frame of a palliative care ethic. While such a
distinction was a source of reassurance for some of our participants, who
are loath to conflate MAiD and palliative care, for others this boundary
created moral tension. For palliative care nurses who might contribute
their end-of-life care expertise to improve MAiD care, there is a risk they
will stay silent for fear of violating this boundary. And for palliative care
nurses who are asked by their patients to be involved in MAiD, there is a
risk of feeling forced to choose between their patient and their profes­
sional community. While the International Association of Hospice and
Palliative Care claims that tasking palliative care professionals with re­
sponsibility for MAiD care will put them in “untenable” positions (De Lima
et al., 2017), our findings raise a different question, about the extent to
which a master narrative about MAiD as “distinct” from palliative care
contributes to nurses’ experiences of moral conflict. This master narrative
sets limits on the roles that palliative care nurses might play in this
practice. It also limits the availability of interpretive resources that nurses
have at their own disposal, to make sense of experiences they find chal­
lenging (Fricker, 2007).
Our findings further suggest that harm results when dominant voices
about MAiD, within palliative care, silence the potential for open dia­
logue and reflection. Given that within our sample, a diversity of views
around the ethics of MAiD was apparent – a result echoed in other
qualitative research with individual palliative care providers (Mathews
et al., 2020) – such dialogue and reflection is essential. Amidst their
ambivalence about MAiD as an ethical end-of-life care intervention, our
participants expressed a strong commitment to non-abandonment in
nursing care, and to respecting and honouring patients’ and families’
D.K. Wright et al.
autonomy and choice. As the professional nursing group that is most
accustomed to having end-of-life conversations with patients and fam­
ilies facing death, the palliative care nurses in this study honoured this
responsibility for MAiD patients, just as they would for any other pa­
tient. They told touching stories about caring for specific patients who
had chosen MAiD, helping them to overcome stigma – as in the case of
the woman concerned about the reaction of her church community – and
to feel loved and supported in their final choice. However, support for
MAiD as a potentially ethical practice in specific situations was in all
cases counterbalanced by a simultaneous and omnipresent concern for
the under-availability of palliative care services, and concern over op­
portunities lost because of MAiD’s decidedly final quality. Our partici­
pants expressed a clear wish for safe forums to share their perspectives
and to discuss issues related to MAiD, in ways that move beyond
simplistic pro/con arguments. We see a potential for leaders in palliative
care to take guidance here from Pesut et al. (2019), who in writing more
generally about MAiD within Canadian nursing practice, argue for the
creation of practice communities that can respectfully hold a diversity of
opinions and stances about MAiD in end-of-life care.
…. the fact that some nurses choose to participate in MAiD, while
others choose to conscientiously object, is, ultimately, a good thing.
We can learn from one another as some hold firm to conscientious
objection, others participate fully, and yet others engage tentatively
to varying degrees as they learn more of the potential impact. Such
diversity allows us to strategically engage this new moral landscape,
all the while observing the consequences of our choice (p. 4).
5. Conclusions
In this study, we invited and then analyzed palliative care nurses’
moral reflections about MAiD. In interviews, participants told stories
about caring for specific patients who had requested MAiD, and offered
their general impressions of the ethics of MAID in end-of-life care.
Participants offered nuanced and context-specific perspectives that,
taken together, challenge the validity of a singular master narrative that
palliative care and assisted death are “distinct.” Beyond rehearsing this
distinction, palliative care leadership should implement strategies to
better hold the identities of its nurses who are willing to take re­
sponsibility for MAiD care, and to respond to the distress of those
palliative care nurses who struggle with the irreversible nature of this
end-of-life intervention.
Credit author statement
David Kenneth Wright: Conceptualization, Methodology, Formal
analysis, Writing – Original Draft, Writing – Review & Editing, Funding
acquisition. Lisa Chan: Formal analysis, Writing – Original Draft,
Writing – Review & Editing, Project administration. Jennifer Fishman:
Conceptualization, Methodology, Writing – Review & Editing, Funding
acquisition. Mary Ellen Macdonald: Conceptualization, Methodology,
Writing – Review & Editing, Funding acquisition.
Declaration of competing interest
None.
Acknowledgments
We are grateful to Kristina Ma for comments on an earlier version of
this paper. This study was funded by the Canadian Institutes of Health
Research (#150144). We acknowledge the helpful assistance of the
Canadian Nurses Association and the Canadian Palliative Care Nursing
Association, who supported this study. As authors, we take sole re­
sponsibility for the ideas presented in this paper.
Social Science & Medicine 289 (2021) 114366
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