On February 6, 2015, the Supreme Court of Canada unanimously ruled to strike down the provisions of the Criminal Code that prohibit Physician Assisted Death (PAD, which includes both physician-assisted suicide and euthanasia). Although public support for PAD in Canada has been very high for decades, support among the medical community has been lukewarm at best. The Quebec Federation of Medical Specialists was an early supporter of legalizing PAD in Quebec, and participated in the drafting of Bill 52 (which legalized PAD in Quebec prior to the Supreme Court decision). The Canadian Medical Association had long opposed the legalization of PAD, but shifted to a “neutral” position in August 2014.
Yet many within the Canadian palliative care community remain opposed to PAD. The Canadian Society of Palliative Care Physicians reaffirmed its longstanding opposition to PAD immediately prior to the release of the SCC decision. Following the decision, the society suggested that although PAD has been legalized, it “should not be provided by palliative care services or palliative care physicians,” a position supported by 75% of its members. The Canadian Hospice and Palliative Care Association -a group that includes physicians, allied health, caregivers and volunteers in hospice and palliative care – does not officially support or oppose PAD, but has suggested that its members should “Talk about Hospice Palliative Care instead”.
There are fears amongst palliative care providers that ready access to PAD might lead to the erosion of Canada’s already patchy palliative care delivery networks, although data from other jurisdictions that have legalized PAD do not necessarily support this. Unless and until there exists a national strategy by means of which to improve Canadians’ access to quality end-of-life care, it is likely that the Canadian palliative care community will resist the suggestion that we should improve access to PAD. For decades, the Canadian Senate produced reports that documented Canada’s failure to meet the care needs of its dying citizens, but these reports have been largely ignored by governments and healthcare organizations alike. If the quality and availability of palliative services are to grow in the coming years, there will need to be a dramatic change at all levels of decision-making.
Even with markedly improved access to quality palliative care in Canada, however, it remains unlikely that most members of the PC community would endorse PAD. Many are opposed for foundational reasons, including a religious or moral opposition to the intentional ending of human life. For these people, “thou shalt not kill” is an absolute duty without exception. On the other hand, some people who favour legalized euthanasia and assisted suicide do so out of similarly deeply held religious and moral convictions, and an obligation to attend to the suffering of others. It is vital that we all appreciate the integrity with which both sides of this debate put forth our arguments.
Secular humanists tend to assume naiveté on the part of religious people and their adherence to ancient proscriptions. But civil societies have long known that a society that liberalizes and normalizes killing does so at their peril. Many in the palliative care community appreciate that the near universal prohibition, whether by gods or by men, of the deliberate killing of other humans persists because it protects the community, the killers as much as the killed.
The proponents of legalizing PAD emphasize the importance of autonomy- they are pro-choice rather than pro-PAD. They argue that there is comfort in having the right to PAD, even if only 0.2-3% of people in permissive jurisdictions choose to exercise this right. The palliative care community applauds choice and celebrates autonomy, but many question whether Canadians can make a truly informed choice when they have such poor access to Palliative Care, and may have limited experience with the process of death and dying. The palliative care community fears that people may not choose PAD as the result of an informed decision between 2 legitimate options, but rather out of desperation or a lack of understanding about what can be done for the dying.
Many in the palliative care community are confronted daily by the fact that technological advances in medicine have outpaced our ability to make rational decisions about whether or not treatments should be used. Life-prolonging therapies (e.g. mechanical ventilation) are often started reflexively and continued indefinitely. New and promising cancer therapies are rapidly disseminated and used in situations for which they have little or no benefit. And these actions often work to the detriment of the patient- palliative measures are delayed or avoided entirely. Although PAD is not used to prolong life, it may be another example of a therapy that is used instead of compassionate Palliative Care.
Of course, PAD will likely become legal across Canada on February 6, 2016, irrespective of the concerns of many in the palliative care community. The debate has necessarily turned to other considerations, such as the logistics and scope of conscientious objection on the part of both individuals and institutions. How this tension is resolved, between rights of conscientious objection on the one hand, and rights of patients to access physician assisted death, may have profound implications.
Conscientious objection, if too liberally applied, could lead to poorer access to PAD, but it could also lead to poorer access to palliative care. Many organizations (including hospitals with a religious affiliation) have stated publicly that they will not permit PAD to be performed on their premises. This may or may not be enforceable, but there is concern that if patients (84% of whom apparently support the right to request PAD) believe that their end-of-life options will be limited if they are admitted to a particular palliative care unit or hospice, some will choose to not avail themselves of palliative care services. We must all remember that even in permissive jurisdictions, the vast majority of people who ask about PAD do not ultimately end their own lives- they opt for palliative care. Palliative Care physicians who conscientiously object may reduce the use of PAD, but an overzealous objector will likely prevent more palliative care than PAD in the long run. This is an important consideration for opponents and proponents alike, since everyone agrees that palliative care should be more widely accessible, and should be the preferred option for suffering patients.
Both “sides” in this complex debate are deeply troubled by the suffering we witness in our patients and their families, and work tirelessly toward the amelioration of this distress. The long-running and emotional debate about PAD has divided the medical community and left many concerned about the future. We need to work together to support our colleagues (both those who object and those who do not), and we need to be circumspect when exercising our right to conscientious objection, so that we do not impede care that would help our patients.
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Vera, Which disease qualifies for PAD? Which disease qualifies for MAID?
Once we get over the hump of dealing mainly with cancer and let all others suffer and die in wretched states, and act according to something that smacks of being logical, rational and ethical, compassionate and according to law, possibly we can include all sufferers and not have canadian doctors direct them to Switzerland.
I don’t desire PAD. I don’t even qualify. Doctors decide what I qualify for. I very much agree with your statement and point of recording death. I go a step further. If we record a person’s suffering in the quiet of their home, that would be enough to stir up the ones who not just have compassion, but those who have insight.
Too many medical people are trying so hard not to get emotionally involved and believe that rationality is superior to emotions. What is missing is that your emotions are needed to make rational decisions.
I strongly support the Canadian Society of Palliative Care Physicians position on PAD (sic).
PAD advocates fail in every direction to contextualize assisted suicide in terms of service delivery realities and patient experience.
Current health policy is removing access to treatment, from patients with chronic, degenerative and debilitating disease. We are quickly losing primary care, urgent response, specialist consults, pain medication and surgical options. The policy agenda however, is not about patient need or choice, nor does it privilege patient dignity. The goal is simply to transfer costs onto patients themselves, for those who can afford those costs. Even the language of chronic disease and related pain is changing, to shift our expectations from treatment to the passive response of ‘living with’ and ‘coping’. The neurobiology of pain is misunderstood and misapplied as psychosomatic or depression related. (My GP kept pressing my sternum because he said pain there indicated stress. Turns out I had a hiatus hernia and referred pain from lumbar degeneration). Chronic care patients without remedial options or effective pain relief, who are on wait lists without end, given ineffective medication and facing hostile, unprofessional attitudes, will lose hope and are more likely to hasten death than other patients.
At this point, terminal and palliative care units become part of the PAD ‘gatekeeping’ agenda , destined to become short-stay hostels and whenever possible, to hasten death. Example: A friend of mine was in palliative care, and had six months to live. He even flat- lined a few times on the unit. In spite of his condition and imminent death, he was allowed to stay on the unit for only 4 weeks, their maximum bed capacity. He was discharged to a nursing home outside of his community where he died 2 weeks later. That is not palliative care, that is warehousing. With a PAD option, the palliative care patient has to die within 4 weeks, or be discharged to some random facility, or to hasten their own death. These are not the conditions of respect, dignity or free choice. Canadian health policy is setting up patient trajectories that begin with refusal to treat followed by prolonged suffering and a hastened, premature death. No choices, no dignity. It is a deliberate construction of patient care that I believe is truly sinister and medically unethical. (Current research including health policy papers, in addition to an excellent patient advocacy site are available for further consideration).
Very thought provoking essay. Thanks for the insights and expansive perspective on this subject.
We should retread the last paragraph over and over. It summarizes well how we should be going forward.
I am trying to find a reason why you decided to bring up secular humanists finding religious people naive then follow this up with civil society knowing killing is wrong. Religions have a long history of bloody torture and massacre of others who don’t believe in what they do whereas as far as I know secular humanists have no history or reputation of being uncivil or blase about death and killing. I would wager good money that secular humanists have an exponentially smaller ‘kill rate’ than religious people. Odd to read this strange combination of sentences from an educated person who must be capable of logic.
The argument from palliative care physicians seems to be that they oppose PAD because they are worried they will be out of jobs because the need for palliative care will decrease. I don’t think I know anyone who would rather be in a bleak environment amongst other dying people in a half-conscious suffering state of slowly perishing out of altruistic feelings towards palliative care professionals instead of at being at home amongst loved ones and having their last time on earth be peaceful, conscious, and dignified. You make is sound like your argument is down to keeping a job and a place to work rather than thinking of the person and their loved ones. I choose the side of the debate that focuses on the person.
Dying is similar to pregnancy and giving birth. Both have a process of changes and things you need to do to prepare followed by a final event. With giving birth you only hear the horror stories about terrible pain lasting for days. You don’t hear the stories about the beautiful normal birth that happens most of the time. The same is true for dying and death.%featured% Our society is afraid of giving birth and of dying. Mostly because we don’t hear the other stories. I have been very fortunate the hear many times patients say that they couldn’t believe how good they felt going through the dying process. Many have said that until they knew they were dying they never appreciated life to its fullest, worrying about trivial matters instead of seeing life and the world and right in front of them.%featured% Most people experience suffering all through life at various points and many will experience suffering when dying. Most of that suffering is due to being human, caring about others and feeling the anticipatory grief of leaving them.
If it were not for the brave, our species wouldn’t continue to exist. Many people are eager to experience new life and understand that the end of our lives is as important as our beginning and don’t want to miss it. As Canadians we all want people to have choices but interestingly most of the people I have asked want the choice for some one else. Not themselves. We live in interesting times. Thank you James for this thoughtful article.
David—
When was the last time you gave birth. ?????
Linda Knopper
I applaud Dr. Downar for his bold attempt to tackle the disconnect between the public and the medical profession regarding physician-assisted death (PAD).
As a recent graduate of a family medicine residency program, I can attest to the fact that palliative care certainly has a large presence in our training. Not only do many of us seek dedicated elective time in palliative care, but even in our everyday interactions with patients, the palliative approach certainly plays role a significant role in shaping our management plans.
What I struggle with is the blanket objection on the part of palliative care professionals to including PAD as a viable option as part of their care portfolio. If a capable person decides that his her life should end earlier in the course of a terminal disease than might be expected naturally, are we not imposing our own values and principles, and thereby impinging on the patient’s autonomy, by trying to dissuade him or her from doing so, and encouraging a more natural death, no matter how protracted it might be? %featured%If a person wants to shield his or her loved ones from the sequelae of witnessing the downward spiral of ongoing suffering and disability, both physical and emotional, shouldn’t we respect that person’s right to do so, rather than insisting that they somehow find meaning and dignity in the experience?%featured%
I look forward to a future where Canadians can truly make an informed decision about all the available options for end-of-life care, without prejudice, and with the knowledge that no matter what decision they make, it will be respected and supported.
Hurray for you, Dr. Weiss.
Have you opened your practice yet?? You are certainly the kind of Doctor I would choose.
Thank you for your intelligent response to Dr. Downar. I couldn’t have said it better myself.
All the best to you.
Linda Knopper
The perception amongst palliative care physicians is that PAD is a “failure” of Palliative care. The best of palliative care will not satisfy those few in our society who choose not to suffer. As Dr Downar suggests we risk alienating them from the palliative care team, a team which will not only support the patient but also the family and loved ones after the individual’s death. We must be open and non judgemental. If, after our best efforts the patient insists and we feel obliged by conscience to request the help of another physician we should do so with love, understanding and forgiveness.
As someone who has sat and watched someone die using so-called palliative care, nope I would never choose it. I don’t think starving and dehydrating someone while giving them a jab in the arm every so often to render them senseless is any way a good way to go. Gillian Bennett’s death is what I would choose. So I really don’t care if palliative care is available, I would go to Dignitas, or use a mega dose of street drugs before ever choosing it, if nothing else was available here in Canada. In jurisdictions where it’s legal it’s generally the most educated and informed people who choose it. The average person puts too much faith in the medical system and lives with the consequences.
It’s why you could post a video of a Dignitias death online and not upset anyone but posting the last 24 hours of a death in palliative care would sicken and disgust most lay people.