Why are so many members of the palliative care community opposed to physician assisted death?

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.

James Downar is a critical care and palliative care physician at the University Health Network in Toronto, Ontario.