COVID-19 (or coronavirus) has dominated headlines and the media, many portraying very negative scenarios. The fact is most people can overcome this virus. And we can all take easy steps to keep ourselves, our loved ones, and the most vulnerable safe. The World Health Organization advises simple protective measures (that do not include wearing a mask!) by cleaning your hands frequently and thoroughly with soap and water (use rubbing alcohol if clean water is not available), avoiding touching your face, and keeping a distance of three feet (one meter) from persons who are coughing or sneezing. And if you feel sick or think you may have the virus, you can protect yourself and others by staying at home and calling a health facility to report, avoiding travel and close contact with others, and not participating in group gatherings.
Above all, we should not stigmatize people or promulgate unfounded fears. In fact, we hope that this situation will further strengthen ties, enhance global collaboration, and serve as an opportunity to support each other in times of need. And we hope that people currently affected by the virus will get well soon!
On another important topic, there have been new reports and articles about physician-assisted suicide (PAS) — also called physician-assisted dying (PAD) or medical assistance in dying (MAiD) — and euthanasia, so we would like to highlight some relevant issues in this message.
Portugal recently approved euthanasia and physician-assisted suicide, Germany’s Federal Constitutional Court overturned a five-year-old law banning professionally assisted suicide, and in Canada, two events have been receiving attention in the media: Delta Hospice Society in British Columbia, Canada, is being forced to give up local government funding for the hospice they operate because they refuse to make provisions for MAiD, and since the land where it is built is owned by the government, by February next year the government will take over the building. And on February 24, the Ministry of Justice tabled a bill called C-17, striking down the requirement that a person’s “natural death be reasonably foreseeable” to qualify for death by lethal injection, as ruled by the Quebec Court last September.
There are differences between these countries. In Portugal, Parliament has approved several laws that the executive branch seems reluctant to implement. In Germany, the legislative and executive branches supported a law banning professionally assisted suicide, which was subsequently overturned by the judiciary. In Canada, the executive branch, both at the local and national level, is pushing the provision and expansion of MAiD.
We are concerned that governments seem to be adopting aggressive measures to push for PAS/MAiD and euthanasia, while palliative care is receiving tepid political support or none at all. In high-income countries such as Canada, Germany, and Portugal, the push for assisted suicide or euthanasia seems to be related to the predominant focus on autonomy in modern Western culture. The German Constitutional Court left no doubt that every person has a basic right to self-determination, which includes the right to determine how their life will end. This may include suicide, and the right to have a third party facilitate that suicide. The court did not restrict this basic right to severely ill patients but ruled that it applies to all stages of life. As the presiding judge said, “We can regret the person’s decision, we may try everything to convince him to change his mind, but ultimately we have to accept his decision with all its consequences.”
As palliative care professionals, we hear a lot about wishes for hastened death, as well as patients’ ambivalence and double awareness (those who wish to die but hope to live). Not all patients with palliative care needs have access to appropriate care in these high-income countries – and much less so in others with fewer resources. Although we now know that millions of patients and their families around the globe experience serious health-related suffering, there are still far too few health professionals trained to provide appropriate care, far too few facilities in place to meet the needs, and a vacuum of policies and regulations to facilitate palliative care integration. The vast majority of people in the world lack essential palliative care medicines, such as morphine, to relieve severe pain and symptoms.
In this context of increased political support for medically assisted dying, we wish to remind our readers that in 2017 the IAHPC published a Position Statement on Euthanasia and Physician-Assisted Suicide available through open access. The position statement emphasizes that:
“...no country or state should consider the legalization of euthanasia or PAS until it ensures universal access to palliative care services and to appropriate medications, including opioids for pain and dyspnea.”
In order to achieve universal access, palliative care must be integrated into the public and private health care systems of all countries through policies and budgets that ensure safe and adequate access to opioids, care delivery, and appropriate education for health professionals.
In states and countries where euthanasia/MAiD/PAS are now legal, in its position statement, the IAHPC agreed that palliative care units and hospices should not be responsible for overseeing or administering these practices, as doing so places the professionals, their staff, and, in some cases, their patients and families, in untenable positions. And in other health institutions where PAS or MAiD is implemented, health professionals should have the legal right to conscientious objection. They should be entitled to refuse to provide health care services that involve the intentional killing of a human being, and to exercise that right without incurring drastic personal or institutional consequences.
Until next month,
Lukas and Liliana