Professor of psychiatry & Joint University of Toronto/University Health Network Harold and Shirley Lederman Chair in Psychosocial Oncology and Palliative Care, Toronto; Head, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto; Director, Global Institute of Psychosocial, Palliative and End-of-Life Care, Toronto
I am grateful to the IAHPC for the opportunity to comment on this members’ survey on assisted dying and euthanasia. My own views on this subject have been recently shaped by our experience of Canada, where assisted dying has been legal since 2016 and where the criteria for medical assistance in dying (MAiD) are now broader than almost anywhere else in the world.
The narrative comments in the survey are largely critical of the practice of assisted dying or euthanasia, although the quantitative data suggests that there is a broader range of attitudes within the membership. More than half of respondents believe that assisted dying practices have actually helped the development of palliative care by bringing it up as a topic for discussion, although 61% believe that the public may be confused about the distinctions between palliative care and medically assisted dying. The members are equally split overall on whether euthanasia should be legalized, but the majority of those in countries where it has been legalized support this practice. This is consistent with our experience in Canada, where this highly controversial practice became normalized and widely accepted by both the public and the medical community relatively soon after its legalization.
Personal opinions about whether assisted dying should be legalized are often shaped by strongly held religious and moral beliefs and/or by experience as a health care provider or as a family member. Those who regard assisted dying or euthanasia as immoral often hold this as a bedrock view that is not open to reconsideration. Others have equally strong and unshakeable views about the primary importance of individual autonomy and the right of individuals to decide about when and how life should end. These positions have the virtue of clarity, although the view that assisted dying undermines the provision of palliative care or contributes to confusion and stigma about palliative care is not borne out by the experience in countries where it is legalized. Evidence suggests that patients with advanced disease in Canada understand the distinction between these practices and palliative care and, in some countries, those who pursue assisted dying are even more likely than other such patients to access specialized palliative care.
There is broad agreement amongst the members and elsewhere that the act of assisted dying is not palliative care, although this distinction may not be so critical since everything before and after this act is end-of-life care and is within the purview of palliative care. The disengagement of formal palliative care organizations and mainstream medicine from assisted dying and euthanasia is understandable and principled. However, this has meant that these official organizations have not had a voice in the development of the policies, practices, or laws that govern assisted dying or euthanasia in countries where it has been legalized. It has also meant that there has been a lack of coordination of these services, which are being delivered concurrently.
The disengagement of formal palliative care and mainstream medicine from physician-assisted dying has resulted in a lost opportunity in Canada and elsewhere for these groups to have a moderating influence on the practice of physician-assisted suicide and euthanasia. The lack of this influence is evident in the legislation for medical assistance in dying in Canada, in which patient autonomy is privileged, and in which clinical judgment, beyond the assessment of competence, plays little role. It may also have permitted the extension of the boundaries for assisted dying and euthanasia to include those who are not expected to die in the reasonably foreseeable future, including those who may have benefited from psychological or social interventions.
Palliative care professionals are obliged to care for all patients near the end of life, including those who choose assisted dying and euthanasia. My hope is that official representatives of palliative care also become involved in the development of policies and practices regarding assisted dying and euthanasia, which are otherwise being developed without them.