Emeritus Professor of Medicine and Community & Family Medicine, Dartmouth Geisel School of Medicine, Missoula, Montana, USA
Medically hastened death is an evolving socio-cultural phenomenon with important implications for palliative care and the people we serve.
Befitting its membership and mission, IAHPC’s survey reflects the views of palliative care clinicians from widely varied geographical, cultural, and clinical contexts. Most respondents indicated that physician-assisted suicide (62%) and euthanasia (70%) are criminal offenses in their countries. Where one or both acts are publicly debated, 51% of those surveyed perceive that the debate helps and 40% believe it hinders development of palliative care, while 61% believe the debate confuses the public. Nearly half of the respondents support legalization of physician-assisted suicide (49%), and the availability of euthanasia (47.5%).
The responses of IAHPC members encourage us to revisit and perhaps rethink what we know of these issues.
In recent decades, views of both the general public and medical professionals have gradually shifted—particularly where the issues have been publicly debated—toward more acceptance of these physician-assisted dying practices. Although support tends to be lower among physicians than the general public, in jurisdictions that have legalized one or both acts, physician acceptance has usually increased over time.
Opinion surveys have found that personal traits associated with support for physician-assisted dying in surveys include being male, relatively younger, economically advantaged, religiously unaffiliated, and identifying as White.1,2 Collectively, such traits do not explain, but seem in line with, regional and national differences of opinion and public policies. Countries in which physician-assisted dying have become legal, such as Australia, Belgium, Canada, the Netherlands, Switzerland, Spain, and several northern US states, are by and large economically stable, comparatively liberal, and have predominantly White populations.
There has historically been tension between the field of palliative care and proponents of legalizing physician-assisted dying. Palliative care practitioners and proponents have long worried that the public would conflate treating pain and alleviating suffering with ending the lives of ill and suffering people. Proponents of legalization assert that physician-assisted suicide and euthanasia are needed because of cases of unrelievable pain and suffering—a framing of the issues that survey methodology studies have shown generates higher respondent approval.3 Somewhat reflexively, palliative care policy agendas have assumed that improving availability and quality of pain management and palliative care would decrease the level of perceived need for hastened death among the public.
Several observations challenge these assumptions. 4 The countries mentioned above that allow physician-assisted dying in defined circumstances also offer comparatively good health care, including some degree of pain management and palliative care. Data from several countries regarding reasons that people ask to hasten their death indicate that only a minority of people do so because of pain. Instead, significant majorities are motivated by a loss of dignity, feeling like they are a burden to others, and similar concerns.1,4
Another regional and cultural trait may contribute to the geographic distribution of public attitudes and legal policies toward hastening death. In mainstream cultures of Western Europe, Australia, and the northern parts of North America, people typically identify themselves as distinct from their family and community, and, correspondingly, individual autonomy is a driving principle in law and medical ethics. In contrast, in much of the developing world, including many African and Asian countries, people’s identity and experience of self are commonly rooted in connections to family and community. In such societies, fears of becoming a burden or losing one’s dignity likely have less salience.
Palliative caring and acts that hasten death will coexist in a possibly increasing number of countries; nevertheless, they remain importantly distinct from one another. By its very nature, palliative care recognizes an inherent dignity of people through illness, physical dependence, and dying. It is our privilege to care, not a burden. In addition to alleviating a patient’s physical suffering, in the way they are spoken with and touched, palliative care clinicians strive to enhance people’s dignity and sense of worth. Additionally, treating a patient’s physical distress—up to and including proportionate sedation for otherwise intractable pain or other miseries—remains decisively different, clinically and ethically, from administering a drug with the intention of ending a patient’s life.
The IAHPC 2017 position statement on these issues wisely concluded that, “In countries and states where euthanasia and/or physician-assisted suicide are legal…palliative care units should not be responsible for overseeing or administering these practices.” More than two-thirds of members who responded to IAHPC’s survey agreed with maintaining a clear separation between palliative care and hastening death.