South America
When options are limited, such as poor access to essential pain relief medicines, are patients’ decisions truly acts of self-determination?
María Adelaida Córdoba
Pediatric palliative care physician; President, Palliative Care Association of Colombia (ASOUPAC)
In the last 30 years, assisted dying has been decriminalized or legalized in 12 countries where 26% of survey respondents reside. The number of countries in which assisted dying is permitted is likely to increase, based on the survey findings that more than 50% of countries are having public debates on assisted suicide and euthanasia, or both. While I personally do not consider assisted dying to be part of palliative care, palliative care professionals should be prepared to participate in these debates.
In Colombia, the decriminalization of euthanasia in 1997 helped to foster the development of palliative care:
- In 2014, the National Palliative Care Law, gave all patients the right to palliative care, coverage that currently sits at 16%.
- The public health system covers all palliative care interventions and medications, which include the full list of essential medications enumerated in the Lancet Commission on Palliative Care and Pain Relief. However, this does not translate into adequate access.1,2
To a large extent, these advances were generated by the joint work of health teams, scientific societies, civil society, and government entities; their advocacy led to public policies aimed at better access to palliative care and pain relief medications.
Today, the participation of civil and palliative care societies in the debate on assisted dying and euthanasia should focus on the importance of increasing access to high quality palliative care at all levels of care, and to medications that alleviate pain and suffering.3,4 For example, in Colombia, Constitutional Court ruling C-239/975 on euthanasia focuses its argument on dignity, autonomy, self-determination, and the right to decide how one wants to live with dignity. However, fundamental elements when making this decision include: availability of options, access to adequate palliative care, and access to medications that relieve pain and suffering. When these options are limited, society should question whether a patient’s decision is an act of self-determination, or the result of lack of access to high-quality palliative care.
Assisted death and euthanasia are end-of-life scenarios that affect professional practice in palliative care: it is necessary to provide a space for conversation that allows us to know our personal attitudes. About 50% of survey respondents support the availability of assisted suicide and 25.5% support the availability of euthanasia. As palliative care providers, we can’t forget that our professional task is to provide—and advocate for—the best quality of care for our patients. And that the doctor-patient relationship must allow patients to feel the confidence to live their experience of suffering and death. Our personal position toward euthanasia should not mean the abandonment of patients, as long as it does not violate our autonomy.
References
- Rosa WE, Ahmed E, Chaila MJ, Chansa A, Cordoba MA, et al. Can You Hear Us Now? Equity in Global Advocacy for Palliative Care. J Pain Symptom Manage 2022; 64(4): e217-e226. DOI: 10.1016/j.jpainsymman.2022.07.004
- Pastrana T, De Lima L, Knaul F, Arreola-Ornelas H, Rodriguez NM. How Universal Is Palliative Care in Colombia? A Health Policy and Systems Analysis. J Pain Symptom Manage 2022; 63(1): e124-e133. DOI: 10.1016/j.jpainsymman.2021.07.007
- World Health Assembly, 67. 2014. Strengthening of palliative care as a component of comprehensive care throughout the life course.
- Pettus KI, De Lima L. Palliative Care Advocacy: Why Does It Matter? J Palliat Med 2020; 23(8): 1009-1012. DOI: 10.1089/jpm.2019.0696
- Sentence C-239/97. 1997. Unconstitutionality action against article 326 of decree 100 of 1980-Criminal Code (homicide by mercy). [Spanish]