Volume 24, Number 4, April 2023 Supplement - Section II: Opinions

South America

How a discussion of MAiD served as a catalyst for a Universal Palliative Care Law. Also, life as “sacred” is increasingly exposed to a qualitative evaluation.

María Alejandra Palma
Professor, Department of Internal Medicine, Faculty of Medicine, University of Chile; Continuous and Palliative Care Section Head, University of Chile Clinical Hospital, Santiago, Chile

Most respondents to the IAHPC survey reported that MAiD remains illegal, but a topic of ongoing public debate, with mixed results on how this debate affects the development of palliative care, probably reflecting different cultural, social and political contexts. 

In Chile, a Universal Palliative Care bill had been proposed by politicians several times but was not passed. Thus, since 1994, only advanced oncology patients have had access to palliative care. The political discussion about palliative care provision completely halted in 2019. In April 2021, the Chamber of Deputies, Chile’s elected body of national politicians, approved a Death with Dignity and Palliative Care bill that establishes the right to receive MAiD in case of terminal illness. However, subsequent discussion in the upper house of parliament was suspended by the Executive, which represented a social sector whose values leaned contrary to MAiD. Instead, priority was given to the postponed Universal Palliative Care bill. 

Quickly approved, the Universal Palliative Care Law 21.375 officially came into force on March 21, 2023. This is an example of how public discussion of MAiD generated a political juncture that, at least in the short term, can lead to the support of palliative care development. 

Another interesting finding of the survey is that the majority of respondents (86%) agree with the statement that palliative care representatives should be part of the MAiD discussion, but disagree that MAiD should be part of palliative care (68-70%), with fewer in favor of legalization (47.5-49%).

This might be explained by the fact that this study represents a group composed mostly of physicians (65.4%) with Christian religious beliefs (56.2%); therefore, personal value bias could underpin the data. The discussion surrounding MAiD often takes the form of polarized confrontations between ethical and philosophical positions, considering that the legalization of MAiD reflects the tendency to move from a system of protection of life, which responds to the paradigm of the sacredness of life supported by different religious beliefs, to a system of gradualist protection, which considers the weighting of the quality of life as the axis of decisions, thus claiming the legal recognition of the right to the autonomy of individuals. In other words, life, traditionally considered sacred and inviolable, is increasingly exposed to a qualitative evaluation. 

In my opinion, however, this analysis does not exhaust the underlying complexity of this issue. Palliative care is a discipline with a relatively recent professional development, which strongly claims the importance of taking care of sick people’s suffering in a holistic and responsible way. Suffering is at the origin of requests for MAiD, and respect toward the autonomy of those who request it is a vision that must be complemented by a perspective of solidarity, equity, and justice. Guaranteeing access to quality palliative care will eventually succeed in reversing the intensity of this suffering. So, the limited support of palliative care providers to MAiD does not necessarily represent an ethical stance contrary to the moral legitimacy of MAiD itself. I strongly believe this approach seems relevant, especially in countries where the population's access to quality palliative care is limited. 

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