Olaitan A. Soyannwo
Palliative care expert; President, Hospice and Palliative Care Association, Ibadan, Nigeria; and representative, The Centre for Palliative Care, Nigeria
I agree with the IAHPC’s position statement that “no country or state should consider the legalization of euthanasia or physician-assisted suicide until it ensures universal access to palliative care services and to appropriate medications, including opioids for pain and dyspnea.”1 It is my view, however, that the futuristic goal of universal access to palliative care is almost an unachievable target in many developing countries due to many competing priorities, poor health facilities, poverty, and lack of awareness about quality of life and quality of death.
For example, palliative care development in Nigeria only started in earnest in the 1990s, and its National Palliative Care Policy was only released in 2021.2 Thus, any form of assisted dying or euthanasia, as well as suicide, is still regarded as a criminal offence as per Section 326(3) of the penal code that states: “any person who aids another in killing himself is guilty of felony and is liable to imprisonment for life.” Furthermore, Section 68 of the Rules of Professional Conduct for Medical and Dental Practitioners, adopted in 1990, states that it is antithetical and contradicts the physician’s Hippocratic Oath to terminate the life of a patient who is in sound health or terminally ill, or to help a patient commit suicide.3-7
There are no moves to change these laws yet, although there is opportunity for palliative care advocates to forge ahead with efforts to integrate palliative care into health care systems, as recommended by the World Health Organization and the IAHPC.
On a personal note, as a medical and palliative care professional and a Christian, I have a conscientious objection to taking part in euthanasia or physician-assisted suicide. I believe that saving life is a physician’s goal that must be kept sacrosanct. The philosophy of palliative care is that there is a lot of care and support that can be offered to prevent pain, suffering, and anguish until the very end of a person’s remaining life. Rather than participate in assisted dying, I prefer to be involved in use of terminal sedation for end-of-life care, with clear guidelines and good communication between the care team, patients, and families. This method of ensuring a dignified end will still be relevant even when there is universal access to palliative care.
Patients in Nigeria do not like to give up hope of cure, and some refer to palliative care experts as “angels of doom.” In over 20 years of palliative care practice, I have had many patients wishing for death when they are first referred for palliative care with advanced disease, but I have only had two who specifically requested help to die. One made a failed attempt to overdose: afterward, continued holistic palliative care brought succour to the patient, and he died peacefully months later surrounded by his family and caregivers.
Early referral of patients in need of palliative care is essential to establish long-standing relationships and psychosocial support, apart from physical symptom management. If palliative care professionals are expected to be involved in euthanasia or physician-assisted dying, the guidelines must be endorsed universally and participation should be optional.