Europe

Let us pay attention to cautionary experiences and not move rapidly toward new laws, which are blunt instruments that respond poorly to ethical complexities.

Robert Twycross
Emeritus Clinical Reader in Palliative Medicine, University of Oxford, United Kingdom

What can we take from a survey completed by 263 IAHPC members from 66 countries with widespread differences in the availability of hospice/palliative care (HPC), and mostly from countries where no form of assisted dying is permitted? Because of the inevitable impact of culture on beliefs, I imagine that those in jurisdictions where assisted dying is not permitted will be less inclined to support it, whereas those in jurisdictions where it is permitted are more likely to approve. Further, the impact on society is likely to be different in jurisdictions permitting only physician-assisted suicide, as in the United States, compared with those with more liberal statutes, as in Belgium, Netherlands, and Canada.

Two responses in particular stand out for me. 

First, 25% agreed with the statement that “Patients should have a right to choose euthanasia and receive it for any reasons the patients may choose. It should be legalized and made available in countries where [it] is not.” Really? The context for the survey was assisted dying for “medical conditions that are incurable, untreatable, or irreversible.” Thus, not limited to progressive end-stage disease—as is the case in Belgium, Netherlands, and Canada, where assisted dying is permitted for chronic debilitating conditions, extending to fibromyalgia and chronic fatigue syndrome; and, in the two European countries, intractable psychiatric conditions, including depression and chronic persistent anorexia nervosa. By framing the question as it is, are we in danger of allowing individual autonomy to become an ethical trump card?  Given that a healthy society should act in the interest of the common good and protect the vulnerable, the essential questions would seem to be: Can a law be devised that would:
     1. protect those considering assisted dying because of psychological and social vulnerabilities or because of inadequate HPC, mental health care and/or social support?
    2. prevent endangering those who do not desire assisted dying? Endangerment can occur if cultural attitudes of compassion for the disabled, elderly, or dying are undermined, or if governmental support and funding for HPC is weakened. 

I doubt it. Although, in the US, where physician-assisted suicide (but not euthanasia) is permitted in 10 states and the District of Columbia,¹ it might be. In these states, if requested, a doctor can prescribe a lethal cocktail of drugs to a patient with a terminal illness and, generally, an anticipated prognosis of six months or less to be kept at home for use “just in case,” should they feel that life is becoming intolerable (the “Oregon model”). Only about three-quarters of issued prescriptions are used.¹ In contrast, in draft proposals in the United Kingdom, a doctor would personally deliver the drugs to the bedside only when the patient deems the time is right, and would remain while the fatal overdose is taken. This immediately introduces the potential for coercion: it could be difficult for a patient with last-minute doubts to change their mind if they felt that they were wasting the doctor’s time. 

Second, 20%-22% agreed that assisted dying should be part of palliative care. However, there are people (certainly in the UK) who decline referral to HPC because they believe patients are drugged to death with morphine. I have no doubt that legalizing assisted death—particularly if incorporated into HPC—would lead to more patients dying in pain and distress than at present. The underlying philosophy of HPC, “You matter because you are you, and you matter to the last moment of your life,” implies a commitment to non-abandonment. Once assisted dying is included in the range of therapeutic options, everything changes. A Canadian palliative care doctor recently said: 

“The MAID [medical assistance in dying] situation in Canada is disastrous... At the bedside level, we deal with the resulting chaos on a daily basis as patients agonize over how they should choose to die, and families are furious when incapacity rules out MAID since families have come to believe from media that the only good death is a MAID death.” 

—J. Scott, personal communication, 2023 

This will become an even bigger problem if the professional expectation shifts toward routinely informing potentially eligible patients about assisted dying as an option for consideration, as mooted recently by the College of Physicians and Surgeons of Ontario. 

Unconscious bias in doctors associated with transference and countertransference can lead to the misuse of assisted dying.² Depression greatly influences requests for hastened death in terminally ill patients,³ but is often not recognized or is dismissed by doctors, some of whom proceed with assisted dying anyway. Requests are often based on exaggerated fears of what the future holds or a sense of hopelessness. The desire for death is unstable and generally responsive to psychosocial interventions.⁴ Further, there is a lack of awareness among doctors that a request to hasten death may be a subtle way of finding out whether a doctor still regards the dying person as worthy of respect and support. Thus, there is a pressing need to specifically include compassionate listening in communications skills training for all health professionals. (For patients’ stories illustrating what this means, see de Hennezel.⁵) Equally important is the need for doctors, particularly oncologists, to be more realistic and avoid therapeutic obstinacy—futile treatments with no patient benefit, which are a major cause of suffering—and to include palliative care as a positive option that enhances quality of life. 

It is important to emphasize that, where assisted death is permitted, it does not mean that it need become part of palliative care. Also, it is perfectly consistent to argue that, ethically speaking, assisted death may be permissible in rare cases, but it would be unwise to change the law. The law is a blunt instrument, unsuited for dealing with ethical complexities. It could be better to continue with the status quo rather than introduce legislation with the likelihood that it will become too permissive, and undermine the ethos and practice of HPC. The Canadian experience strongly suggests that assisted death (almost entirely euthanasia) will lead to more harm than good, particularly since the so-called “foreseeable death requirement” was scrapped. ^6,7   

Finally, it should be noted that, if the law is changed, there is no reason why doctors or nurses should be involved. For patients fulfilling the legal criteria, a separate assisted death service could be established. Taking all these factors into account, I believe that HPC must remain steadfast in its opposition to attempts to having assisted death incorporated into it.

A pioneer of the hospice movement during the 1970s, Dr. Twycross helped palliative care gain recognition as an accepted field of modern medicine.

References

1. CNN Editorial Research. Physician-Assisted Suicide Fast Facts. Updated on May 26, 2022. 
2. Hsiao-Rei Hicks M. Physician-Assisted Suicide: A review of the literature concerning practical and clinical implications for doctors. BMC Fam Pract 2006; 7(39). DOI: 10.1186/1471-2296-7-39
3. Rodin G, Lo C, Mikulincer M, Donner A, Gagliese L, et al. Pathways to Distress: The multiple determinants of depression, hopelessness, and the desire for hastened death in metastatic cancer patients. Soc Sci Med 2009; 68(3): 562-569. DOI: 10.1016/j.socscimed.2008.10.037
4. Chochinov HM, Wilson KG, Enns M, Mowchun N, Lander S, et al. Desire for Death in the Terminally Ill. Am J Psychiatry 1995; 152(8): 1185-1191. DOI: 10.1176/ajp.152.8.1185
5. de Hennezel M. Intimate Death: How the dying teach us to live. Little, Brown & Company, Boston, New York, Toronto, London, 1997, pp. 30–40.
6. Webster P. Worries Grow about Medically Assisted Dying in Canada. Lancet 2022; 400(10355): 801-802. DOI: 10.1016/S0140-6736(22)01733-0
7. Raikin A. No Other Options. The New Atlantis, 2022. Published online on December 16, 2022.

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