This resource is under development and will change regularly over coming weeks. Please take the opportunity to register for updates if you wish
APM PAS Position Statement June 2019
This resource was created to inform members of the Association for Palliative medicine of their views about medical involvement in intentionally ending a patients life.
Palliative Medicine and the APM have a wide and blended workforce. We are members or Fellows of the RCGP, RCA & RCPsych, and the APM is a Society of the Royal College of Physicians (RCP). Through our link to the RCP, this resource initially addressed the RCP Poll on physician assisted dying that began February 2019 and concluded in March 2019.
This Poll was not about the rights and wrongs of assisted suicide, but whether it should become a new duty for doctors
The RCP poll result was published on 21st March 2019…..
RESULT including Palliative breakdown…
neutrality position Vs not supporting a change
Given the potential for this to be a new duty of care for doctors ,were the law to change ,the APM created this resource to inform , guide and enable opinion . This included the input from Palliative physicians who advocate and who oppose change
This subject is core to any clinician practicing in Supportive, Palliative and End of Life Care
- This resource is not about the rights and wrongs of actively and intentionally ending life per se, which is a personal matter, but the role of medicine in assisting suicide/death’.
- It focuses on a doctor’s potential involvement should the Laws change in any of the four nations of the UK and Ireland. Based upon the APM Survey of its members in 2014/15 and confirmed by the RCP Survey’s subset of results for palliative medicine. The APM opposes a change in the Law however, practitioners, irrespective of their personal opinions, must;
- be well versed and confident in discussing aspects of the subject from the perspective of those who advocate and those who oppose;
- feel confident in engaging patients and families when they raise the question in a clinical encounter.(The RCP clearly supports this drive and with the APM produced this document here)
- The public and other professions may find resources and information to aid discussions
Over time, resources will be added on relevant theory and ethics to inform your thinking
- We refer readers to relevant sites and materials elsewhere wherever possible
- We welcome contact to notify us of faulty hyperlinks or if you feel that other resource or papers will enrich the content in any way.
Suggestions for additional evidence and material are welcome. Email Compleat Secretariat.
The RCP 2019 poll was not a direct re-run of the 2014 poll.
The language and questions changed
- The 2019 poll replaced the term ‘Physician Assisted Suicide’ with ‘Assisted Dying’
- For the purposes of the 2019 Royal College of Physicians poll, the RCP defined ‘assisted dying’ as:
“The supply by a doctor of a lethal dose of drugs to a patient who is terminally ill, meets certain criteria that will be defined by law, and requests those drugs in order that they might be used by the person concerned to end their life.”
From this definition it is clear that the RCP referred solely to the involvement of doctors who will be involved explicitly in the assessment, decision making and implementation in bringing about the premature death of an individual
- The change in the language in the consultation means there was no clear opportunity to distinguish between a support for assisted suicide personally, whilst being opposed to assisted suicide by doctors
- In the poll, there was a free field in which such points could be made
The RCP has now defaulted to neutrality
- The College has now moved to a position of neutrality. This was as a result of the poll failing to meet with a Supermajority result. The Council imposed this stipulation on the outcome and has set this at 60% either opposing or favouring legal change. The college previously and explicitly did not support the change in the law.
- This was an important change from the method used in 2014
- The 2014 position was based on a simple majority vote
- 57.5% of members (Question 1) opposed change outright
- A further 10.2% favoured assisted suicide but not by doctors,
- Only 31% supported the College being neutral
Neutrality over Physician Assisted Suicide and its Implications
What does neutrality mean?
- Here is a general definition:
- This reference, gives a good account. Whilst Koukl thinks neutrality is a myth, he does put both sides of the argument
Arguments for neutrality
- Articles favouring neutrality for assisted suicide, are here from UK General Practice and America
- In 2006, when the RCP briefly took a neutral position, its then president made the case here
Arguments against neutrality
- A profession’s representative body must have a clear position on what might become a new duty;
- This is particularly important when the proposed change will bring about a profound, fundamental and irreversible shift in medicine’s philosophy and practice;
- The RCP should therefore have a clear position because if physician assisted suicide or death becomes legal, it will affect directly the majority of doctors, especially in palliative medicine and related specialties.
- Moving from opposition to neutrality is not a neutral act: it is a move towards support and outside of the profession it will be understood as tacit approval of assisted suicide.
- All doctors should form an opinion, and if unable to do so, should default in favour of safety.
The Current Position of UK Medical Organisations
- GMC is medicine’s regulatory body.
- Their role as regulator is to ensure doctors act within the law, whatever that legal framework is.
As the regulator that ‘polices’ doctors, it cannot have a view or position
No position on Assisted dying
Royal College of Physicians, London (March 2019 – in relation to the above)
Royal college of Psychiatrists
Royal College of Anaesthetists
Royal College of Obstetricians and Gynaecologists
Royal College of Paediatrics and Child Health
Royal College of Physicians of Edinburgh
Royal Society of Medicine
Royal College of Nursing
Royal College of Nursing Scotland
Polling on the Opinion of Doctors
Knowing people’s view in principle can be helpful and should be based on an even-handed presentation of principles. However, questions and responses are necessarily broad and open to all sorts of interpretation when one looks at precise meanings.
The APM made a decision at the end of 2014 to survey against specific Bills for the very reason that
- they were real and present
- people could see and respond to what may become their duty of care and not just consider matters in the abstract
The results of our 2014/5 survey are here
Public Opinion and Medical Opinion Should Be Separate
A view of the rights and wrongs of assisted suicide is not the same as a view on a doctor’s direct involvement enabling assisted suicide or administering lethal drug. As in Switzerland doctors do not need to be involved for assisted suicide to be available.
- In the 2014 RCP Poll 10.2% of respondents favoured legal change but opposed doctors’ direct involvement
- A shift from opposition to neutrality will be misinterpreted by society, the media and Parliament to mean that physicians as a whole support legal change. This happened in 2004, when the RCP briefly took up a neutral position. In legislatures where medical societies became ‘neutral’, such as Canada and California, a change in the law placing the responsibility with doctors, followed quickly and irreversibly.
For the purposes of the 2019 Royal College of Physicians poll, the RCP defines ‘assisted dying’ as:
The supply by a doctor of a lethal dose of drugs to a patient who is terminally ill, meets certain criteria that will be defined by law, and requests those drugs in order that they might be used by the person concerned to end their life.
The RCP is referring solely to the involvement of doctors in bringing about the premature death of an individual and is distinct from palliative care.
- ‘Assisted dying’ means bringing about death. It is physician assisted suicide.
- Palliative care controls symptoms or distress whilst a person dies.
- Expert and appropriate symptom control with sedatives, opioids etc. does not hasten the dying process.
- ‘an act capable of encouraging or assisting the suicide or attempted suicide of another person, and that act was intended to encourage or assist suicide or an attempt at suicide’
- Adding Physician or Doctor makes clear whose action it is
Canada: Medically Aid in Dying (MAID)
MAID includes clinician assisted suicide and physician administered euthanasia
This involved doctors, nurses and others such as pharmacists. It is defined by eligibility criteria that are listed as:
- be eligible for health services funded by the federal government, or a province or territory (or during the applicable minimum period of residence or waiting period for eligibility)
- generally, visitors to Canada are not eligible for medical assistance in dying
- be at least 18 years old and mentally competent. This means being capable of making health care decisions for yourself.
- have a grievous and irremediable medical condition
- make a voluntary request for medical assistance in dying that is not the result of outside pressure or influence
- give informed consent to receive medical assistance in dying
Oregon: Death With Dignity Act (DWDA)
This also involves doctors and has eligibilities, but is confined to physician assisted suicide
Their definitions are very clear
‘Euthanasia is performed by the attending physician administering a fatal dose of a suitable drug to the patient on his or her express request. The relevant Dutch legislation also covers physician-assisted suicide (where the physician supplies the drug but the patient administers it). Palliative sedation is not a form of euthanasia: the patient is simply rendered unconscious with pain reducing drugs and eventually dies from natural causes.’
Belgium has now extended their law to apply to mature minors
Some people welcomed it, underlining the “pioneering” role Belgium played in establishing a legal framework for euthanasia, which was presented as the ultimate “humanitarian act” of which any patient, major or minor, should be able to take advantage. In contrast, others in Parliament and in civil society opposed the extension of the law. Among these were nearly two hundred paediatricians and paediatric palliative care specialists.
Are Assisted Suicide and Euthanasia different or the same?
When a doctor treats a bacterial infection with an antibiotic, the difference between prescribing it and administering it is practical and not moral
- The moral decision is that the infection ought to be treated
- The practical decision is how to ensure the patients gets the right dose to kill the bacteria
The same reasoning applies to ending a person’s life: the way in which a doctor does it is practical and not moral
- The moral decision is that the life, for one reason or another, is no longer worth living and that the person is better off dead
- The practical decision is how to ensure the person gets the right dose to kill them
Physician assisted suicide involves prescribing lethal drugs intended explicitly to end a life.
- The person takes the mediations themselves or is assisted in some way to take them;
Physician administered euthanasia is the administration of a lethal cocktail of drugs intended explicitly to end a life
- The physician administers the drugs, usually by infusion
In Jurisdictions such as Canada, the Netherlands and Belgium, where both physician assisted suicide and physician assisted euthanasia are permitted. The overwhelming number of deaths are brought about by physician administered euthanasia
- the APM does not distinguish between physician assisted suicide and euthanasia and for this reason
- gives equal weight to the evidence from all jurisdictions when it comes to safeguards etc.
Note the in language and definitions of physician assisted suicide and euthanasia across jurisdictions. They are summarised here
These have remained broadly the same over time, Here they are.
2011 on assisted suicide and disability here
2015 on whether judicial consent for assisted dying will protect vulnerable people here
2017 on how Dutch safeguards are failing individuals with intellectual disability and/or autism here
2019 A sobering article by a Dutch Journalist entitled Death on demand, has euthanasia gone too far? Summarises the situation there:
His Jan 2019 Guardian article describes what happens when assisted dying becomes accepted practice. The increasing numbers and expanding criteria in the Netherlands are viewed by some as progress, but voices of alarm are growing. Concerns over the lack of adequate safeguards and the lack of conformity over decision-making are causing concern. The author comments: Without consensus on these basic motivations, euthanasia won’t be an occasion for empathy, ethics or compassion, but a bludgeon swinging through people’s lives, whose handiwork cannot be undone.
- In the Netherlands the number receiving an assisted death have trebled in 10 years and the range of conditions considered eligible has expanded.
- Some, such as the Dutch End of Life Clinic welcome the ‘slippery slope’ as progress, but in recent years voices of alarm have been raised over the increasing numbers and expanded criteria for assisted dying.
- Two areas are causing the greatest concern:
– the definition of ‘unbearable suffering’ is interpreted in very different ways
– the impact of a loss of capacity and the authority of an advance directive
- As review boards become increasingly concerned with the legality of physician assisted suicides and euthanasias, the question of whether in certain cases good is done by killing threatens to get snowed under.
- Despite the wide access to assisted deaths 1900 people still killed themselves in 2017.
- There is no uniformity of response to requests for a physician assisted death and personal views often weigh decisively. The author comments: As the most solemn and consequential intervention a Dutch physician can be asked to make, and this in a profession that aims to standardise responses to all eventualities, the decision to kill is oddly contingent on a single, mercurial human conscience.
- The question for any country contemplating physician assisted dying is whether the practice must inevitably expand. The author comments: The more I learned about it, the more it seemed that euthanasia, while assigning commendable value to the end of life, might simultaneously cheapen life itself. Without consensus on these basic motivations, euthanasia won’t be an occasion for empathy, ethics or compassion, but a bludgeon swinging through people’s lives, whose handiwork cannot be undone.
Based on these arguments and facts, The APM does not support a change in the law.
Are Safeguards sufficient?
Suggested safeguards from supporters of physician assisted suicide cannot be clearly defined in law. Should the RCP outcome favour physician assisted suicide, safety will be a major concern.
- Permissive laws, such as ones allowing assisted suicide, do not limit bad practice.
- The monitoring of safeguards in other jurisdictions is poor or almost non-existent.
- Relevant links are here
Close scrutiny of legal proposals and issues can be found here
As a summary:
- Restrictions have gradually reduced in Belgium, the Netherlands and Switzerland and Oregon. This includes children
- Concerns about legislation in Canada are expressed here
- Canada after only three years is consulting on extending its criteria to include minors and have reported here and for mental illness here other comments are here
- Vulnerable patients groups are said to be safe here and disputed here
- In the Netherlands 20% of psychiatric patients undergoing euthanasia never had a psychiatric inpatient stay.
- In Belgium individuals with autism and Asperger syndrome are being accepted for euthanasia,
- The proportion of psychiatric cases undergoing euthanasia rose six-fold over a 10 year period, mainly in women with a ‘mood disorder’. A Dutch End of Life Clinic is likely to accept patients refused by other doctors.
- Of note, many of these writers consider the stopping of futile or harmful treatments to be morally equivalent to actively ending life. This is an inadequate consideration of defensible distinctions between action and omission. It reflects the dominant philosophy in permissive jurisdictions. We will write a summary of the arguments under the Ethics section in due course.
- Relevant references are
In Oregon concerns have been raised about inadequate protection for patients with depression and anxiety.
- In 2014 the Belgian Society of Intensive Care endorsed doctors actively hastening the dying process with sedatives ‘in the absence of distress.’
- It is extremely dangerous to have any form of physician assisted suicide or euthanasia as part of medical practice as safeguards are ineffective
- The Courts are best placed to testing the wisdom of an individual patient’s judgments, and from that the rights to assisted suicide for some, while protecting the lives of others.
- Assisting suicide, if legalised, is the proper province of the courts and independently licensed implementer’s, not that of doctors.
Will Conscientious Objection protect dissenting doctors?
Can a doctor conscientiously object to involvement in assisting suicide if it becomes legal?
- The answer may well be No.
Both supporters and opponents of legal change appeal to it, yet conscientious objection in medicine is under fundamental challenge.
One argument used to reassure clinicians who object to physician assisted suicide is its similarity to termination of pregnancy where a doctor with a conscientious objection has a right in law
- Not to participate in the procedure actively, but
- must refer on to a clinician who is willing to perform it:
- in refusing to perform a procedure a practitioner can object only to the actual‘doing’ of a procedure
There is no actual ‘doing’ in Physician Assisted Suicide, just facilitating or assisting.
- This calls into questions the applicability of conscience to physician assisted suicide in English law.
A Bill, Conscientious Objection (Medical Activities) Bill HL 2017-19 that is still at the House of Lords level, seeks to broaden conscientious objection once again. it is unknown how successful this will be.
The APM does not believe in the long-term that conscientious objection will afford protection to doctors if Physicians Assisted Suicide is made legal.
Trust is a very difficult thing to pin down, but we all know when we have it and when it’s lost.
Most can be learned from examples from practice.
Katherine Mannix’s tells a story about a man, Ujal, living in the Netherlands who is desperate to come to the UK to die (Pp 179-195). He says:
“They didn’t mean to frighten me. I think they thought it was a comfort. But it was every day, every ward round, they told me that if I want to, I can choose to die……”
Mannix goes on to explain that
‘His only criticism is that there was a subtle, entirely unintended nuance in every consultation once his cancer had spread. In the end this nuance was too frightening to tolerate … Ujal ran away from that certain, controlled dying to live with the hope of uncertainty … Ujal lived with us [at the hospice] for two months … before dying very quietly while Tabitha [his daughter] was running and laughing in the garden outside his room.
Once the euthanasia genie is out of the bottle, you must be careful what you wish for.’
A recent Guardian article gives further reinforcement to this concern and extends it to tensions between doctors in a tragic cameo.
‘For all the safeguards that have been put in place against the manipulation of applicants for euthanasia, in cases where patients do include relatives in their
decision-making, it can never be entirely foreclosed, as I discovered in a GP’s
surgery in Wallonia, the French-speaking part of Belgium.
‘The GP in question – we’ll call her Marie-Louise – is a self-confessed idealist who sees it as her mission to “care, care, care”. In 2017, one of her patients, a man in late middle-age, was diagnosed with dementia and signed a directive asking for
euthanasia when his condition worsened. As his mind faltered, however, so did his
resolve – which did not please his wife, who became an evangelist for her husband’s death. “He must have changed his mind 20 times,” Marie-Louise said. “I saw the pressure she was applying.”
‘In order to illustrate one of the woman’s outbursts, Marie-Louise rose from her desk, walked over to the filing cabinet and, adopting the persona of the infuriated wife, slammed down her fist, exclaiming, “If only he had the courage! Coward!” Most medical ethicists would approve of Marie-Louise’s refusal to euthanise a patient who had been pressured. By the time she went away on holiday last summer, she believed she had won from her patient an undertaking not to press for euthanasia. But she had not reckoned with her own colleague in the practice, a doctor who takes a favourable line towards euthanasia, and when Marie-Louise returned from holidays she found out that this colleague had euthanised her patient.
‘When I visited Marie-Louise several months after the event, she remained bewildered by what had happened. As with Marc, guilt was a factor; if she hadn’t gone away, would her patient still be alive? Now she was making plans to leave the
practice, but hadn’t yet made an announcement for fear of unsettling her other patients. “How can I stay here?” she said. “I am a doctor and yet I can’t guarantee the safety of my most vulnerable patients.”
- The specialty is very aware of how good relationships with patients and families matter and how our actions and words affect how patients and families see us.
- Physician assisted suicide or euthanasia is an unnecessary additional pressure on our clinical relationships
Doctors' involvement makes this a treatment
Having physician assisted suicide in medicine makes it a treatment subject to the economic pressures of the NHS
Here is a sobering podcast from an American Physician.
In Canada an economic analysis concludes with these words:
“Providing medical assistance in dying in Canada should not result in any excess financial burden to the health care system and could result in substantial savings.”
Reports on the ground from Canada to the APM from programme directors and clinical leaders in palliative care show that the promised investments in palliative care that were to accompany the introduction of ‘Medical Assistance In ending Life’ (MAID) have not materialised, that is some areas investment in palliative care has fallen, and heat maps of the areas in which MAID is most common are where palliative care is least available.
The APM considers that the economic factors that are relevant in deciding between treatments of any kind will extend quickly and inevitably to physician assisted suicide or euthanasia were they made legal in the UK.
Social and not Medical Pressures
Wanting assistance to suicide or die may be triggered by something clinical, but Oregon’s data show that the majority of reasons people seek assisted suicide are social and not medical. They relate to concerns about the inability to enjoy previous activities, fears about the future, worry about being a burden in needing support with care and losing autonomy.
We all have our limits. Because of our caring and compassionate relationships with our patients, we are not always best placed to judge objectively the social factors affecting a ‘settled’ wish to die such as the coercive psychological, relational and cultural pressures that may be in play.
The impact of one person’s actions always affects others and may go beyond friends, family and carers. Patients’, carers’ and society’s attitudes to doctors and their expectations of us, and probably their attitudes to the dying generally, will change if deliberately ending life early is seen as part of medicine and illness
- Society’s wish, if it is genuine, for people wanting assisted suicide or euthanasia to have access to it, stands in its own right;
- It should be a responsibility and provision entirely separate from medicine and healthcare.
- If there are any medical factors in a decision, then doctors should furnish them, but
- any system of assessment and implementation is not the province of medicine and health care
Autonomy is not simply an isolated expression of control. The impact of one person’s action to end his or her life affects friends, family and carers, as well as society’s attitudes to the dying generally. Physician-assisted dying creates expectations that deliberately ending life early is one of a physician’s responsibilities.
A discussion of autonomy and its relationship to assisted suicide is available here
Clinical Burden and the Workforce
Many young doctors are feeling increasing pressure and worry about their own and colleagues’ mental health and burnout. The literature on the personal impact on them of being involved directly in assisting suicide and euthanasia reports significant psychological morbidity. Given existing challenges in our workforce this could well be a concern for the future.
Other views include
A shift away from the fundamental values of medicine to heal and promote human wholeness can have significant effects on many participating physicians. Doctors describe being
- profoundly adversely affected,
- shocked by the suddenness of the death,
- caught up in the patient’s drive for assisted suicide,
- having a sense of powerlessness and feeling isolated.
There is evidence of
- pressure on and intimidation of doctors by some patients to assist in suicide
Implications for Hospices & Specialist Palliative Care
One of the difficulties of commenting on the impact of legislation here, in comparison with elsewhere, is that Specialist Palliative and Hospice Care in the UK is that we rank as the best in the world. It is highly developed and what we define as hospice care will have little or no resemblance to that elsewhere. Consequently, claims from the countries with legislation around physician assisted suicide or euthanasia that palliative care has been unaffected or may have improved may be true for them. That does not make it true for us. The recent experience in Canada, which has pockets of very high quality palliative and hospice care that we would recognise as comparable to the UK, bears this out.
The APM continues in direct conversation with clinicians in Canada from both sides of the divide to try and understand the implications for us. One major proponent MAID (medical assistance in dying, that includes euthanasia) came from palliative care and is zealous in his perspective. He has presented to a lobbying Parliamentary Group in Westminster recently. Others have many concerns.
Apart from the authors above along with Harvey Chochinov and Mike Harlos. Others have expressing worries that are widespread and many would rather remain anonymous because of the impact speaking out may have on them personally. Below is a distillation of some anonymised comments we have on record.
Focus on how to support the ongoing provision of palliative care services regardless of whether MAID is also being considered by the patient.
The broad philosophy of palliative care (as described by the WHO or the recently-revised IAHPC definition) can be challenging to implement within the constraints imposed by the realities of health care service provision. This was highlighted early on when MAID became available – many palliative care practitioners expressed strong philosophical opposition – that assisted death represents the antithesis of the philosophy of palliative care.
I recall a Medical Director colleague from another city saying that he will never allow MAID to occur on “his unit”. The reality is that he was powerless to prevent it; his only option would be to resign as director. Although I could never see myself providing MAID, I felt that it was important for me to support our palliative care team in approaching this new development in health care.
Even if the palliative care community maintains that there should be no connection between palliative care and MAID,
- it is impossible to deny the overlap between those whom palliative care aspires to support and those who are eligible for MAID.
- Our federal legislation requires a “grievous and irremediable medical condition” and that “their natural death has become reasonably foreseeable” – this essentially paraphrases most palliative care program criteria, and the connection is pretty much legislated.
In my experience, the following issues/challenges stand out as having been significant for our palliative care team:
Health care providers wishing to avoid involvement in MAID (conscientious objection)
For the most part there is support for clinicians who oppose involvement for religious or moral/ethical reasons. However, the framework for addressing conscientious objection is a combination of legal requirements outlined in the legislation as well as the statements/guidelines of the practitioner’s regulatory body (medicine, nursing, pharmacy, social work).
We have had many of our team members express opposition to any connection MAID; unfortunately, it seems rare that these same clinicians will take the time to inform themselves about the issue, such as reading the legislation, the requirements of their own regulatory body, and literature regarding ethical considerations around conscientious objection.
Faith based facilities, as you would imagine, have also had their own unique struggles.
- some allow an initial assessment to take place within their facility,
- none allow the MAID procedure itself to take place there, which means the patients must be transferred elsewhere.
- While this seems a reasonable solution, there have been instances where this has caused patients great suffering i.e the ambulance ride itself has caused tremendous pain and required extensive analgesia (not to mention the disruption for patients and families at this most vulnerable time).
Palliative Care programs will need to develop an approach to meeting patients’ needs and ensuring compliance with legal and regulatory requirements around MAID, while still supporting clinicians who object.
- Our provincial medical regulatory body requires that even if physicians object to MAID, they must at minimum provide information outlining how to contact the MAID providers
- In our program we have physicians who feel that they cannot even meet this minimum requirement; rather than make this an issue, I have let them know to contact me and I will do so.
Ongoing education and support is needed for the team about these complex ethical and moral issues.
- Some might feel that even in just providing palliative care support to a patient who is awaiting the MAID procedure, they are complicit in the process.
- Ongoing meetings and discussions to help the team compartmentalize how they view their involvement is important.
Palliative Care clinicians feeling they have failed in addressing a patient’s suffering if the patient chooses MAID
This is a very real challenge. The data locally indicates that
- virtually none of the patients seeking MAID are doing so because of uncontrolled symptoms.
- it is a desire for autonomy and control.
- Reaffirming this with our palliative care team has been helpful – i.e. the patient is not seeking MAID due to the failure of the nurse or physician.
Palliative Care team members feeling upset when they were unaware that the patient was pursuing MAID (they sometimes find out after the fact).
We have had situations where the patient does not feel comfortable sharing their intentions to receive MAID. This may be concern
- that they will be judged, or
- their ongoing care might be compromised, or
- that people will try to talk them out of it.
- This can leave the palliative team member feeling hurt, or even betrayed.
- It can also have implications for our program functioning and scheduling as well, as we have had community palliative nurses show up at a patient’s house after a weekend, only to find that the patient had received MAID over the weekend.
We have worked with the MAID providers to
- keep us informed when needed for our own provision of clinical care.
- We have also worked with our team to reinforce the patient’s right to privacy.
Clinicians uncertain how to respond to comments from the patient about a desire for death.
Prior to MAID, palliative care clinicians were generally comfortable and skilled at exploring comments such as “I just wish this was all over”, or “I wish that I could go to sleep and not wake up again”, or “Why can’t you just give me something to end this – we treat animals better than this”.
- We approached such comments by exploring the underlying suffering, and looking for ways to provide support.
- Now that MAID is on the landscape, we might forget that we still have a role in exploring suffering
It can also be difficult to know if the patient is actually asking about MAID, or simply expressing an exasperation with existence.
- It doesn’t go over well to connect someone with the MAID providers if what they were really wanting for was help for their loved ones who are not coping well.
- let’s not let a request for MAID suggest that we still don’t have a responsibility to try to understand and address the patient’s suffering.
- A resource used in Canada is here
In our jurisdiction we have challenges related to faith-based facilities being exempt from the provision of MAID. This has had significant implications for patients who are in designated palliative care beds within those facilities.
The routinisation of MAID
If there have been any surprises for me, it is how quickly this has become so normal and even routine. Locally
- MAID is not administered under the auspices of Palliative Care;
- palliative care, after all is about addressing the patients quality of life, while MAID is about ending life … the distinction in my mind is very clear.
That said, the fact that it has so quickly become part of mainstream medicine is not something I had not anticipated, nor feel particularly comfortable with. As a psychiatrist, I understand the importance of presence and how powerful that can be in supporting patients and their families. It is hard for me to reconcile that approach with a stance that would see me having to participate in hastening the patient’s death.
Criteria seem uncontrollable & safeguards ineffective
In Canada the main MAID criterion is ‘death being reasonably foreseeable’.
- Quebec has its own legislation which limits MAID to ‘end of life’,
- the rest of the country grapples with how to interpret reasonably foreseeable and the
- variability of interpretation is vast (from less than six months to years).
But opening the door on MAID has also meant that there are proponents who continue to push for expanding the criteria (you may find the report regarding advance directives, mature minors and psychiatric justification alone of interest);
I hear of virtually no one contemplating restricting the criteria as they currently stand. My sense is that public support for MAID is broad, and like the observation in have seen in medicine, is perceived to now be quite routine; I’ve even seen quite a number of obituaries that openly acknowledge and thank the MAID team for their involvement in the persons death. While I remember observing this outlook of ‘normalcy and routine’ when I visited The Netherlands, I never imagine that Canada would so quickly follow in suit.
I remember one physician in Holland saying that PAS was not a medical issue but a societal issue; and another American physician describe it as ‘an act of love’. Either way, I think both were saying that fall outside of usual medical practice. I understand that for some people, this will be a compelling choice no matter what palliative interventions are offered or available.
As a society, we need to determine if this is a choice they should be entitled to; here in Canada, the decision to provide Canadians that choice came about as a result of a Supreme Court decision, followed by federal legislation passed by Parliament in February 2016.
A very separate choice is who should be responsible for providing PAS/MAID. Like you, I too argued that it is best situated outside of medicine with judicial oversight. The role of medicine, as you point out should include diagnosis, prognosis – but let us not forget our duty to address suffering (the article by Dr Harlos makes that point well). And if medicine must take this on, it should only be by those who are specifically licensed to do so, with appropriate oversight and adherence to the Vulnerability Standards.
- A change in the law to legalise PAS will inevitably call for involvement from palliative care physicians and hospice services.
- Evidence from Oregon and Washington suggests the vast majority of individuals who request PAS are hospice patients.
- Participating Hospices will be required to develop new practices and respond to requests from patients for PAS.
- Hospices that permit PAS must accept the risk of institutional stigmatisation and damage to their caring reputation.
- The risk to hospice healthcare practitioners must be considered, including the emotional burden, strained professional relationships and possible legal repercussions where a decision is disputed.
- Clinicians could feel pressured from within their organization to cross their own moral boundaries following a request for PAS if such a service is commissioned.
- Counselling patients and their families with regard to PAS has been shown to be time consuming. A single assessment is likely to be insufficient to fully evaluate and address the needs of a person requesting PAS.
- Scarcity of palliative care clinicians in rural areas may lead to patients moving areas to access PAS from services that have not had time to develop a relationship with the patient.
- Not all patients who proceed with PAS die quickly. Hospices will need to develop clear and ethical guidance for how to manage a patient who does not die after taking the prescribed medication.
- If a hospice agrees to be involved with PAS, a significant number of employed and voluntary workers may retire or resign.
- Funding and development of hospice and community palliative care services may be reduced with resources diverted toward service provision and administration of PAS.
New Zealand Medical Association - EoL Choice Bill
Canada - Medical Assistance in Dying Interim Report
Canada - MAID Minors ACP Psychiatry Summary
Canada - A Cautionary Tale
Belgium - Trends in Continuous Deep Sedation
Belgium – Sedation and Euthanasia
Belgium – Involvement of Palliative Care in Euthanasia Practice
Belgium – No Evidence PC and Euthanasia Compatible
Belgium – Drugs Used for Euthanasia
American Medical Association - Physician Assisted Suicide
Code of Medical Ethics Opinion 5.7
Physician-assisted suicide occurs when a physician facilitates a patient’s death by providing the necessary means and/or information to enable the patient to perform the life-ending act (e.g., the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide).
It is understandable, though tragic, that some patients in extreme duress—such as those suffering from a terminal, painful, debilitating illness—may come to decide that death is preferable to life. However, permitting physicians to engage in assisted suicide would ultimately cause more harm than good.
Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.
Please click here to read full article
Belgium reformed law 2014 - Euthanasia in Minors
On 28 February 2014 a law was enacted “amending the Act of 28 May 2002 on euthanasia in order to extend it to minors”1. Belgium thus became the first and only country to authorise euthanasia of minors without specifying that any conditions with respect to their age should be met.
Some people welcomed it, underlining the “pioneering”2 role Belgium played in establishing a legal framework for euthanasia, which was presented as the ultimate “humanitarian act” of which any patient,major or minor, should be able to take advantage. In contrast, others in Parliament and in civil society3 opposed the extension of the law. Among these were nearly two hundred paediatricians and paediatric palliative care specialists4.
What is the Role of Healthcare professionals for Assisted Dying?
Should We Have The Right To End Our own Lives - Louis Theroux
Legalising Assisted Suicide
Assisted Dying Yes or No: Debating Matters UK Final
Is Assisted Dying Ever Ok?
I’m a doctor. Here’s what it’s like helping terminally ill patients end their lives.
Why I decided to provide assisted dying: it is truly patient centred care
Health practitioner participation in voluntary assisted dying
Assisted Dying is an ethical minefield - Daily Telegraph 9th February 2019
Assisted dying is an ethical minefield and not just a matter of personal choice
Click here to read full article
Patient Autonomy at the End of Life