We Must Speak for Those Who Can’t

Hospitals and health facilities across the country are not equipped to deal with physician-hastened death.

On June 6, the Supreme Court of Canada’s decision making physician-hastened death legal will come into effect. A parliamentary committee asked to help the government plot how that would roll out in Canada has made some far-reaching recommendations, well beyond what was contemplated by the court in Carter v. Canada.

The committee, for example, said physician-assisted dying ought to be available in all publicly funded hospitals and health facilities, including palliative care centres. But some health facilities are ill equipped, and others are inappropriate settings for medically hastened deaths.

Even some of the best health facilities across the country are simply not up to the job.  Many of these centres do many things well, including providing a range of critical health services, such as emergency rooms to specialized pediatric and neonatal intensive care units; from in-patient wards for surgery, oncology, burns and plastic surgery, to various specialty outpatient clinics.

In many urban settings, tertiary care hospitals host leading edge technology, state of the art diagnostics and even robust programs of biomedical and clinical research. And yet, too few hospitals host palliative care wards. There are also far too few hospices in most regions across the country, designed to offer the privacy and calm that dying patients and their families need and deserve.

Some healthcare facilities may have a palliative care physician or nurse on-site to give their advice upon request. The further you are from a major urban setting, the less likely such expertise is available. Only 15 to 30 percent of dying Canadians have access to or receive hospice palliative care or end-of-life services, dedicated to addressing all forms of suffering — physical, psychological and existential — affecting patients nearing death and their families. And yet, should the report’s recommendation come to fruition, all healthcare facilities would be required to offer physician-hastened death, i.e., euthanasia and assisted suicide.

The situation for children facing end-of-life is no less dire. The option of a pediatric hospice is more often the exception than the rule. Yet these considerations did not stay the hand of the parliamentary committee, which recommended that within the next three years — despite a nationwide scarcity of expertise in pediatric palliative care — that eligibility for medical assistance in dying be extended to those younger than 18.

Related: Assisted Suicide for Those with a Mental Illness is a Risky Proposition. 

What about the notion of forcing euthanasia and physician-assisted suicide into faith-based health-care organizations? Most are built on the foundation of inviolable moral, religious and ethical traditions. Failure to find a more nuanced solution that respects conscientious objection and safeguards patient autonomy will place faith-based facilities on a direct collision course with the federal government.

So what about physician-hastened death in palliative care facilities?

People are often already afraid of palliative care; many refuse early referral, which results in protracted and avoidable pain and suffering. Some even suspect that pain medication might inadvertently hasten their death (it will not).

Requiring palliative care services to include medical assistance in dying would do little to assuage those fears. The World Health Organization, in fact, insists on the separation between palliative care and death-hastening practices.

These are just some examples of concerns that would arise if all publicly funded facilities have to offer physician-assisted deaths. The same observations could be made at many health centres, including personal care homes.

Some people have called the recommendations of the parliamentary committee bold. I fear they lack the wisdom the Supreme Court called for when it described “a complex regulatory regime” needed to balance physician-hastened death with protecting vulnerable persons from being induced to commit suicide at a time of weakness.

With the advent of physician-hastened death, there has never been a more pressing moment in history demanding we get our approach to human suffering and palliative care right. Fewer than two per cent of patients will likely choose to have their lives ended; most will want to live out the length of their days in care and comfort. That should not be asking too much.

One thing is for certain: the dying are too ill to speak, and the dead will never complain. We, the living, must give voice to their needs, remembering our turn will come soon enough.

Dr. Harvey Max Chochinov is a distinguished professor of psychiatry at the University of Manitoba and an expert advisor with EvidenceNetwork.ca. He holds the only Canada research chair in palliative care. He led an external panel, appointed by the federal government, looking at legislative options to Carter v. Canada.