Is euthanasia part of palliative care?

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr Harvey Chochinov and Dr Joseph Fins have written an excellent article that was published in the Journal of the American Medical Association (JAMA) on October 8 titled: Is Medical Assistance in Dying Part of Palliative Care?

The authors are actually asking the question whether or not MAiD, better known as euthanasia, is a part of medical treatment and therefore can be part of palliative care. The problem is that in many jurisdictions, where it is legal, MAiD is already considered as part of palliative care.

The authors begin the article by stating that most national palliative care organizations, including the Canadian Palliative Care Association, believe that MAiD does not fall within the practise of palliative care. The authors therefore determine the purpose of this article is:

to determine whether MAID is part of palliative care, based on characteristics embedded within the practice of medicine.

Dr Harvey Chochinov

The first question the authors examine is whether or not MAiD is part of medicine? The authors examine this question based on the four canons of therapy as defined by Thomas et al. which are: restoration, means-end proportionality, parsimony and discretion.

Concerning restorative measures the authors conclude:

It is hard to conceive of MAID as restorative because the very act makes any return impossible.

Concerning means-end proportionality, the authors conclude:

It is difficult to regard death as “well-fitted” because nonexistence negates alternative means to address pain. Death cannot be titrated and trialed; hence, it does not qualify as a therapeutic, which means its pursuit resides outside the realm of medicine.

Concerning parsimony, the authors conclude:

This tailoring of a therapy to a specific condition, drawing on evidence based guidelines, is violated under MAID, where patient preference effectively dictates practice. By way of example, Canadians seeking MAID are under no obligation to try other treatments they deem unacceptable. In those instances, physicians may have to dispense with parsimony—despite their clinical judgment pointing toward other options—yielding to the patient’s intent on receiving MAID.

Dr Joseph Fins

Concerning discretion, the authors conclude:

Discretion “counsels that an awareness of the limits of medical knowledge and practice should guide all treatment decisions.” Since MAID was launched in Canada, eligibility has broadened from those whose deaths are reasonably foreseeable, to individuals who are not dying but living with disability; with consideration now being given to mental illness, children, and those anticipating the loss of mental capacity. Although some may see this as affirming individual autonomy, ethicist Paul Ramsey reminds us that physicians must recognize that the function of medicine is not to relieve the human condition of the human condition.

The authors then examine the Patient-Physician Relationship and conclude:

MAID undermines the patient-physician relationship by violating the principle of nonabandonment, even when it is well intended. At the height of patients’ distress, MAID truncates care and eliminates the possibility of healing. This distinguishes it from palliative medicine, which embraces patient and family at life’s end with fidelity and relationality extending into bereavement care for survivors.

The authors then MAiD, Hope and Palliative care and conclude:

It is impossible to sustain this therapeutic stance when assessing a patient’s readiness for MAID. The former (palliative care) entails holistic medical care, whereas the latter shifts to a legalistic paradigm centered on determining eligibility for MAID.

The authors then examine MAiD in relation to policy considerations and state:

The policy arguments separating MAID and palliative care are rooted in the notion that palliative care affirms life, regards dying as a normal process, and is committed to “neither hasten nor postpone death.” Organizations representing palliative care have been resolute in asserting that MAID falls beyond their mandate.

Chochinov and Fins have provided excellent arguments and prove that MAiD is not a medical treatment and thus it cannot be part of palliative care.

Nonetheless, in many jurisdictions, including Canada, MAiD is administered as if it is part of palliative care. One problem is that health care administrators, within the government and on a regional basis, have implemented euthanasia, which is the killing of a patient upon request, as if it were medical treatment.

The goal of medical researchers, such as Chochinov and Fins, must be to convince the medical administrators that MAiD is not a part of medicine and, if legal, it needs to be separated from services that actually constitute medical treatment, such as palliative care.