Canada's Medical Assistance in Dying (MAiD) act began to operate in 2016. It is a laboratory for how legalised euthanasia will operate in other English-speaking countries - although it has also firmly established itself in Francophone Quebec as well.
Palliative care helps people to die a natural death in as much comfort as possible. But in jurisdictions where euthanasia and assisted suicide have been legalised, "assisted dying" is increasingly regarded as an alternative to palliative care.
Unsurprisingly, most palliative care doctors do not agree. In fact, Baroness Findlay , a Welsh palliative care physician who is a leading opponent of "assisted dying" in the UK, says that "In Canada and Belgium doctors are leaving palliative care, traumatised by what they see and bullied when they dissent."
Another British palliative care consultant, Carol Davis, recent wrote in the UK website UnHerd , that: "Physicians have reported that patients are hesitant to enrol in palliative care and hospice services for fear that they promote euthanasia".
No wonder. Hospices which refuse to host euthanasia deaths have been defunded in Canada. The 10-bed Irene Thomas Hospice in British Columbia lost C$1.5 million this year because its management refused to cooperate. It had to transfer the hospice to the provincial government.
How has the option of euthanasia affected palliative care?
There is not much information about this contentious issue. But according to an article in the journal Palliative Care written by five Canadian specialists, its effect has been negative.
The authors interviewed 13 doctors and 10 nurses about their impressions. Some of them helped to provide MAiD; some were conscientious objectors. But their feedback raises troubling questions.
First, all of them spoke about conflicts between the provision of palliative care and eligibility for MAiD. To ensure that their patients remained eligible, they sometimes had to withhold medications which would have otherwise removed or alleviated their pain. "Maintaining lucidity and eligibility for assisted death, by avoiding sedative medications, took priority over achieving good symptom control for some patients," they write. Both the patients and the PC providers found this distressing.
One doctor told the researchers: "I worry about inadvertently affecting their ability to access MAID . . . [there is] a reluctance towards using benzos [benzodiazepines] or opioids, because of the fear that they'll get sedated. . .Sometimes from them [patients], but sometimes it's from me."
Second, simply mentioning the existence of MAiD can be interpreted as an invitation to the patient to request it. This adds to the emotional and existential burden upon the patients and their families. Conversations have become very difficult.
Palliative care providers end up providing indirect support for MAiD, even if they are not personally involved. Participants described challenging conversations around supporting patients and resolving tension with families around MAiD. One nurse told them: "They [patients considering MAiD] struggle.. . . [They say] I love my kids, how can I choose to leave them, you know. Those are big words. . .it's hard to know how to respond to some of that."
Third, MAiD has a significant emotional and personal impact on palliative care providers. Many of the clinicians described a large emotional toll created by exposure to Medical Assistance in Dying. One nurse said: "I was as prepared as I could be for our first MAiD case here, but I recall that morning, I went outside and felt like I was about to throw up."
Of course, other doctors, even if they were opposed at first, made their peace with the new regime.
One doctor who is a conscientious objector noted that: "Initially there was a very strong opposition from palliative care providers to MAiD ... just the very idea that MAiD would be considered an end-of-life option. Now those same physicians who were so strongly opposed. . .are understanding. . .they see a separate parallel system that exists for MAiD and so they [palliative care] could exist with it."
Fourth, the existence of MAiD has complicated the relationship of palliative care providers with their patients. Some fear that palliative care means assisted dying and shrink from the doctors. Other patients who want MAiD regard conscientious objectors with hostility. Doctors or nurses with moral or religious objections to MAiD find that it is difficult to build a relationship with patients who want assisted dying.
Finally, some palliative care providers believed that palliative care and MAiD were competing for funding and resources, especially in rural and underserviced areas. It was a zero-sum game. One doctor explained:
"Good palliative care takes a lot of time and interdisciplinary resources. . .when a patient is requesting MAiD [Medical Assistance in Dying], most of the resources have been sucked up by that one case and it's all everyone's talking about and they're rushing to get stuff done. . .everyone from admin down to the bedside nurse is focusing on MAiD. And all of the high-quality palliative care that we do falls by the wayside for the other patients."
Good palliative medicine provides holistic care for patients who are in the last stages of life. It helps them psychologically and even spiritually as they confront the final challenge. The Canadian experience suggests that there is a danger that "assisted dying" - which only "cures" pain - could gradually displace one of the finest achievements of modern medicine. That would be an unspeakable tragedy.