North America

Euthanasia and palliative care: synonyms, antonyms, or a different language?

Eduardo Bruera
Department Chair & Professor of Medicine, Department of Palliative, Rehabilitation and Integrative Medicine, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; F.T. McGraw Chair in the Treatment of Cancer, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA

This special issue the IAHPC newsletter publishes an international anonymous survey of attitudes and beliefs of their membership regarding euthanasia and physician-assisted suicide. IAHPC should be congratulated for addressing this highly divisive issue in the most useful and less frequent way: generating data. “In absence of data all opinions are good” is an old saying in medicine, but in practice the absence of data gives those more powerful and extroverted a stronger voice, and this can influence media and government political leaders.

The survey was conducted online, very recently (the second half of 2022) in a post-COVID-19 environment, and the authors provided clear definitions for euthanasia, physician-assisted suicide, palliative sedation, and voluntary stopping of eating and drinking. While the response rate was low (25%, from 66 different countries), this was to be expected from a global organization polling members on a controversial subject. Similar response rates have been observed even among more homogeneous samples of members of American society on controversial subjects, such as sexual harassment.1 Surveys on assisted death where the practice is legalized had a higher response rate.2 These findings suggest that other methodologies might be used in the future, such as paper surveys, surveys conducted during in-person scientific meetings,3 and stronger reassurance of the method used to secure anonymity of participants. 

There was strong consensus (about 80%) that neither physician-assisted suicide nor euthanasia should be part of palliative care. The vast majority also believed that palliative care should be part of the assisted death debate. These important findings reflect frustration among palliative care teams, as they have been given a minimal role in the debate, media coverage, legislation, and regulation of physician-assisted dying practices. Palliative care clinicians share a good proportion of the patient population with assisted death teams, and communication is a major concern.  

There was also consensus (71%) that clinicians should be allowed to opt out of performing assisted death. This is also a major finding since there are already some anecdotal reports that palliative care and hospice clinicians are being pressured to practice assisted death in multiple countries. 

There was also consensus among participants that requests for physician-assisted death happen in a relatively small percentage of their patients.

There is much to be learned about physician-assisted death. Who is receiving it? A recent report identified physical and psychosocial suffering as the reason for assisted death, but it was vague about how this diagnosis was made, and 60% of patients did not have a palliative care consult.4 Medical schools and academic hospitals, even in the richest countries, do not have adequate structure and processes to address suffering, educate the next generation of clinicians, and make discoveries.5 Receiving “palliative care” is not synonymous with appropriate palliative care.6 

This survey suggests that IAHPC members are concerned by the rapid and not very transparent implementation of assisted death, are not interested in making this practice part of palliative care, and want to be allowed to stay away from participating in assisted death.  

After years of support for assisted death, the media are starting to capture major flaws and ethical concerns in assisted death in Canada.7 More accountability for the process and clinicians involved in assisted death, more dialogue with palliative care teams, and, especially, much more research is needed.

References

  1. Graff SL, Subbiah IM, Markham MJ, Matt-Amaral LB, Close JL, et al. Frequency, Barriers, Outcomes, and Consequences of Reporting Sexual Harassment in Clinical Oncology. JNCI Cancer Spectr 2022: pkac081. DOI: 10.1093/jncics/pkac081 
  2. Lum HD, Ressalam J, Kini V, Kessler ER, DeCamp M, et al. Use and Influence of Medical Aid in Dying Service on Physician Experiences. J Palliat Med 2022. DOI: 10.1089/jpm.2022.0235
  3. Reddy SK, Yennu S, Tanco K, Anderson AE, Guzman D, et al. Frequency of Burnout Among Palliative Care Physicians Participating in a Continuing Medical Education Course. J Pain Symptom Manage 2020; 60(1): 80-86.e2. DOI: 10.1016/j.jpainsymman.2020.02.013 
  4. Simmons JG, Reynolds G, Kekewich M, Downar J, Isenberg SR, et al. Enduring Physical or Mental Suffering of People Requesting Medical Assistance in Dying. J Pain Symptom Manage 2022; 63(2): 244-250.e2. DOI: 10.1016/j.jpainsymman.2021.08.010 
  5. Hui D, De La Rosa A, Chen J, Dibaj S, Delgado Guay M, et al. State of Palliative Care Services at US Cancer Centers: An updated national survey. Cancer 2020; 126(9): 2013-2023. DOI: 10.1002/cncr.32738 
  6. Bruera E, Editorial Board Member. What Is the Minimally Effective Dose of Palliative Care? J Palliat Med 2022; 25(11): 1614-1615. DOI: 10.1089/jpm.2022.0432
  7. Brassolotto J, Manduca-Barone A, Zurbrigg P. Medical Assistance in Dying: A review of related Canadian news media texts. J Med Humanit 2022: 1–20. DOI: 10.1007/s10912-022-09764-z

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