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How will assisted dying legislation affect care?

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If one has been in medical practice for a very long time, one gets a chance to see how modes of practice, clinical improvements and societal values evolve from jurisdiction to jurisdiction and within the same jurisdiction.

This has been the case with the concept of what has been called by many terms, including physician-assisted suicide (PAS), which appears to have been replaced by the term physician-assisted death (PAD). I have had an interest in the topic in general as geriatrician, ethicist and participant in a palliative care unit.

My interest began years ago when the Netherlands first allowed PAS, but combined it with euthanasia, as a complex attempt to develop what came to be a spectrum of life-ending medical interventions.

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Over the decades since the time this practice at first became allowable but not actually legal in the Netherlands until the time it was legalized, there have been other European countries that have followed through with similar or comparable facilitating legislation, namely Belgium and, although within a different mode of administration, Switzerland.

Following the experience in Europe, Oregon became the first state in the United States – after a number of starts and legal challenges – to finally receive approval to only allow for PAS within a well-formulated structure of laws to protect patients and physicians, and over time, to promote improvements in palliative care.

After Oregon, a number of other American states followed through with similar approaches, including the state of Washington, Montana, Vermont and California. Some states attempted to approve the legislation but were not successful, and others are preparing to introduce such legislation.

In Canada just over 10 years ago, the Supreme Court ruled against a proposal to remove assistance with dying from the Criminal Code, and just over a year ago, in a similar clinical case of a patient with amyotrophic lateral sclerosis (Lou Gehrig’s Disease), the Supreme Court of Canada, in a landmark decision, overruled the Criminal Code and gave the government a year (which received a short extension because of the election) to frame legislation to legalize how to end a person’s life at the patient’s “capable” request.

The criteria would include symptoms that were deemed to be sufficient to allow health-care practitioners to do something that for some, is anathema to them: to actively take the life of a person, even if that person fulfils what will be the legal requirements for assistance in dying.

It has been a very emotional and contentious period within the health-care professions, with particular emphasis on the role of physicians, who will ultimately, in most situations, be the health-care professionals responsible for the act of prescribing and/or administering the lethal dose of medications.

Some consider it an immoral and unprofessional act, while others deem it an act of merciful intervention that is not just part of the spectrum of compassionate end-of-life care, but an act that respects one of the foundational ethical tenets of medical practice – the respect for patient autonomy.

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Although it appears very contentious at present, the experience from other jurisdictions is such that, in the end, it is likely that the correct balance will be achieved. Those that support the process will be able to legally act on their beliefs, and those who oppose it will not be required to directly participate in the act.

But ultimately, most of us hope and anticipate that high-quality palliative care will become more accessible, which may result in fewer requests for PAD, and as in other jurisdictions, the balance that’s achieved will meet the needs of those for whom such an act is proper for them, while for others, their end of life care will be achieved with dignity and care and without the need for PAD. Let us hope so.