Is there any difference between euthanasia and palliated starvation?


Xavier Symons

While euthanasia and assisted suicide are currently illegal in most countries, the practice of voluntarily stopping eating and drinking (VSED) is seen by some as an ethically and legally permissible alternative. VSED refers to seriously-ill patients refusing to eat and drink for a sustained period of time with the intention of bringing about their own death.

Yet a new paper published in BMC Medicine argues that VSED is ethically indistinguishable from assisted suicide, and should be subject to the same legal regulations as more salient cases of assistance in dying.

The paper, lead-authored by Ralf J. Jox of the Institute for Ethics, History and Theory of Medicine at the University of Munich, argues that “supporting patients who embark on VSED amounts to assistance in suicide, at least in some instances, depending on the kind of support and its relation to the patient’s intention”.

While VSED does not involve an invasive or aggressive act like many other means of suicide, the authors write that “VSED should [nevertheless] be considered as a form of suicide, as there is both an intention to bring about death and an omission that directly causes this effect”. Doctors who assist patients in VSED — by encouraging them, or promising pain-relief if VSED is undertaken — are potentially instrumental in the deaths of the patients, as the suicide would not occur without them, and they share the patient’s intention of inducing death.

The authors of the paper conclude that the same legal prescriptions or regulations that apply to physician assisted suicide should also apply to VSED.

“[We] maintain… that future ethical discussions on assisted suicide require consideration of medically supported VSED, and vice versa…Thus, the widely held position by palliative care societies, professional bodies of physicians, legal scholars, and ethicists to disapprove of assisted suicide but approve of and even promote medically supported VSED appears inconsistent”.

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Accessed 2017-08-11


Assisted killing still part of Ontario’s palliative care plan

Catholic Register

Michael Swan

The agency responsible for expanding Ontario’s network of hospice care wants hospice patients to have the option of assisted suicide, even if most hospices and the majority of doctors oppose it.

“The OPCN (Ontario Palliative Care Network) promotes early and equitable access to hospice palliative care for all patients with a life-limiting illness, including individuals who have requested medical assistance in dying,” a spokesperson for the Ontario Palliative Care Network told The Catholic Register in an email.

The provincially-funded OPCN, a sub-agency of Cancer Care Ontario, “recognizes that there may be an intersection between palliative care and medical assistance in dying (MAID). Both medical assistance in dying and palliative care are health care services that exist within the health care system,” wrote Cancer Care Ontario communications advisor Jayani Perera. “However, the focus and mandate of the Ontario Palliative Care Network is advancing palliative care in the province.”

A year into legalized killing in Canada, the big question is how palliative care and hospice beds will be expanded, said bioethicist Bob Parke. Will governments fund hospices that refuse to perform or refer for assisted dying? . . [Full text]


Quebec’s split over euthanasia a warning for Canada

Palliative care specialists’ reluctance to administer life-ending drugs indicates it may be easier to change laws than attitudes.

Toronto Star

Allan Woods

MONTREAL―Quebec”s euthanasia law is the template and test case for the rest of the country, but problems emerging just months before the terminally ill can start demanding their deaths show that laws are easier to change than attitudes.

Since legislation was adopted in the summer of 2014 that would allow dying patients access to a life-ending drug cocktail under strict conditions, politicians here have celebrated the perception of Quebecers being the vanguards of social change.

But with time running out before Dec. 10 — the date that patients can begin requesting the procedure — hospitals and health-care providers are scrambling to draw up policies and find the staff who will carry out those patients” wishes.

If that wasn”t tough enough, some of those who might be expected to lead the change — palliative care physicians and hospice administrators — have let it be known that they are instead digging trenches for the battle.

“The vocation of a palliative care hospice is to provide care, and that doesn”t include medical aid in dying,” said Élise Rheault, director of Maison Albatros Trois-Rivières. . . [Full Text]

Palliative care centres say no to medically assisted death

West Island Palliative Care Residence won’t obey Quebec’s ‘dying with dignity’ law

CBC News

The director of the West Island Palliative Care Residence says patients seeking assistance with dying will have to go elsewhere.

“We are absolutely one of the 29 [palliative care programs in Quebec] that are opting out of providing this service,” says the residence’s executive director, Theresa Dellar.

“The basic philosophy of palliative care is we do nothing to hasten death, and obviously euthanasia does hasten death. Our philosophy to provide comfort, care and dignity at the end of life and to allow for the natural process of death to take place,” she said. . . . [Full text]

Protect doctors’ right to choose


It’s all about choice. The Supreme Court of Canada has ruled that suffering Canadians have the right to choose to end their life through assisted suicide.

But doctors must also have the right to choose  –  to choose whether they are a part of this process or not.

A recent article in the Canadian Medical Association Journal showcases several points worth repeating. They report that a majority of palliative care physicians actually don’t envision assisted suicide as part of their work. . . [Full text]


York Region health care professionals offer mixed views on doctor-assisted suicide

Lisa Queen

Let the soul searching begin.

True, the Supreme Court of Canada delivered a unanimous and historic decision last Friday, striking down the country’s ban on doctor-assisted suicide for consenting and severely ill adult patients. It gave Ottawa a year to enact new legislation.

And true, an opinion poll last fall indicated 84 per cent of Canadians believe “a doctor should be able to help someone end his or her life if the person is a competent adult who is terminally ill, suffering unbearably and repeatedly asks for assistance to die.”

But the issue is striking closer to home for health care providers, who, some day in the very near future, could be asked to help patients end their lives, according to Dr. Cindy So and Jonathan Breslin. . . [Full Text]


Ethical Issues Experienced by Hospice and Palliative Nurses

Journal of Hospice and Palliative Nursing. 2015;17(1):7-13.

Jooyoung Cheon, Nessa Coyle, Debra L. Wiegand, Sally Welsh


Nurses encounter ethical dilemmas in their clinical practice especially those associated with palliative and end-of-life care. The Hospice and Palliative Nurses Association (HPNA) members were asked to participate in an ethics survey. The survey aimed to identify ethical issues experienced by hospice and palliative nurses, identify resources available to them and barriers if any to their use, and to identify how HPNA can be of support to hospice and palliative nurses.

One hundred twenty-nine (n = 129) HPNA members completed the online survey. The information from each of the surveys was carefully reviewed, and responses were collapsed into 6 themes.

The ethical dilemmas included inadequate communication, provision of nonbeneficial care, patient autonomy usurped/threatened, issues with symptom management and the use of opioids, issues related to decision making, and issues related to discontinuing life-prolonging therapies.

Approximately two-thirds of the nurses used resources in an attempt to resolve the ethical issues, including a formal ethics consultation, involvement of the palliative/hospice team, consulting with other professionals, and use of educational resources.

One-third of the nurses said there were institutional or personal barriers that prevented the ethical dilemma from being resolved. Participants suggested ways that HPNA could help them to effectively manage ethical dilemmas. [Full text]


Redefining the Practice of Medicine- Euthanasia in Quebec, Part 8: Hospitality and Lethal Injection


Doctor Examining an Elderly PatientUnder the Act Respecting End of Life Care (ARELC) palliative care hospices may permit euthanasia under the MAD protocol on their premises, but they do not have to do so.  Patients must be advised of their policy before admission.  The government included another section of ARELC to provide the same exemption for La Michel Sarrazin, a private hospital.  The exemptions were provided for purely pragmatic and political reasons.

The exemptions have been challenged by organizations that want hospices forced to kill patients who ask for MAD, or at least to allow physicians to come in to provide the service.  Hospice representatives rejected the first demand and gave mixed responses to the second.  A spokesman for the Alliance of Quebec Hospices confirmed that palliative care hospices that provide euthanasia will not be excluded from the Alliance.

A prominent hospice spokesman predicted that the pressures would increase after the passage of ARELC, and that hospices refusing to provide euthanasia would operate in an increasingly hostile climate.

A former minister of health rejected the challenges to the exemptions and insisted that the policy of hospices be respected, appealing to the principles of autonomy and freedom of choice.  Consideration of freedom of conscience is irrelevant to this approach, and the description of the problem as a conflict of autonomy actually precludes a successful resolution by an appeal to the principle giving rise to it.

While the former minister of health wanted the autonomy of hospices explicitly set out in law, the only requirement in ARELC is that regional health authorities consult with institutions and palliative care hospices in their territories before making rules.  Mere consultation may be insufficient to protect the integrity of hospices in the long term. [Full Text]

West Island Palliative Care Residence clarifies care it offers following passage of Quebec’s end-of-life legislation

Hospice statement 5 June following passage of euthansia law in Quebec

Will continue to provide care and comfort to terminally ill but will NOT act to hasten natural process of death

For immediate release

KIRKLAND, Quebec – June 5, 2014 – In light of the passage today by the National Assembly of new Quebec end-of-life legislation, the West Island Palliative Care Residence wishes to clarify that the new legislation will not change in any way the services it provides to terminally ill patients.

The Residence will continue to act in the way it always has – to provide the best possible care and comfort, including symptom relief to the dying but without taking any actions that hasten the natural process of death.

The new Quebec legislation permits, under certain conditions, Quebec health institutions and health professionals to provide “medical aid in dying” – the administration of drugs or other actions to intentionally cause the death of a patient. The legislation also permits any health professional as well as “palliative care hospices,” of which the West Island Palliative Care Residence is one, the option to choose not to do so, provided patients are informed that this is the case.

The West Island Palliative Care Residence has chosen to exercise this option and to make no change to the type and methods of care it delivers, meaning it will not take actions that intentionally cause a patient’s death.

“The goal of good palliative care is never to hasten the end of life,” said Teresa Dellar, Co-Founder and Executive Director of the Residence. “We make the last days of life as comfortable and pain-free as possible so patients can live them in the best possible manner.” In fact, she noted, good palliative care from early on in a terminal illness has been shown in clinical studies to both extend patients’ lives and improve their quality of life.

“If we as a society are going to offer more choices to patients at the end of life, as this legislation does, then we must ensure one of those choices is ready access to high-quality palliative care in the patient’s community, as we offer at our Residence,” continued Ms. Dellar. “If quality palliative care is available, few will choose to end their lives prematurely. We can’t allow the premature ending of lives to become a substitute for our responsibility to provide compassionate care and symptom relief at the end of life.”

The West Island Palliative Care Residence will be changing its application forms and information for patients and families to comply with the new legislation and make it clear to them that the Residence will not provide the intentional end-of-life services now permitted.

About palliative care

Palliative care does not hasten death – as do euthanasia and assisted suicide – but ensures it is as comfortable, dignified and pain-free as possible. It is a conservative estimate that palliative care could be useful in more than half of Canadian deaths, or more than 125,000 patients per year. As proportionately fewer Canadians die suddenly or quickly from accidents or acute illnesses, more face end of life with chronic illnesses or diseases such as cancer that can extend over a relatively long period of time. Many dying patients end up in hospital ERs during the last weeks of life, an indicator of poor-quality end-of-life care and a very expensive and unsatisfactory alternative to palliative care.

About the West Island Palliative Care Residence

The West Island Palliative Care Residence is an independent, community-based, non-profit institution, accredited by the Quebec government to provide end-of-life palliative care services to residents of the West Island of Montreal. The Residence allows terminally ill patients to die in comfort and with dignity in a warm, home-like environment, close to their family, and in their community. It is not part of or affiliated with any hospital or health institution and services are provided without charge. The Residence has 23 beds in two pavilions, making it the largest freestanding palliative care residence in Canada. Since opening in 2002, the Residence has welcomed more than 2,500 patients in the final stages of ALS, multiple sclerosis, cardiovascular disease and cancer, as well as 10,000 of their family members. To learn more, visit

For more information:
Joanne Myers, Director of Development
Tel.: 514 693-1718, ext. 234
Mobile: 514 978-0793

Canadian Society of Palliative Care Physicians rejects euthanasia

The Canadian Society of Palliative Care Physicians has rejected a recommendation from a Quebec legislative committee that euthanasia and physician assisted suicide be legalized.  The Society stated that the procedures contradict “a fundamental tenet” of the Society and most palliative care physicians.  The president of the Society said “We are concerned that, despite the fact that our members are unwilling to provide these services, this may be mandated if it becomes law in Quebec.” [CSPCP statement]