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]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 4: The Problem of Killing


Impartiality, complicity and perversityThe original text of Bill 52 did not define “medical aid dying” (MAD), but it was understood that, whatever the law actually said, it was meant to authorize physicians to kill patients who met MAD guidelines.  The Minister of Health admitted that it qualifed as homicide, while others acknowledged that MAD meant intentionally causing the death of a person, and that its purpose was death.  Various witnesses in favour of the bill referred explicitly to lethal injection and the speed of the expected death of a patient.

Given the moral or ethical gravity involved in killing, it is not surprising to find serious disagreement about MAD among health care workers.  Conflicting claims made about the extent of opposition to or support for euthanasia within health care professions are difficult to evaluate, but a review of the transcripts of the legislative committee hearings into Bill 52 is instructive.

One physician member of the committee was shocked by the assertion that there is no  moral, ethical, or legal difference betwen withdrawing life support and lethally injecting a patient.  Hospices and palliative care physicians rejected participation in euthanasia.  Sharp differences of opinion among other health care workers were reported.  Support for killing patients by lethal injection was likened to support for the death penalty; that is, many more agreed with the act in principle than were willing to do the actual killing.  So marked was the evidence of opposition to euthanasia that doubts were raised about the possiblity of implementing the law.

Since the law was passed as a result of assurances from the Quebec medical establishment that it could be implemented, a committee member who is now a minister of the Quebec government warned that they would be called to account if it is found that few physicians are willing to participate.  This political pressure is likely to provide an additional incentive for the medical establishment to secure the compliance of Quebec physicians.

The introduction of euthanasia into Quebec’s health care system is to be accomplished using the structures and powers established by other Quebec statutes that govern the delivery of health care in the province, which have established a multi-layered and overlapping bureaucracy of committees, councils, commissions, boards, directors, examiners, coordinators, syndics and commissioners.  Physicians and other health care providers who object to euthanasia will find their working environments increasingly controlled by a MAD matrix functioning within this system, a prominent feature of which is an emphasis on patient rights.

Everyone authorized to enact or supervise adherence to policies or standards can become a MAD functionary, using codes of ethics, protocols, guidelines, directives, etc. to normalize euthanasia. Similarly, every disciplinary and complaints procedure can be used to force participation in MAD services.  Those who openly advocate refusal to provide or facilitate euthanasia can be fined from $1,500.00 to $40,000.00 per day under Quebec’s  Professional Code if they are deemed to have helped, encouraged, advised or consented to a member of a profession violating the profession’s code of ethics. [Full Text]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 1: Overview


quebec-001An Act Respecting End-of-Life Care (“ARELC”) is intended to legalize euthanasia by physicians in the province of Quebec.  It replaces the original Bill 52, the subject of a previous commentary by the Project.  The original text of the Bill 52 did not define medical aid in dying (MAD), but ARELC now makes it clear that Quebec physicians may provide euthanasia under the MAD protocol.  In addition, substitute decision makers can order legally incompetent patients who are not dying to be starved and dehydrated to death.  This practice, identified here as Euthanasia Below the Radar (EBTR), is completely unrestricted and is not even reportable.

Neither ARELC nor MAD guidelines can abolish the criminal prohibition of euthanasia, so physicians who kill patients in the circumstances contemplated by the new law would still be liable to prosecution.  However, the Quebec government has promised that it will refuse to prosecute physicians who kill patients in accordance with MAD guidelines, thus circumventing the criminal prohibition.  Beyond that, Quebec general practitioners have asked for immunity from prosecution for failing to conform to MAD guidelines.  Some Quebec physicians may be unwilling to provide euthanasia while the criminal law stands. Quebec’s Attorney General may be unwilling to provide the extraordinary kind of immunity sought by physicians, and some physicians may be unwilling to provide euthanasia without it.

The introduction of euthanasia will require the complicity of thousands of health care workers and administrators.   Many are likely to comply because official representatives of the legal and medical establishments of Quebec have formally declared their support for the new law.  On the other hand, palliative care physicians, hospices and an undetermined number of other physicians and health care workers are opposed to euthanasia and assisted suicide.

Section 4 of ARELC states that eligible patients have a right to “end-of life-care,” which includes euthanasia and palliative care.  The statutory declaration of a “right” is the most powerful weapon in the legal arsenal likely to be used to enforce compliance with ARELC and to attack freedom of conscience among those who refuse to facilitate the procedure.

It appears that, even where euthanasia or assisted suicide is legal, the majority of physicians do not actually provide the services.  The Act may lead to discriminatory screening of physicians unwilling to kill patients, effected by denying them employment in their specialties and denying them hospital privileges.

However, objecting physicians not only refuse to kill patients, but also often refuse to do anything that they believe makes them morally responsible for the killing. Hence, it is likely that most of the attacks on freedom of conscience resulting from ARELC will be precipitated by refusal to participate indirectly in killing.

Physicians may refuse to provide euthanasia if the patient is legally ineligible, and for other reasons, including conscientious objection.  ARELC requires physicians who refuse to provide euthanasia for any reason other than non-eligibility to notify a designated administrator, who then becomes responsible for finding a MAD physician.  The idea is to have the institution or health care system completely relieve the physician of responsibility for facilitating the procedure.

The protection of conscience provision in ARELC distinguishes physicians from other health professionals, providing less protection for physicians than for others.  Physicians may refuse only  “to administer” euthanasia – a very specific action –  which seems to suggest that they are expected to participate in other ways.

Palliative care hospices and a single Quebec hospital 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 exemptions were provided for purely pragmatic and political reasons.  The exemptions have been challenged by organizations that want hospices forced to kill or allow the killing of patients who ask for MAD. Hospice representatives rejected the first demand and gave mixed responses to the second.  A prominent hospice spokesman predicted that hospices refusing to provide euthanasia will operate in an increasingly hostile climate.

Refusing to participate, even indirectly, in conduct believed to involve serious ethical violations or wrongdoing is the response expected of physicians by professional bodies and regulators.  It is not clear that Quebec legislators or professional regulators understand this.  A principal contributor to this lack of awareness – if not actually the source of it – is the Code of Ethics of the Collège des médecins, because it requires that physicians who are unwilling to provide a service for reasons of conscience help the patient obtain the service elsewhere.

As a general rule, it fundamentally unjust and offensive to human dignity to require people to support, facilitate or participate in what they perceive to be wrongful acts; the more serious the wrongdoing, the graver the injustice and offence.  It was a serious error to include this a requirement in a code of ethics.  The error became intuitively obvious to the Collège des médecins and College of Pharmacists when the subject shifted from facilitating access to birth control to facilitating the killing of patients.

A policy of mandatory referral of the kind found in the Code of Ethics of the Collège des médecins  is not only erroneous, but dangerous.  It purports to entrench  a ‘duty to do what is wrong’ in medical practice, including a duty to kill or facilitate the killing of patients. To hold that the state or a profession can compel someone to commit or even to facilitate what he sees as murder is extraordinary.

Since ARELC explicitly authorizes physicians to kill patients deemed eligible for MAD by the Act, the federal government can go to court to have the statute declared unconstitutional.  However, it is possible that the federal government will take no action until after the Supreme Court of Canada ruling in Carter v. Canada and after the 2015 federal election.

It seems unlikely that Quebec physicians who provide euthanasia under MAD guidelines will be prosecuted even if the prohibition of assisted suicide and euthanasia is maintained by the Supreme Court of Canada, and even if ARELC is ultimately struck down as unconstitutional.  The continued de facto decriminalization of euthanasia in Quebec would probably generate considerable pressure in other provinces to follow suit.

Those who refuse to provide or facilitate euthanasia for reasons of conscience will likely find themselves in increasingly complicated and contentious working environments. In the end, freedom of conscience for Quebec health care workers who object to euthanasia may come to mean nothing more than the freedom to find another job, or the freedom to leave the province. [Full text]