Excellent Patient Care Must Be Our Priority Always, No Matter What Is Said in the Media

Abstract

I do not support the practice of physician-aid in dying (PAID). I will say this openly and upfront, so there are no misconceptions about covert reasons for writing this editorial. Despite many technical definitions, I consider PAID to encompass what has been termed medical-aid in dying (MAID), physician-assisted death, or physician-assisted suicide (PAS)—each term having more nuanced definitions and relative values discussed further in this piece. When I have written about the topic previously, I have often tried to present both sides as equally as possible, keeping my personal views private as to not bias the reader. So this piece is different, as an ‘‘editorial’’ allows one to be. For me, PAID does not comport with my personal system of moral, ethical, and religious beliefs that guide how I live and how I practice medicine. Furthermore, the Journal of Palliative Care does not have an official position on PAID, although I know many of our editorial board members have opinions on one side or the other, and they may or may not choose to keep those private. Despite the recommendation of ‘‘studied neutrality’’ which has been the organizationally rendered stance of the American Academy of Hospice and Palliative Medicine, most individual clinicians find themselves in a position other than ‘‘neutral.’’ On the individual level, recent works have urged that ‘‘neutrality . . . is neither neutral nor appropriate,’’ which is reasonable to consider of individuals, but harder to expect from organizations that represent a broad array of constituents. In previous work, I have argued that the practice of PAID, regardless of the methods discussed herein, is fundamentally different than withholding or withdrawing of a life-sustaining treatment, or providing aggressive symptom-based palliative care (see Table 1). The Supreme Court of the United States has left it to individual states to decide the legality of PAID in each jurisdiction, and paraphrasing the rulings in Vacco v Quill and Washington v Glucksburg, patients have a right to be left alone and not receive treatments they do not desire, but they do not have a fundamental ‘‘right to die’’ with a clinician’s aid. For me, providing patient-centered, goal-concordant palliative care allows me to practice medicine in a way that I can live with personally, and I have always encouraged other providers to carefully examine their own practices and consciences regarding what they view as acceptable in their own practices. As PAID is practiced in the United States, physicians prescribe a lethal prescription to the patient and it must be used by the patient alone, to produce the desired effect. Thus, some might call this ‘‘PAS’’ since the patient takes the medication himself or herself with the primary goal of avoiding suffering or maintaining dignity by ending their life. Nevertheless, the term PAS has fallen out of favor and is not preferred by organizations such as American Public Health Association, which see it as value-laden and inaccurate. In this edition of the Journal of Palliative Care, Ball and colleagues describe the creation of their policy and operating procedures for the provision of MAID in Toronto, Ontario, Canada. In the article, Ball and colleagues articulate many of the concerns that were raised with the practice of PAID in the United States, in particular, erratic absorption of enterally ingested medications and concerns about safety of these medications in the community at large. Thus, Ball and colleagues have favored a protocol more similar to the traditional Dutch or Belgian practices, where parenteral medications are administered via reliable venous access to patients who have requested aid in dying. The result of this is the same as PAID/PAS in such that the drugs result in death of the patient. Most would categorize this as ‘‘euthanasia,’’ as defined in Table 1. Indeed, Ball and colleagues discuss the legal options for MAID in Canada which include both ‘‘PAS’’ or ‘‘voluntary euthanasia,’’ using those specific terms to describe the options. Some argue that both PAID/PAS and MAID have the same intent and only differ in who is administering the lethal compounds. To proponents of MAID and PAID, the procedures have the intent of ‘‘ending suffering,’’ ‘‘respecting autonomy,’’ or allowing ‘‘death with dignity.’’ To opponents, either one of these methods introduces a lethal process, which results in the death of the patient that is distinct from the underlying terminal process. Furthermore, opponents can argue that the mitigation of suffering is only achieved indirectly via death occurring from the drugs received, not the underlying process, which violated the Doctrine of Double Effect. Sulmasy has argued this brilliantly in a 1998 essay, where he offered a clearly articulated argument distinguishing acts of ‘‘killing’’ and ‘‘allowing to die’’ based on arguments of action and intention. Recent papers, including an