Tom Koch is a consulting medical ethicist and gerontologist. His most recent book is Ethics in Everyday Places.
Because something is legal doesn’t mean it is ethically acceptable or, in medicine, clinically appropriate. The debate swirling over the Delta Hospice Society’s refusal of medical termination, “medical aid in dying” (MAID), in its beds is an example.
Diagnosed with terminal cancer, Clint Gossard, 59, hoped for a bed at the society’s 10-bed Irene Thomas Hospice in Delta, B.C. But he also wanted what they refuse to permit: medical aid in dying. For that, he had to go to Delta Hospital where his life was ended last January.
His widow and MAID advocates found that unacceptable. As a result, B.C. Minister of Health Adrian Dix has threatened the society’s funding if they don’t permit medical termination on their premises. Hospices I know elsewhere are similarly under pressure.
Speaking for the Delta Hospice Society, its founder and former director, Nancy Macey, argued not only that MAID violates the hospice’s constitution but the goals of palliative and hospice care. The society’s position is shared by many including those, like me, who are at best agnostic. Instead, it follows the guidelines in this area.
In November, 2019, for example, the Canadian Hospice Palliative Care Association (CHPCA) and the Canadian Society of Palliative Care Physicians (CSPCP) issued a joint statement stating categorically that “National and international hospice palliative care organizations are unified in the position that MAID is not part of the practice of hospice palliative care."
Medical aid in dying, they argued, is not an “extension of palliative care” but a violation of hospice and palliative medical goals of care. It is simple to administer the correct drugs (dosage by weight) to stop the heart and lungs. It is hard to assure the best possible life for those with chronic, progressive illnesses.
In its focus on the best of life to the end of life, hospice practice requires an understanding not only of clinical but also psychological needs. I have several times been engaged in discussions with those who wanted to die because of problems, clinical, personal or social, that were then addressed by palliative caregivers. In these cases, “I want to die” was really “I need help with this.”
A simple "it's your choice" removes our opportunity to find and provide the necessities of an acceptable life to the end of a patient's days. It replaces complexity with a simple, “Well, they wanted it” even where the reasons for wanting could be palliated.
The issue is greater than one hospice society and one minister. Mr. Dix’s threat seems to violate the spirit if not the letter of enabling federal legislation that assured the rights of practitioner conscience would be protected.
We do not insist every practitioner perform every legally permitted procedure upon request. They may refuse to perform non-therapeutic abortions, for example. Because a patient reads about a procedure on the internet doesn’t mean a physician must perform it. Clinical, ethical and social judgment has been in every other area of medicine not simply protected but encouraged.
A hospice society following professional guidelines should be lauded, not censored. After all, they take on the onerous job of organization and supervision of complex cases with at best partial funding from their provinces. Most I know are endlessly fundraising to make up for shortfalls in the monies the province provides.
Mr. Gossard received the end he wanted. He just didn’t get it at the hospice dedicated to palliative care. So the referral system worked. And yet Mr. Dix insists the Delta Hospice Society should violate CHPCA and CAPCP practice guidelines of if they want to be funded. Conscience and best practices of those governing professional associations be damned.
If he is successful, it will mean we are all allowed our convictions, ethics and clinical judgments as long as they are deemed appropriate by the minister of the day. To say “you have rights” and then to make practice impossible violates the spirit of the laws in which individual conscience and professional judgment are protected.
That is not a result I would like. It is also one whose ramifications extend far beyond this one hospice society and its firm conviction on what best practices might be.
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