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The European Association for Palliative Care White Paper on euthanasia and physician-assisted suicide: Dodging responsibility

The White Paper of the European Association for Palliative Care (EAPC) on euthanasia and physician-assisted suicide in a previous issue1 is the result of a consensus-seeking process among representatives of the national palliative care organisations in Europe as well as the EAPC board members about the position statements that had been formulated in an earlier position paper in 2003.2 With the aim of providing ‘a viewpoint from the palliative care perspective’ and an overarching ‘normative ethical framework’, the authors end by reaffirming that ‘euthanasia is not a part of palliative care’ despite noting strong dissent and a lack of consensus on pivotal statements. Though we applaud the willingness to address the issue of euthanasia and physician-assisted suicide within the EAPC, many aspects of the exercise itself are disappointing. Leaving aside obvious criticism relating to the methodology (i.e. norm setting by majority vote of ‘representatives’) and philosophical argumentation of some statements, we will focus here on what we believe to be the fundamental problem with the White Paper, namely, that it completely avoids the most pervasive questions for palliative care. Seeking a shared normative framework in abstracto, without reference to a possible context of legalised assisted dying, does not address the actual questions posed within the palliative care community, which relate to how palliative care could position itself in a scenario of legalised assisted dying. We believe it would have been much more worthwhile for the EAPC – in an exercise akin to a thought experiment – to systematically focus and reflect on the practical implications of all possible normative stances for people who are dying, for palliative care professionals, for the palliative care movement and for society at large. This dimension of practical implications – which in our view is pivotal in establishing an ethically defensible position – is lacking in the White Paper as the design of the exercise precludes it by default. Consequently, the White Paper ignores the extensive experience and substantial body of relevant empirical evidence in jurisdictions that have legalised euthanasia and/or physician-assisted suicide. Palliative care organisations within these jurisdictions have already had to react to legal assisted dying and thus provide prime ‘case studies’. In these jurisdictions, professional palliative care is in fact involved in the vast majority of cases where requests have been made.3–5 The Canadian palliative care community is performing this exercise at the moment. This involves reflecting on ways of reconciling traditional palliative care values with the choices now available to people when they are dying. If we accept assisted dying and make it part of our practice, what will this mean for our professional integrity? If we reject it and dismiss every request as merely a cry for help and reassurance, to what extent are we violating our values of the centrality of the person who is dying and their right to self-determination? If we, as a palliative care community, refuse to participate in requests for euthanasia, how can we be sure that the dying person could not have benefited from conventional palliative care? These are all questions that need to be answered. As an authority for palliative care in Europe and beyond, the EAPC has reiterated a navel-gazing framework that has no value to the palliative care community, be it in countries with or without a legal framework for assisted dying. If nations choose to legalise assisted dying, they are most likely to do so through political and societal debate, with or without the input of the medical profession. Legalisation will be largely out of the control of the palliative care community, and therefore, it is necessary to reflect thoroughly on how we can respond to what is seemingly an increasingly likely scenario. We will have to take into account the wider costs and benefits. For palliative care does not exist in its own cocoon but has a responsibility to the broader society in which it is embedded and which it serves.