Palliative care before physician-assisted death?

It’s a common belief that patients, particularly those with terminal cancer, would choose death if their pain became unbearable because of inadequate palliative care. The argument is as follows: enhance palliative care access, adequately control pain and watch society’s support for physician-assisted death erode.

But, should palliative care come before doctor-assisted death, or do these go hand in hand with helping patients achieve the “best” death possible?

One concern is that legalizing physician-assisted death makes it an easy option. In other words, that once it’s legal, patients immediately choose it after receiving a terminal diagnosis, which in turn leads to inadequate funding to improve palliative care and opting for doctor-assisted death out of desperation because of palliative care’s poor quality.

However, the evidence does not support this. In fact, countries where physician-assisted death is legal are also world leaders in several palliative care metrics. For example, the five states (Oregon, Vermont, Washington, Montana and New Mexico) in the U.S. where doctor-assisted death is legal by statute also rank in the top eight regarding the availability of palliative care in their hospitals. This may be because legalization has been accompanied by increases in palliative care funding, as well as official palliative care policies.

Moreover, physician-assisted death is not only a medical issue but also a societal issue involving complex social questions. Doctors should not lead the way in making these choices because they impact all human beings. This is not something that physicians alone should or can decide. If the laws are going to change that has to be understood, and all of us need to be actively involved in this process.

In an ideal world doctor-assisted death would be legal and palliative care quality improved and physicians would have the right to conscientious objection (refusal to perform physician-assisted death) when they believe this is the right choice.