Harvey Max Chochinov, MD PhD

Like so many people who work in palliative care, I am frequently, though  reluctantly, drawn into conversations about euthanasia and assisted suicide.  There is an assumption somehow that knowing how to care for people near the end  of life confers expertise on the rights of patients to seek out a hastened  death. Because I do research and publish studies that try to understand the  psychological landscape of people with life-threatening illnesses, my phone  rings whenever the media features someone requesting physician-hastened death,  or when there are rumblings about a challenge in the legislative status quo.

For years now, our research group has been studying the whole notion of what  it means to maintain dignity in the face of a life-threatening or life-limiting  illness. And no surprise, my phone rings more than ever. The term dignity, after  all, has become synonymous with the right to die movement, the key platform of  which is that the ability to end one’s life at a chosen time affords the  ultimate dignity. In their continued effort to promote social policies that  include euthanasia and physician-assisted suicide, it is worth asking if they  are pushing us toward or away from the most pressing questions facing palliative  care today.

Take for a moment the issue of hunger and imagine being asked to focus your  attention on how to suppress appetite in people who are starving, rather than  engaging the question of how to feed them. In view of the problem, the solution  would seem, putting it diplomatically, off the mark. As for the right to die  (not so much a right, but rather a physiological obligation), I think the most  intriguing questions relate to the myriad factors that influence a sick person’s  desire to go on living. No doubt, a thorough and honest examination of these  questions informs how to provide better care for the dying, while offering  important lessons for the living.

Study after study has shown an association between a loss of will to live and  uncontrolled pain, inadequate social support and psychological distress. Our  more recent studies have also pointed to the importance of existential  considerations, such as loss of dignity, lack of control, loss of sense of  meaning or purpose and a sense that one has become a burden to others.

In  these particular ways then, the dying and the living may not be so dissimilar.  Without a sense of purpose, meaning or being valued—all subsumed within what we  have coined a “dignity-conserving model of care”&mdash;whose will to live might not be  in jeopardy? Even the Hemlock Society has conceded, “If most individuals with a  terminal illness were treated this way [according to the dignity-conserving  model of care], the incentive to end their lives would be greatly reduced.”

For now, palliative care professionals will continue to be coaxed into  weighing in on the issue of physician-assisted suicide—to be or not to be. The  reason for their hesitation, however, should now be transparent. They are  tactfully trying to shift the question to how to help people live the best and  fullest quality of life possible. In all likelihood, in spite of the very best  that palliative care can offer, there will always be a tiny minority of patients  who will push for death-hastening options. Finding compassionate and moral ways  to address their needs will remain a challenge for policy-makers and caregivers  alike.

—Harvey Max Chochinov, MD, PhD, is the Canada  Research Chair in Palliative Care, director of the Manitoba Palliative Care  Research Unit at Cancer

 Manitoba, and professor of psychiatry at  the University of Manitoba.

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