Matters of conscience and end-of-life care

We’re here now in the land of assisted dying as one option for those eligible for and in need of quality end-of-life care.  An evolving practice context that must respond to those distressing requests to end someone’s intolerable suffering (and other criteria as any new law stipulates).  In response to this new situation, the Ministry of Health and Long Term Care has helpfully begun a voluntary registration process for physicians to log their position on involvement in elements of assessing for and providing assisted dying.  This will hopefully help connect willing clinicians with those needing their assistance while allowing those not willing to either register as such or remain quiet, as their consciences direct them.

In thinking about how conscience enters the realm  and deliberations around assisted dying, it is evidently a key factor for all.  For those who actively participate, for those who facilitate in various ways and for those who object to any involvement, conscience will lead us each to our ‘last, best judgement’, as Charles Curran described it.  Conscience is multi-factorial – coming from within and outwith, to borrow a Scottish word.  Sometimes what we feel most at ease doing is not what those external guideposts tell us to do.

In reaching our decisions, many will rely on faith.  By faith I do not mean religion, per se, but belief in some more supernatural or divine entity which can offer guidance to those seeking direction from outside the realm of the human.  This is often very distinct from organized religion.

For others, it is their connection with more formal religious institutions that offers additional direction and guidance.  For some, religion may be the most central or even sole consideration – religious leaders and laws indicate decisively what is right and wrong.

Many will look to their own secular understanding of morality to help them discern what would be the most ethical action in any situation.  This may be in addition or faith or religion, or it may be the primary source of one’s sense of what is the right thing to do.

In any of these cases, we may not feel particularly comfortable with what we are called to do by the sum of our deliberations and discernment.  In the case of assisted dying, I know of no one who feels good about the idea.  For those who feel it is lamentably right, that sense of right might at times appear to have an air of enthusiasm.  However, from all I know of colleagues who have been arguing in favour of access to assisted death, it is with a clear lament that they do so.

Pondering or encountering patients whose illness leads to contemplating an assisted death is and should always be gut wrenching – the ‘yuck factor’ in extremis.   It is invariably something of a last resort option when all else seems to be ineffective in achieving what the patient seeks from care.  In this unfortunate context, death is good, counter-intuitively good.

When one looks from a distance, there is broad overlap in our shared aims in achieving a patient’s goals of care, particularly remediating intolerable suffering.  There are also clear differences of opinion on how best to shape this new practice as it becomes part of our reality.  Our own moral and ethical guideposts will present each of us with certain preferred parameters in the broader landscape of options that are now legally open to patients.  The right of providers to practice within those differing parameters is also protected by law.

Together, relying on each other to step in where some of us as individuals might feel we cannot go, we can, as a broad collaborative system, offer eligible capable and informed patients all the options they may wish to pursue to achieve their own goals of care.  Such decisions by patients will also be very conscientious ones – informed by their own guideposts – their own unique combination of values, faith and/or religion.  Where they pursue the option of assisted death through to its provision, it will be their own last, best judgement.