Should residential hospices opt-out of providing assistance in dying?

By Jonathan Breslin

By now the general public is probably well aware that religiously-affiliated health care organizations in Ontario will not provide medical assistance in dying (MAiD).  But these are not the only facilities that are opting out.  Over the past year several media stories have reported decisions by various hospice organizations to opt out as well.  Some of these are individual residential hospices, while others are hospice organizations that include residential hospices and professionals who provide home palliative care services.

In the case of religious organizations, such as Catholic hospitals, the rationale for opting out is fairly obvious.  These organizations are required to provide service consistent with the religious beliefs of their tradition, and if the religious beliefs clearly forbid the intentional ending of a human life, they don’t have much wiggle room.  In the case of hospice, however, the rationale isn’t quite as obvious.  Why is it that some hospice organizations are deciding not to provide MAiD?

The simple reason is that many who work in hospice see MAiD as directly conflicting with the philosophy of hospice and palliative care.  Consider this statement from the website of Hospice Palliative Care Ontario: “Quality hospice palliative care neither hastens death nor prolongs life. The goal of hospice palliative care is to improve the quality of life for patients and their families facing problems associated with life-threatening illness” (emphasis added).  This is borrowed directly from the World Health Organization’s definition of palliative care.

On its own this reason isn’t very convincing.  After all, medicine has evolved a great deal over its history and palliative care can evolve too (there was once a time, not too long ago, when withdrawing life-sustaining treatment was considered in direct conflict with the philosophy of medicine).  The argument “because this is how we’ve always done things” is never a convincing reason for why things have to continue to be done that way.

On a more practical level, however, the concern of many in hospice and palliative care is that providing MAiD would further the already problematic association many people make between hospice/palliative care and death.  The concern is that the public may become fearful and avoid hospice and palliative care (more than they already do) because “that’s where they end people’s lives.”

We can accept this as a legitimate concern but still inquire as to the ethical considerations on the other side of the ledger – and there are several.  For one, a decision by a residential hospice to opt out of MAiD does impede access to the service.  It is simply not easy for dying patients to shop around for a willing provider, especially since there a very limited number of residential hospices in Ontario.  In some cases a transfer to another facility may not be feasible, which would directly violate the patient’s right to access MAiD.  This is especially true if a critical mass of residential hospices choose to opt out.

Second, while there is a concern that some people may avoid hospice out of fear of being put to death, it is at least equally likely that a policy to opt out of MAiD will hinder access to hospice for many patients.  At last check approximately 80% of Canadians support the right to seek MAiD.  An opt-out policy essentially forces an unfair choice on dying patients: to access residential hospice you may have to give up your right to access MAiD.  It is not difficult to imagine that there will be patients who decide against admission to residential hospice because they don’t want to risk not being able to access MAiD.

Third, there is the impact on patients in residential hospice to consider.  These are patients at the end of their lives who have been fortunate to access a comfortable and supportive environment in residential hospice, who will be required to transfer to another facility to carry out their final wish.  This may mean spending their last hours in a hospital, or traveling quite a distance to another residential hospice if there even is one with an available bed.  This can result in added discomfort and anxiety for the patient, not to mention the impact on the patient’s significant others.

Jonathan Breslin PhD, is an ethicist for Southlake Regional Health Centre and Mackenzie Health.