19/01 2018

When is Pallliative Care no longer Palliative Care? How did Football become Rugby?

If we change the rules of the game we are playing, how far can we go before it is no longer the same game? We can make small changes to the size of the goals or the offside rules, but if we make big changes like picking up the ball rather than kicking it-now we are dealing with a different entity entirely. So when did Football (Soccer-for the North Americans) become Rugby? What happened and why? We’ll get to that, but first a few questions.

Separation, is it always a bad thing?It seems to me that there are times when it is entirely correct for things that are different to remain separate; simply because they are different. Not all things are going to fit well together, or even remain together, if we try to force them. Oil and water can be mixed together to form an emulsion with a degree of effort-(think vinegarette /salad dressing) but ultimately the components will separate again as they are completely different entities, though it may taste good at the time.

In our desire as a society to be fair, to be seen to comply with the law, or even in our desires to fulfill the ethical principle of justice, (with all people having equal access to resources and treated the same) we can create a situation that really didn’t need to occur. Also ultimately it may not be the best we could do.

When I began this post I was sitting in Arizona and realizing how different that environment is from my home in Canada. Trees, plants and animals that live and thrive here will not do so in British Columbia. To try to force the issue, however well intentioned will not change the basic facts that there is a difference that sometimes cannot be overcome simply by our own human will or desire. Yes we can build glasshouses and design microclimates to simulate things, but this does not change the basic underlying principles. Their are differences here that maybe need to be more celebrated rather than overridden.

Much of what I see reported in the news and media, often quite correctly, is the reverse argument. I am not for one moment suggesting that there are not times when separate is quite clearly the wrong thing. We don’t have to look far in history for examples of this, in terms of segregation, injustice, racism and genocide. What I am wondering though, is whether there are legitimate reasons that certain things should remain separate for the protection of individuals as well as rights, principles and some times just plain common sense. Maybe their are times when it is the right thing to say no for the greater good rather than yes, even if this is the more difficult path to take or explain.

We are standing at a junction in Canada’s history where Euthanasia has been legal for over a year but so far in the main (not everywhere) has been allowed to remain separate from Palliative Care, something for which I personally have been very grateful. Not necessarily just for the reasons that you may think for those of you that know me. I will explain further.

Palliative Care at it’s heart, as in the World Health Organization definition is “care for the living until they die” with thus the emphasis placed on life not death. The paradox of this is that being involved in Palliative Care as a Physician, death for me is an almost daily experience but the focus remains on life. If you meet me (at work!) and are admitted to the unit I work on you have a 50% chance of dying there, but also you have a 50% chance of living and our focus remains that “life is and always has been one day at a time.” So our question and remit becomes “how can we make the time you have the best it can be?’ This then is a core value.

We would not expect to see raw meat being prepared in a Vegan restaurant, what does this say of the rights of those who enjoy eating meat. There has been a choice on their part to go to this establishment clear in the knowledge that will not be able to get certain things. It is not considered an infringement of personal autonomy-simply respect for the majority who choose to be vegetarian there.

We don’t ask people who are seeking for whatever reason a medical termination of pregnancy to be in the next bed to another who is having fertility investigation or treatment in a hospital facility. This would clearly be potentially very distressing for all involved and a situation that is unnecessary, unkind and at worst unethical. Put next to this, having family members meeting each other on the hospital unit and discussing why their loved ones are in hospital-surely not something we would ever do. I would hope not, it simply doesn’t make sense to consider it.

Unfortunately, again in my opinion, it is not a big jump from this last analogy to where we are heading with our health authorities now mandating Euthanasia for patients that request it and fulfill the criteria, in hospital Palliative Care Units and Hospices. These units become small communities and patients and families are aware of what is happening in the various rooms, because they talk to each other. We know that 97-98% of people who go through our units have no interest in Euthanasia in fact quite the reverse, so why would we be introducing something so potentially problematic and distressing there.

This is not now an argument about whether Euthanasia or Termination of pregnancy should be available, but where and how for the greater good. I am in no way standing in judgement of anyone who make these choices for whatever reason, this is their legal right and decisions that have been made for us as a society, by those we have elected to govern us. It is clearly not up to me to make choices for others who are independent of me.

So far I have not heard a good explanation from anyone, and believe me I have heard a lot of explanations, as to why Euthanasia has to be provided in Palliative Units and Hospices. I understand the relative arguments involved and that personal autonomy in Canada sometimes seems to just trump every other argument. That it is never right or acceptable to say no or even question someone’s choices. Why introduce things that don’t need to be there to programmes that are founded on principles that are clearly opposed, founded on life, which clearly assisted dying is not. Is it not possible for us to see that whatever our views and beliefs are, that their are things that are better off remaining separate for the greater good and the protection of everyone involved?

The laws that have been passed say many things, but where Euthanasia is to be provided is not one of them. I had hoped that wiser heads and hearts would prevail and that things that need to remain separate will be allowed to do so. If we were to change the markings on a Football (Soccer) field and alter basic fundamentals like the shape of the ball are we still playing Football? I am hearing comments like “Could we not be world leaders and change Palliative Care to accommodate Euthanasia?” Which part of caring for the living until they die allows that to happen?! Which part of a foundational International definition is not clear enough?

In 1823 during a game of Football (Soccer) at Rugby school in the UK, William Webb-Ellis is reported to have picked up the ball and run with it. This new approach was not added to the rules of Football but generated a new sport of Rugby. Definitions are important, we are not free to dispose of them simply because they seem to no longer suit our purpose or are inconvenient.
Palliative Care and Euthanasia are about as separate as it is possible to be this is a situation that should remain.




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