JOURNAL OF PALLIATIVE MEDICINE

Volume 26, Number 7, 2023 Special Report

ª Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2023.0209

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Medical Assistance in Dying and Palliative Care:

Shared Trajectories

James Downar, MD, MHSc (Bioethics),1,2 Susan MacDonald, MD, CCFP(PC), FCFP Founder,3
and Sandy Buchman, MD, CCFP(PC), FCFP4,5
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Abstract
Medical Assistance in Dying (MAID) and palliative care often have an antagonistic relationship in jurisdictions
where both are legal, but the early ethical and legal history of palliative care closely mirrors that of MAID in
important ways. Palliative practices that are commonplace today were considered homicide or ‘‘medically
assisted death’’ in most jurisdictions until quite recently. Moreover, while many patients request MAID today
for reasons that are criticized as ‘‘ableist,’’ the same rationale is accepted without comment or judgment when
used to justify withdrawal of life support or a discontinuation of life-prolonging therapies. Concerns about
factors that undermine autonomous decisions for MAID would apply equally to routine palliative care practices.
By the same token, palliative care exists because no field in medicine is able to fix every problem it encounters.
It is ironic, therefore, that some palliative care providers oppose MAID with the hubristic argument that we can
relieve all forms of suffering. Palliative care providers may choose not to participate in MAID, but palliative
care and MAID do not have to be mutually exclusive and are often complementary and synergistic for patients
and families.

Keywords: active; assisted; editorial [publication type]; euthanasia; palliative care; suicide; voluntary

their patients.2,3 Even as late as 2002, an international survey

L ooking at the (sometimes) antagonistic relationship
between Medical Assistance in Dying (MAID) and
palliative care today,1 it is easy to overlook the parallels
between the two practices in terms of legal status and his-
torical acceptance by the medical community. The hospice
movement that formed in the 1960s and 1970s in United
Kingdom was far from accepted by mainstream medical
practice anywhere in the world. Core elements of modern
palliative care (e.g., disclosure, withholding ineffective and
unwanted therapies, advance care planning) were virtually
unknown and considered unethical or even illegal.
In the 1960s and 1970s, very few physicians anywhere in
the world would routinely disclose a diagnosis of cancer to
of oncologists found a substantial hesitancy to disclose a poor
prognosis or suggest hospice care,4 and many reported giving
treatments they knew to be ineffective so as not to ‘‘destroy
hope.’’4 In 1974, the American Heart Association Guidelines
for Cardiopulmonary Resuscitation explained for the first time
that cardiopulmonary resuscitation (CPR) should be withheld
(i.e., a ‘‘Do-not-resuscitate’’ order) in some situations where it
would not offer benefit; they did not suggest discussing (or
even disclosing) this decision to patients or family members.5
Advance Directives only became legal for the first time in
California in 1975,6 and were not legally valid in many ju-
risdictions for years afterward. Even when the limitations of

1
Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
2
Department of Critical Care, The Ottawa Hospital, Ottawa, Ontario, Canada.
3
Departments of Medicine and Family Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland and Labrador,
Canada.
4
Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
5
Freeman Centre for The Advancement of Palliative Care, North York General Hospital, Toronto, Ontario, Canada.
Accepted May 23, 2023.

896
 MAID AND PALLIATIVE CARE: SHARED TRAJECTORIES
medical care were recognized, they were often not ac-
knowledged to the patient or the public. There was a strong
‘‘culture of cure’’; health care professionals were expected to
maintain a positive attitude and to continue to provide
treatment until the bitter end. Palliative care was not neces-
sary because high-quality medical care was sufficient to cure
virtually every problem.
Withdrawing life-sustaining measures, a routine practice
in much of the world today, was widely considered to
be homicide in the same jurisdictions until quite recently. In
1975, Karen Ann Quinlan’s parents requested that she be re-
moved from a mechanical ventilator after she showed no sign
of recovery following anoxic brain injury. Her physicians
refused, and the New Jersey Superior Court indicated that
withdrawal of life-support would constitute homicide.7
Although this decision was overturned on appeal,8 physi-
cians in other jurisdictions continued to oppose even com-
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petent requests to discontinue life-sustaining measures in
favor of palliative care. In 1992, Nancy B required a ruling
from Quebec’s Superior Court to have her ventilator legally
withdrawn after she developed a case of severe, refractory
Guillain-Barre syndrome lasting 2.5 years.9 Notably, her at-
tending physician had initially refused to grant her wish,
explaining that ‘‘She is young; she is lucid, conscious, and
she could go on living for many years.’’10 Although such
practices are commonplace today in Canada and completely
in alignment with the philosophy of palliative care, this case
was described at the time as a medically assisted death.9,10
We May See a Difference, But Most Patients Do Not
Notably, the history of the hospice movement and of pal-
liative care practice in general is one of patient-driven
changes in practice and law, often without the support (and
sometimes with the active resistance) of medical practition-
ers and organizations. For better or worse, patients and
families have embraced the idea that quality of life is
sometimes more important than quantity of life.
Generally, this is not a dichotomy, and patients can pursue
quality without compromising quantity. However, when this
cannot be achieved, palliative care providers work with the
person to help them choose when and how they may wish to
prioritize quality over quantity. This is the core ethos of
palliative care, to the degree that Dr. Harvey Chochinov re-
cently described it as a ‘‘Platinum Rule’’11 (‘‘doing unto
patients as they would want done unto themselves’’). It is also
the core ethos of MAID. The goal of the MAID provider,
similar to the palliative care (PC) professional, is not to
hasten death. The goal of each is to support choice.
Of course, there are many physicians who would support a
palliative philosophy for their patients, yet strongly oppose a
request for MAID. Palliative care professionals often per-
ceive that some patients or family members resist a palliative
approach to care (e.g., limiting life-sustaining measures,
adding comfort medications) because of concerns that it
would compromise survival. From this observation, they
assume that excluding MAID from palliative care settings
and practice will make palliative care more acceptable to
patients and family members. It is important to emphasize
that palliative interventions do not appear to shorten life.12
However, while people may fear unintentional shortening of
life when they are pursuing a cure or prolongation of life, they
897
are deeply supportive of the right to request an intentional
shortening of life when this is no longer realistic.13,14 Palli-
phobia is not driven by a fear of MAID.
MAID and palliative care are not mutually exclusive op-
tions. Studies of MAID recipients have routinely shown very
high rates of PC involvement (70–90%).15–18 In the Nether-
lands, palliative care professionals are also the MAID assessors
or providers in 60% of MAID cases. This can be reassuring for
those concerned that MAID might be driven by poor access to
PC services. Nevertheless, it is notable that PC involvement
generally precedes the MAID request by many weeks or
months.18 This suggests that PC is not merely being consulted
by a medical team as a procedural step before performing
MAID, but that the patients themselves may be driving both.
People who request or agree to involvement of the palli-
ative care team are likely more accepting of their prognosis,
and more willing to self-advocate for prioritizing quality of
life over quantity of life. And herein lies a cognitive disso-
nance for palliative care professionals who are opposed to the
legalization of MAID. It is well and good to invoke the
‘‘Platinum Rule’’ when people are not requesting MAID,11
but then we cannot immediately discard the Platinum Rule
when a competent person is requesting MAID. A rule is not a
rule if it is selectively applied or abandoned to achieve the
result desired by the provider (i.e., no MAID).
Why Do We Only Question Autonomy When People
Request MAID?
Autonomy and decisional capacity can obviously be un-
dermined by a variety of factors (e.g., socioeconomic, illness-
related, societal), but again, we cannot selectively apply this
concern to reject autonomy only in situations where a person
is requesting MAID.19 People who are structurally ‘‘vulner-
able’’ are at risk of receiving treatments they don’t want, but
they are also at risk of not receiving treatments that they do
want. And if we are concerned that vulnerability or societal
pressure is shortening life by driving a decision to request
MAID, we must be equally concerned about these factors
influencing people who choose to stop life-sustaining or
disease-modifying treatments in favor of palliative care.
When Nancy B requested that her ventilator be discontinued
in 1992, she explained,10
I am fed up with living on a respirator; this is no longer a
life..I do not want to live on this machine.. The only thing I
have is television and looking at the walls. It’s enough. It’s
been 2 1/2 years that I’ve been on this thing, and I think I’ve
done my share.
Conspicuously absent from the public response was any
notion that her decision was influenced by societal ableism, or
the lack of personal or home care resources to allow her to live
at home, while dependent on the ventilator. Nor was there any
public comment that her desire to die would have changed if
she had received psychotherapy, or more emotional support
from health care workers and family. On the contrary, Pro-
fessor Margaret Somerville (a law professor and MAID op-
ponent) commented that she was ‘‘pleased’’ with the decision
and that ‘‘.if you think of the consequences of the alternative,
that is completely unacceptable. Here she is.a completely
conscious young adult. There obviously was clear and con-
vincing evidence that she wants to end it.’’10
 898
Although this case referred to the discontinuation of a
ventilator and not MAID, Nancy B was clearly requesting
death. She was not hoping to continue living in the same state
once the ventilator was discontinued. And this request was
supported by the palliative care community then as it would
be today. Similarly, when patients transition to comfort-
focused care as they near the end of life, the decision is
frequently motivated by a loss of independence, or an in-
ability to perform activities that gave their life meaning. As
PC providers, we do not dismiss this rationale as ‘‘ableism’’;
we respect a person’s right to rate their own distress and
accept that they are best positioned to determine when that
distress should prompt a change in treatment.
One legal expert did observe at that time that in the United
States, courts had ordered life-prolonging care continued for 2
of 14 cases of critically ill women whose family members felt
they would want it discontinued, but had not ordered life-
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support continued for any of 8 cases involving men.9 The
reasoning in these cases appeared to be based on gender-based
stereotypes—women being ‘‘emotional’’ and ‘‘liable to
change [their minds],’’ required ‘‘protection against their own
instincts’’; men, being more ‘‘rational’’ and ‘‘capable of taking
responsibility for the preferences they exhibit,’’ clearly did not
require such protection.9 Of course, nobody can rationally
argue today that we should treat men and women differently in
terms of their autonomous choices. However this is a recent
example of how the concept of vulnerability has been used to
selectively undermine the autonomy of individuals and force
them to receive care they do not want.
Conclusion
Palliative care professionals may choose not to participate
in MAID, but MAID and palliative care do not need to have
an antagonistic relationship. In a recent poll of the Interna-
tional Association for Hospice and Palliative Care member-
ship, a small plurality supported the legalization of MAID
(49% vs. 45%), and a majority felt that MAID debates ‘‘help
palliative care development by bringing [PC] up as a topic in
discussions’’ (51% agreed vs. 33% disagreed).20
There are differences between MAID and palliative care,
but there are many similarities in terms of history and patient
perspectives, which is likely one reason why opinion polls
show such high levels of support for both among the public.
There are also many conceptual similarities, making it dif-
ficult to raise any concern about factors that undermine au-
tonomous decisions for MAID, which would not apply
equally to routine palliative care practices. By the same to-
ken, palliative care exists because no field in medicine is able
to fix every problem it encounters. It is ironic, therefore, that
some palliative care providers oppose MAID with the hu-
bristic argument that we can relieve all forms of suffering.
Over time, palliative care and MAID teams have evolved
to work congruently in parts of Canada21 and Europe.1 In
these situations, patients are supported by the palliative care
team. If the patient requests MAID, the palliative care team
should work seamlessly with the MAID service to ensure that
the patient has no disruption in care and that new providers
are not necessarily required.
If the patient decides to proceed with MAID, it should be
performed where the patient chooses, whether this be at home
or in a palliative care setting. Any palliative care clinician who
DOWNAR ET AL.
does not feel comfortable with MAID should have the support
of a team, who can supplement care or take the patient in
transfer.21 Palliative care and MAID do not have to be mutu-
ally exclusive and are often complementary and synergistic for
patients and families. Both respect and support patient au-
tonomy. Cooperation and collaboration enhance trust in the
patient’s health care providers, the very foundation of patient-
centered, effective, and compassionate health care.
Funding Information
No funding was received for this article.
Author Disclosure Statement
J.D. has received honoraria from Joule, Inc., for develop-
ing educational material related to MAID provision, and is a
former advisor to Dying with Dignity Canada, an advocacy
group. S.M. has no conflicts to declare. S.B. is a palliative
care physician, a cofounder of Neshama Hospice in Toronto,
a MAID Assessor and Provider, a member of the Canadian
Association of MAID Assessors and Providers (CAMAP),
and a co-founder and advisor to MAiDHouse, a not-for-profit
organization aimed at providing a home-like setting for eli-
gible patients to receive MAID.
References
1. Gerson SM, Koksvik GH, Richards N, et al. The relationship
of palliative care with assisted dying where assisted dying is
lawful: A systematic scoping review of the literature. J Pain
Symptom Manage. 2020;59(6):1287–1303.e1281.
2. Friedman HJ. Physician management of dying patients: An
exploration. Psychiatry Med 1970;1(4):295–305.
3. Oken D. What to tell cancer patients. A study of medical
attitudes. JAMA 1961;175:1120–1128.
4. Baile WF, Lenzi R, Parker PA, et al. Oncologists’ attitudes
toward and practices in giving bad news: An exploratory
study. J Clin Oncol 2002;20(8):2189–2196.
5. Standards for Cardiopulmonary Resuscitation (CPR) and
Emergency Cardiac Care (ECC). JAMA 1974;227(7):833–
868.
6. Fine RL. From Quinlan to Schiavo: Medical, ethical, and
legal issues in severe brain injury. Proc (Bayl Univ Med
Cent) 2005;18(4):303–310.
7. ‘‘Karen Ann Quinlan.’’ Wikipedia, The Free Encyclopedia.
2023. Available from: https://en.wikipedia.org/w/index
.php?title=Karen_Ann_Quinlan&oldid=1136369181 [Last
accessed: March 24, 2023].
8. In re Quinlan, 137 N.J. Super. (Superior Court of New
Jersey, Chancery Division 1975).
9. Dickens B. Medically assisted death: Nancy B v. Hotel-
Dieu de Quebec. McGill Law J 1993;38(4):1053–1070.
10. Claiborne W. Paralyzed Canadian Woman wins Court
Ruling on Right to Die. The Washington Post. January 7,
1992, 1992.
11. Chochinov HM. The platinum rule: A new standard for
person-centered care. J Palliat Med 2022;25(6):854–856.
12. Hui D, Heung Y, Bruera E. Timely palliative care: Perso-
nalizing the process of referral. Cancers (Basel). 2022;
14(4):1047.
13. 2022 poll: Support for medically assisted dying in Canada.
Ipsos Polling. 2022. Available from: https://www.dying
withdignity.ca/wp-content/uploads/2022/05/DWDC_Ipsos_
2022-Final-Report.pdf [Last accessed: February 27, 2023].
 MAID AND PALLIATIVE CARE: SHARED TRAJECTORIES 899

14. 7 in 10 Britons support assisted dying in latest Ipsos poll.
Ipsos. 2022. Available from: https://www.ipsos.com/en-uk/
7-10-britons-support-assisted-dying-latest-ipsos-poll [Last
accessed: February 27, 2023].
15. Loggers ET, Starks H, Shannon-Dudley M, et al. Im-
plementing a Death with Dignity program at a compre-
hensive cancer center. N Engl J Med 2013;368(15):
1417–1424.
16. Downar J, Fowler RA, Halko R, et al. Early experience
with medical assistance in dying in Ontario, Canada: A
cohort study. CMAJ 2020;192(8):E173–E181.
17. Dierickx S, Deliens L, Cohen J, et al. Involvement of
palliative care in euthanasia practice in a context of legal-
ized euthanasia: A population-based mortality follow-back
study. Palliat Med 2018;32(1):114–122.
18. Third Annual Report on Medical Assistance in Dying in
Canada 2021. Health Canada; 2022. Available from: https://
Downloaded by University of Toronto via COAHL from www.liebertpub.com at 07/13/23. For personal use only.
20. Key findings of the 2022 IAHPC Assisted Dying Practices
and Euthanasia Survey. International Association for Hos-
pice and Palliative Care. 2023. Available from: https://
hospicecare.com/what-we-do/publications/special-issues/
assisted-dying-practices/methodology-and-key-findings/
[Last accessed: May 1, 2023].
21. Wales J, Isenberg SR, Wegier P, et al. Providing medical
assistance in dying within a home Palliative Care Program
in Toronto, Canada: An observational study of the first year
of experience. J Palliat Med 2018;21(11):1573–1579.
Address correspondence to:
James Downar, MD, MHSc (Bioethics)
Division of Palliative Care
Department of Medicine
University of Ottawa
43 Rue Bruyere, Suite 268J

www.canada.ca/en/health-canada/services/medical-assistance- Ottawa K1N 5C8

dying/annual-report-2021.html [Last accessed: May 1, 2023]. Ontario
19. Downie J, Schuklenk U. Social determinants of health and Canada
slippery slopes in assisted dying debates: Lessons from
Canada. J Med Ethics 2021;47(10):662–669. E-mail: jdownar@toh.ca