I was surprised to read a recent editorial by Dr. Chochinov in this journal (Chochinov Reference Chochinov2014). One does not often come across psychiatrists using the acronym “MAD” in a pejorative way to describe anything, certainly not in a medical journal. Dr. Chochinov quotes me as saying, “Take for instance the former chair of the Royal Society of Canada Panel on End-of-Life Decision-Making (Schüklenk et al., Reference Schüklenk, van Delden and Downie2011), who found it ‘highly problematic’ that ‘there is little support today, in Canada, for making assisted dying available to treatment-resistant incompetent depressed people, very young children, and people who are incompetent, for instance due to mental illness' (Schüklenk, Reference Schüklenk2014).”
It does look as if I advocated assisted dying for random young children and incompetent patients, does it not? It turns out, unsurprisingly perhaps, that that is not the case. I was clear in the article from which he quotes that I had very specific patients in mind. The quote, in context, actually reads thus, “They [Canadians] want the availability of assisted dying for competent patients suffering from a terminal illness. There is little support today, in Canada, for making assisted dying available to treatment-resistant incompetent depressed people, very young children, and people who are incompetent, for instance due to mental illness. This I consider deeply problematic. Majority opinion essentially insists today that the suffering of incompetent patients must continue, even in circumstances where many or most of their competent counterparts would have asked for assisted dying” (Schüklenk, Reference Schüklenk2014).
I simply express my concern here that dying incompetent patients could be excluded from access to assisted dying. Why would I lament very young children's lack of access to assisted dying otherwise? It would make no sense to even mention the issue. Undoubtedly that is a controversial view to express, given that typically competence is seen as a necessary condition for access to assisted dying. However, what is not fair game is to suggest that I had discussed this issue without addressing scope, in this case dying patients.
In any case, a broader point must be made with regard to Dr. Chochinov's commentary. It is unclear against whom he is arguing in his editorial when he writes that assisted dying would not “solve the overwhelming problems facing dying patients and their families in this country” (Chochinov, Reference Chochinov2014). He is correct, but he would be hard pressed to find a single person in Canada who disagrees with him. Having been at the receiving end of probably hundreds of journalistic inquiries since our report (Schüklenk et al., Reference Schüklenk, van Delden and Downie2011) was released, I have yet to come across a Canadian journalist sufficiently ill informed to think otherwise. Canadians wanted to discuss assisted dying because they were overwhelmingly in favor of it, and because politicians ignored their wishes on that count. Our Supreme Court judges have since agreed, in a unanimous finding, with the recommendations in our report and concluded that the criminalization of assisted dying violates our constitutional rights. This debate is about a small part of the rich mosaic that constitutes end-of-life care, the part that will make assisted dying available in the country to those who have run out of alternative options. It has never pretended to address all end-of-life issues comprehensively.
Palliative care specialists would be well advised to interpret assisted dying as part and parcel of our future end-of-life care as opposed to something that must be fought at all costs. After all, it is not as if palliative care and assisted dying are in some sort of competition with each other. Even in the best of all possible palliative care worlds there would be some patients preferring assisted dying. They are entitled to make such choices, and palliative care specialists should not interpret that as some kind of personal or professional failing.
Fighting strawmen based on out-of-context quotes and stories about ill-informed journalists does a disservice to this important debate.
