Euthanasia & hospices: the unexpected link

Quality of Death: an EIU report commissioned by the Lien Foundation

A major new global study, released today by the Economist Intelligence Unit, has ranked the UK as top of the world league for palliative care. But some evidence also suggests right-to-die campaigners are successfully pressuring policy-makers into improving that very end-of-life care. So why the traditional tension? As philosopher Janet Radcliffe-Richards has rather piercingly observed, “If we could reliably make everyone’s life worth living, no-one would want to die, and laws preventing assistance would have no purpose.”

The study ranks countries for their ability to a) deliver basic palliative care, b) do so at a reasonable cost, c) the quality of that care, and d) its availability – with the UK coming top overall. The UK also scored highest in terms of availability and quality. Right-to-die options do not form part of the rankings data, but the report does highlight some interesting facts about countries allowing some form of voluntary euthanasia and their palliative care standards, as well as countries with strong pressure for ‘right-to-die’ legislation.

  • The Netherlands is ranked first equal in terms of affordability, together with Australia, New Zealand and Norway. (The United States is 31st, behind South Africa and Turkey).
  • Switzerland – where assisted suicide has been legal since 1941 – is ranked is ranked first in the world when it comes to providing a good basic end-of-life healthcare environment.
  • Belgium, the UK and Ireland all score first equal on the issue of public awareness about end-of-life care.

The report claims the UK leads the world in ‘quality of death’ ranking it top out of the 40 countries measured in the Index, despite having a far-from-perfect healthcare system (it ranks 28th on the Basic End-of Life Healthcare Environment sub-category, which accounts for 20% of the overall score – this is attributable to its record on life expectancy, hospital beds per 1,000 patients, its number of doctors, and its national healthcare spending). But the UK is again top in the Quality of End-of-Life Care sub-category, which includes indicators such as public awareness, training availability, access to pain killers and doctor-patient transparency (and accounts for 40% of the overall score).

It notes that pro-euthanasia legislation in the Northern Territory of Australia (subsequently overturned by the federal government) prompted new funding for end-of-life care. It also observes that, “. . . most recently attention has focused on the UK, where prominent campaigners such as author Sir Terry Pratchett, who has Alzheimer’s disease, and Debbie Purdy, a multiple sclerosis sufferer, are pushing legalisation of assisted suicide. However, such demands are coming largely from the public, rather than the palliative and hospice care profession. “If you look at the percentage of palliative care doctors who are opposed to assisted suicide in the UK, it’s over 90%,” says David Praill of Help the Hospices. “This is a publicly driven debate and definitely not a hospice and palliative care driven one.””

So why are euthanasia and palliative care such uneasy bedfellows – especially in countries that lack ‘right-to-die’ legislation? Palliative care groups have to strive for funding as well as assert the effectiveness of their regimes. They focus on the (large number) of patients they can potentially help the most. Right-to-die campaigners, on the other hand, represent the tiny number of cases that feel poorly served by palliative care. These are two distinct groups. Just as the organ transplant team standing by to recover a heart from a person at death, by law, have to be independent of the medical team trying to keep the potential donor alive.

But just as each team works separately, they are incorporated philosophically within end-of-life heath care.

Exit’s view on the dilemma is encapsulated in its Constitution and Mission Statement. It sees three main objectives: the ‘right-to-die’; improved palliative care; equal access to resources for people with unbearable and unrelievable suffering (ending the ‘postcode lottery’). Yet Exit’s main duty becomes the practical implementation of the right-to-die aspects of that policy and, within that, a focus on self-deliverance. (Even though Exit produces leaflets campaigning for improved palliative care and an end to the postcode lottery.) Maybe the political dynamic of urging assisted suicide legislation also helps the hospices and palliative care groups to achieve better healthcare in their chosen fields. We are all seeking, from different angles, a ‘good death.’

Quality of Death (animated index)
Life Before Death (beautiful look at death from different angles)
The Quality of Death: Ranking end-of-life care across the world (EIU summary)
The Quality of Death: Ranking end-of-life care across the world (full White Paper)
The Quality of Death: Ranking end-of-life care across the world (press release)
Palliative care funding to be reviewed (Nursing Times)
End of life issues (NHS page on access to palliative care, bereavement, registering a death)
National Council for Palliative Care (website)
Euthanasia and other end of life decisions and care provided in final three months of life: nationwide retrospective study in Belgium (BMJ 2009;339:b2772 )
The ethics of palliative care and euthanasia: exploring common values (Palliative Medicine (2006)  20(2), 107-112)

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