Line between acts and omissions blurred, euthanasia critics argue.

suicide and voluntary euthanasia is an unethical alternative to redressing current deficiencies in palliative care in Canada, physicians, ethicists and patient advocates argue. Decriminalization would offer a false choice so long as Canadians lack access to palliative care, the critics contended while panning the recommendation of the Royal Society of Canada panel report, End-of-Life Decision Making, which called for sweeping reforms to the Criminal Code on the grounds that there is no ethical distinction between assisted suicide or voluntary euthanasia, and withholding or withdrawing life-sustaining treatment from competent adults (www.rsc-src .ca /documents/RSCEndofLifeReport2011 _EN_Formatted_FINAL.pdf). The critics assert that it is “naive” and “disingenuous” for the panel to blur the line by arguing there is no ethical distinction (www.cmaj.ca/lookup /doi/10.1503/cmaj.109-4059). The critics also contend that the Royal Society panel is giving short shrift to concerns about abuses that might occur if decriminalization of assisted suicide and voluntary euthanasia is implemented. “What about people who already feel like they’re a burden? If it’s very difficult for their families, it’s a failure of our social services and health care system,” argues Rhonda Wiebe, cochair of the Council of Canadians with Disabilities’ end-of-life ethics committee. “They shouldn’t be paying with their lives because health and social services can’t step up to the plate.” As many as 70% of Canadians lack access to hospice and palliative care, and what programs exist are uncoordinated and unevenly distributed across the country, the report states. “When my wife passed away seven years ago, I was a guy who had worked in health care for 25 years as a physician, who knew the system, had a comfortable income, and yet I still couldn’t get her home because there was no way it could be done with the resources available,” says Dr. John Haggie, president of the Canadian Medical Association. “The solutions the report suggests [represent] failures of the palliative care process. By not having a system, we have a population that are afraid of the process of dying, and that drives them [to request suicide].” Adequate access to palliative care may not entirely prevent requests for assisted suicide, but until people have “relatively good options to manage their suffering,” decriminalizing euthanasia would present a false choice between pain and death, argues Dr. Larry Librach, director of the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital in Toronto, Ontario. The report asserts that Canada cannot wait until palliative care is optimized to have a policy on assisted dying. But Dr. Romayne Gallagher, palliative care physician lead at Providence Health Care in Vancouver, British Columbia, counters legislation isn’t needed because there isn’t a great demand for assisted suicide or voluntary euthanasia. “The uptake of the right to physician-assisted suicide in Oregon is about 1 to 2 deaths per 1000 deaths,” Gallagher says. “To me the low uptake of physician-assisted suicide in Oregon only demonstrates the greater need for improved palliative care.” Critics also dismiss the proposition that high numbers of Canadians support assisted dying. “There is ongoing confusion in the general public and in some health care providers about what constitutes euthanasia and physicianassisted suicide. For example, many people will confuse the removal of life support in a terminally ill patient as euthanasia,” Gallagher says. The Royal Society report contributed to the confusion by equating the act of killing a patient or giving a patient the means to kill themselves News CMAJ