No Occultation in the International Association for Hospice and Palliative Care Position Statement on Palliative Care and Assisted Suicide

Dear Editor:

Thank you for the opportunity to respond to the letter to the editor by Bernheim et al., entitled Casting Light on an Occultation in the IAHPC Position Paper on Palliative Care and Assisted Dying. ¹ In the letter, the authors criticize the International Association for Hospice and Palliative Care (IAHPC) position statement on Euthanasia and Physician Assisted Suicide, ² also published in a previous edition of this journal.

Bernheim et al. criticize that IAHPC deliberately occulted the dissenting position from the Federation of Palliative Care Flanders (FPCF) from the northern, Dutch-language half of Belgium. ³ However, the IAHPC working group selected only statements from national and pan-national organizations, and purposely did not include position statements from subregional or local organizations. This is clearly stated in the Methodology section. The FPCF does not cover the whole of Belgium and is one of the three organizations represented in the Inter-Federation. ⁴ There are 193 countries in the world made of subregions with multiple cultural differences, and as a global organization, the IAHPC was incapable of including statements from all the different subregions in the analysis. We acknowledge that in the process of filtering out position statements of subregional organizations, we lost some relevant statements. We find it very interesting that there are major differences between the different regions in Belgium in attitudes toward as well as in practices of euthanasia. The number of euthanasia cases, for example, is much lower in Wallonia than in Flanders, although both regions have the same legislation on euthanasia. We think that these differences merit discussion, but this is the task of national and regional associations. The European Association for Palliative Care has highlighted these differences in more detail in their white paper on euthanasia and assisted suicide. ⁵

Bernheim et al. also criticize our argument in which we state that in states and countries where euthanasia and/or physician-assisted suicide (PAS) are legal, palliative care (PC) units should not be responsible for overseeing or administering these practices as doing so would place the professionals, their staff, and, in some cases, their patients and families in untenable positions. Bernheim et al. state that if euthanasia and PAS are carried out only in settings that are less competent for end-of-life (EOL) care, patients who desire the possibility of euthanasia and PAS will tend to shun professional PC and may hence not receive optimal EOL care. We respectfully disagree and the basis for our disagreement is clearly stated in the IAHPC position paper.

Bernheim et al. argue that the IAHPC is imposing a single form of perspective on an entire profession or across society, and that this belongs to the past. The IAHPC recognizes the sovereignty of Member States and respects the decisions taken by the citizens of each country. The organization is not imposing its views or opinions on any individual or country and the members and the societies at large are welcome to have their own views and opinions, in the same manner that we have stated ours. The IAHPC has a specific focus on resource-poor settings in low- or middle-income countries. In many regions of the world, suffering patients will not find access to PC, as there is no or only very isolated provision of PC. This is reflected in our core statement that reads: The IAHPC believes that no country or state should consider the legalization of euthanasia or PAS until it ensures universal access to palliative care services and to appropriate medications, including opioids for pain and dyspnea. In this statement, we are recognizing the freedom that governments and citizens have on choosing, even if they decide to approve any form of euthanasia and PAS. We hope that the patients in Flanders have universal access to PC services and medications, in the same manner that they have access to euthanasia and PAS.

From the wider perspective of the IAHPC, the unmet PC needs of millions of patients and their families around the world, and the urgent obligation that governments have to ensure access and the integration of PC in national health systems, should be the priority in its discussions and not the legislation of euthanasia or PAS.