Original research

J Med Ethics: first published as 10.1136/medethics-2017-104339 on 30 October 2018. Downloaded from http://jme.bmj.com/ on 1 November 2018 by guest. Protected by copyright.
Of dilemmas and tensions: a qualitative study of
palliative care physicians’ positions regarding
voluntary active euthanasia in Quebec, Canada
Emmanuelle Bélanger,1 Anna Towers,2 David Kenneth Wright,3 Yuexi Chen,4
Golda Tradounsky,5 Mary Ellen Macdonald6

►► Additional material is Abstract and therefore unconstitutional.3 Together, these

published online only. To view Objectives  In 2015, the Province of Quebec, Canada two legal processes resulted in a legal framework
please visit the journal online
(http://d​ x.​doi.o​ rg/​10.​1136/​ passed a law that allowed voluntary active euthanasia for deliberately hastened death (ie, ‘medical aid in
medethics-​2017-​104339). (VAE). Palliative care stakeholders in Canada have dying’) in Quebec and Canada. The Quebec legis-
been largely opposed to euthanasia, yet there is little lation is particular because it explicitly confers to
1
Center for Gerontology research about their views. The research question guiding all citizens a positive right to receive a deliberately
and Healthcare Research, this study was the following: How do palliative care hastened death, assuming they qualify for and wish
Department of Health Services,
Policy and Practice, School of physicians in Quebec position themselves regarding to receive this intervention: ‘Every person whose
Public Health, Brown University, the practice of VAE in the context of the new provincial condition requires it has the right to receive end-of-
Providence, Rhode Island, USA legislation? life care’, where ‘end-of-life care means palliative
2
Department of Oncology, Methods  We used interpretive description, an inductive care provided to end-of-life patients and medical
McGill University, Montreal,
methodology to answer research questions about aid in dying’. ‘Medical aid in dying’, as it is referred
Quebec, Canada
3
School of Nursing, University of clinical practice. A total of 18 palliative care physicians to in the Quebec legislation,2 is consistent with
Ottawa, Ottawa, Canada participated in semistructured interviews at two voluntary active euthanasia (VAE) as it is known in
4
Palliative Care McGill, McGill university-affiliated hospitals in Quebec. the international literature. For clarity, VAE will be
University Montreal, Montreal, Results  Participants positioned themselves in
Quebec, Canada
used throughout this paper.
5
Department of Family Medicine, opposition to euthanasia. Their justifications were framed Palliative care is care that promotes quality of
McGill University, Montreal, within their professional commitment to not hasten life for patients and their families when facing a
Quebec, Canada death, which sat in tension with the value of patients’ life-threatening illness through the relief of phys-
6
Faculty of Dentistry, McGill autonomy to choose how to die. Participants described ical, psychosocial and spiritual suffering. The inclu-
University, Montreal, Quebec,
VAE as unacceptable if it impeded opportunities to sion of VAE as an end-of-life care option contradicts
Canada
evaluate and alleviate suffering. Further, they contested the ethos of palliative care philosophy, at least
Correspondence to government rhetoric that positioned VAE as a way insofar as palliative care neither hastens death or
Dr Emmanuelle Bélanger, Center to improve end-of-life care. Participants felt that VAE prolongs life.4 Observation of advocacy efforts by
for Gerontology and Healthcare would diminish the potential of palliative care to relieve the Quebec palliative care community during the
Research, Department of Health suffering. Dilemmas were apparent in their narratives,
Services, Policy and Practice legislative consultations that led to the legalisation
about reconciling respect for patient autonomy of VAE provides insight into its normative stance
School of Public Health, Brown
University, Providence, RI with broader palliative care values, and the value of on this practice. For example, in 2014, the Cana-
02912, USA; accompanying and not abandoning patients who make dian Society of Palliative Care Physicians and the
e​ mmanuelle_​belanger@​brown.​ requests for VAE while being committed to neither
edu
Quebec Palliative Care Network expressed concern
prolonging nor hastening death. about the blurring of boundaries between palliative
Received 21 April 2017 Conclusions  This study provides insight into nuanced care and medical aid in dying in an early draft of the
Revised 22 July 2018 positions of experienced palliative care physicians in law. The palliative care community was successful
Accepted 8 October 2018 Quebec and confirms expected tensions between an in advocating that the definitions of VAE and of
important stakeholder and the practice of VAE as guided palliative care be completely separated in the final
by the new legislation. version. They were also successful in persuading
the government to exempt free-standing residen-
tial palliative care facilities from having to provide
Introduction VAE to patients who would request and otherwise
In December 2015, the Canadian Province of qualify for this option. Hospital-based palliative
Quebec enacted legislation that added euthanasia as care units, however, were not exempt.2
a legal option among end-of-life interventions.1 Law Several articles have addressed the attitudes of
© Author(s) (or their physicians towards euthanasia, but few have focused
employer(s)) 2018. No 2 permits the deliberate injection of lethal medica-
commercial re-use. See rights tion by a physician when a request has been made on physicians with palliative care expertise.5 6 For
and permissions. Published by a terminally ill, cognitively apt adult patient, and instance, in a survey of 914 Belgian physicians,
by BMJ. has been approved by two independent physicians.2 90% of respondents agreed that ‘the administra-
To cite: Bélanger E, Quebec was the first and only Canadian province to tion of life-ending drugs at the explicit request of
Towers A, Wright DK, et al. pass such legislation, although a parallel process led a patient is acceptable for patients with a terminal
J Med Ethics Epub ahead of the Canadian government to develop a federal law disease with extreme uncontrollable pain or other
print: [please include Day in compliance with a 2015 Supreme Court Ruling, uncontrollable suffering’ (p583), and there was no
Month Year]. doi:10.1136/
medethics-2017-104339 which found existing prohibitions on assisted death relationship between agreement with this state-
to be violations of fundamental rights and freedoms, ment and self-reporting any palliative care training
Bélanger E, et al. J Med Ethics 2018;0:1–6. doi:10.1136/medethics-2017-104339    1
 Original research
in either basic training or continuing education.5 Conversely, a
survey of 3299 American oncologists suggests that those who
feel comfortable providing end-of-life care are less likely to
report having performed euthanasia or assisted suicide.7 Zenz
et al also found that a majority of palliative care professionals in
Germany would refuse to perform euthanasia.8
Research in the USA, where a number of states allow physi-
cian-assisted suicide (PAS) but not VAE, also highlights the
challenges that palliative care providers have faced when imple-
menting different state laws. A study of hospice policies regarding
PAS in the states of Oregon and Washington revealed that
although hospices do not participate directly in hastened deaths,
there were inconsistencies and dilemmas regarding their role in
providing information, in participating in the decision-making
process and in accompanying patients.9 10 Finally, according to
a qualitative study from Switzerland, where requests for assisted
suicide are managed by right-to-die societies in parallel to the
healthcare system, palliative care providers reported advising
patients who made requests, but most refused to write lethal
prescriptions.11 The authors report that participants struggled
to reconcile their commitment to palliative care principles with
patients’ wishes to exercise their autonomy.11
Much has been written in the media about the opposition of
key palliative care actors to euthanasia in Quebec,12 but there
remains little academic research on these views. In a study about
palliative care physicians’ perspectives about specific end-of-life
care practices in Quebec, VAE was viewed as falling outside of
what should be considered the scope of palliative care prac-
tice.13 Policy-makers and the public, however, are surprised by
the opposition of palliative care providers towards VAE.14 This
opposition deserves to be explored further, especially given that
it will have implications for the implementation of the provincial
legislation in practice.
In this study, we aimed to capture the perspectives of a key
stakeholder group as the law in Quebec was changing. The
research question guiding this investigation was the following:
How do palliative care physicians in Quebec position themselves
regarding the practice of VAE in the context of the new provin-
cial legislation? An indepth understanding of the moral perspec-
tives of palliative care physicians about euthanasia is essential to
move forward in the planning and delivery of ethical end-of-life
care in the new legislative context. Such movement will need
to account for the challenges that palliative care physicians are
likely to face to their moral integrity when confronted with
requests for euthanasia.
Theoretical framework and methodology
In this study, the methodology of interpretive description was
selected to ensure a thorough depiction of the positions of palli-
ative care physicians. Interpretive description is an inductive
analytical methodology that can provide indepth descriptions
and interpretation of data to answer research questions about
clinical practice.15 This methodology is being used increasingly
in health science research because it is responsive to the expe-
rience-based questions of interest to practice-based disciplines.
As we explored the data, however, it became clear that some
of the positions of palliative care physicians on this topic were
contradictory, and that a theoretical framework would help
us unpack these findings further. Therefore, we borrowed the
theoretical notion of ideological dilemmas from the field of
social psychology.16 Ideological dilemmas refer to the tensions
and contradictions that occur between peoples’ values and
commitments, revealed in the way they talk. This concept has
2 Bélanger E, et al. J Med Ethics 2018;0:1–6. doi:10.1136/medethics-2017-104339
J Med Ethics: first published as 10.1136/medethics-2017-104339 on 30 October 2018. Downloaded from http://jme.bmj.com/ on 1 November 2018 by guest. Protected by copyright.
mainly been examined in the context of rhetorical analysis. We
explored the positions of palliative care physicians and focused
on the dilemmas within their narratives, in order to consider the
multiple ways in which their own perceptions of moral integrity
are challenged by the recent legislative changes. The assumption
is not that participants might be disingenuous or confused in
positioning themselves, rather that they are negotiating poten-
tially conflicting identities and expectations.
Data generation and analysis
Data sources consisted of semistructured interviews. A resi-
dent in palliative care (YC) and a palliative care physician and
researcher (AT) conducted the interviews throughout 2015.
Interviews were audio-recorded with participants’ consent and
were transcribed verbatim. During the field research period,
the Quebec Parliament adopted Law 2, which added VAE as an
end-of-life care option, and the Supreme Court of Canada ruled
that existing prohibitions on both PAS and VAE were uncon-
stitutional.2 3 Some participants were therefore approached
for follow-up interviews to update their positions and react to
current changes. The interview guide is provided in the online
supplementary appendix. Analysis was led by a health services
researcher with specific expertise in qualitative research (EB),
without affiliation with palliative care organisations. Transcrip-
tions were analysed in several iterations by the first author and
following discussions with the entire research team. Analysis
was conducted in accordance with interpretive description and
also guided by the theoretical framework, as we examined the
emerging themes for contradictions and dilemmas, and consid-
ered what these might reveal about the ideological commitments
and moral positionings of our participants. The NVivo qualitative
analysis software was used to help manage the data. Data collec-
tion and analysis occurred concurrently in an iterative process,
to enhance understanding and to permit deeper probing into
the issues at hand. Thematic categories and dilemmas regarding
these categories were found through a consensual process of
discussing excerpts involving all the authors. The researchers
met regularly to ensure a uniform data analysis process and to
confirm the emerging thematic categories. Participants signed
informed consent forms guaranteeing their confidentiality.
Results
Eighteen palliative care physicians participated in the study; they
represent the majority of the palliative care physicians on staff
at the palliative care units of two public hospitals located in an
urban area of Quebec. All participants were full-time palliative
care physicians, and like most palliative care providers in Canada
the majority of them (16 out of 18) were family physicians. As
expected, all participants expressed discomfort with euthanasia
as an aspect of end-of-life care. All but one denied the influence
of religious or political positions in shaping their views. At a
surface level, their shared discomfort is consistent with position
statements from palliative care associations. Further, though,
our participants felt that the richness of the issue was lost when
the debate was framed in binary terms. Ultimately, participants’
normative stances about VAE cannot be reduced to simply being
‘for’ or ‘against’. As one participant said, “There is this attitude
from the palliative care community that, you know, there’s no
discussion, we know how to take care of patients, and, you know,
[those performing VAE] are killing patients. So I don’t think it’s
as black and white as that’ (participant 7). Our findings suggest
that there were recurrent dilemmas in the ways that palliative
care physicians positioned themselves on this issue, as members

of a professional community of palliative care and as members of
Quebec society. As we explored the justifications that palliative
care physicians gave to explain their position against the new
medical aid in dying law, we also found areas of uncertainty and
ambiguity.
Professional roles versus a person’s right to choose
As healthcare providers pursue their training, they adopt the
norms, values and behaviours of the professional groups they
aspire to belong to, and integrate them with their background
and pre-existing personal identities and experiences. Controver-
sial issues such as VAE raise the challenge of personal conscience
and of potentially conflicting positions between personal
and professional positions. Participants reported not having a
problem with individuals choosing euthanasia for themselves,
thereby making their own decisions:
I feel that it’s an extremely personal choice, I feel that part of some
of the resistance at times can be related to [the fact that] that this
is something new. Would I practice euthanasia? No, I would not
be able to do it. […] I think it’s a very dangerous thing. I think on
an individual level, it might make sense, but I think on a societal
level, I think it sends a … message. I worry about what it sends [as a
message]. But do I have the arrogance to think that someone should
not have something that they want? (participant 3)
The arguments that participants used to justify a position
against euthanasia were framed within their professional roles,
which could then contrast with their respect for patients’
autonomy to choose end-of-life options. “I can see that it’s a
very personal view, and there is not a single way of seeing things.
Therefore when you ask me if I’m in favor or not of the Bill, it’s
very hard to answer. Obviously based on my own beliefs, I don’t
want to use that right, but I cannot say that it’s wrong for other
people to use that right” (participant 6). Overall, their concern
for the integrity of the palliative care profession prevailed as they
discussed their own positions on VAE. As will be explored below,
tension became more prominent when the practice of euthanasia
explicitly conflicted with their professional roles.
Euthanasia as impeding the evaluation of suffering
The analysis revealed a tension between the need to explore
patient suffering in order to alleviate it and the need to respect
patient choices even when shaped by the extent of that suffering.
Participants reported occasionally encountering demands for a
hastened death in their practice and interpreting those demands
as a plea to explore the patient’s suffering. There was concern
that once VAE would be legal, palliative care physicians would
no longer be able to explore requests for death in as much
depth. There was concern that with euthanasia as an option,
their patients would be less willing to allow them the time and
the engagement required to address suffering adequately and
explore other care options. This concern revolved around the
implementation of the law, which guarantees rapid access to
euthanasia after a patient request. Taking the time to explore and
palliate suffering was presented as a fundamental component of
palliative care practice:
When someone asks for hastened death, I spend time with
them, I try to explore the question, I try to explore existential,
physical, emotional and psychological things, we all [palliative care
physicians] put in a lot of effort in trying to figure it out. I think if
euthanasia is available, I’m not sure if that person really wants me
to spend that time. It may actually be easier in a sense, I will have
less work but I’m not sure that it will be, you know, I will feel bad
Bélanger E, et al. J Med Ethics 2018;0:1–6. doi:10.1136/medethics-2017-104339
Original research
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for the patient, because you always wonder like, maybe we could’ve
done something, maybe they would have stopped asking for that. I
will feel like the patient is not getting the best care. (participant 8)
In the following excerpt, the same participant defends the
contrary position of accepting and understanding a patient’s
choice. “I wouldn’t choose against the patient. […] I’d feel for
the patient, they are choosing it because they are suffering, and
they don’t necessarily want to choose it but they are choosing
it because they are suffering and they believe that that will help
them suffer less” (participant 8). There was an inherent tension
between respect for autonomy and what they perceived to be the
time required to provide good-quality palliative care.
Concern that VAE legislation is a policy response to poor-
quality end-of-life care
Participants were concerned that VAE legislation was, at least
partly, developed in order to fix a broken healthcare system: that
is, it was being offered instead of working to improve the quality
of palliation and symptom control. In the excerpt below, the
desire for a hastened death is seen to make sense when embedded
in a patient’s desire for control; however, it becomes problem-
atic when it is a response to poor access to palliative care.
I think that as an individual, I would feel a certain level of comfort
in knowing that I had that degree of decision or control of my life.
[…] I think that professionally I’m very uncomfortable with it, as an
option in the current state of the health care system in Canada, as I
feel that many individuals within the greater society in Canada do
not have the ability to make fully autonomous choices. I think there
are many external factors that affect people and even as simply as
the access to palliative care. (participant 15)
Participants acknowledged that some patients might indi-
vidually want euthanasia when faced with poor health services
and uncontrolled symptoms; however, they felt that this was
not a situation that should be condoned socially and profes-
sionally. Participants asserted that they could not condone VAE
as a policy response to a healthcare system that provides poor
end-of-life care. As professionals closely involved with accompa-
nying patients at the end of life, they suggested that expanding
access to palliative care was an important prerequisite and they
did not believe that Law 2 would improve access despite explicit
engagement to do so in the provincial legislation.
Potential of palliative care to provide peaceful deaths
A contention that there was a lack of knowledge about palliative
care among both the general public and other healthcare profes-
sionals was evident throughout the interviews. Participants felt
there to be a need for better end-of-life care in our society and
felt themselves best placed to address this need. As such, they
commonly mentioned the lack of knowledge about palliative
care and the fear of dying that is present in the general public.
In a sense, I do understand why some people are supporting this
Bill. It’s because people want to have control over their lives, and
so control over their death as well. That may stem from their fear
of losing that control at end of life, suffering and not being able to
make decisions for themselves. I do understand where they come
from. But on the other hand, I do think there are ways we can
work around that, I think people need to be educated about what
palliative care is. A lot of people may not be aware of what we
do. In a sense, they see it as black and white. Either I live a happy
life, healthy no suffering; if I suffer, then I need to terminate my
suffering myself, instead of having a team of professionals whose
job is to help relieve that suffering. (participant 5)
3
 Original research
The notion that causing patients’ death directly is not necessary
to relieve suffering was also prevalent in the interviews. “People
who actually deal with patients who are dying are opposed to
the Bill. Why? Because we don’t see it as a great need. We are
able to treat patients and we’re able to alleviate their suffering.
And for the most part, do so without even having to sedate them
in a continuous manner” (participant 2). Participants felt that
the public and policy-makers were not aware of the potential
of palliative care to relieve suffering and help patients attain
a peaceful death. There was an understanding of the societal
need that came from this lack of knowledge about palliative
care and of the distress that came with it, even among health
professionals. The fear of dying and of suffering is a powerful
force that has to be addressed with public policies. “Everyone’s
afraid of dying. Everyone’s afraid of suffering. So I think to put
together a Bill that would sort of meet the needs of the popula-
tion, I think makes sense” (participant 2). However, even when
acknowledging the challenge of alleviating pain and suffering,
participants emphasised that there is already an ethically accept-
able treatment, palliative sedation, that can be used in the rare
cases where suffering endured: “Now, statistically speaking, are
there some people who persist in asking for it? Will there be
some people I can’t manage their symptoms so they will persist
in asking? For sure, but it hasn’t happened really that often and
[…] palliative sedation was an option” (participant 8).
Reconciling accompaniment without participation in
hastening death
There was a general agreement among participants that palli-
ative care should neither hasten nor delay death, and should
therefore remain separate from the implementation of the new
provincial legislation. Further, there was agreement that pallia-
tive care physicians should not be involved because participants
felt it would threaten the therapeutic relationship and reduce
trust: “I have great concerns as to how that makes a population
feel that they can trust the health care system” (participant 3).
However, participants were also aware that as physicians, they
have expertise which could help ensure that euthanasia would
be carried out without inducing more suffering than necessary.
A major dilemma for the participants appeared to be the need to
remain true to the definition of palliative care, not abandoning
patients and continuing to care for them even if they requested
euthanasia. For some, this meant removing VAE patients from
the palliative care units; for others, this was problematic: “I
would question the not-doing-it-on-a-palliative-care-unit, if the
patient has been trying palliative care and it hasn’t, to their mind,
been successful. Or, at this point, they want to then make use of
euthanasia; it seems a bit harsh to me to then somehow transfer
them off of the palliative care unit to be killed, you know, some-
where else” (participant 4). The question of who should be in
charge of providing VAE was a persistent one, one which few
participants had an answer to, beyond “not us, palliative care
physicians”:
I don’t know that I have that expertise and I don’t know that
I feel that I’d be capable and competent to do that really. That
being said, I’m torn, because who is it going to be? Is it going to be
some person they are going to hire that’s going to be a euthanasia
specialist? Is it going to be like a pharmacist-driven thing? Who else
would be the best advocate to do it? So at the same time, I’m so
utterly protective of humanity and patients, especially the ones that
have no mandate, that have nobody, I worry about who would be
that identified person. Who would be that competent person? So
the answer is, wow, I don’t know. (participant 3)
4 Bélanger E, et al. J Med Ethics 2018;0:1–6. doi:10.1136/medethics-2017-104339
J Med Ethics: first published as 10.1136/medethics-2017-104339 on 30 October 2018. Downloaded from http://jme.bmj.com/ on 1 November 2018 by guest. Protected by copyright.
Discussion
This study provides insight into the nuanced positions of expe-
rienced palliative care physicians in Quebec during the adoption
of a provincial legislation about VAE. The integration of VAE
and PAS in palliative care practice remains a highly contentious
topic.14 17 In this study, in addition to a concern for patients’ right
to choose, the position that prevailed was one of professionals
with a commitment to improving the state of end-of-life care and
to promoting awareness about the potential of palliative care to
provide adequate symptom control and maximise opportunity
for valuable end-of-life moments. Few studies have focused on
the attitudes of palliative care providers and how they position
themselves beyond the official position of professional associa-
tions. We identified dilemmas that appeared when justifying an
opposition to VAE, which were framed within professional roles
and contrasted with positions that emphasised personal prefer-
ences, and patients’ autonomy and right to choose. In our data,
participants acknowledge that positions are deeply personal, but
justified their opposition as part of their professional roles and
palliative care values. Participating physicians did not explicitly
align with religious or politically conservative agendas, contrary
to a Belgian study.5 Similarly, Lavoie et al did not find religious
affiliation to be associated with the intention to practise eutha-
nasia among Quebec physicians.18
Participants perceived that truncating the dying process
undermines the value of end-of-life experiences and that desire
for hastened deaths implies a lack of awareness of the potential
of palliative care to provide peaceful deaths. Their perspectives
resonate with the position of the International Association for
Hospice and Palliative Care and the European Association for
Palliative Care, both of which recommend that requests for a
hastened death should be addressed as part of palliative care
practice through interventions that can help relieve suffering,
such as palliative sedation.19 20 The advocacy notion that eutha-
nasia would not be necessary if access to palliative care was
adequate was identified in a previous discourse analysis of Cana-
dian physicians’ positions in the print media.12 Although often
not explicitly stated in official position statements, this theme
implies that palliative care is able to create value at the end of life.
Dying is presented as a ‘natural’ process that should be neither
hastened nor delayed. The palliative care movement seeks to
restore meaning and dignity at the end of life.21 This movement
has historically positioned itself in opposition to assisted death,
although this positioning is not without controversy. Bernheim
and Raus,22 for example, argue that criticisms of the Belgian
model of end-of-life care (which integrates both euthanasia and
palliative care) fail to consider that ‘there is a plurality of reason-
able and defensible views on the ethical acceptability of eutha-
nasia’ (p493). For these authors, respecting patient autonomy
in a way that makes room to consider euthanasia as an ethical
option in some cases is a more authentic way of enacting empathy
(a core palliative care value) than rigid adherence to historical or
doctrinal positions of outright moral rejection.
The work of Quebec’s Commission on Dying with Dignity that
took place in 2010–2011 was central to the development of the
medical aid in dying legislation in the province. This Commis-
sion explicitly concluded that end-of-life care is inadequate in
the province, and therefore euthanasia should be provided as an
option for patients who are inevitably suffering as a result.23 In
our study, participants described euthanasia as an inappropriate
response to poor-quality end-of-life care, one that was also
incompatible with their professional role as palliative care physi-
cians. This point again aligns with associations that advocate

against the decriminalisation of physician-assisted death in the
absence of universal access to palliative care.19 20 The main
ethical issues that have been raised in previous work surrounding
the provision of physician-assisted deaths in the context of insuf-
ficient access to palliative care services concern the absence of
meaningful choice, the risk of health inequity regarding access
to care and the development of VAE as a potential barrier to
the development of palliative care.24 Yet emerging evidence indi-
cates that the decriminalisation of euthanasia has not impeded
the development of palliative care services in Benelux coun-
tries.25 In cases reported in the Dutch-speaking part of Belgium,
there appears to be an increase in the percentage of euthanasia
cases where palliative care was consulted, from 34.0% in 2003
to 42.6% in 2013.26 However, a unique feature of the Belgian
context may be synergy between the euthanasia and the palli-
ative care movements, something that has not been observed
elsewhere.27 A remarkable feature of the situation in Quebec is
the tension inherent in Law 2, which includes VAE as an option
on the continuum of medical care at the end of life, despite the
opposition of palliative care providers who provide a large part
of this care.14
The findings of our study speak directly to ongoing debates
regarding the integration of euthanasia into modern notions of
ethical end-of-life care, specifically with regard to the role that
palliative care providers ought to play in the care of patients
requesting and/or receiving euthanasia. In this paper, we high-
lighted dilemmas apparent in participants’ narratives about
reconciling respect for patients’ right to choose their own deaths
with palliative care values, and about accompanying patients
who make requests for euthanasia while remaining committed
to neither prolonging nor hastening death. Our findings show
that palliative care providers are sensitive to a host of ethical
issues at play in the care of patients seeking euthanasia, including
(but not limited to) the limited access to palliative care that many
patients face, and the time that it takes to provide adequate
end-of-life care to people who are suffering, as well as the value
of non-abandonment for ethical therapeutic relationships. Lack
of time to properly evaluate suffering and provide the stan-
dard of care that palliative care providers feel patients need
and deserve puts such providers at risk of experiencing moral
distress.28 Regarding non-abandonment, a similar concern was
also documented among Swiss palliative care physicians, who
found it difficult to accompany patients in decision-making
about assisted suicide while honouring palliative care principles
that do not support this practice.11 Interestingly, the theme of
non-abandonment figures among the reasons that US physicians
provide for supporting the decriminalisation of euthanasia.29
Research in the Netherlands has shown that tension between
what physicians consider to be a good death and patients’ views
and preferences can have significant implications for the imple-
mentation of physician-assisted death.30 It is worth highlighting
that the majority of arguments mobilised by participants were
also identified in a review about the moral issues surrounding
euthanasia as presented in palliative care journals.31 Arguments
about dying as being a part of life, euthanasia diverting atten-
tion from good palliative care, as well as the non-necessity argu-
ment when receiving good palliative care were encountered in
the data. The dilemmas documented further shed light on the
challenges involved in upholding these principles while also
respecting autonomy, being compassionate and acknowledging
the fallibility of palliative care.31 Less attention was paid to the
slippery slope argument or the dehumanisation that can result
from a culture of death, perhaps because participants were not
envisioning VAE as part of their palliative care practice. Given
Bélanger E, et al. J Med Ethics 2018;0:1–6. doi:10.1136/medethics-2017-104339
Original research
J Med Ethics: first published as 10.1136/medethics-2017-104339 on 30 October 2018. Downloaded from http://jme.bmj.com/ on 1 November 2018 by guest. Protected by copyright.
that foundational ethical principles of palliative care and physi-
cian-assisted death appear to be at odds for a majority of profes-
sional palliative care associations, some argue that the practical
implications of decriminalisation for palliative care services
should have been taken into account explicitly as part of legisla-
tion to minimise conflict in implementation.17 At the same time,
other critics observe that continued and unequivocal rejection of
euthanasia by the palliative care community will only result in
the marginalisation of palliative care within euthanasia-permis-
sive jurisdictions.22
Our participants perceived tensions between their personal
and professional identities, which undoubtedly will have impli-
cations for their self-evaluations of moral integrity. Exposing
the nuanced views of stakeholders who are heavily involved
in providing end-of-life care is meant to contribute to further
ethical analysis and debate on this topic, especially in the light
of recent considerations by Quebec and Canadian governments
about potentially broadening access to medical aid in dying to
cognitively impaired adults through advance directives. The end
of life is often depicted as unavoidably painful and undignified
in public debate, with what appears to be limited awareness of
palliative care practice. The role of palliative care providers in
the implementation of physician-assisted deaths remains unre-
solved. Regardless of whether or not the law is expanded over
the coming years, there is no doubt that more research is needed
to assess the impact of this provincial legislation in the context
of the Quebec healthcare system. This impact will undoubtedly
be shaped by the degree to which palliative care providers are
involved, or not, in the care of these patients moving forward.
This study has certain limitations. First, participants were
interviewed by either a palliative care resident or a palliative care
physician, which might have triggered social desirability and
affected responses. However, questions were open-ended and
confidentiality was guaranteed; it is reasonable to assume that
we obtained authentic responses. In addition, an independent
health services researcher (EB) led the analysis with the input
of team members who have a diversity of viewpoints, including
as palliative care providers (nursing, medicine) and researchers
with training in social science and bioethical approaches to
health research. The presence of dilemmas and of nuanced
answers conveying uncertainty also suggests that participants
could adopt any position. Another limitation is that the physi-
cians involved in this study take care primarily of patients with
cancer. While this is transferable to the practice of other pallia-
tive care providers in the province, the views of physicians who
are not primarily palliative care providers but who still provide
palliative care to patients who have other diseases might be
different. For instance, patients with neurodegenerative diseases
such as amyotrophic lateral sclerosis have contributed signifi-
cantly to the development of current euthanasia legislation in
Canada and largely die under the care of neurologists unless they
are transferred to palliative care units. Finally, all participants
practised palliative medicine in one urban area of Quebec, and
early evidence of implementation practices suggests that there
may be disparities in access to VAE across regions, suggesting
that clinicians working in other regions might have different
opinions; conducting similar research in different regions would
be informative.
In conclusion, this study documented the dilemmas and
tensions that palliative care providers face when discussing the
inclusion of euthanasia as an end-of-life care option in the Prov-
ince of Quebec. These positions highlighted some of the struggles
inherent in reconciling commitments to values—such as respect
for autonomy—with broader identities that are shaped within a
5
 Original research
disciplinary context, one that opposes hastened death. Insofar
as palliative care providers are a major stakeholder of end-of-
life care in Quebec, we need to further explore how the policy
allowing euthanasia is shaping the practice of palliative care and
the evolving role of palliative care providers more generally
when faced with patients who request a hastened death.
Contributors  AT and YC planned the study and conducted the semistructured
interviews with the participants. YC conducted the descriptive content analysis of
the material. EB conducted the first iteration of interpretive analysis and prepared
the material for discussion with all coauthors before the next iteration of analysis.
All authors contributed substantially to reporting the work through direct input
about organisation of the argumentation, quote selection and discussion of
relevant literature. EB and AT are responsible for the overall content of the article as
guarantors.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests  None declared.
Patient consent  We used the standard consent forms from the IRB that reviewed
the study.
Ethics approval  The Institutional Review Board of the hospitals involved and McGill
University Health Centre approved this study.
Provenance and peer review  Not commissioned; externally peer reviewed.
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