People desire a dignified and humane end of life. The social debate over euthanasia as an option for the end of life should not be considered as opposed to palliative care. It is a mistake when the reflection on euthanasia is presented as a polarized debate between “life” versus “freedom”. What is actually underlying the issue is how we face a human being’s experience of suffering, especially when it is refractory, irreversible, and reveals the responsibility of the system and of professionals to respond in their accompaniment.

The proposed law decriminalizing euthanasia in Spain fundamentally lacks deliberation and conceptual warmth. We are unable to affirm that it is a “guarantor” law when conceptual errors exist. A polarization of points of view, independently of the reasons behind it, always entails moral damage. Maximum social consensus is desirable.

There is still much work to be done so that the community and scientific societies comprehend the importance of palliative care in advanced chronic processes and end of life. Actually, now that the euthanasia law has appeared on the social and legal scene, the concepts may become even more confused. The hastiness in the proposal of this law and the avoidance of ethical and technical assessment lead to some fundamental questions which still remain unanswered. Who is the responsible physician in each case? What is the role of nursing? Who should carry out conscientious objection? What is the role of clinical ethics committees? Why is the training of professionals set to take place one year after the law comes into effect? 

Euthanasia entails a complex decision making process in which it remains to be seen how it will be accompanied and which agents will assume the responsibility of implementing it. The deliberative and communicative process that must be undertaken in therapeutic maneuvers such as initiating palliative sedation is equally complex and sensitive as that which must be applied in euthanasia. Who can guarantee that citizens will be accompanied with excellent criteria in this planning? The law does not reflect this, nor is this assured given the current state of training in our country in these particular areas.

Good praxis in palliative care entails a timely referral of the person suffering from an advanced, active, and progressive illness and one that is not susceptible to curative treatment, for advanced care planning. This praxis guarantees the person’s control over their own experience of the illness. It allows them to manage the uncertainty about what will take place and to offer support to their loved ones. Adjustment or limitation of therapeutic effort is a little known concept among the general population. It refers to not initiating or withdrawing a futile treatment (one that adds no benefit and lacks usefulness), and supports not prolonging life in circumstances of suffering. We have done little research on Dignity Therapy as a response to Demoralization Syndrome, which is identified by three elements: meaninglessness; hopelessness and the wish to hasten death, in the absence of depression. 

Palliative Sedation Therapy is a resource used to reduce consciousness by pharmacological
means when a refractory symptom exists producing suffering that cannot be avoided by other means. Palliative care professionals, working in inter-disciplinary teams, are experts in dealing with requests to hasten death and relieving physical, psychosocial and spiritual suffering. The experience of human suffering is complex, and expert personnel is needed in this area to carry out an impeccable assessment and good quality, comprehensive intervention. There is an urgent need for training of health care professionals in attending to human suffering from early phases of the illness, not only when reaching advanced stages when there is little time left to make calm and shared decisions with patients and family members.

The Spanish Palliative Care Society (SECPAL) is a scientific society with plural stances on the advisability or not of decriminalizing medical assistance to die, whether it be by prescription mode (medically assisted suicide) or by administration (euthanasia). SECPAL has the mission of promoting the universalization of palliative care, but not of developing the law of euthanasia. As SECPAL, we do not wish to enter a dynamic of omnipotence, believing ourselves capable of relieving all experience of end-of-life suffering. In fact, it is a reality that in some cases these treatments might not be sufficient. We understand that euthanasia could be a course of action, always, however, as an exceptional condition. This entire conceptual reflection ought to be carried out in a conciliatory manner, protecting those most vulnerable, and in the spirit of dialogue. The law passed is neither conciliatory, nor does it protect the vulnerable, nor has it established any dialogue. This lack of dialogue, and the fact that in some sectors the law is being referred to as the death with dignity law, may give rise to decision making bias. Dignity is a complex term, and shouldn’t be used in a simplistic fashion. We are concerned about the creation of this law, which is confusing in its practical implementation and hasty in its timeframe, as an attempt to solve these cases that confront us with the limits of palliative care, when there is no end of life law accompanying this latter, and guaranteeing that palliative care be offered to all citizens. It ought to be recalled that Spain is a country in which, in comparison with the rest of Europe, social aide programs are very insufficient and palliative care is also not sufficiently developed. And this factor makes for a difficult comparison with other cultures (such as the country of Canada, where euthanasia has been legalized). It must be taken into account that these underdevelopments directly threaten people’s autonomy and greatly influence the experience of illness. 

Correct comprehensive patient care during the trajectories of advanced illness and end of life should be a priority, with the capacity to integrate palliative care into the entire process. Unfortunately, palliative care does not seem to be a priority for Spanish legislators. This is not only apparent by the abandonment of the Palliative Care Strategy, but also by the inexistent organization of professional specialization and the lack of legislative activity in this matter. All of the above are clearly competencies of the National Government. Neither has the Central Government taken into account the European Council recommendations of 2018 that, once again, highlighted the declining development of palliative care in Spain, as demonstrated in the Atlas of Palliative Care in Europe 2019 by the Atlantes Group. 

Reflection, participation and dialogue must not be absent. Alleviating people’s suffering at the end of life and that of their loved ones has to be the inspiration that marks the path to follow in legislative decisions for end of life care in The National Health Care System.
Spanish Palliative Care Society (SECPAL)
Spanish Association of Nursing in Palliative Care (AECPAL)

SECPAL © 2014
Paseo de La Habana 9-11. 28036 Madrid.
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