Hospice and Palliative Care Association of South Africa on Euthanasia

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Hospice Palliative Care Association of South Africa
Position paper on Euthanasia and Assisted Suicide
Compiled by: Dr Niel Malan
Dr Sarah Fakroodeen
Dr Liz Gwyther
Reviewed by: HPCASA Ethics
Date of
31 May 2011 Date of approval: June 2011
Signature: Signature:
Update: March 2013 Review date: March 2015

1. Introduction
1.1 Purpose
1.2 Value Statement
1.3 Definitions
2. Background
3. Policy statement
4. Advance care planning and advance directives
5. Recommendation to South African government

Hospice Palliative Care Association of South Africa
To describe the HPCA position on Euthanasia, Assisted Suicide and Palliative Sedation, to
advise members organisations and to inform media and the general public.
The Hospice Palliative Care Association of South Africa affirms life, regards dying as a
normal process, and intends neither to hasten nor postpone death. Euthanasia and
physician assisted suicide are not part of palliative care practice.
(from Materstvedt LJ et al. Euthanasia and physician-assisted suicide: a view from an
EAPC Ethics Task Force. Palliative Medicine 2003; 17: 97-101)
Euthanasia means killing on request and is defined as a doctor intentionally killing a
person by the administration of drugs, at that person’s voluntary and competent request.
In euthanasia the intention is to kill the patient, the procedure is to administer a lethal drug
and the successful outcome is immediate death.
Assistance in suicide means knowingly and intentionally providing a person with the
knowledge or means or both required to commit suicide, including counseling about lethal
doses of drugs, prescribing such lethal doses or supplying the drugs.
Physician Assisted Suicide is defined as a doctor intentionally helping a person to commit
suicide by providing drugs for self-administration, at that person’s voluntary and competent
Palliative sedation is defined as the use of sedative medication to relieve intolerable
suffering in palliative care. In palliative sedation the intention is to relieve intolerable
suffering, the procedure is to use a sedating drug for symptom control and the successful
outcome is the alleviation of distress. Death occurs naturally through the disease
progression with dignity and comfort.
Most commentators make no formal ethical distinction between euthanasia and assisted
suicide, since in both cases the person performing the euthanasia or assisting the suicide
deliberately facilitates the patient’s death. There is also disagreement about whether
euthanasia and assisted suicide should rightly be considered “medical” procedures.

When a patient`s medical diagnosis precludes the hope of health being restored or
maintained, and the death of the patient is inevitable, the physician, the care team, the
patient and the family are often faced with a complex set of decisions regarding medical

The duty of doctors is to heal, where possible, to relieve suffering and to protect the best
interests of their patients. There shall be no exception to this principle even in the case of
incurable disease. The primary responsibilities of the doctor and care team in end-of-life
care are to assist the patient in maintaining an optimal quality of life through controlling
pain and other distressing symptoms and addressing psychosocial and spiritual needs,
and to enable the patient to die with dignity and in comfort.
Health care practitioners must ensure decisions are properly documented including clinical
findings, discussions with the patient or others involved in decision making and details of
treatment. Records should be legible, clear, accurate, unambiguous and accessible to
team members.

The HPCA of South Africa opposes euthanasia and doctor assisted suicide on the basis
that it does not in fact support an individual’s dignity nor express the value of that
individual. It is also an unnecessarily extreme measure given the palliative alternatives that
neither prolong life nor hasten death. The philosophy of palliative care is holistic, paying
attention to the multidimensional aspects of the whole person. The expressed desire for
euthanasia needs to be explored holistically as an expression of existential suffering. This
is done by engaging the patient in a dialogue with active listening and empathy, and
exploring the following themes:
 Reality of the disease progression
 Exploring and understanding the person’s goals for care
 Perceptions of their suffering and sense of burden to others
 Anticipation of the dying trajectory
 To explore the timing of desired death (this is often seen as sometime in the
future – not yet)
 The desire for good quality end-of-life care
 The care and support that is or can be offered by good health care and
supportive significant others care
 Clinical depression as co-morbidity.
This dialogue requires clinicians to be skilled in sensitive communication, to have
knowledge and skills in clinical care and in addressing bioethical issues.
An expressed wish for euthanasia may represent a person’s wish for a choice of action, of
having an option or possible future way out. HPCA of SA acknowledges that patients have
a right to be involved in the decision-making process concerning their treatment or nontreatment
(c.f. Policy on withholding and withdrawing treatment), and that a request by a
patient for euthanasia is identified as part of this process. Understanding and respect for
this alternate view point is not the same as ethical acceptance of this view.

Hospice Palliative Care Association of South Africa

The Hospice Palliative Care Association of South Africa supports and encourages
advance care planning as an important aspect of palliative care. Advance care planning is
the process of discussing and documenting a person’s wishes for care in the event of their
not being able to communicate this in the future.
The value of an advance directive is to guide medical and healthcare decisions. The
importance of the Advance Directive is that the person drawing up this document in
discussion with family and healthcare providers indicates their preferences for care while
they are able to discuss these preferences. This will assist families and health care
professionals to make decisions relating to a person’s care.

The obligation of a health care professional in the palliative care setting is to try, as far as
possible, to offer care that will ease the dying, but not deliberately bring about death.
HPCA of SA promotes the effective relief of pain and other distressing symptoms for
people with life-threatening and life-limiting illness. The submission is that access to quality
palliative care removes the need for euthanasia as a means of relieving suffering.

The HPCA recommends that:
1) The South African government integrates palliative care into their country’s health
care system. This will enhance the accessibility and affordability of palliative care to
those people in need of this service. The essential steps to integration of palliative
care into the formal health care sector include:
i) the development of a palliative care country strategy, documenting
policies, procedures and standards for delivery of palliative care and
recognition of palliative care as a specialization;
ii) education of healthcare workers in palliative care and support of these
workers to transfer learned palliative care skills into their work
iii) a review of the Essential Medicines List to ensure the availability and
affordability of essential palliative care medication including opioid
2) Health care providers undertake training in communication skills, bioethics and
palliative care and ensure that they maintain their knowledge and skills to provide
quality palliative care.
3) Health care providers encourage advance care planning and discussion of
preferences for end-of-life care
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