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Is there any place for conscience in medicine?

Currently, the technocratic answer is no. If the state says euthanasia is a right, then euthanasia there must be – and it must be provided everywhere, even by faith-based institutions and by groups that have pledged to care for the most vulnerable people in society.

Dr. Constant Leung disagrees. He's a family physician in Vancouver and his specialty is the elderly. He has persuaded hundreds of old, gravely ill people to accept palliative care in their last weeks or months of life. In his view, services that hasten death should not be part of that. "The ethos of palliative care is completely contrary to medical aid in dying," he told me.

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It's going to be an uphill battle. Across the country, the dogmatists for death-on-demand insist that medically assisted dying is a right that must be offered by every medical facility. Hospitals and hospices that refuse to offer it should be defunded. People might have consciences, but institutions don't.

Many people who work in palliative care are appalled by this prospect. Their objections are practical as well as ethical. They've spent years trying to overcome the stigma of palliative care, to persuade people that it is not about hastening their death, but about helping them to live in reasonable comfort for as long as they can. They're worried that if the two services are offered together, vulnerable patients will be even more reluctant to accept care.

Dr. Leung told me that at a recent conference on palliative care, people had already begun talking about when it might be appropriate to introduce the idea of medically assisted death to patients who might be eligible. In his view this is the slipperiest of slopes. "I've seen so many seniors in hospitals," he says. "They're alone, they're frightened, and they don't know what their doctors are doing. We need to keep safe spaces for them."

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Perhaps his fears are exaggerated or misplaced. I'm not so sure. Now that assisted death is on the table, a lot of old people are going to ask for it – and not always because they fear the pain and agony of dying. The greatest fear of many old people is that they're useless, a burden to their families and society. I've seen this for myself. They want to die because they think they're a nuisance.

"They say it takes a village to raise a child, but it also takes a village to help someone die well," Dr. Leung says. "Our failure is that we as a society haven't given those patients enough support to know that their lives are still worthwhile." He has started a petition to urge the B.C. government to keep palliative care and medical aid in dying as strictly separate programs. So far, 3,000 people have signed it.

Faith-based hospitals, like St. Paul's in Vancouver and St. Michael's in Toronto, face the same dilemma. Enabling death cuts to the very core of their mission. Hardliners argue that their reluctance to provide assisted death only proves that faith-based institutions are obsolete, and that they should either cut their ties or lose their funding.

If that's the way the world is going (and I fear it is), it will be the world's loss. Faith-based institutions are places where you're most likely to find that elusive promise of "patient-centred care" (the cruellest cliché in medicine, in my view). The culture of an institution is what makes all the difference to the quality of care. Many secular people who work in faith-based institutions are among the biggest opponents of the idea that they must be made to offer medically assisted death.

The death dogmatists argue that people will suffer terrible hardship if they can't get assisted death anywhere. They'll be shipped around like so much freight, until someone takes them in and helps them die. This is rubbish. In fact, patients are transferred all the time for procedures (including assisted death) that aren't offered where they are. Issues of access are pretty easy to resolve if people of goodwill put their heads together.

The trouble is that tolerance and compromise are going out of style – not only in the U.S., but increasingly in Canada, where activists for human rights of all kinds like to argue that every human right is a case of either/or. They have no time for pluralism, or accommodation, or compromise, or anyone who doesn't see things exactly their way. And that's not good – especially when it comes to life and death.

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