In Canada, according to a study published in the British Medical Journal Open (BMJ Open), low-income hospital patients who receive palliative care are less likely to receive medical assistance in dying than those with high income.
Medical assistance in dying (MAID) is legal and free under Medicare, Canada’s universal health care system. However, patients with low socioeconomic status (SES) generally tend to have less access to medical care than their counterparts with high SES.
Eldar Shafir, professor of psychology and public affairs at the Princeton School of Public and International Affairs, as well as a team of researchers at Sunnybrook Hospital in Ontario, investigated whether this trend of declining care for children low-income patients includes physician-assisted dying.
I have long been interested in the influences of SES on decision making. I often discuss with my friend and collaborator, Dr Redelmeier, ways to illustrate some of our findings in the medical field, especially, where possible, among experts. … In this case, MAID was a really interesting area, because it’s a “big” decision, and finances aren’t an issue. “
Eldar Shafir, Professor of Psychology and Public Affairs, Princeton School of Public and International Affairs
Medical assistance in dying was declared legal in Canada in February 2015 and officially implemented and covered by Medicare in June 2016. To be considered, a patient must have a serious and irremediable illness, such as a metastatic cancer, which causes unbearable suffering or death is foreseeable, according to the Government of Canada.
However, a person’s socio-economic status can influence the way medical care is administered and received by a patient in several ways. “People can be easily susceptible to pitfalls and reasoning biases,” Shafir said.
Low-income patients, for example, may feel less equipped to advocate for their care and express dissatisfaction. Clinicians may also succumb to the “thick skin fallacy” or the negative perception that low-income people are accustomed to hardship and therefore less affected by it.
The team explored the association between socioeconomic status and physician-assisted dying by identifying inpatients aged 65 and over in Ontario, Canada, between June 2016 and 2019. At the time of their death, all patients, all of whom were suffering from serious illness, were in palliative care, receiving pain medication for symptoms. They were then divided into groups based on their socioeconomic status, which was calculated using an official algorithm created by Statistics Canada based on the location of the neighborhood of origin and whether or not they got d ‘medical assistance in dying.
During the three years, 50,096 patients received palliative care in their last month of life. Of these, 920 received medical assistance in dying. Only 1.5% of identified low-income patients received medical assistance in dying, compared to 2.4% of high-income patients – a reduced likelihood of 39% for those of low socioeconomic status. This disparity in care was seen consistently across a variety of patient subgroups that varied in age, sex, location of residence, type of cancer, health care use and status. general fragility. It has even been reproduced with patients treated by the same responsible physician.
The results of the study support previous findings from other countries on the relationship between physician-assisted dying and the socioeconomic status of patients. In countries like the United States, the Netherlands, Switzerland and Belgium, people who received MAID or the equivalent of MAID tended to be highly educated, financially secure, or living in rich neighborhoods.
Researchers, however, suspect that this difference in patient care may be influenced by factors that exist outside of financial capacity. “I suspect that most of what’s going on here is a function of the doctor-patient interaction,” Shafir explained. “I think, all other things being equal, physicians might consider patients with low SES to be less in urgent need of MAID.”
Some limitations of the study, such as biased and imperfect measures of socioeconomic status, warrant further research exploring the link between social class and physician-assisted dying. “Both views, that of physicians and that of patients, need to be better understood by the medical community in order to provide patients with low SES the same care as those with higher SES,” said Shafir.
The observations made by Shafir and his team challenge an earlier misconception in Canada that physician-assisted dying can adversely target low-income people. The researchers are optimistic that their findings can help promote increased communication and engagement between patient and clinician.
Princeton University, Woodrow Wilson School of Public and International Affairs
Redelmeier, DA, et al. (2021) Association of socioeconomic status with physician-assisted dying: a case-control analysis. BMJ Open. doi.org/10.1136/bmjopen-2020-043547.