Response

Dr Orkin’s critique of my argument is quite right—I provided a positivist answer to a normative question. My only defense is that the original question that I was asked to address was “Is palliative care a specialty?” Only after my submission was the question changed to “Should…?”

The editors were right to change the wording. “Should” is the question with which we need to grapple. My answer is still yes, although my argument is different. Our ultimate goal must be to improve the care of people with palliative needs. In the long run, this involves not only knowledge translation (ie, helping all providers to employ best practices) but knowledge generation (so that best practices 50 years from now are better than best practices today). In every field of medicine, knowledge generation comes primarily from those engaged in the field full-time. Therefore, part of a broad strategy to improve palliative care would be to encourage physicians to engage in palliative medicine full-time and to enhance the knowledge and skills of this cadre of physicians. It isn’t about the title. It is about raising the bar.

What happens if we don’t? One of 2 things: either the bar will not be raised (which will be a disappointment for every Canadian at risk of dying) or it will be raised by someone else within the Royal College alone (which will be a disappointment to those who see family medicine as the beating heart of palliative care). Should palliative medicine be a specialty? Yes, because the bar needs to be raised. And we need to take a leading role in raising it.

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