Politicians in two main states are working to legalise euthanasia under defined guidelines, but it’s doctors who would have to implement their policies. Dr Jane Barker discusses her reasons for opposing physician assisted suicide.
As we will be the ones expected to write the scripts, administer the medications and make the final decision within the boundaries of the law, the euthanasia debate is our debate, yet we have not adequately engaged in it. How will we respond if pressurised by patients or family members, or accused of lacking in compassion?
By definition, physician assisted suicide (PAS) is a medical issue, but the question of whether we as a group, or as individuals, wish to play this role, and the regulatory parameters, has not been fully discussed with us.
Legalising euthanasia
Last week a bill supporting physician assisted suicide was passed in the Victorian State lower house. It will now go for debate in the Victorian Senate. NSW is also preparing to debate the subject.
Several countries have legalised voluntary euthanasia, including The Netherlands, which was the first country to do so, introducing it in 1984 and fully legalising it in 2000. As such, there is extensive literature about the practice of euthanasia.
Others, including Canada and some American states, have legalised physician assisted suicide.
In Australia euthanasia was legalised in the Northern Territory for a short period before the bill was overturned. There have been robust and recurrent debates in many states. In South Australia alone the death with dignity bill was rejected for the 15th time last November.
Both in the media and in the parliament we have heard highly emotional stories. These indeed invoke compassion in us all, but they do not lead to the informed debate that is needed.
The bill passed in Victoria has very strict and well formulated guidelines limiting the availability of PAS to those in severe pain - but only if over 25, not cognitively impaired and likely to die in the next 12 months.
Of concern is how these conditions could be expanded over time. There are ethical concerns in the Netherlands because of an increase in the number of people choosing euthanasia because of mental health issues. In 2010, 2 people with insufferable mental health conditions chose euthanasia, by 2017 this number had increased to 56 (1). Some of those people seemed very young. What constitutes “unbearable suffering” is very subjective and making such decisions would be complex. In other countries which have brought in euthanasia laws, while the initial laws have been tight they have subsequently been expanded for instance to cover patients with dementia, disability and mental illness, and also to cover children. This is what we risk if euthanasia becomes legal in Australia.
Society & profession divided
Just as there is a diversity of opinion within the community so there is division within the medical profession.
Studies have found that a higher percentage of the general public agree to euthanasia compared to doctors interviewed. Attitudes varied amongst doctors working in different specialties. Importantly those working in palliative care, perhaps at the ‘coal face of dying’, were least likely to agree, in some studies unanimously disagreed. Of those who did agree, a very small proportion felt that they themselves would perform this task.
A 2016 AMA survey found 38% of doctors think euthanasia should be legalized. In Australia there is an acceptance that death hastened by treatment to alleviate symptoms does not constitute euthanasia. Indeed, this is what is currently practiced in palliative care in the final phases of life. However, the AMA states that “doctors should not be involved in interventions that have as their primary intention the ending of a person’s life”.
Globally, 107 0f 109 national medical associations affiliated with the World Medical Association have stated opposition to PAS.
“Debates on euthanasia and ways of reducing futile treatment may both have their answers in effective, accessible palliative care”.
The ‘no’ case
While I may have some questions, there is a resounding “No” from my heart; a strong negative reaction in my body. It is not something I could do, nor do I think I should be expected to do it. If that is the case how could I ask another to do it?
I chose this profession to attempt to bring relief to suffering in life, not to take that life. It has been generally accepted by the public, by the government and by the profession that doctors are the appropriate professionals to work with those who wish to die prematurely to relieve their pain, be it by euthanasia or by physician assisted suicide.
I have over the years cared for many people dying. I have clear memories of a 4-year-old dying of leukemia whom I treated as a houseman. The little fellow laughed merrily at me riding my bicycle … and later that week died peacefully.
More recently I helped in the care of a 2-year-old with an inoperable brain tumour. He loved cows and whenever he was well enough would say “cows” and his beautiful family would take him to the fence where he seemed to find those big brown munching creatures in some way healing.
Did I prescribe pain relief and sedation when it was needed? Of course yes. Could I have even considered euthanasia for those little people? The very thought sends shivers down my spine.
Better palliative care
The proponents of euthanasia would say that those opposing it are disrespectful of patients’ autonomy and dignity and that choosing their way of dying is a basic human right. They would say that to deny this right is lacking in compassion because we are asking that patients continue to suffer in pain.
Having witnessed many deaths from medical causes, some of those prolonged, others accompanied by severe pain and many by loss of autonomy, I still feel there are other ways to bring greater dignity into dying.
One of the other important ethical issues facing medicine currently is so called “futile treatment” where life is prolonged for inappropriate reasons. There are times as doctors when we share in hard decisions to withdraw care and allow the dying what nature has decreed.
Debates on euthanasia and ways of reducing futile treatment may both have their answers in effective, accessible palliative care.
The science of palliative care increasingly understands ways to effectively treat pain and other symptoms associated with dying which in the past have had the potential to cause untold suffering and generated fear for both the patient and their carers.
Pain control in palliative care is not euthanasia: it aims to improve the quality of life experienced in the process of dying and to help patients to retain their dignity. In my experience doctors are not afraid to give increasing levels of pain relief or sedation to reduce suffering.
We are grateful if there has been discussion in the form of advanced care directives that can assist in decision making, but these need to be more effective, universal and readily accessed perhaps through a central controlled and confidential data bank. Priority needs to be given to researching and funding effective symptom control for people dying, so that some of the fear may be removed, making euthanasia less needed.
It should be noted that there is strong association between requests for euthanasia and depression, as indeed there is between chronic disease and depression. Although the public tends to thinks of such requests being in response to intolerable pain or fear of such pain, studies (for instance in Oregon) show that the most common reason behind such a request was loss of the ability to do the things they enjoyed and a loss of autonomy.
While in many ways it is fear of the unknown, in my experience it is the dying that people fear and not death itself.
Taking time to explain how the patient may be helped, who may assist and answer questions as truthfully as possible may allay fears.
The suffering of those with mental health issues cannot and should not be underestimated. Nor should the suffering of those who feel lonely and isolated, or that of carers watching their beloved partners, children and family in their illness.
Does the answer to these problems truthfully lie in euthanasia, or is it time that we as a profession and as a society develop more compassionate solutions?
I fully respect other physicians’ beliefs, but for me the answer as to whether euthanasia should be legalised is firmly ‘No’.
I do not believe it is right and I do not believe I should be asked as a doctor to do it. It is not that I lack compassion rather that I believe there are more loving ways to support the dying.
