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WE all die – the only question is how and when. Most would prefer to die peacefully after a long and fulfilled life, but not everybody is so lucky. Some less fortunate people would prefer to shorten the time of suffering while waiting to die by asking a doctor to administer a dignified peaceful death.
Under most current legislations, this is not allowed. Doctors fulfilling their patient’s request face legal prosecution and deregistration. The debate about euthanasia has recently been rekindled by the passing of legislation in Victoria, and by the Royal Australian College of GPs’ support for that legislation.
Instead of focusing on rational facts and addressing ethical questions of autonomy, justice, benevolence and non-malfeasance, the euthanasia debate appears to be dominated by emotions, religious beliefs, hypocrisy, political correctness, and assumptions that will not stand to scrutiny.
Does palliative care negate the need for euthanasia?
Palliative care can make a valuable difference to the quality of life of patients who suffer, but is it good enough for all of them? A search of MEDLINE, PubMed and Google Scholar did not reveal any study or meta-analysis showing a universal acceptable relief of suffering and patient satisfaction with any modality of palliative care. The trend in publications appears to suggest that “more than half” of the patients experience satisfactory relief of their distressing symptoms, where distressing dyspnoea appears to be the most substantial unresolved problem for many (here and here).
A Cochrane systematic review of the effectiveness of home palliative care services for patients with cancer from 2014 confirmed cost effectiveness, but showed only a small effect on reducing symptom burden and conflicting evidence of pain relief – hardly reassuring when facing weeks, if not months, of agony that will end in death no matter what.
In Belgium, where euthanasia is legal, more than 70% of patients applying for euthanasia were actually receiving palliative care. In fact, euthanasia requesters were more than twice as likely to have received palliative care than people dying of other non-sudden causes – palliative care and euthanasia are complementary rather than alternatives.
One must not forget that merely managing pain does not equal relieving suffering. Consider complete loss of autonomy and sensory input – for example, in the case of quadriplegia with loss of audiovisual capabilities after brain injury – would you prefer to continue living in such a state, unable to move or communicate, where you have no means of ending your life yourself? Some might, some might not. Some might have specified their preferences in that matter when they still could. What right do we have to deprive such people of a dignified ending of their choice?
We can’t ignore the evidence that even among patients receiving optimal palliative care, there will be some undergoing distress and suffering that only ends with their life eventually expiring, and at least some of them would prefer to die earlier in order to shorten the agony. What can we offer to those patients in the current legal climate, other than grandstanding and patronising words about how well palliative care works in some other patients?
Is palliative care available when needed?
The reality in Australia is that in most rural and remote areas palliative care services are scarce, and even in larger centres there may not be enough to manage the actual need. Palliative care rarely ranks on top of the priority list in medical education in a context where we can “save lives” by maintaining acute procedural and emergency skills. In the same way that we triage our patients, we triage our ongoing education needs. There is a reason why palliative care has become a specialty in its own right – it requires substantial education and training, rather than a few weekend courses, to become proficient.
Do we have any right to deny euthanasia when we fail to provide acceptable alternatives to alleviate suffering?
The assumption that law or governments regard all life as equally worth protecting is questionable.
Terminations of pregnancy, the death penalty and military actions in other countries are all examples of governments sanctioning the taking of life. While that in itself is not an argument for euthanasia, it is proof that humans are capable of making exceptions in extenuating circumstances.
Surely, helping a person who is in insufferable distress and is asking for help to end their life represents just such an extenuating circumstance and is reconcilable with rationality and fairness?
I say this as a doctor who has performed terminations of pregnancy, which, each time, caused me far greater conflict of conscience than any request for euthanasia from a terminally ill patient who is suffering ever could. I get relief from the fact that I can delegate this task to a more willing colleague when I want to draw the line – just as objecting doctors can do under the Victorian voluntary assisted dying legislation (Part 1, Clause 7).
Interestingly, as long as it is not humans suffering, the law sometimes mandates euthanasia. If somebody is found to let a badly injured, suffering animal die a natural death without shortening the suffering, under many legislations (including Australia) they can be prosecuted (and here) – perhaps this is why some (human) patients argue that “nobody would be allowed to let their dog suffer the way you want me to continue suffering”.
I believe that we have established that palliative care will not be able to alleviate all suffering adequately in everybody.
Many opponents of euthanasia do not have the courage to allow people to have their suffering shortened and die a dignified painless death when they literally beg for it, when the patient is prepared to spend their life savings on one last journey to a country that grants them their desperate wish. These stances appear irreconcilable.
Personally, I would be prepared to give “the good death” to a patient requesting it, provided I was satisfied that the patient had thought this through enough and was capable of making an informed decision, and the law permitted it.
I respect colleagues who would not perform such service for whatever reason they may have – such duty should never be forced on somebody who would not voluntarily do it and be at peace with it.
What I fear is the zealots and hypocritical crusaders who believe it is their right to foist their personal preferences on to everybody else.
Dr Horst Herb is a rural procedural generalist, a Fellow of the RACGP, and originally trained as a surgeon in Germany and Norway. He is currently senior medical officer at Mornington Island hospital.
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FROM THE EDITOR: Okay, that’s it. I’m now closing down comments on this story. When the conversation slides into “evolutionary weakness” and comparisons with Nazis, then you’ve proved that you’re not capable of civil or reasonable debate on this topic. Thanks to those who managed to keep it sane and polite, albeit for a just a few days.
Phillip, it is refreshing to read someone who advocates for euthanasia state the pro-suicide pro-death “progressive” agenda so honestly – particularly your celebration as superior and “progressive” ethics, the practice and extension of ending the life of the evolutionarily weak. We haven’t seen that sort of openness since the Nuremburg Trials. I did wonder if you are trying to troll this forum, but I believe you are serious. I also wonder if you are actually a doctor. Such callousness
So I thought I would add a few comments. Firstly, it seems to me your apparent hostile fixation on judeo-christian morality is actually detrimentally influencing your ability to engage with both sides of this topic. You as much as said it is not possible to hold an anti-euthanasia position unless you are religious.
Actually, I am an atheist but I am strongly opposed to doctors providing euthanasia – for what seem to me purely rational reasons, such as the corrosive effect on medical ethics and wider society, the undermining of doctor-patient trust, and the creation of a culture of death.
The prioritising of individual autonomy and failing to recognize wider social impacts is already well acknowledged as the cause of significant detriment to the environment. I suggest a reasonable argument can be made that the “social ecosystem” is similarly harmed when “individual rights” are elevated to an absolute, over every social consideration.
Similarly, the previously absolute right of individuals to smoke has been progressively restricted over recent decades as the community has recognized such absolute individual choices have had significant detrimental effects on others – including causing cancers through passive smoking. That is what I call “progressive” ethics – that as we learn how individual choices have subtle but measurable harms on others, we rightly restrict individuals’ ability to make those choices.
I suggest to you, Phillip, there is plenty of evidence from overseas experiences that there is actually a “slippery slope” with extension of “voluntary euthanasia” to more and more contexts. The doctors who practice it, naturally see it as a legitimate “solution” to more problems than just terminal illness, and prescribe it “off label” so to speak, precisely to the suicidal young, the depressed, to children and so on. You might call that “progressive” and evolutionarily “efficient” medical practice. But don’t pretend it is caring medical practice.
I believe these are reasonable and rational objections.
As a “progressive” you have more in common with the Margaret Sanger or Joseph Mengele school of ethics.
I continue to be inspired by the Hippocratic medical ethical tradition, including the commitment:
“I will give no deadly medicine to any one if asked, nor suggest any such counsel”.
And just as a final comment, I remind you Hippocrates was no judeo-christian, and the traditional “oath” dates from around 400BCE.
I think so Paul, in so far as we are able to determine they have not had a change of mind, I think the most loving thing to do would be to aid them complete the suicide, and prevent the untoward effects (organ failure etc) of the botched attempt.
I understand that my opinions are not generally accepted at present, but I guarantee you they most likely will within the next ten to twenty years, as we become more progressive and accepting as a society, and as the old ethical framework melts away. A new generation of doctors do not think the way you do.
And finally, can I ask, why would you oppose such a thing? If someone wishes to suicide it shows their evolutionary weakness, and helping them to do so would only progress our advancement as a race…
Phillip,, you seem quite convinced that when people want to suicide we really have no role in preventing them from doing so as long as they are not coerced into doing so.
What do you think we as doctors should do if they have some sort of botched attempt at suicide so that we as doctors could easily help them back to normal or even functional physical health ? Should we help them complete their suicide?
Eg overdose in ED
If there is some limit to when we should intervene to help them complete their suicide?When and under what circumstances?
Who decides?
Euthanasia corrupts every aspect of medical care.
In reply to Randal, your argument is really an argument for a Judaeo-Christian framework, which was exactly my point: “though shalt not kill” (though you quote a poet and not the Torah/Bible). I would argue that we now have no need to follow such a line of thought, since science has progressed far beyond that. Our morality now could be summed up in the words “do no harm to another, but do as you please with yourself.” On that line, I believe that any patient who wishes to end their life for really whatsoever reason ought to be given the freedom to do so, so long as they are not coerced into such a decision. What a liberty it will be once society is finally stripped of its senseless historical religious ethic framework. Evolution, which is now solidly backed up by science gives us freedom to think thus. Though I honour your right to your opinion…
In reply to Phillip, once we start facilitating the deaths of ‘sick people and mentally disturbed people’ at their request we start on a very slippery slope indeed, the criteria becoming broader and broader until it merely requires a request ( however misguided ). Also conflating the right to prolong life with the right to kill is fatuous in my view.
This does not mean that we should prolong life artificially when death is inevitable and imminent. My attitude was well expressed over one hundred years ago by the poet Arthur Hugh Clough;
“Thou shalt not kill, but needst not strive officiously to keep alive”
I suggest that those opposed to medical euthanasia or only opposed to it on the ground of religious argument, and not any rational thought process or evidence. If we have the right to prolong life via various medical modalities, then we also have the right to end our lives if we so choose. Even the idea of reducing ‘suicide risk’ is an erroneous thought, and tends against the natural evolutionary process. There is a reason that sick people and mentally disturbed people wish to die, and as medical professionals it is part of our duty to ensure their comfort in so doing.
Today, 18 eminent medical experts are proposing to travel to Manus Island to give pro bono health care to refugees who are suffering extreme distress. Admittedly a somewhat ironic gesture, considering no such eminent team has ever volunteered to solve the native PNG citizens’ heath problems.
Drs Shipman and Kevorkian propose to offer their services and guarantee to the government that their treatment will be cheaper. Furthermore, as dispassionate scientists, they propose that their techniques be contrasted with those of the other experts, in a randomised controlled trial. Their hypothesis is that euthanasia will be objectively superior to any other treatment, in relieving the patients’ symptoms. They are confident enough to guarantee zero recurrence rate, and of course, they stress that their treatment will be cheaper.
They point out that a mental state of utter hopelessness in their prospective patients is entirely appropriate and rational (not delusional nor even depressive), and that someone who intends to kill himself by strangulation hanging, or jumping from a height, clearly has no significant life expectancy. This therefore fulfils the legislative requirement for a terminal condition. And, Mr Treasurer, it is cheaper.
For people who have no hope of living with dignity, how tempting would be the prospect of ‘death with dignity’?
As Dr Herb puts it: “What right do we have to deprive such people of a dignified ending of their choice?”
If we are to enquire of our most experienced euthanasia practitioners (sadly, Dr Shipman is no longer with us, but was logically internally consistent to the end) who are of course the vets, it may be telling that they are not manning the barricades for the pro-euthanasia cause. Every vet has euthanased patients for financial reasons, because the relatives/government/insurance company would not pay for palliative or even curative treatment. Every vet has benefitted from surgical techniques practised on anaesthetised patients who were being euthanased.
And yes, “nobody would be allowed to let their dog suffer the way you want me to continue suffering” – no vet has ever asked the patient for informed consent. Veterinary euthanasia at its best is medical paternalism (in the true sense of the phrase), at its worst…well, it is cheaper.
Now, Mr Stateless Refugee, Ms Aborigine with poor quality of life, Mr Martin Bryant with locked in syndrome, 21 year old unemployed Mr Stephen Hawking facing a terrible demise with no realistic life expectancy: Do you really want to suffer, or do you want the latest, evidence-based, government-endorsed treatment, guaranteed to cure your condition? Just sign here, and this painless, Medicare bulk billed green syringe will solve all the health department’s budgetary problems… Oops sorry I read the wrong line, ‘solve all your problems’. The vets call it Lethobarb, but we caring doctors call it 20 seconds of pure Dignity.
I am frustrated by the general use of anecdotes ( usually from distressed relative(s) ) to justify legal euthanasia, a major and radical change in our laws. I submit that in these cases we will be treating the relatives rather than the dying person; Also those who use their high profile or celebrity status, a position of privilege denied to most of us, to promote legal euthanasia. I found the sight of Victorian politicians hugging and backslapping after successful passage of euthanasia legislation ( now cleverly rebadged as “voluntary assisted dying ) disturbing and frankly a little sickening. I am pleased the AMA continues to oppose medical involvement .
Dr Horst mentions justice,beneficence and malfeasance (he probably meant non-maleficence,the antonym of beneficence and meaning evil acts),but does not really address those in his contribution.
And then there’s autonomy.
It’s very sad the disabled ,who rightfully campaign relentlessly for their autonomy,are very threatened by legislation that allows other people to end their lives with the help of the medical profession for the reasons that mirror their reality every day of their lives.The implications for them are obvious.
The key in this debate is “palliative care and euthanasia are complementary rather than alternatives” as pointed out by Dr Horst Herb.
Ending suffering by ending the life of a patient is not just about opinion, beliefs and the law. The suffering that leads many to request euthanasia is rarely straight forward and more often than not involves a fear of suffering – a suffering that goes deeper than what appears on the surface. My concern is, how well equipped is the medical profession to hear what is not being said by those requesting euthanasia and how comfortable are we in sitting with another’s suffering without looking at how to ‘fix’ it.
I do not have the right to dictate to any individual the nature of their death. I can only help facilitate their conscious and rational decision. Having seen ‘palliative care’ on a personal level on three occasions with close family, as a doctor I have lost faith in it. It may reduce the pain, but the indignity prevails.