Two doctors look at the case for and against assisted dying
Two medical professionals with decades of experience look at the issues surrounding assisted dying
By John Buchanan and Barbara Burge
September 28 2017
Law change for assisted suicide, or expand palliative care?
Dr John Buchanan
In a few weeks the Victorian Parliament will consider a Law change to permit assisted suicide. This can appear compassionate until some questions are asked; the first and foremost being is such a dramatic change in medical ethics necessary?
A reading of the 1037 submissions to the recent Parliamentary Inquiry reveals many cases of a single family death which has so upset family members that they think assisted suicide is an appropriate option. Many such deaths occurred decades ago. Palliative care is a developing specialty, but is often under-used due to limited government funding.
Palliative care practitioners pay careful attention to control of distressing physical symptoms, but also psychological and spiritual issues, for both patient and family. It is a whole-person type of care, assisting the patient and their family, as they navigate the journey of a terminal illness. No legal protection of doctors is necessary for good palliative care. There have been no doctors charged for providing appropriate palliative care.
Public polls can be extremely misleading. It is often stated that 75% of Australians are in favour of assisted suicide: but what question were they asked? They have generally been asked something like: “If a person has a terminal illness, and has unrelievable pain/suffering, are you in favour of assisted suicide?” That is an unrealistic question, because that need not ever be the clinical situation, if available measures are used properly. Pain management using a variety of tools is well advanced in 2017.
An opinion about any issue is only as good as the knowledge and experience informing it. Private medical polls indicate that the more doctors have to do with palliative care, the less they are in favour of assisted suicide. Indeed, the Australian Medical Association policy is that doctors should not be involved in such activity.
Research into end-of-life decisions overseas reveals that the main reason for requests for assisted suicide is not poorly controlled suffering at all, but a desire to control the circumstances at the end of a life. It is the notion of autonomy which appears a driving factor. However, autonomy alone does not trump other ethical pillars: there is also ‘do no harm’. It is not really autonomy at all, if other people are involved, and are asked to change a key tenet of medical ethics (that doctors do not participate in taking the lives of patients).
There is an assumption that if this sort of legislation is passed, it does not affect anyone other than the individuals immediately concerned. That is not the case. Changing the Law will change it for everyone in the community, and has consequences which have been poorly understood.
No doctor can actually tell you how long you have to live. What suffering is experienced depends on what palliative treatment has been used, and the attitudes and messages which surround the patient. Notably assisted suicide legislation has taken hold in The Netherlands and Belgium, where palliative care was less well developed. If people around the patient give the impression that the person is a burden and a family do not adjust well to illness, one can easily see how a patient can request assisted suicide. People feel a burden just because they are ill. It is virtually impossible to detect whether someone is being coerced by the attitudes of their family or their medical or nursing practitioners, some of which may be to do with financial gain (so-called early inheritance syndrome).
To believe there is no ‘slippery slope’ is to deny the facts. The slippery slope is clearly evident in The Netherlands and Belgium, where those who may seek assisted suicide now include people with psychiatric illness and dementia, and there is involuntary euthanasia documented by government statistics. The Netherlands government is currently considering permitting euthanasia for those over 75 and “tired of life”. In Victoria, advocates are already lobbying for wider criteria to include any chronic illness, before a Bill has even been presented to Parliament.
Furthermore, assisted suicide legislation would harm the medical care of future patients. In The Netherlands and Belgium, it is becoming the expected norm that people should “get out of the way” - essentially a “duty to die” - if they have serious illness. Consider too that mixed messages about suicide will undermine public mental health messages. How will beyondblue square messages which suggest people see their doctor for treatment of depression and suicidal thought if at the same time we have people being told that if they have suicidal thought, the State laws will assist them to suicide? Once this ethical line is crossed, it leads to a deterioration of medical care.
On balance, the risks to the common good and the unintended consequences of such legislation are sufficiently great that this legislation should be rejected. Instead, the State Government should be expanding training and funding for palliative care.
Dr John Buchanan (MB.BS, DPM, M.Med, FRACP, FRANZCP) is a former Chair Vic Branch Royal Aust & NZ College of Psychiatrists. He has worked as a physician, then Medical Director Citimission Hospice Program after training in psychiatry as a Liaison Psychiatrist Oncology and palliative care in Melbourne. In 2013 he was the recipient of the RANZCP Medal of Honour. He is a member of St Alfred’s North Blackburn.
Patients should have the freedom to decide
Dr Barbara Burge
I recently wrote a letter, published in the September edition of The Melbourne Anglican, on assisted dying. It arose out of my concern that the statement made by a group of Victorian bishops on the issue was unduly harsh and in some areas inaccurate.
Bishops are portrayed as shepherds of their flocks. Jesus declared Himself to be the Good Shepherd who led his flock, but who also searched out the single lost sheep and brought it tenderly back to the fold. When we talk about Physician Assisted Dying (PAD), I suspect we are talking of relatively small numbers of people, but they are still important. Most people still want life preserved rather than taken.
The available figures suggest that 75% of people in the community want legislative change. It is reasonable to assume this figure includes numbers of Anglicans who disagree with the Church leadership’s position on the issue. It is not inconceivable that some may sadly walk away from the Church; it is a subject that arouses strong feelings. The Church should see this as an opportunity to provide spiritual support rather than judgment. We should ask ‘What is the theological underpinning of the freedom to decide?’ The Creation story suggests that it is a God-given gift, not a modern development contrary to Christian belief.
I also suggest that many doctors are guilty of making dogmatic statements rather than involving their patients in a discussion which leads to informed decisions. However patient autonomy is now a stronger focus in medical education, and patients are demanding it.
As a doctor, I believe I would be obliged to provide the means for a patient to have PAD, because I believe it is my function to help patients make decisions for themselves in the context of intelligent discussion and counselling and with the legislated constraints and regulations in place. The legislation is in fact very conservative, and this is why I am not impressed by the ‘slippery slope phenomenon’ that is feared by those who are so ardently opposed to the proposed legislation. I see the legislation as sensible, safe, informed and compassionate.
Physician Assisted Dying as it stands cannot apply to patients with dementia, and many people who support the PAD would see this as a serious deficiency. The reason for this is that in order to qualify a patient must be seen to be ‘competent’ to make decisions for themselves in the context of a terminal illness; in fact they must make the decision three times. For people who can no longer speak for themselves, Advanced Care Directives, preferably accompanied by an Enduring Power of Medical Attorney, help prevent inappropriate intervention and treatment. For example, a person may decide ahead of time in the event of a supervening infection such as pneumonia or a urinary tract infection or a fall leading to a significant head injury, that they be given Palliative Care rather than active hospital treatment.
As a practicing Christian, I am uncertain at this stage what I would want for myself if I was in intolerable pain and suffering at the end of life. It may be almost impossible to know until one is in the situation. However, like many, I would welcome the knowledge that the possibility of PAD is ‘out there’.
The evidence is that many who request it do not in the end use it, but find enormous comfort and relief of anxiety knowing that it is there if needed.
The proposed legislation places enormous stress on palliative care, as is entirely appropriate, and requests and recommends that more resources are dedicated to this. Palliative Care is effective in most circumstances, and I admire and support the dedicated work that is done in this area.
However, there are a small number of patients for whom it does not work, and a small number of patients who are sincerely asking for a different death.
When we look for scriptural references for ethical decisions in this area, I believe it is inappropriate to select specific texts to prove one’s point. Context is important. We have to factor in the difference that medical research has made. Modern medicine has extended the life span for many people, so, for example, some cancers are more common.
We need to be involved in compassionate discussion. We need to reflect that Jesus often did not follow the party line. He instituted a new way based on love and compassion. He surprised many; he angered some, so much so that they crucified Him. This in the context of the Resurrection became the means of our salvation.
Dr Barbara Burge (MBBS FRACGP Mast GP Psychiatry) is a retired general practitioner having been in full time general practice for 50 years. She has over that period of time cared for many people across all the stages of a person’s lifetime, including the care of people with terminal illness, often seeing them in their homes in the context of their families.
At the present time she tutors medical students at The University of Melbourne in a relatively newly established course called Ethical and Empathic Practice.