Euthanasia

The story so far…

In the June issue of Grey Power Magazine we looked at healthcare consumers' rights and the legal documents that can help us keep some control of decision-making towards the end of life, when we may not be  able to speak for ourselves.

The September issue explored our rights in regards to our end-of-life choices.  We noted a limited right to refuse medical treatment, including refusal of all food and drink even if this should hasten our death (as Margaret Page chose to do earlier this year).

In this final article we summarise some of the strengths and weaknesses of overseas death-with-dignity legislation and ask whether NZ is ready for such a law.  Our main aim is to stimulate informed public discussion.

Since the Voluntary Euthanasia Society was formed in the late 1970's public acceptance of, and demand for, some form of medically assisted death  under certain circumstances has been gathering momentum.  In the last decade several people have come before the Courts after helping a loved one to die.  A number of public figures, including medical professionals, are speaking out positively about medical assistance to hasten death.  Several newspaper columnists are also calling for an enlightened approach to euthanasia.  And media coverage has greatly increased.

VES keeps the idea floating by advertising regularly in national magazines.  EXIT International has a committed following here.  Dignity Trust NZ, set up by Leslie Martin in 2003, recently held their first and successful National Conference on Assisted Dying in Wellington, where issues arising at the end of life were discussed from a number of different viewpoints.

Terminology

The terms used in end of life discussions assume a clarity which is not necessarily there. What does it all mean?

• Euthanasia (Greek, meaning "good death") strictly speaking refers to a deliberate intervention to end a life to relieve intractable suffering.  The act of euthanasia is carried out by a third party, usually a doctor or nurse and usually at the explicit request of the patient.  However, it is now also often used to equate with the following terms:
• Voluntary Euthanasia (VE), Assisted Suicide, Physician-Assisted Dying (PAD) and Death with Dignity (DWD), refer to the practice whereby a competent patient is assisted to die at their explicit request by medical assistance.  It may involve direct assistance (such as the provision of a lethal dose of medication), or the means by which a patient can self-administer (such as a lethal prescription).
• Self-directed dying refers to the process of a competent patient dying by refusing all food and drink.[i]

Current overseas legislation

The Netherlands (2002), Belgium (2002) and Luxembourg (2008), allow euthanasia and physician-assisted dying, whilst the US States of Oregon (1997), Washington (2008) and Montana (2009) allow physician-assisted dying, but not euthanasia.

Since the 1940s Switzerland has allowed assisted suicide that is not necessarily physician-assisted, as long as the motive of the assistant is totally unselfish (for instance, they have no financial interest in the person dying).  It is also the only country that allows people from other countries to die there legally by assisted means.  Euthanasia is illegal in Switzerland.

With one exception, Death with Dignity (DWD) legislation has as its main qualification a terminal, physical illness with unbearable suffering that can't be relieved by current palliative care.  In The Netherlands, legislation does not stipulate that the patient's suffering must be physical nor does it require the patient's disease be terminal.

In Oregon, Washington and Montana in the USA, a doctor writes a prescription for a lethal medication when a patient's request is granted.  But the doctor must not actually administer it or be present at the death.  In The Netherlands a doctor has to be present when a patient ingests the drug that has been supplied.  In no jurisdiction can a doctor administer the lethal medication to the patient.

All applicants for a hastened death must be shown to be competent to make decisions for themselves and more than one medical opinion has to be sought to validate such a request.

Most countries specify "adult" meaning 18+, except for The Netherlands which specifies 16+, and allows an informed request from someone between 12 and 16 if approved by parents or guardian.

Safeguards

Safeguards against abuse have been built into all DWD legislation, proving fears of a "slippery slope" or "victimisation of minority and other vulnerable groups" unfounded.

In a recent study of two decades of research on euthanasia from the Netherlands, the authors write "Our studies show no evidence of a slippery slope. There is no evidence for a higher frequency of euthanasia among the elderly, people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses, including depression, or racial or ethnic minorities compared with background populations"[ii]

Oregon's 10-year data similarly show no evidence of vulnerable or minority groups being targeted: "As in prior years, most participants were between 55 and 84 years of age (78.0%), white (98.3%), well-educated (48.3% had at least a baccalaureate degree), and had cancer (79.7%).  Patients who died in 2009 were slightly older (median age 76 years) than in previous years (median age 70 years)."[iii]

Since claims of potential abuse are so often raised, the following letter in the Herald (7/8/10) is relevant.  Dr. Johan Rosman, who as a physician "trained and worked in the Netherlands, as well as in this country..."  wrote that "your correspondent Hylton Rhodes claims that in the Netherlands the 'frail elderly are pressured to die prematurely' and do so 'without consent'.  That is an insult to those with terminal diseases who have had the chance to die with dignity in that country.  Watertight processes are in place there...  In the Netherlands, there was a significant reduction in violent suicides by people with terminal disease...  We should have had the courage to discuss this [here] 20 years ago.  A lot of unnecessary suffering would have been prevented".

In both Belgium and The Netherlands a commission made up of medical, legal and other experts check each reported act of assisted dying by a doctor for proper adherence to the law.  Other safeguards are that a period of time must elapse between the initial application by a patient and final acceptance of their request.

Peace of Mind

The Oregon data show that for many individuals, to know that an assisted death is available allows them to get on with whatever life is left to them in a more positive way without having to worry about how their end may come. A considerable number of individuals do not make use of the lethal medication provided.  For instance, during 2009, 95 prescriptions for lethal medications were written under the provisions of the DWD Act in Oregon:  53 patients took the medications, 30 died of their underlying illness (without using the medication), and 12 were alive at the end of 2009.  A similar trend was evident in other years.[iv]

Dr. John Pollock's statement just before he died on 18 September 2010, reiterated that point: "I may not make use of [medically assisted dying] …[but] just knowing it's there, just knowing it's a possibility is a huge comfort and relief."[v]

A possible limitation

Judgements of eligibility for all current DWD legislation lie in the hands of the medical profession, with emphasis on physical suffering.  A Dutch physician, whose practice includes assisted dying and who is a consultant to other physicians, says: "Suffering is not only pain, but also fatigue, dependency and loss of dignity.  One can't relieve that with palliation. [Patients themselves] indicate when [they] find living is no more an option."[vi]

With the exception of Switzerland, doctors are the professionals actively involved in the DWD deaths of their patients.  This has been acknowledged as a tremendous burden that many doctors are reluctant to undertake.  Some Dutch doctors have spoken of how assisting patients to die has taken a huge emotional toll on their well-being.  Since 1999 The Netherlands has an organisation of doctors with special training and experience who support and are available for consultation by doctors facing requests from patients.[vii]

The issue of who might assist a person to die remains controversial: Should the practice of assisting a person to die be part of a doctor's role?  Would allowing doctors to hasten a person's death irrevocably undermine the trust relationship between doctors and their patients?  If doctors weren't to assist patients to die, who would/should?  Should certain individuals be specifically trained in end of life practices?  These are difficult questions to answer, but very important to critically consider.

Is New Zealand ready for a Death with Dignity Act?

In 1995 Michael Laws' Death With Dignity Bill failed by 61 votes against and 29 for.  Peter Brown's 2003 Death with Dignity Bill fared rather better, though it was also defeated at its first reading by 2 votes: 60-58.  This prevented it going to a Parliamentary Select Committee which would have allowed a wide public debate with both written and oral submissions.  The Bill provided that "a patient… who because of a terminal or incurable illness is experiencing pain, suffering, or distress to an extent unacceptable to the patient, may request [their] attending medical practitioner to assist [them] in ending [their] life".[viii]

We are fortunate in this country to have a Parliamentary system with Select Committees where a Bill that gets past its first reading, can have both written and oral input from the public before further debate and action by MPs themselves.

If legislation is to challenge the law on assisted dying (under certain carefully controlled conditions), then wide ranging and vigorous public debate is needed.

There is strong and understandable opposition from many religious and cultural groups and from others objecting to the basic concept of hastening a person's death, and/or fearful of what such legislation could eventually lead to.  Many of those commenting in this area raise concerns about potential abusive practices towards the most vulnerable in society. Christina Odone, commenting on the situation in the UK, makes this point in her recent article "Assisted suicide: how the chattering classes have got it wrong".[ix] Others reflect on the sanctity and value of life. Yet others raise concerns about how legalising medical assistance to hasten death may compromise the doctor-patient relationship. For instance, would some patients near the end of life come to view their doctor with suspicion were he or she to initiate a conversation about end of life decision-making, especially if the patient felt that hastening death was the primary focus of the conversation?

However, religious opposition is not as clear-cut as it is sometimes portrayed.  E.g., in South Australia, the Reverend Trevor Bensch, a Baptist hospital chaplain, is leading Christians in a campaign to legalise voluntary euthanasia.  He said his call was compassionate and "thoroughly consistent with the teachings of Jesus''.[x] Dignity Trust NZ claims support from "members of the medical, legal, nursing, theological and academic professions".[xi]

In an article 'There's much more to death than dying' (NZ Herald, 19/10/10), Annette Pereira of the Maxim Institute considers that "... Death is not something we choose or control, no matter how much we try.  Our much-touted values of 'liberty' and 'choice' do not work in this territory... Death...is intensely personal, but like life, death is public.  We are connected to one another - deeply connected.  The poet John Donne wrote: 'Any man's death diminishes me, because I am involved in mankind.'"

In response Dame Jenny Gibbs wrote: "... With the advent of antibiotics, contraceptives and modern medical procedures, we interfere with nature all the time.  None of this is compulsory; they are tools available to those who choose to use them.  Medically assisted dying should be the same - available to those who choose it..." (NZ Herald, 21/10/10).

In light of a rapidly aging population and increasing demands for health care services it has also been argued, that the legalisation of assisted dying will be motivated not by competent requests from autonomous individuals, but rather by economic constraints.  In other words, assisted dying will be legalised as a cost-containment issue.

Dr. Peter Foley, Chairman of the NZ Medical Association has publicly stated that "the NZMA is opposed to both the concept and practice of euthanasia and doctor assisted suicide".   He claims doctors are "trained to promote life" not act to deliberately end it.[xii] In spite of this there is well documented evidence that some NZ general practitioners are actively assisting their extremely ill patients to die.[xiii]

Dr. Jack Havill of Hamilton, Specialist in Intensive Care Medicine responded: "… Good palliative care will remain the choice for most terminal patients, but the option of being able to have the last phase shortened in a legal way and with family and friends and maybe a spiritual adviser present, should also be in place.  This is quite different from suicide, which is lonely and desperate and can be very hurtful to those left…  I belong to the Dignity NZ Trust…  I am also a medical doctor, and many of us support a move to good legislation to enable voluntary euthanasia." (Listener letters, 2/10/10)

In early October this year, Dr Ann McPherson launched Healthcare Professionals for Change, a UK group of doctors, nurses and allied health professionals who are seeking to challenge the British Medical Council's position that opposes assisting terminally ill individuals to die.  She states that "many of us believe dying patients should not have to suffer against their wishes at the end of life. Alongside access to good quality end of life care, we believe that terminally ill, mentally competent patients should be able to choose an assisted death, subject to safeguards"[xiv].

Formal public opinion polls by Brunton Colmar and Massey University in the last few years, as well as informal ones by newspapers and media, consistently quote a 70% + public vote in favour of some form of physician-assisted dying.[xv]

After a serious health threat Kerre Woodham wrote a thoughtful column, "I hope I know when it's my time to go" in the Herald on Sunday (1/8/10).  She ends: "...as the population ages, the issue of euthanasia will be one we all have to come to terms with."

Jude Dobson, in her column in The Aucklander (2/9/10) wrote: "...As my lovely supportive mother said, we are kinder to our pets than we are allowed to be to the humans we love which, sadly, is true.  Mum added that if she were ever in that position she would opt for the blue injection..."  Jude finishes with "...perhaps if New Zealand can become more enlightened, a doctor one day might be able to grant such wishes to the many consenting dying patients.  They and their families, I believe, would be thankful for such a service".

Many older citizens are becoming more vocal and assertive about what they want for themselves at the end of life, as they contemplate the possible loss of dignity and quality of life with medical science able to keep us breathing ever longer.  A number now either have "Do not resuscitate" tattooed on their chests or on a Medicalert bracelet or pendant.   Younger people often simply say that they will not put up with being refused help to die when life, for one reason or another, has irretrievably lost quality and meaning.  Maintaining 'dignity' and 'quality of life' can be more important to some people than length of life.

The recent words by British fantasy novelist Terry Pratchett are poignant and relevant: "It seems to me that the two centuries of medical progress that has allowed us to outlive ourselves - that is to live long enough to catch the most dreadful of diseases - ought to be able to come to our aid in allowing a consensual and dignified end".[xvi] One question of course, is whether we want doctors to be the ones to 'come to our aid' at the end of life, assuming that assisted dying is 'coming to our aid'.

NB

Restrictions on length prevent us from doing full justice to the subject of voluntary euthanasia. We have tried to provide balance and avoid misrepresentation and oversimplification.