“IT’S not that I’m afraid of death; I just don’t want to be there when it happens,” film-maker Woody Allen wrote in his 1975 book Without feathers.

Most of us would probably agree. Perhaps it’s why we so often find it hard to have clear-headed conversations about death and dying.

Nowhere is that more apparent than in debates around the practice that you may call – depending on your perspective – euthanasia, assisted dying or, for some, just plain killing.

Is it the humane response to intractable suffering or a fundamental threat to civilised society? Can it be effectively managed, with appropriate safeguards put in place around it, or is it the top of a “slippery slope” that will lead to the abuse of some of the most vulnerable people in our community?

All the terms used to describe the practice are loaded in some way, but I am going to use “assisted dying” as it seems the most neutral to me (though I understand not everybody will agree).

Whatever you call it, surveys show that most of us support the idea, at least in principle.

I should declare that I am part of that majority. I would want the option of an assisted death to be available to me if I ever found myself facing unbearable suffering.

That said, the devil is definitely in the detail.

Legislators in Victoria and NSW have recently been grappling with the many questions raised by proposals to make assisted dying legal.

In Victoria, legislation expected to be introduced later in 2017 would make doctor-assisted dying available under certain circumstances to adults with decision making capacity who have a serious and incurable condition and are close to death.

NSW currently has draft legislation that would make this service available to terminally ill people aged 25 years and over who are expected to die in the next 12 months and are experiencing severe pain, suffering or physical incapacity.

Both proposals are flawed. Well, of course they are. There is no perfect system for dealing with such a complex practical and moral issue.

If safeguards are too lax, the system could be open to abuse. If they are too stringent, people could be unjustly denied access.

Speakers at the recent Sydney Writers’ Festival raised questions about both states’ plans to limit the option of assisted dying to those who are already close to death.

What about people with debilitating chronic illness, motor neurone disease or profound stroke, asked Dr Rodney Syme, a Melbourne surgeon and vocal advocate for voluntary assisted dying.

Dr Syme also questioned the age limitations in the legislative proposals, saying: “It’s very strange that before you turn 18 years you are not supposed to have any suffering.”

With perfection out of reach, it is understandable that legislators tend to go for the cautious approach.

Perhaps, though, they could take comfort from another speaker at the writers’ festival, British neurosurgeon Dr Henry Marsh.

“There’s plenty of evidence that assisted dying does not cause the collapse of society,” Dr Marsh told the audience.

The experience in the US state of Oregon, which has allowed doctors to prescribe a lethal dose of drugs to terminally ill adults since 1997, would seem to support that view.

The most recent figures show that just 204 people received lethal prescriptions under the scheme in 2016. By the end of the year, 56% of those people had used their prescription to die. Nearly 18% had died of other causes without taking the medication, 5% had died of unknown causes, and 22% were still alive.

Some of those 22% may still go on to use the drugs, but it seems that a sizeable minority of terminally ill people may want to have the prescription “just in case” and will not necessarily end up using it.

Another of the festival speakers, writer Nikki Gemmell, believes the availability of an assisted dying service might have saved her mother’s life.

One of Gemmell’s friends has recently been preparing to die with the help of Dignitas, the Swiss organisation that provides doctor-assisted dying to terminally ill patients and to patients with severe physical or mental illness.

“The process is just so exhaustive,” Gemmell says. “If Dignitas existed here, Mum would have had her depression and pain investigated further, instead of suffering in silence. She may not have felt the need to end her life the way she did.”

Legal assisted dying carries some risk of unintended harm – of course it does – but so does a system that bars people from making decisions about the way their life will end.

Jane McCredie is a Sydney-based health and science writer.

 

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Poll

I support the concept of voluntary euthanasia for people with terminal or chronic diseases








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9 thoughts on “Assisted dying: the devil’s in the detail

  1. Anonymous says:

    It should not only be for persons who are 12 months away from dying, but also for patients who have diseases where they have no quality of life, and would prefer to die with dignity at their chosen timeline.

  2. John Buchanan says:

    There are poorly recognised problems with such legislation.
    Firstly safeguards are inadequate:
    a. there is no assessment of why a person is requesting assisted suicide, and the issues may be able to be dealt with by good palliative care
    b. it is impossible to detect coercion by attitude- from family, or zealot medical professionals
    c. such coercion by attitude may be part of elder abuse, and “early inheritance syndrome”- a form of abuse of vulnerable people

    Secondly, there is a ripple effect of assisted suicide legislation
    a. creeping criteria clearly evident in the Netherlands and Belgium, so that people with minimal issues such as grief are being euthanised
    b. a ‘duty to die’ is created, and assisted suicide becomes part of ‘normative practice’ with health care professionals desensitised to assisted suicide
    c. inevitably this will lead to health economists asserting that it is cheaper to pay for assisted suicide than more expensive alternatives such as good palliative care, or chemotherapy etc.
    This will lead over time to a degradation of medical practice to the harm of future patients.

  3. Richard Middleton says:

    @John Buchanan
    I do not know where you got your incorrect information.
    The European experience is that the safeguards worked out are thorough and exhaustive. If applied. The suggested ‘thin end of the wedge’ is not seen. If the thinking is coming around to listening to the considered interests and clear desires of the person involved, that is as it should be.
    Bottom line is that it is the right of every sane sentient sensible person to be able to chose when, where and how they die. Personally I believe it is the only real human right. All else is a need or an added benefit.
    Nobody has (should have) the authority to take that away.
    If you don’t want it for yourself, that is your choice.
    If I do, that is my choice and none of your business.

  4. randal williams says:

    We have some very eloquent and prominent people who are evangelical in promoting euthanasia. The majority are not doctors, and can take this view from the comfort of their armchairs, never having to be directly involved. Doctors will have to be involved.
    You can soften it by calling it “assisted dying’ but it is still medically- sanctioned killing. I don’t believe there is any foolproof legislation that will prevent errors and abuse. There is no comeback if a mistake is made. Familiarity and acceptance will eventually make it available on demand, like abortion.
    Put the money and resources into funding good palliative care for all.
    Doctors who take part in medical euthanasia risk losing the trust of their patients, particularly the elderly and frail, and support by the profession risks the trust of the whole community.

  5. Ian Hargreaves says:

    Some years ago I was chatting to a Supreme Court Judge, about capital punishment in extreme cases like Martin Bryant or Ivan Milat. To me it seemed very reasonable, given they had zero chance of release or rehabilitation, and that repeated polls show that the vast majority of the general public approves.

    The Judge’s response surprised me, in that, while it would be very popular in many electorates with the politicians, the judiciary would oppose it because all were aware of circumstances where there had been wrongful executions. The mere existence of capital punishment for the worst offenders, would inevitably lead to mistakes.

    Have you ever pressured a patient into doing something they did not want to do? I certainly have.

    Mostly, where I was suspicious of malignancy, and occasionally in cases of infection, where the wonders of modern antibiotics have rendered patients unaware of life-threatening infections that require surgery. I have even dragged a nurse off the wards for a biopsy under local anaesthetic in the operating theatre (yep, it was a melanoma).

    I have watched my physician tutor twisting a teenager’s arm to take antihypertensives, even though his 180/110 was completely asymptomatic. And my GP friends bemoan the number of times they have told their patients to use barrier contraception in blunt terms like “you will get Chlamydia”.

    Every cardiologist tells patients to decrease their lipids, and every endocrinologist tells patients to watch their blood sugars – while any reasonable patient would rather have booze and chips than broccoli and brussels sprouts.

    So the question is, would a euthanasia doctor be any less diligent in recommending the treatment he sincerely thought was best for the patient? Would he allow his patient to suffer needlessly from a terrible disease, when it was blindingly obvious to him that he had the optimal treatment? Just one little pill for what ails you? Take a simple case, a 21-year-old man with motor neurone disease, a 2 year life expectancy, and I think we would universally agree, one of the most horrible ways to die. It would clearly be negligent of a good euthanasia doctor not to persuade a man like that to take his medication, given the certainty of his suffering without this treatment.

    So, much like the situation of getting the capital punishment wrong, and in one’s zeal, executing the wrong man, how many euthanasia advocates can honestly say that they would not have tried to convince young Mr Stephen Hawking to abandon his PhD studies and be released from his misery?

    ‘In 1963, Hawking contracted motor neurone disease and was given two years to live…..He still hopes to make it into space one day.’ From Hawking’s official website.

  6. Dr Raymond Yeow says:

    Umm, the poll at 791 votes is 56% strongly disagree and disagree. Looks like MJA Insight readers do not represent the often quoted 80% pro-euthanasia that is the justification for a lay down misere plebiscite.

  7. Michael King says:

    As Jane McCredie said, this is a very emotive subject. It is doubtful that anyone involved in the debate can honestly claim an unbiased view. The fact that there are such eloquent opposing views shows that there is no “right” position in our current dominant paradigm. As different folk have different views on the sanctity or otherwise of human life, it is imperative that any legislation takes this into account. Whether or not we, as a society, come to accept deliberate acts that cause a person’s early death as acceptable, such acts should never be considered the standard of care. Under no circumstances must we allow coercion of medical professionals to be involved against their consciences. Similarly, as a humane and inclusive society we must decry, in the strongest terms, the vilification of those whose beliefs do not allow them to be involved in a practice they consider abhorrent.

  8. Michael says:

    TO THOSE THAT WOULD NOT ALLOW: With all due respect.

    Modern medicine while doing remarkable things also creates horror show end of life scenarios in the aim of extending life. What grants them that power? Moral authority + Consent to treat? Thankfully a person is allowed to refuse treatments. In the US this also includes stopping of eating and drinking in the name of dying— for any reason. So there it is, I can choose to die if I want to. And then I ask why do doctors have to be in charge of a pharmaceutically assisted death? Don’t put them in the middle. Or don’t let them advocate one way or another.

    I think we all need reminding: no one gets out alive. We are all going to die. Why would you deny a person the right to end their life to avoid unbelievable suffering? What is it about your life that would deny that for someone? What suffering do you want to avoid? What is so precious about a life that has become an insurmountable torment? Why should doctors be the gatekeepers of my life? They are not. Who should have that right? I have an “incurable progressive neurodegenerative” disease. Now look me in the eye. If it gets bad, how long will you let me cry into that night when I am through with crying? I ask of you, hug me and let me go if that is what I choose.

  9. Anonymous says:

    Thank you to Jane McCredie for her rational and sensible comments.

    Richard Middleton is right in stating that John Buchanan’s claims are incorrect. They have no basis in evidence or reasonable assumptions or arguments and have been refuted by every thorough recent review including the latest one, the Victorian inquiry into end of life choices. Despite this refutation, he continues to make them but what is much more disturbing is that they have also been supported, endorsed and given credibility at the highest levels of the AMA. Dr Buchanan was a member of an AMA delegation that made a presentation to Tasmanian Liberal MPs against the Tasmanian Voluntary Assisted Dying Bill on 23 May, the day before the debate on the Bill. It was defeated when 13 out of 14 Liberal MPs voted against it.

    The invitation to MPs was sent early on the day of the presentation by Dr Chris Middleton, who signed it as Chair of Council. AMA Tasmania, and Member, Drs Opposed to Euthanasia. The group included Dr Chris Moy, described as representing the Federal President of the AMA, Dr Michael Gannon. Dr John Buchanan was included as “co-author of submission from Doctors Opposed to Euthanasia”. Another member of Doctors Opposing Euthanasia in the group, Dr Helen Lord, was described as “representing Hobart Christian Doctors Network”. The other member of the group, Dr Helen McArdle, is described as “AMA Tasmania” but what is not mentioned is that she is also Deputy Chair of the Board of Catholic Southern Cross Care Tasmania Inc.

    In addition to this extraordinarily biassed representation, the AMA provided no representation of the views of the substantial proportion of doctors in favour of voluntary assisted dying legislation. The AMA survey last year revealed: “More than half of respondents (52%) believe euthanasia can form a legitimate part of medical care and 45% believe the same for physician assisted suicide.”

    It is way past time for the AMA to take the same professional, fair, rational, informed and evidence-based approach to assisted dying as to other issues on which doctors have different views including abortion and marriage equality.

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