Euthanasia is an oppression of the vulnerable and a profound corruption of the doctor-patient relationship. Victorian doctors will be free to participate in this corruption from mid-2019, giving lethal injections or lethal prescriptions to their patients. With enquiries up and running in Western Australia and Queensland, can this fatal error be quarantined to a single state?
This essay appears in the latest Quadrant.
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In the twenty years between euthanasia being extinguished in the Northern Territory and rekindled in Victoria, more than twenty euthanasia Bills were brought to state and federal parliaments in Australia. They were all defeated for the same compelling reasons:
- Euthanasia shatters the foundation of law. In all civilisations, the prohibition of intentional killing is the foundation of law. Euthanasia is intentional killing, and that is a line that should never be crossed.
- Euthanasia shatters the foundation of medicine. It turns society’s bringers of life and health into society’s bringers of death. It violates our Hippocratic Oath: “I will not give a lethal drug to anyone if I am asked.” That is why the Australian Medical Association so strongly opposes euthanasia, stating in 2016, “Doctors should not be involved in interventions that have as their primary intention the ending of a person’s life.”[i]
- There are no effective safeguards against abuse. There is nothing – no law, no bureaucratic regulation – that can prevent demoralised old people, in the loneliness of their nursing home, feeling pressure to seek early death. And there is nothing that can protect vulnerable patients from doctors who think they should be dead, as we have seen in Holland.
- There are no effective limits on who will be euthanized. There is no ethical principle or legal logic that can stop the so-called “right to die” being extended to ever wider categories of people, as we have seen overseas – from the terminally ill to the disabled and those with depression; to anorexics, autistics, and those merely “tired of life”. Advocates who say we can limit euthanasia to “the terminally ill in terrible pain” are defying the facts of history.
- Palliative care, not euthanasia, is the way to go. When we reject euthanasia we are not abandoning those who suffer; as a community we are supporting them with ever-improving palliative care, a powerful field of medical and nursing care that comforts the patient as they approach their natural death, without ever crossing the line into intentional killing.
In the land of Victoria, where the shadow lies, these compelling considerations were no match for the assertion of absolute autonomy: “my body, my choice”, the slogan that gave Victorians abortion on demand, now extends to death on demand. If every child must be a wanted child, lest they cramp our lifestyle, surely every parent must now be a wanted parent.
See also, Vanessa de Largie: Flatlining in Victoria
Dishonourable exceptions aside, I have found over twenty four years that this debate is marked by good will. Many of those who support euthanasia do so because members of their family have died a distressing death. Many of those who oppose euthanasia do so with full empathy for human suffering but with grave concerns about the wider consequences of such a revolutionary change.
I have also found it necessary to define key words in advance of any discussion: we must get clear what we mean by “euthanasia” and “assisted suicide”. Too many people still think that turning off futile life support in a dying patient is euthanasia. It is not. Or that giving adequate doses of morphine to relieve pain in terminal cancer amounts to “bumping off Granny”. It does not. If such actions did amount to euthanasia, then we should all support it. But that is not euthanasia.
A lethal injection
Euthanasia is best understood by the image of a lethal injection. Euthanasia is where a doctor makes a patient die in order to end the patient’s suffering. If there is an intention to make the patient die, to ‘mercy-kill’, that is euthanasia. If there is no intention to kill, that is not euthanasia.
For example: there is no intention to kill when a doctor gives adequate morphine to relieve pain, and therefore that is not euthanasia. Sometimes morphine appears to hasten death, and sometimes morphine appears to delay death by relaxing a distressed patient. As palliative care doctors we have no interest in either hastening death or delaying death; we intend only to ease a patient’s symptoms while they die of their underlying disease.
Second example: there is no intention to kill when a dying person is taken off life support; there is merely an acceptance of inevitable dying and the provision of all supportive care while the person dies of their underlying disease.
Third example: there is no intention to kill in those extreme cases when a doctor can only relieve suffering by inducing a form of light anaesthetic called ‘terminal sedation’ – a necessary but very rare form of pain control that ignorant people slur as ‘slow euthanasia’. It is not, because there is no intention to make the patient die, only to do whatever it takes to ease suffering, while they die of their underlying disease.
With euthanasia, by contrast, there is a clear intention to kill – so if you give a lethal injection to a patient and she keeps living, you give another and another until she is dead.
With medically assisted suicide there is also an intention to make the patient die, but instead of a doctor giving the patient a lethal injection, the doctor gives the patient a lethal prescription: “Here it is. Swallow this drug and you will die”.
The intention in palliative care is never to make the patient die, but only to relieve symptoms until the patient dies naturally of their underlying disease.
Having defined our terms, let’s get to the heart of the matter.
Let me take you back 24 years to a moment of great significance during the first great euthanasia debate in Australia. It was a moment that crystallised the concerns of many that the so-called ‘right to die’ would come to be felt by the most vulnerable in our community as a ‘duty to die’.
The year was 1995, just before the Northern Territory passed its euthanasia law. At the height of the debate, our Head of State at the time, Governor-General Bill Hayden, addressed the Royal Australian College of Physicians on the Gold Coast about why he supported euthanasia.
It was a scene rich in symbolism. The two key concerns about legalising euthanasia are what it would mean for the relationship between the State and its most vulnerable citizens, and what it would mean for the relationship between doctors and their most vulnerable patients. Here we had a person speaking in his capacity as Head of State advocating euthanasia for citizens once they had passed their usefulness to society; here we had the heirs of Hippocrates, whose Oath forbids them to give lethal drugs to a patient, being asked to become society’s approved dispensers of death as well as its healers.
The main significance of this address by the Governor-General was his suggestion that voluntary euthanasia is not merely a matter of choice but, more nobly, a positive obligation to society. He spoke of elderly citizens who, after “a full and satisfying lifetime” can become “unproductive burdens”. He then made the portentous declaration that: “there is a point when the succeeding generations deserve to be disencumbered – to coin a clumsy word – of some unproductive burdens”.[ii]
This stunning message from the Head of State to his most vulnerable subjects was supported the next day by a former state governor, Sir Mark Oliphant. He told ABC radio about an aged colleague in Canberra who “should be dead” and was cluttering up the world when he shouldn’t be. These are the sentiments, not of neo-Nazis snarling about “useless eaters”, but of respected governors, shapers of social attitudes. They were seriously proposing that we develop a culture, like those described by Mr Hayden, where “unproductive burdens” will act for the greater good of society.
Mr Hayden had told his audience about past cultures where unproductive grannies and grandads would take poison or wander off into the forests when their usefulness to society was done. The elderly Japanese, defined as such by loss of all teeth, would jump from the rim of a volcano for the greater good. But this is the point: did the toothless Japanese granny jump, or was she pushed? More subtly, did she indeed jump, but only because of an irresistible cultural push?
That cultural push of euthanasia is the new oppression that we do not need to have.
Former Prime Minister Paul Keating wrote of this irresistible cultural push in the context of the Victorian legislation in 2017, “It is fatuous to assert that patients will not feel under pressure, once this bill becomes law, to nominate themselves for termination.” And the Australian Medical Association President at the time, Dr Michael Gannon, cautioned that “the sick, the elderly, the disabled, the chronically ill and the dying must never be made to feel they are a burden.”
But of course, they will be. Consider an elderly (now deceased) patient of mine, a woman with depression and minimal self-confidence, who received a vicious letter from a close relative effectively telling her she should be dead, and demanding certain arrangements in her will. She then developed cancer. What would the ‘right to die’ mean to such a patient, so isolated and intimidated?
This concern for mistreatment of vulnerable people by selfish family members is highlighted in the Australian Human Rights Commission report, Elder Abuse in Australia, published in 2017.[iii] Euthanasia laws are a prescription for elder abuse and neglect. An Oxford palliative care specialist reports on a case from Holland:
An old man was dying from disseminated lung cancer. His symptoms were well controlled and he asked if he could go and die at home. When his four children were told about his wish, they would not agree to take care of him. Instead, they pointed to their father’s suffering and the need to finish things quickly “in the name of humanity”. When the doctor refused, they threatened to sue him. As the patient insisted on going home, a social worker went to investigate. She discovered that the patient’s house was empty and that every piece of furniture had been taken by the family.[iv]
For sophisticated types like our former Governor-General, death on demand would enlarge their autonomy. But given the psychological vulnerability of the average old person and the plain nastiness of some family dynamics, a decision on euthanasia will be made from a position of humiliation and weakness.
Pressure to seek early death
One central concern runs through the international enquiries into euthanasia over the last thirty five years: that liberty for some would mean oppression for others.
The UK House of Lords Select Committee on Medical Ethics in 1994 remains the most comprehensive enquiry into euthanasia.[v] Its conclusions are all the more significant given that the majority of the Committee’s members were previously on the record as favouring legalised euthanasia. The Select Committee’s report shows empathy for the plight of the dying person:
Our thinking must be coloured by the wish of every individual for a peaceful and easy death, without prolonged suffering, and by a reluctance to contemplate the possibility of severe dementia or dependence.
Yet the Committee had to consider these moving appeals within their terms of reference of the “likely effects” of euthanasia “on society as a whole”:
Ultimately we concluded that none of the arguments we heard were sufficient to weaken society’s prohibition of intentional killing, which is the cornerstone of law and social relationships. Individual cases cannot establish the foundation of a policy which would have such serious and widespread repercussions.
The Select Committee’s core concern was about an injustice inherent in the social establishment of euthanasia — a new and subtle form of intimidation:
It would be next to impossible to ensure that all acts of euthanasia were truly voluntary. We are concerned that vulnerable people – the elderly, lonely, sick or distressed – would feel pressure, whether real or imagined, to request early death. We believe that the message which society sends to vulnerable and disadvantaged people should not, however obliquely, encourage them to seek death, but should assure them of our care and support in life.
That statement goes to the heart of the matter – the insidious pressure on the vulnerable to comply with social expectations of euthanasia.
When Kevin Andrews introduced his Euthanasia Laws Bill 1996 into the Australian Parliament, he summarised this central concern:
We should take note that every major committee of inquiry in the world, every parliament bar one, the Aboriginal people, the various religious groups, the world medical profession and those representing people with disabilities have all rejected euthanasia. They have rejected it on one unifying principle: the people who are most at risk are the most vulnerable, and a law which fails to protect vulnerable people will always be a bad law.[vi]
Two decades after the House of Lords report, the UK Parliament reaffirmed its opposition to euthanasia, rejecting the Assisted Dying Bill in 2015 by a large margin. That vote provoked an angry outburst from one of Britain’s leading neurosurgeons, Henry Marsh, who said, “Even if a few grannies get bullied into [suicide], isn’t that the price worth paying for all the people who could die with dignity?”[vii]
That is a brutally honest statement of what is at stake. Do we think it acceptable for “a few grannies”, a few “unproductive burdens”, to be bullied into suicide if that means strong-willed people like Dr Marsh can assert their autonomy and be put to death by their physician at a time and place of their choosing?
No protection against doctors
There are no effective safeguards against abuse of the vulnerable under a euthanasia law, not only at the hands of selfish family members, but also at the hands of unscrupulous doctors.
Professors of psychiatry in Brisbane, Frank Varghese and Brian Kelly, warned years ago of the impossibility of protecting patients from doctors under laws for euthanasia:
Much of the debate about euthanasia and physician-assisted suicide has as its underlying assumption that doctors will always act in the interests of their patients. This assumption fails to take into account the doctor’s unconscious and indeed sometimes conscious wishes for the patient to die and thereby to relieve everyone, including the doctor, of distress … Legislation to enable assisted suicide has been designed to provide a safeguard, through psychiatric assessment, that protects patients from themselves. What these laws do not do and cannot do is protect the patient against unconscious factors in the doctor. [viii]
We see this abuse of a doctor’s power played out in Holland, where official evidence from the Dutch Government’s own confidential survey shows that, year after year, doctors euthanize hundreds of patients without their request or consent – even where many of those patients, on the doctors’ own admission, were able at the time to give or withhold consent.[ix] In the Dutch data we see played out “the doctor’s unconscious and indeed sometimes conscious wishes for the patient to die and thereby to relieve everyone, including the doctor, of distress”. Doctor knows best, doctor has all the power, and nobody in Holland can stop it. But of course, that wouldn’t happen here…
Former Greens leader Bob Brown asked me, at the Senate enquiry into his Rights of the Terminally Ill (Euthanasia Laws Repeal) Bill 2008, to what extent there had been a reduction in what he called these “unpermitted killings” in Holland since the Dutch officially legalised euthanasia in 2002.[x]
I assume Senator Brown thought that bringing euthanasia “out into the open” by legalising and regulating it would have reduced rates of medical homicide. Not at all. I provided him with the 2007 official Dutch data on euthanasia which found that the rate of patients killed “without explicit request” after legalisation in 2002 is “not significantly different from those in previous years”.[xi]
And why would we expect a reduction in such unscrupulous behaviour? Doctors who were prepared to ignore the rules on euthanasia when it was strictly illegal would be even more comfortable and relaxed about ignoring the rules once it was socially approved.
Even if patients cannot be protected from such doctors, Varghese and Kelly suggested that they could be protected from themselves by “a safeguard, through psychiatric assessment” designed to pick up depression that might be marring their judgement. But even this so-called psychiatric safeguard appears to be ineffective in detecting and protecting depressed patients, according to evidence from the US State of Oregon and the Northern Territory.
Looking at the figures for one year in Oregon, of the 49 patients who died by physician-assisted suicide not a single patient underwent the recommended psychiatric assessment prior to taking their lethal drug. Not one. [xii]
We observed the same failure of this “safeguard” in the Northern Territory legislation during the brief era of legalised euthanasia (1996/7) where all the patients died under the one doctor, euthanasia advocate Philip Nitschke. We have detailed knowledge of the clinical circumstances of Dr Nitschke’s patients, as he co-authored an article in the Lancet journal entitled “Seven Deaths in Darwin” along with psychiatrist and palliative care specialist Professor David Kissane.[xiii]
Of the cases described, the most pitiful was a lonely English migrant with cancer who was suffering, in Kissane’s assessment, “a demoralised mental state”. The compulsory psychiatry assessment was not carried out until the very day the patient had selected to be put to death and was completed in less than twenty minutes. That, in my view, is inadequate to properly assess and counsel a suicidal and socially isolated man. At the 2008 Senate Inquiry into Bob Brown’s Bill, one Senator asked Dr Nitschke if he believed such a brief assessment was “adequate and proper”. Dr Nitschke replied. “I do… I had no concerns about it. In a sense we were going through the requirements of the legislation”.[xiv]
There is a troubling passage from Professor Kissane’s submission to that Inquiry, describing Dr Nitschke taking this lonely man home after the psychiatry assessment:
From the psychiatrist’s office, he was taken home to a musty house that had been shut up for several weeks. Nitschke had to hunt for sheets to cover the bare mattress. It rained heavily in Darwin that summer afternoon, and in administering euthanasia Nitschke felt sadness over the man’s loneliness and isolation.[xv]
As I told the Senate Inquiry,
Does that not cry out to all of us that this man needed company? He needed social work intervention. He needed church groups to go and involve him in this society where he was so isolated. He needed anything else but a lethal injection.[xvi]
Professor Kissane, as a psychiatrist, expressed a view on this much-touted “safeguard” of compulsory psychiatric assessment:
This was the part of the certification schedule most feared by patients and Nitschke reported that all seven patients saw this step as a hurdle to be overcome… Indeed, four of the ‘Seven deaths in Darwin’ revealed prominent features of depression, highlighting its strong role in decision-making by those seeking euthanasia. Alarmingly, these patients went untreated by a system preoccupied with meeting the requirements of the Act’s schedules rather than delivering competent medical care to depressed patients.[xvii]
And so we see the corruption of medicine by a culture of euthanasia. Instead of proper psychiatric care, the patient gets a lethal injection. Instead of proper palliative care, the patients gets a lethal injection. Instead of the beautiful work of bringing dignity and love to the frail residents in a nursing home, these unproductive burdens get a lethal injection.
An ever-expanding circle
And there are no effective limits on who may be given this lethal injection. There is no containing euthanasia once it is out of Pandora’s Box.
Consider Belgium, next door to Holland, whose euthanasia law from 2002 states that the patient “must be suffering intractable and unbearable pain”. Thirteen years later, a review in the New Yorker shows how broad the criteria had become for euthanasia in Belgium, involving cases with no physical pain at all:[xviii]
Although most of the Belgian patients had cancer, people have also been euthanized because they had autism, anorexia, borderline personality disorder, chronic-fatigue syndrome, partial paralysis, blindness coupled with deafness, and manic depression.
In 2013, (psychiatrist) Wim Distelmans euthanized a forty-four-year-old transgender man, Nathan Verhelst, because Verhelst was devastated by the failure of his sex-change surgeries; he said that he felt like a monster when he looked in the mirror. “Farewell, everybody,” Verhelst said from his hospital bed, seconds before receiving a lethal injection.
Incredibly, Dr Distelmans (who euthanized this transsexual man) was also in charge of the Belgian Commission “which reviews euthanasia deaths to insure that doctors have complied with the law”. As they say in the Netherlands, “De vos heeft de leiding over het kippenhok”.[xix]
The New Yorker reporter describes how Dr Distelmans interprets “intractable and unbearable pain” to mean deep unhappiness, and so expands the criteria for acceptable euthanasia to a surreal degree. Listen to this:
Distelmans told me, “We at the commission are confronted more and more with patients who are tired of dealing with a sum of small ailments—they are what we call ‘tired of life.’ ” Although their suffering derives from social concerns as well as from medical ones, Distelmans said that he still considers their pain to be incurable. “If you ask for euthanasia because you are alone, and you are alone because you don’t have family to take care of you, we cannot create family,” he said.
Let nobody again claim that euthanasia can be limited to “the terminally ill in terrible pain”. We have seen the facts on the ground in Holland and Belgium.
And we see the proposal before us from the Queensland Government. The first criterion for Labor’s proposed euthanasia law is this: “A person must want to end their life for a reason they consider to be valid.” No need for pain, or terminal illness or any objective measure at all: the person just has to consider their reason to be “valid” for requesting euthanasia. Just like it was valid for the transsexual man who was distressed by his surgery; valid for the anorexic and the autistic and “valid” for Distelmans’ lonely man with no family.
Because, if there is a “right to die”, who are you to limit that right? Who are you to question what is “valid” for someone else?
“It’s a different world”
This corrupting social change of euthanasia and assisted suicide:
# Shatters the foundation of law
# Shatters the foundation of medicine
# Has no effective safeguard against abuse by family or by doctors
# Has no effective limit on who may be euthanized
It remains to shine one light in this darkness, to show another path.
As I tell my medical students, we cannot get rid of all suffering in dying any more than we can get rid of all suffering in childbirth – but we can now get very close. For the first time in history, this lucky generation in this lucky country can have an expectation of a tolerable dying – and yet this same generation is demanding most stridently to avoid dying altogether and simply be made dead.
The euthanasia movement wants us to be free to tear out of our life’s story that chapter called “Dying”. The palliative care movement wants to help make that final chapter as meaningful as any chapter of our story; it accepts dying as part of living; it seeks, in the words of the modern founder of the hospice movement, Dame Cicely Saunders, “to help the patient live until she dies”.
I have had a patient ask me to commit euthanasia. She had come to Mt Olivet Hospice in Brisbane with terminal cancer, she was in pain and she wanted to die. The next day she was pain-free and she said to me: “It’s a different world, doc, isn’t it?”
When we look after such patients well, thoughts of euthanasia often fade. As the National Hospice and Palliative Care Organization in the US states:
When symptoms or circumstances become intolerable to a patient, effective therapies are now available to assure relief from almost all forms of distress during the terminal phase of an illness without purposefully hastening death…[xx]
Nevertheless, the rejection of euthanasia does not depend on perfecting palliative care for all patients. Its rejection stands on the rock-solid ground of justice, on the “one unifying principle” referred to by the Hon Kevin Andrews on presenting his Euthanasia Laws Bill 1996: “The people who are most at risk are the most vulnerable, and a law which fails to protect vulnerable people will always be a bad law”.
David van Gend is a Toowoomba GP and a university lecturer in palliative medicine. He served on the Queensland Health Working Group for Palliative Care in Children
[i] AMA Position statement on euthanasia and physician assisted suicide, 2016, https://ama.com.au/system/tdf/documents/AMA%20Position%20Statement%20on%20Euthanasia%20and%20Physician%20Assisted%20Suicide%202016.pdf?file=1&type=node&id=45402
[ii] The Hon Bill Hayden, Governor General, Address to the Royal Australian College of Physicians, 21/6/95, reported Courier Mail 26 June 1995.
[iii] AHRC report, “Elder Abuse in Australia – a National Legal Response”, May 2017 https://www.alrc.gov.au/sites/default/files/pdfs/publications/elder_abuse_131_final_report_31_may_2017.pdf
[iv] Twycross R, Journal of the Royal Society of Medicine, Feb.1996, pp.61-63.
[v] House of Lords, Report of the Select Committee on Medical Ethics, 1994 HMSO.
[vi] Andrews K, second reading speech, Euthanasia Laws Bill 1996, House Hansard 28/10/06 p.5904:
[vii] Chustecka Z., “Renowned neurosurgeon on assisted dying and his ‘suicide kit’”, Medscape, 27 April 2017, http://www.medscape.com/viewarticle/879187
[viii] Varghese F, Kelly B, Physician-assisted suicide, Psychiatric Services, April 1999, Vol. 50 No. 4
[ix] Onwuteaka-Phillipson B, van der Heide A, et al, Euthanasia and other end-of-life decisions in the Netherlands in 1990, 1995 and 2001, Lancet 2003; 362: 395-99.
[x] Senate Legal and Constitutional Committee, Enquiry into the Rights of the Terminally Ill (Euthanasia Laws Repeal) Bill 2008, Darwin Hearing 14th April 2008, transcript https://www.aph.gov.au/~/media/wopapub/senate/senate/commttee/S10740_pdf.ashx L&CA17.
[xi] van der Heide A. et al, End-of-Life Practices in the Netherlands under the Euthanasia Act, NEJM Volume 356:1957-1965 May 10, 2007 No. 19 at http://content.nejm.org/cgi/content/full/356/19/1957
[xii] Oregon data on referrals to psychiatrist at http://www.oregon.gov/DHS/ph/pas/docs/yr10-tbl-1.pdf
[xiii] Kissane DW, Street A, Nitschke P. Seven deaths in Darwin: case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia. Lancet 1998; 352: 1097-1102. https://www.ncbi.nlm.nih.gov/pubmed/9798585
[xiv] Nitschke P, Senate Legal and Constitutional Affairs Committee, Darwin Hearing 14th April 2008, transcript https://www.aph.gov.au/~/media/wopapub/senate/senate/commttee/S10740_pdf.ashx L&CA42.
[xv] Kissane DW, submission to the Senate enquiry into the Rights of the Terminally Ill (Euthanasia Laws Repeal) Bill 2008 https://www.aph.gov.au/~/media/wopapub/senate/committee/legcon_ctte/completed_inquiries/2008_10/terminally_ill/submissions/sub589_pdf.ashx p.12.
[xvi] van Gend D, Senate Legal and Constitutional Affairs Committee, Darwin Hearing 14th April 2008, transcript: https://www.aph.gov.au/~/media/wopapub/senate/senate/commttee/S10740_pdf.ashx L&CA21.
[xvii] Kissane DW submission op cit p 16
[xviii] New Yorker, June 2015, Letter from Belgium: “The Death Treatment” http://www.newyorker.com/magazine/2015/06/22/the-death-treatment
[xix] “The fox is in charge of the hen house.”
[xx] US National Hospice and Palliative Care Organisation http://www.nhpco.org/templates/1/homepage.cfm