by Rob Pollnitz

Euthanasia will be a hot topic in Australia in 2011, with a federal bill and several state bills to allow lethal doses on request. At the same time, Dr Philip Nitschke is trying to set up a death clinic in Adelaide — a sort of DIY peaceful-death thing. He visits the patient in a private setting, sets up his laptop and the equipment that will provide the lethal dose and then he leaves the room. It is entirely up to the patient to choose whether to push the ‘I want to die’ button or not. She is in charge. My point is: if this patient chooses to end her life by gassing herself, that is not a crime under Australian law. But if she asks someone like Dr Nitschke to help her end it all in a gentle, peaceful manner, that is a crime. Where is the sense in that?

Suicide and attempted suicide are not against the law because the person making the attempt is considered legally incompetent at the time, usually because of major depression. Aiding or assisting in a suicide remains illegal in Australia for the reason that once the key witness is dead we can never know whether or not she or he was acting under duress.

With respect to the patient’s right to choose how and when she dies, the notion that personal freedom of choice is the highest moral value might work in a perfect world, where fully informed and competent people weighed all the issues carefully to reach a totally correct decision every time. That is not our world. Over the years I have learned not to trust some doctors, some relatives and some politicians. I do not believe it is possible to make a safe law that allows some doctors to kill some patients some of the time.

But what if a person wants to be killed? What if their distress is so bad that they just can’t bear it anymore, and they want to end it — and they ask someone to help them do it. What’s wrong with that?

It’s wrong because if they have the opportunity to live, their circumstances might change or their health might improve or their depression might lift, and they’ll be very glad that nobody got to kill them. In my 40 years as a medical doctor I have encountered five reasons why patients may request a lethal dose of medication:

• They have pain which has not yet been fully treated.
• They have depression which has not yet been recognised. We doctors can easily miss depression and yet clinical depression is very treatable. Reducing depression also reduces perception of pain and so is doubly effective in improving quality of life.
• Women especially may fear that they have become a burden to their families and so ask about euthanasia. My experience is that they want to hear they are loved and valued, regardless of their illness.
• Patients who are weary and have no family support may ask about ending their lives. Managing fatigue and social isolation is not easy, but a genuinely caring community should be able to develop a creative response. Attentive volunteers and sensitive pastors are often more help than a doctor’s prescriptions.
• People who acquire a degree of disability will often go through the usual phases of shock and anger, despair and depression before adjusting to their new level of ability.

My experience is that once people have worked through feeling suicidal they are grateful to be alive.

But surely there would be safeguards built into euthanasia legislation to ensure that not just anybody who’s having a bad day could qualify for a suicide pill or lethal injection?

First, just one story from my experience as a paediatrician. After a baby check a young mum saw a newspaper on my desk. ‘Oh, that Dr Nitschke again’, she said. ‘You know, four years ago when I was at uni, I was badly depressed. If his “peaceful pill’’ had been available I would have taken it. I’m so glad it wasn’t, because my life is really great now’ (beaming at her baby).

That’s just one story. How many hundreds and thousands of them there are we’ll never know. What we do know is that depressed people - not only those suffering from painful terminal illnesses - are likely to use a suicide pill if they have access to it. For example, Melbourne’s Herald Sun last year reported, ‘The Victorian Institute of Forensic Medicine found 51 Australians had died in the past decade from overdoses of Nembutal, promoted by Nitschke as the ‘‘peaceful pill’’. Of the 38 cases thoroughly checked by a coroner, only eleven were of people with serious pain or illness. Even sadder, eight of the dead were in their 30s, and six younger still. Nitschke has for years promoted Nembutal and has suggested how best to get it from Mexico. He says he’s tried to restrict his advice to the elderly, but even now shrugs, “There will be some casualties”.’

But what about the will of the people? The overwhelming majority of Australians are in favour of euthanasia. This is a democracy: why shouldn’t we respect the will of the people?

You may be walking through your local mall when a pollster asks you, ‘If someone is terminally ill and suffering terribly, should they be able to ask their doctor to help them die?’ Previous polls suggest that the immediate response of about 80 per cent of Australians is to answer yes. When you put suffering and help together you get a yes. Salesmen and pollsters know the way the question is framed usually determines the answer. But of course suffering and help is not the full story when it comes to euthanasia.

So if euthanasia is not about helping a terminally ill and suffering patient to die, what is it? How do you define it?

I would define it as intentionally taking the life of a patient either by a deliberate act (as with giving a lethal dose) or by the deliberate omission of ordinary care (as with not offering milk feeds to a newborn baby who has a disability). This should not be confused with turning off life support machines or with stopping unwanted treatments. In euthanasia the key is that death is the intended outcome. Essentially the euthanasia debate is about giving lethal doses.

Those in favour of euthanasia always describe it as ‘voluntary’ and present it as a simple issue of autonomy, of personal freedom of choice: ‘It’s my life and I should have the right to die when I choose’. But I believe that euthanasia and suicide are different. By always involving a second person, euthanasia is about how we as a community respond to someone who is feeling suicidal.

Under the failed 2010 SA euthanasia bill a person recently diagnosed with diabetes who found the idea of daily insulin injections ‘intolerable’ would be eligible for a lethal dose. Given that Australia has one of the highest youth suicide rates in the world, I believe a law that allows persons of 18 and over to seek death is sending the wrong message to society. Surely there is nothing genuinely compassionate about telling people who are feeling worthless that they are right.

Speaking about compassion, isn’t that the primary motivation behind the push for euthanasia? Most people seeing an animal in intolerable pain wouldn’t hesitate to put it out of its misery. A peaceful death in some instances is surely the more compassionate response to suffering than forcing a person to endure it.

Humans are more important than animals. In 2011 health professions in Australia and New Zealand can provide palliative care at world-best standards. Palliative care can be defined as the active care of patients whose disease is no longer responsive to curative treatment. We doctors are bad at predicting when patients are going to die. People do make unexpected recoveries - provided they have not been given lethal doses.

Palliative care aims to provide control of physical symptoms, especially pain; control of emotional symptoms such as fear and anxiety; honest communication; respect for patient choices between treatment options; involvement of the family; and attention to social and spiritual issues.

What people describe as pain varies widely, and in my experience women often have a higher pain tolerance than men. Pain may not be a major problem in terminal illness; even among cancer patients, a third will have little or no pain. I believe that in 2011 Australian and New Zealand palliative-care experts can always relieve physical pain to levels that are tolerable. When treating chronic pain, doctors often use regular medication three to four times daily to break the pain cycle and prevent pain from recurring.

Where chronic pain requires opioids such as morphine, patient and family may need reassurance to overcome popular but misplaced fears about addiction, respiratory depression and early death. The evidence is that adequate relief of pain actually prolongs life and improves its quality.

What about a patient in the terminal phase of a fatal illness? With just a few days to live, he is having break-through pain and distress. Is terminal sedation morally acceptable?

I believe it is, given that the intention is to relieve pain and distress and to provide better comfort during the time of dying. Our judges recognise the principle of double effect. This means that, provided the intention is to relieve distress, the side-effect of possibly hastening death is considered acceptable.

State laws vary, but throughout Australia people have the right to have their medical condition and their treatment options fully explained to them by their doctor. You can refuse any treatment that you do not want. You can write an advance directive indicating your wishes if you become unable to express them. You can appoint a trusted person to act as your medical agent (enduring power of guardianship). But you and your agent cannot insist on specific treatments and you cannot require a doctor to break the law by deliberately hastening your death.

What about life support, such as prolonged tube-feeding in patients who are in a persistent unconscious state or have advanced dementia?

There are different views on this issue. Many Roman Catholic leaders insist that such provision of food and water is natural and ordinary care and should continue until natural death occurs. Others see tube-feeding as a medical procedure and in some circumstances as prolonging the dying process. They believe that tube-feeding can ethically be withdrawn, with the consent of the patient (as in an advance directive) or of the family. As with organ donation, all of us should think about what we want for ourselves and tell our family about our choices.

It’s not only people of religious faith who argue against euthanasia. What is the secular case against it?

Many current bills to allow lethal doses on request use weasel words like ‘intolerable’. If you are depressed enough to claim that your arthritis or other condition has made life ‘intolerable’ for you, you can request a lethal dose. The claim has only to be made to be considered proven - your body, your choice - and a pro-euthanasia doctor will comply.

The Netherlands has had legal euthanasia since 1984, when their Supreme Court decided that voluntary euthanasia would not be punished provided certain conditions were observed. No supervision of the guidelines was provided. Slowly lethal doses for the sick, aged and disabled became a part of medical practice for some doctors. In the 1990s Dr John Keown of Britain examined the Dutch system and found that over 50 per cent of the acts done or omissions made with the intention of causing death were without the consent of the patient. These doctors believed that they were the best judges of when people had reached their use-by date. The Dutch government’s own reports note that at least 500 patients are being euthanased each year without requesting it. Now in the Netherlands the ‘benefits’ of euthanasia are being extended to newborn babies who have a disability, and to those who are simply ‘tired of life’. Yet in the past year journalists such as Tory Shepherd and MPs such as Steph Key have insisted there is no evidence of a slippery slope; people like me are merely ‘scaremongering’.

All pro-euthanasia bills tend to place great faith in the judgement of medical doctors. I regret to say that we doctors are human and are liable to make mistakes. Even a good doctor can make a wrong diagnosis and we can label an illness terminal when it is not. And not all doctors are good doctors. Throughout Australia and New Zealand there are doctors who are emotionally unstable and there are some who abuse alcohol or drugs. I urge you not to trust me or any of my colleagues with the right to kill.

What is the LCA’s current position on euthanasia, and why?

The LCA statement rejecting euthanasia and mercy killing was drafted by the late Dr Daniel Overduin and adopted by General Synod in 1981. It can be accessed on the church website at www.lca.org.au/csbq

As Christians we believe that our lives are a gift from God, that we are made in his image and he has chosen how long we live. ‘The days allotted to me had all been recorded in your book, before any of them ever began’ (Ps 139:16).

The British Medical Journal has reported a major study showing that patients with ‘stronger spiritual beliefs’ cope better with dying. Families sharing those beliefs resolve their grief more rapidly and completely than do those who have no such faith.

Thinking about death makes me grateful to be a Christian. Our Lord Jesus himself holds our hand and walks with us through our dying, with the empathy of one who has already travelled that path himself. Even so, people of deep faith in their Lord may be tested as they seek to live well to the end and to die well. So the mission of our church in response to the euthanasia debate is to reflect the love of Jesus in an open fashion, to affirm the God-given dignity and worth of each person, however disabled, to dispel the fears and myths about dying and to encourage the dying to take the adventure of faith.

‘As in Adam all die, so in Christ all will be made alive ... Death has been swallowed up in victory. Where, O death, is your victory? Where, O death, is your sting? ... But thanks be to God! He gives us the victory through our Lord Jesus Christ’ (1 Cor 15).