Former Senator Amanda Vanstone used her Fairfax column recently to advocate for assisted suicide and euthanasia legislation. We should note former PM Paul Keating used the same forum last year to describe the Victorian euthanasia legislation as “misguided” and “warned that advocates were in a state of denial about other human failings which exist also, including errors of diagnosis, the potential for selfish and sometimes predatory behaviour by family members, and commercially motivated decisions by nursing homes, hospices, and hospitals.”
This variety of ‘opinion’ raises the question as to the understanding of the issues and decision-making process behind opinions on this important community issue.
Firstly, words matter. What is being described as “assisted dying” is really physician-assisted suicide. It is rather, palliative care which assists people in the dying process, not by taking life, but by controlling troublesome symptoms to allow dying in peace.
People requesting physician-assisted suicide, under the Victorian legislation, need only get agreement by two doctors, and the person’s own doctor need not be involved, or even notified.
There will be no assessment by a palliative care physician to see what symptom treatment would relieve distress, nor by a psychiatrist to assess if the person has the distorted negative perceptions of someone depressed and who may benefit from treatment.
Diagnostic mistakes exist; people have misunderstandings about illness and palliation, and rogue practitioners exist.
What about polls? The questions asked in opinion polls about assisted suicide are usually similar to “if a person has uncontrollable distress, should they be able to request assisted suicide?” This question makes two assumptions: there is uncontrollable distress (the implication being often); and that changing the law about assisted suicide concerns only that person and does not harm anyone else. These assumptions bear examination.
Clinical experience suggests most people polled about ‘euthanasia’ think they are ‘voting’ for good symptom control because they believe it is not available. Often this is on the basis of their experience with a parent or relative, often decades ago –-before palliative care even existed, and indeed it was not available then. But it is available now, although not as fully in the community as is needed. The reality is that there are not patients dying in agony (as is often represented) in specialist palliative care units. So expert palliative care is able to relieve terminal clinical distress in patients if the necessary skills and knowledge are available.
The problem with end-of-life care in the community, seen by specialist palliative care physicians, is that the skills and knowledge are often not present in the general medical and nursing community.
What do the general public (and many doctors who have no involvement in end-of-life care) know about the effectiveness of palliative care management, or the consequences of law change, when they are polled by a black-and-white clinically unrealistic question?
The other argument advanced by some is that of ‘choice’. The implicit assumption is that exercising ‘choice’ to suicide should be taken at face value, and also does not affect anyone else.
Psychiatric experience indicates that the vast majority of people with suicidal thought have a depressive element, which may, of course, be part of a wider physical illness.
If the law is changed, does ‘choice’ for assisted suicide affect others? (Philip Nitschke believes this should be available to everyone even in the absence of illness).
To consider this matter, we need to understand the dynamics of illness. When people are ill, or older, they often feel they are of little use, are ‘in the way’ and ‘a burden to family and society’.
If, additionally, they are told their prognosis is poor (even if not terminal), and their family and others surrounding them indicate they are ‘in the way, and a burden’, it is not hard to see how such people can come to think they should request euthanasia, if the law is changed to make it available. The very law change makes the option of assisted suicide one that families, and medical professionals, may feel obligated to put before ill vulnerable people.
Do families have something to gain from urging their relatives in this direction? Clearly many do. Accountants often have tales to tell of families wanting to get their hands on the assets of parents, even before they are ill. My experience in psychiatry is that such is often the case. It is even now called ‘early inheritance syndrome’ — a form of elder abuse, a situation sadly more often recognised now than formerly.
In 2017, Paul Keating criticised what he called the “bald utopianism” underpinning the idea that the state could codify protections for its most vulnerable people, while also making it legal to participate in a person’s death. “The advocates support a bill to authorise termination of life in the name of compassion, while at the same time claiming they can guarantee protection of the vulnerable, the depressed and the poor,” he wrote. No law and no process can achieve that objective. This is the point. If there are doctors prepared to bend the rules now, there will be doctors prepared to bend the rules under the new system. Beyond that, once termination of life is authorised, the threshold is crossed.”
So, in summary, firstly, sufficient ‘assistance in dying’ is available where treating doctors possesses the necessary skills and knowledge.
But further, unintended consequences of the Victorian legislation include: cursory ‘box ticking’ of the criteria by doctors who do not know the patient; elder abuse, family pressure, and the inevitable spread of interpretation of the criteria to include people with psychiatric illness, dementia, and those who come to feel ‘life is complete’, especially if they are lonely, and feel unwanted. Trust in doctors is diminished. Bureaucrats will inevitably come to see cost savings as an effect of such legislation.
Many palliative care physicians, oncologists and other doctors have expressed the view that they see these processes as unethical, and they will not be involved. Evidence from The Netherlands and Belgium, where these processes have been practised for some time are revealing. It is not a pretty picture. Change to legislation or formal criteria are not necessary for changes of interpretation and a ‘slippery slope’ of clinical practice to occur.
One wonders how much Amanda Vanstone and others understand about the way such legislation would work in practice and what the medical consequences are to the community.
The better course of action is to radically promote the rapid dissemination of palliative care skills in the medical community. The law is a blunt instrument indeed in complex medical illness and is better kept out of it. We will regret such legislation, which will do more harm than good. Hopefully, the non-Victorian jurisdictions in Australia will have more wisdom.
Dr John Buchanan is a former chair of the Victorian Branch for the Royal Australian & New Zealand College of Psychiatrists and has practised as a psychiatrist in palliative care and oncology, as well as in general medicine.
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