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While the debate about euthanasia continues, society should focus
more on palliative care which is clinically safe and ethically sound
MJA 1997; 166: 176
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The most important thing is promoting the comfort, dignity and autonomy of people who are dying |
In studies which generated the first data on the incidence of
euthanasia in the Netherlands,1-3
the practice was categorised as a type of "medical decision at
the end of life", defined as: "all decisions by physicians concerning
courses of action aimed at hastening the end of life of the patient or
courses of action for which the physician takes into account the
probability that the end of life of the patient is hastened." Two other
categories which van der Maas and colleagues created were the
administration of "high" doses of opiates that "almost certainly
would shorten the life of the patient" and decisions in which
"life-prolonging" treatment was withheld or withdrawn.4 In this issue of the Journal, Kuhse et al. report the results of their Australian study
based on the approach taken by these studies.
One line of argument advanced by those in favour of legalising euthanasia is to suggest that if doctors already cause (or hasten) death by stopping "active" treatment or by palliative interventions, such as the use of escalating morphine doses for pain control, they should not object to the administration of a lethal injection or the supply of the means to commit suicide at the explicit request of a terminally ill patient. By demonstrating a high incidence of so-called "medical decisions at the end of life" which are argued to cause death (approximately 65% of deaths in the study by Kuhse et al.), advocates of the legalisation of voluntary active euthanasia presumably hope to show that existing medical practice is inconsistent in both its principles and processes. There are two major false premises which need to be challenged. Firstly, it is a common belief, and the basis of a considerable body of legal and legislative opinion, that the dose of morphine (or other opioid) per se is the main determinant of whether the drug causes or hastens death.5 In fact, there is no such determinative dose. What matters is the relationship of a dose to the previous dose. In pain management gradual dose escalation by 50%-100% of the previous dose is usual practice, although substantially higher increases can usually be well tolerated by patients who are not new to the drug. It is therefore the size of the initial dose, and the rate of subsequent increases, which are important. Unlike most other forms of drug treatment, there are no predetermined dose ranges of morphine for achieving satisfactory control of cancer pain. Therefore, treatment has to be skilfully adjusted on an individual basis. For most adults a daily dose in the range 30-200 mg, orally, will achieve initial pain control. The accepted practice, used safely for at least 20 years, is to adjust the regular dose (usually) upwards according to the requirements to keep the pain under control, balanced against the occurrence of side effects. Many doctors still believe that they are causing or hastening the death of patients by this process, despite an extensive and sustained international campaign by the World Health Organization and a lack of any evidence to support this view. Like any drug, morphine is dangerous if used without clinical skill. Appropriate opioid use is surrounded by myths and fears among both the general public and health care professionals, appearing to be largely attributable to the history and non-medical use of this class of drugs.6
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Secondly, surely nobody benefits from lines of argument which equate
the cessation of treatment or decisions not to treat when a person is
dying (even if treatment is potentially life-prolonging)
with giving a lethal injection to end a life. "Moral-equivalence"
arguments based on outcome cannot ignore the assessment of clinical
proportionality and appropriateness. Although Keyserlingk has
argued against overemphasis on "but-for" causality in this debate,7 the death is surely caused
only if the treatment can be demonstrated to be clinically effective
in the circumstances, and the underlying condition is potentially
reversible (i.e., there is a disruption of a pre-existing chain of
causation).8 For a competent
patient who expresses a wish to reject any medical treatment
whatsoever, this has been clearly accepted as morally and legally
permissible, and the issue is not controversial.
While van der Maas et al.9 and Kuhse et al. are right to draw attention to situations in which patients were not consulted about medical decisions, treatment abatement cannot be negotiated with incompetent dying people. Unfortunately, incompetence due to organic brain dysfunction is fairly common during the dying process and medical decisions do have to be taken.10 Although the Australian doctors in the report by Kuhse and colleagues may be reflecting a degree of honest pragmatism, this finding clearly needs more exploration -- with particular emphasis on the transparency of process, negotiation and consultation. Kuhse et al. state that death was the "partly or explicitly" intended outcome of a medical decision to end life in 36.5% of all Australian deaths. While they attempted to ascertain intention, neither their study nor the Dutch studies validate the doctors' responses by examining clinical data and prescription records. In the absence of formal training in palliative care -- a relatively recent advent in most medical schools -- doctors' attitudes and clinical behaviour are complex and variable. They range from abrupt cessation of treatment, minimalist palliative care and treatment directed at bringing about a rapid dying process, to excessive caution about being seen to be instrumental in causing the death, particularly with regard to providing pain and symptom relief, withdrawal or non-initiation of artificial hydration and alimentation, and cardiopulmonary resuscitation.11 While academic study in this area is essential and welcome, neither reliance on empirical research12 (despite its attractiveness to doctors and policymakers) nor the generation of increasingly ingenious ethical or legal arguments will resolve the issue of euthanasia. The debate has become stagnant, circular and divisive and it distracts our society from the on-going task of improving care and decision-making at the end of life. The most important thing is promoting the comfort, dignity and autonomy of people who are dying. Divergence about whether third-party assistance (medical or non-medical) to die is permissible reveals a deep and complex fault line in modern Western democracies, as they chart their courses based more on individual conceptions of liberty and autonomy than those of organised religion and deontological codes.13 This process is ongoing and resolution will not come easily. Society's energy should be more focused on palliative care, about which we can nearly all agree, and where modest investments have yielded excellent results for patients and families by improving care and decision-making at the end of life. There is much still to do. Euthanasia should be narrowly defined as "the deliberate action to terminate life by someone other than, and at the request of, the patient concerned",14 which is the matter at stake in the on-going societal debate. The Australian public need to have complete confidence that there is a safe and morally sound body of modern palliative care practice which is clearly and unambiguously distinguished from euthanasia. Palliative care practitioners are confident to give this re assurance. Michael Ashby
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