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The end of life: We need a humane and informed framework, not only a medical model, to deal with death and dying
MJA 1996; 165: 535
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Dealing with death and dying (which includes requests for euthanasia) is an integral part of the practice of medicine. Surveys of health care professionals in Australia and overseas now consistently show that a considerable proportion of them support euthanasia or physician-assisted suicide under certain conditions. 1-4 A minority of health care professionals also admit to having practised euthanasia or physician-assisted suicide. For example, the most recent Australian survey found that one in seven doctors had helped a 0atient to die. 5 Other surveys have reported that 19 per cent of doctors in South Australia 6 and 29 per cent of doctors in Victoria had taken active steps to hasten death in patients with terminal or incurable disease who had requested they do so . 7
In one of the most detailed surveys of the practice of euthanasia in Holland, van der Maas et al. 4 found that in 1.8 per cent of all deaths a lethal drug was administered, at the patient's request, to end life, and in 38 per cent of all deaths doctors had taken medical decisions concerning the end of life that may have shortened the patient's life. van der Maas et al. 4 concluded that medical decisions concerning the end of life were common in medical practice and should be the subject of increased research, teaching, and public debate. Other recent international studies have reported similar findings. 1,2
Surveys of community attitudes also show increasing support for euthanasia and physician-assisted suicide. In 1962 only 47 per cent of Australians, when asked "if a patient in great pain, with no hope of recovery, asks for a lethal dose, should a doctor be allowed to administer one?", replied in the affirmative. In 1996, 76 per cent gave the same response. Correspondingly, the response "not give lethal dose" declined from 39 per cent in 1962 to 17 per cent in 1996. 8
The study by Waddell et al. reported in this issue of the Journal makes a significant contribution to the euthanasia debate in Australia. Unlike most previous Australian studies that elicited doctors' responses to general questions concerning end-of-life treatment decisions, 5,6 this study used real and comprehensive clinical scenarios. Based on a recent Canadian study, 9 Waddell et al. used a questionnaire that presented clinical cases in which the patients' sociodemographic characteristics, mental competence, severity of illness and wishes for treatment varied. (One of these clinical vignettes involved the issue of physician-assisted death requested by a 56-year-old competent man with a debilitating, but not imminently terminal, condition.) The respondents were asked to state what they would do.
A major finding was that Australian doctors did not make consistent decisions in the treatment of severely and terminally ill patients. The doctors' decisions were influenced by their medical training and sociodemographic background, and the data suggested that there were no clear criteria to guide doctors in managing these clinical situations. Waddell et al. suggest that the capacity of doctors to treat severely and terminally ill patients in accordance with the patients' wishes may be aided by the informed-consent process, as well as by advance care planning. The study also revealed that only a small minority of doctors would have complied with the wish of the patient for euthanasia.
This study again raises questions about medical decisions concerning the end of life -- questions that deserve an informed public debate. Why are most doctors against the legalisation of euthanasia? 3 Are public interests in Australia served by existing medical practices that deal with the dying patient?
Several factors may explain the opposition of doctors to euthanasia. First, in general, in modern medicine death is viewed as a failure; hence the reluctance of medical professionals to reinforce this perception by accepting euthanasia and physician-assisted suicide. The response of modern medicine to the complex set of problems surrounding the dying patient is to provide effective and accessible palliative care. Second, the various surveys mentioned earlier suggest that dealing with death and dying is seen as an integral part of the practice of medicine. Doctors would prefer to keep this management within their professional practice to allow them the flexibility to respond to the very complex realities of differing clinical situations, in which decisions must take into account the unique nature of the suffering of the individual patient and the availability of the appropriate medical facilities to care for the patient.
The regulation of death and dying through a formal legal process could make it difficult for doctors to respond to the individual needs of the patient and could also subject doctors to unreasonable and extended legal scrutiny.The intrusiveness of legislation into the doctor-patient relationship was alluded to by Brendan Nelson, the former federal President of the Australian Medical Association, when he stated: "We can't reach for a legislative pen every time we have a problem or we see something in life we'd like to regulate. In the end doctors will continue to do what they believe to be right in the interests of the patient and his or her immediate family." Dr Nelson also said that euthanasia should not be legalised, as this could lead to its unethical use. 10
The opposition of doctors to euthanasia and physician-assisted suicide may also be related to their "self-image". As Lickiss 11 points out, putting someone to death will fundamentally change the character of the doctor; and the contribution of doctors to carrying out requests for euthanasia may have profound effects on their image in our society. Doctors see themselves as the bringers of life, hope and healing -- not as the bringers of death. Legalisation of euthanasia also raises a serious moral dilemma for those doctors who may be opposed to it on religious or ethical grounds.
The community's unease about the legalisation of euthanasia is related to the concerns of some religious and ethnic groups that, besides violating the ultimate human value -- the sanctity of life -- such legislation may render the less privileged and the poor in the community more vulnerable to unethical practices. However, notwithstanding the concerns of the medical profession and some key groups in society, the debate about the right of an individual to make a decision about his or her own death is not going to disappear. Society will ultimately have to resolve the issue by balancing two central human values: sanctity of life and human dignity. Legislation now before the European Parliament stipulates that human life cannot be reduced to mere biological functions. Is it desirable that, as a civilised society, in our efforts to protect and celebrate the sanctity of life we may have to compromise human dignity? A civilised society must protect, cherish and celebrate both the sanctity of life and human dignity. 3
Society needs an informed and humane framework to deal with death and dying. In Australia, the Northern Territory Rights of the Terminally Ill Act presents an opportunity to assess whether the legalisation of euthanasia may help us to meet this need. Allowing this legislation to function would be consistent with the values of a pluralistic democracy.
Riaz Hassan
Professor of Sociology, The Flinders University of South Australia,
Adelaide, SA
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