Doctors in support of law reform for voluntary euthanasia

Facts about the end of life, confirmed either by our own life experiences or by reference to peer-reviewed medical literature,1 are:

• dying may be associated with intolerable suffering and there may be a crescendo of suffering as death approaches;

• some suffering will only be relieved by death;

• some patients rationally and persistently request assistance to die;

• palliative care does not relieve all the pain and suffering of dying patients;2 and

• palliative care may include terminal sedation in order to alleviate intolerable suffering.3

Accepting these facts leads to the inevitable conclusion that the medical profession is failing in its duty of care for some patients at a time of desperate need.

The following statements, extracted from the Australian Medical Association (AMA) Code of Ethics, would be widely acknowledged as ethically sound:

• treat your patient with compassion and respect;

• approach health care as a collaboration between doctor and patient; and

respect your patient’s right to . . . make his or her own decisions about treatment or procedures.

And for the dying patient:

• remember the obligation to preserve life, but, where death is deemed to be imminent and where curative or life-prolonging treatment appears to be futile, try to ensure that death occurs with dignity and comfort; and

• respect the right of a severely and terminally ill patient to receive treatment for pain and suffering, even when such therapy may shorten a patient’s life.4

In a later, clarifying, AMA position statement on the role of the medical practitioner in end-of-life care,5 the AMA again commits to the principle of preserving life, although it is supportive of withdrawing or not initiating life-extending treatment when thought to be futile. With regard to active treatment of symptoms, the position statement does not consider to be euthanasia treatment intended to relieve suffering which has the consequence of hastening death — an example of which we discuss later. However, both the AMA Code of Ethics and the subsequent position statement carry within them an intrinsic problem. The injunction “to preserve life” will sometimes be contrary to a patient’s rational and persistent request to die. Further, although the doctor may “try to ensure that death occurs with dignity and comfort”, this desirable outcome does not always occur. The code leaves unstated the ethics of how to manage a patient when there is no treatment for certain forms of distress and suffering, when death is not imminent, or when a disorder is not terminal. It does not deal with all aspects of the reality of suffering and death.

It is these situations that motivated the formation of a national lobby group of medical practitioners, Doctors for Voluntary Euthanasia Choice. Members lobby for the legalisation of voluntary euthanasia, so that people who are suffering and who will continue to suffer have the right to request assistance to die gently and, if possible, at a time they choose.

It is often argued that legalisation of voluntary euthanasia is unnecessary. It is stated that, in the presence of pain, additional pain-alleviating morphine may lead to death and such an outcome is acceptable. Here, morphine used to alleviate pain secondarily causes cessation of breathing and death occurs as an unintended side effect of the treatment — the so-called “double effect”. One issue, however, is that the legality of such treatment relies entirely on what is in the practitioner’s mind. Provided the intention was to relieve pain and not to cause death, such management is not illegal, but the intention can never be ascertained without doubt. An unhappy person involved in the process somewhere in an instance of death by morphine could take a hostile view about the practitioner’s intentions and seek to involve the law. A second, not infrequent issue is that pain may not be a prominent symptom, making death by morphine legally unjustifiable.

We believe that the current situation, in which voluntary euthanasia is illegal, inevitably leads to optimal management being denied to some patients. Some have unrelievable forms of pain; others are forced to endure a wretched but ongoing existence. Legalised voluntary euthanasia now exists in several European countries (eg, the Netherlands, Belgium, Luxembourg and Switzerland) and some states of the United States (Oregon, Montana and Washington), and has given medical practitioners in those jurisdictions the option of complete, compassionate medical care for their patients. Copies of voluntary euthanasia legislation can be obtained from various websites, for example, for Oregon6 and for Belgium.7

Active or retired Australian medical practitioners in agreement with the position of Doctors for Voluntary Euthanasia Choice may register on the website (http://www.drs4vechoice.org) to receive information and to add their weight to lobbying for the legalisation of voluntary euthanasia in Australia.