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Exit this way?

Medical needle preparing for an injection
How do we live with the question of dying?

Surely one of the most difficult questions to hear must be, ‘Why must I continue to live? Why can’t I just die when I’m ready to die?’

How much ‘easier’ it would seem to be, to reply, ‘Well, that’s okay, we can end this here. You can take these tablets, or we can inject this solution—and we’ll say goodbye.’

But sometimes the easy answers are too simplistic. Answers that satisfy a small group within society can place others at significant risk of harm or abuse. If not today, then tomorrow. At least, that’s the conclusion I’ve reached over recent weeks.

Last month, I attended two Wellington-based meetings focused on the difficult moral question of euthanasia. One was a networking meeting of people opposed to euthanasia. The other was a public forum organised by the Museum of Wellington City and Sea as part of its ‘Death and Diversity’ exhibition. The forum featured speakers from both sides of the euthanasia debate.

My interest was piqued by MP Maryan Street’s announcement earlier this year that she was preparing to introduce a Private Members End of Life Choice Bill. The Bill will seek to win legal rights to kill people or help them commit suicide in some circumstances.

There have been two previous attempts to legalise euthanasia in New Zealand. MP Michael Laws’ Death with Dignity Bill in 1995 was defeated 61 votes to 29. In 2003, New Zealand First MP Peter Brown’s Bill was defeated by a far smaller margin of 60-57. Pro-euthanasia advocates are feeling optimistic that, should Street’s Bill be drawn from the ballot, it might be a case of third time lucky when MPs vote in a conscience vote.

Diverse concerns

Pro-euthanasia supporters are claiming massive support for their cause, but a wide range of people—including doctors, palliative care workers, members of the disability sector, bioethicists and church leaders—are deeply concerned at what it would mean for New Zealand to embrace euthanasia.

Addressing the Wellington public forum, Janet Marsland of the Voluntary Euthanasia Society of New Zealand championed the cause of people having the right to choose to die, but admitted she would not want to be in the position of having to kill a family member. ‘It’s against human nature,’ she said. So who would be required to follow through on someone’s desire to end their life? Are we prepared to move toward a situation where doctors are taught to both care and kill?

Paul Ockelford, chair of the New Zealand Medical Association (NZMA), has said the NZMA would not support the proposed law change. The NZMA is opposed to both the concept and practice of euthanasia and doctor-assisted suicide, regarding both as unethical. Ockelford has asked, if the NZMA condoned doctors taking a life, ‘Would we have a course that teaches [medical] students to kill?’ There is a conflict for doctors and other medical staff (including hospice workers) whose primary purpose is to care but may be required to promote or even administer euthanasia.

Others have expressed worry about the impact of the law change on vulnerable members of society—the elderly, the disabled, the cognitively impaired and the terminally ill—who may find themselves discriminated against or feel an expectation to take up the option of assisted suicide to escape being a burden. And, while certainly not the intention of the pro-euthanasia lobby, there is the risk of a shift in decision-making power from patient to health care system, with patients steered toward suicide.

Elder abuse is of real concern. This exploitive misuse of power is more common than people may think in New Zealand. Every day at least two more cases of abuse or neglect of older people are uncovered by Age Concern Elder Abuse and Neglect Prevention Services. Many more incidents remain hidden. Euthanasia opponents highlight the risk of elder abuse, cautioning that family members may use their influence over a vulnerable older person to push them to choose an ‘early exit’ through euthanasia.

Such abuse may be driven by a desire for an inheritance or to escape the need to continue accommodating an older person’s needs and care within a busy lifestyle. More likely, it would be compassionately motivated by the desire to end someone’s suffering. Whatever the motivation, it is clear there would need to be the strongest safeguards possible to protect older people if euthanasia was legalised.

Without appropriate oversight and support, it would be possible for family members or someone else to administer a lethal dose to someone without their consent. While this scenario would be an abhorrent aberration, we must still recognise that it would be possible and that the current legislative framework is keeping us a distance from this particular dangerous slippery slope.

It may seem crass to suggest that economic considerations weigh into this debate. I doubt anyone would be prepared to argue that public policy around end of life decisions should be formulated on the basis that it is cheaper to have people die sooner than later, but there is an undeniable dollar benefit from decreasing the expense of ongoing medical treatment and palliative care along with reducing the spiralling cost of superannuation. It would be naive to believe that matters of economics do not influence people’s thinking, even on such a sensitive issue as this.

Although the finer details of Street’s Bill have not yet been made public, she has indicated that two attending physicians would be required to attest that a patient is of sound mind, and in some cases a physician would administer a lethal dose. The Bill, if passed, would protect family members and doctors from criminal liability. ‘In the end,’ Street says, ‘choosing your moment to go should be a final act of dignity and free will.’

Free will?

But are we really prepared to redefine death as a matter of ‘free will’? There is at least one stark contradiction in Street’s premise, as one of the younger members of the Wellington forum audience quickly appreciated. He posed the question: Where and how do we draw the line for youth suicide or ‘ordinary’ suicide at some other age?

This is a pertinent question. At one end of the scale we’re energised around sending anti-suicide messages to young people caught in the sometimes gloomy despair of adolescence, while at the other end, some would have Parliament signal it is worthy to end one’s life early (or to help someone else die). Despite protestations of the pro-euthanasia lobby—that the basic difference between suicide and ‘end of life’ choice is that one person is facing death while the other is not—these are mixed messages. It also sends a message to younger generations that they cannot be expected to stand in the face of suffering or to stand alongside another with comfort and care for however long it takes as that person faces death.

There is a strong link between depression and suicidal thoughts. Some people with terminal or debilitating illnesses experience periods of deep depression, but many come through this to a more peaceful acceptance of their situation. Of those that have become severely disabled later in life (perhaps wanting to die as a result), many in time come to accept and adjust to their situation. Some have expressed that, for a range of reasons, life eventually became more satisfying after they became disabled than it had been before.

There are times when a person chooses to assist another to end a life early. When that happens, it is appropriate that this is examined before the court, which considers what steps were taken to end the life, by whom and in what circumstances. Judges have some flexibility over sentencing, and the New Zealand court has shown compassion in the way it approaches a case and examines its facts.

There is no doubt it would be a harrowing thing to defend one’s part in a loved one’s death. But in a civilised society that guards every person’s right to live, this remains an appropriate response.

Dignity?

And what do we mean by ‘dignity’? The word has been hijacked by the pro-euthanasia lobby when it is a touchstone principal of palliative care and the modern hospice movement, which support people to die with dignity and comfort. Dignity in this context neither hastens nor postpones death, but it does aim to ensure that:

  • people that are dying can still live well
  • no one has to die in avoidable pain and suffering
  • care is given to whomever, whenever and wherever it is needed
  • carers and the bereaved get the help and support they need
  • people accept that dying is part of the experience of living.

Palliative care is not a form of euthanasia. Dr. Frank Brennan, an Australian palliative care physician, explains that ‘palliative care is the concerted endeavour to control pain and other symptoms, to support the patient and the family through this time, which is simultaneously challenging and precious, and to allow death, when it comes, to be dignified and loving.’ In contrast, euthanasia is ‘the deliberate act to cease the life of a patient who is suffering with a serious illness’.

Brennan gives the example of an elderly patient with a serious illness affecting her bone marrow, which means she cannot make any blood herself. She is reliant on blood transfusions, which are having less effect. The decision is made between the doctor, the patient and her family to cease the blood transfusions and allow the natural process of dying from the underlying disease to progress. This is withdrawing of treatment; it is not euthanasia, says Brennan. ‘It is simply an appropriate and ethical response to her condition. Yes, in modern medicine we can do many things, but we need to recognise a simple and incontrovertible truth—we are all mortal. An 82-year-old man with very poor kidney function meets with his kidney specialist. The decision is made not to commence dialysis. This is withholding treatment. It is not euthanasia.’ Sadly, too often patients and families worry it is, he says, and wonder if they are doing the right thing.

Dying can be difficult

It is hard for us to be alongside a loved one who is dying and not to be in control, says Anne MacLennan, a palliative care specialist with Capital and Coast District Health Board and one of the speakers at the Wellington forum. People fear a difficult dying, with the associated loss of control. ‘We are programmed to be human doings, not human beings,’ she says.

Our fear of death causes us to hide its reality. Some of this ‘hiding’ has occurred with the shift from dying as a social event, usually at home and always involving family and friends, to a medical event that occurs in hospitals, hospices and nursing homes.

Writing in Is God Still at the Bedside?, Abigail Rain Evans speculates that ‘death has replaced sex as a taboo in drawing-room conversations’. She writes, ‘We are never ready for death; life’s concerns are too absorbing and we cannot bear to leave those we love. If we already have a serious illness, then we may bargain with death: “Just let me live till my son is married, or my daughter finishes college, or I can visit my home once more.” Or, when we think about death in the future, we dicker with death: “Just let it be fast when my time comes. Spare me a lingering, painful illness.” ’

All of us would voice an ‘amen’ to that prayer. We want to avoid a lingering, painful death, and we want our loved ones to be spared such an end as well. But even as we understandably want to minimise the anguish and despair that can be experienced toward the end of life, it is our duty to consider what enshrining euthanasia in law would mean for society as a whole.

Euthanasia carries significant risks and diverts attention from some important questions, particularly around our commitment to value and protect the vulnerable, the sick and the infirm. It is a simplistic solution for the benefit of the minority, which is never a good starting point for law. It is not scaremongering to ask people to consider and discuss what the long-term implications of legalising euthanasia may be and to ask: Will the right to die become a duty to die? And will the right to die also become the right to kill?

By Christina Tyson (abridged from War Cry, 16 June 2012, p5-7)