Euthanasia in Tasmania - Assisted suicide in Tasmania - Dying with Dignity in Tasmania

Medical viewpoints
Viewpoints from eminent Tasmanians...
Medicall viewpoints

Tasmanian doctors and specialists refute the claim that euthanasia is already occurring and clear up misconceptions around patient choice, pain management and dying

Video interview
Q and A
with Dr Paul Dunne

Dr Paul Dunne, a Senior Palliative Care Specialist with over 20 years experience in assisting patients in their final stages of life, responds to questions around the standard of palliative care in Tasmania; the management of pain; and the threat that euthanasia poses to the practice of medicine

Written article
Paul Dunne

Palliative care in Tasmania - an excellent standard

Dr Paul Dunne

Senior Palliative Care Specialist

 

 

Key Reasons why Euthanasia should never be legalised:
  • Very often it is not death that patients fear most but the manner in which they will be managed before their death.
  • It is true that even with the best palliative care some people (5%) will have physical pain that cannot be managed without increasing medical levels to the point of coma.
  • Although it is often the hardest thing one has to do, there is value in being by the side of a dying person – there is a social value to the broader community as well.
  • We underestimate the important role the dying person has. The shared experience of many families at this time provides many opportunities for reflection and spiritual growth.
  • Legislation that allows death to occur by a timetable will ultimately devalue human life and will weaken society.
  • For doctors to have the dual role of healer and killer is an anathema to the practice of medicine and will lead ultimately to a breakdown of trust in the patient doctor relationship.
  • If a doctor is not able to communicate effectively with a person who is dying it is possible to reinforce a patients feeling of demoralisation and fear and not be able to help objectively. The patient’s request for euthanasia may then be more than a reflection of individual despair and may be an indication that others have despaired of the patient.
  • It is highly unlikely that any society will be able to uphold the principles of freedom of will in the presence of subtle pressure on vulnerable people to end their lives.
  • The hallmark of a society should be how we care for and protect the vulnerable, not how efficiently we dispose of them.
  • It is naïve to believe that social barriers against non-voluntary euthanasia would not crumble in a society that legalises voluntary euthanasia on the basis of compassion.

 

 

 

Dr Paul Dunne AM
MBSS, FRACGP, FAFPHM, FAChPM
Palliative Medicine Physician

The Secretary,
Joint Standing Committee on Community Development,
Parliament House,
Hobart 7000.

 

30/07/2009


Dear sir / madam,


I am writing to express my opposition to the Dying with Dignity Bill 2009. Whilst I believe the proponent(s) of the Bill may be acting with the best of intention and are acting from a basis of trying to provide succour to the dying, I feel that for the Parliament of Tasmania to legitimise the killing of vulnerable patients by members of the medical profession is for it to act against the best interests of the community it serves.


Introduction
I am a Specialist in Palliative Medicine and have held the position of Medical Director of the JW Whittle Palliative Care Unit for the past 18 years. I believe I have a broad experience of the issues of end of life care and can speak as an expert in the field.  As a Palliative Medicine Specialist I have cared for patients and their families in their homes in, aged care facilities, in the Palliative Care Unit and in the Hospitals, Public and Private in Southern Tasmania. My role is not only to provide direct care to patients but also I am involved in mentoring and providing advice to General Practitioners and other Medical Specialists to assist them in their care of the dying.  I am also involved in teaching doctors, nurses and medical and pharmacy students about Palliative Care and the care of the dying.


We live in a society which is becoming more unfamiliar with death and dying as an everyday part of life.  The prevalence of death in our society has changed in the past 100 years from 1,700/100,000 to 800/100,000 in the current day. The manner of death has also changed over this time as well. Taking out the influence of death from war, the proportion of people dying suddenly has changed from 75% to 50% over this time as there has been a shift from acute, generally infectious, illnesses to the complications of chronic disease, end stage organ failure and cancer, Doctors are also exposed to less death and dying than in the past and the accent in medicine now in on the cure and amelioration of illnesses rather than the acceptance of death as a relatively constant companion to the management of patients.  In Australia at present General Practitioners will in average provide direct Palliative Care to approximately 6 patients a year whose deaths are expected, a Physician will care for 30 to 40 patients a year.  A Surgeon will have very few patients to whom he or she will provide Palliative Care for.  Most Palliative Medicine Specialists are involved with approximately 200+ patients a year in their terminal phase.

Palliative Medicine / Palliative Care
Palliative Medicine is a new discipline in medicine and in Australia has only been recognised as a Specialty since 2000 though the establishment of most Palliative Care Programs in Australia date from the mid 1980·s.  Palliative Medicine education to the medical profession is patchy.  A Curriculum for Palliative Medicine for Undergraduates was proposed in 1996but the teaching of undergraduates and medical practitioners in Australia is patchy and most practitioners pick up their knowledge about the care of the dying from their peers or though observation of the management of dying in hospital practice. Their exposure to dying may not have been the best learning experience and when they are in the position to provide care to their dying patients may not be able to bring the necessary skills to the bedside to make the dying process for the patient, the family (and themselves) a good experience.


In an editorial to the Medical Journal of Australia, Professor Michael Ashby noted that: "In the absence of formal training in palliative care…doctors' attitudes and clinical behaviour are complex and variable.  They range from the 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 the providing of pain and symptom relief, withdrawal or non-initiation of artificial hydration and amelioration and cardiopulmonary resuscitation." It is interesting to note that the major protagonist for euthanasia in Australia is a doctor with less than 7 years’ experience in general practice.
The modern practice of medicine is risk averse in nature and the default position would seem to be to always act to protect and prolong life in the face of disease and death.  Very often it is not death that patients fear the most; but the manner in which they will be managed before their death.  People fear the loss of control they have when faced with the medical system and the thought of being kept alive with machines, being artificially fed and prolonged in a drugged and stuporous state is the prevalent view of death in the modern era.  It is no wonder that all the surveys on euthanasia have returned a high level of public acceptance.


Pain and suffering
The Bill before the Parliament provides for a person enduring a terminal illness with profound suffering the right to request assistance from a medically qualified person to voluntarily end his or her life in a humane and dignified manner, and to allow a doctor or doctors to be able to assist in ending their life without legal impediment.


The case for legalising euthanasia appeals to compassion.  It should be legalised because it is inhumane to allow people to continue suffering when they request the option of a painless release by termination of life.  The assumption is that patients frequently suffer agony from pain that is uncontrollable and that death is the only way out.  It is argued that even with the best palliative care not all pain can be managed and with a stunning example of binary logic the option of pain or euthanasia are the only options presented.


I fully acknowledge that in providing care I am fully aware that there are some situations which medicine has no solution for. It is true that even with the best Palliative Care that some people (5%) will have physical pain that cannot be managed without increasing medication levels to the point of coma, but the greatest suffering I see is not physical pain, but the sadness and distress that occurs with the grief of losing or leaving loved ones and the missed opportunities of a life cut short. This distress is an inevitable part of life itself.


Palliative Care does not encompass the deliberate ending of life as part of its practice.  In practising Palliative Medicine I do not try to prolong life needlessly nor do I try to shorten life.  However sometimes, when pain and symptoms are properly controlled, people do live longer; on the other side of the ledger when faced with hard to control pain or intractable symptoms it may be necessary and medically appropriate to push analgesia and sedation to the point of coma which will result in life being shortened.  Decisions to use coma inducing levels of medication are made with the consent of the person (if able) and with the family.


The importance of time to families and patients
I have observed many people and their families approach the end of life. There is no uniform way and each person is unique.  Most people do not fear death but they do fear the manner of their dying and I well understand the desire to have it over and done with at a time and manner of one's choosing.  However an individual does not die without leaving any trace.  Family and friends are left to mourn and most of the studies done around grief and loss suggest that grieving begins before an individual's death and the length of grieving can be assuaged by good palliative care and bereavement support.  We know that the grief engendered by sudden death is intense and carries a greater level of morbidity for the survivors than the grief experienced when death is anticipated. The experience in the Netherlands suggests that the relatives of people who are euthanised suffer higher levels of grief and morbidity which is equal to that of relatives who experience the sudden death of a family member.


Not everyone experiences grief in the same way or to the same timetable and in families there is often a wide disparity as to when acceptance occurs of someone's approaching death.  I believe that sometimes an individual may "hang on" (prolonged dying) in order to allow family members to catch up and "let them go".  Although it is often the hardest thing one has to do, there is value in being by the side of a dying person and I believe there is a social value to the broader community as well.


I also believe that we underestimate the important role the dying person has; for although they may seem relatively powerless, held captive by their dying, they are powerful in many ways.  The shared experience of many families at this time in ones life can provide many opportunities for reflection (life review) and spiritual (not religious) growth for the individual and for families at the end of life.  I believe that having legislation that allows death to occur by a timetable will ultimately devalue human life and will weaken society.


Euthanasia and the Medical Profession
This Bill if passed has the potential to destroy public trust in the medical profession.  For doctors to have the dual role of healer and killer is an anathema to the practice of medicine and will lead ultimately to a breakdown of trust in the patient doctor relationship.  Even though the bill is framed in ways that is supposed to help individuals, I believe that as it is society that is the loser in that it will encourage poor medicine.  One of the major problems with current medical practice is that doctors do not have and patients do not recognise boundaries to what is acceptable care.  Very ill patients with limited life expectancy are subjected to often futile treatments without prospect of improvement or cure and have their quality of living and dying diminished.


The practice of medicine is both an art and a scienceand it takes some years before most General Practitioners and other doctors become adept and comfortable in caring for the dying patient and their family.  Unfortunately not every doctor has up to date knowledge of modern pain management principles.  The majority of advances in the understanding of pain and its management has been in the last 10 to 15 years and is still evolving.  Patients may suffer intolerable pain because their doctor may not know how to manage it and will not refer on.  Patients may also believe that pain is inevitable and not seek a second opinion to see if pain can be improved.  The reasons as to why pain is poorly managed in our community are very complex and should be the subject of public scrutiny and debate.  If the knowledge of pain management is not consistent in the medical community then a number of patients will suffer intolerable pain and could possibly have their lives foreshortened by well-meaning but insufficiently knowledgeable doctors.


It is illusory to believe that all doctors are masters of the sensitive art of I communication with the dying.  It is difficult because dying people can provoke in their doctors the feelings of hopelessness, helplessness, failure and impotence which are not helpful in providing a patient help and guidance when they too may be lost as well.  If a doctor is not able to communicate effectively with a person who is dying it is possible to reinforce a patient's feeling of demoralisation and fear and not be able to help objectively.  The patient's request for euthanasia may then be more than a reflection of individual despair and may be an indication that others have despaired of the patient or have been perceived by the patient as having experienced despair.


If euthanasia is legalised it may perilously simplify communication between patient and doctor to the point that when issues of dying come to be discussed the default option may well become the euthanasia option rather than providing support and encouragement to find ways to continue to lead life in a meaningful fashion.  The availability of euthanasia as a medical option will, I believe, result in physicians losing the knowledge about how to deal with suicidal thoughts of the gravely ill. Patient - doctor conversations that would explore the meaning of suicidal ideation and help a patient to find her/his adaptive and coping strengths may never happen.


I believe it is unwise to give doctors legal mandate to administer death when some physicians are insensitive to the psychological complexity of their conversations with dying patients. There should be no move to decriminalise or legalise euthanasia until we have mounted a credible and sustained effort to train doctors in the including the communicative skills, required for professional care of the dying.


Regarding Voluntariness
One of the precepts of the Bill is that there will be no coercion and that only people in full control of their faculties will avail themselves of the option of euthanasia of their own free will.  I contend that it is highly unlikely that any society will be able to uphold the principles off freedom of will in the presence of subtle pressure that will fall on to vulnerable people approaching the end of their lives to request euthanasia when they may rather wish to continue to live in the midst of their family and be cared for till the end.


Many people harbour fears of being a burden to their families and friends when they get old, become sick and dependent.  These fears are often cited as the most common reasons for people to request euthanasia.  The other reason is facing a painful death. I believe the hallmark of a society should be how we care for and protect the vulnerable amongst us not how efficiently we can dispose of them.  "People who are sick already feel that they are a financial and emotional burden to their families and to society ...Now society is telling them "You have an option. You have the right to die." For them, this translates easily into an obligation to die!


Extending Euthanasia to those who cannot assent
The Bill is supposed to contain safeguards which will ensure that only voluntary euthanasia will be allowed and there will be no way that there will be a slippage to extend to those who cannot consent an option of termination of their lives. The assumption that, after legalisation of euthanasia in Tasmania, our society will be able to withstand the pressure for an extension of euthanasia to those who have irreversibly lost the ability to request or to consent to having their lives terminated.


It is, I believe, naive to believe that social barriers against non-voluntary euthanasia would not crumble in a society that legalises voluntary euthanasia on the basis of compassion.  Shouldn't compassion also extend to those who are considered to be suffering the indignity of profound mental and physical handicap, even if they are not suffering pain, but who cannot request euthanasia?


The 1994 Dutch law on notification procedures for euthanasia included a notification procedure for euthanasia when persons, such as handicapped new-born children or comatose patients, cannot request or consent to the termination of their lives. Some physicians in the Netherlands do not even consider such terminations of life to be euthanasia because they consider that euthanasia, by definition, has to be voluntary.  Some would consider the rapid and painless termination of life in these circumstances to be little more than normal medical practice.


Conclusion
I have strived over the time I have been practising Palliative Medicine to provide as much care and support to patients and families as I am able.  I have been well supported by a dedicated team and I thank them for their support.  There are times when I may not have had the necessary skill to relieve distress and I hope these have been few.  We all live in a complex society and are bound by a system of laws based on ethical and moral principles.  If these laws are to change then society has to have a deeper discussion about end of life decision making and what it means to society as a whole.


I thank the Committee for its forbearance in accepting this submission.  I would be more than happy to appear before the Committee to elucidate further if so desired.


Yours Sincerely

 

Dr Paul Dunne AM

 

 

Footnotes:

I Oxford Textbook of Palliative Medicine, 2004, Doyle, Hanks, Cheiny & Caiman editors, Ch2.2 pp

Australian Undergraduate Medical Palliative Care Curriculum, Ashby, M, Brooksbank, M, Dunne, P & MacLeod, R, Australian and New Zealand Society for Palliative Medicine, 1996

Ashby, m. The fallacies of death causation in palliative care [Editorial], Med J Aust 1997; 166; 176-77

Annas, GJ (1993). Physician-assisted suicide: Michigan's temporary solution. NEJM 328,1573

Varghese FT find Kelly B, (2001). Countertransference and assisted suicide.  Issues in Law & Medicine 16, (3), 252

Hamilton, NG, Hamilton, CA, (2000). Therapeutic response to assisted suicide request.  Issues in Law & Medicine 16 (2), 167·76

Oxford Textbook of Palliative Medicine, 2004. Doyle, Hanks, Cherny & CaIman editors, Ch3 p92

Brock, DW. (1992) Euthanasia, The Yale Journal of Biology and Medicine, 65,121·9

Fein, EB, Will the right to suicide become an obligation? The New York Times, 7 April 1966, p24

Schwartz, RL. (1995). Euthanasia and assisted suicide in the Netherlands.  Cambridge Quarterly of Healthcare Ethics 4, 117-18

II ten Have HAMJ and Weile JVM. (1992). Euthanasia: normal medical practice? Hastings Center Report 22 (2), 34-8

Biography
Author bios
Dr Paul Dunne

Dr Paul Dunne is a senior palliative care specialist with over 20 years experience in assisting patients at the end of their lives.

 

Dr Dunne resigned as the Department of Health and Human Services Palliative Care Medical Director in September 2008, a position he held for nearly ten years.

 

He is a Board Member and past Vice President of Palliative Care Australia. He has special interests in primary care, motor neuron disease and paediatric palliative care.

 

He spent part of his 2008 sabbatical developing the Tasmanian Adult Palliative Care Formulary.

 

Viewpoints

Viewpoints on euthanasia and assisted suicide from eminent Tasmanians