ABC’s Q&A program took on euthanasia last night, and in the process reinforced its reputation as the leading television forum for political and social debate.
Former broadcaster and television producer Andrew Denton led with a strongly held and persuasively (if at times abrasively) argued position in favour of assisted dying. He moved the issue’s debate platform from the “right to die” to the “right to choose the way you die”. This subtly but importantly changed the nature of the debate.
A telling exchange also took place between palliative care specialist Dr Ralph McConaghy and prominent euthanasia advocate Dr Rodney Syme. It emerged that both were prepared to use Nembutal, a sedative that can cause death by suppressing breathing.
The difference was that the former’s intention would be to relieve suffering only, while the latter was fully aware that death was the means by which this suffering would cease.
The separation between these two views seemed paper thin, and the Twitterverse lit up to highlight this.
To an agnostic observer, it seemed entirely possible that the difference between Australia and the Netherlands (where euthanasia and assisted suicide are legal) lies more in the way we think about what we are doing than what actually happens.
Research into how patients are treated at the end of their life found that more than a third of Australian surgeons reported giving drugs at doses higher than necessary to relieve suffering for terminal patients, with the ambiguous intention of hastening death. But within this passive form of euthanasia, most doctors were uncomfortable to engineer a death in too speedy a fashion.
Described by critics as “slow euthanasia”, terminal sedation is where patients with symptoms unresponsive to all other treatments are rendered unconscious. Commonly used drugs include propofol, an intravenous anaesthetic, or barbiturates such as Nembutal. Generally, the patient would live for days rather than the few minutes that a large single dose would allow.
While I am not a palliative care specialist, I regularly manage dying patients in the intensive care unit (ICU), where removing life support is commonly accompanied by sedation and opiates. This process happens in ICU’s around Australia 40,000 times a year (or once every 15 minutes).
There is a somewhat fine distinction here as well, between letting die, and actively ending a a person’s life. Perhaps the Australian public is not aware of how actively we already intervene to reduce suffering at the end of life.
Or maybe Australians are, and this apparent convergence between the practice of terminal sedation and speeding up of dying lobbied for by euthanasia advocates explains a puzzling finding. That is the rarity of direct requests doctors receive for euthanasia.
Not in high demand
On Q&A, Dr McConaghy said that among the 5,000 dying people he had cared for, only one had explicitly requested euthanasia. In my own practice of 40 years and 4,000 deaths, I also have only been directly asked once. It was by an elderly lady with a broken hip who wanted to be put under for the operation and not woken up again, thinking that I could euthanise her under the cover of an anaesthetic.
Recently, oncologist Ranjana Srivastava wrote that she too had only ever been approached once in the 15 years of practising medicine with a similar request.
It seems then, that although the demand for legalising euthanasia is high in the general population, the demand for the practice in real life in Australia may be very low.
So why do we care so much? Although the Q&A audience was as generally divided as the panel, a clear uniting thread was the agreement that people who are suffering deserve a choice about how their suffering is managed.
Although we may weary of talk of “patient autonomy”, it clearly drives passion for change in the way we treat the elderly, the suffering and the dying. People want choice – indeed choice and control feature in half of the twelve components of a “good death”.
A good death
While many could argue that a “good death” is an oxymoron, there is some consensus that good pain relief, choice about where death happens and having time to say goodbye all matter. Sadly, many deaths in acute care don’t tick any of these boxes.
Ralph McConaghy described the status quo as patients being treated like “cardboard boxes on a conveyor belt”, and this may well represent popular perception. So the real work, the real debate, becomes how to actively provide choices for elderly, chronically ill and dying patients.
Evidence exists to show the medical system is not only uninterested in the choices and preferences of its customers, but may downright disregard or even misrepresent them.
How do we manage the necessary conversations, and how do systems of care have to change in order to become responsive?
It seems unlikely to me that changing the law to permit doctors to deliberately assist patients to die will provide the root-and-branch changes those suffering from incurable disease would want.
The much less sexy issues around end of life planning – such as advance care plans, appointment of substitute decision-makers and so on – offer a more broadly based benefit. It’s true that advance care plans may have limited legal support. But they have proven effective in the area of end of life suffering, particularly among the survivors.
Advocates would do well to get behind promoting a “right to choose”, with a corollary of an obligation on doctors to communicate; rather than a “right to die”, with its unfortunate corollary of an obligation to kill.