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Thursday 21 August 2014

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Key Questions

“Physician-assisted dying” or “physician-assisted suicide” refers to situations where a patient asks a doctor to prescribe lethal medication but the patient takes it without help.

 “Physician-assisted dying” refers to situations where the patient is terminally ill, i.e. a doctor thinks the patient has a certain time to live, and “physician-assisted suicide” refers to where a patient is incurably ill but not about to die.

 “Voluntary euthanasia” [called simply “euthanasia” in European legislation]refers to situations where the doctor administers the lethal medication at the patient’s request.

In Switzerland, Oregon and Washington the patient must self-administer the medication.  In Belgium, Luxembourg and the Netherlands the law provides for both types of assisted dying.

Nearly 150 000 people die in Australia each year. More than half of those deaths occur in hospitals in painful and undignified circumstances. Medical science is continually finding ways to extend life into older age but that does not make death any more peaceful, and possibly it increases the average time taken to die.

For each person dying there are friends, relatives and medical staff who are affected by a painful and undignified death.

An Advance Care Directive (ACD) is a list of instructions from a patient to a doctor, made out in anticipation of possible treatments for health problems. It must be signed and witnessed.

An ACD must be obeyed by medical staff, though in a health crisis the doctors may be unaware of the existence of an ACD or the directions may not be sufficiently specific to cover all eventualities.

 State Health Departments advocate the use of ACDs and some, including Queensland Health, even provides them on their web sites. Various different ACDs have been produced, ranging from one to more than fifteen pages.

There are two examples of ACDs on this web site.

Many forms of suffering cannot be relieved by palliative care. Pain is not always relievable, and it is just one of many symptoms that people may suffer during the end of life stage. Other symptoms include weakness, disability, incontinence, severe constipation, agitation, insomnia, difficulty swallowing, psychological distress and loss of dignity.

In addition, many people do not want to go into palliative care. They would prefer to die at home, surrounded by their loved ones. When suffering and indignity are likely to go on for a long time, with death the inevitable result, people should have the choice of ending their life.

The Catholic Church and some protestant churches regard assisted dying (or voluntary euthanasia or physician-assisted suicide) as a sin that is never acceptable.  The UK Church of England, however, acknowledges that there may be “exceptional cases” in which euthanasia is morally permissible, but does not see that as sufficient reason to change the law.

If you believe in an all-powerful, all-knowing God, you might believe that issues of life and death are for God alone to determine and that to interfere with this is “playing God.”  But if so, how then do you justify transplants, triple bypasses, chemotherapy, and blood transfusions?  It is, apparently, theologically acceptable to intervene in order to prolong our life span, but not to shorten it. 

The commandment “Thou shalt not kill” is cited as a divine and universally applicable law, although there is a lot of God-sanctioned killing in the Bible.   Some of this Biblically-sanctioned killing extends to what we would now see as pretty harmless activity.  Those who break the Sabbath are to be executed (Exodus 31:14).  Students who disobey their parents and get drunk are to be stoned to death (Deuteronomy 21:20-21). 

Killing opponents in war is fine and Churches did not lead the fight against capital punishment for crimes.

There are some other Christians who appeal to Biblical authority in a different way.  In Australia there is a group of Christians supporting Choice for Voluntary Euthanasia who think assisted dying is quite consistent with Jesus's message of love and compassion and with his Golden Rule: "In everything do unto others as you would have them do unto you" (Matthew. 7:12).

The opposition to physician-assisted dying comes much more from the Church’s institutional hierarchy than from individual Christians.  A poll in 2011 showed that 65 per cent of Australian Christians believe in legal voluntary euthanasia.  For those aged over 65, the proportion went up to 73%

Generally speaking, about 30-40% of individual doctors would now agree that it is sometimes right for a doctor to take active steps to hasten the death of a patient who has asked for this.

A majority of nurses would support assisted dying legislation.

However, the main health professional organisations oppose assisted dying as being “fundamentally incompatible with the physician's role as healer”.  Some, like the Royal College of Nursing, have switched from opposition to assisted dying to neutrality.

Some claim that the Hippocratic oath prevents doctors from helping people to die, in part because it says “I shall do no harm”.  But surely is it harmful to force a dying patient to suffer a slow, lingering death against his or her will, perhaps kept alive artificially with respirators and feeding tubes.

Very few universities now require their new doctors to swear to a 2000 year old guideline.  Medical codes of ethics now indicate the importance of respecting patients’ rights, goals and values, and of recognising when continuing treatment is more harmful than beneficial.

A major dilemma for doctors is in increasing the dosage of medication to alleviate pain or symptoms but at the same time recognising that this may or will shorten a patient’s life.  According to the “double effect” principle, this is legal, provided the stated intention is to relieve pain.  Surveys in Australia and the UK show that about one-third of doctors have given drugs to terminally ill patients, knowing or intending that it would shorten their life.


Sadly, some doctors have not given adequate pain relief because of a fear of being accused of hastening death. 

Some disability organisations oppose assisted dying because they think it sends a message that "certain kinds of life are not worth living".  

The decision to shorten a disabled person’s suffering should and does rest solely in the hands of the person who is dying.  Only the individual can judge the value of his or her life.  Voluntary euthanasia legislation does not permit anyone to decide, "He/she would be better off dead".  

A disabled individual who believes it is his/her choice, but is unable to enact that choice wholly on his/her own, should have the choice of being helped by someone willing to do so without the fear of being treated as a criminal. There is no evidence in that VE legislation has been abused to the detriment of disabled people in any jurisdictions where it is legal.

VE laws lay down stringent conditions that have to be met before a doctor will agree to a patient’s request for help to die.

 A typical example of legislative safeguards is in the Belgian Act on Euthanasia 2002.  The physician must ensure that the patient’s request for euthanasia is “voluntary, well-considered and repeated, and is not the result of any external pressure.”

Other common safeguards ensure that two doctors confirm that:

  • the patient is mentally competent (and not suffering from clinical depression), and
  • the patient is informed of all other options, including palliative care.

This version - 12 Oct 12