Victoria: a grave matter demands clarity

Few would question the need for accuracy and clear language in any public debate with such grave and possibly irreversible (for the individual) consequences as euthanasia and assisted suicide.

On occasions people will get it wrong. No-one should begrudge anyone any understandable mistake made with good intent. Nevertheless, those who venture into the public arena on these matters do hold themselves up to scrutiny and possible correction. Of course, I include myself in that cohort.

I find cause for such correction in the recent article in The Age newspaper by Member of the Victorian Upper House and Member of the Victorian Parliamentary Committee looking into end-of-life issues, Fiona Patten MLC.

Ms Patten may well celebrate the recommendations of the committee she was part of; after all, they align quite well with her position and that of her party. But while she may claim to have 'initiated a parliamentary inquiry into End of Life Choices' the record shows otherwise. It was, in fact, the Victorian Labor Government in the Upper House who did so via a motion tabled and passed on the 7th of May last year. Ms Patten and Ms Hartland both had motions on the Notice Paper seeking similar outcomes; Hartland withdrew her motion while Patten's was never debated.

Ms Patten claims that the committee 'travelled to five countries' where either euthanasia and/or assisted suicide was legal. Actually, it was four (see below). Strangely and without explanation, the committee chose not to visit Belgium.

In addition, the Committee travelled to the Netherlands, Switzerland, the Canadian Province of Québec, Canada and Oregon, United States to speak to stakeholders about their jurisdiction's assisted dying (sic) framework.

Ms Patten goes on to juxtapose matters supposedly raised in submissions to the Inquiry with what the travelling committee supposedly found that, she seems to suggest, speak to the contrary:

We had heard of mobile death vans in Amsterdam but what we found were compassionate doctors who had long-term relationships with their patients.

The network of travelling doctors willing to provide euthanasia does exist. No-one is denying that the Dutch pride themselves in their local GP networks that do provide the possibility of a life-long relationship with one doctor. Professor Theo Boer commented on these 'mobile death vans' as Patten describes them, in an article in March this year:

NVVE (the Dutch 'Right-to-die' Society) also initiated the End of Life Clinic, a network of traveling euthanasia doctors who provide assisted dying for patients whose own doctors will not agree to help them. On average, the traveling doctors see a patient three times before providing an assisted death. The clinic has neither the funding nor the license to provide any form of palliative care, so it offers death or nothing. Doctors at the End of Life Clinic report that they've handled about 500 cases since 2012.

Patten continues:

We were told by people in Australia that overseas doctors were killing anyone who asked. They told us that doctors were killing people with mental health issues and they were killing babies. What we learned overseas was the accountability and transparency is extremely high and, no, they are not euthanizing babies and people suffering from depression.

I read most if not all of the submissions to the inquiry and I did not come across any claim that 'doctors were killing anyone who asked'. This is a gross exaggeration. Many requests for euthanasia are indeed refused and, not withstanding that such refusal may be circumvented as described above, most doctors seem to comply with the structure of the law and apply the law 'carefully'. But most is not all as Boer points out:

Neither the Netherlands nor Belgium has made a serious attempt to address the rising incidents of assisted dying and the shift from seeing assisted dying as a last resort to seeing it as a normal death. It appears that once legalization of assisted dying has occurred, critical reflection is difficult. To be sure, many cases of euthanasia and assisted suicide in these countries align with the original intentions of the law. But there is no point in stressing what goes well while ignoring the risks. If there's even one case of assisted dying for which there was a less drastic alternative, then that is one case too many.

Patten may well be right to say that 'they are not euthanizing babies' but, as the author of the protocol in 2005 that codified the killing of newborns has observed, it is the prenatal screening developments since that time that have reduced the incidences to virtually (if not precisely) nil and not some newly-found aversion to the practice. It did happen and may still happen. Moreover, an amendment to the Belgian law in 2013 included children in the reach of euthanasia practice and the Dutch are reviewing their practice with a view to perhaps a similar amendment at the moment.

Concerning depression and other psychiatric conditions, Canadians, Baker and Lemmens cover the field:

Physician-assisted death in those countries (Holland and Belgium) is increasingly being performed on people who are lonely and are concerned about becoming dependent on others, people who are tired of life, and people suffering from mental-health conditions, including depression, anxiety, schizophrenia, eating disorders, autism, post-traumatic stress, and even complicated grief.

In many analyzed euthanasia cases, treatment options were available but not used. Reports from those countries raise questions about how some physicians assess competency, and about how vulnerable patients have been able to shop around until they find a physician who, having had no prior therapeutic relationship with them, are willing to end their life.

The authors noted that a Canadian committee had ignored this 'strong evidence'. The Victorian Inquiry seems to have followed suit.

I must admit that I find myself in broad agreement with Ms Patten and the committee that the use of so-called 'terminal sedation' should perhaps be reportable and become subject to a well-defined medical model. However, while Holland does have a 'well defined model', the dosages of sedatives recommended is well above that of places like the UK, suggesting the possibility that some of the already-high percentage of deaths under sedation in that country amount to deliberate killing. In 2014, the head of the Dutch 'Right-to-die' society made such an admission:

The percentage of people dying from palliative sedation, is rising disproportionately. (Government sponsored mortality report: 2005: 8.2"% and 2010: 12.5%). I call this disproportionate because it obviously is not likely that in five years the number of people qualifying for this treatment would rise so sharply while palliative care in general has qualitatively improved so much in the meantime. It has all the signs of the fact that physicians are using palliative sedation as a backdoor for euthanasia. Petra de Jong.

Ms Patten admits that she has moved away from what we could call a 'Nitschke' position (that government has no role) to accepting that the law has a role in regulating euthanasia and assisted suicide practice. The law currently speaks to that reality by protecting all citizens from abuse in allowing no exceptions to the laws on homicide - a role that, on reflection, we should all want to uphold. Moving away from that position invites risk; risk that can never be controlled by the inclusion of regulation and accountability through post mortem reporting. What doctor in their right mind would self-incriminate by reporting that they had acted outside of the law?

Strangest of all of Ms Patten's commentary must surely be her closing assertion that, 'As a community we need to be prolonging life ... not death.' I don't know anyone who wants to prolong either, but, surely, a natural death - neither prolonging nor deliberately foreshortening - at home or in a place of our choosing, with effective pain and symptom management is what we all really want.