Can voluntary Euthanasia be contained?

In the debate about wether we should legalise voluntary euthanasia, the statement is often made that "No adequate safeguards could be devised to protect the vulnerable in our society". The vulnerable are described as the poor, the uneducated, the frail, aged and the disabled.

Opponents to voluntary euthanasia have been very successful at convincing politicians that no law could be drafted which would prevent the ‘vulnerable’ becoming unwilling victims, put to death against their will or at the very least being afraid of doctors who would have a ‘licence to kill’.

These unsubstantiated claims have been seized upon by politicians reluctant to become embroiled in this most controversial subject. The phrase "No adequate safeguards could be devised" is probably the most used excuse of all, a convenient scapegoat to avoid addressing the issue.

The fact is safeguards can be drawn up that would ensure only genuinely suffering, hopelessly or terminally ill adults, acting voluntarily, were able to receive medical assistance to die peacefully at a time of their choosing. To claim this cannot be done is to ignore or misrepresent the authority Parliament has to enact laws for the benefit of our society.

Any responsible law on voluntary euthanasia would include safeguards covering seven important areas :-

• To ensure the patient and others are acting voluntarily.
• To avoid misdiagnosis.
• To ensure the patient is fully informed.
• To ensure the patient is not acting hastily.
• To prevent a conspiracy between the doctor and the family to murder the patient.
• To avoid perceptions that patients need fear doctors.
• To monitor VE as practiced.

These topics must be covered to ensure that the system is not abused and that no person has anything to fear from enabling legislation .

The first requirement is absolute, and must be included in any responsible legislation, only the patient can initiate a request for euthanasia.

The worldwide voluntary euthanasia movement is based on the principle of individual autonomy. In the words of John Stuart Mill "The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others … over himself, over his own body and mind, the individual is sovereign."

Legislation must clearly provide that a spouse, members of the family and/or the doctor, cannot initiate a request on behalf of the patient.

Voluntary euthanasia is not simply voluntary for the patient, it’s voluntary for everybody involved in the process and each individual’s right to retain autonomy in this respect must also be protected by legislation. Any doctor, specialist, psychiatrist, chemist or nurse required to be involved in fulfilling a patient's request for assistance to die, must do so voluntarily. Anyone involved has the option not to be involved.

This is a voluntary process between consenting adults.

Avoiding misdiagnosis is obviously crucial in any process and is protected against by requiring multiple opinions from qualified persons. A written opinion from a specialist in the particular disease is an obvious minimal requirement. Draft legislation often stipulates that doctors must have been in practice for a minimum period and they cannot be in partnership or from the same medical practice.

It is worth noting that there are no laws requiring adults who choose to die by refusing medical treatment to obtain even one second opinion regarding diagnosis or prognosis. Nor are they required to be assessed psychologically.

Ensuring an individual seeking assistance to die is fully informed can be done by prohibiting assistance until the doctor(s) are satisfied that the patient is fully aware of diagnosis, prognosis and palliative care options. The patient may be required to consider specific palliative treatment and the effect of their request on their family. Only when a doctor is satisfied that the patient fully understands their situation (and other conditions are met) would the patient be eligible for assistance.

Cooling off periods are intended to ensure that a patient seeking help to die has been forced to reflect on their intentions. More than one compulsory delay can be required and they may range from days to weeks. Care needs to be taken when considering cooling-off periods that the already suffering patient is not forced to endure more - simply to satisfy society that they really are ‘suffering enough’ to want to die.

Many of the safeguards contained in current and draft voluntary euthanasia legislation would prevent the process being used as a cover for murder. That only a terminally or hopelessly ill patient can initiate the request, that multiple medical personnel from different practices must personally sign off that the request is made freely and voluntarily, that the patient has been assessed as not suffering treatable clinical depression, translators should be required where necessary and doctors cannot benefit from the estate of an individual assisted to die, all mitigate against a plot to murder.

Anyone eliciting the aid of a doctor to do away with a relative to inherit the estate would be more likely to succeed under current Australian law, whereby very sick patients are assisted to die daily under the convenience of ‘double effect’ without safeguards or scrutiny. No second opinions, no witnesses, and no telling the coroner.

To avoid the perception it is alleged may develop that some patients in aged care institutions or hospitals will fear doctors if voluntary euthanasia is legalised, provision could easily be made for private organizations to determine that VE would not be conducted on their premises. It is also open to Government to determine that VE will not be permitted in any public hospital.

Providing for VE would in fact allow for the first time, the opportunity for patients and doctors to discuss end of life issues openly, something which is near impossible at present.

It is important that a legislative regime include compulsory reporting and monitoring requirements. Patient records should be kept for a specific period, the coroner should be advised of every VE death and have full powers to investigate. Statistics should be collated and tabled in Parliament. A parliamentary committee could be established to monitor that the legislation is operating as intended.

The suggestion that no adequate safeguards can be devised is ludicrous when you examine the question closely. The fact is of course, that safeguards can be as tight as Parliament dictates.

It would be easy to be overly prescriptive and restrictive to limit the number of patients who could access medical help to die if that was desired. For example, if one were uncomfortable about the possibility of misdiagnosis, or perhaps there might be a conspiracy between medical personnel and a family to do away with a patient, then the number of doctors, specialists, psychologists, psychiatrists etc. involved could be increased. The point is made simply to demonstrate that legislatively Parliament can do whatever it likes. You can include as many hoops and hurdles to jump through and over as you want.

A reasonable list of safeguards might include : -

1. The patient has to be competent and terminally ill. (alternatively, hopelessly ill)
2. Only the patient can initiate the request for assistance to die.
3. The patient must be informed regarding diagnosis, prognosis and palliative care options.
4. To avoid misdiagnosis, specify the number of doctors to be consulted.
5. Specify the minimum experience of doctors.
6. Specify that doctors cannot be members of the same practice.
7. Specify the number of specialists and palliative care experts to be involved.
8. Specify that a psychiatrist must state that the patient is not suffering treatable clinical depression.
9. Specify the number and duration of cooling off periods.
10. Prohibit VE in public hospitals.
11. Provide the option for private institutions to prohibit VE on their premises.
12. Require interpreters in circumstances where the patient’s first language is not the same as the doctor’s first language. Interpreters are used to ensure absolutely that there is no possibility of misunderstanding by the patient.
13. Specify that the patient’s final request be videotaped. (hardly necessary but it would record the patient’s demeanour at this crucial point, it was not required in the N.T., nor is it in Oregon or Holland)
14. Require complete records to be kept and that the coroner be advised of every VE death with full powers to investigate.
15. Require statistics to be tabled in parliament and establish a standing Parliamentary Committee to monitor how the legislation is working.

If a mix of those safeguards is not enough to convince you that the so called vulnerable members of society would never get caught up in the process against their will, legislation could specify that assistance is only available to those who have completed an Advance Directive or a Living Will and have it registered with a public registrar or trustee. This would absolutely ensure that no citizen who is not so registered would ever have anything to fear from being inadvertently caught up in the process. I do not believe that such a provision is necessary however it would not be difficult or expensive to put in place.

The point I make is this:

The often repeated, but never substantiated statement, that no adequate safeguards can be devised to control voluntary euthanasia, is nonsense. We need more politicians committed to reducing the senseless and needless suffering of a very few, to work together devising the appropriate mix of safeguards, rather than simply accepting that it is a stumbling block that cannot be surmounted. To say this can’t be done is to ignore the unfettered authority Parliament has to devise legislative responses to meet the needs of constituents.