'Name three people you would want to have dinner with?' An interesting pastime. Comedians, commentators, sport stars, philosophers, dead poets, there's an endless list of possibilities, all which, I guess, provide a window into a person's character and what they think is important.
Here's a variation: 'Who would you want to provide you support and care through a terminal illness?' A comedian or a highly trained palliative care specialist?
Okay, that's a set-up, and an obvious one. Anyone who has followed the recent public discussion in Australia on euthanasia and assisted suicide knows full well that I'm talking about Andrew Denton; a comedian turned euthanasia advocate. It's a great irony that only days before Denton's assault on our sensibilities last week we saw the effective gagging of Dr Nitschke – a euthanasia advocate who thinks he is a comedian. There's a joke in there somewhere with the punchline that goes something like, '…one of them is still occasionally funny!'
And no matter what one might think of Denton's apparent epiphany, his understanding of palliative care is yet rudimentary to say the least. His faint praise of the discipline and its exponents while, at the same time, as I see it, trying to undermine public confidence by exploiting it's every possible imperfection, real or imaginary, is, at best, a matter of ignorance.
When palliative care peak bodies tell the public that they "cannot relieve all pain and suffering even with optimal care", what are they really telling us? Firstly, they are being honest. Would you expect anything less than honesty from a medical philosophy and discipline built on trust and care? Of course not?
So, when palliative physician, Ralph McConaghy, told the Q and A audience this week that 'perhaps 2 per cent' of patients are in that category, what was he telling us? When another palliative care physician, Richard Chye told Fairfax readers yesterday that 'complex pain can be temporary and treated' he was filling in the picture a little. 'Treated pain does not mean free of pain; it means that patients and families can still function and enjoy their limited time.'
So, clearly the possibility that you or I might fall into this putative '2 per cent' is not necessarily the dark spectre of abandonment and pain that we are being encouraged to think that it is. Death ain't beer and skittles, we all know that; and when we think about it, none of us honestly expects it to be smooth sailing. And just as some people can carry on through their day while nursing a nasty migraine others, like me, head for the covers and the medicine cabinet at the first signs of pain. We're different, each and every one of us.
We need to hold onto this idea of difference alongside notions of autonomy. Over many years of personal engagement with palliative care doctors and nurses, they have expressed many times to me their frustration at the narrow-focus of this debate and the false dichotomy created between palliation and a dignified death. I have heard from practitioners with more than 30 years' experience who have said that they have heard only a handful of requests for an early death. I have heard others claim that the rate of request is much higher. Given that we're talking about Australian services, then it is most likely that such differences are attributable to a variation in care standards or expertise. The reality is that we can and should be doing better as Dr Chye points out:
More Australians die in pain because of lack of access to palliative care, not because of palliative care. Euthanasia is not a substitute for palliative care. Good-quality palliative care is not going to work for everyone, just as heart surgery is not 100 per cent successful. But for the majority, a palliative care experience is a good one.
Doctors need to take some responsibility as well. Palliative care is a small part of general medical training; we tend to focus on the saving and not enough on the right time to let someone go. Palliative care is not only resisted by patients who see it as an end game, but their doctors, who see it as a failure. It is neither of those. In palliative care we often help patients and their families come to terms with what is happening to them, perhaps we need to sit with their doctors as well.
In light of that, Denton's crie de couer for the ill and the dying is best served and answered by better care for all. The suggestion that, because Denton thinks we should have some form of 'assisted dying' that doctors should somehow accommodate that to the abandonment of age old principles - and on his say-so - is ludicrous; as is the subtle suggestion that this somehow means that doctors currently 'look away' from the difficult cases in ideological abandonment of their patients.
But, you see, it is all the fault of the 'Catholics' according to Denton. Again, while quickly passing over light praise he claims that the 'doctrine of double effect' described by a monk over 700 years ago is really to blame for palliative care associations not adopting some form of euthanasia or assisted suicide. Never mind that the principles of modern medicine stem back two millennia and bind a doctor to 'do no harm'; such harm, as understood by most – even today – to include killing a patient or helping them to suicide. The idea that a doctor "will neither hasten nor prolong death" is not a 'Catholic conspiracy'; it's just good medicine.
Which is why it was entirely appropriate that Palliative Care Australia should encourage its membership to engage with Q and A and its audience in "ensuring that everyone has access to high quality care as they face their final days". You see, they do care, they do not turn away and they are not silent. They continually push for more funding, better training, more outreach and specialised services.
In the final analysis, I'm backing professionals over comedians, the learned over Logies. Call me self-interested, but I'd rather be sure as sure I can be that we'll get the best care available when I or my loved ones need it. Happy to have a laugh Mr Denton but, no offence, when it comes to my demise, I'll take expert opinion based on years of compassionate practice any day.