Legal safeguards can make euthanasia a legitimate option

Senator Amanda Vanstone recently re-opened the euthanasia debate by opining in a newspaper interview that it was inhumane to deprive Australians of “sane sensible and humane euthanasia laws”.

The arguments the palliative care movement make against euthanasia are similar to those made by the anti-choice movement against abortion. This is unsurprising, given the religious origins of both schools of thought of late, both have taken what one scholar describes as a decidedly “secular turn”.

Both movements argue that the only reason why those they claim to represent - women and terminally ill patients - choose as they do is because both groups lack adequate knowledge of other alternatives. If only women knew about Centrelink parenting payments, and the terminally ill recognised the improvements in pain management, the demand for abortion and physician assisted suicide would disappear.

Both movements also question the decision-making competence of those choosing abortion and physician-assisted suicide. Female pregnancy hormones and the poor physical and mental health status of terminally ill patients, not to mention the stress of crisis decision-making, are deemed legitimate reasons to doubt the rationality - and disregard the choices - of those pursuing control over their bodies and their deaths. Palliative care providers, argues a recent article in Palliative Medicine, deem all patients who “think that their life is irretrievably bad” to be “wrong”.

Finally, both advocacy groups suggest that the availability of more options has the counter-intuitive outcome of reducing choice. The mere availability of abortion and physician-assisted suicide, the argument runs, coerces women and terminally ill-patients to “choose it” so as to avoid burdening others with their need. Real choice, it is claimed, requires the continued criminalisation of abortion and physician-assisted suicide so that more legitimate options like adoption and palliative care can flourish.

So what is the truth? Surveys across the western world, including Australia, clearly show support for a right to die. A 2002 Gallup poll found 72 per cent of Americans supported doctor-assisted suicide for those with terminal illnesses, while in the same year 70 per cent of Australians were found to be in favour of giving terminally ill and severely suffering people a choice about the timing and method of their death.

Data from Oregon suggests that the most frequently given reasons for choosing physician-assisted suicide by the approximately 30 people who die this way every year are loss of autonomy” (87 per cent), “loss of dignity” (80 per cent) and “loss of the ability to enjoy the activities that make life worth living” (84 per cent). This data, which suggests that mental rather than physical suffering is the main driver of decisions to die, undermines the assertion of anti-euthanasia forces that the effectiveness of modern-day palliative methods obviates the need for legal reform.

Such figures also undercut claims that the legal freedom to die would exert the greatest coercive pressure on those lacking options other than death: namely, the ill-educated and those too poor to afford palliative care. The overwhelming majority of Oregonians seeking physician-assisted suicide were highly educated and well off. Indeed, 86 per cent were enrolled in hospice care at the time of their suicides, while only 2 of the 208 people who have used the legislation so far were uninsured.

There are some values that palliative care and right to die advocates share. These include a belief in the importance of reducing human suffering and a distaste for the over-medicalisation of the dying process.

However, disagreements between the two groups are profound. They include theoretical disputes about the legitimacy of death as a choice as well as more empirically-based spats about the competence and capacity of the terminally ill to make adequately informed decisions, and the likely effect of making physician-assisted suicide a legal choice.

Palliative care advocates see decriminalisation as an invitation to what Melbourne writer Juliette Hughes (in The Age on July 13, 2006) recently described as a culture of death that would enable the preferences of greedy relatives and stingy hospital bureaucrats to be privileged above those of vulnerable patients.

In contrast, advocates for physician-assisted suicide believe safeguards can be put in place to protect patient-autonomy and reduce the risks of involuntary euthanasia: risks currently managed in secretive and ad hoc ways.  One survey found that while 30 per cent of all Australian deaths involving a medical decision designed to end the patient’s life, only 4 per cent of these decisions were in response to a direct request from the patient.

Some Australians speed and drive drunk. Yet few would seriously moot the criminalisation of driving as a solution to this undeniably serious problem.

Instead, as we do to minimise the risk of irresponsible driving to self and others, we must move to enact sophisticated regulatory and compliance regimes around end of life decisions. Ones that will offer those of us who meet threshold conditions for competence to exercise our reason and our values when it comes to critical decisions about our bodies, our lives and our deaths.