Dangers for the vulnerable

25/06/2019

Serious question: how do people who believe in minimising the power of the state reconcile that view with support for giving the state the power over the life and death of vulnerable people?

The Bill that seeks to legalise euthanasia would restrict its availability to people with terminal illnesses with less than six months to live.

Doctors can predict how long someone might survive, but they can be wrong.

A year ago a friend was told he had five months to live.

He has just bought a neighbouring farm and is about to launch a newly built boat.

He still has cancer but he is on a drug which has not only kept him alive but is allowing him to live a good life.

Eighteen months ago a friend emailed to say she was on the way to look after her grandchildren because their other grandmother was in the very last stages of life with hours or at best days to live. At the 11th hour she was given a new drug and she now has no signs of the cancer that was killing her.

These are true stories, Jacqui Dean who sat on Parliament’s Health Select Committee, which launched an inquiry in response to a petition calling for a law change to permit medically assisted dying in the event of terminal illness. heard more:

. . . I am opposed to euthanasia, with my resolve only strengthened after sitting on that committee and hearing the heartfelt testimony of hundreds of people who bravely faced death and the families who lost loved ones.

I heard some wonderful stories of love and tenderness, sad stories of heartbreak and loss, stories of great courage and inner strength, and through it all I had the utmost admiration for those who came before us to share their deepest fears and their greatest joys.

The Samoan grandmother who talked of the death of her father – a beautiful and moving family experience which she told us was gentle and loving and filled with prayer.

The woman whose husband was diagnosed with a brain tumour at 28, but who outlived three fatal prognoses and didn’t actually pass away for fourteen years.

This woman pointed out that no-one can predict the final outcome of a terminal illness, and she and her daughter were grateful that they never gave up and that the family got to share those extra years together.

And the blind man who had fought against adversity all of his life and wanted to encourage people to live in hope and not give in to despair.

There were stories of courage and strength, which reflected the best of the human spirit.

Stories from those who made it their life’s work to support the dying through palliative care, and submissions from groups motivated by strong beliefs around death and dying.

We also heard from those approaching the end of their lives.

This included a man, in his 40s who was dying of prostate cancer, who spoke with anger about his life being robbed. And others who said they feared death and wanted to take the pain away as quickly as possible when their time came.

There’s no doubt decisions made at the end of life are emotionally charged, highly personal and reflect circumstances and timing that vary from individual to individual.

The care that people get at this time can make a fundamental difference to people’s experiences.

For that reason, I support the power of good that hospice and palliative care services provide.

Dedicated and diligent guidance from these providers can assist terminally ill people to die peacefully and with dignity.

They believe that if people can come to a place where they can accept their end of life, it can have a huge impact on them and a lasting positive effect on their families.

I was deeply affected by the impassioned testimony the committee also heard from groups representing the disabled, elderly and the mentally ill.

Many of these people genuinely fear for the future if they become a physical or a financial burden on their families. They also questioned whether there could be circumstances where they may be manipulated or pressured into ending their lives.

This worries me deeply. If we legislate for the right to die, the negative impact on vulnerable groups will be huge.

In my heart I simply cannot accept that a law can be developed which will completely protect the vulnerable.

One of the most moving moments of the select committee process came when we heard from a Wellington man who said in the past he had been suicidal.

He recognised the grave consequences if euthanasia was made legal in this country. The option of taking one’s life would become much more normalised and he believed vulnerable people might make a decision that could never be reversed.

Our suicide rates are already too high – we don’t need death by choice as another signal that ending one’s life is OK.  . . 

The Select Committee that dealt with the Bill said it was unworkable. the doctors in the Care Alliance agree with them.:

. . . The Care Alliance, a charity which opposes physician-assisted euthanasia, has taken out a full-page ad in the New Zealand Herald.

The signatories endorse the views of the World Medical Association and New Zealand Medical Association, that euthanasia is unethical, even if made legal.

The letter says it supports effective pain relief and palliative care, and the right for patients to decline treatment if they wish.

But it says crossing the line to assist a person to die would weaken the doctor-patient relationship.

Dr Sinead Donnelly, who organised the letter, said the bill is unworkable.

“The message is that as doctors we don’t want to be part of it. You’re going to, in our view, destroy the profession of medicine by drawing us in to ending the life of our patients and two, the risk to the vulnerable is much too great.”

The letter has been signed by 1061 doctors, of the 17,000 registered doctors in New Zealand. . . 

The NZMA opposes the Bill:

It’s current chair, Kate Baddock said that had not changed and would not. 

“It would be impossible to craft a law that would completely protect people from sublte coercion and it’s also impossible to craft a law that means that people are totally competent,” she said.

“Therefore there should be no law, there should be no euthanasia.”

She is backed up by the Secretary General of the World Medical Association, doctor Otmar Kloiber.

“We have a huge and overwhelming majority that says no, this is not for us, and doctors should not be involved in killing patients,” he said.

“That is a very clear and very broad view which we have.”

Australian ethicist doctor Margaret Somerville spent 40 years in Canada and has nine doctorates, and said it was not over the top to use the word “killing”.

“This is a momentous decision, to say that you will allow intentional killing,” she said.

“You’ve got to be clear about what we really are authorising. This voluntary assisted dying – we all want assistance in dying. And then you give it to the medical profession, the healers in our society, it’s a radical change in our most fundamental values.” . . 

Lawyers have concerns too:

. . .Public lawyer Grant Illingworth QC said it was a very serious issue and mistakes about death and dying could not be undone.

“That’s why we abolished the death penalty in this country,” he said.

“The kind of legislation currently before parliament must contain safeguards that are so clear and so comprehensive, that any possibility of dying by mistake is excluded beyond a reasonable doubt.

“The statute proposed by David Seymour fails to meet that standard by a very wide margin in my opinion.” . . 

Life is terminal, but who can say when it will terminate?

It’s impossible to be precise about how long even very ill people might live and there are very real dangers in giving the state the power over life and death of vulnerable people.


What about the doctors?

30/08/2016

Proponents of euthanasia argue that people have autonomy over themselves which includes the right to die.

They rarely look at the debate from the point of view of doctors who would prescribe lethal doses of medication or administer them.

At The Spinoff, Medical Association chair Stephen Child gives that perspective:

For many, the key discussion point is whether it is possible to write and administer perfect legislation that permits someone autonomy at the end of life without the secondary negative consequences of:

  • inappropriate deaths
  • reduction in quality of palliative care
  • normalisation of suicide.

Both sides of this debate will emphasise anecdotes, surveys or “research” demonstrating cases of potential intolerable human suffering, or cases of coercion/inappropriate decision making, resulting in potentially unnecessary death. . . 

The ethical standards of a profession often go beyond public opinion, the law and market demands, and may also differ from the personal values held by some individuals within that profession. The role of professional ethics, however, is not only to prevent harm and exploitation of the patient but also to protect the integrity of the profession as a whole. This often requires the professional body to fulfil a leadership role to ensure clarity and provide direction.

The NZMA, along with the World Medical Association and 53 national medical associations, holds the following positions on voluntary euthanasia and assisted dying:

  • We recognise the rights of patient autonomy, so we recognise the right for society to have this discussion. We also acknowledge that people currently have the right to end their own life and that this legislation focuses on third-party assistance with this act.
  • We recognise the rights of patients to refuse treatment or for the removal of lifesaving treatment, and that the natural consequences of an illness may progress to death.
  • We recognise the rights of patients to have good access to high quality palliative care services and we passionately advocate for improved resources, education, workforce and facilities to achieve this goal. We strongly oppose the current necessity for our major hospice facilities in New Zealand to have to raise half their funds themselves.
  • We recognise the patient’s right to have administered analgesia and sedation to relieve pain and suffering – even if a secondary consequence of this is the shortening of life. Morphine is not an agent of euthanasia, and will not by and of itself reliably end the life of a patient. These agents are administered to relieve suffering, applying a risk/benefit analysis similar to all treatments, with a shared understanding of the potential risks in their prescription.

It might look like dancing on the head of a pin but there is a difference between giving something to alleviate pain and suffering in the knowledge it could hasten death and giving to deliberately kill.

. . .  Many people, however, still find confusing the difference between the concept of administering terminal analgesia/sedation to a dying patient, and that of administering voluntary euthanasia to a patient with concurrently stable physiology. The difference between palliative care and assisted dying is well documented and clear. The World Health Organisation definition of palliative care includes the statement that palliative care “intends to neither hasten nor postpone death”.

In jurisdictions where euthanasia and assisted laws exist, concern is growing about the impact on palliative care, where those seeking euthanasia are referred first to palliative care for assessment. This has led to confusion in patients as to the role of palliative care and – in some instances – patients who are opposed to euthanasia declining palliative care services.

The profession as a whole has also echoed concerns about the accuracy of diagnosis and prognosis, as well as the lack of certainty around measuring the capacity of patients facing terminal illness, who often also have reactive depression, altered brain physiology from medications or metastases, as well as potential external coercion factors.

For the profession, as well as ethical considerations, physician-assisted dying raises issues of:

  • potential impacts on palliative care delivery
  • potential changes to a doctor-patient relationship
  • difficulties with adequate training, assessment and regulation of the profession
  • potential negative impact on health providers participating in such acts.

Principles of autonomy and self-determination are, of course, central to this debate. The NZMA respects and supports patient autonomy but is concerned about relying on these principles to enact euthanasia or assisted suicide. Principles of autonomy demand full knowledge of risks and alternatives, and consent must be free of coercion, duress or undue influence.

An absolute guarantee that those who choose assisted dying are doing it voluntarily would be extremely difficult to establish in legislation and ensure in practice. Doctors are often not in a position to detect subtle coercion – as is also the case when trying to identify signs of emotional or financial abuse of elders more generally. Coercion also extends to assumptions of being a burden, giving rise to a sense of an “obligation” to die.

Given the gravity of the risk involved for individuals where autonomy is claimed but cannot be guaranteed, the belief that autonomy should trump all should be viewed with caution. . . 

 

I gave doctors permission not to keep trying to save the life of our first son and seven years later asked them not to call the crash team when our second son stopped breathing.

Both had degenerative brain disorders and any treatment would have only prolonged their suffering and postponed their inevitable deaths.

If I faced the same decisions in the same circumstances I’d do the same thing.

That isn’t euthanasia though.

It’s also very different from an adult in full control of their minds who requests the right to die and I understand how the fear of  what might be ahead could lead someone to that decision.

But legalising euthanasia isn’t only about fully competent individuals who want the right to control their lives and deaths.

It’s also about others who might feel pressured to choose a premature end or who might forgo high quality palliative care for fear euthanasia will be an inevitable consequence.

And it’s about medical professionals and what it asks of them too.

In abridging the article from which I’ve quoted, I missed a paragraph on surveys carried out in Canada, New Zealand and the United Kingdom. Each survey showed while roughly 30% of doctors agree “in principle” with the concept of assisted dying only 10% would feel comfortable in participating.

That’s what is often missed in the debate. It’s not just about the right to die and the patients, it’s also about the right to kill and the doctors.

P.S.

There’s an assisted suicide table-talk in Auckland tonight:

Broadcaster and comedian Jeremy Elwood hosts the Ika-Spinoff.co.nz current affairs cabaret, Table Talk, on the subject of Assisted Suicide. Join panelists David Seymour MP, promoter of the End-of-Life Choice Bill; Dr Jan Crosthwaite, University of Auckland Proctor and formerly Department of Philosophy; and Dr Stephen Child, Chair of the NZ Medical Association for a free-ranging discussion of a topic that defies politics.

Enjoy the full & delicious Ika menu, join a table or book for a group. Doors open and bar and dinner service from 5.30 pm, the discussion will start at 7.30 pm.

Follow the discussion on the TheSpinoff.co.nz

WHEN
August 30, 2016 at 5:30pm – 10:30pm

WHERE

Ika Seafood Bar and Grill
3 Mt Eden Rd
Auckland 1023


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