Abstract
Euthanasia is an ever-present topic in the community, but every decade or so it becomes more prominent, usually in association with impending legislation. Now is such a time.
Euthanasia is a deceptively simple term. It can have different meanings, as emphasised by Kelleher (1998) in his paper entitled ‘Humpty Dumpty and the language of euthanasia’. In Australia, Kuhse et al. (1997) noted that euthanasia had traditionally been defined using the Vatican’s definition of ‘an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated’. However, this broad definition encompasses at least five clinical situations (van der Maas et al., 1996).
Thus, van der Maas et al. (1996) noted that euthanasia was ‘the administration of drugs with the explicit intention of ending the patient’s life, at the patient’s request’; physician-assisted suicide was ‘the prescription or supplying of drugs with the explicit intention of enabling the patient to end his or her own life’; ending of life without the patient’s request was ‘the administration of drugs with the explicit intention of ending the patient’s life, without a concurrent, explicit request by the patient’; the alleviation of pain and symptoms with opioids was ‘the administration of doses large enough so that there was a probable life-shortening effect’; and a decision not to treat was ‘the withholding or withdrawing of potentially life-prolonging treatment’.
Such a delineation appears to have face validity from the clinical point of view, but it is evident that not all commentators address the subtleties that it implies.
In Australia, the debate usually incorporates reference to the Northern Territory experience, and two of the contributions in recent issues of the Australian and New Zealand Journal of Psychiatry are no exception (Nitschke and Stewart, 2011; Parker, 2012). Probably the best overview of that experience is provided by Kissane et al. (1998), and other commentaries include those of Goldney (2001), Street and Kissane (1999–2000) and Nitschke (1999–2000), with the latter two demonstrating differing interpretations of events, even though the three authors had cooperated in their initial review (Kissane et al., 1998).
It is pertinent to reiterate the requirements of the Rights of the Terminally Ill Act 1995 (Northern Territory of Australia, 1995), as it appears to incorporate most, if not all of the safeguards that could be anticipated. For the purposes of the Act, the definition of terminally ill was: ‘an illness which in reasonable medical judgement will, in the normal course, without application of extraordinary measures or of treatment unacceptable to the patient, result in the death of the patient’.
In addition to the requirements noted by Nitschke and Stewart (2011), there were other criteria which should have been met. Importantly, these included the patient being aware of the nature and course of his or her illness with treatment; the patient must have had no treatable depression; there must have been advice on palliative care; the patient had to have considered family implications; and if the patient had not been a native English speaker an interpreter had to have been provided. There was also a ‘cooling off’ period of 7 days before the initial signature of authorisation by the patient and doctors and then a further ‘cooling off’ period of 48 hours before euthanasia could be undertaken. Finally, the doctors participating under the Act could not benefit financially from the patient’s death.
It is probably fair to state that all of the requirements are what could be interpreted as good clinical practice. However, it is evident that even in the glare of not only national but international publicity, these were not always met. This is apparent from a brief examination of the first two individuals of the four who died under the Act (Kissane et al., 1998).
The first was a 66-year-old male who had suffered cancer of the prostate and had a history of depression with suicidal thoughts, although he was said to be not currently depressed. His palliative care team were not aware of him being assessed for euthanasia, and it was reported that ‘the news of it came as a shock to those involved’. In addition, his sons were said to be unaware of events until after his death.
The second person was a 52-year-old woman who had a dermatological condition, mycosis fungoides. There was doubt about the terminal nature of her illness, and a dermatologist and a number of oncologists declined to judge her as terminally ill. Eventually, after national television appeals for assistance, an orthopaedic surgeon completed the required documentation. She was on an antidepressant, doxepin, as well as lorazepam and flunitrazepam, and it was recorded that a dermatologist had suggested various medications, including the psychotropic drugs haloperidol, pimozide and fluoxetine. However, there was no indication that there had been further manipulation of psychotropic medication.
These two clinical vignettes give some insight into limitations in compliance with the legislation. Thus, while the legal requirements embodied the safeguards most proponents of euthanasia would agree to, reservations about the propriety of what occurred in the first two individuals must be expressed.
It is acknowledged that it is easy to criticise from a distance, but these issues need to be raised. It is also on record that it was acknowledged that palliative care services in the Northern Territory were not well developed, and it was reported that Dr Nitschke conceded that he had limited experience in palliative care (Kissane et al., 1998).
In contrast to the first two patients, the other two who died appeared to sit more comfortably within the requirements of the Act, with their final days or weeks being sacrificed with the intention of providing a more dignified and acceptable death.
In this regard, it is pertinent to explore further the terminology in this contentious area. The distinction between narrowly defined euthanasia and assisted suicide is blurred, as is illustrated by the actual mechanism of death in these Australian examples. Thus, Dr Nitschke provided an infusion device whereby the patient made the final decision to go ahead with the lethal injection. By the use of this mechanism the deaths could be considered more as assisted suicide, rather than euthanasia, as acknowledged by him (Nitschke and Stewart, 2011).
However, it could be argued that the term ‘assisted suicide’ has connotations which are not necessarily in the best interests of either the patient, the health professionals involved, regulatory authorities, or, indeed, those who struggle with suicide prevention in its usually accepted context. Although ‘suicide’ may be etymologically strictly correct, it hardly conveys the usual situation in which death occurs in those who die by suicide, particularly in relation to the almost invariable presence of psychiatric illness.
By contrast, probably without exception, extant legislation in other countries requires that those seeking euthanasia should not be unduly swayed in their pursuit by psychiatric illness. Therefore, it appears to be pragmatic, and arguably more accurate, to speak of ‘assisted death’ or ‘assisted dying’ in these circumstances, rather than ‘assisted suicide’. Thus, ‘death’ and/or ‘dying’, while in themselves capable of eliciting strong emotions, are more neutral than ‘suicide’, which as Parker (2012) has noted, ‘is a word that carries much evaluative baggage’. It is also apparent that the terms ‘assisted death’ or ‘assisted dying’ encompass the different clinical situations described by van der Maas et al. (1996).
This leads to the issue of whether psychiatrists should act as ‘gatekeepers’ to euthanasia or assisted death. It has been noted that in Oregon, where euthanasia legislation has been enacted, as few as 6% of psychiatrists considered that they could make a competent decision after a single assessment (Ganzini et al., 1996). Furthermore, with the patient wishing to be seen as unimpaired, that in itself could be an impediment to the disclosure of sensitive information (Kissane et al., 1998). Therefore, the ideal clinical situation would appear to be a multidisciplinary and longitudinal approach, with shared information.
The need for such a comprehensive approach appears to be challenged by Nitschke and Stewart (2011) and Parker (2012), particularly in regard to psychiatric assessment. The correctness or otherwise of such a position cannot be resolved by randomised controlled trials. Therefore one must fall back on the clinical experience of seeing terminally ill patients whose wish to die has been modified by appropriate intervention, be it medication or otherwise. This experience is inferred in the paper of LaBode and Sher (2011), who have urged greater clinician awareness and readiness to treat the elderly.
Whether one, like Parker (2012), invokes Wittgenstein, or the more readily accessible Humpty Dumpty (Kelleher, 1998), words are important. This is seen in the polarisation of opinions in this debate, where extravagant and, at times provocative language, is often presented without acknowledgement of the different conceptualisations of the broad term euthanasia. Such debate certainly ensures that compromise will rarely be reached.
But it appears that the reality of the situation is probably not as starkly demarcated as either enthusiastic proponents of euthanasia or social conservatives may sometimes portray. Many, both clinicians and lay persons alike, have experienced vocal opponents of euthanasia, gratefully embracing what in essence could be regarded as aggressive palliative care in assisting the death of a relative in a humane and dignified manner.
Just as we have felt the need to change the names of psychiatric facilities from asylums to hospitals, and, for example, manic-depressive psychosis to bipolar disorder, so it is time to consider seriously whether we should abandon terms such as euthanasia and assisted suicide in this context. By replacing them with ‘assisted death’ or ‘assisted dying’ there appears to be more common ground between extreme views.
Naturally there are still shades of grey. That is part of the human condition, and the tolerance of such ambiguity is an area in which psychiatrists practice. The remaining ambiguity will also give ample opportunity to those who wish to dwell on the minutiae of the clinical, philosophical, religious and moral aspects of this debate.
For the rest of us, let us trust that the clinicians we meet as our lives ebb away share the goal of a ‘good death’ (Singer et al., 1999). That is, to avoid suffering; to avoid the prolongation of dying; to have a sense of control; to relieve any burden on the family; and to strengthen relationships. As noted recently, this can be achieved by advance care planning with a view to the most acceptable end-of-life care (Silvester and Detering, 2011).