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Sunday, 12 November 2017

Dying with Dignity: Read the Evidence


The major opposition to legalising medically assisted dying comes traditionally from religious institutions and individuals. Despite decreasing membership, sustained and ever-growing demand for the legal right to die with dignity, including the right to seek voluntary assisted dying (VAD), churches still retain great influence in the political world. Facilitating this influence is the use of the so-called “conscience” vote in parliament, more often than not used to impose the individual member’s personal views or the party’s policy, even in the absence of opposing views of the electorate.

Opponents’ views are often religiously-inspired although they may deny this and say they argue from fear of possible adverse social outcomes. They say they fear erosion of respect for the sanctity of life, which must be protected at all costs and/or of the medical profession, which vows to protect life, mistakes, that doctors cannot adequately assess a person’s capacity or autonomy to decide to seek VAD, and of a ‘slippery slope’ to wider and wider grounds for assisting people to die.

If that is the case, they should address the copious and extensive evidence refuting these fears from studies of jurisdictions that have legislated for VAD for years, indicating that safeguards work and ‘slippery slopes’ are not inevitable. To be valid, their opposition should be based on real evidence of abuse of the dying through unwanted or coerced hastening of death, rather than speculation and fearmongering.

The evidence of the effectiveness safeguards is easily accessible on the web. It includes peer-referenced, academic articles based on statistics and surveys. But opponents fail to address these, as they are non-existent. This makes their arguments hard to accept. If they want to convince us of their legitimacy, they could start, for example, with considering some wide studies that are cited in this article.

Firstly, for example they could consider that assistance to die is common


Despite the apparent illegality of VAD, and those who decry its morality, VAD happens frequently. Fear that legalisation of VAD will result in abuse is misguided, because it is lack of legalisation is likely to lead to abuse. Studies have shown that up to a third of physicians who have attended the dying have administered a drug with the intention of hastening death. The Catholic-generated ‘double effect principle (potentially lethal medication can be administered if the stated intention is to alleviate pain) has led to ‘ambiguity the in how physicians understand death hastening practices’[1] as highlighted by a large multinational survey of 1,478 Australian physicians:

·         7% complied with patient requests for euthanasia.
·         28% said they were willing to comply under certain conditions
·         66% said they would never comply.
·         77% reported withholding or withdrawing treatment
·         83% provided pain through analgesia with the probability or certainty of hastening death.

This indicates that physicians are performing these practices without patient consent, the authors conclude.

 

One study found that Australia had a higher rate of intentional ending of life without the patient's request than the Netherlands. Australian law has not prevented doctors from practising euthanasia or making medical end-of-life decisions explicitly intended to hasten the patient's death without the patient's request.[2]

Another researcher found that

‘death hastening practices, frequently at a clandestine level, continue unabated across Australian medical settings and by a multidisciplinary range of practitioners Such practices sometimes occur without patient consent (up to half the cases) and sometimes with nurses and others acting autonomously without instruction from doctors. Indeed, over one third (36.5%) of all Australian deaths are caused or hastened by medical end of- life decisions but over two thirds are subject to them.[3]

In New Zealand, a 2015 News/Reid Research poll showed 71% of respondents wanted the law changed with 24% opposed.[4] .New Zealand Parliament's largest-ever inquiry into VAD did not make any formal recommendations to the Government about whether VAD should be legalised, instead providing a summary of the arguments for and against assisted dying. This may be due to the fact that, ironically, the NZ Herald recently reported that between 75 and 80 per cent of the submissions were opposed to legalising voluntary euthanasia and the rest wanted a law change.[5]  Meantime, the recently elected Labour-New Zealand First Coalition government has made a commitment to hold a conscience vote in Parliament when votes on whether the issue of legalising VAD should be decided by referendum.

A study of 1,100 New Zealand GPs working in end-of-life contexts in New Zealand[6], found:
·         63% had made medical decisions in the previous 12 months that could actually hasten death;
·         5.6% (39) of deaths were consistent with physician-assisted suicide or euthanasia. ‘In '7 of these deaths doctors did not discuss their actions with the patient. ‘In other words, non-voluntary euthanasia occurred, and in 34 (87%) of the deaths palliative services were available’;
·         13.6% New Zealand physicians reported actions that were “partly” intended to hasten death and 50 (53%) of these did not discuss with the patient beforehand.
·         19%) withdrew or withheld treatment or increased medications to alleviate symptoms knowing it would probably hasten death.[7]

The Principle of Double Effect is a handy way of protecting those who hasten death intentionally or otherwise, impairing transparency and honesty, no matter what the doctor’s/nurse’s motivation.

In expressing my aspiration for VAD with a medical professor, I was told confidentially ‘Don’t worry, if you ever want assistance, you can come to me.’ He was surprised at my angry response that a) he was happy to act in this hypocritical clandestine way, with possible abuse of the system, and b) I was expected to accept that I had no right to request VAD, but should be dependent on chance access to it.

Why don’t opponents address the reality of this situation? Surely legislation can impose a layer of regulation and accountability at least more effective that current practise.

2 They could consider evidence showing legislative safeguards are adequate


Opponents argue that safeguards in the Bill cannot protect the vulnerable. Copious studies of the many safeguards in legislation elsewhere conclude they are adequate to prevent abuse, while providing autonomy, dignity and comfort in the face of an inevitable and unbearably painful death. The Supreme Court of British Columbia (Carter v. Canada 2012) considered extensive expert testimony on VAD legislation overseas both for and against VAD. The Supreme Court upheld its conclusion, finding that there was ‘no evidence that doctors cannot reliably assess a person’s competence, informed consent and non-ambivalence. There was no evidence of increased abuse of patients, carelessness, callousness, distrust of doctors or an inevitable ‘slippery slope’, even in the more permissive jurisdictions. As well, they found palliative care, which must be considered, often actually improved with such legalisation.
The Victorian Parliamentary Inquiry into Life Choices[8], an extensive study tour in 2016 of jurisdictions legalising VAD considering evidence for and against VAD, found that ‘[T]he evidence is conclusive that assisted dying can be provided in a way that guards against abuse and protects the vulnerable in our community in a way that unlawful and unregulated assisted dying does not’ (p. xxviii).

I believe opponents would have to disprove this evidence to justify prohibiting VAD outright.
Such evidence and much more like it, however, is missing from consideration by those opposing VAD, making their arguments questionable and potentially misleading. Only when those who oppose this legislation can convince us that they are factually wrong will their case be worth considering seriously.




[1]            [Löfmark R, Nilstun T, Cartwright C, Fischer S, van der Heide A, Mortier F, Norup M, Simonato L, Onwuteaka-Philipsen BD: ‘Physician’s experiences with end-of-life decision-making: survey in 6 European countries and Australia’, BMC Med 2008, 6(4):1–8.]
[2]            Helga Kuhse, Peter Singer, Peter Baume, Malcolm Clark and Maurice Rickard End-of-life decisions in Australian medical practice MJA 1997; 166: 191
[3]            Steven A Trankle ‘Decisions that hasten death: double effect and the experiences of physicians in Australia’ BMC Medical Ethics 2014, 15:26  http://www.biomedcentral.com/1472-6939/15/26
[4]            "Poll: Kiwis want euthanasia legalised". Retrieved 2016-01-18.
[5]            2 Aug, 2017 
[6]            Mitchell K, Owens RG: National survey of medical decisions at end of life made by New Zealand general practitioners. Br Med J 2003, 327:202–203, cited in Trankle, above.
[7]            Trankle P2.
[8]            http://www.parliament.vic.gov.au/lsic/inquiry/402

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