DOE: Letter to SA Parliament re Such Bill June 2013

Dear

We are writing to you regarding the Hon Bob Such’s ‘Ending Life with Dignity Bill’ 2013.

We note that the AMA has written to you twice opposing this Bill, and it will be no surprise to you that we also oppose it.

We whole-heartedly affirm the general concept of ‘Ending Life with Dignity’.  Many of our members are directly involved in end-of-life care, either as Palliative Care physicians or as doctors working in acute medical settings where patients frequently die (for instance, Acute Stroke Units).  To this end, we have been enthusiastic supporters of the principles underlying the recent ACD Bill and have contributed to discussions and amendments to ensure the legislation achieved its stated goals.  However, we do not agree that euthanasia should be allowed as a valid or licit means of achieving a dignified death.

It is of great concern to us that Dr Such’s Bill still seems to demonstrate confusion as to how euthanasia is defined.  Section 28.2.b states:

The medical practitioner may only carry out the request by 1 or more of the following methods:

i. by administering drugs in appropriate concentrations to end life;

ii. by prescribing drugs for self-administration by the person to allow the person to end his or her life;

iii. by withholding or withdrawing medical treatment in circumstances that will result in an end to life;

The last ‘method’, as the AMA and others have pointed out, is not euthanasia, but the refusal of medical care, the legality or ethics of which is not in dispute.  Patients’ right to refuse medical care has our support.  This was enshrined in the recent ACD Bill.  Any euthanasia Bill must be quite clear as to what is, or is not euthanasia.  Otherwise the penalties for supposed ‘non-compliance’ with euthanasia provisions will lead medical practitioners into conflict with patients’ previously stated, licit, Advance Directives.

The proposed amendment to section 17(2a) in Dr Such’s Consent to Medical Treatment and Palliative Care (Withdrawal of Nutrition and Hydration) Amendment Bill 2013 once again appears to demonstrate this confusion.  It states that "a medical practitioner must not withdraw or withhold life sustaining measures consisting of the artificial nutrition or hydration of a patient".  This is in direct contradiction to the recent ACD Bill, in which these procedures are defined as being medical interventions which a patient (or their proxy) may legitimately refuse.  This would, for example, require indefinite provision of artificial hydration and nutrition to a 96 year-old patient who presents with a brain-stem stroke which would leave them in a permanent coma.  The current ACD Bill strikes the correct balance in this respect, stating that health professionals may not legitimately withhold oral hydration and nutrition (if tolerated).

There are several other concerns.  Firstly, the ‘forced referral’ provision in Section 29 will make doctors who are morally opposed to euthanasia accessories to the fact.  Failure to refer appears to be punishable under section 32.

Additionally (Section 39) it is disingenuous to say that patients dying of euthanasia should not have euthanasia listed as the ‘cause of death’. Under ICD-10 guidelines (SA Health document) the Immediate Cause is the final disease, injury or complication directly causing the death. This could only be listed as euthanasia.  Of course there should also be listed (as the guidelines state) the Underlying Cause of Death, as the disease or injury that started the sequence of events leading to euthanasia.

Lastly the terms ‘Terminally Ill’ and ‘Unbearable suffering’ are undefined in the Bill.  As others have pointed out, any illness which is associated with a decreased life-expectancy (e.g. Multiple Sclerosis) could be defined as a terminal illness and suffering of any nature (e.g. diagnosis-related anxiety) could be grounds for euthanasia.

These concerns aside, we would agree that the Bill is ‘as tight as possible’.  However, we would agree with many others, that, when it comes to euthanasia legislation, as tight as possible is not tight enough.  Inherent in any euthanasia legislation is the potential for abuse.  As many others have pointed out, so-called safeguards in the Netherlands and Belgium are routinely ignored with impunity.

More broadly, DOE believes that there are only two logically consistent positions on Euthanasia: 1) that euthanasia should be forbidden, or 2) that it should be granted to any adult of sound mind who believes that their suffering (of any sort) is unbearable.  We believe that the gradual drift of practice in the Belgium and Netherlands bears this out, as does the gradual shift in many Euthanasia supporters (for instance Dr Nitschke) towards this position.

And it is not, we feel, morbid and fantastical speculation to extrapolate the final consequences of breaking this fundamental taboo: 1) a euthanasia right will become for the frail elderly a euthanasia obligation (most healthcare resources are consumed in the last year of life); 2) euthanasia will be encouraged as a means of providing healthy organs for transplantation (as has occurred in The Netherlands); 3) suicide prevention efforts will be weakened; 4) Palliative Care will become a luxury rather than a right.

As correspondence from the AMA makes clear, despite exceptions, the majority of medical professionals do not want euthanasia legalised.  In fact, it seems that the more frequently Health Professionals interact with dying patients, the less likely they are to support it (Palliative Care Physicians are almost all opposed).  The British and New Zealand Medical Association have recently reaffirmed their opposition to euthanasia laws.  A recent Massachusetts referendum has shown that public support for euthanasia is actually far softer than it appears (confirming what many of us opposing euthanasia believe).

DOE affirms that patients have a right to a dignified death; however, along with the majority of doctors, we deny that euthanasia should be enshrined in law as a valid means to this end.  We endorse the AMA’s opinion that this bill is, “in the realms of dangerous folly which have the potential to damage the basic tenets of clinical practice in ethical and compassionate end-of-life care” and we urge you to reject it.

Yours sincerely,

Dr Timothy Kleinig PhD FRACP MBBS (Hons) BA
Head, Stroke Unit Department of Neurology Royal Adelaide Hospital
Head, Neurology and Stroke Units Lyell McEwin Hospital
Senior Clinical Lecturer University of Adelaide

Mr Robert Britten-Jones, AO MB BS FRACS FRCS (Eng)
Emeritus Consultant Surgeon Royal Adelaide Hospital

For and on behalf of Doctors Opposed to Euthanasia

  Letter to SA Parliament re Such Bill June 2013