The Limits of Palliative Care
The following article first appeared in The Age of 10 October
1996
God grant me the serenity to accept
the things I cannot change,
the courage to change the things I can,
and the wisdom to know the difference.
We must all, sooner or later, confront the inevitability of death - this
cannot be changed. But we can change the way we live and die. Early in
my work as a palliative doctor, caring for terminally ill patients and
their families, I learnt that an enormous amount can be achieved when loving
care and support are combined with knowledge and skill. For most people,
pain and suffering can be eased, lives can be better rounded off, healing
and reconciliation can be encouraged, and dying can be made more peaceful
and dignified. The gratitude of patients and families, and the sense of
belonging to a caring multi-disciplinary team, add to the personal rewards
in this meaningful vocation.
To minimise suffering, it is necessary for palliative services to be
adequately funded, and for the effectiveness of treatments to be evaluated.
However, I believe palliative care will never eliminate all suffering -
this is an impossible dream. Currently, terminally ill patients experience
an array of distressing symptoms despite the provision of state-of-the-art
palliative care. For example, patients commonly experience progressive
weakness, which causes loss of function, diminished quality of life, and
dependence, and there is no effective treatment to increase their strength.
I've also witnessed people suffering disfigurement, nausea, suffocation,
incontinence, pain, psychological distress, confusion and more. Sometimes
dying can be horrifying.
Cancer is the leading cause of death in Australia, accounting for 26%
of all deaths. Research suggests about five to ten per cent of people with
terminal cancer request euthanasia. These people, like Max Bell and Bob
Dent, and others with diseases including end-stage AIDS and motor neurone
disease, are the proper focus for the euthanasia debate, yet amid the clamour
they are seldom heard. In over twelve years of palliative caring, I have
encountered, befriended, been challenged and influenced by many such people.
I have become convinced there is a small but definite place for euthanasia
in terminal care.
Career churchmen seem more concerned about protecting their doctrines
than the plight of real people. They claim that euthanasia is "murder",
which is like saying a surgical incision is assault by stabbing, and making
love is rape. They reveal a complete lack of understanding about the patient-initiated
process of negotiation with a doctor who is motivated by compassion to
become involved in what Bob Dent called "an act of love". The churchman's
idea that suffering has redemptive value could perhaps lead them to refuse
palliative care as well as euthanasia, but they cannot demand others to
follow.
Officials of the AMA cling to the dogma that euthanasia is unethical.
Surveys show that they do not represent the view of the majority of Australian
doctors. They insult the medical profession by implying that doctors can't
be trusted, and they fail to support doctors who help patients to die.
They will not acknowledge that medical practice and the law should be congruent.
It is puzzling why they no longer take a position against abortion, when
the life is taken at its very beginning, has no say in the decision, and
is not suffering, while remaining strongly opposed to voluntary euthanasia
for a competent, suffering person who has lived a full life.
It is a fact that doctors make deliberate decisions every day which
contribute to the foreseen death of patients. This occurs when ventilators
and other treatments are switched off, and when high doses of pain killers
and sedatives are administered to render patients oblivious to suffering.
These decisions which shorten life have none of the scrutiny which the
NT legislation demands.
Kevin Andrews, who introduced a federal Bill to overturn the NT Rights
of the Terminally Ill Act, also ignores the wishes and interests of the
person suffering with terminal illness, and claims the law should be based
entirely on the intention of the doctor in relation to the time of death.
This detracts from open and honest discussion about interventions. In switching
off a ventilator, for example, a doctor is forced by law to claim absolutely
no intention of bringing about the patient's death, even though this outcome
is foreseen and wanted by the patient. Surely a better basis for the law
would be to ensure the doctor acts in accordance with the wishes and interests
of the patient.
Euthanasia opponents often raise fears about potential abuse, and manipulate
data from The Netherlands in an effort to portray a "slippery slope". Their
argument is that euthanasia will undermine society, so the wishes and interests
of patients wanting euthanasia must be sacrificed for the common good.
However, this treats these patients as the "means" to a presumed benefit
for imaginary persons, rather than as "ends" in their own right. Clinicians
are morally obliged, I believe, to treat each and every patient in their
own right, not as the means to benefit someone else. It is not clear to
me how society is diminished by helping people like Bob Dent end their
terminal suffering. Indeed, society is enriched by upholding the principles
of respect for autonomy, liberty and compassion which are central to the
concept of voluntary euthanasia.
In Australia, we are good at prolonging life and reasonably good at
providing palliative care, but only the NT has taken the extra step to
offer a civilised way out instead of backyard mercy killing. Morgan Gallop
Polls indicate an overwhelming 76% of Australians want reassurance that
euthanasia is possible if needed. Our political representatives, therefore,
should give the NT legislation a "fair go".
Dr Roger Hunt has worked as a palliative care doctor for over 12
years and is currently a Senior Consultant and Clinical Lecturer. He is
a pioneer of hospice development in South Australia and a former Chairperson
of the SA Association for Hospice and Palliative Care.
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