SAVES is not affiliated with Exit International / Dr Philip Nitschke and opposes the public availability of a 'peaceful pill'.

Advocating choice for voluntary euthanasia, and promoting palliative care, are often viewed as divergent causes. This easily overlooks commonly held values including respect for human agency, reducing futile suffering, acknowledging that death is not the worst thing that can happen, and that there is such a thing as the ‘good death’. However one important difference between these two positions is around views on whether any kind of suffering can ever justify choice for voluntary euthanasia (1). Other points of disagreement focus on claims of erosion of trust in doctors, ‘slippery slope’ arguments, and whether there would be less compassion shown to the severely ill.

Those who advocate for the right to choose will argue that a person’s own view about their life as ‘worth not living’ (implying choice to act on this view), may be correct and should be respected. Palliative care providers are less likely to give credence to this view, claiming that appropriate care would always improve quality of life (2). Both positions agree about the importance of patient autonomy, but disagree over whether autonomy can ever include choice for assisted death, the degree of decision-making capacity of patients who request voluntary euthanasia, and whether or not legalization of voluntary euthanasia will erode choice through coercion of patients to follow that path.

When it comes to the ‘good death’, palliative care organizations often oppose a view that this may include voluntary euthanasia, and focus on a ‘natural’ life span, underpinned by views of the sanctity of life. The worst ‘evil’ for both is poor quality of life. For those who support choice, this is being forced to go on living, whereas for palliative care it is the curtailment of enjoying life’s remainder (3).

Need these differences be irreconcilable for publicly funded palliative care services in a liberal democracy? A ‘shared reflection’ has been called for in a 2003 position statement of the European Association of Palliative Care ethics task force calling for open dialogue between palliative care and those who promote choice. This is seen as important because:

• "it is dangerous to ignore each other’s experience and expertise
• refusing to engage in debate only leads to avoidance of difficult questions arising from ones own position
• addressing remaining questions may involve agreement with the other side
• there is a shared interest in fostering public discussion as, paradoxically, each side may need each other to keep ‘the important nuances of quality terminal care on the public agenda" (4).

It is important therefore to consider the views expressed by Palliative Care Australia (PCA) in a recent media release in response to the death of Dr John Elliott by assisted suicide at the Dignitas clinic in Zurich (5). PCA rightly highlighted that the focus of media attention may have created the impression of a ‘one issue’ debate at the end of life.

Palliative Care Australia President, Professor Margaret O’Connor, stated that there are equally important considerations:

"the rights to have access to expertise when and where it is required, the right to choose treatment or not, the right to be cared for in the place of choice, be that at home or an institution’.

Professor O’Connor was also correct to point out that Australia needs adequate systems in place and funding to promote the best possible ‘end to life’, allowing a broad picture of how we ensure care; including ‘psychological, emotional, spiritual and cultural needs of all involved’. Inadequate funding is, of course, a key barrier to care.

The argument was made by PCA that it is not uncommon for requests for a hastened death being the sign of psychosocial distress or just a ‘passing comment’. This could be valid comment. However rational requests for a hastened death are acknowledged in the PCA Position Statement on Euthanasia:

Palliative Care Australia states that palliative care practice does not include deliberate ending of life (euthanasia), even if this is requested by the patient.

Acknowledges that while pain and other symptoms can be helped, complete relief of suffering is not always possible, even with optimal palliative care.

Recognises and respects the fact that some people rationally and consistently request deliberate ending of life (6).

As has been stated elsewhere:

There is a very obvious inconsistency in these statements which creates a serious dilemma. It is exactly those patients whose pain and other symptoms are not completely relieved and who rationally and consistently request deliberate ending of life whom Voluntary Euthanasia Societies aim to help by establishing legislation. Palliative care says it respects their views but denies them assistance. Presumably it would continue to do so if voluntary euthanasia were legalised because its objection is not based on legality. It does not state what its objection is but I presume it is based on religious dogma since the hospice movement was founded by Christian idealists who wished to improve the very poor care provided to the terminally ill in the 1960s. They should be applauded for that, but as palliative care becomes the mainstream government supported model for the dying, religious dogma should no longer underlie its fundamental principles (7).

PCA also states that they:

welcome open and frank discussion within the community and the health professions about all aspects of death and dying, but recognise that an informed discussion about euthanasia cannot be heard until quality palliative care is available for all who require it.

It is a valid point that rational choice can only be made when one has all the facts about available options. Without the ability to then gain access to these options a person’s choices are less than optimal. This is why SAVES consistently supports increased funding for palliative care and promotes it in public meetings or events. However as SAVES has argued in a joint media release, with the West Australia Voluntary Euthanasia Society, Dying with Dignity Tasmania, Voluntary Euthanasia Society of Queensland, Voluntary Euthanasia Society of New South Wales, Dying with Dignity Victoria, and Northern Territory Voluntary Euthanasia Society, in response to the comments made by PCA, establishing the legality of voluntary euthanasia should not be contingent on the resolution of funding difficulties around palliative care (8). The two issues should run in parallel, as both hold equal merit. People must be free to make informed choices from available options, while also advocating for better services and funding. PCA calls for curtailing discussion on voluntary euthanasia could be construed as a gag on democracy. Importantly they also ignore the plight of those suffering here and now under even optimal palliative care.

It is of concern to SAVES that the earlier inclusive approach to open and frank discussion by Palliative Care Australia appears to have been abandoned, especially in light of their official neutral position on voluntary euthanasia. In 1990 SAVES display was welcomed at the first Australian Conference on Hospice and Palliative Care. Subsequent approaches by SAVES have been refused and this points to a position of opposition rather than neutrality.

In Oregon, where there is the right to choose an assisted death, the Oregonian Hospice Association acknowledges the social benefits (9):

The Oregon Hospice Association, and Oregon’s hospice community respect Oregonians’ right to choose. Oregonians need to know, however what their choices are. In public debates over physician assisted suicide, opposing alternatives are often offered. "Suffer or die", "Hospice or physician-assisted suicide". But no dying Oregonian must suffer, and no dying Oregonian must choose between hospice and physician-assisted suicide. A dying Oregonian can choose both from among the options on the end-of-life continuum of care... Oregon’s hospices support patient choice.

Further, on 14th February 2007 the nation's leading organization of hospice physicians dropped its opposition to doctor-assisted suicide (10). The American Academy of Hospice and Palliative Medicine has now adopted a neutral position on the issue, acknowledging that even with state-of-the-art pain management which can ease most suffering at the end of life, unacceptable suffering sometimes persists. Board member and Medical Director at the Community Hospice of Maryland, Dr. Nancy Hutton, stated doctor-assisted death is not the antithesis of palliative care:

I think it's taken as a way of providing comfort for unrelieved suffering. And so in that respect, it would be consistent with a palliative care approach (11).

In 2003, in arguing a case for such studied neutrality by professional organizations, Quill and Cassel argued: The question ‘Would you rather have excellent palliative care or access to physician-assisted suicide?’ offers a false dichotomy. A better question might be something like ‘If you have access to excellent palliative care, and your suffering becomes intolerable, what options should you be able to pursue with your physician?’ Or, from a policy point of view, ‘Is it better to have an open, legally regulated response, or an underground, more idiosyncratic, passively prohibited process?’ As our multicultural society seeks to recognise and strengthen respect for different religious and cultural views, patients and physicians will sometimes have diverse opinions on this subject (12).

It is SAVES’ intention to continue to promote the excellent work of palliative care associations while at the same time reiterating the above view and working towards its realisation.

References:

1. Hurst, S.A. & Mauron, A. (2006) ‘The ethics of palliative care and euthanasia: exploring common values’, Palliative Medicine, 20 107-112.
2. McMahon, J. (2002) cited op cit.
3. Hurst & Mauron op cit.
4. ibid.
5. http://www.pallcare.org.au/
6. http://www.pallcare.org.au/Default.aspx?tabid=1145
7. Dr Rodney Syme, quoted in The VE Bulletin, Vol 16 No 3, November 99
8. http://ww.saves.asn.au/media
9. http://www.oregonhospice.org/
10. http://www.aahpm.org/positions/suicide.phpl
11. Goldberg, K ‘Leading Hospice Organisation Drops Opposition to Doctor-Assisted Suicide, KPBS News, 28th February 2007.
12. Quill, T. E. & Cassel, K. (2003) ‘Professional Organisations’ Policy Statements on Physician-Assisted Suicide: A Case for Studied Neutrality’, Annals of Internal Medicine, 138 208-211.