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

The following article appeared in the Florida newspaper, The Tampa Tribune, on 4 July 97. It could just as well have been describing the situation in Australia.

When the Supreme Court ruled last week that States may continue to ban doctor-assisted suicide, it addressed the kind of death in which doctors actively help patients kill themselves.
    What was not considered in that decision is the fact that nowadays many, if not most, Americans die because someone - doctors, family members or they themselves - has decided that it is time for them to go.
    What might be called managed deaths, as distinct from suicides, are now the norm in the United States, doctors say.
    The American Hospital Association says that about 70 percent of the deaths in hospitals happen after a decision has beenmade to withhold treatment. Other patients die when the medication they are taking to ease their pain depresses, then stops, their breathing.
    There is less information on the deaths that occur in nursing homes and in private homes. But doctors say they often discharge patients from a hospital with the implicit understanding that they are sending them home to die, with a morphine drip for pain or without the ministrations of what they would call overzealous doctors at a hospital who might start antibiotics to quell a fever or drugs to stabilise a fluttering heart.
    "It's called passive euthanasia," said Norman Fost, director of the Program in Medical Ethics at the University of Wisconsin. "You can ask who's involved and is it really consensual, but there is no question that these are planned deaths. We know who is dying. Patients aren't just found dead in their beds."
    Doctors, Fost said, decide not to provide antibiotics to treat an infection, or they withdraw drugs that maintain a patient's blood pressure, or they remove a patient from a ventilator.
    Maurie Markman, a gynaecological cancer specialist at the Cleveland Clinic, said a typical case might involve a woman with ovarian cancer who at first responded to chemotherapy but whose cancer now seemed impervious to the powerful drugs, and had developed bowel obstructions. He could operate to try to remove the obstructions, but the chances are that it would do no good. Or, Markman said, "you can put a tube in to drain her stomach so she doesn't throw up." "But then", he added, "you have to ask the woman, 'Is that what you really want?' " She would have to live with that tube for the rest of her life.
    Markman, who said he sees such patients "at least once a week," tells the woman that he wants to focus on her symptoms rather than on her underlying disease. He sends her home with pain medications if she is in pain and anti-nausea drugs if she is nauseous, but the woman will never eat or drink again because of her obstructions. She will not return to the hospital for any sort of aggressive treatment.
    Markman said he never bluntly tells the woman that there is no hope and she is going to die, but he, and probably she, know what is going to happen - and soon.
    Is that assisted suicide or assisted death, or is it relief of suffering? For Markman, the answer is clear. "My intent always is to relieve suffering. If that's my goal, I can look myself in the eye. I can go to sleep at night."
    Joanne Lynn, director of the Center To Improve Care of the Dying at George Washington University School of Medicine, said her typical case might be an old man, fragile and with multiple medical problems. She will finally discharge him from the hospital and send him home to his family, knowing that the decision to send him home is a decision to let death come soon.
    If he develops a fever, there is no reason even to take his temperature, she said. "The agreement is that he will not come back into the hospital for almost anything."
    Lynn added: "Many of the decisions may be ambiguously articulated. They may be as much as a nod, something brought up in conversation, 'How do you feel about staying here?'"
    But underneath the nods and significant glances, she said, is a conclusion that it is time for the patient to die.
    Yet, Margaret P. Battin, an ethicist at the University of Utah, asks, "How much do the patients and family members really understand?" She said patients and family members might not grasp the hidden message in their doctor's words.
    "When a patient is asked, 'Do you want to go home and be with your family?' it would be easy to misinterpret that," Dr. Battin said. "Or", she said, "if a doctor says, 'I can see you're in pain, let's start a morphine drip' ", a patient may not realise that the pain medication will shorten his life. "I can imagine a great many patients who would say, 'I don't want this pain, but if the medication is shortening my life, I can live with the pain,' " she said.
    "That lack of candour about how the patient's death will occur and under what conditions is the thing that's particularly troubling", Dr. Battin added. "The patient is being invited to make a choice without understanding what the stakes are."
    It is even worse, she said, when family members make these choices for patients.

Gina's article highlights the inherent complexity of health care in many end-of-life situations and the potential for misunderstanding and confusion. Although the approach taken is usually regarded as ethical and certainly as legal, it is not satisfactory. It is hypocritical to take the position that once death is decided as in the patient's best interests, a slow death is always better than a quick one. As in Irma's situation described in the preceding article, the denial of the latter option prevents clear communication about prognosis and options. The potential for abuse and mistakes, so much a part of the minority opposition to legalising voluntary euthanasia, must surely be greater when clear communication is denied.