Assisted suicide - a counsel of despair

By Paul Russell:

The Age newspaper reports barely a week before the Victorian Parliament's Report into 'end-of-life' choices that it expects the committee to recommend some form of legislative change. A form of assisted suicide is widely rumoured.

Whether this suggestion is taken up by the government or by a backbencher as a private member's bill is yet to be seen.

The Age journalist concludes by saying that, '(w)hether Parliament agrees that it's time for reform is yet to be seen, but one thing is certain: the evidence to the inquiry has been compelling.'

Compelling it certainly is. More than one thousand submissions is a significant public response to what is clearly a vexing and polarising issue for the community. In addition, the committee heard from about 100 witnesses who appeared before them over a number of months at forums held across Victoria.

Of those 100 or so witnesses, many were from professional bodies such as palliative care units, regional health centres, institutes of study, public interest groups and academic institutes. The vast majority of these, something like nearly 80%, were either against euthanasia (about 10%) or were focussing on other issues such as improving care, improving regional services, reform and improvement of advanced care planning and the like. This latter cohort overwhelmingly did not mention euthanasia or assisted suicide at all.

It was a similar situation with the submissions: approximately 78% of substantive submissions (submissions of detail and from health providers, institutes, lobby groups etc.) were either against euthanasia and assisted suicide or were neutral and preferring to focus on end of life care more generally.

Overall, the total submissions were about 56% in favour with the remainder either being opposed (approx. 35%) or neutral (approx. 7.3%). It must be said that some of the personal stories of difficult deaths were very hard to read and cannot be ignored. The question that needs to be asked is how to help all Victorians have a 'good death' and not just those who have some notion about wanting to be made dead? The professional submissions, setting aside the lobby organisations both pro and con, spoke magnificently to that end.

If the rumours about the committee's recommendations for some sort of assisted suicide legislation are proven true, I expect that they will also comment about these professional submissions that point to the need for improved care with a 'yes but…' type of summary. It is the 'but…' part that points to the problems associated with assisted suicide and euthanasia legislation, as evidenced in The Age article mentioned above, and the submission by the Victorian Coroner, John Olle and his colleagues.

Olle's evidence before the committee, cited in the above article, focussed on the Coronial data of suicides by people who they defined as people 'with 'irreversible decline', so terminal disease; death was foreseeable; incurable, chronic disease but death not imminent; permanent physical incapacity and pain. But the cohort did not include mental ill health or feared imminent decline.'

The numbers were defined as '50 cases per year between 2009 and 2012. It is a small cohort, but a significant number. We are looking at 8.6 per cent of suicides that meet this criteria set out in our definition of our cohort.'

A panel question from The Hon James Mulino MLC has Mr Olle respond with what I consider to be a counsel of despair:

Mr MULINO - "I am just wondering whether, firstly, even within that subset that you have looked at you feel that there are instances where there is the potential to help people feel less alone and more supported and, secondly, whether in the data that you have looked at there is any change over time as palliative care perhaps improves. Have you noticed that that cohort is changing the composition of the overall rate of suicides over time?"

Mr OLLE - "I do not think it is an issue in this small cohort we are referring to, where very tight criteria are applied. The numbers might be far greater than the numbers we have found - very tight, very conservative. No, to my knowledge the people we are talking about in this small cohort have made an absolute clear decision. They are determined. The only assistance that could be offered is to meet their wishes, not to prolong their life." (emphasis added)

So, the only intervention Mr Olle sees in helping these people who want to suicide is to help these unfortunate people to die.

Olle's colleague, Dr Dwyer follows offering support to Mr Olle's point but then, curiously, seems to contradict him:

Dr DWYER - "On that point, at the time when they have made the decision to suicide, I completely agree that the potential for intervention in a number of these cases would be a long time before that. There are some well-documented issues that coroners have been discussing repeatedly, particularly around the management of pain and the need to get more pain specialists involved earlier rather than it being like the mental health system, which devolved to where you could not get into the mental health system unless you were in crisis. It appears to be that way at the moment with pain treatment, and this has been pointed out by all kinds of organisations involved in pain treatment and so on."

Dwyer makes it clear that there may well be opportunities for intervention - even if it needed to be far earlier. Mr Mulino follows up with a request for confirmation:

Mr MULINO - "So in some cases, by the sound of it, intervention earlier might have been possible."

Dr DWYER - "I think so. In a lot of these suicides there is a trajectory over time. It is not like something suddenly happens and they make a decision. There is this trajectory, and there are attempts to engage in treatment. It would be interesting to get some kind of review of whether earlier and different treatment might have made a difference, but by the time they are at the point where they are suiciding, as Coroner Olle has indicated, these are not people where you can say 'Oh, if we just switch medications, everything will be okay'. It is a long way past that."

Setting aside the sad reality that people do and probably always will take their lives in response to difficult circumstances, as Dr Dwyer makes clear, there are issues of intervention that have not been explored here that may well have made life more bearable for these people. There is more assistance that can be offered.

Olle and Dwyer are clear, this is not about the kind of suicide prevention that we normally would think of. Rather, it is about a system failure that did not or could not care enough earlier on so as to foresee possible problems and to provide better care.

It is also true that some simply do not want the kind of care on offer, for their own reasons. We all have that choice. But that does not mean that because people refuse genuine and effective care options that we as a society have any obligation to provide death as the answer. But it would be a very sad day if we did not provide the very best of care and timely interventions and people chose suicide for lack of genuine choice which, I suggest, is precisely the counsel provided by Olle.

The Age's portrayal of the Coroner's submission is that it argues the case for euthanasia and or assisted suicide. In their testimony, Olle and his colleagues seemed to shy away from formally supporting such a program, though it is hard not to conclude that this was at least partly their intention.

The article concludes, in part, that the Coroner's information is, 'the kind of information that many would rather ignore - shocking, sad, hard to fathom - but in the context of an inquiry into end-of-life choices, it's the kind of data you just can't avoid.' It should not be ignored. The question is, as always, how do we respond?

The fact that Olle seems to be writing off any other solution to this cohort of suicides than death is, unfortunately, loading the information. It is also a snap shot of the reality of euthanasia and assisted suicide from the perspective of disabled people who oppose euthanasia; the characterisation of a subset of humanity who are constantly rebutting the implicit and even explicit message that they would, indeed, be better off dead. It would seem that they are not the only ones…

The Committee Report is due to be tabled on the 7th of June.

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