This week, two front line doctors from Australia and New Zealand have given voice to their concerns about the legalisation of euthanasia and assisted suicide and the consequences for the practice of medicine, as well as for the long term care of patients at end of life.
Their perspectives provide an incredibly important contribution to the current debate, given that they are the ones who daily care for people at end of life and have either witnessed first-hand the impact of legislative changes, or understand deeply what a threat potential laws will undoubtedly have on the doctor/patient relationship.
Dr Odette Spruijt is a Victorian palliative medical specialist with more than 25 years of practice. Her reflections on the impact of the Victorian euthanasia and assisted suicide laws are sobering:
“I have found the institution of the Victorian law to have a devastating effect on my practice of palliative medicine. I have witnessed the devastating impact of this law on the cohesion of teams, on the relationships within clinical units, and as a cause of deep moral distress among many of my medical colleagues, for whom this law, and its accompanying narrative, is anathema to the very core of our sense of what it is to be a doctor.”
Erosion of trust in the doctor/patient relationship
The dynamic of trust that is fundamental to the doctor/patient relationship is put at risk when the state grants doctors the power to take people’s lives.
Dr Spruijt describes the established approach taken by palliative care specialists when it comes to therapeutic conversations with patients. They are trained to be reflective practitioners who listen to their patients and work hard not to project their own values or judgments onto patients. The potential for a doctor, however, to subconsciously influence a patient’s decisions plays on her mind, especially now that one of the legal “options” that a patient may choose is fatal:
“How can I be sure that my exhaustion, my anxiety, my discouragement, my fear of my own mortality, as well as my value system and the limitations of my knowledge are not adversely influencing this patient in their decision making? Just as I examine these relational dimensions of my practice, so I wonder about the intersubjective dynamic between consenting and consulting clinicians and the patients they see. How do they ensure that they are not influencing or being adversely influenced by the interaction? No legislation, with its accompanying rulebook, can detect the subtleties at the depth of these interactions.”
As a doctor opposed to euthanasia and assisted suicide, Dr Spruijt describes the way in which she has a new hesitation to:
“…invite open discussion about end of life care wishes, for fear that this will be interpreted as an invitation to discuss VAD, with which I cannot engage. Previously, this discussion took place in a secure space of ‘even if I (patient) wished for this, I know you (doctor) cannot do it and will do all you can to help my suffering”, whereas now there is uncertainty as to what I am saying or meaning and what the patient is saying.”
The elephant in the room is now enormous.”
“Currently, my patients know that whatever their station in life, their age, gender, sexuality or ethnicity, I will do all in my power to support life, promote life, enhance life, and when life is ebbing away, relieve symptoms and provide support.
As long as current laws stand, my patients do not have to fear the fact that I also hold the power to legally end their life.
I … believe that to allow a doctor to end a patient’s life, be that with full consent and with the considerations proposed by the [New Zealand’s End of Life Choice Act] is to fundamentally erode the doctor/patient relationship.”
Dr James experiences first-hand the way that many patients feel they are not as ‘worthy as others to receive treatment’.
“The other day I phoned a patient to discuss the options for treatment of her cancer and she pleaded with me not to deny her treatment. ‘I know I may have terminal cancer and I am older but I have so much to live for; please allow me to have treatment.’ I reassured her that she would be given any treatment that was suitable for her.”
Dr James fears that many of her terminally ill patients may, should the End of Life Choice Act in New Zealand become law, become “open to subtle coercion to feel that receiving [euthanasia or assisted suicide] would be the ‘right thing to do’ to avoid being a financial or physical burden to those who care for them.’”
These fears are not unfounded. In Oregon, year after year, the statistics show that many people are requesting assisted suicide because they fear being a burden on family, caregivers and friends.
A less humane approach to patient care?
Perhaps one of the most alarming consequences regarding the doctor-patient relationship is the way that an expression of a wish to die can now be taken at face value:
“I feel deep distress when I see junior doctors respond to patients’ expressions of a wish to die by beginning the VAD process. There is no longer the mental health review, no longer the palliative care pathway, now there is just the simplistic acceptance that a wish to die in a person with life-threatening illness can be taken at face value and acted on.”
Is that really where we want medical care for our terminally ill to end up? Do we want a dumbing down and a de-humanising of the care that patients receive? How many wrongful deaths are occurring as a result? How many unspoken cries for help and support have been missed because the magic words “I want assistance to die” were uttered by a patient?
Every person, no matter what their state in life, is worthy of society’s care and concern.
We deserve better than euthanasia and assisted suicide.