Why do we want to turn our doctors into death dealers?

What the proposed Victorian assisted suicide and euthanasia regime may do to the medical profession.

We’re told repeatedly that having the ‘option’ on the table for an early death by way of a lethal dose or a lethal injection will help our medical professionals talk more openly to their patients about their medical situation and their eventual death. This is a slur upon the medical profession.

Professionals who deal with patients with difficult diagnoses know well how to have full and frank conversations about all sorts of matters with their patients. Simply because they cannot currently agree to assist their patient to die by suicide or euthanasia doesn’t mean that the conversation does not happen; that there is no resolution to the question. The reverse may actually be the case; the inclusion of such an option may change those conversations for the worse.

This is because an adverse diagnosis may see a patient push for a prognosis where, absent a law, there may have been no pressing need. They have every right to gain some perspective on life expectancy, certainly, but skilled medical professionals will normally shun providing a time line to death, simply because, at the early stages of many cancers any determination outside ‘days to live’ is fraught with inaccuracy.

As one palliative specialist told me recently: “The problem is, if you say 3 months for example, every day after the 3 months the person expects to die that day – it creates additional anxiety. If you say 3 months, and the person dies earlier, people say they felt unprepared.”

“To prognosticate more specifically is always fraught, because you will always be wrong!”

The early days, weeks and even months of a difficult diagnosis/prognosis are incredibly difficult. The person’s life and plans are thrown up in the air. It’s the same for family members. The world as they know it seems to stop for a while. What will it all mean? Will their thoughts turn to thinking about an ‘early exit’ and even asking their doctor about it? Sure will. Even those most firmly opposed to assisted suicide or euthanasia will surely have such thoughts, even if only for a moment. The availability of being able to be made dead may compel the conversation.

Right now, here’s how a clinician would respond: “If a patient speaks of assisted suicide, it should trigger a clinical response to assess fully the suffering experience, to dissect out its components and act to reduce each one (eg. pain, depression, anxiety, fear of dependence, nausea, family conflict, Wills and estates etc.).”

If the Premier, Daniel Andrews gets his way and assisted suicide and euthanasia become legal options in Victoria, people may still submit to such clinical good practice, but they may not. In the latter case if a patient persistently asks for assisted suicide, will a medical professional succumb to that pressure when he or she knows well that clinical best practice may resolve the underlying reasons for the request?

Remember, under the Victorian proposal it is the patient themselves who determines if their pain and suffering is intolerable. The doctors must simply acknowledge the assertion. Remember also that a ’12 months or less to live’ prognosis is determined, for the sake of qualifying for the new law, on the basis that the person does not accept any treatment. The person may have years to live with good care and may even experience remission. None of this will not sit well with professional clinicians whose role is to treat and to care.

Medical professionals are understandably reluctant to provide prognoses for reasons already explored. Experience will guide them, rather, to look to treatment options, to build genuine hope, to solve existential difficulties and to forge a relationship of trust with their patient.

Pro-euthanasia advocates are keen to point out that the data from Oregon shows that there’s a cohort of people who receive the lethal dose who do not eventually take it; the argument being that the very presence of ‘the option’ is somehow palliative. It gives them some peace of mind. This is likely to be true. However, that’s not the full story and it seems to me to be a dangerous and unnecessary path to take when there are other clinical options at the disposal of medical professionals that may have precisely the same effect without the grave risk.

My palliative care contact observes: “The lethal drug making people feel more in control, indicates to me the anxiety element to their suffering experience, which needs to be recognised (as does the family fears and anxiety) and treated; if these things are ignored (as they often are) by the doctor missing them, people tend to think of legalistic solutions.”

His reference to doctors reflects a commonly held sentiment amongst palliative care professionals that general practitioners have insufficient training to detect and to treat in the manner described. “I maintain a large part of the background problem is poor knowledge of palliative care in the average doctor and average nurse.”

Yet it may be such doctors that become part of the assisted suicide regime, referring their patients to their likeminded colleagues for the mandated second assessment. The recommendation that such doctors need to be ‘qualified as a Fellow of a College’ may not mean that they have the same level of clinical skills as a do their palliative care counterparts. One of the two confirming doctors would need to have expertise in the person’s disease, illness or medical condition, but the level of expertise is not further defined. It is entirely possible that a small cohort of doctors may decide, to make things easier for themselves and their patient, to refer to each other; making a sham of the assessment process.

One only need look to the report on the suicide cases under the short-lived Northern Territory law in the 1990s to see just how ineffective such processes can be. There, even the mandated psychiatric assessment (note: not to be mandated in Victoria) was successfully circumvented.

Returning to the prognosis and noting clinicians’ reluctance to be specific, what are we to make of any assertion that a person has 12 months or less to live? Not only is a ‘best guess’ possibly way off the mark, it is also likely to be incontestable. The doctor only need assert that they ‘acted in good faith and without negligence’ even if he or she were wildly wrong. Even if it were ever suspected that they had nominated ‘12 months or less’ when they knew that this was not the case, they are protected from prosecution under the ‘good faith’ provision – and no one will ever know.