EDITORIAL ‘You do it, Mr Seymour’: Euthanasia is not part of healthcare
A senior New Zealand doctor, Ross Boswell, made headlines recently with his submission to the Justice Select Committee on the End of Life Choice Bill because of his tongue-in-cheek suggestion that MPs and mayors carry out euthanasia since doctors are ethically barred.1
The reaction of many to this will surely be: ‘Well that is simply ridiculous’, and I would be one of those. But, that does not mean I disagree with Dr Boswell. As I see it, the point being made is that it is equally ridiculous to think that the agents and gate-keepers of euthanasia should be doctors or health professionals. Yet this point is lost on most people, MP’s included, who assume, uncritically, that the medical profession and euthanasia belong together.
Dr Boswell argues that the ethical proscription of euthanasia by the World Medical Association, reflected in the position statement held by the NZMA and many other health professional organisations, is for practical and clinical reasons: “… patients must be able to consult their doctors in the clear knowledge and trust that the doctor is working to provide care and support, not sizing them up to administer a lethal dose of medication.”2 As Palliative Care doctor Tim Harlow has stated: “We are worried about the very real potential for normalising something that is not, and should not be considered, normal and should not be a part of routine medical practice”.3
It is well known that the original proponents of euthanasia in the Netherlands wanted it to be 'self-determined', that is, available as a personal choice without the need to fulfil any particular conditions such as being terminally ill – effectively euthanasia-on-demand. However, it was originally deemed necessary for doctors to be involved in order to gain public acceptance for the practice and to precipitate the passing of legislation. With the debate in the Netherlands now centring on introducing a ‘peaceful pill’ (allowing people who believe their lives are ‘complete’ to kill themselves without reference to or without the help of a doctor), that goal is likely to be realised soon. In the meantime, groups such as de Einder openly acknowledge they are already promoting such pills illegally on the basis that every person has the right to end their lives without outside interference.4 Bizarrely, but not surprisingly, the fact that it is already happening illegally is one of the key arguments used for making the suicide pill legal; ‘Legalisation is essential for preventing abuse,’ it is claimed.
Over the years, various researchers have studied the effects on doctors of being involved in euthanasia. One such qualitative study by van Marwijk et al (2007),5 titled ‘Impact of euthanasia on primary care physicians in the Netherlands’, used four focus groups involving a total of 22 primary care physicians (PCP’s). It provides a number of useful insights capable of informing the current debate in New Zealand.
Reflecting on the first occasion they were involved, many PCP’s described “problematic, and sometimes even traumatic experiences, such as loneliness, mixed feelings and contradictory emotions”.
While some PCP’s had “‘heroic feelings’ because they were able to help someone”, others “regretted their first performance for reasons such as ‘insufficient awareness of the other palliative possibilities’” or “‘having been manipulated by the family or the patient’”.
Many PCP’s describe feeling relief after the event and feeling satisfaction when it went well, however “a number of physicians remarked that the relief was greatest if the request for euthanasia or assisted suicide was withdrawn.”
Many PCP’s in all groups talked about feelings of loneliness after the event.
PCP’s mentioned various feelings concerning the role of families, “varying from gratitude and satisfaction to pressure, manipulation and tension and sometimes even conflict.”
The study authors conclude: “Euthanasia is a drastic, and sometimes even traumatic event … [The PCP’s] cannot simply resume their daily routine afterwards.”
While some PCP’s said they had no problems or “considered it their duty” to perform euthanasia, many others “are wrestling or have wrestled with the dilemma of why they, as doctors, have to end life or perform euthanasia.”
Most PCP’s have become more reluctant over time to perform euthanasia and a number have decided not to do it.
One quote in the study is particularly instructive regarding the impact of euthanasia on patients. “I hate it. The patient is no longer granted the time for a natural dying process. He’s saddled with the question ‘when do I want euthanasia?’. To have to decide about the moment of death has created enormous unrest around the deathbed.”
There is much to learn from the overseas experience of countries such as the Netherlands. Four lessons stand out, however: (i) Euthanasia is not part of healthcare; (ii) the categories will inexorably widen; (iii) its very availability will impose a significant burden on doctors and (iv) create enormous unrest for families and patients while also burdening patients.
Dr John Kleinsman is director of The Nathaniel Centre, the New Zealand Catholic Bioethics Centre
3 Harlow T. BMJ Supportive & Palliative Care 2015;5:122–123.
4 See https://www.deeinder.nl/
5 Journal of Palliative Medicine (2007), 21, pp. 609-14.