Whose choice should it be?

2011-10-19 00:00

THERE are attempts being made again to get the government to consider introducing legislation to allow doctor-assisted suicide in this country. These attempts are motivated by compassion for suffering people and a desire to allow people dignity when they die.

But as a doctor, I am filled with trepidation­ about the idea of including euthanasia in the package. Why am I concerned?

To lobby for euthanasia will be a departure from 2 400 years of ethical wisdom in medicine. It was about 400 BC that Hippocrates first had doctors swear: “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.” Jewish, Christian and Islamic physicians agreed with this stand, citing God’s sixth commandment: “You shall not kill.”

Acceptance of the sanctity of human­ life has been an essential pillar­ of the practice of medicine ever since.

It is this ethic, which underpins their sacrificial service, that allows us to trust our doctors.

You just have to look at examples of nations that have debunked that ethic to test the truth of that statement.

In the twenties, German physicians led the campaign that allowed euthanasia for terminally ill men and women­. By 1939, the government was practising genocide.

In Dr Leo Alexander’s 1949 report on the Nuremberg War Crimes Trials in the New England Journal of Medicine­ he wrote: “ ... it became evident to all who investigated that [the Nazi crimes] had started from small beginnings. It started with the acceptance of the attitude that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually, the number of those included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted, and finally, all non-Germans. It is important to realise that the infinitely small wedge — the lever from which this entire trend of mind received its impetus — was the attitude toward the non-rehabilitable sick.”

But surely the Nazis were a special case?

Well, consider the case of Holland, a nation whose people suffered so gallantly­ to save Jews from Nazi death chambers.

In 1973, a physician gave a lethal injection to her mother, and that event sparked a strong campaign to legalise euthanasia. In 1981, criteria were promulgated for voluntary euthanasia for people with terminal illnesses.

In 1982, criteria for voluntary euthanasia were extended to include people with chronic illnesses.

Good research shows that doctors are very poor at correctly judging the quality of life of their patients. Yet since 1985, Dutch doctors have been making value judgments on patients’ lives and killing them without their permission. Reporting of cases is very erratic, but in reported cases of euthanasia in 1996, 56% of the patients had been killed without their consent.

Doctor-assisted suicide has been allowed for mental suffering in Holland since 1994. So now doctors are assisting depressed people, who have a treatable condition, to commit suicide­. One doctor helped a young woman in her early 20s to kill herself as she was depressed because she could no longer dance. Her feet had been damaged. When challenged, he could only reply: “We do not like doing this kind of thing, but that was her request.”

Now 16-year-olds may legally make a decision for voluntary euthanasia without parental consent.

By 1997, it became clear that there were no penalties for not obeying the rules because the whole issue in Holland is so muddied, both legally and ethically, where doctors are concerned. Holland has since lagged seriously behind other European nations in its delivery of terminal care.

Dutch doctors receive some of the best training in the world, yet in palliative care so many now fail the ethical tests of respecting the patients’ autonomy, of avoiding malificence and of acting justly. They practise the worst forms of paternalism.

Holland has a good judiciary and police service. Yet many people carry cards in their wallets instructing that they should not be killed by a doctor if hospitalised. They no longer trust their medical fraternity,

Now, we South Africans do not live in a stable country like Holland or Switzerland.

We live in a fragile democracy with a recent history of a low-intensity civil war. Many of our people are very poor and angry. We also have deep racial and political divisions, with the associated continuing violence. In those respects we are a bit like Germany in the thirties.

In addition, we have serious problems with the management of health care, policing and justice. We are not even able to police our abortion legislation properly.

There is not the slightest possibility of our policing legislation for any sort of active euthanasia, and it will be impossible to confine it to well-structured “havens” if it is made legal in this country. Given our current political instability, there is a real chance of it being turned into an instrument of oppression.

Every decision for voluntary euthanasia will inevitably draw others into it. Spouses, siblings, children, grandchildren and friends must be free to grieve a death without having their grief subverted by a decision for doctor-assisted suicide, if they are to grieve freely and healthily.

With active euthanasia, we will be adding deaths by the well-researched process of “suicide contagion” — later suicides which follow one that has occurred in a family or peer group. This is all very well documented in relation to abortion.

One argument advanced for the introduction of doctor-assisted suicide is that suicides are common among patients who are terminally ill. In fact, the incidence of suicide among terminally ill people is low, making up only two percent to four percent of cases of suicide in a number of large studies from the United States, the United Kingdom, Sweden and Australia. And good Hospice care is an excellent medical intervention to prevent such suicides.

Finally, it is essential that medical staff be protected from ambivalence in their work, so that they can always concentrate on the tasks of saving lives and providing excellent care for those needing it.

If euthanasia is legalised, it will be a whole lot easier for a doctor to learn that you do not need to try too hard to save lives in difficult and exhausting clinical situations — that it is okay to give up.

The author of a report in a major American medical journal concluded: “Most patients expressing a desire to die want to know whether they are still worthwhile. So often, the suicide request is really asking the question, ‘Does anyone care?’ The worst thing doctors can say in such a situation is to agree that physician-assisted suicide is a ‘good’ option.”

Death with dignity is only possible if the relational, existential and spiritual issues at the end of life are addressed — such things as offering and receiving forgiveness, or having time for a family to gather around a dying member to celebrate his or her life and affirm his or her worth. Encouraging a rapid escape from facing these issues by doctor-assisted suicide implies defeat, not dignity.

The objective of good Hospice care is death with integrity. That allows the patient to reach for wholeness. That brings dignity, and it is greatly preferred.

• This is an edited version of a paper Jon Larsen presented at the recent launch of Dignity SA, an organisation dedicated to getting access to doctor-assisted suicide in this country to which he is opposed. Larsen is a member of Doctors for Life, and a senior gynaecologist. He has been in medical practice for 49 years.

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