What can Australia learn from other countries in legalising physician assisted suicide or voluntary euthanasia? Jessica Qi takes up the cause.
In his famous work ‘On Liberty,’ John Stuart Mill proposes that if a person is observed preparing to cross a bridge that you know to be dangerous, you may intervene to inform them of the risk of the bridge’s potential collapse should they continue, but you must ultimately move aside as only they know the importance of crossing and balancing that against the comparative risks. Philosopher Peter Singer draws on Mill to propose that this same right to autonomy extends to the euthanasia debate. Indeed, at the crux of the pro-euthanasia argument is the notion, that it is individuals who represent the best guardians of their own interests.
Support for autonomy in end of life decision-making is now eschewed by the majority of the Australian public. A 2016 survey of over 200,000 Australians garnered an approval rate of 75% for euthanasia.
Despite such support, Australia currently lacks jurisdiction that legally permits either voluntary euthanasia or physician-assisted suicide (PAS). Euthanasia is where the physician administers the lethal dose whereas with PAS, the physician provides the prescription that is the means of death but does not directly administer it.
The growing trend towards the legalisation of euthanasia or PAS in countries worldwide, means that Australian legislators will continue to face mounting pressure and will need to carefully consider the issue.
One of the major concerns for opponents is that the legalisation of euthanasia is a slippery slope. There is a fear that vulnerable people will be pressured into consenting, as they are perceived as a nuisance by their families or because of cost-cutting measures by their health providers. However, does citing examples of the abuse of a legal right provide sufficient cause to justify withholding that right?
To answer this, Benatar in his article disputing the slippery slope argument, makes an analogy to driving. People will always drive faster than they should; run traffic lights; drive vehicles that are un-roadworthy and often choose to drive under the influence of drugs and alcohol. Despite all this, few people would then accept the argument that driving should be outlawed altogether.
The answer must not be to deny a right, but instead to regulate and implement safeguards to mitigate the risk of abuse. This has been demonstrated in the numerous jurisdictions where legalisation has occurred, with little evidence of abuse emerging.
A 2016 study of the “Attitudes and practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada and Europe” concluded that, “the argument that minorities, the disabled, the poor or other socioeconomically marginalised groups might be pressured to accept does not appear to be borne out.” In fact, the demographic profile of patients in the United States, who had received these interventions were white, well-educated and well-insured.
It was further noted that the incidence of deaths following administration of lethal drugs without explicit consent declined from 0.8% of deaths in the Netherlands in 1990 to 0.2% of deaths in 2010. Similarly, in Belgium, deaths without explicit consent were estimated to have dropped from 3.2% to 1.7% of deaths following legalisation.
Approaches to implementation vary, in the US states where PAS has been legalised, recipients must be terminally ill with a survival prognosis of 6 months or less. In Belgium, Luxembourg and the Netherlands patients must possess “unbearable physical or mental suffering” without the prospect of improvement. Often a cooling off period is imposed to safeguard against rash decision-making.
All US states require a 15-day period between two oral requests, and then a 48-hour waiting period before the final written request. Canada requires a waiting period of 10 days whilst Belgium requires 1 month.
Allowing someone to end their life on the grounds that they are experiencing profound mental anguish has been the subject of intense debate as their ability to make rational decisions is questioned. Opponents argue that people with suicidal ideations are experiencing a merely transient mood, often onset by depression or another mental illness; we therefore have a duty to treat these individuals rather than facilitate impulsive decision-making.
The existence of ‘transient’ cases however does not justify overlooking individuals suffering from ‘treatment resistant depression’. For these individuals, depression is not merely a transient mood and they will have not responded adequately to multiple differing courses of antidepressants. It is estimated that 10 to 30 percent of depressed patients are in fact treatment resistant.
Faced with this suffering, is there not inhumanity in depriving these individuals of their autonomy and the opportunity to decide for themselves whether such a quality of life is endurable?
A comprehensive screening process that separates ‘determined suicides’ from impulsive ones is an essential consideration of any potential change in Australian euthanasia law. A regulatory system will need to be developed to improve access to mental health services and social care to ensure Euthanasia or PAS presents as an absolute last resort.
Data from the Netherlands indicates that roughly a quarter of psychiatric patients die with assistance from a physician not previously involved in their treatment, and thus determination as to whether a condition is untreatable would have been made by someone who has known the patient for only a short time.
Qualified psychiatric evaluation must be compulsory for patients with suspected depression or mental illnesses to ensure available means to reduce mental pain and suicidal ideation are exhausted – currently, this occurs in Belgium but not in the Netherlands or Switzerland.
In line with the slippery slope argument, critics of PAS warn that the prospect of death will become an acceptable alternative to the adequate provision of resources in palliative care, with PAS viewed as a ‘quick fix’, which policymakers may begin to favour.
Interestingly, the empirical reality suggests such fears have not been borne out according to findings from a report of the European Association for Palliative Care, which compared changes in palliative care amongst European countries where PAS and or euthanasia has been legalised with those where it had not.
Luxembourg and the Netherlands made great strides to grow their palliative care resources between 2005 and 2012 moving closer to the level of the top four European countries, of which Belgium is one. The overall Belgian palliative care expenditure doubled in the run up to legalisation, growing at a rate several times that of overall healthcare. This was a deliberate move by Belgian and Luxembourg legislators who wanted to ensure that palliative access was made universal concurrent with the legalisation of PAS.
Taking action to oppose a person’s decision that life is no longer worth living inflicts on them serious harm. We must respect individual autonomy and the ability of a competent individual to make rational decisions about their life, even if that decision is to end it.
If Australia is to legalise voluntary euthanasia or PAS, regulation and enforcement of safeguards to deter abuse of any potential laws is imperative. As a society, we must ensure that individuals are afforded the palliative care and mental health services so that euthanasia or PAS is viewed a last resort.
* Support can be accessed through Lifeline, on 13 11 14.
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