A GOOD DEATH: An Argument for Voluntary Euthanasia
By RODNEY SYME
Melbourne University Press, 2008, 301 pp, $32.95 (pb)
Review by Phil Shannon
Dr Rodney Syme was nervous when he took the call from the Victorian Homicide Squad in January 2006 wanting to interview him about his involvement in the suicide of Steve Guest, a cancer sufferer who had, with Syme, made a very public case for legalising voluntary euthanasia (VE). At the police station, Syme, a urologist, was treated as a suspect and fingerprinted like some common criminal but the detectives seemed a touch apologetic about it, as if they had no real desire to prosecute.
As Syme concludes in his moving book reviewing dozens of personal case studies of VE (or, in Syme’s preferred term, ‘physician-assisted dying’), the lack of serious prosecutorial intent is because of the negligible chance of securing a conviction, despite VE’s illegality, from any jury drawn from a public which overwhelmingly supports compassionate medical assistance to die for people with unmanageable, incurable pain.
Syme’s history with patients experiencing unbearable suffering began thirty years ago. Cancer, the neurological diseases of multiple sclerosis (MS) and motor neurone disease (MND), and other diseases are appalling ways to die, often involving a crescendo of suffering towards the end. They can cause debilitating chronic pain and acute pain, with intensely distressing side-effects (such as nausea and mental clouding) from the morphine used to treat the pain. Inexorable muscular paralysis and total dependence can be the only future.
Incontinence (requiring colostomy bags), constipation (requiring enemas) and the discharge of mucus and faecal matter from mouth and vagina are all possible, a terrible assault on personal dignity. Stomach feeding tubes replace eating. Cachexia (loss of appetite, weight and energy) can seriously degrade a life. Mental function can deteriorate. Dementia can leave sufferers in a permanent vegetative state, a caricature of a human being.
Severe emotional and psychological suffering can also result from the physical degeneration, and a profound sense of burden to others, total dependence and loss of control, dignity, worth, personality and reason for being (‘existential distress’) are often feared more than pain.
In the face of this reality of suffering, there is a widespread practice – covert, illegal and often unsatisfactory – of hastening death, based on the futility of further treatment or the necessity to relieve further profound suffering. What Syme calls a “benevolent conspiracy of medicine, law and government” to not challenge the practice hides the reality that physician-assisted deaths happen in homes, hospitals and hospices.
Surveys of health professionals in Australia have found that around a third of Australian doctors have administered lethal doses of drugs to relieve suffering by hastening death. Other methods used include withdrawal or non-initiation of life-prolonging medical treatment, and the voluntary withdrawal of food and fluids (with sedation so the patient sleeps through any distress from starvation and dehydration).
The problem, says Syme, is that the most dignified and efficient methods (such as oral, quick-acting barbiturates, the best of all methods by causing deep sleep and death in under two hours) are illegal (because they can be seen to cross the line between intent to relieve suffering and intent to cause death) whilst the least dignified, most protracted and most unsatisfactory methods operate with relative immunity from criminal prosecution (because they blur the difference in intent).
The result is a choice between dying badly (the de facto practice) and dying well (which legalised VE would allow). Increasing the dosage of morphine and sedatives, for example, can be crude, undignified and ‘macabre’, with waking and distress during the process, because maximal palliation at the beginning, sufficient to cause a quick death, runs the risk of being seen by the law as intending to cause death rather than to relieve pain.
In addition, whilst VE remains illegal, it may be occurring without due care and skill with bungled attempts making things worse for the patient. The disastrous toll of do-it-yourself deaths from ‘mercy killings’ by partners, and the savagery of gruesome, lonely suicides, round out the grim picture. The situation is similar to the terrible suffering of backyard abortions, says Syme, when that illegal medical procedure is zealously prosecuted.
It is a sorry reflection on the state of the ‘civilised’world that VE is legal in only Belgium, the Netherlands, Switzerland and the state of Oregon in the US, and that all other countries, including Australia, engage in involuntary prolongation of end-of-life suffering.
The dearth of legalised VE worldwide is not, as the opponents of VE like to argue, made up for by palliative care, the management of end-of-life pain. As Syme, a supporter of palliative care, argues, palliative care is good for most people but it is not a universal panacea for all dying, or hopelessly but not terminally ill, people.
The origins of the palliative care movement, in the 1960s, had intensely religious motives, notes Syme, and its opposition to VE springs from religious, not medical, ethics. Its most dogmatic advocates treat palliative care not as a model of care but as a “moral crusade”in the Catholic Church’s campaign for ‘right to life’ from ‘womb to tomb’. As Syme argues, however, a “right to live does not include an obligation to do so, under every circumstance”, where to prolong a life is to prolong suffering. In prolonging life in futile and undignified circumstances, says Syme, these religious conservatives impose their religion on others who do not share it.
Hastening death in terminal and hopeless circumstances can be the best medical treatment, says Syme, and even just providing the knowledge and means of how to end their life can be good palliative care for a patient by reducing anxiety and fear about the future. In Oregon, up to 305 VE-eligible people prescribed lethal drugs did not take the medication before death. In Switzerland, 70% of those eligible for oral, lethal medication do not proceed any further to VE, the prescription for drugs alone greatly diminishing psychological suffering.
VE is strongly supported by the broad community where 70% or more support is regularly recorded (including amongst lay Catholics). The health professions also want the laws changed to allow people with unbearable suffering to be helped to die: 40-60% of Australian doctors, and 75% of Victorian nurses, support legalised VE.
Whilst VE remains on the criminal statute books, however, the practice is forced underground, people are denied merciful release of suffering if they luck out on a sympathetic doctor, or they become victims of botched jobs. They pay cruelly for what Syme, a Christian humanist, sees as a craven buckling of politicians before conservative religious forces. Syme, by going public with his book on his sixteen years of helping patients to die to relieve suffering, is opening himself up to prosecution for the crime of compassion and, by risking jail, is showing the courage so lacking in most politicians and medical professionals.
As VE reform repeatedly runs aground against the undemocratic religious and political right, people who are terminally or hopelessly ill could well ask who is respecting life here - the lawmaker and dogmatic religious moralist prepared to inflict involuntary prolonged pain and suffering on the patient or those who would help to end it, through a voluntary, dignified, peaceful and good death?