Truth About Euthanasia

Protecting the Vulnerable

The current push for euthanasia in Britain has caused for some shocking revelations, in particular in relation to the attitude of euthanasia supporters towards the sick, the elderly and the vulnerable. Campaigners such as Baroness Warnock (who has been brought to Ireland by state-appointed bodies on issues such as embryo research) recently controversially declared that people with dementia had ‘a duty to die’ and that treating premature babies was a ‘waste of resources’.

In April 2009 the Irish HSE used taxpayer funds to sponsor a lecture by pro-euthanasia campaigner Len Doyal entitled “Why Euthanasia should be Legalised”. A huge controversy arose when the Life Institute helped to make this known. In the event, the lecture was cancelled when relatives of terminally ill patients expressed their anger at the outset.

The Life Institute produced an advertising campaign in May 2009, booking adverts in several local and national newspapers highlighting the need to oppose euthanasia.

In March 2010, a so-called “DIY Euthanasia workshop” was to take place in Outhouse in Dublin’s Capel Street, a centre which was purchased at the cost of €860,000 by the HSE (ie the taxpayer), and which continues to be almost entirely funded by the HSE to the tune of €200,000 every year. Australian euthanasia campaigner Dr Philip Nitschke, was to host the event. Nitschke heads up Australian organization Exit International which assists people in committing suicide, usually by taking a lethal dose of a veterinary medicine, Nembutal.

Following complaints from the Life Institute to the HSE, the venue was withdrawn. The Life Institute wrote to the HSE Chief Executive, Professor Brendan Drumm, and the Irish Medicines Board regarding the proposed event, and following calls to the HSE the venue was withdrawn.

The Life Institute has commissioned a major report on euthanasia which will be issued this summer.  

Opposing Nitschke’s grisly workshops: Report from the Life Institute

February / March 2010

• Listen to Niamh Uí Bhrian on LMFM, 19 March 2010
• Éist le Niamh Uí Bhrian ar Radio na Gaeltachta, 19ú Márta 2010

In February 2010 a strange and objectionable organization called Exit International announced that it would hold a “DIY-Euthanasia workshop” in London. The debate regarding assisted suicide has been heating up for years in the UK and Dr Philip Nitschke, who heads up Exit International, is not the first campaigner to attempt to influence the law and public opinion there, nor was this his first intended visit to Britain. However, on this occasion he decided he would also host a ‘suicide workshop’ in Dublin.

Nitschke courts controversy and had doubtless heard that, while the ugly business of euthanasia has reared its head of late in Ireland, it had met with determined opposition. It seems however that he had not expected such widespread public resistance to his distasteful campaign: he lamented to the Irish Times that “he had never encountered such resistance to his meetings”. That resistance led to four venues being canceled and to Nitschke’s reliance on the oddballs in an Seomra Spraoi to come to his aid.

Nitschke’s first publicized booking was with the Outhouse in Capel Street - a community venue purchased and maintained by the HSE. The Life Institute called the HSE and made a formal complaint. We then called the office of the CEO of the HSE, Professor Brendan Drumm, and pointed out that it was not acceptable that a taxpayer-funded venue be used for this objectionable event. We also called Dublin City Council, and we sent out an alert encouraging others to do the same. Within 48 the event had been cancelled in that venue.

Nitschke then moved to Buswell’s Hotel. We called the hotel and sent out another alert. Pro-life people started calling in growing numbers. Buswells also cancelled the booking. Nitschke then moved his “workshop” to Macro Community Centre in Dublin 7 – another taxpayer-funded venue. On St Patrick’s day we sent out another alert and a press release saying “It is absolutely unacceptable that our taxes would be used to give a platform to this organization. What they are doing is dangerous and exploitative. Many families in Ireland have been touched by suicide and mental illness and this ‘workshop’ is cruel, illegal and disgusting.”

The Irish Daily Mail ran a front cover saying “Dr Death is on his way”. Pat Kenny picked up on the story and conducted a sympathetic interview with Nitschke, although the Australian revealed a little of his motivations when he said that he had taken on this ‘cause’ since it was ‘better than writing prescriptions'.

The Macro Centre received a pile of complaints about the proposed “suicide workshop” as did the co-sponsors of the centre, Pobal and Dublin City Council. They cancelled the booking.

Another booking in the Carmicheal Centre only lasted a matter of hours. Nitschke was lashing out at this stage, accusing pro-life people of a “well-orchestrated campaign of censorship”. The Life Institute responded by saying that this was not simply a matter of free speech and that encouraging suicide was illegal in Ireland. Niamh Uí Bhriain used radio interviews to call on Dermot Ahern as Minister for Justice to ensure the law was enforced to protect elderly and vulnerable people.

At this point an organization called Atheist Ireland got involved. They circulated an email decrying the efforts of “anti-choice” campaigners and called for Nitschke to be supported. At the last minute Nitschke was offered an Seomra Spraoi, a pretty scruffy backroom venue owned by a left-wing organization.

He was also brought onto RTÉ’s Prime Time and handled with kid gloves. At no point did the reporter or the presenter question him about his controversial past, in particular regarding the very dubious circumstances surrounding the “assisted” death of several mentally ill patients in Nitschke’s native Australia. Deirdre Madden, the UCC lecturer who devotes considerable time to supporting embryo research also featured on the program and was supportive of Nitschke.

Another alert was issued by the Life Institute calling on the Justice Minister to intervene. Niamh Uí Bhriain said that Dermot Ahern was now obliged to act, and to instruct the Gardai to stop the suicide ‘workshop’. She also said that the owners of the Seomra Spraoi should hold themselves accountable for the subsequent harm or death brought about by or to elderly or mentally ill persons because of the platform granted to Nitschke.

“All week the people of Ireland have made their voices heard in opposition to this gruesome and disturbing event,” she said. “This workshop which counsels and assists in the procurement of suicide is illegal under the Criminal Law (Suicide) Act 1993 and the Minister now needs to instruct the Gardai to get involved.”

The Act states that ‘A person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, shall be guilty of an offence and shall be liable on conviction on indictment to imprisonment for a term not exceeding fourteen years’. “Clearly what Nitschke proposes is against the law - and with good reason. ,” said Ms Uí Bhriain. “This law was written to protect vulnerable people from fanatics who believe that suicide should be a widely-considered and offered option. Nitschke’s workshop is not just morally wrong, it’s illegal.”

We’re going to keep the pressure on Minister Ahern to enforce the law. Nitschke says that he will be back, but also that his operation got “record” opposition in Ireland, and we’re determined he won’t be allowed to run these utterly objectionable, illegal workshops here again.

Medical and Philosophical Considerations

An article by Lorcán Mac Mathúna on medicine and ethics based on a discusion with Dr Christopher Cowley, Lecturer in Philosophy, UCD

Autonomy

Although the autonomy of the individual is generally valued as a principle in western liberal democrocies there are two justifications for intervention in personal liberty. The first justification is the harm principle. If what I do is harmful to anyone else I should not be allowed do it. This is an uncontroversially accepted principle in western democracy.

The second more controversial principle is paternalism, where the state can intervene, possiblty against our wishes, when it comes to matters that would be in our interest. There are many occasions where our autonomy is restricted for the good of others and for our own good; the question is whether End of Life Decisions is one of these contexts.

Normally paternalistic clinical decisions are made on the basis that the patient will be grateful later on when their condition improves. In end of life decisions we are talking about possibly irreversible decisions so how can we say whether the person will be grateful later on.

You could say that euthanasia is a red herring: that the real question is how we treat the elderly. The more important question, especially with an ageing demographic, is what are we going to do about older people. And the question is not ‘how do we manage the elderly as a class;’ but why is the attitude towards the elderly so lacking in empathy and respect. Why are resources for the elderly; homes, palliative care, etc., of such inadequate standard? When we look at the matter from this angle euthanasia becomes an artificial question deflecting from the more urgent issue that the alternatives to dieing are so bleak in so many cases. So rather than talking about euthanasia as a quick fix and dressing it up in the language of autonomy, we should be looking at why resources for the elderly and palliative care resources are below par. Surely we should be able to look forward to a comfortable twighlight period.

Dependencies

Autonomy is one of the primary concepts on which euthanasia is discussed but autonomy is perhaps the wrong term to focus on because it makes it sound like the ideal we should all aspire to is personal independence. That we as healthy young and middle aged, financially independent people, have reached this apotheosis where we are in control of our own lives and of society, without accepting that all of us are dependent throughout our lives, its just a matter of degree. Perhaps opur focus should be a more rounded discussion on autonomy; that it might not be such a guiding concept as the western tradition has it. Maybe we should be talking about different degrees of dependence and different kinds of dependence as we move into old age.

Imagine a different scenario,which would require we adjust our concept of values. In a society where venerability and wisdom are valued old people have a very valid and necessary societal function, and young people are dependent on them. In truth every society benefits from this wisdom of experience; and we all need to recognise our interdependence.

Advanced directives and dementia

There is a philosophical argument that asserts that if you can’t remember being a person in the past, then you are no longer that person. That we are who we remember being and that it is not just a matter of bodily continuity. In the same way people of good conscience would feel uneasy about punishing old war criminals who genuinely can’t remember that atrocities they are accused of committing,(We can’t punish them in the full sense of punishment: we can lock them up but it is not reformative and the prisoner doesn’t see that justice is being done. S/he is just bewildered and doesn’t see his/her condition as a consequence of actions) it is tempting to say that the advanced directive of a person who is now in a state of dementia is no longer a valid reflection of the will of the person who now exists in a different reality.

This subjective philosophy has its counter that there are residues of the past in that person’s life such as children, personal items, etc. It highlights the danger, or rather the deficiencies of advanced directives, which never take every conceivable sequence of developments into account and in most cases end up being inapplicable to the developing clinical condition of the incompetent patient. The ideal advanced directive would speak of the life values accumulated in the arc of a persons life and would not be simply a statement of the persons opinion of preference during a moment of their life.

The Ethics of Acts and Omissions

Is it ok to let somebody die when you could do something to prevent it? Take the example of a child drowning in a shallow pond. In terms of legal and moral responsibilities, if the proximity is close and the action required is low cost; and you are competent to take that action; then you have a moral obligation to act. The moral obligation does come with the question of what is close proximity, what is a great cost or risk, etc., all of which make it difficult to define the concept. Like many ethical issues it starts with an intuition and the ethics are built to solidify this. This difficulty to tangibly define this obligation is manifest through absence in common law where there is no legal obligation to act - In English as in Irish law there is no Good Samaritan clause. In contrast, in French law; there is an explicit duty of care in these circumstances.

There is a utilitarian frame of thinking that there is no difference between acts and omissions. That if the result is the same that the cause is morally equivalent. This is one of the arguments for liberalising euthanasia: that people’s death is hastened when they receive some forms of treatment for pain; that there would have been no difference in the length of their lives if they were just euthanized; therefore morally there is no diference between the two actions. The question it poses is whether there is a difference between acts and omissions. The following example of the nephew in the bath, in one form or other, is often cited.

A child is in the bath and he drowns whilst his uncle is in the room watching. Nobody else knows what happened in the room but it is clear that the uncle either held the boy beneath the water or that the boy was unconscious and that the uncle let him drown. Knowing that either one of these circumstances must have been true is the uncle a murdered regardless of what he did? The utilitarian argument says yes and morally the callousness of the second scenario is damning, but is it murder?

The counter intuition is that the act is different to the omission especially if it involves bodily contact. Holding the boy underneath the water seems a lot more serious from the point of view of personal responsibility; than doing nothing. Bringing this rational into the clinical context; is there a difference between withholding antibiotics or not rescusitating as might be called for in an advanced directive, and administering a poison? Whereas the answer may clearly seem to be yes that surely there has to be; it leaves the conclusion open to the paradoxical interpretation employed in the Anthony Bland and Terry Schiavo cases. Here we have the willing of a person’s death by doing nothing, by letting them starve or die by dehydration. But perhaps this again is a case of framing the issue in the wrong argument. Maybe what we have here is a distinction between medical care and basic care –where basic care is not only food and water but also hygiene- which brings us back to the concept discussed earlier of what actions are morally obligatory based on assements of proximity, cost, and competence.

Although it provides material for thought, the heading ‘acts and omissions’ does not give satisfactory answers. But perhaps that’s because it is not the right concept with which to address the question. The Bland case would seem to point to anomalies which lead to a cruel and undignified termination of a person’s life. In some cases omissions leave the patient’s life to faith, for example: will the patient die from this untreated bout of pneumonia; and in other cases it can be a calculated campaign to kill the patient, for example: to starve the patient to death. Maybe the real context for analysis is the goal of care, where care of the patient’s present comfort and psychosocial needs is paramount.

Dying and Pastoral Care

An article by Lorcán Mac Mathúna on dying and care on a discusion with Dr. Des O'Neill, consultant geriatrician, Tallaght Hospital

Death

Death is when spontaneous heart and lung function is no longer possible.

Brain stem death is when the unconscious reflexes which maintain respiratory functions and allow for higher functions are no longer functioning. This state as a definition of the irrecoverable end of life is a bit more challenging than previous understandings of death because with technological advances we can maintain people in that state. And there is no doubt there would be some concerns over whether we are giving people enough time to recover though it is most unlikely that you would recover from that state.

You want to be certain that diognosis of brain stem death is done by at least two senior clinicians (i.e. consultants) and you need to be certain that there aren’t reversible casues. There is a protocall to ensure the patient is not in a coma due to their tyro gland being inactive; that their sugars are normal; and then you have a process whereby you take people of the ventilator for trial periods and look for signs of distress or recovery. There is potential imperfections in the protocall, as outlined by the (US) presidents commission on bioethics, which are largely concerning the issue of what is driving us to decide people are dead: is there unconscious rationing going on in the background?

Keeping people alive on highly invasive forms of therapy is very challenging. It is very different from your Christopher Reeve situation, what we are talking about here is intensive invasiory ventilatory support. There is always going to be a grey are here and pushing of frontiers. Chronic ventilation without the likelihood of higher brain function; of spontaneous breathing, raises serious issues of whether people would have asked for this.

Cost (in human terms) Versus Benefit

There is a point, measuring: human cost versus benefit, and cognisant of the fact that we are all eventually going to die and that this is natural; what is an ordinary and extraordinary measure, where it is possible to withdraw life support without it being labelled euthanasia.

The other thing is we are not omniscient, we don’t know what will happen once we withdraw care life support.One of the most famous treatment withdrawal cases was Karen Quinlan who lived for ten years after they turned off life support. It was assumed that withdrawing the treatment would hasten her death. There are issues around an adequate care matrix: where you are sure that anything remedial has been treated; where due consideration is given to the patient and their family’s culture in terms of what they consider ordinary/extraordinary intervention; as well as an as carefully as can be measured cost benefit analysis, where cost is measured in human not economic terms.

The other thing to bear in mind is consent! This is referring to people who have full capacity, and who do not wish to have specific life sustaining treatments such as for example, chaemotherapy or a ventilator.

We are talking of people who are conscious at the time not the expressed wish of an advanced directive. The fault with advanced directives and living wills is that they feed into age and disability prejudices. An advanced care preference is perhaps a better template for containing a guide to the future treatment wishes of a competent person. An advanced care directive, while giving the allusion of givig control to the patient, does not hold nearly as much value as contemporaneous consent. Many people are very scared of a perceived disability but once they get it they tend to be more sanguine about it. They change their mindset. They grow and adjust to their changed circumstances.

Life support

‘Withdrawing life support’ is probably not a helpful phrase anymore. People should be more specific in what they mean. We should talk about withdrawing: artificial ventilation, invasive artificial ventilation, pacemaker support, or artificial tube feeding. Just as we saw in the Karen Quinlan case, it proved not to be life support as she continued to breath. So the phrase ‘life support’ is unhelpful in this context and people should be a lot more specific.

Ordinary extraordinary support

Whether support is ‘extraordinary’ or ordinary depends on the condition and this is where there needs to be a certain amount of professional discretion. What is ordinary for someone who comes in to an emergency ward from a car crash, who is otherwise fit and healthy, a high level of intensity, is not necessarily deemed helpful for someone who is at the end stages of a progressive neurological disease. So for example, you wouldn’t be doing a procedure like a transplant to help the latter. So there is not a set standard, it is a highly individualised process.

To a certain extent the accepted duty of care standard is normed to a civilisation, and there are are always those who would seek to up the norm. For example we have breast cancer screening up to 65 whereas some would like to see that age barrier removed.

Minimally conscious state – an ethics question

There is huge literature on the area of tube feeding and what some people call a persistent vegetative state or a minimally conscious state (MCS). Tube feeding and whether it is ordinary, extraordinary, or artificial, seems to be the ethical question that occupies most people about this illness but perhaps a bigger concern is that people discussing the illness seem blind to the fact that we don’t actually know what the experience of people in a minimally conscious state is, and they are automatically assuming that it is bad. We have to be agnostic about what the condition of people in this state is. They might be happy, they might be sad, we don’t know, but the assumption that it is a negative condition is probably first and foremost the biggest problem. The issue at present is framed as ‘is this a bad way to be?’

While all illnesses are undesirable per se, we have to deal with the issue of distress here. What is dealt with badly when we focus on the issue of the tube is the distress of the relatives. The relatives are distressed and they say “isn’t this a shocking way to be,” but in fact they are not that person; and that person might say “well actually it’s not that shocking.”

Doctors have a role to play in standing up for the patient. In acting to reconcile relatives who are distressed so that there is a common understanding amongst all the people connected with the patient; and in justifying the cost of treatment. It costs no more to care for a person in a MCS than it does to keep a prisoner in jail, and it is always a small number of people we are talking about. Also as technology comes along we have a bit more sense that we might pick up more signals than we thought were there from people like this and that we might also find cures. But again the most important thing is that we are agnostic as to whether this experience is a good or bad one.

The most important thing to keep conscious of is the pastoral, supportive care for the families. Very often you find that in cases where the families push for the removal of tubefeeding, they are not satisfied with the degree of care, the degree of communication, and the degree of attention to their stress.

Labelling

The labelling of the withdrawal of extraordinary measures as euthanasia is not helpful its a deliberate blurring of the boundaries.

Feeding

The medical council quite sensibly say that food and water are basic necessities where reasonable and practicable. As we understand more, for example about advanced dementia, we understand that giving people tube feeding may actually shorten their lives in some cases. The decision of whether it is reasonable and practicable should be made by clinical experts and should be made in context of a consensual decision with relatives. It’s always going to be normed to societal norms, but thats a pact that has to be defended in a way that is humane and understands the clinical condition.

Euthanasia

Any gesture or act whose primary aim is to shorten life, and which is not related to any therapeutic intent. Euthanasia is the deliberate ending of a life rather than the withdrawal of a treatment that is considered, at that stage, to be extraordinary. Intent, a key factor in euthanasia, is an established legal principle.

The acid test is: If we turn off the respirator and the patient doesn’t stop breathing do we give them something to stop them breathing or do we deal with the situation here and continue to treat them. Once we stop the treatment and find that they didn’t need it will we continue giving them usual treatments.

Sedation

In terms of appropriate palliative care you don’t get oversedation. The intentention is allways symptom control not sedation itself as a form of comatising those who are actively dieing.

Providing the alternative

There has tobe a two-pronged approach to this issue. It is not enough to say euthanasia is not good enough, there is an imperative to provide adequate and appropriate care and support for these people. A fairly comprehensive view is one that recognises the wider people affected by the illness without ever loosing sight that the patient is the priority and that the agenda of the partient and relatives may not be the same, and that much of the work of doctors and health care workers is to reconcile them when possible so that there is a common understanding