Chapter 4 - Euthanasia policy issues
Introduction
4.1
This chapter examines some of the key moral, ethical and social
arguments for and against the legalisation of voluntary euthanasia.
4.2
Some submissions expressed the view that the legal and constitutional
policy issues were the only issues that should be considered by the committee
during its inquiry. For example, the South Australian Voluntary Euthanasia
Society submitted that 'the Bill is not about the issue of euthanasia and this
should not be considered as its basis'.[1]
In contrast, the ACL described claims that the bill is not about euthanasia as
'deeply disingenuous'.[2]
Indeed, some suggested that the moral issues addressed in the Bill should
override all other considerations.[3]
4.3
The legal and constitutional policy issues examined in Chapter 3 raised important
threshold issues for the committee. That said, the committee also received a
considerable amount of highly polarised evidence focussing on the policy arguments
for and against voluntary euthanasia. Further, the committee considers that
discussion about the legalisation of voluntary euthanasia cannot be avoided,
given that the Bill proposes to revive the NT RTI Act.
4.4
The committee notes that many of the issues raised during this inquiry were
similar to those raised, and discussed in detail, during the 1997 Euthanasia inquiry.[4]
The committee therefore refers readers to the 1997 Euthanasia Inquiry report
where relevant for a more detailed discussion of some issues. However, this
chapter will endeavour to highlight relevant developments that have occurred
since 1997.[5]
4.5
This chapter will first examine some of the key arguments in favour of
legalising voluntary euthanasia, together with some contrasting perspectives on
those arguments. Key arguments against the legislation of voluntary euthanasia
will then be discussed, again incorporating some alternative perspectives on
those issues.
Key arguments in favour of voluntary euthanasia
4.6
In summary, some of the key arguments advanced in support of legislating
for voluntary euthanasia included that:
- it is a matter of individual rights, autonomy and choice;
- it is the compassionate and merciful answer to insoluble pain, suffering
and indignity in the case of terminal illness;
- it is merely regulating what in reality is already common
practice, particularly now that Australians have resorted to travelling
overseas to obtain euthanasia;
- opinion polls show that the overwhelming majority of Australians
support voluntary euthanasia; and
- several overseas jurisdictions (such as Switzerland, Belgium, the
Netherlands and Oregon) have legalised voluntary euthanasia.
These issues are
considered in turn below.
Individual rights, autonomy and
choice
4.7
Many submissions supporting voluntary euthanasia put forward arguments
based on the principle of individual rights and autonomy. That is, a competent
individual should have the right to determine how and when to die as long as
this does not interfere with the rights of others.[6]
4.8
For example, the NSW Council for Civil Liberties told the committee that
'the principal argument for legalising voluntary euthanasia is that a
terminally-ill adult should have the right to choose to end their own
suffering.'[7]
The NSW Council for Civil Liberties further submitted its belief that:
...the Bill will restore respect for the rights of the terminally
ill in the Northern Territory to choose the time of their own death. The Bill
will ensure that the terminally ill, if they so choose, can die with dignity
and in a humane manner. The Bill will respect the fundamental principle that
the individual is sovereign over their own body and mind.[8]
4.9
The West Australian Voluntary Euthanasia Society submitted that:
It is time we decided to give the people the right to decide
about their life according to their conscience and judgement. It is sheer
arrogance to think that anyone else can or should decide someone else's fate.[9]
4.10
Dr David Leaf, a medical practitioner, told the committee that:
...the majority of patients who are facing this terminal stage of
illness just want the option of whether to participate in voluntary euthanasia,
where they have some control over what is going to happen to their lives, or,
frequently, they would elect not to participate in that action as well. One of
the options I would like to have as a doctor treating these people is the
option to offer them voluntary euthanasia. In the same way that they can have
an operation or elect to go down the palliative care route, they would like to
have options.[10]
4.11
Mr Marshall Perron also argued that:
...voluntary euthanasia legislation does not require anybody to do
anything. If you disagree with it, you can go through life pretending that the
law does not even exist and it will never affect you.[11]
4.12
However, concerns were expressed that if a legal right to euthanasia were
granted, more vulnerable people would be at risk, particularly if they feel
they may be a burden to family or society.[12]
As a result, the Australian Catholic Bishops Conference argued that the demands
of the common good must be measured against claims of liberties:
A request for voluntary euthanasia is a request to be killed by
another. It is not a private matter. Aspects of the common good affected by the
legislation of euthanasia include equal protection under the law, the ethos of
the practice of medicine, and factors affecting an individual's sense of
security at times when they are particularly vulnerable.[13]
4.13
The Australian Family Association (WA) also suggested that euthanasia
cannot be considered as autonomous:
Firstly, since it involves at least one other person, it must be
viewed as a public action, and so be assessed in relation to its social
implications.
Second, as a public act, it should be assessed via the
perspective of societal ethics. In other words, does sanctioning private
killing benefit society to a greater extent than its prohibition?...[R]ecognition
of euthanasia not only extends personal autonomy, but also redefines the
concept of private killing in society. The magnitude of this change needs to be
evaluated, as well as its social impact.
Thirdly, and perhaps ironically, the right to personal autonomy
on which euthanasia supposedly depends is actually contradicted when one cedes
to another, either directly or indirectly, the right to take one's life.
Handing the power over one's life to another destroys one's freedom...[14]
Compassionate answer to pain, suffering
and indignity
4.14
Proponents also argued that voluntary euthanasia is the compassionate
and merciful answer to insoluble pain, suffering and indignity in the case of
terminal illness.[15]
For example, Emeritus Professor Philip Ley pointed to reasoning given by
patients seeking euthanasia in the US state of Oregon and the Netherlands. Key
concerns for these patients, included loss of autonomy and dignity and a
decreasing ability to participate in activities that make life enjoyable.[16]
4.15
The committee also received many submissions detailing case studies of
patients who had a difficult death and who may have benefited from the
availability of voluntary euthanasia.[17]
In this context, Dr David Leaf told the committee that 'death is not the worst
outcome for them at times like this':
...if you are...subject to daily incurable pain, loss of dignity,
immobility and being a burden to your family, to many such patients that is a
worse outcome than quietly passing away at a time of their own choosing in a
painless manner.[18]
4.16
Dr Leaf further told the committee that a lot of patients:
...do not want to be at a stage where they are immobile, they have
a lack of dignity, someone else is cleaning them up several times a day. Even though
they might be out of pain, they do not want to be at the stage where a
palliative care team, doctors, nurses and GPs, are looking after them.[19]
4.17
In contrast, the ACL argued that:
There is no dignity in euthanasia, which effectively means a
person's life is viewed as so awful it should be brought to a premature end.
Rather there is dignity and comfort in knowing that Australian society
recognises that all human beings, even in the agony of suffering or in a
twilight mental state, deserve respect, empathy and protection from abuse,
harm, manipulation or wilful neglect and which affirms that every patient, no
matter how deformed the body, deranged the mind or diminished the personality,
should receive equal protection and medical care.[20]
4.18
Similarly, Mr Christopher Meney, Director of the Life, Marriage and
Family Centre of the Catholic Archdiocese of Sydney told the committee that:
A key element of respecting human dignity is the need to respect
and value human bodily life. Hence, the individual and social resolve to
respect all human life and to never regard a life as lacking worth is essential
for a society that wishes to protect and equally value all its citizens.[21]
4.19
Many submissions opposing euthanasia also pointed to the need for good
palliative care (discussed later in this chapter). Others told the committee
that 'hard cases make bad laws'.[22]
However, the Australian Federation of AIDS Organisations argued to the
contrary:
...when individual cases are clinically evaluated and confirmed
for their presentation and specific circumstances, and it is evident there are
no other options to relieve a person's pain and distress, that it is entirely
appropriate to have a process whereby that person can rationally request an end
to their life...
Surely when no other options are open to a person in the final
stages of a terminal illness, a person suffering unrelievable pain and distress
who consistently and rationally requests an end to their agony, there should be
some process whereby their dying wish can be granted.[23]
Opinion polls indicate popular
support
4.20
Most submissions supporting the Bill pointed to opinion polls indicating
that the vast majority of Australians (80%) support voluntary euthanasia.[24]
For example, the Voluntary Euthanasia Society of NSW submitted that:
In the last two decades, surveys have consistently shown that a
majority of Australians believe that terminally ill individuals should have a
right to seek and obtain assistance to end their life with dignity. In 1962 it
was close to a majority (47%) and by 1978 it was up to 67%, and in 2002 was
73%+. An independent poll [was] conducted by Newspoll in 2007 and found 80% of
Australians in favour, and just 14% opposed.[25]
4.21
Others disputed the legitimacy of arguments based on opinion polls. For
example, Dr Brian Pollard submitted that:
...many people have erroneous ideas of what actually constitutes
euthanasia...it is well-known that the wanted results can be manipulated by the
structure of the questions, opinion polls can carry no certainty about
euthanasia. Would it really become OK to rob old ladies when 80% thought so?[26]
4.22
Dr Mark Boughey, a palliative care physician, told the committee that, despite
these opinion polls, in his experience the reality was quite different:
Even though populist opinion states that euthanasia is popular
and is something that the Australian population wants, I think the reality when
you are actually working with and dealing with people in the dying phase of
their palliative condition is very different. The reality, which we are exposed
to every day, is that people are still trying to engage actively in life, even
though their life may be fast approaching the end.[27]
4.23
Support for voluntary euthanasia within the medical profession was a
matter for debate. For example, Dying with Dignity Victoria pointed to opinion
polls indicating that 78% of Victorian nurses favoured law reform (in 1992),
and 80% of nurses in NSW gave support in 1997.[28]
However, in its submission, the Australian Medical Association (AMA) opposed
the Bill and voluntary euthanasia.[29]
At the same time, it recognised:
...the divergence of views regarding voluntary euthanasia and
physician‑assisted suicide in Australia. Indeed, the range of views, from
those who fully support voluntary euthanasia to those who totally oppose it, is
reflected within the medical profession itself.[30]
Regulating a common practice
4.24
Another argument raised in favour of legalising voluntary euthanasia is
that it is regulating what in reality is already common practice.[31]
Submitters pointed to a study, also examined during the 1997 Euthanasia Inquiry,
indicating that, in practice, many Australian doctors already take steps that
lead to an earlier death for patients.[32]
It was therefore suggested that it was better to regulate the process to ensure
that it was open to scrutiny. For example, the Humanist Society of Victoria argued
that:
The practice [of euthanasia] occurs frequently, in a clandestine
mode, as testified by doctors and nurses. It is essential that the process be
open to scrutiny and performed by experienced and accountable medical
practitioners.[33]
4.25
The Australian Federation of AIDS Organisations similarly submitted
that:
...some seek assistance to end their own lives at a time they
choose despite the fact that doing so is illegal. Numerous studies and polls
suggest that acts of euthanasia and assisted euthanasia are not isolated
occurrences...work on HIV positive people also reveals cases of 'botched' suicide
attempts resulting from euthanasia's illegality, and the dreadful impact on all
involved.[34]
4.26
In this context, Associate Professor Cameron Stewart, from the Division
of Law at Macquarie University, submitted that:
By providing a different process for dying the Rights of the
Terminally Ill Act does not depart in a massive way from existing laws but
rather it provides a safeguarded process for the management of death in the
terminally ill.[35]
4.27
Dying with Dignity Victoria was also concerned that 'continuous deep
terminal sedation' is 'now commonly used in palliative care', in the same
circumstances where a person might otherwise request voluntary euthanasia:
Its undoubted advantage is that it relieves intolerable
suffering, but it has two major disadvantages. It is often provided without any
explicit discussion with the patient, and it may take days before death occurs.
In addition there is no reporting procedure and no prescribed safeguards.[36]
4.28
Dying with Dignity Victoria therefore queried 'why it is acceptable to
deliberately put a person with intolerable suffering to sleep for days before
they die, but not to allow the same person the choice for a quick death.'[37]
4.29
There also appears to have been another significant development since the
1997 Euthanasia Inquiry: Australians are now travelling overseas to obtain
euthanasia. In particular, Dr Philip Nitschke of Exit International gave examples
of patients seeking euthanasia who had ended up travelling overseas.[38]
Dr Nitschke explained that there were two key overseas options. Mexico was
the 'predominant choice of nation', as people could lawfully acquire the drug
Nembutal and bring it back to Australia (illegally) to die here. Australians
are also opting to die in Switzerland under their system of legalised
euthanasia, where certain preconditions must be met.[39]
Indeed, the committee heard directly from submitters who had travelled overseas
– for example, one whose husband had travelled to Switzerland to obtain
euthanasia,[40]
and another who had travelled to Mexico to obtain 'a product leading to a
'peaceful death''.[41]
4.30
Dr Nitschke told the committee that he knew of at least 150 people who
made a trip to Mexico last year to obtain the drug Nembutal – and effectively
broke Australian law to import a class 1 prohibited drug.[42]
Dr Philip Nitschke told the committee at its hearing in Darwin that:
...what started off as a trickle but has now turned into a flood
of people who are taking this so-called overseas option to try and establish
for themselves viable end-of-life choices.[43]
4.31
Supporters of voluntary euthanasia expressed the view that this meant
that those who could afford to travel overseas were 'lucky', but that those who
could not afford to do so were 'penalised'.[44]
Overseas examples
4.32
In support of the Bill, the committee also heard that several overseas
jurisdictions have now legalised voluntary euthanasia. For example, the
Voluntary Euthanasia Society of NSW submitted that:
In the Netherlands, Belgium, Switzerland, and the American state
of Oregon physicians are permitted to assist a patient in ending his or her
life by means other than withdrawing life-sustaining medical treatment.[45]
4.33
The committee notes that the practice of euthanasia in the Netherlands, Switzerland
and the US State of Oregon were considered during the 1997 Euthanasia Inquiry.[46]
Since then, legislation relating to voluntary euthanasia and/or physician assisted
suicide has now come into force in: the Netherlands (in April 2002 – prior to that,
guidelines had been in place since 1990);[47]
the US State of Oregon (in October 1997);[48]
and Belgium (in September 2002).[49]
4.34
Some suggested that the experience in those places would reassure those
opposed to legalising voluntary euthanasia. For example, Dying with Dignity Victoria
submitted that:
Practice in those places has been carefully studied. It is no
longer a matter of conjecture as to the effects on the community and the
medical profession of such laws. As a result, attitudes of many significant
people and bodies have changed towards acceptance of VE [Voluntary Euthanasia].[50]
4.35
However, there was considerable debate in evidence about the practice
and regulation of euthanasia overseas, particularly in the Netherlands. Many opposing
euthanasia expressed concerns about the experience in the Netherlands.[51]
This is discussed further later in this chapter in the section on the potential
for a 'slippery slope' in the regulation of euthanasia.
4.36
Others opposing the Bill pointed to several international inquiries
which have rejected proposals for euthanasia.[52]
Many of these inquiries were canvassed by the 1997 inquiry into the Euthanasia
Laws Bill 1996.[53]
Some also noted the defeat of a Bill for voluntary euthanasia in the House of
Lords in the United Kingdom in 2006.[54]
Key arguments against voluntary euthanasia
4.37
Some of the key arguments against
legislating for voluntary euthanasia included:
- the availability of quality palliative care for people with
terminal illnesses;
- the problem of adequate safeguards and the possibility that it
would lead to a 'slippery slope' – for example, acceptance of voluntary
euthanasia would lead to involuntary euthanasia and/or euthanasia for lesser
diseases and conditions;
- the potential for erosion of the doctor-patient relationship;
-
that it places pressure on people to end their lives even if they
are not ready, for example, to reduce the burden on their family or the health
system;
-
the sanctity of human life; and
- in the case of the NT legislation, the particular impact on the
Indigenous community.
These issues are
considered in turn below.
Palliative care
4.38
Many suggested that, rather than legalising voluntary euthanasia, there should
be an increased emphasis on, and funding for, palliative care.[55]
For example, Palliative Care Australia submitted that:
...informed community discussion about euthanasia cannot be had
until quality palliative care is available for all who require it and there is
enhanced community understanding of existing end of life decision making
options, including advance care planning.[56]
4.39
Similarly, the ACL submitted that:
Whilst no-one wants to see someone they love endure pain,
euthanasia is not the answer to this. Instead, we should put far greater
resources into high quality, easily accessible palliative care so that people's
last days can be made as comfortable as possible.[57]
4.40
Mrs Lois Fong, NT Director of the ACL told the committee that:
...society's duty to terminally ill people is to improve the
quality of their palliative care as well as support those who are isolated and
who feel their lives are meaningless...The negative impact on hospice and
palliative care if euthanasia is legalised cannot be underestimated.[58]
4.41
Indeed, many were concerned that, if euthanasia were legalised, there
would be a negative impact on palliative care. For example, Mr Christopher Meney
of the Life and Marriage Centre of the Catholic Archdiocese of Sydney told the
committee:
It is also easier and cheaper to kill a patient than to provide
palliative care. Good palliative care can become a secondary concern and [is]
less likely to be able to be accessed by those patients not wanting to be
euthanised.[59]
4.42
Similarly, the ACL argued that:
...once a society rejects the right to life and instead legalises
killing as a form of treatment it will quickly begin to ask why it should foot
the bill for expensive medical care that will, in any case, fail to save the
life of a terminally ill patient. Why bother paying for expensive palliative
care and support when euthanasia is so cheap?[60]
4.43
The NSW Council for Civil Liberties disputed these sorts of suggestions:
It is argued that if we allow the 'easy' option of voluntary
euthanasia, researchers will not make the effort they otherwise would to
improve palliative care, both by relieving pain and by reducing or eliminating
the side effects. This supposes that we should require patients to suffer
intense pain, so that others will do what they ought to be doing anyway. This
is obnoxious: a denial of the moral significance of the person, who is to be
used, contrary to his or her own values, for others' benefit. This view also
presupposes that everyone will choose voluntary euthanasia.[61]
4.44
Other evidence suggested that requests for voluntary euthanasia are
often revised when palliative care alternatives are offered. For example, some
pointed to evidence from the US State of Oregon indicating that where
palliative care and/or counselling was offered:
...nearly half of those initially requesting PAS [Physician
Assisted Suicide] changed their minds after treatment for pain or depression
commenced or referral to a hospice was undertaken. Where no active symptom
control commenced, only 15% changed their minds.[62]
4.45
In this context, several submitters emphasised the importance of
psychological considerations and counselling.[63]
For example, Mr Christopher Meney, from the Life, Marriage and Family Centre of
the Catholic Archdiocese of Sydney, told the committee that:
A wish to die can often be an expression of depression, pain or
poor symptom control rather than a sincere desire to be killed.[64]
4.46
However, the Australian Psychological Society recognised that:
A patient's depression may be a response to a loss of control
over the situation which could be alleviated by the perception of choice over
terminating one's life. A diagnosis of clinical depression should therefore not
automatically negate a person's right to request euthanasia. Rather, the
presence of a depressive illness needs to be carefully assessed and treated,
and form part of a detailed and thorough clinical assessment, administered on
more than one occasion with a reasonable time interval between assessments.[65]
Advance care planning
4.47
In the context of palliative care, several submissions also pointed to
the importance of 'advance care planning',[66]
and the developments in advance care planning which have occurred in many state
and territory jurisdictions since 1997.[67]
4.48
Associate Professor Cameron Stewart advised that there are now
legislative schemes in most state and territory jurisdictions which have enshrined
the right to make an 'advance directive'.[68]
Associate Professor Stewart explained further that:
'Advance directives' or 'living wills' are decisions made by
patients about what medical treatments they would like in the future, if at
some point, they cannot make decisions for themselves. Advance directives
ordinarily record decisions about refusing life-sustaining treatments, but they
can also contain the patient's preferences and desires about a whole range of
treatment matters.[69]
4.49
In the context of the euthanasia debate, the AMA endorsed advanced care
planning 'as a means for supporting patients' wishes in their end of life
care'. The AMA submitted that:
Some patients may fear that when they lose decision-making
capacity, their goals and values in relation to their end of life care will be
unknown or even disregarded by their families and/or the health care team since
the patient can no longer actively participate in their own health care
decisions. As such, this fear may lead some patients to consider undergoing
euthanasia or physician-assisted suicide before they lose decision-making
capacity.[70]
4.50
The AMA expressed its view that an advance care plan reassures patients
that 'they can participate in future decisions regarding their health care by
articulating their wishes and goals of care in their plan'.[71]
4.51
Palliative Care Australia further suggested that there should be an
inquiry to identify and address the 'barriers to greater use of advance care
plans and directives, to ensure patients' rights to determine their course of
care are respected'.[72]
Palliative care in the Northern
Territory
4.52
The committee received evidence that, at the time of the enactment of
the NT RTI Act, the standard of palliative care in the NT was 'poor'.[73]
Dr Mark Boughey told the committee that palliative care services have developed
significantly in the NT in recent years, and are now probably above national
standards.[74]
Indeed, Mr Gerry Wood, MLA, a current member of the NT Legislative Assembly, submitted
his belief that 'the NT and specifically Darwin now has a world class
Palliative Care Unit'.[75]
He suggested that:
...with the increasing knowledge about palliative care there has
been a lessening of support for the option of euthanasia. No doubt there is
still support for euthanasia in our community but I feel that with more
community education about palliative care more people are realising that you
can have death with dignity without deliberately shortening life.[76]
4.53
At the same time, several submissions called for further improvements to
palliative care and other medical services in the NT.[77]
Indeed, for these reasons, Dr David Gawler of the Darwin Christian Ministers'
Association, told the committee that:
The Northern Territory is really the most unsuitable of all
places in Australia to legislate to legalise patient killing. There are
insufficient medical services—for example, radiotherapy is not available in Darwin
for cancer sufferers. There are remote communities with inadequate health
services. There is the tyranny of distance.[78]
Limits to palliative care
4.54
Some suggested that the option of good palliative care makes euthanasia
altogether unnecessary – because, for example, it addresses the issue of pain,
suffering and indignity in dying.[79]
However, the committee also heard that palliative care does not always provide
a solution.[80]
For example, Dr David Leaf told the committee that, in his experience,
'palliative care is like any other medical specialty: it does not always have
the answers...palliative care has its limits'.[81]
4.55
Similarly, Dying with Dignity Tasmania submitted that:
Advances in palliative care have undoubtedly done much to make
the final days of those suffering from terminal disease more comfortable and
more bearable. However, there remain a small proportion of patients whose pain
can not be relieved and there are others for whom freedom from pain is not the
single factor that makes a life worth living. Debilitating factors that often
accompany terminal disease may include extreme fatigue, paralysis, blindness,
deafness, aphasia and incontinence and as a consequence, many of the most
fruitful and rewarding activities of a previously full working and social life
may no longer be possible. After a lifetime of being in control of one's
destiny, a future of total dependence on others for all, even the most personal
details can be a most horrific prospect.[82]
4.56
Dr David Leaf told the committee further that:
...there are a minority of patients...in whom the pathway of
palliative care is not what they choose, for whatever reason. If it is a
misguided idea or lack of education about the specialty then that needs to be
corrected. But if it is with informed consent; if they know what the idea of
palliative care is about, and they do not wish to pursue it, or frequently they
cannot pursue it for whatever reason then this [voluntary euthanasia] should be
the next option.[83]
4.57
However, in this context, the AMA submitted that:
The AMA absolutely recognises that for most patients in the
terminal stage of illness, pain and suffering can be alleviated by therapeutic
and comfort care; however, there are still currently instances where the
satisfactory relief of suffering cannot be achieved.
We must, therefore, ensure that all patients have access to
appropriate palliative care and advocate that greater research must go into
palliative care so that no patient endures such suffering. No one should feel
that their only option for satisfactory relief of pain and suffering is to end
their own life.[84]
4.58
Dr Leaf also recognised that the availability of palliative care in
rural and regional Australia needs to be increased.[85]
Similarly, Palliative Care Australia submitted that 'services are highly
limited in some geographical areas and service demand outstrips supply in many
others' and that:
For many Australians access to appropriate care at the end of
life is not a reality. For these people the fear of unnecessary pain and
suffering, poor quality of life and loss of control over care — which drives
much of the community discussion about euthanasia — is justified.[86]
4.59
Palliative Care Australia concluded that further consideration of
voluntary euthanasia must be preceded by, among other matters, a guarantee of
access to quality care at the end of life for all terminally ill Australians.[87]
Committee view on palliative care
4.60
The committee welcomes evidence that palliative care has improved markedly
in the NT since the 1997 Euthanasia Inquiry. Nevertheless, the committee is
concerned about evidence, particularly from Palliative Care Australia, that
palliative care is not widely available and that demand for palliative care in
some areas is not being met. The committee suggests that Commonwealth, state
and territory governments consider increasing funding and resources for
palliative care as a high priority.
Safeguards and slippery slopes
4.61
Many arguments against voluntary euthanasia were based on the notion of
a 'slippery slope' and/or the 'thin edge of the wedge' – that is, for example,
that acceptance of voluntary euthanasia would lead to involuntary euthanasia
and/or euthanasia for lesser diseases and conditions.[88]
For example, the ACL submitted that:
Once legalised, death becomes an acceptable treatment for an
ever‑increasing list of treatable, non-terminal conditions such as
depression or for those whose quality of life is judged by others to be too
poor to make caring for them worthwhile.[89]
4.62
Dr Brian Pollard told the committee:
...voluntary euthanasia tends to morph into non-voluntary
euthanasia—that is, taking life without a patient's request...The reason it
happens is that when you regard euthanasia as providing those patients who
request it with a benefit and you become accustomed to providing euthanasia as
a benefit, when you come across other people who are perhaps comatose or for
some reason are unable to make their request but who are suffering just as
much, then it seems discriminatory to the doctor to withhold that benefit from
that patient also.[90]
4.63
Mr Meney of the Life, Marriage and Family Centre of the Catholic Archdiocese
of Sydney also suggested that:
....if a patient's suffering is deemed unacceptable by the patient
or by others, why does it matter whether or not this suffering is due to a
terminal illness? If unacceptable suffering is sufficient, as euthanasia
advocates appear to imply, there is a broad premise for an ever-widening range
of individuals to be killed provided they satisfy this highly subjective
criterion. Indeed, the argument which calls for the caring state to euthanise
those unfortunate persons usually incapable of articulating a choice—such as
the chronically ill, the elderly and the mentally handicapped—is given further
momentum. [91]
4.64
Others disputed these arguments. For example, the NSW Council for Civil
Liberties submitted that:
If there is a real moral difference between two cases, accepting
that one is permissible does not in any way commit us to the other. Each case
should be accepted on its own merits.[92]
4.65
Many also argued that the notion of a 'slippery slope' has been
disproved by the experience from overseas jurisdictions which have allowed
voluntary euthanasia, such as the Netherlands, Oregon in the US and Belgium.[93]
For example, Dr Alan Rothschild submitted that:
..the Oregon Dying with Dignity Act...actually has
fewer safeguards than the Rights of the Terminally Ill Act 1995 but its
annual reports show that it has not been abused. The vulnerable such as the
poor, uneducated and elderly have not been targeted. Research shows that it is
largely the educated, employed, and medically insured who make use of the
Oregon Act.[94]
4.66
At the same time, many alluded to the experience in the Netherlands to
illustrate their concerns about the potential for a 'slippery slope' in the regulation
of euthanasia.[95]
Many pointed to studies indicating a high level of non‑voluntary
euthanasia in the Netherlands.[96]
Others argued that more recent studies, conducted since the introduction of
legislation in 2002, indicate that there is no slippery slope and that both
non-voluntary euthanasia and voluntary euthanasia have declined.[97]
However, this was also disputed.[98]
4.67
As noted in Chapter 3, several submissions were concerned about the
adequacy of the safeguards in the NT RTI Act, and the operation of the RTI Act
while it was in force.[99]
Some queried whether legislation governing euthanasia can ever be properly
safeguarded against abuse.[100]
For example, Dr Brian Pollard claimed that 'every major published inquiry in
the world into the legalisation of euthanasia has independently concluded that
such law could never be made safe'.[101]
Similarly, the ACL expressed the view that:
...euthanasia cannot be controlled once legalised and patients
cannot be safeguarded against the fundamental philosophical shift from care to
killing. The disturbing ramifications of legalised euthanasia include: the
acceptance of killing as a very cost-effective form of treatment; the murder of
terminally ill patients who have not asked to die; the 'mercy killing' of wider
groups of people whose lives are deemed worthless such as handicapped newborn
babies; and a forever changed doctor-patient relationship.[102]
Impact on doctor-patient
relationship
4.68
Several submissions expressed concern about the impact of voluntary
euthanasia legislation on the doctor-patient relationship.[103]
The AMA, in opposing the Bill, believed that medical practitioners should not
be involved in interventions that have the ending of a person's life as their
primary intention:
...medical practitioners participating in euthanasia or
physician-assisted suicide undermines the trust that is the cornerstone of the
doctor-patient partnership. The public trusts medical practitioners to care for
patients (and their families and carers) throughout the course of their disease
or condition and to advocate for their health and well-being.
We cannot confuse the role of the medical practitioner as
someone who supports life with someone who takes life.[104]
4.69
The ACL was similarly concerned that:
Euthanasia is essentially about giving doctors the rights to
kill their patients, as the decision over whether to terminate or preserve a
patient's life will rest with the medical profession. Such a drastic move
severely reduces patient autonomy and gives doctors the power of life or death
over those in their care.[105]
4.70
However, Dr David Leaf told the committee that 'one of the options I
would like to have as a doctor treating these people is the option to offer
them voluntary euthanasia'. Dr Leaf emphasised that:
...the term 'voluntary euthanasia' should also mean that it is
voluntary for the doctor. I acknowledge that there are some doctors who would
not feel comfortable in participating in that. That is their right, and I would
seek to protect that. Equally, it is my right, I feel, to say that I would be
comfortable to have that to offer my patients, should they so desire—after
sufficient screening and sufficient counselling, and ruling out other
conditions that would prejudice their ability to make a competent decision.[106]
4.71
Dr Leaf also took issue with the AMA's position:
The AMA does not represent all doctors...[T]he AMA is not
reflective, in my opinion, of current medical opinion. One of the AMA's chief
problems with the voluntary euthanasia bill is that it changes the therapeutic
relationship between a doctor and the patient. I do not believe this to be the
case. I would say, based on what I have said already, that it would enhance
some doctors' relationships with their patients. It would give them another
option, and people are looking for options at this stage.[107]
4.72
As outlined earlier, others also submitted that, in practice, many
Australian doctors already take steps that lead to an earlier death for
patients,[108]
and that many doctors and other medical professionals support voluntary
euthanasia.[109]
4.73
The Australian Nursing Federation took a neutral position on the issue
of euthanasia. It recognised that its 'members hold a range of ethical views on
the subject of voluntary euthanasia'. The Federation further noted that if voluntary
euthanasia becomes legalised, 'nurses and midwives have the right to
conscientiously object to participating in the carrying out of voluntary
euthanasia.'[110]
Pressure and fear of being a burden
4.74
The committee also received evidence suggesting that the legalisation of
voluntary euthanasia would place pressure on people to end their lives even if
they are not ready so as to reduce the burden on their family or the health
system.[111]
The ACL expressed the view that:
Legalised euthanasia places immense pressure on those who are
ill and especially those who feel that they have become a burden to society and
especially to their loved ones. In an age of spiralling health costs and
complex care needs it is all too easy for some patients to feel that they are
simply too much of an economic and emotional drain on their families and that
the best way out is to end their life.[112]
4.75
The ACL was particularly concerned that vulnerable people, such as those
who are elderly, lonely, depressed or disabled will feel such pressure.[113]
Similarly, Mr Christopher Meney expressed the belief that:
Legalisation over time affects hospital practice and societal
expectations, ultimately resulting in undue pressure on patients to not
overburden family, medical staff and/or resources. The subtle or not so subtle
forms of persuasion ultimately diminish a person's freedom and personal choice.[114]
4.76
In this context, many submissions noted the 1994 House of Lords Select
Committee inquiry into euthanasia, which found that:
We are concerned that vulnerable people – the elderly, lonely,
sick or distressed – would feel pressure, whether real or imagined to request
early death...[T]he message which society sends to vulnerable and disadvantaged
people should not, however obliquely, encourage them to seek death but should
assure them of our care and support in life.[115]
4.77
Dr Mark Boughey informed the committee that 'it is often not the person
dying who is expressing the wish to be euthanased', and that the pressure for
voluntary euthanasia often comes from families.[116]
He acknowledged that this pressure occurs even without voluntary euthanasia
legislation in place, but considered that it would be a greater problem if
voluntary euthanasia were legalised.[117]
4.78
However, the ACT Committee of the Voluntary Euthanasia Society of NSW
claimed that:
Arguments that older people will be exploited by being pressured
into decisions to die are disproved by anecdotal and any other evidence
available. Younger family members are more likely to resist the rationally
thought-out wishes of an older member to seek release.[118]
Sanctity of human life
4.79
Many of those who opposed the Bill and the concept of voluntary
euthanasia did so on the basis of the sanctity of human life.[119]
These arguments were often based on religious beliefs – for example, the
Australian Catholic Bishops Conference submitted that the concept of the
sanctity of life in the western world 'owes much to the Judeao-Christian
tradition which affirms that every individual is made in the image and likeness
of God'.[120]
4.80
The Life, Marriage and Family Centre of the Catholic Archdiocese of
Sydney submitted that:
...all human life has value and...the life of every person possesses
inherent and equal dignity. This is an important principle for the security and
safety of us all. The accumulated wisdom of all successful cultures and
societies tells us that the most advantageous way to nurture the understanding
that all human life is precious and of equal worth is to maintain the
prohibition on killing. Human bodily life has intrinsic value and respect for
each human life is integral to respect for human dignity.[121]
4.81
Mr Christopher Meney, Director of the Life, Marriage and Family Centre
of the Catholic Archdiocese of Sydney, told the committee that: 'respect for
the inviolability of human life prohibits intentional killing':
...the legalisation of voluntary euthanasia would have damaging
private and public effects. It would say that some patients' lives have no
value.[122]
4.82
Others also raised concerns that the Bill would send the wrong message
about the sanctity of human life, and could thereby encourage suicide. For
example, the organisation 'Suicide: NO' submitted that:
...the underlying message that suicide is ok at least some of the
time is highly likely to encourage other suicidal members of Australian society
to consider their desire to commit suicide to be a reasonable desire. In other
words, the Bill will strengthen the tendency for suicidal people to rationalise
their desire to commit suicide.[123]
4.83
However, others countered the arguments based on the sanctity of human
life with arguments relating to individual autonomy, as outlined earlier in
this chapter. In particular, where this argument stemmed from religious
beliefs, Emeritus Professor Philip Ley submitted that:
...the issue is voluntary euthanasia. Those with religious beliefs
forbidding euthanasia do not have to avail themselves of it. Nor does anybody,
religious or not, have to take up the option.[124]
4.84
Similarly, the NSW Council for Civil Liberties pointed to evidence given
to the 1997 Euthanasia Inquiry by its Vice President:
It all comes down to choice. If a person disagrees with
voluntary euthanasia for a religious reason, whatever reason it might be, that
person does not have to exercise the right, but I don't think they should impose
that moral or religious view - whatever their view might be - on those who do
wish to die.[125]
4.85
Dr Alan Rothschild also argued that:
...the sanctity of life is already compromised, it has exceptions,
such as the right of a patient to ask for the withholding or withdrawal of life
supporting medical treatment, knowing the result will be that he or she will
die.[126]
4.86
Indeed, several submitters were at pains to make a distinction between voluntary
euthanasia and the withdrawal of futile treatment.[127]
The committee notes in this context that most submissions commenting on the
sanctity of human life had no objection to the refusal or withdrawal of
treatment.[128]
This led some, such as the Australian Federation of AIDS Organisations, to
argue that:
Laws allowing patients to refuse medical interventions mean
those requiring interventions or life support are 'lucky' – they can refuse.
Others whose conditions are as painful or worse, are given only the right to
refuse palliative care to reduce their pain, ironically the same care which may
eventually expedite their deaths.[129]
Impact on the Indigenous community
4.87
Several submissions expressed concerns about the impact of the Bill, and
any subsequent voluntary euthanasia legislation, on the Indigenous population
in the NT, which comprises approximately 30% of the NT population.[130]
As the Aboriginal Medical Services Alliance of the Northern Territory (AMSANT) submitted:
The jurisdiction of the Northern Territory is comprised of some
30% Indigenous residents, many of who[m] are from remote and isolate
communities. This fact marks the NT as being a highly unique jurisdiction in
the Australian context with significant cross-cultural issues, challenges and
opportunities being a regular part of business and life in the NT.[131]
4.88
AMSANT continued:
As such, we believe the NT is a special case when considering
such issues as the Rights of the Terminally Ill Bill of 2008 in that
significant ground‑work and consultation needs to occur with Aboriginal
residents to ensure understanding of such a Bill and also whether communities
are in support of the Bill, or otherwise.[132]
4.89
It was put to the committee that the Indigenous population of the NT was
opposed to euthanasia, or that euthanasia was contrary to Indigenous law.[133]
For example, the Aboriginal Resource and Development Services (ARDS) submitted
that it was opposed to euthanasia on the basis that it conflicts with
traditional law. ARDS quoted its Chairperson, Rev Dr Djiniyini Gondarra:
Euthanasia is murder according to our traditional law. If our
people want to die because they are in pain the patient tells the whole family
that they will close their mouths to water and food and then spend the time
left to get ready to transit to the other side. For someone to administer any
form of substance to end the life of a person is murder in the eyes of our
traditional law.[134]
4.90
The committee also received a standard letter signed by several hundred
Indigenous residents of the NT opposing the Bill and raising concerns about the
revival of the NT RTI Act.[135]
4.91
However, AMSANT was more circumspect, suggesting that there needs to be
full consultation with Indigenous people to ascertain their support or
otherwise.[136]
4.92
In response to concerns about opposition from the Indigenous community, Mr
Marshall Perron stated:
...prostitution, abortion, organ donation, autopsies and cremation
are probably all grossly offensive to Aboriginal culture. A group in our
society finding them offensive does not stop us from having laws regulating
those areas and indeed permitting them. In regard to the Aboriginal situation,
there is clearly a huge amount to be done educating remote Aborigines about the
health system, much of which is a complete mystery to truly remote and tribal
Aborigines. It is hardly a reason to deny the terminally ill the relief they
seek because we have a big job ahead in educating the Aboriginal community...To
presume that we should never have voluntary euthanasia legislation because an
Aboriginal group somewhere will oppose it is not a sensible way to go.[137]
4.93
However, AMSANT recommended that 'the views of Aboriginal residents of
the NT be given pre-eminence in any ultimate decision-making on [the Bill] and
the ultimate practice of euthanasia in the NT'.[138]
Fears and impact on Indigenous
health
4.94
Many expressed concern that euthanasia legislation in the NT would
impact on the willingness of the Indigenous population to seek medical
treatment. It was suggested that euthanasia legislation would contradict
efforts to close the gap in health and life expectancy between Indigenous and
non-Indigenous Australians.[139]
For example, Father Frank Brennan stated that, in his opinion, legislation for
voluntary euthanasia would have a negative impact on Aboriginal health.[140]
4.95
ARDS submitted that 'the prospect of legalised euthanasia has added to
the confusion and fear that Yolngu [of north-east Arnhem Land] have of western
medical practices and procedures'.[141]
ARDS explained that this fear was exacerbated by historical experiences and by
the language divide.[142]
ARDS was therefore concerned that the Bill could exacerbate the Indigenous
health crisis: 'Indigenous health in the Top End of Australia can be expected
to worsen even further, as Yolngu stay away from medical professionals and
institutions'.[143]
4.96
Similarly, Dr David Gawler told the committee that:
Euthanasia legislation has the potential to prevent Aboriginal
people from seeking health care because of the fear that they could be
misunderstood, that their lives would not be valued or that they could be put
down with a needle.[144]
4.97
Dr Gawler continued:
Aboriginal people, with their history of displacement,
marginalisation and even massacres at the hands of white people, find it
difficult to form trusting relationships with white doctors. In Arnhem Land,
the debate continues as to whether doctors are healers or witchdoctors. Consequently,
many patients fear visits to white doctors and especially visits to hospitals,
where they must often travel long distances to another part of the country. To
add to this uncomfortable equation, the knowledge that the doctor may also kill
people or have the power to do so will generally increase anxiety and may mean
some patients refuse treatment.[145]
4.98
The committee also heard anecdotal evidence that Indigenous patients had
left hospital when the NT RTI Act was enacted,[146]
or had refused immunisations 'because of the perception that doctors could
intentionally kill people with those injections'.[147]
Similarly, AMSANT also submitted that at the time of the NT RTI Act:
...there was considerable confusion and angst amongst elements of
the Aboriginal community, particularly amongst remote area residents, about
what the Act actually meant and how it would be applied in practice for
Aboriginal people...[148]
4.99
Mr McKenzie of AMSANT was concerned that, if euthanasia legislation were
re-enacted, Indigenous people would avoid coming to the health services
altogether.[149]
4.100
However, The Hon Daryl Manzie told the committee that there was some
misinformation at the time of the NT RTI Act:
Anecdotally, I was told by some Indigenous people that they were
informed that the government was going to be able to give them or their
children a needle when they came to Darwin and get rid of them because it does
not want too many Aborigines...[M]isinformation can cause a lot of grief. These
are very sensitive issues but they are also very emotive and they do generate a
lot of comment from people. Sometimes it is very ill informed.[150]
4.101
In response to questioning from the committee about the impact of
euthanasia legislation on Aboriginal communities in the NT, Mr Perron expressed
the view that:
If the situation is handled sensibly, there will in my view not
be an impact on Aborigines failing to come forward and seeking medical
attention.[151]
4.102
Mr Perron then pointed to evidence given to the 1997 Euthanasia Inquiry
which disproved rumours that Indigenous Territorians had avoided attending
health services as a result of the RTI Act.[152]
4.103
Indeed, the issue of the impact of the NT RTI Act on the Aboriginal
community was also of significant concern during the 1997 Euthanasia inquiry.[153]
The inquiry considered whether misinformation was being provided to Aboriginal
communities about the legislation,[154]
and whether or not there had been a decrease in the numbers of Indigenous
Territorians seeking health care.[155]
Appendix 3 of that report outlined statistics, provided by the NT Government,
on hospital services supplied to Aboriginal people in the NT, which concluded
that:
There is no evidence from hospital separations or patient travel
data that the introduction of the Euthanasia Act affected the willingness of
Aboriginal people to present to hospital for medical treatment.[156]
4.104
AMSANT nevertheless suggested that this Bill be delayed, until an
education and awareness campaign on euthanasia is developed and implemented in
the NT, with a particular focus on engaging Aboriginal people and communities.[157]
Father Frank Brennan agreed that an education campaign would be needed prior
to any re‑introduction of voluntary euthanasia, and that 'the sort of
education which would be required in remote Aboriginal communities is very
great'.[158]
However, Dr Teem-Wing Yip, a doctor working in the NT, argued that:
...a large amount of resources would be required to adequately
educate the NT's indigenous population about the right to ask for a doctor to
kill them. Such a use of resources is completely inappropriate in light of the
fact that these people are already dying prematurely of preventable diseases at
an embarrassingly high rate – diseases that are badly in need of resources to
prevent.[159]
Conclusion
4.105
This chapter and previous chapters are a summary of the views and
evidence presented to the committee during the inquiry. However, there is no
majority or minority view attached to this report. The next chapter sets out
the views of the Senators who participated in this inquiry.
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