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0 NM"c" 25, 1997 the membm olthe Commonwealth Senate voted, 38 to 33,to confirm the resolution of their colleaguesin the House of Representatives that thePrivate Member's Euthanasia Bill shouldbecome law.The Bill, introduced into the LowerHouse six months previously by Liberalback-bencher Kevin Andrews, had been approvedby 88 votes to 35 in the House ofRepresentatives.The effect of the Senate vote was tooverturn the Northern Territoryvoluntary euthanasia legislation, TheRights of the Terminally Ill Act 1995,which had been approved with a narrowmajority by the Territory's parliamentarianson May 25th, 1995.The debate which attended the passingof the Andrews' Bill, in both theLower and Upper Houses was complicatedby the following factors:• the support given to the Bill by boththe Prime Minister and the Leader ofthe Opposition;• the whole question of States' andTerritories' rights,• the inadequacies of the NorthernT erritory legislative drafting;• the wider implications that the TerritoryAct might have for the continuingaccess of the Aboriginal community tohealth care;•the distinction between private moralityand public legislation;• the posturings of some of the proponentson both sides.T he way in which variou s responseswere represented in the media confused theissue even further. But those who listenedto the parliamentary hearings and thediscussion in both Houses were on thew hole impressed by the qu ality of thedebate. The manner of our dying, especiallyin this age of m edico-scientific technology,is obviously a matter that concerns usgreatly. The fact that there were over 12,000submissions to the Senate Committee isabundant evidence of this.At the height of the debate on February17th, 1997, three of the m ost outspokensupporters of the N orthern Territory legislationand of active voluntary euthanasiapublished a research study on 'End-of-lifeETHICSW.J. U RENLife and death mattersDecisions in Australian Medical Practice'in the Medical Journal of Australia. T heywere Dr Helga Kuhse and Professor PeterSinger, from the Monash University Centreof Human Bioethics, and Professor PeterBaume, from the School of Community Medicineat the University of New South Wales.They based their study on the 24 itemsof a questionnaire which replicated onecirculated origina lly to medicalpractitioners in the Netherlands by theRemmelink Commission in 1990 and 1995.Questionnaires were mailed to 3000Australian doctors who might possibly beinvolved in m aking end-of-life m edicaldecisions. There were 1918 responses ( 64percent) of whom 1361 hadattendedanonacutedeath within the last 12 months. Thisfield was further narrowed 'by excludingdoctors who in respect of that death had nocontact with the patient until after thatdeath or where the death had been suddenand totally unexpected'. Of the remaining111 2 doctors, 800 doctors reported m akinga decision either intended to shorten life orforeseen as probably or certainly shorteninglife. The other 3 12 doctors did not makesuch a decision .In analysing the responses from these1112 doctors the authors of the researchdrew as a 'main finding' that 30 per cent(±3.3 per cent) of all Australian deaths werepreceded by a m edical decision explicitlyintended to hasten the patient's dea th:doctors prescribed, supplied or administereddrugs with the explicit intention ofending the patient's li fe in 5.3 per cent(±lper cent) of these deaths, and withdrewor withheld life-prolonging treatment withthe explicit intention of not prolonging lifeor of hastening death in 24.7 per cent (±3 .1 percent) of these deaths.Further, 'in 22.5 per cent ('3. 1per cent)of all Australian deaths, doctors withheldor withdrew treatment from patients withoutthe patient's explicit request, with theexplicit intention of ending life' (M[A,17 February 1997, p195) . TheseAustralian figures, it was furthermaintained, are in the range of 50per cent higher than the figures forcorresponding categories"""J"'"' in the Netherlands..1. HE CONCLUSION DRAWN by the authorsof the study from their analysis of thesurvey was that one of the reasons whysome Australian doctors may be choosingintentionally to end the li ves of theirpatients without consulting the patientsthemselves, was that existing Australianlaws prohibiting euthanasia maymake doctors 'reluctant to discussm edical end-of-life decisions with theirpatients lest these decisions be construedas collaboration in euthanasia or in theintentional termination of life'.The authors are then, in effect, arguingfor a relaxation of the existing laws topermit active voluntary euthanasia. This,they say, will ensure that patients would beconsulted by their doctors, where possible(i.e. if they are competen t) both before lifeprolongingtreatment is withdrawn or withheldwith a lethal intention, and beforeanalgesic drugs were administered in suchquantities that the hastening of death wasnot only intended but virtually inevitable.This line of argument may well seem tobe more than a little paradoxical. One isinclined to subsume: if this is what ishappening when there is no legislationcondoning active voluntary euthanasia, willnot the practice of all forms of euthanasiabecome even more prevalent if it is legalised?The authors of the study argue to thecontrary. Not only will such legislation,they say, promote the autonom y of those18 EUREKA STREET • MAY 1997
patients who spontaneously and explicitlyrequest euthanasia (active voluntaryeuthanasia), but it will also reduce the incidenceof non-voluntary and involuntaryeuthanasia, that is, euthanasia without, oragainst, the explicit wishes of the patient.For doctors will then not fear to bring up thesubject of euthanasia with their patients,the authors claim, and so patients will beconsulted rather than bypassed when thesedeath-dealing decisions are taken . Nonvoluntaryand involuntary euthanasia willthus either be eliminated or become voluntaryand full autonomy will be maintained.Which of these two arguments houldwe accept?If we look to the study, we find thatthere were 234 doctors who decided not totrea t their patients either by withholding orby withdrawing treatment and in each casewith the explicit intention of hasteningdeath. When asked in item 15 of the questionnaire,'Why was the (possible) hasteningof the end of the patient's life by the lastm entioned act or omission not discussedwith the patient?', two replied that thepatient was too young, 55 said that thepatient was unconscious, and 28 said thatthe patient was demented, mentally handicapped,or suffering from a psychiatric disorders(i.e. 85 or 36 per cent were in effectnon-competent). In29 of the remaining 149cases the doctors replied that 'the actionwas clearly the best for the patient or thediscussion would have done more harmthan good'. Even more significantly, in 109cases (47 per cent) the doctors 'didnot answer the question'.HOW FROM THESE FIGURES did the authorsof the study conclude that, if euthanasiahad been legal, the doctors who did not as amatter of fact discuss their lethal intentionswith their patients, would then havediscus ed the matter with their patients?It is, to say the least, a very moot point.It seems to assume that the 47 per cent whodid not provide an answer to the foregoingquestion were unwilling to disclose to theMonash Cen tre for Human Bioethics, aknown supporter of the active voluntaryeuthanasia legislation, the real reason fornot discussing with their patients theirlethal intentions in withdrawing or withholdingtreatment, and that the real reasonwas th e fear of th eir decision beingconstrued as 'collaboration in euthanasiaor in the in tentional termination of life.'T his seem s very coy on the part of thesedoctors, and especially so when apparentlythey had no hesitation in admitting quiteopenly to the explicit intention to hastendeath. This coyness can only cast gravedoubts on the conclusion drawn by theauthors from the survey.Nor is the conclusion any more cogentlyvalidated when the survey addresses thecohort of 99 doctors who admitted toadministering large doses of opioids with atleast a partial intention of hastening death.In 22 of these cases the doctors reportedthat the patient was non-competent (young/unconscious/demented). In 20 cases theaction was said (by the doctor) to be clearlythe best for the patient, or discussion wouldhave done more harm than good. But onceagain the 'did not answer the question'cohort constitutes about half the responses(51 :52 per cent). If euthanasia had beenlegal, the authors conclude, then these doctorswho did not, as a matter of fact, discusstheir intentions withtheir patients wouldthen have discussed their intentions withtheir patients. How they feel authorised toconclude this is a mysteryWhat the survey does show, however,(and I leave to one side here the criticismsthat have been made of both the originalRemmelin k and more recent Monash questionnairethat they conflate 'intending tokill' with 'foresight of death' and 'hasteningdeath' with 'not prolonging life') is thatactive voluntary euthanasia and physicianassisted suicide (that is with the explicitrequest from the patient) in Australia as inthe Netherlands, is accompanied by at leasteight times the incidence of non-voluntaryor involuntary euthanasia.Perhaps, this is because we do not have alaw clearly legalising active voluntaryeuthanasia to the exclusion of all other fom1s.Perhaps, the reason why the incidenceof non-voluntary and involuntaryeuthanasia in the Netherlands is significantlyless than it is in Australia is becausethey do have some form of legal condonationwhile we have none.Bu t the survey, at least as published in theMedical fomnal of Australia, does not supportthe authors' stated conclusion that if euthanasiawere legalised in its active voluntaryfonn, the incidence of non-voluntary andinvoluntary euthanasia would be reduced.All the figures seem to show is thatgranting autonomy to some in activevoluntary euthanasia is accompanied by alarge denial of autonomy to others in nonvoluntaryand involuntary euthanasia. •W.J. Uren SJ is a bioethicist and lectures inm oral philosophy at the United Faculty ofTheology, Melbourne.AUGUSTINIANSSharing life and ministry togetherin .friendship and in communityas religious brothers and priests.'You and I are nothing but the Church ... Itis by love that we belong to the Church.'St AugustinePlease send me information aboutthe Order of St AugustineNAME ........................................................... .AGE ........... PHO E ................................. ...ADDRESS ..................................................... ..................................... P/CODE .................. .The Augustinians Tel: (02) 9938 3782PO Box 679 Brookvale 2100 Fax: (02) 9905 7864V oLUME 7 NuMBER 4 • EUREKA STREET 19
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