Euthanasia What do doctors think?
Allowing doctors to end patients’ lives presents a complex ethical question for many. Hannah Martin reports on a deep divide within the profession.
If New Zealand’s End of Life Choice Act referendum passes next month, terminally ill adults will be able to access assisted dying, or euthanasia.
In some cases, a medical professional would administer the medication to end a person’s life. But that is a step some are unwilling to take.
Euthanasia is one of the curliest issues in medical ethics. Fledgling doctors swear a Hippocratic Oath to ‘‘do no harm’’, but in the face of suffering what this means can be interpreted in a number of ways.
Stuff has spoken to members of the medical profession about the End of Life Choice Act, and the conundrum it represents for those who care for us.
Assisted dying is defined in the End of Life Choice Act as a doctor or nurse practitioner giving a person medication to relieve their suffering by bringing on death; or, the taking of medication by a person to relieve their suffering by bringing on death.
If the referendum passes, people aged 18 or older suffering a terminal illness likely to end their life within six months could approach their healthcare practitioner about assisted dying. Two doctors must agree the person meets the criteria.
As with the wider population, opinions on assisted dying vary among the medical profession.
Research in 2018 analysed Kiwis’ opinions on assisted dying over the past 20 years. It found public support averaged about 68 per cent over that period, with similar support among nurses (67 per cent).
Of 298 New Zealand doctors surveyed, 34.5 per cent would be willing to prescribe lethal medication, and 28.5 per cent would administer the medication if it was legal to do so, they found.
The doctor-patient relationship
The New Zealand Medical Association (NZMA) is staunchly opposed to euthanasia and ‘‘physician-assisted suicide’’.
In its submission in 2018 to Parliament’s justice select committee, the NZMA, which holds the Code of Ethics for the medical profession, stated it regards these practices as being ‘‘unethical and harmful to individuals, especially vulnerable people, and society’’.
It states euthanasia in any form ‘‘conflicts with the ethical principles of medical practice and would change the fundamental role of the doctor and the doctor-patient relationship’’.
Dr Kate Baddock, GP and NZMA chair, says those in the medical profession have the ‘‘utmost respect for human life’’.
Part of a doctor’s role is ensuring they do the ‘‘very best’’ to make a patient as well as possible – ‘‘to conflict that with deliberately taking a life crosses an ethical line’’, she says.
Doctors are concerned that safeguards in the act ‘‘will not be sufficient to avoid a wrongful death’’.
Baddock is aware that, as in society, there will be doctors who are comfortable with the concept of euthanasia – but says the ‘‘significant majority’’ support the NZMA’s position. ‘‘We are comfortable we are reflecting the majority of the profession.’’
The World Medical Association is also ‘‘firmly opposed’’ to euthanasia.
But the NZMA’s stance has been questioned by independent medical professionals, who told Newsroom it has a reputation that is ‘‘conservative, moralistic, paternalistic even’’.
Close to 1750 New Zealand doctors have signed an open letter in opposition to assisted dying, entitled ‘‘Doctors say No’’, stating that assisted dying is unethical, regardless of whether it is legalised.
They say doctors are ‘‘not necessary’’ in the regulation or practice of assisted dying, and are ‘‘included only to provide a cloak of medical legitimacy’’.
A question of conscience
The Royal New Zealand College of General Practitioners takes a neutral stance on the End of Life Choice Act.
The college, which has close to 5000 members, does not endorse euthanasia or physician-assisted suicide, as it considers it a matter for individual members’ consciences. Instead, GPs are encouraged to vote ‘‘along their own conscience lines’’.
Dr Samantha Murton, college president and a Wellingtonbased GP, says though it has not formally surveyed members, anecdotally there is hesitancy and concern among them.
‘‘Quite a few are quite worried about how it will play out’’, with many likely to ‘‘not want to be involved’’, she says.
The college has concerns about how stringent the protections are for doctors who choose to conscientiously object.
Under the act, no health practitioner has to engage with assisted dying if they have a conscientious objection. However, if they do object, the person who requested assisted dying has a right to ask for the details of a replacement doctor.
Murton says drawing a line on involvement is ‘‘tricky’’, particularly in rural communities that may have only one GP.
Regardless, members are motivated to provide compassionate care – a ‘‘fundamental tenet of the medical profession’’ – whether they are for or against euthanasia, she says.
Those in palliative care are also split, with some physicians and groups supporting assisted dying, while others – such as Hospice New Zealand – object.
The New Zealand Nurses Organisation’s position is not clear. A spokesman says it will be releasing a position statement after the referendum.
Dr Mark Lawrence, chair of the Royal Australian and New Zealand College of Psychiatrists’ New Zealand National Committee, says legislation does not make something ‘‘ethically correct’’.
Under the act, if either doctor is unsure of the person’s ability to make an informed decision, a third opinion from a psychiatrist is required.
Lawrence says putting the onus on a psychiatrist to determine this, if two doctors cannot, puts them in a ‘‘challenging position’’. It could also cause practical issues for an already stretched workforce.
‘‘We find it really hard to find positions already at the moment . . . [this] would add another burden to the situation.’’
‘Patients shouldn’t suffer’
However, there are medical professionals who strongly support assisted dying, saying patients should not have to suffer against their wishes at the end of their lives.
Doctors for End of Life Choice, comprising 23 doctors from a range of specialities, says assisted dying should be a choice to terminally ill New Zealanders.
Even with the best hospice and palliative care, some patients still suffer ‘‘unbearably’’ as they die, the group says. It believes the End of Life Choice Act will give those who want it the option to decide for themselves when their suffering has become unbearable.
Emergency medicine specialist Dr John Bonning supports the act. He has ‘‘very firm’’ views on assisted dying, which he sees as having ‘‘no conflict in my role as a doctor’’.
‘‘For me, it’s about choice, and respecting the dignity and autonomy of my patients to make informed decisions.’’
The concept of giving a person an injection to hasten their death is something Bonning has never done, and ‘‘would find sad, because it’s the end of somebody’s life . . . but then death is inevitable’’.
‘‘I’ve seen some very unpleasant deaths, and I’ve seen suffering where no amount of love or medical care can ever change an inexorable deterioration towards death.’’
As well as providing choice to those suffering, Bonning says the checks and balances in the legislation as it stands would be the most stringent in the world.
He lives by the oath to ‘‘first, do no harm’’. ‘‘There are so many things we can do [as doctors] that can and do cause suffering: order needless investigations, do unnecessary procedures, give antibiotic
‘‘For me, it’s about choice, and respecting the dignity and autonomy of my patients to make informed decisions.’’ Dr John Bonning
courses for viral illnesses. Not allowing the end of suffering at the end of someone’s life is doing harm.’’
Dame Margaret Sparrow, retired doctor and reproductive rights advocate, also supports the act. Though she would not be involved if the referendum were to pass, she ‘‘certainly’’ would participate if she was still practising. ‘‘I have always felt it should be a choice at that stage of life.’’
Sparrow, who has long been involved with the End of Life Choice Society (formerly the Voluntary Euthanasia Society), says she has had older patients ask her about assisted dying. ‘‘You just feel there’s nothing you can do but be sympathetic.’’
Sparrow told Stuff she was disappointed the NZMA took such a strong stance on assisted dying, saying it was ‘‘not reflecting the varied views of their membership’’.
What about the Hippocratic Oath?
Dr Rhona Winnington, a registered nurse, and lecturer of nursing at Auckland University of Technology, says the Hippocratic Oath – explicitly preventing the administration of lethal drugs – is a ‘‘bone of contention for many in the healthcare profession’’.
Drugs that are potentially lethal are given to patients every day, just in doses that do not cause death. Even too much paracetamol can lead to liver failure, and even death.
There is a ‘‘very fine line’’ between relieving suffering and giving too much medication, Winnington told the Science Media Centre last year.
But the Hippocratic Oath is also based on beneficence (charity, mercy and kindness) and non-maleficence (not harming, or inflicting the least harm possible to reach a beneficial outcome), so this is where doctors and nurses can decide if what they are giving is in the best interests of the patient, she says.
‘‘It would be easy to argue, however, that by not allowing assisted dying, harm is caused to some individuals.
‘‘A position of balance is needed, and this may be where some practitioners feel able to support this bill,’’ she told the centre.