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SPEECH By

The Rev Hon Dr Gordon Moyes AC, MLC

In the

NSW LEGISLATIVE COUNCIL CHAMBER

On the

THE VOLUNTARY EUTHANASIA TRIAL (REFERENDUM) BILL 2003

(An expanded version of the speech delivered in the NSW Parliament including references, quotes and footnotes).

15th October 2003

THE VOLUNTARY EUTHANASIA TRIAL (REFERENDUM) BILL 2003

The Voluntary Euthanasia Trial (Referendum) Bill 2003 is an important Bill because it touches some of the most precious values that Western society have preserved for several thousand years. The issue is of international concern and has been debated widely throughout the world. However it is appropriate that this Parliament makes its own decisions on the issue.

The object of this Bill introduced by the Green Party is to require the holding of a referendum to determine whether the people of New South Wales approve in principle of a legally and medically supervised trial of voluntary euthanasia for a period of 18 months. It is a matter of debate, as we have seen with the heroin injecting room, if a trial can be held on a matter that will result in the deaths of people, and as we have seen with that trial, there is a tendency to extend the period of the trial until it becomes a permanent fixture, the institution of a process by subterfuge. There is also uncertainty, that the failure of proper assessments and quantifiable data as happened with the heroin injecting room, will be repeated with a voluntary euthanasia trial.

But the issue that concerns most people in this State, of all political persuasions, is whether such a trial should proceed on moral and ethical grounds in the first place.

This Bill proposes a referendum to be held on the question of a legally and medically supervised trial of voluntary euthanasia for a period of 18 months with the vote for the referendum to be taken in conjunction with the next ordinary elections of local government councillors, and that the voters at the referendum are to be the persons entitled to vote at those elections.

Honourable members need to decide if local council elections, where the issues often concern roads, rates and rubbish removal, are the most appropriate occasion for a referendum on a matter of such vital moral and ethical concern. I do not think this is an appropriate occasion, but I do not wish to be side-tracked on this issue just now, as I believe the whole moral and ethical issue should be the focus of our attention.

In recent times the subject of euthanasia has become a hotly contested issue in most Western cultures. The fear of seeing a person suffer has led many to believe that the compassionate response is to send them to an early death. Indeed, as medical science enables people to live longer and to overcome more and more disease, there is a fear that many elderly patients are being kept alive artificially and against their will.

People now speak about a "right to die" and some pro-euthanasia societies have sprung up, actively lobbying on behalf of their cause. I believe this is a strange kind of compassion, which says that the way to relieve suffering is to kill the sufferer. The practical problem today is not that of over-treatment, but really one of under-treatment. That is, we have become all too willing to allow loved ones to die, without looking at all the options, or exhausting all the alternatives.

Euthanasia is now often proposed primarily for mental suffering or anguish, which can be less easy to treat than physical pain. To date, it has been found impossible to write precise descriptions of distress, especially emotional distress, into a proposed law, so as to ensure that they could not be applied to persons for whom they were not intended. Since this difficulty still remains after decades of searching for a solution, a breakthrough would now seem unlikely, and the supporters of euthanasia themselves do not offer any helpful suggestions. True compassion is compatible with objecting to a dangerous law.

In this important debate, it is imperative that we clearly define our terms before proceeding. From the point of view of the Christian Democratic Party, euthanasia is not about halting futile treatment. Nor is it about the alleviation of suffering. This is well handled as palliative care, and having established over twenty-five years ago a hospital based palliative care program, with Sydney doctors and nurses trained in pain control, I know how effective this can be. In essence this Bill allows legal acts that directly and intentionally causes a person's death.

Thus there is a "crucial difference between taking a life intentionally and allowing a death naturally. The first is homicide, and the second is a natural death". (Geisler and Turek, p. 185)

As Andrew Lansdown explains, "euthanasia has little to do with refusing futile or extreme treatment. The man who rejects a heart transplant or declines a third bout of chemotherapy is not committing suicide, but rather is accepting the inevitability of his own death. The doctor who withholds or withdraws undue treatment at the request of a terminally ill patient is not killing his patient but rather is refusing to prolong his patient's life at any cost. Properly understood, euthanasia involves an intentional act to end a person's life. Opponents of euthanasia do not advocate the unnecessary and unwelcome prolonging of human life by artificial means. Rather, they oppose active measures to bring human life to a premature end."

And as ethicist Leon Kass reminds us, the ambiguity of the term "right to die blurs the difference in content and intention between the already well-established common-law right to refuse surgery or other unwanted medical treatments and hospitalization, and the newly alleged 'right to die.'

The former permits the refusal of therapy, even a respirator, even if it means accepting an increased risk of death. The latter permits the refusal of therapy, such as renal dialysis or the feeding tube, so that death will occur. The former would seem to be more about choosing how to live while dying, the latter mainly about a choice for death." (Kass, 2002, p. 206)

We are not the only Parliament to consider such a motion. Five Independent Parliamentary Inquiries in recent years, all concluded that euthanasia law could never be made safe from abuse. But as the reports are both difficult to obtain and somewhat demanding to read, it may be helpful to set out some of the arguments that led to that common conclusion. But what is reasonable for one person can be simply ignored by others, if it does not conform with their prejudices.

Though one might think parliamentarians, when considering a draft euthanasia law, would see the force of these arguments, many MPs find it hard, if not impossible, to separate their personal views on euthanasia from their duty to examine the safety of the draft before them. The committees of inquiry all included members who were personally in favour of euthanasia, so the fact that three of them issued unanimous reports means that many of their members, to their credit, did in fact make this critical distinction.

The committees and their reports were:

  • Select Committee on Medical Ethics, House of Lords, January 1994.
  • New York State Task Force on Life and the Law, May 1994, titled Euthanasia and Assisted Suicide in the Medical Context.
  • Senate of Canada, June 1995, titled Of Life and Death.
  • Community Development Committee, Parliament of Tasmania, June 1998, titled The Need for Legislation on Voluntary Euthanasia.
  • Social Development Committee, Parliament of South Australia, October 1999, titled Inquiry into the Voluntary Euthanasia Bill, 1996.

Because it is commonly claimed that the only real opposition to euthanasia comes from the churches, it is worth commenting that none of these reports relied on any religious arguments. In the following excerpts, readers will find the common threads of evidence that Dr Nitschke and people of his ilk refuse to concede or confront.

1. House of Lords.

"Society's prohibition of intentional killing is the cornerstone of social relationships, protecting each person impartially and embodying the belief that all are equal. That protection should not be diminished".

"Delineating the point at which the duty to try to save a life is exhausted and at which continued treatment may be inappropriate cannot be defined or legislated for, because it relates to the condition, circumstances and values of individual patients".

"It would not be possible to frame adequate safeguards against non-voluntary euthanasia. It would be next to impossible to ensure that all acts of euthanasia were truly voluntary, and that liberalisation of the law was not abused".

"The product of an adequate legal framework should be public confidence that the law protects life. There can be no more important area in which the law's protection should be complete and transparent than where individual's lives are at stake".

"Creating an exception to the general prohibition on intentional killing would open the way to further erosion, whether by design, by inadvertence or by the human tendency to test the limits of any regulation. These dangers are such that any decriminalisation of voluntary euthanasia would give rise to more, and more grave, problems than those it sought to address".

"The message which society sends to vulnerable and disadvantaged people should not, however obliquely, encourage them to seek death, and instead, should assure them of our care and support in life".

"The issue of euthanasia is one in which the interest of the individual cannot be separated from the interest of society as a whole".

2. New York State Task Force.

"For public policy, one cannot rely on ideal cases, where all terminally ill patients are treated at the highest standards and all doctors are well informed and competent in terminal care, while reality does not meet the expectation".

"Concentration on dramatic individual cases obscures the impact of what it would mean for the state to approve of medical killing. It will be the doctor's values and judgements about pain, disability and dependence that will determine what is recommended and what is done. Since those values will be randomly met, that would be profoundly unjust".

"Suffering is ultimately a human, not a medical, problem. Euthanasia would extend medicine from the realm of curing and caring to dispensing death for problems endemic to the human condition".

"The common reason to want to die is intolerable psychological pain. More people over 50 commit suicide in the mistaken belief they have cancer than those who actually have it and commit suicide".

"Changing the law will encourage further change, partly because the law conveys acceptance and approval. There could be no certainty that the guidelines will remain stable".

3. Senate of Canada.

"Since a second person is directly involved, adequate safeguards could never be established to ensure consent was given freely and voluntarily, though this would be essential to prevent abuses and to avoid opening the door to non-voluntary euthanasia".

4. Parliament of South Australia.

"Law would not just control the practice of voluntary euthanasia, but would likely confirm and encourage it. Dying is never strictly private because the death of one individual affects others too".

5. Parliament of Tasmania.

"Individuals presently enjoy equality of society and protection under the law. If voluntary euthanasia were to be legalised, an inequality would arise where one category of individual was deemed to be of less value than another and could therefore be killed".

"The codification of voluntary euthanasia could not adequately provide the necessary safeguards against abuse".

"A determination of the need for legislation on voluntary euthanasia cannot be made on the basis of subjective moral choice".

"Legalisation of voluntary euthanasia would pose a serious threat to the more vulnerable members of society and the obligation of the state to protect all members equally outweighs the individual's freedom to choose euthanasia".

A referendum at local council elections is not the best way to gain informed public consent on such a vital ethical and moral matter.

Euthanasia, is about one thing only: the killing of another person. It does not matter whether this is done with a gun or a lethal injection - the effect is the same. With this definitional framework in place, here are our objections to legalised euthanasia which no referendum could counter.

FIRST, THE DOCTOR-PATIENT RELATIONSHIP IS WEAKENED

When the medical profession becomes involved in the killing, the delicate trust relationship between patient and doctor is undermined. People trust their lives to doctors and health care workers in the knowledge that they are dedicated to the preservation of life, to healing, to caring. This after all is the basis of the Hippocratic tradition. The Hippocratic Oath includes the commitment not to kill a patient, even if the patient requests such a course.

Once doctors became involved in killing, once they become "legalised terminators" as Morris West calls them, patients will be in a state of fear and suspicion, not knowing from where the doctor is coming. Some may rightly fear whether "every injection, pill or new IV bag is designed to cure or to kill - to end the pain or the patient." (Kilner)

But it is not just the patient who is at risk. Doctors too risk becoming desensitised, seeing the taking of life as just another routine procedure. This was exactly the case in pre-Nazi and Nazi Germany. The medical establishment played a large role in the killing of hundreds of thousands of Germans and non-Germans. (See, for example, Burleigh, Friedlander, Alexander.) It took less than 20 years for German medicine to make the practice of the widespread euthanasia of "undesirables" acceptable. (Fumento, 1991) And the horrible Nazi crimes "started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived." (Alexander).

Moreover, legalised euthanasia gives too much power to doctors. Doctors, not patients, are empowered by euthanasia. Even for a doctor who acts only from the noblest of motives, there is a chance of making the wrong decision for the wrong reasons. But what of unscrupulous doctors? What if doctors make a straight commission from each patient they kill, as is the case with some abortionists? As T.C. DeLacey notes, "Doctors like anyone else can be selfish and lazy. It is not unknown for doctors to take self-interested short-cuts, for example, putting a pregnant woman to the added and unnecessary strain of an induced or caesarean section birth on a Friday in order to guarantee an uninterrupted weekend for themselves. Why, then, would they never be tempted to kill as the quickest or easiest way of dealing with a troublesome case; likewise, why would they never be prepared to falsify a patient's 'living will'?"

There is also the problem of faulty diagnosis and predictions. To terminate a patient's life, a doctor must have pretty good assurance of his diagnosis/prognosis. But surveys have found that one-half of responding physicians said they were not confident to predict that a patient had less than six months to live. (Lee) A study published in the British Medical Journal found that there is an astonishing level of misdiagnosis of persistent vegetative state (PVS). The study of 80 patients supposedly in a deep and presumably irreversible form of coma found that three-quarters of them had been misdiagnosed. Many of the patients had either woken up spontaneously or had shown signs of brain activity. (The Age)

One study found that eleven patients admitted to a New York hospital who were diagnosed as having "advanced cancer in its terminal stages" did not have cancer at all. (Kamisar) Indeed, as one doctor put it, "Significant numbers [of patients] have been told by doctors that they have only months to live, and have lived on, often with a good quality of life, for many years. As with capital punishment, if you get it wrong, it's too late!" (Muirden)

Examples are common. Doctors at a Sydney hospital decided that a man who lapsed into a coma after a drug overdose would be better off dead, claiming he had irreversible brain damage. His sister intervened, and with the help of a NSW Supreme Court judge, managed to prevent the hospital from shutting down his life support. Four weeks later the man was smiling, and kissing loved ones. (McIlveen) And a Queensland grandmother, ill with bowel cancer, who had demanded the right to die, has now gone into remission, and is living a healthy and happy life. (Taylor/Whiting)

The story is the same at the other end of life. For example, a faulty prognosis about unborn twins was recently made. A mother was told by a specialist that her twins were deformed with abnormalities and would not survive. The mother did not heed her doctor's advice to get an abortion, but instead gave birth to two perfectly healthy daughters. (Lambert)

Doctors are not perfect and giving them the right to terminate life will permanently weaken the doctor - patient relationship.

SECOND, THE RIGHT TO DIE IMPLIES A DUTY TO KILL

There are no rights without corresponding duties. If society goes down the path of legalised euthanasia, this right to die will lead to its corollary, the duty to kill. Once a society has said that its citizens have the right to die, it will be forced to provides the means to do so. That is, if a state says there is a legal right to die, logically, anyone can bring suit to ensure that governments comply. (Kass, 1993) Just as today society tells us a woman has a right to abort her own child, so it provides, via medicare and tax-payer funding, the means to carry out this activity.

Indeed, once legalised, it is possible that doctors may one day face lawsuits if they violate someone's rights by not killing them. As one commentator put it, "Imagine doctors purchasing malpractice insurance that covers 'denial of death' suits. That day may not be far away." (Fournier)

In our view, a right to die refers to an entitlement to all necessary aid to provide comfort of body and mind when a person is dying, and not to have his or her dying unnecessarily prolonged. An appeal to a "right to die" is perverted when it is intended to mean a right to be killed, as in euthanasia, though the same words are used. No code of ethics or law has ever recognised a right to be killed, or the other right which would exist if it were genuine, namely the right of another to kill when asked. In the absence of supportive argument, a right to be killed may be presumed not to exist.

For all the talk about choice, about freedom to choose, about giving people options, the legal and social legitimisation for assisted suicide will effectively eliminate one option, namely, staying alive without having to justify one's existence. With legalised euthanasia, the burden will be upon people to justify being alive - we will have to prove that we ought to be allowed to live. Lest that sound too far out, consider the words spoken in 1984 by the then Colorado Governor Richard Lamm who said, "Elderly people who are terminally ill have a duty to die and get out of the way." (Cited in Spring) Or recall the comments made here by the then Governor-General Bill Hayden who, thinking of his own advancement in years, spoke of "unproductive burdens" which we need to be "disencumbered" of via euthanasia. (Fagan)

But as Simon Leys (Pierre Ryckmans) has noted, why is Bill Hayden as a senile, incoherent old man in a wheel chair (one day) any less of value and worth than Bill Hayden was as Governor-General? A society that allows such distinctions is one that has "simply forsaken the very principle of civilisation and crossed the threshold of barbarity".

Moreover, would Hayden set up a test whereby we determine who is an unproductive burden? Will people be forced to give written evidence as to why they should be allowed to remain alive? After all, in a world of scarcity, such proposals are not all that far off. Indeed, some people are calling for such measures already.

Some people, concerned by what they see as a crisis in over-population, have called for a drastic reduction in population levels. Consider some existing proposals: one Australian Museum palaeontologist told a Canberra Parliamentary audience in March 1995 that Australia should aim for a population target of fewer than 10 million by the end of the century. What will become of the other 8 million Australians is anybody's guess. (Cribb)

In 1995 a Gosford councillor told an inquiry into population control that people who choose to have three children should be compulsorily sterilised and forced to pay the government $200 per fortnight. He also said that couples who choose to have no children should be given a "community service award" of $50,000 and $200 a fortnight until they are aged forty-five. (Central)

In 1992 the then Leader of the Democrats, John Coulter, told a Sydney audience that no Australian family should have more than two children. (Cited in Joseph) All these respected leaders in Australia have come up with fairly draconian measures to cut back population growth. It does not take much imagination to see that euthanasia will be enlisted to supported such population-reduction goals.

Again, this is not far fetched. In January of 1994 the Economic Planning Advisory Commission (EPAC) discussed the rising costs of health care for the elderly. In its publication EPAC actually looked at the issue of euthanasia as one option in the whole discussion. There was no talk about alleviating suffering or being compassionate - the whole proposal centred around cost-cutting measures. (Clare)

Indeed, it is estimated that around half of all health care dollars are spent on people in their last six months of life. (Chamberlain, p. 89) Thus cost considerations are increasingly becoming a major part of the decision making process. In a recent case of a brain dead man on life support, a Monash University medical ethicist said that there would be a high cost involved in maintaining the man, so the economic factor would have to be considered in deciding his fate. (Cited in Coffey)

Despite repeated attempts to maintain the opposite, there is a qualitative difference between forgoing futile treatment and killing or assisting suicide. Life-sustaining treatment may be withdrawn from a person who has an underlying illness that is incompatible with spontaneous life, when the treatment has been shown to be useless or too burdensome. The natural course of the illness, which had been temporarily stayed, is thus allowed to run. If the diagnosis is correct, death will then result from the illness, which was going to be the eventual unavoidable cause, and this cause is recorded on the death certificate. If, for some reason, death does not occur, this is not regarded as a failure, all other appropriate treatment is continued and there should be no cause for legal liability against the doctor.

Euthanasia is different in its nature and its intention. Death is now the sole intended and inevitable outcome. It is not due to any natural cause, even in those with terminal illness, but is artificially induced so that a new and otherwise impossible cause of death has been substituted for the one, which was to be expected. From both the ethical and the legal viewpoints, making a person die is different from letting a person die when it is medically proper to do so. If the death certificate is honestly completed, it will tell the story. Even the nature of the person's request is different; one risks death, and the other seeks it. No matter how often forgoing treatment and killing are asserted to be equivalent in the terminally ill by those who cannot see the difference or who wish to obscure it, prescribing for death would be unlike any other medical action.

Legalising euthanasia in any of its forms would fundamentally alter our concepts of what constitutes medical treatment and the practice of medicine. Using a narcotic as a pain-killer cannot be likened to its use as a patient-killer. If the former is therapeutic, what is the latter?

Even if the law is changed, drug actions would not change. Under what heading in the text books of therapeutics might the new uses now appear? If, as seems likely, some doctors were prepared to carry out euthanasia, it would have to be decided how and where it was to be done; would it be at home, in hospital or in segregated suicide or euthanasia clinics? Would these doctors be specialists? Would they be listed in a directory? Would they be required to undergo special training? Would they be accredited and be subject to peer review? What kind of medical indemnity would they need? How would standards of practice be established and regulated?

If such questions seem grotesque, it is because killing people has nothing whatever in common with what it means to be a doctor. Doctors dispense treatment, not poison. No medical skill would be required to kill. If respect for the person's autonomy is thought paramount, why could not any person carry out legalised killing? People who want to die do not need a doctor to help them reach that decision. It could be seen as restrictive to confine killing to doctors, whose powers over patients would be increased at a time when some think they already have too many.

Those who advocate euthanasia rarely address the known difficulties regarding the guaranteeing of competence and freedom from coercion in the subject groups. Studies have shown that suicidal intent in sick persons is highly dependent on the presence of mental disorder, and that those with terminal illness have a higher than average incidence of this, though it be in subtle form and difficult to diagnose. Up to 58% of cancer patients develop clinical depression at some time, and in one series, every terminally ill patient who suicided or wished to suicide was depressed. How many of the sick elderly, so-called competent persons might be allowed to be needlessly killed it current proposals were introduced?

It has been pointed out many times that legalised euthanasia would be a possible disincentive to the search for new treatments and for high quality of care for all, especially for the most difficult and unpleasant illnesses and patients. There can be no doubt that it would sometimes be easier and cheaper to kill than to care. Although such possibilities have been labelled as scaremongering, they would not only be likely, they would probably be inevitable. In Holland, euthanasia is now openly discussed as a variant of medical care, with its own indications and standards. The risk would always exist that an option would become an expectation, and perhaps in time even an obligation, as is also reported from Holland.

There would be considerable risks for medical practice in the possibility of coercion and deception. These elements regrettably are already sometimes to be found in medical decision making, and they could be relatively easily hidden in respect of euthanasia. Would euthanasia be expected to enhance or poison the relations between patients and doctors?

The core of the case for legalised euthanasia in competent patients is that it would be a benefit for those who request it. If it were a genuine benefit, for how long and on what reasonable grounds could it be consistently withheld from incompetent persons whose plight was thought to be as bad or worse? Since involuntary euthanasia is unquestionably murder, is it preposterous to suggest that murder may be a likely extension of legalised voluntary euthanasia? Such extension is now known to be common in Holland and commoner than voluntary euthanasia.

Though legalised voluntary euthanasia has been described as one of the greatest moral challenges of our times, the practice of involuntary euthanasia at the hands of doctors or nurses would go further; it would destroy those professions in their present forms.

The only proper functions of a doctor are: to prevent illness where possible, to diagnose, to treat by curing when it is possible and by caring when it is not, to teach, and to conduct research. All other things are done in a private capacity, and if doctors kill patients deliberately, it cannot be claimed to be part of their vocation.

Killing the failures of medical or social care would be negative, in that it would not contribute to finding solutions to their problems. The more positive course is to find and deal with causes, and to implement the known modes of better care. It is no exaggeration to say that, in some critical respects, the future of medicine depends on the way in which this challenge is met, starting with better preparation of doctors and nurses in the care of the incurably ill.

Some reference must be made to medical euthanasia as currently practised in Holland, since it is often cited as a progressive reform, well controlled, and deserving of our emulation.

The statute law which prescribes it as a criminal offence in Holland is held in contempt, as the courts establish increasingly wide categories of exemption from prosecution. Government and medical authorities have developed and published guidelines for its indications and performance, and these are quoted as evidence that the practice is under control. On most occasions, the death certificate is falsified after euthanasia to make it appear that death was due to natural causes, and the killing is not reported. For this, the doctor faces no penalty and both government and medical bodies have admitted that they have no control over euthanasia. One prominent Dutch author concedes that, 20 years on, it still "lacks any agreed moral, social, legal or medical guidelines".

The results of a recent investigation of Dutch euthanasia over a one-year period, by a committee established by the Ministries of Justice and Welfare, were published in The Hague in September 1991, as the Remmelink report. The following statistics are taken from it.

With a strict definition of euthanasia as "intentional killing at the patient's request", there were about 2300 instances in the year. But the report's compilers thought that certain other practices should also be included to present a more complete picture. These practices are intentional killing without any request, and intentionally shortening the lives of both conscious and unconscious persons. When these are included, the results are dramatically altered.

It then appears that medical killing is practised nearer to 25 000 times per year, that is, in almost one-fifth of all deaths in the country. This figure comprises 2300 instances of active voluntary euthanasia (ref. 11, p. 13); 400 of physician assisted suicide (ref. 11, p. 15); 1000 instances of terminating life without any request (ref. 11, p. 15); 4756 instances of non-treatment or withdrawal of treatment, on request, with the intention to end life (ref. 12, p. 64 and following); 8750 instances of withdrawal of life-supporting treatment, on request, with the implicit or explicit intention to end life (ref. 12, p. 72); and 8100 in which large doses of morphine were given to shorten life (ref. 12, p. 58).

One of the most disturbing figures concerns non-voluntary euthanasia, which occurs when the patient is incompetent and cannot give consent, or is competent to give consent but is not consulted. The Royal Dutch Medical Association itself described this as murder in its guidelines for euthanasia, published in 1984. Though the Dutch have for some time been accused of this practice, it has been denied consistently. It is now revealed as having occurred on about 14,500 occasions in the year, that is, it was commoner than voluntary euthanasia, and in many of these instances, not even the family was told what was happening.

Twenty-seven per cent of doctors admitted to having killed patients without any request (ref. 12, p. 47, Table 6. 1) and 72% routinely falsified the death certificate after euthanasia (ref. 12, p. 38, Table 5.14). The published guidelines for euthanasia, which are presented to the world as evidence that Dutch doctors exercise the most stringent safeguards against abuse, are shown to be often disregarded (ref. 12, p. 39, Table 5. 15; p. 52, Table 6. 8; and ref. 14).

High doses of morphine which were expected to shorten life were used on 8100 occasions, in 5000 of these without the consent of the patient (ref. 12, p. 61, Table 7. 7)

We reject a referendum at council elections to legalize euthanasia, for the single reason that most of the community would not realize that the right to die is really a licence to kill.

THIRD, THE MOST VULNERABLE WILL BE AT RISK

We reject the referendum proposal because essentially it means the most vulnerable would be in mortal danger. The elderly are especially at risk. A poll taken in the Netherlands found that almost all of those living in nursing homes opposed euthanasia. (Fumento, 1995) And with good reason. Similar feelings can be found in disabled persons, "who report that they are being roughly treated by medical staff who resent their 'hopeless' condition". (Caton) Comments like those by Bill Hayden can only multiply such situations.

Legalised euthanasia will put pressure on people for a number of other reasons. For example, family members who may gain from a person's will may wish to speed along the death of someone in the family. And the most vulnerable will be on the defensive. The entire class of the elderly, terminally ill and disabled people "would be forced to justify their own continued existence, and this at the most vulnerable time in their lives." (Chamberlain, p. 147)

But it is not only the elderly, the infirm or the disabled who are at risk. Soon everyone could be at risk. If someone is suffering from depression or loneliness or some other non-life threatening illness, cannot they ask for euthanasia as well? After all, if we decide that people are entitled to take their own lives, why limit it to the elderly? Why not terminate any life at any time? (Wennberg)

If we declare that everyone has a right to die, then how can we say only certain people can be euthanased? In an age fixated on rights, and on equal rights for all, anyone can demand, and receive, the same treatment. Indeed, doctors in Holland have been reported as taking the life of non-elderly people who asked to be euthanased simply because they were depressed. (Jochemsen) The Royal Dutch Medical Association has said that teenagers and children should have the right to choose to be killed, even without parental consent. (Fumento, 1991) As one commentator put it, "Once the fundamental 'right' to euthanasia is created, that right must be and is being extended to all who claim fundamental humanity". (van Gend, 1997)

Indeed, the situation in the Netherlands continues to deteriorate. It is now known from official sources that in Holland, the only place where euthanasia is widely practised though in defiance of the law, the authorities have no control over it, and it is indeed associated with many abuses, including the frequent killing of persons without their consent. (Mad J Aust 1993; 158: 426-429) A new bill introduced recently in the Dutch government would allow anyone over twelve years of age to choose the right to die. In case of 12 - 16 year-olds disagreeing with their parents, the child's wishes will be met. One Dutch cancer specialist said this in support of the bill: "I think if these people want to die then it is their right. There are situations where a 16-year-old manic depressive should be allowed to die". (Jones). And a recent case of a 15-year-old Dutch girl who was euthanased shows this is not just theory. (Ibid.) And on April 11 2001, a vote in the Dutch Senate allowed the Netherlands to become the first country in the world to legalise euthanasia. (Iley)

Giving depressed young people an easy way out is simply unthinkable, given our very high rates of youth suicide. Indeed, some euthanasia advocates would only compound the problems. Consider the proposal by Dr Philip Nitschke to allow anyone, including troubled teens, to get access to suicide pills. (O'Malley) This is not a matter to be decided along with the issues of roads, rates and rubbish!

FOURTH, LEGAL EUTHANASIA SENDS OUT THE WRONG MESSAGE

"Some lives are not worth living." That is the clear message being sent out by a society that enacts assisted-suicide legislation. As a clinical intensive care specialist put it, "To solve the problems of the suffering by killing them does not help the next suffering person ... it sends signals of despair and helplessness. It weakens the social prohibition against killing, and allows that some lives might not be worth protecting." (Wright) At the moment very few people request euthanasia, and of those who do, many change their minds. (Lickiss) But once legalised, it may well seem to be an option to many people, simply because it is legal. Indeed, people may feel they have a duty to be killed.

Once euthanasia is legally allowed, questions may arise as to the desirability of killing off certain sections of society. One utopian bioethicist told a Harvard university audience in 1987 that once euthanasia becomes more accepted, it could be used to "get rid of morally undesirable people". (Cited in Caton) And once we get to that point, the obvious questions that come to mind are: who will judge who is worth living? What criteria will we use?

It needs to be remembered that the Nazi holocaust was preceded by this line of thinking which says that certain lives are not worth living. Indeed, a very influential essay appeared in 1920 by Dr Alfred Hoche and jurist Karl Binding entitled, Releasing Persons from Lives Devoid of Value. (Cited in Bell)

The cheapening of human life is the outcome of the euthanasia mentality. Talk of 'dying with dignity' is clearly misplaced here. How can one affirm life by eliminating it? Life is not dignified by 'putting down' lives. As Dr Robert Bernhoft put it, "My idea of death with dignity is facing it with courage and humor. Putting one to sleep like a rat is not dignified". (Cited in Geisler and Turek, p. 192)

Moreover, there is what is known as the normative effect of the law. Whenever we legalise something, we send out a message that as a society we endorse that activity. That is, what a society allows intellectually, and more importantly, legally, will impact on how individuals respond to those conditions. One study found, for example, that not one AIDS patient in England who wanted to end their life did so, while 30 % did in the Netherlands. The reason? Physician Assisted Suicide is illegal in England and hospice care widely available, while the exact reverse is true in Holland. So those who wish to legalise euthanasia will inevitably see a rise is such cases. Bad thinking leads to bad laws which leads to bad outcomes. (Dyck)

Today, many diverse philosophies compete for attention, some of which give an impression that the moral value of human life is, or has become, a matter of opinion. Against this, there are two sets of contemporary objective moral criteria, universally recognised and accepted, based on a perception that the best interests of society lie in upholding and protecting the right to human life.

The first is the Western legal tradition, dedicated to providing justice for all and protection for the weakest. Statute law respects every innocent citizen's right to life and protects it, recognising it as a basic human good and the prerequisite of all other human rights. There are no legal exceptions - no person may kill another or ask of another to be killed. Thus, innocent life is seen to be inviolable and inalienable. Confusion can arise when the decriminalisation of attempted suicide is wrongly thought to equate to legal endorsement. The law perceives that suicidal intent is probably the product of mental disorder, unless proved otherwise, deserving of mercy rather than punishment. Any person is entitled by law to use reasonable force to prevent attempted suicide, and assisting in suicide remains a criminal offence.

The second is the Declarations of the United Nations, compiled when the world was recoiling from the evidence of the widespread abuse of human rights during the Second World War, when there was a felt need to define and protect valid human rights. The 1948 Universal Declaration of Human Rights, which, on last available figures (1988), was supported by countries with 97% of the world's population, recognises "the inherent dignity of the equal and inalienable rights of all members of the human family" as "the foundation of freedom, justice and peace in the world". It declares that "everyone has the right to life", and that "all are equal before the law, and are entitled without any discrimination to equal protection of the law". Article 6 of its International Covenant on Civil and Political Rights says: "Every human being has the inherent right to life. This right shall be protected by law. No one shall be arbitrarily deprived of his life."

The moral insights underlying these statements would be overturned by legalised euthanasia which would remove the protection of law from some lives, and are too important to be simply ignored, as they usually are, by those who favour euthanasia. From being the most protected, the weakest would be the least protected. Neither the one asking for euthanasia nor the one providing it has a moral right to choose the morally wrong.

FIFTH, THE SLIPPERY SLOPE

A council based referendum on legalizing euthanasia is the slippery slope to one of the worst moral decisions. For all the talk about "safeguards", there really can be no safeguards in legalised euthanasia. The Dutch experience is an excellent example of this. The "guidelines" for euthanasia in Holland have often been flouted. Dr John Keown has studied the Dutch situation in great detail. For example, he found that in 1990, 52 per cent of the 10,558 cases of a doctor's intent to hasten death were done with no explicit request from the patient. (Clark)

The Remmelink Report, an official Dutch government survey of euthanasia practices, found that more than one thousand patients are involuntarily euthanised each year. (Jochemsen, Keown, Smith, van der Maas) As one Oxford philosopher put it, the Dutch experience clearly shows that "even with stringent safeguards, once voluntary euthanasia is legalised the descent down the slippery slope is inevitable". (Oderberg)

In South Australia, where voluntary euthanasia is illegal, a recent survey of doctors who had taken active steps to end a patient's life found that 49 per cent of them had never received a request from the patient to do so. (Fleming) A more recent survey of nearly 1000 Australian surgeons found that more than one third had intentionally hastened the death of a patient by administering more medication than was necessary to treat the patient's symptoms. Of this group, more than half said they did so without an explicit request from the patient. (Brett Foley)

Another survey of 683 general surgeons, conducted a year later by the University of Newcastle, found similar results: over a third had sped up the death of terminally ill patients, and over half of the patients had not explicitly asked for a lethal dose of drugs. Only a few of the patients had clearly asked for euthanasia. (Baskett)

It seems that abuse is inevitable. Voluntary euthanasia will lead to involuntary euthanasia. It is already happening. As one Australian expert in palliative care put it, "No proposal has ever been devised which could be guaranteed not to be abused." (Pollard)

But more importantly, as noted earlier, once we have opened the door to the killing of the elderly, why stop there? This is the really dangerous slippery slope. And again, it is not just theoretical. Respected Australians are actually proposing that infanticide for example be seriously considered. Peter Singer is one well-known proponent of this view.

Indeed, while some argue that policies permitting the killing of patients can be strictly controlled, in the real world such controls quickly dissipate. As Wesley Smith has put it, "The carefully shaded moral distinctions in which the health-care intelligentsia and policymakers take so much pride are of little actual consequence in the real world of cost-controlled medical practice, in busy hospital settings, and among families suffering the emotional trauma and bearing the financial costs of caring for a severely brain-damaged relative. Once killing is seen as an appropriate answer in a few cases, the ground quickly gives way, and it becomes the answer in many cases." (1997)

SIXTH, PALLIATIVE CARE AS AN ALTERNATIVE.

Over twenty years ago, as Chairman of the Board of The Lottie Stewart Hospital in Dundas, I led in the introduction of a special Palliative Care ward being developed in that Hospital. I had some experience in a non-hospital based, home-based Palliative Care work, but I wanted to see if a medical model of Palliative Care could work here in Sydney. It has been outstandingly successful.

Palliative care is one of the great overlooked issues in the whole debate. What the terminally ill want is pain relief, not an end to life. In America there are 31,000 suicides annually, of which only approximately 2 per cent are by people who are terminally ill. (Krauthammer) Although relatively new, palliative care has made tremendous advances in recent years. Yet it is still under-utilised. One medical doctor has said that between 50 and 75 per cent of cancer patients' pain is under-treated, even by specialists. (Cited in Bernhoft)

But palliative care, if used, can now relieve suffering in the majority of cases. As a pro-euthanasia doctor in Holland, Dr Peter Admiral, has admitted, "essentially all pain can be controlled ... euthanasia for pain relief is unethical". (Cited in Van Gend, 1995) One doctor has said that "there is no pain that I cannot treat". (Dunne) Perhaps 95 per cent of all patients can find relief from palliative care. (K.M. Foley) Dr Ian Gawler has said, "in many years of working with people facing death I have never been confronted by a situation where the urge to provide ongoing compassionate care was outweighed by the pragmatic need for a prematurely induced death." And a doctor from Western Australia has said, "there are very few symptoms indeed which cannot be controlled through the application of good palliative care". (Dean)

Those who work with dying people know that the overwhelming majority want their pain controlled, but do not want to be killed. Paul Dunne, who has worked with over 1,000 dying patients in Hobart, has said that only five patients have ever said, "Kill me".

The unanimous report of the House of Lords Select Committee on Medical Ethics has recommended that there be no change to law in the United Kingdom to permit euthanasia. More and better palliative care was instead recommended. (Finlay)

Finally, it should be pointed out that as euthanasia becomes legal and accepted by the community, there will be an inevitable lessening of interest in palliative care and the care of the elderly. As Dr John Buchanan put it, "A risk of the denial of the right to palliative care may arise for those who do not wish to request euthanasia". Indeed, when "death is seen as a treatment, then medicine will allocate more and more resources to develop the technological advances to improve this treatment." (Crum)

Australian author Lisa Birnie concurs. As she began writing her book on death and dying, she had an open mind on the issue of euthanasia, but she ended up recognising its many inherent dangers. She is now a strong supporter of palliative care, and regards the legalisation of euthanasia as "a form of social suicide". She writes, "I am ... convinced that the research required to find the solution to extreme pain in all cases will never be done if euthanasia is permitted simply because it is the cheapest and easiest solution in a world where health budgets are tight, solutions are judged by practical results, and moral standards are determined, essentially, by expediency".

In an unpublished article, "Why doctors and nurses must not kill patients" well known doctors Brian Pollard and Ronald Winton indicate that in Australia, there is now enough information to enable doctors and nurses to decide responsibly that there are no sound arguments why they should become involved, either individually or as groups, even if society decides to legalise mercy killing. There is ample reason to think that they and their patients would be damaged.

The size of the medicosocial problem which it is claimed would be solved by euthanasia is quite unknown, but if palliative care were generally available, it would certainly be small. It is unacceptable to suggest that, since it is not known when, if ever, universal high quality of care may be available, we cannot afford to wait. If health professionals preferred the legalised killing of those who pose no threat to others to a determined effort to implement the humane solution of care, they would merit society's severe and enduring criticism.

We have not yet achieved excellence, or even satisfactory competence, in the limited tasks we have set ourselves in medical decision-making. There are still complaints about inattentive, uncommunicative doctors, inadequate pain control and neglectful care. Agreed patient rights are not always adequately observed. Where is the evidence that we would manage decisions any better when error would be tragic and irreversible?

The progress we have made in developing the means for professionals, patients and others to explore carefully together the ethical withdrawing of unwanted treatment has been predicated on the maintenance of a strict distinction between those practices and killing. Such gains would be lost if that distinction was allowed to be blurred.

The community is repeatedly misled by superficial reporting of the issues, and by inadequate opinion polls conducted among those whose understanding of the issues is unknown. There is now sufficient evidence to encourage professional associations, Royal Colleges, medical schools and individual professionals to take a stand against medical involvement in euthanasia, and to make clear to the community their reasons for this. While some doctors and nurses declare their willingness to act as medical killers, society is shielded from having to confront the reality of euthanasia when it does not have to find other candidates for the distasteful job.

Academic and clinical medical educators have a heavy responsibility in this matter. If doctors who care for the elderly, the dying and the disabled are not well trained in the principles and practices of good palliative care, and if the community does not know that better care is possible, euthanasia will continue to be seen by some as a reasonable alternative, by default. Not only does the community deserve high standards of care for its dying members, it would be tragic if legalised killing of the sick were to be facilitated by the failure of educators to inculcate the best methods for their care.

CONCLUSION

For these and other reasons, euthanasia, or assisted-killing, should never be legalised. Instead, more effort should be put into reducing pain, not killing the sufferer. With the issue of youth suicide again in the public spotlight, we need to heed the words of the 1993 Report of the British House of Lords on euthanasia: "The 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."

When people like former Victorian Premier Jeff Kennett call euthanasia a "beautiful thing," (Alcorn) I can only hope that the reality of what euthanasia is all about hits home. It was not a beautiful thing in Nazi Germany, and it will not be here, if allowed to go through. Such euphemistic language needs to be laid to rest.

As George Orwell so aptly put it: "In our time, political speech and writing are largely the defense of the indefensible. Things like the continuation of British rule in India, the Russian purges and deportations, the dropping of the atom bombs on Japan, can indeed be defended, but only by arguments which are too brutal for most people to face. . . Thus political language has to consist largely of euphemism, question-begging and sheer cloudy vagueness." Indeed, the goal, wrote Orwell, "is to make lies sound truthful and murder respectable."

The conclusion to the House of Lord's Select Committee on Medical Ethics (1984) is worth citing here: "There is not sufficient reason to weaken society's prohibition of intentional killing which is the cornerstone of law and of social relationships. Individual cases cannot reasonably establish the foundation of a policy which would have such serious and widespread repercussions. The issue of euthanasia is one in which the interests of the individual cannot be separated from those of society as a whole."

I will vote against this Bill.

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I express my appreciation to the chief researcher for this paper, Bill Muehlenberg, of the Australian Family Association. Updated March 2003.

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Wesley Mission, Sydney.