Focus On Easing Pain
The Age
Wednesday June 25, 2008
Central to the debate on euthanasia is the provision of quality palliative care, writes Adrian Dabscheck.
ON THE surface, the physician-assisted suicide legislation now before the State Parliament has the appearance of being humane and well-intentioned. We all fear a "bad" death - one involving intolerable levels of pain and physical suffering, often accompanied by loss of autonomy and the perceived indignity of total dependence on others. What humane society would deny people in such dire end-of-life situations legal recourse to the help of a physician to end life prematurely?But, as a palliative care doctor, I find that I have several problems with this proposed legislation, and with some of the assumptions behind it.First, it seems to me, it reflects a disturbing degradation of the value we, as a society, place on human life. I don't know whether it is symptomatic of the fact that we have lost perspective, following a century of mass genocides and the growing prospect of further catastrophic loss of human life as a result of climate change. Or, perhaps, in our consumer-driven society, human life itself has become just another expendable commodity in a throwaway world.Whatever the case, the primacy of human life appears to have been slowly whittled away as we become progressively desensitised to its value.The proposed legislation reflects, too, the attitudes of a "well" society to the perceived predicament of people in end-of-life situations where attitudes might well be very different.Great care should be taken not to impose quality-of-life judgements on the sick. A well person may consider the quality of life of an infirm patient intolerable, but as my experience in palliative care has taught me, the infirm patient may have a very different perspective.There is, in fact, no objective way to measure quality of life. Most efforts to do so are based on factors relevant to the physically, intellectually and emotionally well individual. It is easy to overlook the subjective satisfaction of people whose life appears to the "well" person deficient.I have seen the unreserved love between parents and their children who live with what seem to the able-bodied observer intolerable disability. Likewise in the world of adult palliative care, I have witnessed the loving care of children nursing their adult parents as they become increasingly disabled with progressive disease. In both instances I have seen precious moments of love and life occur that are unpredictable in their occurrence but, in my opinion, of far greater value than any perceived "loss of dignity".Changes in circumstances, too, may put previous decisions about life issues in a different context. I have witnessed patients who held very firm views on euthanasia become ill and then change their attitude completely and want to live every moment of available life. The benefits of life seem to outweigh what was previously thought to be the "loss of dignity" involved with progression of illness.The usual non-medical arguments one hears in support of physician-assisted suicide - concern about being a "burden" to loved ones, fear of "loss of dignity" - come across as spurious in the context in which I work.Many of the patients I deal with, who have had long-term debilitating and life-limiting conditions, could be perceived as having been a "burden" to their families for much or even all their lives. Some have never had the so-called "dignity" of autonomy and have always relied on others in meeting their most basic physical needs.Should that diminish the value of their lives? Would that justify making a physician legally available to deliberately bring a premature end to those lives, to relieve the perceived "burden" on their families and end the "indignity" of dependence?As for pain, it is my primary job, as a palliative care physician, to make my patients' lives as free from pain and suffering as humanly possible. And there is much I can do, very effectively, in this regard.A great deal of the fear healthy people have of pain in end-of-life situations is, in fact, unfounded.In extremely rare cases, a patient may, with consent, be sedated at the end of life. That option is always there. But even in such cases, the intention is beneficent, the primary motivation being to relieve pain and suffering when no other method is available.But it seems to me oxymoronic that a doctor be asked to prescribe medication and instruct patients on their use with the express aim of shortening a patient's life.One final concern I have about the proposed legislation is that its passage may create suspicion about motives and hinder the development of a therapeutic relationship between the doctor and the patient.The development of trust is very difficult when treating patients with life-limiting illness. Patients' and carers' thoughts could easily become contaminated and confused, and there is the possibility that patients with life-limiting illness may be denied appropriate end-of-life care due to the fear that doctors may be purposefully shortening life.In short, my fear is that the passage of a bill legalising physician-assisted suicide would confuse and possibly even endanger the practice of palliative medicine, which has an increasingly vital role to play in an ageing society like ours.Rather than pass legislation, however well-intentioned, that is divisive and open to question, a civilised society would be far better served by promoting and providing adequate palliative medicine, which, to its credit, this current State Government is striving to do.Dr Adrian Dabscheck is a palliative care consultant at the Royal Children's Hospital and Peter MacCallum Cancer Centre. These are his personal views and do not necessarily reflect in any way on his places of employment.
© 2008 The Age