The Healer and the Reaper; One in the same?

In whatsoever houses I enter I will enter to help the sick, and I will abstain from all intentional wrongdoing and harm” ~ Translation of the Hippocratic Oath by William Henry Rich Jones (1817 – 1885)

The Hippocratic Oath is taken by all medical students before practicing as a doctor, this oath depicts the understanding that doctors do no harm.1-3 As depicted in the above quote, it is very vague and what does abstaining from “intentional wrongdoing and harm” really mean?1 Many medical procedures are inducing harm as part of acceptable treatment, however the patient makes the final decision by weighing the benefits and harms.2 Euthanasia, after weighing the benefits and harms, can be the appropriate course of action.

The doctor patient relationship

Since 1987 the majority of doctors have favoured a legislative change to favour voluntary euthanasia.2 In a study conducted in 2007, 53% of doctors in Victoria support Voluntary Euthanasia and of those doctors that have experienced requests to hasten death, 35% have prescribed drugs with that intention.2 With a student pole run within the first year MD cohort at the University of Western Australia (UWA), 95% support Euthanasia.

Many advocates are against euthanasia due to the changes in this doctor-patient relationship. Belief is held that doctors are healers and if given permission to end life, trust and confidence in doctors will dissipate.4 Humane ending of life would require some medical knowledge hence it falls upon the doctor to be the primary duty-holder.5 The Netherlands have accepted Euthanasia and have put many restrictions around the acceptance of Euthanasia. Euthanasia can only be carried out by a qualified doctor with permission from a legal and ethics expert.3 This causes 2/3 cases to be refused euthanasia out of those who apply.3 This can help reduce any change within the doctor patient relationship and keep doctors as healers first.

Evidence suggests that the instances in which doctors’ kill without patients express request has in fact decreased in the Netherlands since 2002, when the Termination of Life on Request and Assisted Suicide Act was introduced.4,6 A good legislation should hinder cases like Philip Nitschke, whose medical license has been revoked on the basis of advising a suffering patient, not terminally ill, to end his life7. There are limits to be set, patients that have the possibility of recovery should not be considered for euthanasia.

There is another dynamic to consider, doctors once legally allowed to carry out euthanasia, are doctors willing to?8 Doctors themselves are moral agents and hence must have their own moral reasons for carrying out Euthanasia.5,8 With the right safeguards and the appropriate circumstances, 64% of UWA first year MD students are happy to be involved in an end of life treatment. The doctor and patient working together to come up with an appropriate treatment plan can make euthanasia a great treatment option.

How is Euthanasia carried out?

Pain and loss of independence are the two main reasons for patients in palliative care to ask for Euthanasia, 5-10% of patients in hospice care persistently ask for euthanasia.2 The Netherlands have a checklist to be fulfilled with guidelines to follow before euthanasia is carried out that Australia can adopt, with the main five points shown below9.

  1. a voluntary, well-informed and well-decided request by the patient9
  2. suffering is unbearable9
  3. no other solution to the situation9
  4. consulted with another physician9
  5. carried out with due care (the case must be reported to a pathologist and euthanasia review committee)9

Alongside this checklist in the Netherlands, there are age restrictions and advance directives if there is a known loss of cognition.9 Youngsters above the age of 12 are allowed to apply for euthanasia, with parent permission and support.9 Advance directives involve pre-planning euthanasia, for example for individuals that shall suffer from dementia or Alzheimer’s disease.9

There are three main methods euthanasia can be administered, either by drugs, injections or gases.10 Seconal (Secobarbital) and Nembutal (Pentobarbital) are the two most effective barbiturates.11 Barbiturates are drugs that supress the central nervous system and can cause total anaesthesia allowing for a swift, painless death.11 They are usually administered alongside an anti-emetic, drugs that decrease vomiting, to help keep the barbiturates down.10 In Oregan, a doctor can prescribe medication to end life and the patient must take all the medications in a single dose.10 In the Netherlands, an injection is first given to comatose the patient and then a secondary injection is given to stop the heart.10 In Australia, there are workshops run by Dr. Philip Nitschke that teach people how to manufacture devices such as the “CO Genie.”10 The “CO Genie” is an apparatus that turns out lethal carbon monoxide that can be made at home.10

Euthanasia is a personal choice and the methods used to carry out euthanasia are made to be painless, swift and efficient. It is a working progress and education, alongside research, is the first step in understanding best practice. Is there room for best practice to include euthanasia? At the end of the day, it is up to us to decide if we can watch people suffer or choose to do something about it!

“Dark times lie ahead of us and there will be a time when we must choose between what is easy and what is right” ~ Albus Dumbledore, J.K. Rowling Harry Potter and the Goblet of Fire.

Resources:

  1. UWA. Bachelor of Medicine and Bachelor of Surgery Student guidebook Levels 1-6 [Internet]. Perth University of Western Australia 2011 [cited 2015 Apr 9 ]. Available from: http://www.uwa.edu.au/__data/assets/pdf_file/0006/1457610/MBBS-Guidebook-2011.pdf
  2. South Australian Voluntary Euthanasia Society. End of Life Choice [Internet]. Kent Town: South Australian Voluntary Euthanasia Society 2014 [cited 2015 Apr 9]. Available from: http://www.saves.asn.au/bulletins/mp_eol_newsltr/mp_newsletter220914.pdf
  3. Morris M. 10 Arguments for Legalizing Euthanasia [Internet]. Listverse; 2015 [cited 2015 Apr10]. Available from: http://listverse.com/2013/09/12/10-arguments-for-legalising-euthanasia/
  4. Ebrahimi N. The ethics of Euthanasia Australian Medical Student Journal [Internet ]. 2012;3(1):73-75. Available from: http://www.amsj.org/wp-content/uploads/files/articles/amsj_v3_i1/AMSJ_v3_i1_pp73-75.pdf
  5. Jones GE. The doctor-patient relationship and euthanasia Journal of Medical Ethics [Internet ]. 1982;8:95-98. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1059426/pdf/jmedeth00015-0027.pdf
  6. ABC. Survey shows support for legalised euthanasia [Internet ]. ABC; 2012 [cited 2015 Apr 10]. Available from: http://www.abc.net.au/news/2012-11-16/survey-shows-australian-support-for-legalised-euthanasia/4376524
  7. ABC. Euthanasia advocate Philip Nitschke suspended by the Medical Board of Australia [Internet ]. ABC; 2014 [cited 2015 Apr 10]. Available from: http://www.abc.net.au/news/2014-07-24/euthanasia-advocate-philip-nitschke-suspended-by-medical-board/5615268
  8. Callahan D. When Self-Determination Runs Amok. The Hastings Center [Internet]. 1992 [cited 2015 Apr 1];22(2):52-55. Available from: http://philosophyfaculty.ucsd.edu/FACULTY/RARNESON/Courses/CallahanSELFDETERMINEAMOK.pdf
  9. Termination of Life on Request and Assisted Suicide (Review Procedures) Act [statute on the Internet]. 2002 [cited 2015 Apr 9]. Available from: http://www.eutanasia.ws/documentos/Leyes/Internacional/Holanda%20Ley%202002.pdf
  10. Methods of Euthanasia [Internet ]. New Zealand: The Life Resources Charitable Trust 2011 [cited 2015 Apr 10]. Available from: http://www.life.org.nz/euthanasia/abouteuthanasia/methods-of-euthanasia/
  11. Smith R. Sedative-hypnotics [Internet]. Missouri Mirssouri Department of Mental Health 1993 [cited 2015 Apr 10 ]. Available from: http://www.well.com/user/woa/fsseda.htm
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