Over the last couple of decades, the trickle of patients abandoning clinical medicine and seeking treatment from alternative health practitioners has become a flood. Self-styled clinics offering consultations in naturopathy, iridology, homeopathy and other exotica have sprung up everywhere, and are doing a roaring trade. Patients often have staggering faith in the sometimes uninformed and usually unscientific opinions of many of these practitioners, and part with huge amounts of money for their continuing treatment.

There is doubtless a range of reasons for this phenomenon. But one reason is clear. In very many cases, the patients go elsewhere because they believe they are listened to, that their complaints and their needs are actually heard with sympathy and concern. Though a sympathetic and understanding demeanour may be a poor model for a consultation, if it is not backed up by scientific knowledge and informed clinical examination, it is clearly enough for a very large number of patients to seek it out in preference to seeing their general practitioner.

The era of doctor-knows-best medicine is fading. The ever-increasing power of consumer lobbies has not spared our profession. And nor should it. There is a clearer view now of the doctor-patient relationship as a partnership, where each party has coexisting rights and obligations. The doctor’s duty of care can be negotiated, according to the patients’ beliefs. This is arguably a far superior model of care, but it does deprive the profession of some of the power and influence it once wielded, which some find difficult to adapt to. It has also shifted the ground in the euthanasia debate.

This debate is an interesting one, and goes to the core of who we believe we are as a society. The recent Dutch legislation on legal euthanasia defines an act subject to certain checks and balances and to proper medical assessment. Although apparently in line with community expectations in that country, and passed by a large parliamentary majority, the legislation has given rise to impassioned protests, largely along religious lines. Holland has always been a leading light in liberal social thinking, and interestingly the country does not appear to have fallen apart.

Pressure groups on such matters come not only from outside the medical profession, but also from within it. There is, within our profession, a broad range of views on medical, social and moral issues, views often held with the deepest of convictions based on experience or faith. Witness the vastly differing attitudes and practice with regard to first-trimester abortions in the medical community. Because of this, there is inevitably a general drift of patient populations to doctors who share value systems with the patient, and this is not a bad thing provided the patients are able to exercise that choice.

The passions aroused within the medical community on the issue of euthanasia are instructive. But just as doctors must be allowed to follow their conscience when their belief system guides them, the voice of patients must also be heard and acknowledged.

It is distressing to hear the oft-repeated mantra of many medical specialists, opposing the concept of euthanasia, that a desire for a medically assisted ending of life is based on an ignorance of advances in palliative medicine and on a lack of understanding on the patient’s part of just how much can be done to alleviate suffering and to pave the way for a gentle and natural death.

Of course, there are patients to whom this applies. There are patients whose gratitude is palpable when this is explained, and who do indeed progress to a "good" death, as their disease takes its course. This is one of the immensely rewarding aspects of terminal care that we all strive for, and which must remain the mainstay of the art of palliative care.

Of course, there are terminally ill patients whose desire to end their life is the result of an undiagnosed or inadequately treated depressive illness. To contemplate with such patients the active ending of life would be a fundamental failure of care, at best. Properly managed, those patients will join the first group, and their inevitable death will come at a time that the progression of their illness will decide.

Of course, there is the sinister situation where medically assisted death is discussed without the active and competent participation of the terminally ill person himself or herself. The doctor’s duty in that situation is clear and utterly unambiguous, both medically and legally.

However, when one takes out of the equation all the above groups, it remains abundantly clear to anyone who listens that there is a small group of people who are not ignorant of what we have to offer, who are not depressed, who are not being manipulated, but who, very simply, wish to be the arbiters of the time of their own inevitable death. They remain genuinely grateful for what we have to offer, and for the promises offered by recent advances in palliative care. However, despite our best encouragement, they simply do not wish to lie there with their symptoms well controlled until such time as circumstances beyond their own control decide when their life will end. Their business on earth is finished, they are ready to die, at peace with themselves.

The whole point of medicine is said to be the empowerment of patients to take control, and to make appropriate decisions on questions affecting their health and their life. How can this concept be consistent with our denial of this fundamental right, in our refusal to contemplate euthanasia? As soon as our own beliefs, religious or other, cloud our judgement on the patients’ rights within their own health-belief system, we stand to be again accused of arrogance, of not listening, of failing again in exactly the way that has driven so many patients to alternative practitioners. And what does "care’, in duty of care, mean, if not the delivery of services which alleviate suffering and allow the patient the dignity of choice?

Richard Chaney

Dr Chaney is a GP and Doctors Reform Society member. An edited version of this article was published in Australian Doctor as "giving patients the right to die" 11 May 2001.

.		.	The Doctors Reform Society of Australia, Box 14, 4 Goulburn Street, Sydney 2000. Phone 02 9264-9084 Fax 02 9267-4393.	.
			This page was last updated on 30th January, 2003.
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