There are not many things that predictably grab people’s attention. Sex and violence are two, although not necessarily in that order. Presumably that is natural selection at work. Death is also of interest, even when neither violent nor sexy. Elephants cry from grief but modern humans do it better and longer. Homo sapiens have been the best mourners on the planet at least since we killed off the last of the Neanderthals perhaps 25,000 years ago. We do not like dying ourselves and, for the most part, do not particularly like other people dying either.

Until fairly recently there was often not a lot we could do about death. Seriously ill and injured people would generally die quite quickly. Now, things have changed. In wealthy countries death can often be delayed although, eventually, even the spammers currently filling our email inboxes with promotions of human growth hormone as a youth-regenerator will die (by natural causes or otherwise).

Relative wealth brings certain perks. One is the spare time to consider, and possibly the wherewithal to influence, how you die. In developed countries there has been much talk about voluntary euthanasia and assisted suicide. This article is yet another example. It discusses pros and cons of allowing voluntary euthanasia and assisted suicide, and includes a critical look at recent developments involving Australia’s Dr Philip Nitschke.

Palliative Care

It is not unusual for opponents of voluntary euthanasia to suggest good palliative care can resolve the desire for euthanasia. Unfortunately, reality indicates otherwise.

In the early 1990’s, I was a palliative care physician in a hospice-home care team. I can recall a couple of dying patients - only one of them Dutch - who articulated convincing cases for their own euthanasia. They made me feel pretty awful. I can turn on the paternalism when necessary (for instance, for drug-seekers) but typically my reflex is to attempt to give patients what they want. Working for a Catholic palliative care team meant that the options regarding euthanasia, even for discussion, were limited. I ended up honestly answering my patients’ questions about the effects of overdosing on various medications but felt a bit subversive doing so.

Back at the hospice, however, I could continue morphine for semi-comatose patients "to make sure they were comfortable" and order papaveretum and hyoscine injections ("Om and Scop") for the already comatose "to treat their death rattle" - laboured, moist respirations that often occur during the final hours of life. These drugs slowed breathing and dried secretions, resulting in a quieter patient who may well have died a few hours sooner.

It appeared that treating a death rattle benefited distressed relatives and staff more than an oblivious and moribund patient but, fortunately, no-one worried about that. Back in the 13th century St Aquinas far-sightedly decided that it was okay to kill the dying if that was an unintended consequence of pain relief medicine. The Doctrine of Double Effect has been with us since. It has been a Good Thing which allows Catholic hospices to provide excellent medical care. The Om and Scop might not have been precisely intended as analgesia but it was close enough.

Discussions on the ethics of death often make a big deal about the ethical distinction between being active (e.g. "killing") and being passive (e.g. "letting die"). This distinction is widely overrated.

Active euthanasia is what most fuss is about but passive euthanasia is more common. Passive euthanasia includes the murky area of death secondary to resource restrictions. It seems many people deny this happens. Politicians who routinely pass bills that create passive involuntary euthanasia from budget restrictions become holier-than-thou if anyone mentions active voluntary euthanasia. Doctors, even those in critical care areas grappling daily with the effect of resource rationing, rarely consider that their work involves passive euthanasia.

In ethical terms, passivity or inaction is widely regarded as relatively neutral compared to action. There is a common feeling that greater moral responsibility is borne for actions which predictably result in some consequence than to inactions which predictably result in the same consequence (1). Doctors who euthanase the endstage terminally ill can end up in prison whereas doctors who allow them to die are just doing their job.

It is sometimes said by utilitarians (the "greatest good for the greatest number" and "ends justifies the means" ethicists) that there can be no moral distinction between killing and letting die because the outcomes are identical (2). In practice, however, it is not this simple. For instance, the outcome of killing could, on the one hand, be better than letting die if it eliminates suffering more rapidly but, on the other hand, be worse if there is more emotional distress and community disquiet associated with killing (3).

There is often ambiguity about what is active killing and what is passive letting die. A spinal injury patient in England recently needed to appeal to the High Court to have her ventilator turned off. Her doctors had argued - with some justification - that to do so would be to act to kill her (4).

A lot of heat gets generated during discussions about active euthanasia. Nonetheless, it is easy to become familiar with the major arguments. There are essentially two arguments for and two arguments against allowing voluntary euthanasia.

Two types of argument are commonly used against ever allowing people to control the manner and timing of their death. These are often labelled the sanctity of life (e.g. "life is God-given and not yours to take") and the slippery slope (e.g. "if we allow this then people will start being killed when they shouldn’t be. Look at the Netherlands"). These arguments often determine medical management of people who would rather be dead.

Sanctity of life arguments are commonly religious and therefore not amenable to refutation. One study found that the strongest physician characteristics associated with lack of willingness to withdraw life support were being Catholic or Jewish (5).

Slippery slope arguments are widely used to argue against legislation to permit voluntary euthanasia. For instance, it is said that permitting voluntary euthanasia will eventually lead to the weak and powerless being killed against their will. This argument is interesting because I think anyone examining the Dutch statistics with neutrality tends to be, like the Dutch themselves, underwhelmed by evidence of a slippery slope. Any trends are subtle enough for some analysts to suggest there may be a slope leading away from problems rather than toward them (6).

The Dutch health system does, however, provide free universal care. It is sometimes speculated that legalisation of voluntary euthanasia would be more problematic in expensive, user-pays health systems where patients might choose to die rather than inflict huge medical bills on their families. Perhaps Dr Trevor Mudge, chair of the Australian Medical Association’s Ethics Committee, AMA National Vice-President and a strong supporter of a user-pays health system, is being consistent in also lobbying against voluntary euthanasia.

Aside from the lack of data supporting a "euthanasia slippery slope", the slippery slope, as a class of argument, has intrinsic drawbacks. For example, the use of a slippery slope argument in any situation suggests that you have no satisfactory primary argument that proves your case (7). Otherwise you would rest your case on this primary argument rather than resorting to speculation about future problems.

In addition, slippery slopes appear to have nowhere dangerous to reach if a clear distinction can be made between the desired and undesired behaviour, such as the distinctions between asking to be killed, not asking to be killed and asking not to be killed. If slippery slopes were a real entity then civilisations should with time come to hold extreme policies on many issues. Instead, it seems we reiterate the same controversies and arguments through history. Social policy swings on pendulums, it does not slip down slopes (8).

There are two main arguments used to support access to voluntary euthanasia. An argument from personal autonomy is hammered by most pro-choice euthanasia campaigners (9). The argument is essentially that some fates are worse than death and it is paternalistic to prevent these people from obtaining the relief they seek.

The second common argument supporting euthanasia rests on compassion for the suffering. Compassion even encompasses respect for personal autonomy because people become miserable if their preferences are denied. Compassion as sole basis for euthanasia can, however, prove problematic because it could support non-voluntary and, if one knows of a person’s unavoidable horrible fate but cannot convince them of it, involuntary euthanasia.

After reflection on the arguments for and against, it does seem plausible to at times allow voluntary euthanasia and assisted suicide. Campaigners against euthanasia appear overly certain that it should never be permitted. Campaigners on the pro-choice side of the debate seem to increasingly make a different and, one would have thought, obvious mistake - that it should always be permitted. This will be discussed shortly.

Most people never seriously want to kill themselves. Nonetheless, some do, often inexplicably to observers.

For a decade, I have provided general practice services for a clinic for young homeless people. Lots of them are self-harming and suicidal and my basic approach is simple. I try to stop them. It feels like the right thing to do and I get paid for it. Not being a psychiatrist, I even attempt to help cutters, drug users and criminals. After the eventual successful suicide of one chronically tormented patient I can recall thinking that perhaps it was for the best. But I did not regret my minor role in keeping her alive until that point and do feel sad about all the ones who have died. So, like most people, when I see someone suicidal I aim to stop them. That being the case, it may not be surprising that I felt uneasy to recently read that a group cheered at the unveiling of Philip Nitschke’s "Exit Bag".

The media circus has regained interest in Dr Philip Nitschke, the current inheritor of that catchy tag, "Doctor Death". Nitschke is now in the suicide device business. Righteous politicians, as ubiquitous as hypocritical politicians, have declared export of suicide devices illegal. Recently, Nitschke seems to be getting routinely harassed at airports.

I can understand how Nitschke ended up where he is. It sounds like he was initially driven by anger at the arrogance and corruption of the medial profession. That is fair enough.

Our profession consumes vast resources without seriously examining the possibility that population health might improve if a slice of the billions directed at doctors and our treatments was instead spent on, say, education and employment programs (12). We allow drug companies to brainwash and bribe us into often prescribing potent chemicals for often trivial conditions. Our medical associations lobby governments - with significant success - to enact health care systems that put the interests of doctors, the private health industry and the rich above those of our patients.

The Northern Territory’s Rights of the Terminally Ill Act 1995 was bitterly opposed by the AMA. Nitschke responded when doctors sought to maintain their power to prevent patients having a say in the manner and timing of their own death. The subsequent overturning of that legislation - largely the result of Federal Parliament’s Christian conservatives - led Nitschke to adopt a more radical position. Now he hopes to remove politicians, legislation and doctors from the equation altogether. Enter the Exit Bag.

The Exit Bag could become the latest accessory for the fashionably suicidal - simpler and decidedly less messy than skateboards. It is a plastic suffocation device complete with conveniently placed drawstring, sort of the opposite of bags children’s toys come in - the ones with a dozen little safety holes pre-punched through the bottom, emblazoned with something to the effect of "Not to be used as a suicide device". As it happens, for legal reasons Exit Bags apparently display not dissimilar labelling.

A few years back, I attended a couple of university guest lectures by Philip Nitschke. I was not thinking of Exiting. I was just curious. He seemed a likeable man, with sufficient insight to realise that the euthanasia debate was not the greatest issue facing humankind. I must have been feeling bold because I asked a question. The question and its reply possibly explained something about both of us. For instance, why one is world famous and the other a barely visible navel-gazer.

I really wanted to know whether Nitschke thought it was possible to make it too easy for people to kill themselves. My question included asking whether he felt it would be better if everyone had a cyanide capsule glued to their gums. This way we could instantly suicide whenever the fancy took us. "Wouldn’t we all be dead?", I wondered aloud.

In reply, Nitschke began by pointing out that cyanide was a lousy choice of drug - it caused too unpleasant a death. Obviously I read too many spy stories when I was a kid. But he seemed to reflect on the more substantive point and indicated he did not think we would all be dead.

And he was right. We wouldn’t all be dead. Just certain overly sensitive types would be - like me. But do not be alarmed. This article is not about to turn into a rant about how Nitschke wants me dead.

Nitschke commented during his reply that he would hate to see young people using his devices to suicide. At least, I thought he said something like that. Reading news articles from that period makes it sound like I misheard him (e.g. "Teen Suicide Booster Comes To Mission Bay" 13). But, perhaps inconsistently, Nitschke seemed to indicate that he felt access to suicide devices should be easy, literally on the supermarket shelves. At that time, the "Peaceful Pill" was planned.

Perhaps making pills peaceful proved more difficult than anticipated because instead we have the Exit Bag. Look forward to old couples tottering down the supermarket aisles - "Groceries today dear, or just an Exit Bag? …Over here! It’s on special." Hopefully the ads will not air during children’s TV shows. Well, maybe that’s our future. Currently these bags seem to be mail order only.

Nitschke appears to believe that it is difficult to make it too easy for people to kill themselves. The following is a direct quote attributed to him in an email interview with the National Review (14). Nitschke was asked "Who decides if a life is worth living?". His reply needs quoting at some length.

Nitschke sounds like he is driven to his current position by a desire for ethical consistency and simple rules. One cannot criticise him for that.

Nitschke starts well enough with "if we believe that there is a right to life". That is a good way to put it because there are excellent philosophical arguments that no-one has "rights" to anything. Not that denying the existence of rights is a position which people on the political Left fall over themselves to air. Arguing for universal rights to this or that (health, education, employment, freedom etc) can be powerful and useful rhetoric. Presumably Nitschke does believe in rights, otherwise he was merely providing a counterargument to his right-to-life critics and not an explanation for his own stance.

So let us accept that one can have a "right to life". Nitschke leaps to assume that this implies that one has a "right to dispose of one’s life" and/or a "right to dispose of one’s right to life". Many philosophers balk at this assumption. It is often argued that unwanted rights cannot be discarded. For instance, John Stuart Mill suggested a century and a half ago that a person could not abandon their right to liberty and sell themselves into slavery (15) - though some employers may disagree. It can be argued that the right to life is another right which cannot be given away.

That is not, however, the main problem with Nitschke’s justification. The crux of Nitschke’s position is the argument from personal autonomy. Using personal autonomy to justify anything always entails two problems. The first is defining competency to make decisions. The second is the prevention of harm to others.

Regarding whom to decree as not competent to hold personal autonomy, typical suggestions are children and the mentally deficient (e.g. by Mill in 15). Grey areas in defining whom shall be deemed a child and/or mentally incompetent must somehow be overcome. Nitschke appears to put this in the too-hard basket, but age of consent and criteria for mental competency comprise a crucial part of any voluntary euthanasia or assisted suicide legislation.

Nitschke’s concession to this in the above interview was his qualifier that suicide pills should only be available to "those old enough to understand death". Perhaps he deliberately avoided saying "those old enough and mentally competent enough" lest putting suicide devices on supermarket shelves create issues for check-out staff. Intellectual and psychological testing would join price checks as a common cause for supermarket queues. In contrast, age is easily confirmed with identity cards. While Nitschke may be disingenuous to sidestep the mental competency issue, this is still not the greatest problem with his position.

Doctors are familiar with the concepts of "harm to self" and "harm to others". They are how we justify locking up psychiatric patients against their will. Self-harm is a common cause for incarceration, if not in a psychiatric hospital then in those larger involuntary psychiatric institutions we call prisons.

Of course, not every suicidal patient is a psychiatric case. The irremediably suffering may be suicidal yet judged sane and, in certain jurisdictions, become candidates for voluntary euthanasia or assisted suicide. Suicide can be rational and not self-harm if one faces a fate worse than death.

Harm to others is a different issue. Personal autonomy of the competent can permit harm to self but clearly never automatically justifies harm to others. Restraining the murderous is morally justifiable. There is a good (utilitarian) argument that suicide can only be sanctioned if on balance the gain for the person desiring death outweighs the pain of those affected by the death. This creates real problems for the view that Nitschke articulates. Deaths usually harm others. Although perhaps illogical, death by suicide is often more harmful to others than death by other causes. Suicides may be intentional but they upset people because they appear preventable. This harmful effect is greater when the person who suicides is young and "healthy".

This is why respect for personal autonomy should not automatically permit anyone who wants to die to do so. Exit Bags and Peaceful Pills should be kept off the supermarket shelves. Nobody has a "right to die" because this would necessitate a "right to harm others". People who would prefer to be dead must carefully appraise the effects that their death will create on others, particularly their nearest and dearest.

These concerns should not be taken to mean that carefully drafted and monitored legislation to permit, under specific circumstances, voluntary euthanasia and assisted suicide would not overall be beneficial. The Northern Territory’s 1995 Bill did appropriately incorporate assessment of consent and competency although an uncooperative medical profession did its best to make these safeguards appear overly stringent. Concerns regarding harm to others might in practice be allayed by giving the "nearest and dearest" certain veto powers. Whilst this might frustrate the occasional individual, in practice most people requesting euthanasia have already obtained at least the tacit support of those closest to them.

The fact that enacting such legislation has proved difficult does not justify promotion of personal suicide devices. Wide availability of such devices will invariably be hazardous. This development again demonstrates the danger of not having legislation that is consistent with current community views.

Dr Harold Shipley, the UK GP who murdered many of his elderly patients, has also been labelled "Doctor Death". One wonders whether he may have escaped conviction if he had only killed the terminally ill and at trial claimed their deaths were consensual. This anomaly arises because the public, including jurors, predominantly support voluntary euthanasia for the suffering terminally ill, yet are aware that its illegality forces practitioners underground. Lack of legislation also resulted in initial acquittals of Dr Kevorkian (another Dr Death) in the US for some killings which were arguably unconscionable. It is very likely that he would have been stopped at an earlier trial had legislation controlling voluntary euthanasia and assisted suicide been in place. His actions would have broken regulations concerning assessment and consent.

Various Australian legislatures will debate bills to permit assisted suicide and voluntary euthanasia over coming years. With satisfactory safeguards regarding competency and harm to others, such legislation can be supported.

Some of the people, some of the time, would rather be dead. Often this preference is irrational and it is justifiable to protect these people "from themselves". Less commonly, a wish to be dead is entirely rational and justifiable.

The community needs to improve the care of people who face fates worse than death. In some cases, better use of technology as palliative care will resolve their crisis. Not uncommonly, however, patients are in a predicament because our technology has kept them living beyond what would have been their "natural" time of death. Medicines and machines that go beep often prolong a traumatising experience for everyone involved.

To attempt to solve this problem by making suicide a readily available option is sure to create more harm than good. The use of suicide devices by a handful of people who most of us would regard as potentially better off dead will not outweigh the harm of their inevitable use by people who most of us would regard as better off alive. Personal autonomy is important but it should never be separated from an evaluation of its impact on others.

Legalisation of voluntary euthanasia and assisted suicide with carefully drafted safeguards should reduce the risk that people who would prefer to be dead are granted their wish inappropriately.

1. Greater disapproval of perceived action over inaction can also apply if the consequences are unintentional. Inadvertently giving the wrong drug and killing a patient is more harshly judged than failing to give the right drug to prevent death. Indeed, tribal induction of junior doctors often involves learning "First, do no harm" (although to "Ultimately, do more good than harm" would be more sensible). Of course, not everyone thinks inaction is ethically neutral compared with action. The case that failure to donate to life-saving charities could be comparable to murder is outlined by Peter Singer in "Famine, Affluence and Morality" Philosophy and Public Affairs, 1(3). At a recent anti-war demonstration I saw a protester with the placard "Inaction means consent".

2. Rachels, James. "Active and Passive Euthanasia" 1975 reprinted in Social Ethics: Morality and Social Policy 4th ed. Mappes & Zembaty eds. 1992 New York: McGraw Hill.

3. Peter Singer aptly notes that "normally there is more to fear from people who would kill you than there is from people who would allow you to die" in Rethinking Life and Death: The Collapse of Our Traditional Ethics. 1994 Melbourne: Text Publishing Co.

4. discussed in Skene, Loane & Paul Nisselle. "End of life decisions: killing and letting die" Modern Medicine 2003; 4:67-70

5. Christiakis NA, Asch A. "Physician characteristics associated with decisions to withdraw life support" American Journal of Public Health 1995; 85:367-372

6. Ryan, Christopher. "Pulling up the runaway: the effect of new evidence on euthanasia’s slippery slope" Journal of Medical Ethics 1999; 24:341-344

7. Cornford, FM. Microcosmographica Academica: Being a Guide for the Young Academic Politician. 5th ed. 1953 Cambridge: Bowes & Bowes quoted in Grey, William "Right to die or duty to live? The problem of euthanasia" Journal of Applied Philosophy 1999; 16:19-32. Of course, whatever their intrinsic problems, we all use slippery slope arguments. I occasionally catch myself using them to argue against various health policy changes.

8. Gunn, Andrew "Euthanasia: levelling the slope" Australian Doctor 14 Mar 1997; p24

9. "Pro-euthanasia" campaigners, like "pro-abortion" activists, are "pro-choice" seeking to allow the option if, and only if, it is desired.

10. Kurt Vonnegut discussing his character Kilgore Trout in Breakfast of Champions 1973 (p72 Granada paperback).

11. This quote attributed to Bertrand Russell (amusingly, sounding very certain of himself) is widely used but its source is obscure. I located a 1999 plea on the internet from a librarian, John J. DiGilio, asking if anyone knew the quote’s origin. I emailed him hoping the question was now answered but he replied that "it remains a mystery to me to this very day!"

12. "With life expectancy for women now averaging 82 years, and men now at 76, medical advances in the past century have given us an extra half a lifetime." (Australian Doctor, Deb Richards, 24 Jan 2003, p19) Note how medical advances are given the credit with no consideration of the role of improved housing, nutrition, hygiene, sanitation and so on.

13. Kumpel, Robert "Teen Suicide Booster Comes to Mission Bay" San Diego News Notes, Jan 2003.

14. Lopez, Kathyrn Jean. "Euthanasia Sets Sail: An Interview with Philip Nitschke, the other ‘Dr Death’." National Review 5 June 2001 www.nationalreview.com/interrogatory/ interrogatory060501.shtml

15. Mill, J. S. 1859. On Liberty

Return to issue 79 index

[ Doctors Reform Society of Australia home page]
[ About DRS ] [ Search ] [ What's New ]
[ Policies ] [ Media Releases ] [ Published Letters ]
[ Online articles ]
[ New Doctor: Journal of the DRS ]
[ Discussion Board ] [ Contacting DRS ] [ Joining DRS ] [ Links ]