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Why elderly people should fear legalised voluntary euthanasia and physician-assisted suicide

By Emeritus Professor David Richmond MD FRACP FRCP(Lond.) Dip. ABIM.
 
The proposal that voluntary euthanasia and / or physician-assisted suicide (PAS) should be legalised targets older people. They form the bulk of the audience at public meetings on the subject. Older people are the main supporters of activists such as Dr. Philip Nitschke and Leslie Martin. It is their membership that holds organisations such as the Voluntary Euthanasia Society together. The reason is not hard to find: it is that people at that end of the age spectrum are beginning to realise that their lives are not infinite, and that sooner rather than later they are going to have more than a nodding acquaintance with the ‘grim reaper’. It is often said that people fear the process of dying rather than death itself and that this is a cardinal driver of their interest in the subject. And so there is a ready audience for the line that people in the later years of life have the most to gain from legalised voluntary euthanasia and / or physician-assisted suicide.

It is ironic then to discover that it is older people (and those with disabilities, of whom older people form a large percentage) who actually have the most to fear from legalising these practices. There are a number of reasons for this.  

1. Ambivalent societal attitudes towards older people based on a variety of concerns:
• after retirement old people make no or little positive contribution to the economics of the country; worse still,
• the proportion of services they use especially in the health and social sectors are seen as a financial liability to society; worse still,
• they block the aspirations of younger people: e.g. by continuing to occupy jobs that could be handed on to younger workers. (Paradoxically, just ten years ago the Treasury was bewailing the probability that with the ageing of the workforce, there would not be enough people in the workplace to sustain New Zealand industry and the country’s economy would sink under the weight of all the pensioners. So whatever happens, the elderly cop the blame.)

Although such notions can be largely refuted, -that is a discussion in itself- it is the perception rather than the facts that tends to rule people’s reactions. The common factor in all this is that we in Western countries live in a society that largely values an individual on what he or she contributes as an economic unit. (How often nowadays do we hear people referred to as ‘units’?) Depersonalisation is one factor that corrodes any expectation held by older people in society that they will not be harmed or, in extreme cases regarded as being expendable. Elder abuse (physical and psychological) is common the world over and in jurisdictions where euthanasia and PAS are legal, it may take that form. Older people are, by and large very sensitive to being thought to be a burden, and more likely than a young person to accede to more or less subtle suggestions that they have ‘had a good innings.’ Statistics from The Netherlands, where voluntary euthanasia is decriminalised, show that more than 30% of people requesting euthanasia do so on the grounds of not wishing to be ‘a burden’. In such circumstances, one has to wonder how free freedom of choice really is.

Dr. Richard Fenigsen a Dutch cardiologist reported, in a paper on euthanasia in that country, that when the Dutch Parliament was considering making euthanasia legal, a group of handicapped adults wrote to the Parliamentary Committee for Health Care and Justice in the following terms: .

“We feel our lives threatened…We realise that we cost the community a lot…Many people think we are useless…Often we notice that we are being talked into desiring death…We will find it extremely dangerous and frightening if the new medical legislation includes euthanasia.”


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2. Loss of control by older people over their destiny


Older people with disabilities lose the ability to control their environment (i.e. lose their autonomy) and are therefore at risk from those (nurses, doctors, pharmacists etc.) who assume that control and who have the power to do them harm – including to euthanase them even though they have not requested it – the so-called ‘slippery slope’ effect. In Holland the practice has moved in 30 years from euthanasia on request (legal voluntary euthanasia) to euthanasia of people who cannot request it, -including newborns) to euthanasia of people who could have but didn’t request it; both of which are illegal. It is laughable that proponents of voluntary euthanasia declare it to be on the grounds of providing death with ‘dignity.’ In countries like The Netherlands and Belgium many more people suffer the ultimate loss of dignity by being euthanased without their consent than are euthanased on request. If voluntary euthanasia were to be legalised, older people would undoubtedly discover that the fear of dying that a minority have is replaced by a majority fear of being killed without their consent, – with the noblest intentions of course. They would not know who their enemy was: the smiling doctor who greets them twice a week on his ward round, the cheerful nurse who attends them so professionally on the evening shift. It is well recognised that legalising euthanasia throws up a cadre of euthanasia-friendly health professionals who can justify its use in virtually any circumstance – Dr. Nitschke is an example – and that eventually end-of life termination procedures run out of control no matter how tightly they are ostensibly regulated. Indeed, there are those euthanatics who argue that people who cannot make an informed decision in favour of euthanasia, are actually being unfairly discriminated against compared with people who are capable of making a decision so that the ethical thing to do is to euthanase them regardless. This is of course, murder, but to my knowledge only one physician has ever been convicted in either The Ntherlands or Belgium and he was given a suspended sentence. The authorities turn a blind eye to the practice.

Dr. Herbert Hendin is a Professor of Psychiatry in New York and the author of a number of books on physician-assisted suicide and euthanasia. He has personally investigated the practice of euthanasia in The Netherlands. After doing so, he and others researching with him concluded that guidelines established by the Dutch for the practice of assisted suicide and euthanasia were consistently violated and could not be enforced. The guidelines specify that a competent patient who has unrelievable suffering must make a voluntary request for euthanasia to a physician. The physician, before actioning the request, must consult with another physician and must report the case to the authorities.

He notes that ‘concern over charges of abuse led the Dutch government to undertake studies of the practice in 1990, 1995 and in 2001 in which physicians’ anonymity was protected and they were given immunity for anything they revealed. Violations of the guidelines then became evident. Half of Dutch doctors felt free to suggest voluntary euthanasia to their patients, which compromises the voluntariness of the process. Fifty percent of cases were not reported, which made regulation impossible. The most alarming concern has been the discovery of several thousand cases a year in which patients who have not given their consent have had their lives ended by physicians. A quarter of physicians stated that they “terminated the lives of patients without an explicit request” from the patient. Another third of the physicians could conceive of doing so’. In other words, the most important thing we can learn from the Dutch experience over 30 years is that the practice of euthanasia cannot be controlled.

 

3.Modern Utilitarian philosophies about what constitutes a person worthy of care.

Bioethics has become a sounding board for utilitarian philosophers such as Peter Singer, John Harris and the late Joseph Fletcher. They contend that only beings that exercise personal awareness are capable of being classified as “persons” who are worthy of respect by society. Thus the fetus, neonates and people with severe confusion / dementia – the majority of whom are elderly – are not, by their definition “persons’. Society is therefore justified in getting rid of them if they are an inconvenience: e.g. using scarce resources. This sort of philosophy is being taught in medical and nursing schools. As a philosophical stance it is not new: it was just such a viewpoint that, taken up nationally, was the theoretical basis underpinning the holocaust in Germany during the time of the Third Reich. In 1895 the German Adolf Jost enunciated the concepts of a “right to die” and “human worthlessness” in his book The Right to Die.” His ideas were taken up and built on by Ernst Haeckel, Judge Karl Binding and above all, Psychiatry Professor Alfred Hoeche. Binding and Hoeche maintained in their book entitled: The Permission to Destroy Life Unworthy of Life, that there were people whose lives were “not worthy to be lived”. They were to be found amongst the terminally ill, those in coma and psychiatric patients, especially those residing in hospitals. With regard to this last group, they emphasised the high financial cost to the German State incurred in their continuing treatment. Finally in 1922, Ernst Mann advocated euthanasia not only for the above groups, but also for children who were crippled or incurably ill. An officially endorsed euthanasia programme began in Germany in 1933 and became compulsory in 1939. It is estimated that 275 000 persons who had been in nursing homes, hospitals and asylums were killed in this programme prior to the onset of World War II. Hence what the world came to know as The Holocaust started with the forced euthanasia of disabled and mentally ill people. Proponents of legalised euthanasia are desperate to try to distance themselves from these unpalatable facts. But they are irrefutable. The only difference between Germany of the Third Reich and Holland today is that the Germans made the euthanasia programme compulsory. In The Netherlands it is still discretionary; at the discretion of the doctors.

 

4. Fraught family relationships

Experience overseas is that those who are less well-off, those who have no close family, and those who have fraught family relationships in older years have the most to fear. In this last case, younger members of families of long – lived elders, may feel thwarted, believing that they could utilise their older relatives’ resources better but being unable to access them while they are still alive. Or it may be that care-giving has become burdensome. Those of us who work in the sector know that these things happen and that is why every District Health Board in the country has an Elder Abuse team. What we see is probably only the surface of a deeper underlying problem because many older people are reluctant to complain about their care-givers’ behaviour, especially if the family is involved, for fear of repercussions. Hence subtle and not so subtle pressure on older people to request euthanasia where it is available as an option for medical ‘care’ is not always because the family has the best interests of their ageing relative at heart. ‘Choice’ in such situations is not necessarily free choice.

 

5. Erroneous diagnoses

As we age, we are increasingly afflicted by disease, some of which may be readily corrected e.g. by wearing spectacles or taking medication, but some of which will likely be fatal. It is well recognised that all diagnoses, even in these days of high powered scanners and sophisticated blood tests etc. are a matter of probability. That is, there is a chance that the diagnosis is not correct. Clearly, the more diseases one has, the greater the likelihood that at least one diagnosis is not correct. On average one third of people aged 65 and over have three or more chronic (i.e. longstanding) disease entities, such as arthritis, high blood pressure, cancer, emphysema, Parkinson’s disease etc. That doesn’t include poor vision and hearing. The older one gets, the greater the number of chronic disorders. Moreover prognostication, i.e. determining how long a terminal illness will actually take to cause death is an even greater gamble. The annals of medicine abound with incorrect diagnoses and erroneous predictions of death. There are now many cases on record of people being euthanased by enthusiastic physicians where autopsies showed no evidence of fatal disease, and others being euthanased who may well have lived comfortably for months or years. In a recent Listener magazine, there is a story about septicaemia (bacterial blood poisoning). It includes a first-hand account by a woman who suffered from a severe episode of it, but recovered. The only part of her story that the magazine highlights is the following; “I had always had an ambivalent attitude to voluntary euthanasia, but to my shock, I found myself vividly understanding the arguments in its favour.” Now consider this: had she been sick in a country where voluntary euthanasia is legal, and had she expressed such sentiments to her doctors, and had they emphasised with her desire to be put out of her pain, she might well have been euthanased (voluntarily) in which case she would not have been here to tell her story. In my own years of practice, I can recall three examples of people diagnosed with terminal cancer by highly qualified teams of medical specialists, who, in the fullness of time proved not to have that disease. The problem is that if voluntary euthanasia had been legal, and if these people had requested it before time and the progress of events proved the diagnosis to be incorrect, an “innocent life” would have been lost, and, the error not discovered until the coroner’s post-mortem (if such were ever held). Such a scenario did in fact occur in the case of Nancy Crick an Australian patient of Dr. Philip Nitschke’s who killed herself whilst surrounded by advocates of voluntary euthanasia, on the basis of a diagnosis of bowel cancer. An autopsy revealed no evidence of cancer.

If as a nation we reject capital punishment on the grounds that one innocent person executed is one too many, why is it that the same standard is not applied to euthanasia?

 

6. Reduced access to palliative and terminal care


Killing sick people is cheap. Providing palliative and terminal care is a highly skilled, labour intensive and expensive enterprise. Despite the fact that the government funds only 60% of the cost of palliative care, we have a very good service in New Zealand. The majority of recipients of such care are old people. If euthanasia were to be legalised, it would not be logical to continue to make funding available for research and service provision in terminal care when there is a cheaper option. This may sound cynical: but I call your attention to the government’s attitude to paying rest home carers a decent wage and the vigorous Ministry of Health led effort of recent years into devising formulas that will enable District Health Boards to shed people from their waiting lists because of insufficient funding. Incidentally, many of these rejects are old people without private health insurance. For some of them, especially those with life-restricting disabilities and no assurance of reinstatement on hospital waiting lists, euthanasia must seem an attractive option.

Conclusion.
Older New Zealanders have to realise that if they allow legislation to pass so that voluntary euthanasia and / or physician-assisted suicide become legitimate components of therapy, in thinking that they have seized control over the end of their life they will discover too late that they have actually lost it.

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