Catholic Medical Quarterly Volume 66(3) Aug 2016
Submission of The CMA (Uk) to The Health Commission of The New Zealand Parliament on Euthanasia and Physician Assisted Suicide (PAS)
Reviewed by Dr Robert Hardie OFS MB FRCS
To start with I have to say that this is a truly magnificent submission by Dr Philip Howard, the Presdient of the CMA. It is almost a definitive work in its own right on the history and current state of play on all aspects of medically controlled departure from this life. It will serve as an excellent referrence paper for many years to come and is a must to read in its entirety. A brief report like this can never fully do justice to its full 52 pages. The full submission is on the CMQ website and can be downloaded from from this website.
We should feel very proud to have as our president a man of such capability and calibre, and the New Zealand Government should feel fortunate to have this detailed work which is totally in accord with Catholic Christian bioethical teaching.
The submission very clearly sets the present scene in its initial Executive Summary and poses the central question as to how countries that have abolished capital punishment and attempt to be sensitive to the needs of the most needy, can allow one section in society to take the lives of other members, and whether it is ever possible to have in place sufficient legal safeguards. We are presented with a picture of a slippery slope with increasing deaths from Euthanasia and PAS, deliberate underreporting and failure to prosecute, and the ever-widening spectrum of conditions demanding such a final and macabre solution. Philip insists, quoting St John Paul II, that democracy is a means of promoting the common good and not an end in itself in which every whim of every pressure group has to be met. True democracy depends on the values which it embodies and promotes, including the inviolable right to life as proclaimed by the General Assembly of the United Nations and as laid down in Article 2 of the European Convention of Human Rights. Conscientious objection is seriously threatened when decisions by patients over-ride the rights of those providing their care and disappears altogether when those providing care are forced to provide access to doctors who have a more libertine code of ethics.
Philip historically traces numerous examples of euthanasia performed in Holland starting with the Potsma Case in 1973 when Dr Potsma killed her mother with a lethal injection after she was left with hemiplegia after a CVA. Following the wave of public sympathy she received a week’s jail sentence which was suspended. And so things continued with the Royal Dutch Medical Assocition (KNMG) and the Dutch Supreme Court accepting euthanasia as standard medical practice in 1984, extending to situations such as the Duntinjer Case in 1985, where Dr Duntinjer assisted in the suicide of a 50 year old lady with depression and alcohol abuse, with the court ruling that after her repeated requests to die “there was no alternative to her intolerable suffering”. In the Chabot Case of 1994, Dr Chabot assisted Mrs Bosscher to die following the tragic death of her two sons, both at the age of 20. She refused all anti-depressant treatment saying that the only way was for her to follow her sons and find her way to them through a dignified death. She had no physical or mental illness. Four psychiatrists were consulted, but none saw Mrs Bosscher. Dr Chabot was found guilty but was not punished as it was thought that he had acted responsibly in consulting colleagues and attempting to persuade Mrs Bosscher to reject suicide.
All the cases obviously cannot be included here but they make riveting reading. Philip gives the figures for the year by year increase in numbers in Holland, with euthanasia far outweighing PAS and with unreported non-voluntary, involuntary and passive euthanasia amounting to up to 40% of the total of these deaths. Terminal deep sedation, although not classified as euthanasia, is gaining in popularity, denies patients food or fluid, is considered a normal medical procedure and is allowed to be converted to euthanasia even though the patient is unconscious. Over the nine years from 2004 to 2013, the number of patients with dementia receiving euthanasia rose from one to 97. How “unbearable suffering” is assessed in dementing patients is open to speculation, and this has to be determined by the physician him or herself. The Royal Dutch Medical Association maintains the view that euthanasia must be restricted to suffering that has as its source “medically classifiable somatic or psychological illnesses and conditions”, and that “suffering that has no medical basis falls outside the domain of medicine and therefore outside the Euthanasia Law”. One can’t help thinking that this is a fairly grey area. There is much else on the Dutch experience that Philip discusses, such as the place of advance directives and Neonatal Euthanasia, that is not included in this review.
Next door, in, Belgium, legal action was enacted after a relatively short public debate to allow euthanasia, but not PAS, in 2002, and for children by lethal injetion in 2014. At the moment the extent is greater and the indications wider than Holland, with a rate of 4.6% of all deaths in 2013, and with terminal deep sedation at 12.0% of all deaths. The level of reporting of euthanasia several years ago in Flanders, the Dutch speaking half of Belgium, is estimated at only 52.8%. The president of the Belgian Federal Euthanasia Review and Evaluation Commission is Dr Wim Distlemans, a leading euthanasia advocate. In 2012 he gave a lethal injection to Nathan Verhelst aged 44, who was depressed after a failed gender realignment, and oversaw the double euthanasia of deaf twins, Marc and Eddy Verbessem aged 45, who chose to die after they learned they would lose their eyesight. He also killed Godelieva De Troyer in 2012 who had depression, without the knowledge of her son who heard of the event the following day. These are in interesting contrast to the case of Frank van den Bleeken, a convicted 51 year old serial rapist and murderer, who after 30 years imprisonment wanted relief from his mental torment. His euthanasia was booked for 11 January 2014, but a week before his planned death, his request was refused by doctors and he was referred to a newly opened psychiatric unit in Ghent. In January this year (2016), Nadine Buntjens was suing a Catholic care home for causing “physical and mental suffering” for not permitting the euthanasia of her mother on Church-led premises in Diest. Dr Distlemans said to the Flemish media that a “majority of hospital and nursing homes in Flanders are still Catholic today”, and that “if the right to euthanasia is refused there, that will be a problem.”
Philip next discusses the experience in Oregon, USA, following their Death with Dignity Act 1997 (DWDA). He compares the medically assisted deaths with figures for unassisted suicide and demonstrates how the introduction of PAS has created a completely different population of those seeking PAS to those who otherwise commit suicide, and in a state that has a suicide rate 41% above the US average. 3.4 times as many men than women die from unassisted suicide, wheres the rates are similar for assisted suicide; almost 3/4 of victims of unassisted suicide had a diagnosed mental disorder or alcohol / substance abuse, for which less than a half were receiving threatment, whereas only 3 in 105 patients who died in 2014 under the DWDA had had any formal psychiatric evaluation. Physical illness, especially cancer, contributed for the majority of cases. For years the three most frequent reasons for requesting PAS have been loss of autonomy, decreasing ability to participate in activities that make life enjoyable and loss of dignity. Over 17 years the assisted suicide death rate has risen sevenfold. The difference between the 2 groups of assisted and non-assisted suicide suggests that the attitude in society and the medical profession have altered the normal approach to dying.
The attitude to dying in these islands in which we live in January 2015 (Survey by Assiciation of Palliative Medicine of Great Britian and Ireland) revealed a far more traditonal and we would say sensible approach with 82% of respondents resisting any change in the law on assisted suicide, and expressing the views that a change in the law might have a detrimental effect on the delivery of palliative care. The different attitude in Oregon suggests that society can easily be influenced by what comes to be accepted medical practice. Dr Elizabeth Kubler-Ross, American author of many books on Palliative Care including “On Death and Dying” (1969) pioneered psychological support for the dying and described her five stages of grief (denial, anger, bargaining, depression and final acceptance and peace). She recognised a phenomenon that patients are selective in seeking help from those who give them time and sympathy, while appearing to remain within the stage of dogged denial and stoicism with those who are less sympathetic or cannot tolerate the thought of their demise. This can easily lay them open to exploitation by those who have a perticular agenda. Most clinicians know that patients change their attitudes and views in the face of unremmitting illness and this is borne out by the Oregon experience where over a third of patients fail to take their lethal dose medication, some taking it years after it was prescribed. Elizabeth KublerRoss stated that, “all patients have kept a door open to the possibility of continued existence, and not one of them has at all times maintained that there is no wish to live at all.”
Despite the prevailing attitudes in the country, there have been attempts to change the law. Philip takes us through the relevant cases from Tony Bland in 1993 to the present time with the different Bills put before the Houses of Parliament from 2004 up to the overwhelming rejection of the Marris Bill last year. All the Bills were based on the Joffe Bill which in its turn was based on the DWDA of Oregon. He goes into the detailed contributions made over the four hour debate of the Marris Bill and very fairly includes both sides of the argument. It makes very interesting reading and should be read in full from his submission.
He concludes in Part IV with his own arguments, which are shared by the Church and the CMA, for opposing Euthanasia and PAS quoting the anthropologist Margaret Mead (quoted in “Psychiatry and Ethics” (1972) by Maurice Levine) who describes the Hippocratic Oath as a priceless possession; it was a major watershed for “for the first time there was a complete separation between killing and curing, (for before) throughout the primitive world the doctor and socerer were the same person. He who had the power to kill had the power to heal.” She says that society is always trying to turn the physician back into a killer, but that it is the duty of society to protect the physician from such requests; but now “in the rise of New Medicine (free from oaths and creeds) killing has been restored to clinical practice and the clock put back to the days before Hippocrates.”
Philip also quotes Thomas Aquinas and St John Paul II on the sanity of Natural Law and the craziness of a society that promotes killing of the persons that society exists to serve.
Philip ends his marathon by clearly stating how “causing death’ can never be considered a form of medical treatment. The paradox being played out is how the autonomous decision of patients, backed by majority and electoral will, threatens to take precedence over the conscience of those protecting the lives of the patients! He reiterates that democracy is not an end in itself but a means towards to common good where the rights and dignity of all are equally respected.
Armed with such amunition from him we are able once more to march back to battle, but to calmly discuss our watertight position. The flaws in the Pro-Choice, Pro-Death position are by and large glaringly obvious and highlighted in this excellent submission. One huge error is that there is blatant discrimination against the disabled, as no law allows healthy people to be disposed of.
If Western Society continues on this course it will ultimately destroy itself. Whatever the circumstances of our response to this Culture of Death, we need to present our arguments, and also ourselves as healthcare professionals, as being full of mercy and compassion, caring deeply even for those that do not share our views and subscribe to policies and ideals that we find abhorent. Unfortunately, in this world of New Medicine many of the problems and dilemmas have been of our making as doctors using whatever means there have been to save and prolong life. During its working lifetime the retirement generation has possibly carried its task to extraordinary and disproportionate levels, and we are therefore duty bound to sympathise with those who are now caught in this strange land between life and death, be they patients or policy makers. However there is no other message for them than the Good News of hope and Message of God’s love which we must pray to have the courage and sensitivity to proclaim. This message will not give solutions, but rises above solutions by being stronger than death; and those who embrace it will find they are supported in all their fears and agonies, and not just their final one, and only then be transported to Kubler-Ross’ fifth stage of Acceptance and Peace. Catholic Health Care Porfessionals must come alongside all runners, especially those who stumble, sharing their humanity and the Gospel of Life and the joy of knowing the One True and Loving God. Only this is true empathy.
Catholic Medical Assoicaiton (UK) Dr P Howard (2016). Submission of the Cathoic Medical Association (UK) to the Health Commission of the New Zealand Parliament on euthanasia and physician assisted suicide (PAS). http://www.cmq.org.uk/Submissions/submission_to_new_zealand_parlia.html