1. EUTHANASIA To be or not to be A/Prof. David O. WATSON Consultant Physician UNDA Fremantle, 12 August 2010

2. EUTHANASIA: To be or not to be MY TASK IntroductionIntroduction The moral dilemmaThe moral dilemma Effects on clinical careEffects on clinical care ConclusionsConclusions

3. EUTHANASIA: To be or not to be INTRODUCTION Who am I?Who am I? My professional background and practiceMy professional background and practice My associations with the Sisters of St. John of God, the care of the dying and UNDAMy associations with the Sisters of St. John of God, the care of the dying and UNDA

4. EUTHANASIA: To be or not to be THE MORAL DILEMMA-1 “ ‘Euthanasia has come from the Greek, and has evolved from the concept of ‘easy death’ to that of ‘mercy killing’ in modern usage” (1)“ ‘Euthanasia has come from the Greek, and has evolved from the concept of ‘easy death’ to that of ‘mercy killing’ in modern usage” (1) From the physician’s standpoint euthanasia will be restrained by the physician’s desire, where possible to find alternatives but it is not impossible that the number of requests for euthanasia…..will increase” (2)From the physician’s standpoint euthanasia will be restrained by the physician’s desire, where possible to find alternatives but it is not impossible that the number of requests for euthanasia…..will increase” (2)

5. EUTHANASIA: To be or not to be THE MORAL DILEMMA-2 “There remains a question which has to be faced by all doctors, including those who support euthanasia. ‘Why would it be thought that doctors should provide euthanasia?’” (3)“There remains a question which has to be faced by all doctors, including those who support euthanasia. ‘Why would it be thought that doctors should provide euthanasia?’” (3) “A generation of doctors has arisen in the Netherlands which has not known a time when there was significant opposition to euthanasia in their country, and who have learned that doctors may treat particular patients or kill them” (3)“A generation of doctors has arisen in the Netherlands which has not known a time when there was significant opposition to euthanasia in their country, and who have learned that doctors may treat particular patients or kill them” (3)

6. EUTHANASIA: To be or not to be THE MORAL DILEMMA-3 Who are these patients?Who are these patients? –The frail aged –Those with dementia –Survivors of severe head injury –Those with serious terminal physical illness –Those with incurable mental illness –Severely impaired children and adults

7. EUTHANASIA: To be or not to be EFFECTS ON CLINICAL CARE-1 In 2010 and beyond good medical care demands teamworkIn 2010 and beyond good medical care demands teamwork “Only 50% of patients report adequate control [of pain] in repeated surveys conducted internationally” (4)“Only 50% of patients report adequate control [of pain] in repeated surveys conducted internationally” (4) “Conducting research in palliative and end of life care is notoriously difficult…..”. (4)“Conducting research in palliative and end of life care is notoriously difficult…..”. (4)

8. EUTHANASIA: To be or not to be EFFECTS ON CLINICAL CARE-2 Medical records are poorMedical records are poor “…..management of end-of-life in acute hospitals is often inappropriate and cruel” (5)“…..management of end-of-life in acute hospitals is often inappropriate and cruel” (5) Acute care is not always the most appropriateAcute care is not always the most appropriate “Doctors have a professional and moral mandate to use every reasonable means available to free patients from the pain and other symptoms that cause them to suffer”. (6)“Doctors have a professional and moral mandate to use every reasonable means available to free patients from the pain and other symptoms that cause them to suffer”. (6)

9. EUTHANASIA: To be or not to be EFFECTS ON CLINICAL CARE-3 “In 2007, 1.9% of all deaths in Flanders were the result of euthanasia (ending of life at the patient’s explicit request), a rate that was higher than that in 1998 (1.1%) and 2001 (0.3%)”. (7)“In 2007, 1.9% of all deaths in Flanders were the result of euthanasia (ending of life at the patient’s explicit request), a rate that was higher than that in 1998 (1.1%) and 2001 (0.3%)”. (7) “In 1.8% of all deaths, lethal drugs were used without the patient’s explicit request, a rate that was lower than that in 1998 (3.2%), but similar to that in 2001 (1.5%)”. (7)“In 1.8% of all deaths, lethal drugs were used without the patient’s explicit request, a rate that was lower than that in 1998 (3.2%), but similar to that in 2001 (1.5%)”. (7)

10. EUTHANASIA: To be or not to be EFFECTS ON CLINICAL CARE-3 The imperatives of clinical careThe imperatives of clinical care –Attend to all the needs of each individual patient –Provide the best possible care that resources allow –Practice in a peer review environment –Practice contemporaneous medicine –Undertake audit and review of practice –Work in teams that include the patient and those who support the patient

11. EUTHANASIA: To be or not to be EFFECTS ON CLINICAL CARE-4 Euthanasia fundamentally upsets the balance between doctor and patientEuthanasia fundamentally upsets the balance between doctor and patient We must consider the advisability of allowing doctors to act in a way contrary to the rest of societyWe must consider the advisability of allowing doctors to act in a way contrary to the rest of society There are serious concerns in removing constraints on the way doctors can conduct themselvesThere are serious concerns in removing constraints on the way doctors can conduct themselves

12. EUTHANASIA: To be or not to be EFFECTS ON CLINICAL CARE-5 Legislating in favour of euthanasia is no substitute forLegislating in favour of euthanasia is no substitute for –Improved record-keeping –Better research –Improved pain and symptom management –Better teamwork

13. EUTHANASIA: To be or not to be CONCLUSIONS Overseas experience suggests legislative support for euthanasia erodes standards of end-of-life careOverseas experience suggests legislative support for euthanasia erodes standards of end-of-life care Euthanasia becomes available to a wider group than those with terminal cancerEuthanasia becomes available to a wider group than those with terminal cancer Support for euthanasia fundamentally upsets the doctor-patient relationshipSupport for euthanasia fundamentally upsets the doctor-patient relationship It is no substitute for better careIt is no substitute for better care

14. EUTHANASIA: To be or not to be REFERENCES-1 1. “Euthanasia: evolution in Holland 1969- 1992”. WATSON D.O. Paper at the Australian Management College. 14 December 1992.1. “Euthanasia: evolution in Holland 1969- 1992”. WATSON D.O. Paper at the Australian Management College. 14 December 1992. 2. “Euthanasia and other medical decisions concerning the end of life”. Van deer MAAS P.J. et al. LANCET 1991;338:669-674.2. “Euthanasia and other medical decisions concerning the end of life”. Van deer MAAS P.J. et al. LANCET 1991;338:669-674. 3. “Medical aspects of euthanasia”. POLLARD B.J. MED J AUST 1991;154:613-616.3. “Medical aspects of euthanasia”. POLLARD B.J. MED J AUST 1991;154:613-616.

15. EUTHANASIA: To be or not to be REFERENCES-2 4. “What physicians need to know about palliative care”. SPRYUT O. RACP NEWS; April 2010:14-15.4. “What physicians need to know about palliative care”. SPRYUT O. RACP NEWS; April 2010:14-15. 5. “Diagnosis of dying”. HILLMAN K. THE HEALTH ADVOCATE; April 2010:17-20.5. “Diagnosis of dying”. HILLMAN K. THE HEALTH ADVOCATE; April 2010:17-20. 6. “Regarding euthanasia”. ROY D.J. et al. EURO J PALL CARE 1994;1:57-59.6. “Regarding euthanasia”. ROY D.J. et al. EURO J PALL CARE 1994;1:57-59. 7. “Medical End-of-Life Practices under the Euthanasia Law in Belgium”. BILSEN J. et al. N ENG J MED 2009;361:1119-1121.7. “Medical End-of-Life Practices under the Euthanasia Law in Belgium”. BILSEN J. et al. N ENG J MED 2009;361:1119-1121.