What does and what does not constitute euthanasia? It is a question of intent which will be determined by law,writes Selma Browde
THE discussion paper recently released by the Law Commission for public comment is an excellent document. Unfortunately the document is entitled Euthanasia and the Artificial Preservation of Life, whereas the draft Bill, which is included in the document, is entitled Draft Bill on the Rights of the Terminally Ill. In my opinion, the title of the document is misleading, and the title should have been End of Life Decisions. This reflects the proposed legislation more accurately. It is unfortunate because members of the public are referring to the Euthanasia Bill, which is a misnomer and adds to the confusion already existing among many with regard to what does, and what does not, constitute euthanasia.
What needs to be clarified is the distinction between “euthanasia” and “palliative care”. The discussion paper makes it clear that the difference is one of intent. If a doctor administers or prescribes a lethal dose of medication with the intention of ending the patient’s life, that is euthanasia. If, however, a doctor prescribes medication with the intention of relieving pain and suffering and, as a secondary effect, the moment of death is hastened, that is known as “double effect”. This is not euthanasia but good palliative care. Withholding treatment or removal of life support, which is artificially prolonging life, is also not euthanasia.
Palliative medicine is a new sub-specialty of medicine, at present only integrated into the medical systems of the “socially aware countries” such as Britain, Canada, Australia and New Zealand. It is defined as providing for the medical and nursing needs of a patient who is no longer curable. It aims to relieve not only the physical pain and symptoms of the patient, but also the emotional and psycho-social suffering of the patient and the family. It requires special skills and, therefore, training is essential.
It is important to note that the Law Commission deliberately did not use the term passive euthanasia, as it is this term that has contributed to the confusion in the minds of lay people and the medical profession alike. Passive euthanasia is the term which, up to now, was used to describe either what today is known as palliative medicine, or to the removal or withholding of life support.
The word euthanasia in this context is counter-productive as it is an emotive word and, as a result, doctors and nurses in many instances are reluctant to administer the necessary drugs to relieve suffering in the mistaken belief that they may be doing something illegal. Palliative medicine specialists urge the elimination of the term “passive euthanasia” from the literature.
That the commission understands the importance of those distinctions is borne out by the fact that of the nine clauses in the Bill, only one refers to voluntary active euthanasia, and part of one other clause refers to involuntary active euthanasia. All the other clauses refer to other end of life decisions and have the effect of legalising what is already accepted practice. These are not punished by law, and not considered euthanasia by medical ethicists or by many religious bodies.
It may further clarify the issues covered by this draft Bill if I mention the headings of some of the relevant clauses. Those who wish to submit comments or make suggestions should obtain a copy of the full document which gives background information relating to each clause to enable an informed and focused submission to the Law Commission:
* “Mentally competent person may refuse treatment.” This refers to the conditions permitting cessation of life-sustaining medical treatment.
* “Conduct of a medical practitioner in relieving distress.” This refers to palliative care and “double effect” as described above.
* “Cessation of life.” This clause deals with assisted suicide and voluntary active euthanasia involving a competent person, and suggests guidelines and checks and balances. This is the only really controversial clause around which most of the debate will ensue.
* “Directives as to the treatment of a terminally ill person.” This deals with the legalisation of the issuing of an advance directive or the “living will” or a power of attorney.
* “Conduct in compliance with directives by or on behalf of terminally ill persons.” This outlines the conditions applying to giving effect to a directive regarding cessation of medical treatment or administering palliative care which may contribute to the hastening of a patient’s death.
It is essential that the public be made aware of their rights, as some medical practitioners seem to be under the misconception that it is their duty to prolong life at all costs, notwithstanding the quality of that life. It is also necessary to understand that doctors or nurses have the right to refuse to administer any of the above to their patients even if they are legal.
But in that case, the patient should be referred to another practitioner who is prepared to relieve the suffering in accordance with the law and the patient’s wishes.
Dr Selma Browde is honorary consultant in palliative medicine to the Gauteng Health Department