Queensland University of Technology Law and Justice Journal
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LINDY WILLMOTT[*]
The death of Nancy Crick earlier this year generated enormous public
interest. The circumstances surrounding her death fuelled the
public debate on
assisted death and euthanasia. The right to life proponents argued that the
case graphically highlighted the immorality
of shortening life, while many of
those supporting a person’s right to die saw Nancy Crick as an articulate
and persuasive
proponent of their cause. Emotions ran high and public opinion
was polarised.
Assisted death and euthanasia are complex issues.You might
consider a footnote to define what you (and the author) mean by the terms
‘assisted death’ and ‘euthanasia’; eg: Assisted death or
assisting a suicide refers to the act of helping
or aiding another (with their
consent) to die. Assisting suicide is unlawful in all Australian jurisdictions.
Euthanasia refers to
the act of bringing about death albeit for compassionate
reasons. In this book euthanasia is used in the context of active voluntary
euthanasia, that is an act done with the consent of the patient or client, to
bring about their death. The distinction between assisted
death and euthanasia
lies in who is responsible for the act that causes the death. They are issues
about which most members of
our community have strong views. In a democratic
society, lawmakers are influenced by community views, and rightly so. However,
in this important debate, the question that must be asked is the extent to which
these differing community views are informed by
existing medical and social
practice. Are the views informed by an appreciation of the experiences of those
who are suffering, and
those who care for them? Magnusson’s book,
Angels of Death: Exploring the Euthanasia Underground, seeks to
injectMaybe avoid the work ‘inject’ in this context –it may be
taken the wrong way; perhaps ‘bring
some reality to the euthanasia
debate... reality into the euthanasia debate by informing readers of what is
actually happening within
our community. The book draws on the information
gathered over a three year period from 49 interviews conducted mainly with
health
care workers based predominantly in Sydney, Melbourne and San Francisco.
Those interviewed were doctors (19), nurses (17), therapists
(psychologists and
counselors (7)), community workers (5) and a funeral director. Most of the
interviewees worked principally with
patients suffering from HIV and
AIDS.
The opening chapters of the book (Chapters 1 – 3) describe
the experiences of health care workers dealing with dying patients
on a daily
basis. These chapters also canvass the positions taken by those in Australia,
the United States and the United Kingdom
who have been outspoken in the debate,
and whose actions have, in some cases, subjected them to criminal sanction.
Magnusson also
reviews recent surveys of medical practitioners and the general
public, and the public stance taken by various key groups and individuals
such
as the peak medical associations, politicians, right to die societies, the
churches and the media.
In Chapter 4 ‘Sanctity of life: the slow
death of an idea’, the author explores how we, as a society that holds
sanctity
of life as fundamental, are now struggling with the issues of assisted
death and euthanasia. Magnusson notes the evolution of the
definition of death
to include ‘higher-brain’ death, and the recognition of the
appropriateness to withdraw life support
to a person in such a condition. He
also refers to the legal right of a competent adult to refuse life saving
medical treatment,
and the lack of criminal sanction for medical practitioners
who administer medication that hastens death in circumstances where their
intention was to provide relief from pain and suffering. The author suggests
that assisting in a patient’s death at that person’s
request may, in
some ways, be regarded as ‘the next logical step’. Magnusson then
briefly considers some statutory responses
to this issue – the now
overturned Northern Territory legislation, and the statutes operating in the
Netherlands and Oregon
and now in Belgium.
Chapters 5 - 7 provide an
interesting perspective on how and why patients seek assistance to end their
lives; how health care workers
respond to those requests; and the various ways
euthanasia takes place. Interestingly, the interviewees articulated many
reasons
that influenced their decision to terminate their life. While
‘intolerable/unresolved/chronic pain or physical discomfort’
was the
most commonly cited factor motivating a request for assistance to die, many
identified the ‘fear of process of dying/not
wanting to suffer as others
have suffered/fear of suffering when dying’, ‘tired of
fighting/exhaustion and hopelessness’
and ‘severe deterioration in
quality of life/lack of quality of life/unable to enjoy life’ as factors
in the decision.
Chapter 9 ‘The underground community’
gives an interesting insight into the euthanasia network within the HIV/AIDS
community.
The interviews indicated that the health care workers and the
funeral director who were prepared to assist those suffering from
AIDS related
illnesses were well known within the community. Information was readily
available to patients who wished to discuss
the possibility of receiving
assistance to shorten their lives, should that be the course that they
ultimately wished to pursue.
The final chapters of the book deal with
other issues of concern that were highlighted by the interviews. Many of these
issues arise
from the fact that euthanasiaIf you do not have a footnote at the
start re: definitions I would clarify the word euthanasia here
in terms of
‘voluntary euthanasia’. is currently practiced in legally dubious
circumstances. Because of the lack of
regulation, there is a lack of quality
control over euthanasia practices. Some health care practitioners may not be
using practices
to bring about death in the most peaceful way for the patient
and, in some cases, so called ‘cowboy operators’ continue
to
practice unchecked. The author also raises concerns about non-consensual
euthanasia taking place, and the danger of those working
in the area suffering
from burn-out. Those who assist others in their death are not only working in
emotionally draining situations
dealing with the sick and dying and their family
and friends, but in circumstances where there is always the risk of prosecution.
In the final chapter entitled ‘Euthanasia policy’, Magnusson
suggests that there are five different responses to the many
complex issues
highlighted in the earlier chapters: choose to ignore the survey data by casting
doubts on the veracity of the data
collected; do nothing and allow current
practices to continue; accept that euthanasia (and assisting others to die) does
occur and
give more attention and resources to the enforcement of the law and
the prosecution of offenders; legalise and regulate voluntary
euthanasia and
assisting a suicide; or, in the absence of such legislation, improve in some
other way current illicit practices.
While acknowledging that there is no one
easy solution to the complex dilemmas that arise, the author suggests that, in
his view,
the appropriate way forward is the enactment of legislation that
attempts to regulate euthanasia practices. Magnusson is guarded
in his
recommendation and is quick to recognise the difficulty of the task of setting
criteria to determine the nature of the disease,
illness or suffering (if any)
that must exist before a medical practitioner is permitted to assist in a
patient’s death, and
to determine the necessary safeguards to be built in
to the patient’s decision to end their life, such as requiring the
decision
be considered by an independent medical practitioner.
By drawing
on the accounts given by the interviewees, the book raises important issues in
the debate in a confronting way. The interviews
put the debate in a focused and
realistic context. The book is important because it enables the euthanasia
debate to proceed in
the knowledge that acts of euthanasia and assisting others
to die are not isolated occurrences. The interviews evidence the stark
reality
that, at least in the HIV/AIDS community, assisted death is available to those
who seek it. The simple fact of widespread
practice of assisted death and
euthanasia is, in itself, a powerful response to those advocating continued
operation of the current
legal position in Australia which prohibits these
practices, perhaps even to a greater extent than arguments based on personal
autonomy
and freedom of choice. The accounts are also a chilling reminder of
the dangers of prohibition (‘the euthanasia underground’).
The
interviewees describe a number of ‘botched’ Are these botched
suicide attempts (ie by individuals) or botched assisted
suicide attempts ie: by
doctors and the like? suicide attempts, and the considerable adverse impact
these experiences have on loved
ones as well as the health care workers
themselves. After reading such accounts, it is difficult for the reader to
conclude that
the existing situation should be allowed to continue unchecked.
Finally, many of the accounts, particularly by palliative care nurses,
personalise the complexity of end of life issues in the context of patients in
extreme pain, suffering or distress. Arguments and
philosophies based on the
sanctity of life seem to lose poignancy when considered in the context of a
mother’s vigil at her
child’s bedside, that child being emaciated,
in pain and wishing only for their life to end.
Magnusson states the
purpose of his book is ‘to expose the social practices, relationships, and
networks that constitute “underground
euthanasia”’ and
‘to demonstrate the complexity of the euthanasia issue, and in the process
to capture some of
the passion, pathos and bitter-sweetness of those bedside
moments, as health professionals care for patients in the midst of pain,
bodily
decay and existential anguish’. The author has achieved both of these
objectives, at least in relation to those suffering
from AIDS related illnesses.
The frank and sometimes startling disclosures of the interviewees certainly
enlighten the reader about
the ease with which information about assisted death
can be obtained by AIDS patients, and the closely guarded network maintained
by
health workers in this area. Through the dilemmas and personal turmoil of many
described by those interviewed, the complexity
of the issues involved are
starkly portrayed. Regardless of the personal views of the reader, after
reading these accounts it would
be difficult to conclude that there are any easy
answers to the current situation.
Though it concerns a very difficult
topic, Magnusson’s book is easy to read. (In this writer’s view,
however, the readability
could have been improved by the use of footnotes rather
than a series of endnotes appearing at the end of the book.) The book is
not
written as a legal text, nor does it purport to be a detailed examination of all
the legal issues concerning euthanasia or assisting
a suicide or a blueprint for
reform of the law in these areas. Rather, it is a book that would be of interest
to all who wish to
gain a deeper understanding of the practice of euthanasia,
especially those in the medical and legal professions. It informs us
of
practical imperatives that operate and which cannot be ignored when forming
policy responses. Having said that, however, the
work is limited in that it
considers euthanasia almost entirely within the HIV/AIDS community. As
Magnusson himself suggested, it
would be interesting to conduct similar surveys
in other end of life circumstances.
The strength of this book is that it
focuses the euthanasia debate on where it needs to be - on the ground with the
sick and dying,
and with those who care for them. The philosophical issues
about the sanctity of life versus the imperative of personal autonomy
should not
be considered in a vacuum. This is a balanced, considered and sensitive work.
While gently concluding that legalising
and regulating euthanasia practice is
probably the appropriate way forward, the author is guarded in his
recommendations and acutely
aware of the challenges such a task presents.
Justice Kirby eloquently commented on the value of Magnusson’s work in the
Foreword:
The special value of this book is that it contributes usefully to the debate about the response of our society and its laws to assisted death. It does so by going beyond verbal analysis, by which clever people express their opinions. It surveys life experiences of people involved in the ‘euthanasia underground’. It is one thing to talk about great principles, whether found in holy texts or in modern statements of fundamental human rights. It is quite another to explore, in dialogue with doctors, nurses, patients, lovers and families, the largely hidden work in which patients in extremis are sometimes helped to die with dignity.
[*] BCom(UQ) LLB(Hons)(UQ) LLM(Hons)(Cantab), Associate Professor, Faculty of Law, Queensland University of Technology.
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