Correspondence

Euthanasia in Australia

N Engl J Med 1996; 334:1668-1669June 20, 1996

Article

To the Editor:

Ryan and Kaye (Feb. 1 issue)1 argue that the Northern Territory Rights of the Terminally Ill Act is “a good first attempt to create an act permitting voluntary euthanasia.” They are unduly sanguine in their conclusion for several reasons. First, their claim that “the requirement . . . that the patient must be terminally ill prevents euthanasia from becoming available to people who are physically well” overlooks the fact that under the act even a patient who is completely free of pain may qualify for euthanasia; it is sufficient that his or her doctor considers that there is no treatment that will relieve the patient's “suffering” (a term that may include emotional or psychological suffering).

Second, the authors claim that “the further requirement that available treatment be `confined to the relief of pain, suffering and/or distress with the object of allowing the patient to die a comfortable death' implies that death must be imminent.” However, they ignore the fact that, for instance, a patient with diabetes who refuses to take insulin in order to die will arguably be eligible for euthanasia under this act.

Third, the act does not require that the patient be given the best palliative care before becoming eligible for euthanasia. It merely requires that the patient be informed of the available palliative care services. Since such services are almost nonexistent in the Northern Territory (there is only one part-time doctor trained in palliative care, and there is no hospice), it is misleading to claim that “the act places a strong emphasis on palliative care.”

Finally, people take time to adjust to the news of illness, disability, or the prospect of death. In the Northern Territory, a patient's request for euthanasia may be honored after no more than nine days. Most people need weeks, if not months, to make that adjustment. Australian legislation that governs consumer credit or the door-to-door sale of products protects vulnerable customers better than this act protects vulnerable patients. We believe the Northern Territory act will put the lives of the most vulnerable Australians — the old, the sick, and the unwanted — at very great risk.

Paul Andrew Glare, M.B., B.S.
Westmead Hospital, Sydney, NSW 2145, Australia

Bernadette Tobin, Ph.D.
St. Vincent's Hospital, Sydney, NSW 2010, Australia

1 References

1
Ryan CJ, Kaye M. Euthanasia in Australia -- the Northern Territory Rights of the Terminally Ill Act. N Engl J Med 1996;334:326-328
Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Regardless of the presence or absence of pain, the fact that patients requesting euthanasia under the act must be terminally ill does mean that euthanasia will not be available to people who are physically well. Most pain can be relieved. Requests for euthanasia are often made for reasons other than pain, such as futile suffering or avoidance of humiliation. Studies in the Netherlands have shown that although pain is mentioned among the reasons in 40 percent of cases, only in 5 percent is pain the most important reason.1 There is no clear reason why legislation allowing euthanasia must require the presence of pain.

The act requires that a physician assisting a patient to die must be satisfied that “any medical treatment reasonably available to the patient is confined to the relief of pain, suffering and/or distress with the object of allowing the patient to die a comfortable death.” We believe that this statement does imply that death must be near. There is no requirement that the reasonably available medical treatment be acceptable to the patient. A patient with diabetes who refused treatment with insulin would not be eligible for euthanasia, because insulin would bring more than “the relief of pain, suffering and/or distress.”

It is impossible to force people to receive palliative care. Under the act, the patient must be informed of palliative care options by a specialist in palliative medicine. The physician must not provide assistance in dying “if in his or her opinion there are palliative care options reasonably available to the patient to alleviate the patient's pain and suffering to levels acceptable to the patient.” Glare and Tobin are right to be concerned about the poor state of palliative care services in the Northern Territory. A positive outcome of the passage of the act is that it has called attention to the inadequacies of palliative care in the Northern Territory and has resulted in a commitment to improve these services. The effective date of the act was delayed to allow time for palliative care services to be upgraded.

The act does specify that a minimum of nine days must elapse between the request for assistance to die and the provision of that assistance. An argument could be made for a slightly longer delay. The Oregon Death with Dignity Act requires a 17-day waiting period. If, however, the legislation is aimed at patients whose deaths are imminent, a much longer “cooling off” period, of weeks or months, would be unworkable.

Some revisions to the Northern Territory act were made in February 1996. The main changes were the addition of a third physician to confirm the diagnosis and prognosis and the restriction of the psychiatrist's role to a determination of the presence or absence of clinical depression. As of May, the act was set to go into effect on July 1, 1996.

Christopher James Ryan, M.B., B.S.
Westmead Hospital, Sydney, NSW 2145, Australia

Miranda Kaye, M.A., B.C.L.
University of Sydney, Sydney, NSW 2000, Australia

1 References