Sydney Morning Herald
By Tanveer Ahmed Surprise Surprise

How to die’ becoming as important a question as ‘how to live’

Opinions are divided on whether euthanasia can be a rational choice.

Bob Brown’s [Greens senator] post-election call for a conscience vote on the territories’ right to pass euthanasia laws has been criticised for being a distraction from issues that really matter to the average Australian.

But such criticism misses the likelihood that the 21st century may well be the one where ”how to die” becomes as important a question as ”how to live”.

Advances in medical care have transformed our relationship to dying. Medical technology will continue to blur what we mean by death and its relation to our lives, foreshadowed by extraordinary cases such as 41-year-old American Terri Schiavo, who was in a vegetative state for more than 15 years. A prolonged legal and political battle eventually led to the stopping of tube feeding in 2005, and her death.

A much less publicised case was played out in Australia in 2003. The New South Wales Supreme Court ruled that treatment could be withdrawn from Isaac Messiha, a 75-year-old man whose life was supported by ventilation and tube feeding after he suffered severe brain damage from a stroke.

It is a difficult discussion to have in a society that has so little exposure to death and dying in comparison with previous generations. The average young Australian may face death only through their pets or when they travel to other parts of the world, especially countries with Hindu traditions where bodies are sometimes cremated on the street.

Half of all deaths now occur in hospitals, three times the rate of 20 years ago. Several colleagues of mine working in intensive care complain that their job is increasingly about prolonging vegetative states and delaying inevitable death.

The greatest proportion of health costs is in the period surrounding death. Much of it is consumed by machines plugged into electrical outlets – respirators, feeding tubes and defibrillators. The longer we live, the longer we take to die.

While euthanasia is the most discussed, there is a spectrum of actions that hasten death, from withholding treatment to physician-assisted suicide. One that happens every day in hospitals, hospices and nursing homes is when medications such as morphine are increased to alleviate debilitating pain, causing the patient to stop breathing and die. It is something I have undertaken myself.

With the growing pressure on Western health budgets, there is a greater urgency to debate issues such as rational suicide, a controversial topic within psychiatry, a field in which all suicide is generally seen as a disturbance of the mind.

Rational suicide has also been called balance-sheet suicide, suggesting that sane individuals can objectively weigh the pros and cons of continued life, and then decide in favour of death. Views vary from the act being the ultimate expression of one’s autonomy to it being morally reprehensible.

Christopher Ryan, a psychiatrist at Sydney’s Westmead Hospital who specialises in mental disorders among the medically ill, ensured that the original Northern Territory legislation stipulated a psychiatric review before euthanasia. He believes in the concept of rational suicide but considers it extremely rare. He thinks depression or demoralisation usually overlies the decision.

Physicians, by contrast, appear to believe ill patients often choose to hasten death for rational reasons. Studies in 2008 in Oregon and the Netherlands, regions where euthanasia is legal, show that in the Netherlands only 4 per cent of patients were referred for psychiatric evaluation. The rates were similar in Oregon.

The studies found that physicians placed a greater weight on the importance of existential issues such as loss of dignity and feelings of being a burden. Such feelings have been shown to be particularly relevant to dying patients’ will to live.

Studies of dialysis patients show that the incidence of depression was not greater in patients who withdrew from the treatment. A key factor for them was the importance of maintaining control, a finding consistent with many patients in Oregon who chose euthanasia. Doctors working with cancer patients have emphasised similar personality characteristics in patients seeking to accelerate their deaths.

Suicide rates among the elderly in Australia, especially the group over 75 years old, have steadily grown in the past two decades. They are now considered one of the highest risk groups. It is difficult to know what proportion could have been saved with appropriate treatment, as many do not seek medical help.

But while suicides among young people are always considered tragedies, attitudes are more ambivalent about the elderly, suggesting the lay public may have a stronger belief in rational suicide than many mental health professionals.

Western attitudes to death have progressed from it being a public and familiar event, to it being the moment when our souls are up for judgment, to present attitudes of material finality. We need a greater understanding of how and why people make certain decisions surrounding their deaths, not to mention greater reflection on the process itself.


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