The consequences for the elderly when even doctors insist euthanasia is an irrational act. By Martin McKenzie-Murray.
On the ethical fringe of euthanasia
In this story
This is how it often ends, with a trip to Bunnings for pipe and electrical tape. It’s how Jack wanted to go early this year – his frail hands, once hardened by a life on the farm, snaking the tube from the exhaust and through his car window. He would check to see if the seals were perfect, inviolable. A practical man, it would be his final handiwork.
Jack had long sold the farm and bought a caravan on the outskirts of a regional town. He wasn’t complicated and the caravan was all he needed. He had fitted it out “with all the mod cons”. He lived alone. His wife had died eight years earlier, and all but one of his friends were dead, too. Later, after the worst happened, he told his nurse that one of his two children had died. The other lived overseas.
Jack had turned 86, entering an awful statistical category – of all age groups in Australia, the over-85s have by far the highest suicide rate.
Jack was weak but not terribly sick. He weighed 48 kilograms and had chronic obstructive pulmonary disease, the result of a lifetime chain-smoking on his tractor. He could get through 50 cigarettes a day sometimes. Regardless, he had so far escaped chronic pain or terminal illness. That isn’t why he wanted to die.
Later, when he woke in hospital, he told the nurse he had lived a good life, but that he had wanted to end it on his own terms. At what was to be the final moment, he opted for a bottle of sleeping pills prescribed a year earlier. He was too frail to drive to the hardware store. But the pills didn’t work. He was revived by paramedics.
Authorial intrusion: this isn’t macabre voyeurism. What follows is undoubtedly dark, and complicated by competing evaluations. But it is precisely those competing evaluations that make this story so important. They highlight the ethical murkiness of passive euthanasia and the difficulty of distinguishing it from suicide. None of this is easy, but if few of our politicians are willing to examine our private suffering – a suffering of which they, in their stubbornness, remain in control – we must.
Jack had confided in his friend, when they still spoke, of the day he would do it. He saw the afternoon out inside his caravan. Then, as the sun went down, he swallowed a handful of the pills with water.
In horror, or panic, his friend relented and broke his promise to keep the pact secret. He rang triple-0 and explained what had happened. Paramedics found Jack and raced him to an emergency department, where he was stabilised. When he woke he was presented a rancid irony – in his attempt to escape institutionalisation, he had forced it. A psychiatric examination was made, which found him to be suffering from a depressive disorder, and an involuntary treatment order was taken out. Jack was now forcibly consigned to a psychogeriatric unit, comprising mostly violent dementia patients. His nurse told me that he “was one of only two patients who could talk and hold a conversation, the rest had very progressed dementia. So it was a fairly mortifying position for a man who had spent his life working on the land, being outdoors, being in control of his job and life.”
Jack’s nurse believes his being diagnosed as suffering depression was inaccurate, and sympathises with his decision to end his life: “If he was a 24-year-old with depression then I would understand the reluctance to allow the patient back out in the community, as there’s a utilitarian argument that this kid might not fully appreciate what he can offer if he ages a bit more. But here is a man who can clearly tell you how he’s arrived at his decision, and to me, there’s no argument. He’s had a great life, his family has died, he’s now 87 and decided to up stumps. Had he used a different drug he’d be in an ICU and we would be having a conversation about switching off life support.”
Jack’s experience reveals the fissure here: the distinction between euthanasia and suicide. It is particularly vexed with the elderly, for whom ending one’s own life is much more common. The latest data we have is from the Australian Bureau of Statistics’ Causes of Death 2012. For males 85 years old and above, the rate of suicide is 37.6 for every 100,000 males. Expressed in a graph, so that the representative bars for ages and gender look like a crude skyline, the block for men above 85 towers above all others. Consistent with all age groups, far fewer elderly women commit suicide than men, but still the highest suicide rate for women is found in the 80-84 bracket.
The prevalence of euthanasia isn’t only difficult to judge by the lack of statistical reporting, but there are also problems of definition. Euthanasia, as it has been defined in many defeated bills in many different Australian jurisdictions, is considered a death that enables the end of terminal and intolerable physical pain. To legislate for euthanasia is to quantify suffering. It’s to be explicit about what it is, and what it isn’t. There’s no room for a person’s ennui or depression. No room for personal choice. In former legislative drafts, and in our public discussions, euthanasia has been moored to gigantic physical suffering.
The definitions are the rub. Not all elderly suicides are effectively backyard euthanasia, and not all acts of backyard euthanasia are suicide.
Which is why Jack’s case is so troubling. Jack wasn’t terminally ill. He wasn’t suffering as we have come to define it. Jack and Jack’s nurse believe that the pills at sunset were the sensible result of sober reflection, a heroic act of will untroubled by mental illness. The Mental Health Review Board disagreed. By upholding the ITO, they were saying Jack hadn’t made his decision independent of mental illness – more likely it was the toxic result of isolation, boredom, loneliness, despair and the state would have to intervene. Old age can bring infirmity and physical suffering, but it can also bring a deadening of the self. Between these two we have drawn the line separating suicide and euthanasia.
Jack’s nurse stated in his initial report on his patient that, “Critically, I could not confidently fit his reported symptoms into the diagnostic criteria for a major depressive episode.” He would later tell me: “I felt he wasn’t depressed. There was no evidence of lowered mood, lack of enjoyment, sleep disturbance. In fact, my bigger concern was that he had cancer, because he had dropped a lot of weight. Quite simply, people with major depressive disorder don’t engage and if they do, they certainly don’t talk eloquently about their life and euthanasia.”
Jack lost his remaining friend in all this too – he has not since spoken to the man who rang the paramedics, choosing to see this act to save him as a betrayal.
Last year the Rights of the Terminally Ill Act was defeated in the New South Wales upper house, 23 votes to 13, after it was introduced by Greens MLC Cate Faehrmann. All party members were permitted conscience votes, but no Liberal or National member voted “yes”. I asked Peter Phelps, the government’s whip, who abstained from the vote, if, in fact, a party line was being followed. “I can confirm it absolutely was a conscience vote,” he said. “Some people abstained from voting – compare the division count with the list of MLCs – and some people voted tactically because they were coming up to their preselections, and social conservatives in the major parties remember these sorts of votes.”
I was confused as to why Phelps, a classical liberal, had abstained from voting affirmatively. “I support the right of people to end their own lives,” he said. “I did not want to vote against it. But then, I did not want to vote for it either, given that it was a cynical profile-raising exercise by the Greens Cate Faehrmann in support of her abortive senate candidacy, which had sat on the notice paper for months and then came on mysteriously via an urgency motion a few weeks before the federal election.”
On semi-collapsing the distinction between euthanasia and suicide, and recognising Jack’s autonomy and philosophical primacy, Jack has another supporter in Phelps. “Why would you seek to limit [euthanasia] to only those circumstances? Why shouldn’t people be allowed to dispose of their property – their lives – when and if they see fit to do so? Why apply a ‘community standard’ for what amounts to ‘acceptable’ and ‘unacceptable’ degrees of suffering, when you reject such a communal veto over the basic principle in the first place?”
Phelps’s candour is admirable for its being so crushingly rare. The former Victorian speaker Ken Smith said recently that political debate on euthanasia had been retarded by “religious fanaticism” within parliament, and that the matter should be referred for independent scrutiny at the Law Reform Commission. The comment was impassioned and sensible – though one wonders if parliament shouldn’t be our principle law reform commission – but it was made with little risk: Smith is set to retire at the November election.
I put a series of questions, threaded around Smith’s theme of religion and political cowardice, to the office of the Victorian attorney-general Robert Clark. After coercion, I received only the following: “The government has no plans to refer this issue to the Victorian Law Reform Commission … Matters of conscience votes are matters for the party room.” And, finally, on religious fanaticism: “It’s a matter for Ken Smith.” In NSW, where Brad Hazzard has recently traded the planning portfolio for the attorney-general’s office, I was told there was no way my questions could be answered before deadline.
It has become an entrenched practice of journalism to pretend these statements are either appropriate or instructive, and then obligingly weave them into our stories. The common wisdom of the newsroom has it that the government’s authority and right of reply compels its inclusion; the common cynicism of governments – all governments – compels it to respond in bad faith, knowing it’s always going to be asked for comment regardless. The hostility of voters is partly attributable to their recognising the shabby dissonance between the warmth and urgency of the inquiries put to their leaders, and the asinine replies. It’s a long and tedious tradition. We might yearn for profundity, but we ain’t gonna get it – not even on matters of life and death.
Jack was kept in hospital against his wishes for two months, before being allowed to move back to his caravan. He was still on a treatment order and considered at risk, receiving regular visits from psychiatric services. He also qualified for Meals on Wheels, but funding was so slight they could deliver only two meals a week. If he ever got even mildly ill, he would have to return to the hospital because, as his nurse said: “No one would risk having him at home to overdose on painkillers, because it’s a coronial inquiry no doctor would want to respond to.”
This week Jack took a fall at home and was readmitted to hospital. In the ensuing days his health deteriorated, as he knew it would. He will be treated, and then perhaps released to die, slowly, at home. Or he might be ferried back and forth from hospital a few times first. It is grim. His nurse thinks he has perhaps six months to live. “To say that he was bitter would be a bit of an understatement – this situation is exactly what he didn’t want.”
Hospital staff are hotly discussing Jack and his failed attempt to end his life, and they’re split. But at least they’re discussing it.
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This article was first published in the print edition of The Saturday Paper on May 24, 2014 as "When the healthy want to die".
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