The language of euthanasia
Euthanasia in its simplest understanding translates from Greek as “a good death”. We immediately enter a subjective world – a good death for me may be something entirely different for you – but it carries a sense of our being involved in our own death. This pleasing concept was, of course, debased and abused by its application to the murderous activities of the Nazis, who by their programs of eugenics and extermination moved it to an involuntary activity. The clearest use of the word is in veterinary practice when, usually in consultation with an owner, a vet peacefully ends a suffering animal’s life. But the animal has no say in the matter.
Coincidental with the great advances of medicine and public health through the 20th century, and the great leap in life expectancy, came the idea of a doctor responding to a request from his patient to end their life in order to stop their suffering. This reached a practical level in the Netherlands from the 1970s. Euthanasia became synonymous with deliberate ending of life by a doctor using a lethal injection, usually at the explicit request of the patient at that time. It was a significantly medicalised form of dying, with a doctor in control.
However, in other countries, such as Switzerland and some American states, particularly Oregon, a different practice emerged – the provision of advice, support and medication to be taken orally, when, where and with whom the person chooses. They may even choose not to proceed, as happens on 30 per cent of occasions in Oregon. Such an action is clearly voluntary. The control, and the responsibility for the decision and the implementation, passes from the doctor to the suffering person, where it should rightly be.
This is a significant and critical development in voluntary assisted dying, and I deliberately use this phrase to distinguish this approach from that of lethal injection, which comes to most reader’s minds when the word euthanasia is used. Voluntary assisted dying by use of oral medication is now the dominant model of discussion and legislative proposal around the English-speaking world, including Australia.
Yet the word euthanasia remains defiantly in common usage despite its having no single clear meaning. It is a word that causes confusion: it has to be qualified with active and passive, voluntary and non-voluntary. To me, it is the word that should be euthanised. I no longer use it.
This brings us to the word suicide, and commonly “assisted suicide”, being used in preference to voluntary assisted dying, because, in fact, the individual ends his or her own life. This is one of the rare occasions where English does not have a range of alternative words to give a nuance to an action. In German, there are four words one can use. While suicide had a respectable air in Socrates’ time, Christianity turned it into a sin, and it became illegal and shameful. With the development of psychiatry in the late 19th century, it became associated with mental illness, particularly depression and schizophrenia, and by the 1960s most Western countries had decriminalised suicide, seeing the suicidal mind as requiring treatment rather than prosecution.
But suicide, like euthanasia, is one word used to describe a range of different circumstances. Most people associate it with an unsound mind, an irrational act, a tragic outcome and a regrettable loss of life. And so it is when a healthy person with years of valuable life before them, in a disturbed state of mind, succeeds in ending their life, often in the most violent, horrific and isolated circumstances. With the right help, advice and treatment, the suicidal may emerge unharmed and live a long and happy life – they have a future. This is not the circumstance in voluntary assisted dying. Here the person has an incurable illness – they are dying, openly discussing their options with their doctor and family, and giving careful consideration to advice. If it is thought depression may be influencing their decision, treatment can be tried. Ultimately they may reach a rational decision to end their life, not because they want to die, but because they want their suffering to end. They need not die alone, then, and they can die peacefully with their family around them saying goodbye.
The contrasts between these two circumstances are so stark that it is illogical, even insulting, to apply the word “suicide” to the mature considered death. Yet our laws draw no distinction, criminalising the doctor who provides such assistance. As a result, violent, lonely suicides are even more common in older people than they are in the young – such people feel they have no one to talk to.
So, let us argue about voluntary assisted dying, not assisted suicide.
For it to be fittingly termed voluntary assisted dying, the person considering it should be rational, fully informed and carefully considering their options. This sort of discussion is part of everyday medicine in relation to serious surgery or chemotherapy. The person must have intolerable suffering without the prospect of reasonable relief; they will usually have a short life prognosis. It is intolerable suffering that is the trigger, not a particular illness, and we should remember that doctors cannot measure suffering. The doctor should do everything to minimise that suffering, but he should not deny or ignore it. People do not ask for assistance in dying unless they are pushed to their limits in physical, psychological and existential (social and spiritual) terms.
Palliative care does all it can to relieve such suffering, but when it fails, as it must in some circumstances, all it offers is refusal of life-sustaining treatment, voluntary refusal of food and fluids, or sedation to gradual unconsciousness. All these end in death over some days. Wouldn’t you prefer another option?
This article was first published in the print edition of The Saturday Paper on Jun 14, 2014 as "Last words". Subscribe here.