Transcript: Dr Pesce, and A/Prof Glidewell with Mark Colvin ABC Radio

 Subject:           Euthanasia

MARK COLVIN: The World Federation of Right to Die Societies began a meeting in Melbourne today. It’s put the question of euthanasia back in the headlines, but it was already being widely debated, with legislation being discussed by some parties in several states.

Membership of the voluntary euthanasia group Exit International has been growing, and polls indicate that many people have an increasingly open mind to the idea that the terminally and painfully ill should be able to end their own lives in their own time.

One US State that’s changed its laws to allow euthanasia is Oregon. Associate Professor Barbara Glidewell is the recently retired hospital ombudsman in Oregon.

Andrew Pesce is President of the peak doctors’ body in Australia, the AMA (Australian Medical Association), which opposes changing the euthanasia laws.

I began by asking Barbara Glidewell to describe how Oregon had changed its system.

BARBARA GLIDEWELL: It’s fairly simple from my perspective; once the law is passed, it’s really incredibly important to have structure and to have safeguards, and frankly, in particular, for the physicians so that they don’t feel that they’re having to plot their own course and reinvent a process.

So the safeguards that were built in provided our physicians with a process by which to follow and it also provided for patients an understanding that one doesn’t just visit one’s physician and say, “alright I’d like a prescription please”.

That there is a process to respect them in their dignity and to determine if this is a true enduring value, something they’ve thought about and that they’ve given a perspective to their physician hopefully about their quality of suffering and what is intolerable suffering to them at the very end of their life.

MARK COLVIN: Well we’ll come to the details of how that structure works a little later, but I want first to get Andrew Pesce’s reaction. I mean basically the AMA’s position is ‘no’ under any circumstances.

ANDREW PESCE: Well the AMA’s position is underpinned by its code of ethics, it’s consistent with the World Medical Association code of ethics, and that code of ethics is one which we offer to our doctors to help guide them in the way that they care for patients.

That code of ethics recognises a very significant obligation of doctors to care for their patients as best they can, recognising that they often have to care for patients at the end of their lives, often when they’re suffering from an illness which is not curable, often which causes great suffering.

And a lot of people, both I suppose the public and doctors, are distressed by the thought that such suffering may not be adequately relieved. Sometimes that’s because of the nature of the illness, sometimes that’s because of the nature of the health services that we work in, and doesn’t allow us to provide the ideal care that we’d like to and …

MARK COLVIN: Is there a big difference between your code of ethics and the American doctors’ code of ethics?

ANDREW PESCE: Oh look, I think for the purpose of the conversation, no. I think it basically says that it is considered by our associations that ethical physician behaviour does not allow administering of a treatment whose sole, fundamental purpose is to end a person’s life.

MARK COLVIN: So Barbara Glidewell, how does the Oregon legislation get around that if you like?

BARBARA GLIDEWELL: In 1994, the bill was placed before the legislature and there was a vote, and Oregonians voted that they wish to have an opportunity for a physician aid in dying, in other words, to have a legal treatment option that included a prescription for a lethal dose of medication.

There were many injunctions, many referendums and the vote was put before the public again in 1997, and again in a wider margin it was approved. Thus the law was formed; it meant of course that no physician is required to participate in physician aid in dying and many – most – do not actually.

And it was required that if a physician was participating, he or she would follow this conscripted set of regulations and would then provide feedback to the health division that would capture those statistics and report it to the public.

So once the law was in place, there was no debate about whether or not a physician chose to participate or not, they simply did not have to, and those that did would be relieved of any prosecution.

MARK COLVIN: Andrew Pesce, would that give you any relief?

ANDREW PESCE: Well look, obviously the laws of the land are one thing, and that’s up to governments and the people to, through whatever processes are available to make decisions on, and obviously we would say that the laws are things which stand separate to what our code of ethics would talk about.

So, my response would be that we recognise that this is something that governments grapple with, the medical profession has grappled with it, it’s come up with our code of ethics. We have our code of ethics as something which guides our profession, we recognise that just, as in the community there is a range of views on this, within the profession there is also a range of views.

So we don’t wish to sort of conscript anyone either, but you’ve asked us …

MARK COLVIN: Doctors are in danger aren’t they? I mean you know and I know doctors who deal with people at the end of their lives who have given a lethal dose of a painkiller. Now in some circumstances, that can put a doctor in a very dangerous position, can’t it, in this country?

ANDREW PESCE: As I said, doctors do have an obligation to care for patients at these very difficult times and their obligation is to relieve suffering. Now the code of ethics recognises that in relieving suffering you sometimes have to administer treatments which A) don’t prolong life, and B) sometimes, although that wouldn’t be the central intention, may hasten the person’s death.

Now your question is do such laws give comfort to the doctors who believe that they would involve themselves in these types of decisions, and I think they probably do, although I don’t believe that the lack of access to such modalities of treatment is centred mainly on legislation.

As I said, I think that our care for people who are dying isn’t what it should be, our palliative care models aren’t as good as they could be, we would certainly hate to feel that this was seen as some sort of alternative to promoting the best palliative care and end-of-life care that doctors could provide for their patients.

MARK COLVIN: Barbara Glidewell, can you just give us a quick walk through the safeguards that are built into the legislation there.

BARBARA GLIDEWELL: Yes I can. If I may add one comment to the good doctor, in Oregon we also have a law that allows for a physician, as you’ve just spoken, to provide adequate medication; as a matter of fact it requires a physician to do so to relieve suffering even if it would have what we call the double effect.

Without the intent of suppressing respirations, but inadvertently it has the effect, and it relieves them from prosecution for providing that adequate medication and in fact they’re required.

But let me go further because you’ve asked me to outline. It suppresses whereby a physician receives a request from a patient to discuss the concept of aid in dying. At the facility where I have worked, it was required that physicians work through the ombudsman’s office in order to coordinate all the efforts in the interviews, and to have witnesses to those interviews.

So indeed there’s a day one where there’s the first interview. It’s a very sensitive, compassionate but probing interview to determine the nature of the suffering that would cause the patient to want to take a medication, how they have considered this and to look for signs of depression or a clinical depression that would need treatment, or any signs of …

MARK COLVIN: But then there’s another interview much later because you don’t want to have caught somebody on a bad day as it were?

BARBARA GLIDEWELL: Exactly, and that’s later; 15 days later is interview number two, day two, and we have to see if it’s still the same request, still the same value. During those 15 days, a second opinion physician reviews all the records, determines that indeed the patient does likely have less than six months to live, is acting voluntarily, does not have a depression and is not under duress, and the patient also signs a written request form as witnessed by two individuals, one who may not be related to him or her.

Then 48 hours later, after the 15th day, then a prescription may be written, if the patient qualifies on all parts. Most patients ask to leave the prescription with a physician and they may ask for it later, or some choose to have it filled at the time and they keep it at home more or less as an insurance in their mind that if the time comes when they feel they want it, that they would be available to them.

MARK COLVIN: And many people don’t, just don’t use it in the end?

BARBARA GLIDEWELL: That’s correct, that's absolutely correct.

MARK COLVIN: It sounds like a sane system, Andrew Pesce, you’re not convinced?

ANDREW PESCE: Well as I said, our opinion and what we say is guided by a lot of deliberation which, although we believe reflects some input of the values that we see in society, is one that we feel is driven mainly by our sort of professional view, and our professional standards.

I guess, everything I’ve heard is very credible and plausible and makes a lot of sense. I guess the proof in the pudding would be, I don’t know, if somehow you could study Oregon as a state and for example New South Wales as a state, in which state is the quality of care for dying people better, I don’t know. I mean, I don’t even know if the studies are there.

The fact that as doctors we would have a very strong obligation to do everything we could to dissuade most people who asked for our assistance to help them end their lives, in the vast majority of cases it’s very difficult for us then to turn it around and say that when someone makes that request that might seem quite a logical request to say “oh yeah, on this occasion we will help you”.

I think it is something we see as an issue in which our response is rooted, I suppose, in our very strongly held values that our duty is to preserve and promote life, not walking away from our obligations to provide care for patients, even those that are dying.

Even though there are always examples at the margins, I think our current system allows doctors to do that reasonably well.

MARK COLVIN: Dr Andrew Pesce, the President of the peak doctors' body, the AMA. And before him Associate Professor Barbara Glidewell, recently retired hospital ombudsman in Oregon who is attending the World Federation of Right to Die Society’s meeting in Melbourne.

 

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7 October 2010

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