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Fellows of the Royal Australasian College of Surgeons were recently asked to complete a postal survey about end-of-life decisions and euthanasia. The questions related to a clinical vignette of a competent and informed woman with advanced intra-abdominal colonic cancer who had made a clear request for assistance to die. She has the active involvement of a specialist palliative care service, and appears to have reached the preterminal stage of her illness course. This means that the goals of her care are palliative, but she is not yet quite at the stage of needing terminal care (care given during the last hours or days of life), and indeed could be some weeks or even months away from death.¹ The grounds for this request are generalised weakness (for which little more can probably be done), lack of a carer at home (for which there are practical solutions, although these may not be emotionally satisfactory), and poor pain control (for which much could still be done, as she has only had an oral opioid and "a co-analgesic").

In this issue of the Journal, Douglas and colleagues present the findings of this survey,² the latest in a series of such studies in Australia and elsewhere.^3-6 The claims to novelty lie in the study population (surgeons in Australia) and the strong focus of questioning on intention, and the presence or absence of patient consent (20% of the surgeons in this study reported that they had performed life-terminating acts without an explicit and persistent request).

Douglas et al infer that the discrepancy between the relatively large proportion of surgeons who report giving drugs with the intention of hastening death and the small proportion who report giving a bolus lethal injection or assisting suicide in response to a specific request is made up of surgeons who "have given generous doses of analgesics or sedatives by infusion to dying patients", and conclude that "the circumstances of these deaths, other than in the agent's reported intention, may not differ substantially from what is widely accepted as good palliative care".

Thus, the argument of the article by Douglas et al might be paraphrased as follows: a small proportion of a sample of Australian surgeons report that they have practised active euthanasia and assisted suicide, but about a third have intentionally hastened death by infusion, and over half say they agree with the practice. As they used infusions, and palliative-care practitioners use infusions, intention is the only basis for a distinction between what the surgeons did and "accepted" palliative care, and indeed there may be no distinction.

The logic of this line of argument is questionable, but it is certainly true to say that modern palliative-care therapeutic practice regularly involves the infusion of analgesic and sedative drugs, and it is based on intention.

In a previous editorial in the MJA, I discussed the variability of palliative care knowledge and experience in the medical profession, which would no doubt also apply to this study population.

In the absence of formal training in palliative care . . . doctors' attitudes and clinical behaviour are complex and variable. They range from abrupt cessation of treatment, minimalist palliative care and treatment directed at bringing about a rapid dying process, to excessive caution about being seen to be instrumental in causing the death, particularly with regard to the providing pain and symptom relief, withdrawal or non-initiation of artificial hydration and alimentation and cardiopulmonary resuscitation.⁷

While a doctor's intention may not always be easy to validate, evaluation of intention and motive is fundamental to legal analysis, and many would argue that intention also determines the moral character of medical interventions.

Any drug can endanger life if used inappropriately. However, the knowledge and skills built up over some 30 years of palliative care practice have shown that opioids and sedative drugs can be used quite safely for symptom control without bringing causation into question if the parameters of accepted practice are followed. Indeed, Douglas et al acknowledge that there are "safe" doses by the very fact that their study questions probe intent by asking specifically about doses "greater than those required to relieve symptoms".

Pain control does not require opioid dose escalation which hastens death, and titration against pain and adverse effects is the norm. In terminal sedation, the sedative drugs (usually the benzodiazepines midazolam and clonazepam) are titrated according to the level of agitation and distress displayed by the patient.

We cannot know when a particular patient would have died in the absence of palliative interventions or treatment abatement, particularly during the final dying process.⁸ There is agreement that the final process of dying should not be prolonged, and that there should be no compromise on symptom control and patient dignity. Searching for the distinction between accepted palliative care and euthanasia in unverifiable outcomes in the last hours of life will not clarify unnecessarily muddied waters, and does not of itself seem to be an important question. This distinction has to rest on intention and the titration of drug doses to effects, balancing the wanted with the unwanted effects.

The volunteered comments of the surgeons quoted in the report by Douglas et al reflect serious causal and ethical confusion. Respondents appear to take dubious comfort from some sort of proximate causal argument, whereby infusions are seen intuitively as a less direct and immediate, and therefore acceptable, means of causing death, in contrast to a bolus injection, where causation is immediate, direct and unambiguous.

The goals and intentions of drug prescribing and principles of pharmacology in palliative care can and should be made clear, and, as in any domain of medicine, honest communication of anticipated outcomes from treatment is required. The Chief Coroner of Ontario (Dr James Young, 1997) seems to have captured the essence of the basic underlying principles of therapeutic intervention in palliative medicine in laying down four conditions which need to be satisfied for palliative care interventions to be legal in his jurisdiction. These conditions should be universally applicable:

• care must be intended solely to relieve suffering;

• it must be administered in response to suffering or signs of suffering;

• it must be commensurate with that suffering; and

• it cannot be a deliberate infliction of death. Documentation is required, and drug doses must increase progressively.^9,10

Australian surgeons have a vital role to play in ensuring that their patients receive timely and appropriate palliative care. Their clinical skills and knowledge about diseases and surgical management are valued, and surgical procedures have a real role in the palliation of symptoms in selected patients. Continuity of care is of paramount importance. However, the community does not look to the surgical workforce to fine-tune pain and symptom control in palliative care patients, and assistance from palliative-care specialists should be sought. If surgeons in this country are really intending to hasten their patients' deaths, with 20% reporting that they have done so without patient knowledge or consent, then the community needs to know, and the study by Douglas et al meets that purpose. However, in the absence of actual case data, it is impossible to say whether these surgeons are delivering good palliative care, whether the patients and families are satisfied, or indeed whether their prescribing really is any different from that of palliative care practitioners.

Michael A Ashby
Professor, and Director of Palliative Care, McCulloch House
Monash Medical Centre, Southern Health; and Southern Clinical School
Faculty of Medicine, Nursing and Health Sciences
Monash University, Melbourne, VIC

1. Ashby M, Stoffell B. Therapeutic ratio and defined phases: proposal of an ethical framework for palliative care. BMJ 1991; 302: 1322-1324.
2. Douglas CD, Kerridge IH, Rainbird KJ, et al. The intention to hasten death: a survey of attitudes and practices of surgeons in Australia. Med J Aust 2001; 175: 511-515.
3. Stevens CA, Hassan R. Management of death, dying and euthanasia: attitudes and practices of medical practitioners in South Australia. J Med Ethics 1994; 20: 41-46.
4. Kuhse H, Singer P. Doctors' practices and attitudes regarding voluntary euthanasia. Med J Aust 1988; 148: 623-627.
5. Baume P, O'Malley E. Euthanasia: attitudes and practices of medical practitioners. Med J Aust 1994; 161: 137-144.
6. Kuhse H, Singer P, Baume P, et al. End of life decisions in Australian medical practice. Med J Aust 1997; 166: 191-196.
7. Ashby M. The fallacies of death causation in palliative care [Editorial]. Med J Aust 1997; 166: 176-177.
8. Ashby M. Natural causes? Palliative care and death causation in public policy and the law [MD Thesis]. Adelaide: University of Adelaide, 2001.
9. Of life and death: Report of Special Senate Committee on Euthanasia and Assisted Suicide. Ottawa: Minister of Supply and Services, Canada, 1995: 26-27. (Catalogue No. YC2-351/1-OIE.)
10. Lavery JV, Singer P. The "Supremes" decide on assisted suicide: what should a doctor do? CMAJ 1997; 157: 405-406.

©MJA 2001
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