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To the Editor: In his recent Commentary on hastening death in terminally ill patients,1 Hunt may not have fully appreciated a very cogent point made in the research by Douglas and colleagues.2 The surgeons surveyed clearly reported the intent of their prescribing. This is contrary to Hunt's assertion that "Intention is inherently subjective . . . complex [and] ambiguous". Some surgeons gave a dose appropriate to the symptoms, others deliberately increased the dose beyond direct symptomatic control, and a few deliberately ended life, at times with no explicit request. As Douglas points out, the dose of a medication given will be an important clue in this. Good clinical practice is about minimum effective dose (MED), not maximum administrable dose (MAD). This is the case for all patients, whether they are near the end of life or not.
Hunt also states that "The duty of doctors is to strive to satisfy the wishes and interests of their patients and their patients' loved ones".1 This is a disturbing comment if left unqualified. There is a broader accountability for doctors to the community through the registration process, quality assurance and continuing education, and the criminal code. If the article by Douglas et al highlights nothing else, it should be clear that there are certain members of the medical profession who believe that they are above the law and have control over the life and death of their patients, with no external review.2 It is frightening that such paternalism still exists. Unfortunately, the Dutch experience of tolerating euthanasia does not appear to have decreased unilateral decision-making on the part of some doctors.3,4
If the premise that the interests of the patients' loved ones is a consideration in the duty of care,1 then we are risking the loss of patient autonomy in an unprecedented way. As a practising clinician, the majority of requests that I receive to hasten death are from relatives, not patients. These relatives ask that they be put out of their own misery by ending the patient's life prematurely. To do something to a patient for a third party, however concerned or distressed, is an unacceptable action for clinicians.
For the profession to credibly engage in the debate about end-of-life care, we must accept that we are part of the community and hence governed by its laws. There are reference points external to the profession by which we will be judged.
Flinders University, Bedford Park, SA.
David C Currow, Professor of Palliative and Supportive Services.Correspondence: Professor David C Currow, Flinders University, Sturt Road, Bedford Park, SA 5042. david.currowATrgh.sa.gov.au
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In reply: MEDicine or MADness
In reply: The survey by Douglas et al1 indicated that, under the current criminal code, about one in three Australian general surgeons are at risk of prosecution for murder because of the way they treat their dying patients. It is likely that many other Australian doctors are similarly at risk of prosecution. This is a serious problem that raises important questions: Why are so many doctors breaking the law? Should these practices be kept covert or brought out into the open for audit and discussion? Is the law serving the needs and interests of dying patients, those who care for them, and the wider community?
Rather than argue that doctors are above the law, I have argued that the practice of medicine should be congruent with the law.2 Laws have been established and refined over time so doctors can help their patients (eg, with procedures and the administration of drugs) in ways that are illegal for others. An integral part of the medical role involves the negotiation of life–death decisions. I believe murder laws should be refined to reflect the reality that some terminally ill patients want death as a release from suffering and seek the help of their doctor to provide this. Just as there are differences between rape and making love, I see obvious differences between common murder and the hastening of death that doctors provide for terminally ill patients out of compassion, mercy, and respect for their wishes. Unfortunately, the ethics of current practices are difficult to elucidate because the existing law makes investigations problematic.
The current crude law does not reflect community values — Morgan Gallup polls indicate about 80% of Australians are in favour of allowing voluntary euthanasia in certain circumstances.3 As Currow observes, these widely held values are sometimes expressed by the relatives of dying patients. In my experience, however, these relatives are usually advocating for the patient's wishes and interests, rather than undermining patient autonomy. I support the established hospice tenet that "the family is the unit of care" and there is a duty to address the concerns not only of patients but also of their loved ones.
I think it is only a matter of time before politicians introduce the reforms that render the legal framework for terminal care more congruent with community values, the wishes of patients and their families, and current medical practices. These reforms should enable research, audit and the better regulation of end-of-life care.
Palliative Care, Flinders University, Bedford Park, SA.
Roger W Hunt, BM BS, GDPH, FAChPM, Clinical Lecturer.Correspondence: Dr Roger W Hunt, Flinders University, Sturt Road, Bedford Park, SA 5042. Roger.HuntATrgh.sa.gov.au
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©The Medical Journal of Australia 2002 www.mja.com.au PRINT ISSN: 0025-729X ONLINE ISSN: 1326-5377