Welcome to episode fourteen of the Ausmed Handover podcast. Worldwide, the pro-euthanasia lobby is slowly but surely gaining traction, and in many jurisdictions, it is only a matter of time before voluntary euthanasia is deemed to be a lawful act. But there are issues associated with this debate that are being wholly ignored by the various stakeholders, and these have direct and deeply unsettling implications for the nursing profession.
Hello and welcome to the Ausmed Handover podcast. My name is Darren Wake, and in this episode, I’m going to be looking at the very precarious place that nurses have unknowingly placed themselves in the euthanasia debate, and I don’t think it’s where we want to be. I’ll also be asking the question, “are you really prepared to end someone’s life?”
SFX CHURCH BELLS (00:10)
This is the BBC world service.
At 11:55pm last night, Buckingham Palace announced the death of his royal highness King George V. According to Lord Dawson of Penn, the King’s last words to his secretary were, “how are things with the empire?”, to which he received the reply, “all is well with the empire, your majesty, all is well”. Soon after the king closed his eyes and passed away peacefully just before midnight. God rest his soul.
At least that’s the version the public heard in 1936. In 1986, the personal diaries of Lord Dawson, who was the king’s personal physician at the time of his death, were discovered, and the reality was somewhat more… unusual.
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Apparently the last words of the king were considerably less prosaic. His personal nurse, Catherine Black, was attempting to give him a sip of water and he told her to ‘f*** ***’. A fairly un-regal ending to his reign, so it’s not surprising that this was omitted from the Royal histories.
But that’s not what was surprising about what was written in these diaries, which were something of a confessional and never meant for public release. You see, the King’s ending was far seedier than portrayed, and Catherine Black turned out to be the only heroine of the whole story.
It seems that in those days, matters of state were reported in two newspapers; The Times, which was by far the most prestigious and had a midnight editorial deadline for news that would be reported the next morning. It was the newspaper of choice for the aristocracy, who liked to read it over their 9 o’clock toast and marmalade.
Far less prestigious were the tabloids, which were essentially afternoon publications purchased by the working masses on their way home from work. They were never read by the aristocracy and had an 8am deadline for news to be reported in the day’s edition.
It seemed that on the late evening of the 20th of January 1936, the King, who had been ill for several years, was close to death. He had been in a coma for some time, and Lord Dawson, who was an experienced physician, could see that the King’s remaining life could be measured in minutes, rather than hours.
But King George the fifth was a tenacious man, and he took much longer to die than expected. He had been ‘Cheyne-Stoking’ for almost the entire evening, and Lord Dawson was getting… well, more than a little impatient.
You see it was looking to his lordship that the King was going to expire perilously close to the midnight editorial deadline for the Times.
If the King died after midnight, then his death would be have to be announced in the Tabloids to the grubbier working class. If he died before midnight, then Lord Dawson could get on the blower to the Times editorial desk and make sure those who first heard of the King’s death were England’s finest.
At a quarter to midnight the King’s breathing was very irregular and shallow, but he still had a faint pulse, and to Lord Dawson, it was going to be a knife edge as to which side of midnight the king would expire.
So he decided that propriety should prevail, and decided to take matters into his own hands and help the King along by giving him a lethal injection just before midnight.
Drawing up a massive dose of morphine and cocaine, he ordered nurse Catherine Black to inject the mixture into a vein in the Kings neck. The Hippocratic oath prevented Lord Dawson from doing so himself.
But against all social conventions of the time, and showing some astonishing pluck, Catherine refused to comply with the order. She had no special objections to deliberately easing the suffering of the sick; after all, she had served as a red cross nurse on the front lines during World War One, but she profoundly objected to ending the King’s life simply as a matter of editorial expediency.
Furious, Lord Dawson discharged Black, and gave the injection himself, ending the life of the King at 11:55pm on the 20th of January 1936.
Just in time for the Times.
Black never said a word about this for the rest of her life, and the only reason we know about it today is from Lord Dawson’s diaries.
What this illustrates is a courageous example of a nurse positioning themselves ethically within a very difficult, and for Catherine, a very immediate debate, on the issue of euthanasia, and this is something nurses aren’t doing particularly well today. We especially need to consider two largely forgotten issues of the debate that, if not carefully handled, could see nurses in countless situations that, whilst not as extreme as Catherine Black’s, could be ethically and psychologically just as confronting.
So in order to understand what these issues are, we need to first understand what the broader issues are in respect to euthanasia, and its related issue: ‘physician assisted suicide’.
There are four issues we need to define clearly in relation to the euthanasia debate:
Suicide is an act whereby an individual makes a conscious and wilful act to bring about their own death.
Broadly speaking, murder is the wilful act of ending another person’s life without lawful consent. Depending on where you live, there are varying degrees of severity defined within the Law, from an act that is pre-meditated to an act that occurs in a moment of passion. Negligent homicide comes under this umbrella too.
Physician assisted suicide
This is a case of where a person makes a wilful and pre-meditated decision to end their own life, and a doctor provides the means or the information for the person to do so, but does not participate in the act itself.
Euthanasia is the deliberate and pre-meditated ending of a life with the intention to ease pain and suffering.
Although the first two terms deserve exploring in themselves, in this podcast, I’m only going to be talking about the nurse’s role in the last two issues: physician assisted suicide and euthanasia.
So let’s expand on them a little more.
Physician assisted suicide, as I mentioned, is where a doctor either provides the knowledge of how to – or the means for – a person to commit suicide. The doctor themselves does not participate in the act, as this is done by the patient.
There are three main reasons that a doctor does not participate in the act itself. Firstly, because the doctor is prevented from doing so for ethical reasons – assisting a patient to end their own life is in violation of the Hippocratic Oath, The Declaration of Geneva and the Statement of Marbella, the three key position statements that define ethical practice for the medical profession.
Secondly, because the legality of the situation changes dramatically once the doctor knowingly participates in bringing about a patient’s death.
Thirdly, because the patient wishes to preserve their autonomy and retain control over how and where their life ends.
The arguments against physician assisted suicide are:
That it is illegal in most jurisdictions to aid or abet a person in the act of taking their own life.
The religious arguments (which generally inform the legal arguments) – they generally revolve around the issue that various canonical texts forbid a person to take their own life and by implication forbids anyone from assisting them in such an act.
That it conflicts with the role of a physician as healer.
That questions arise related to the state of mind of a person who wants to end their own life. Generally, the default position of society is that you must be crazy to want to top yourself.
And finally, there’s the argument that it also gives rise to unconscious prejudices, that value judgments will be made by the physician on the basis of a person’s looks, social status, age, and even the presence of disabilities.
People choose to seek out physicians to assist them in ending their own lives not only because of unbearable physical suffering or the prospect of unbearable physical suffering, but also because of existential crises, intractable psychological suffering or simply even because they want to go out of their lives on a high note; that is, before cognitive and functional decline sets in.
Physician assisted suicide is legal in Canada, the Netherlands, Luxemburg, Switzerland, and some states in America.
So let’s move on to euthanasia.
Euthanasia is the deliberate and pre-meditated ending of a person’s life with the intention to ease pain and suffering.
The main arguments for euthanasia are similar to those for physician assisted suicide, and revolve around the issue that it allows a person who is suffering to choose the when, where and how of their death, and so upholds their autonomy. If they are unable to choose, then the choice can be made by proxy, through those who know the patient well enough to choose for them, or through the courts.
Euthanasia requires a suitably qualified person to administer a lethal agent to the patient, and in most (but not all) cases, it is generally required that all alternative treatment options have been exhausted, including palliative care.
Presently, it is legal in the Netherlands, Belgium, Canada, Columbia and Luxemburg.
The main arguments against euthanasia are:
That is illegal to end another person’s life.
That it violates the ethical codes of healthcare professionals to deliberately end another person’s life.
That once legalised, there is an inherent bias in the concept that favours the ending of the lives of those individuals that are less fortunate; so those that are disabled, old, chronically ill, or from a very poor socio-economic area.
That legalised euthanasia promotes the idea that certain members of society have a responsibility to die if they perceive themselves as a burden.
And finally, another argument is that euthanasia can become a tool of economic convenience. It’s possible that euthanasia may be promoted in those areas that have a poor range of health care resources as an alternative to establishing alternative services. One example might be palliative care services. So offering euthanasia in a place where there is no easy access to a palliative care service. If there is little demand for such services because the euthanasia path has been promoted, then it becomes increasingly less likely that those resources will ever be put in place – because everybody basically expires before they can lobby for them – and a vicious downward cycle takes hold.
Mostly, people request euthanasia for themselves or their family member because they have reached a point where their illness offers nothing but the prospect of endless suffering, substantial loss of autonomy, and their quality of life has become wholly negligible.
At this point, I should point out that neither the Law nor ethics recognise the concept of ‘passive euthanasia’. You either participate in euthanasia by act or omission, or you do not. So if you elect not to give a life-preserving antibiotic, elect to leave oxygen off for a few minutes longer than you should and so forth, then you are knowingly participating in an act that will contribute to the end of a person’s life. Acts and omissions are viewed equally by the Law as causative mechanisms.
But, that’s not the issue I want to discuss here. I know the realities of the clinical world, I’ve worked as a nurse for 25 years, and I’m not keen on stating whether this issue is right or wrong – I think it’s far too grey for that.
What do I want to examine here is how nurses are positioning themselves in this debate. Or more accurately, how they are not.
Statements from the major nursing bodies in Australia, the United Kingdom, Canada and America are either equivocal or very ambiguous about their attitude towards physician assisted suicide and euthanasia. Generally speaking, they all seem to say that nurses should only practice within the Law, and that’s about it.
But this tells me unambiguously that the profession is in a position where it could be pushed into a role nurses are wholly unprepared for and may not want to take on should the legalisation of euthanasia in particular become widespread.
So what am I saying?
Well, let’s break my argument down into two separate questions: who’s actually going to be doing the euthanizing, and what will the consequences of that act be?
Alright. Let’s look at the numbers.
In 2015, around 6,000 people were euthanized in the Netherlands, including around 480 infants and children under 12 years of age. Although the huge majority of these were suffering from advanced cancers, these statistics also include patients who were chronically ill, old and debilitated residents of nursing homes, infants with genetic abnormalities and a significant number of people with chronic psychiatric illnesses who really had just had enough of life.
To get an idea of scale, as a percentage of the population if euthanasia were legalised country-wide, that number would equate to around 68,000 Americans a year.
1.3% of those cases were referred to the department of public prosecutions for further investigation as the eligibility criteria had not been met, or the administration of the actual lethal agent was done by a person not qualified by the Law to do so. But let’s not worry about that just now.
Now, in terms of simple logistics, that’s a huge workload for the Dutch medical profession, so despite the fact it was never intended that nurses in the Netherlands do the hands on euthanizing, in some cases, the act of delivering the fatal agent was delegated to, you guessed it, a nurse.
We even know the reasons for this delegation: it’s been well researched. Either the doctor cited the nurse’s technical expertise (apparently sticking a needle into an IV line is sometimes beyond you average physician), or they claimed it was ‘the easiest way to get the job done’, or they objected to doing the task themselves on ethical grounds (so think Lord Dawson and King George), or believe it or not, because nurses are subordinate to physicians, and that they were told to do so as part of this hierarchical relationship.
In fact, research has shown us that in around 12-15% of all cases of euthanasia in the Netherlands, the fatal agent was administered by the nurse under medical orders and without the ordering physician present.
That’s around 900 cases where a nurse committed an act with the specific intent of ending a person’s life.
If the same scenario existed across the United States, that would be around about 10,000 people a year.
Right, at this point you’re going to jump up and say “I’d do it if it was in the patient’s best interests”, to which I would say “hooray” BUT… let’s look at this a little closer. In around 900 cases of euthanasia last year in the Netherlands, a nurse injected their patient with a fatal medication because they were directed to do so by the patient’s physician. But… it’s illegal for a nurse to euthanize a patient in Holland – in fact, it’s a criminal offence. Doctors have legislated exemption from prosecution for committing the act of euthanasia. That is, so long as they follow protocols, they can’t be charged. Nurses do not have such exemptions and in fact, the only exemption I can locate is in Canada, which last year granted this legal immunity to Nurse Practitioners. So guess who’ll be taking on most of the workload there?
So, if we take Holland as an example, it looks very likely that whether they have legal exemption or not, nurses will be performing acts of euthanasia under medical orders if euthanasia becomes widely legalised.
I imagine that right now, you’re thinking, “well, if euthanasia looks like it is going to be legalised in my state, then nurses just have to make sure they obtain a legal authority to act under medical supervision. And, by golly, if it’s in the patient’s best interest, then I’ll do it.”
Well, good on you, but I haven’t actually haven’t made my point yet. What I’ve tried to make clear so far is that in the event of euthanasia being legalised in your state, based on the available research from those countries where it is already legal, nurses will inevitably be caught up in the delivery of this service, if not being the people who actually administer the lethal agent themselves.
No one is considering the hidden issue: the moral consequence that must be borne by each individual nurse subsequent to actively participating in an act of euthanasia.
I can best illustrate the issue that concerns me in this matter by using an example drawn from my own experience.
A friend of mine, a retired GP in his late 80’s who has since passed away, recounted to me one day how, some 50 years previously, he had agreed to a request from one of his patients to end their life.
This particular patient had very advanced pancreatic cancer, and he was treating her as an inpatient at the local country hospital, which was the norm for the area and the time. Her symptoms were so severe that, given the limitations of the age and the distance from any major facilities, she was in almost constant pain and distress. She had no living relatives and was desperately alone, and she repeatedly begged him to end her suffering. There was nothing, she said, that could convince her to stay another moment on earth given her prognosis.
Finally, he could bear to watch her suffering no longer, and after considerable moral and legal reflection, decided that in this case, the best thing to do was offer her euthanasia, to which she agreed.
So on one cool spring evening in 1966, he walked into the little country hospital, booked 30mg of morphine out of the pharmacy, and took it into her room. They shared a hug, a short conversation and said their goodbyes. He injected the morphine into one of her veins and within a couple of minutes she was dead.
Now, although most of the hospital staff understood his reasoning, not all did, and he was briskly reported to both the police and to the British Medical Council.
Both the public prosecutor and the BMC understood his moral reasoning, but the Law determined that he be punished. He lost his registration for 6 months, but ultimately, he wasn’t prosecuted.
Now, 50 years later we were at an interesting point. In his confessional, for this was as good as a confession, he could still articulate his sound moral and clinical reasoning: there were no treatment options beyond what his patient was already receiving, and they had failed to relieve her suffering. There was no prospect of a cure, or returning home – only of further misery. So as far as he was concerned his conscience was clear in terms of the morality of his decision – he had acted in her best interests. The legal and disciplinary issues, in many respects, were a simple side show; he had done what was ethically the right thing to do within his personal moral framework.
But bear in mind, this 80-year-old man told me this story of something that happened 50 years ago, and he was crying. Literally sobbing his heart out and saying, “I did the right thing, I did the right thing, I did the right thing…”
So it was clear to me that one single case of euthanasia had resulted in this man carrying a dreadful, if not unbearable moral burden, for nearly half a century that wasn’t as well reconciled as he had led himself to believe.
And that’s just one incident, one healthcare practitioner, and one patient.
Mind you, I am sure there are plenty of nurses out there who could cope with the moral issues in their own headspace and walk away fine, but there’s no guarantee of that.
Now, I can’t give you any substantive research that suggests how many of us could or couldn’t cope with actively, legally and appropriately ending the life of a patient in their care in the context of euthanasia, but there are hints about how well we will cope as human beings in general.
Pro euthanasia groups in Switzerland – where physician assisted suicide is legal – regularly conduct research into the most efficient means of ending a person’s life. Now there the Laws are very explicit: if you physically assist a person committing suicide, then you are liable for criminal prosecution, so the research largely consists of setting up the means, and then recording how quickly the person committing suicide dies after they initiate whatever the lethal mechanism is. They are supported by a small group of volunteers prior to and during the process.
This research is conducted by doctors, but the bulk of the setting up and support for the patient is done by volunteers, and these volunteers generally haven’t met the patient before, and the research shows that around 30% of these volunteers suffer severe psychological problems after the research has ended, and they principally cited the fact that, although what they did was legal and ethically right, they never-the-less were having considerable difficulty accepting that they were actively involved in helping someone take their life.
So imagine the burden they would have carried if they were the person who actually administered a lethal agent in a case of legal euthanasia? And they did this say a dozen times a year?
Although nurses have a much more intimate relationship with death than your average volunteer, imagine that you are the person delivering that lethal agent and you, as a nurse, have a far closer relationship with the person whom you are euthanizing. Far deeper than a mere volunteer; you know about their lives, their fears, their family, their loves, hopes, dreams and desires.
How many of us could really deal with that?
The euthanasia debate goes on worldwide, and slowly but surely, it’s becoming a legal and clinical reality.
There’s no doubt that nurses will become part of this everywhere it is legalised, so we need to become actively involved in the debate and not simply passive bystanders.
If we don’t, we may find ourselves in a position we simply don’t want to be in, and find ourselves to be extremely vulnerable. We, as nurses, present an idealised version of our moral fortitude to both the public and to each other. A noble version of ourselves, if you will. But the reality is that nurses are just as sensitive and easily damaged as the frailest of humans. And I’ve seen people permanently damaged in this profession by the things they have seen.
You must ask yourself: “would you really be prepared to end the life of a fellow human being if you were directed to do so?”
This is the Ausmed Handover podcast, my name is Darren Wake, and thank you for listening.
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