Week in Review
Assisted dying’s inequity problem
Emergency medicine resident medical officer Carmen Chan shares her concerns about euthanasia as an equity problem and explains how it broadens the gap in health outcomes for those already having trouble getting fair access to care
I'm awake at 5am and writing this before my shift starts. As a doctor, euthanasia weighs on my mind. Death’s not an easy topic to broach but we need to start talking about it – now. In a few weeks, along with voting in a government, we’ll be making some hefty decisions around how we approach the end of life as a society.
If you had asked me as a medical student some years ago, I would have told you that I supported the proposed End of Life Choice Act. We put down our animals when they are suffering. Who’s to say that we can't have the right to control how we end our own lives when we live with a terminal illness? But now as a practising clinician, I have many doubts about the proposed law on euthanasia. The conversation is much more complex and nuanced than what you’ll commonly read in the media – which is why I feel the need to speak out.
I have witnessed many deaths. I have watched my own grandmother die in ICU, and my uncle die from end stage lung cancer. I have seen people dying on the wards, and I have seen the results of botched attempts at suicide in the emergency department.
Being called to certify the death of someone who has been long suffering through an illness, knowing that they have finally passed away and are no longer suffering is sometimes a relief. Watching someone die can be really hard. By the time someone is at their deathbed – agonal breathing and unconscious, the most difficult thing in the world is being the loved one sitting at the bedside watching it all happen. But think carefully. Who are we most benefiting with this legislation? We need our minds and our hearts open: euthanasia is an irreversible procedure.
I’ve seen this happen: Reginald* is diagnosed with end-stage lung cancer in Auckland. He is rapidly linked with an oncologist, referred to palliative care doctors and they help him to arrange his plans. They offer counselling, arrange family meetings, help him sort out his affairs, and arrange for him to have a hospital-in-the-home bed and oxygen kit. When he reaches his final days, there's a clear Advanced Care Plan organised with Reginald for when to withdraw active treatment. Medicine is used only to ease his discomfort and pain.
A palliative care team or his GP visit him regularly at hospice or at home to make sure that his needs are met. If during that process where his breathing makes home too hard to manage, he can choose to be admitted to hospice to be cared for by nurses for respite so that his family can rest. His needs and comfort are the priority until the day he dies. This is palliative care.
Now let’s look at another situation: Taylah* lives out rurally. It takes four weeks to even get a GP appointment. When she does see someone, it's a different doctor every time. She waits for months on the public waitlist. Eventually, she gets diagnosed with metastatic cervical cancer. She has to transfer to a big town for surgery and radiation treatment, and then go back for chemotherapy at her local hospital. She only sees the oncologist when he travels monthly for rural clinics and is prescribed a lot of pain relief to take home if she’s sore.
The cancer gains ground despite treatment, and she is referred to palliative care. There are not as many services available out here as much as a large city, and she doesn't want her family to have the huge stress of her dying while they're already struggling trying to earn enough to feed the family. Hospice is full, and too far away. The local hospital is tiny and is always short of beds. She doesn't really want to die there either. She opts for euthanasia.
First and foremost, euthanasia is an equity problem. It broadens the gap in health outcomes for those already having trouble getting fair access to care - for example, Māori and Pacific populations, rural communities, those impoverished and anyone already marginalised by the healthcare system. For me, it’s obvious who would be more likely to opt to end their lives early through euthanasia because they cannot access the medical care and support that they need. We need to think very carefully about what this legislation might end up doing.
Euthanasia might seem like a ‘quick fix’ to suffering, but it is not an answer to the gaps in our healthcare system. There's a reason the Palliative Care Council and Hospice are strongly opposed to legalising euthanasia. Contrary to popular understanding, palliative care actually prolongs your quality of life and is life-affirming. Dying is a time that requires just as much care as a birth. Our health care system unfortunately does not provide this care equally to all. Driving our people to kill themselves early because of a euthanasia policy available in the face of existing inequities is not the answer.
Focus on rolling out euthanasia detracts from a healthcare budget that could go towards strengthening palliative care. Furthermore, viewing the economic advantages of euthanasia for already underfunded District Health Boards leads us to nothing by dystopian policies. Inserting an intravenous line, and injecting drugs to kill someone is far cheaper and easier than getting a hospital-in-the-home bed, counselling support, and nursing care. A junior doctor could admit you when you arrive to hospital, you’d wait for a specialist to review and confirm your choice, and a nurse could inject you with a protocolised set of drugs in a quiet room on the ward. We wouldn’t argue otherwise; we’d respect your decision. An orderly would then take your body to the morgue and from there it would be transferred onto the funeral home, or for cremation. It's not rocket science. Nor is it good medicine.
As this referendum approaches, I think we need to think carefully about how we support those living with a progressive disease in our societies. All our lives are ultimately terminal whether we're sick or not. It's the 'illness' that is the problem, and that is the condition we need to address - whether it be emotional, physical or existential. That's why we have counsellors, mental health workers, pain specialists, whānau, friends, and community. This is why we try to build a society where we are supported by those around us in the face of times when we experience suffering. The last thing I want to see is a cultural shift where we feel the need to ‘top ourselves early’ because we fear the capacity to access adequate healthcare and support when we are no longer well.
Rather than endorsing euthanasia, I want to call upon our government to strengthen palliative care, social services and support systems. I want us to talk about plans for dying – a formally documented Advanced Care Plan is as essential as a will. I want us to talk more as families about when to withdraw excessive medical intervention in order to ‘die a natural death’. Euthanasia is not the solution for something we hardly talk about: how we approach death and dying.
So as the election approaches, raise this subject with your friends, and those that you care about. For myself, all that I hope is that when I next consult with someone towards the end of their life, is that I have neither hastened or prolonged death; that I can offer effective pain relief and care; that I can create a space for important shared moments and know that our healthcare system have adequately developed services for supporting people near death. One that supports all people equally, when they are most at need.
* Not their real names
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