Australia's "Doctor Death": Too Controversial for Comfort

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There is a new "Dr. Death" on the international scene. Dr. Philip Nitschke is carrying on the work of Jack Kevorkian, the original "Dr. Death" who is serving a 10 to 25 year prison sentence for his role in killing Thomas Youk, a patient suffering from "Lou Gehrig's Disease." Kevorkian administered a lethal injection to Youk, captured this act of euthanasia on videotape, and sent it to the news program Sixty Minutes, which aired an edited version. Nitschke, a general practitioner in Australia, is fast replacing Kevorkian as the world's most notorious assisted suicide/euthanasia zealot. According to advocates of physician-assisted suicide (PAS), the only problem with Nitschke is that he is too honest--he tends to open up topics for discussion that they would prefer to leave unexamined.

Dr. Nitschke began his assisted suicide career under a short-lived law (passed in 1996 and overturned in 1997) that legalized euthanasia in Australia's Northern Territories. He helped 4 people die using his first "death machine." He provided these patients with intravenous access and connected the infusion tubing to a computer. The patients then had to answer a series of questions on the computer screen by pressing certain keys. The final question indicated that if a patient pressed the space bar, he or she would die. If the patient answered "yes" to all questions, including the last one, the computer automatically switched on a previously prepared solution of Nembutal (a sedative) in an amount intended to be fatal.

Once assisted suicide was no longer legal, Nitschke turned to other means of "helping" his patients in order to avoid prosecution under Australian law. These included suffocation via the sealing of plastic bags around the heads of patients who had ingested oral sedatives; a special tent allowing two people to commit suicide together via the use of inert gases that replaced oxygen in the tent's atmosphere; and, most recently, a machine called the COGen that produces carbon monoxide to be inhaled by patients through a nasal cannula. Nitschke attempted to bring this machine to the U.S. to demonstrate it at the January 2003 national meeting of the Hemlock Society, but Australian customs officials confiscated it because it violated export restrictions.

Unpopular Spokesman

Dr. Nitschke creates controversy with both his actions and statements. He recently assisted in the suicides of a married couple (both 89 years old) and a 79-year-old woman, all of whom were generally healthy but who had grown tired of their lives. He also assisted in the death of a woman whom he claimed had terminal bowel cancer. However, she was found to be cancer-free at autopsy. Nitschke later stated that, while he recognized that misrepresenting the extent of her disease was "a mistake in emphasis," it in no way undermined the legitimacy of her request for suicide.

In a June 5, 2001 National Review Online interview, Nitschke explicitly stated that assisted suicide should be provided to anyone who wants it--including the depressed, the bereaved elderly, and the troubled teen. He went on to assert that the "so-called peaceful pill should be available in the supermarkets so that those old enough to understand death could obtain death peacefully at the time of their choosing." Statements such as these cause consternation among many advocates of PAS because they would prefer that these largely unspoken realities driving the pro-death agenda remain so.

In the U.S., attempts at PAS legislation restrict eligibility to terminally ill patients who are capable of participating in the decision to die. Terminal conditions are typically defined as those in which death is expected within six months, even with appropriately effective medical treatment. Euthanasia is also specifically prohibited. However, neither the eligibility requirements nor the euthanasia prohibition can likely withstand ethical and legal challenges. I will address these problems in the remainder of this article.

Prohibition of Euthanasia

Attempts to limit assistance in dying to voluntary suicide, are, I believe, designed to achieve an initial, and seemingly more palatable, step forward for the pro-death agenda. If the patient both decides and acts, it appears as if those assisting in his or her suicide remain "morally distant" from the action. However, I think that this is logically inconsistent and somewhat akin to the maneuver of Pontius Pilate, who despite trying to distance himself from Jesus' crucifixion is still inseparably associated with it today. It is also ethically indefensible because a patient who is physically unable to self-administer a lethal agent must have someone else give it to him. Using this analysis, if PAS is legal and ethical, physician assistance in euthanasia should also be legal and ethical because refusing to directly administer a lethal injection for a patient who cannot himself end his life would be denying that patient a "right" that a less vulnerable patient could exercise.

The practical reality is that euthanasia is the preferred option in The Netherlands, where there are over eight times more patients killed by euthanasia than by PAS. Such is the case primarily because euthanasia works much better than physician-assisted suicide. Despite this reality, euthanasia proponents are reluctant to push for legalization, probably because the public is not yet ready for it.

Terminal Condition Requirement

The requirement for a terminal condition is indefensible in theory and ineffective in reality. The theoretical basis for requiring a patient to have a terminal condition is flawed on the basis of respect for autonomy. If assisted suicide is legalized, a patient's autonomy would need to be respected and any requirement that he or she have a terminal condition would be insupportable.

This requirement for a terminal condition is routinely ignored in practice as well. Most of Kevorkian's clients were not terminally ill, although he claimed that they were experiencing unbearable suffering. The cases mentioned previously demonstrate that Dr. Nitschke doesn't adhere to this limitation either. Proponents of PAS legalization attempt to downplay this reality, primarily because it is likely to decrease support for their position.

The requirement that a patient be capable of participating in medical decision-making in order to be eligible for PAS runs counter to guidelines that are generally applied for those who have lost (either permanently or temporarily) their decision-making capacity. Accepted ethical theory, borne out in medical practice, supports a person's right to make decisions about his or her treatment and to refuse any medical treatment. This right does not end once the patient becomes incapacitated. Once a patient becomes unable to participate in medical decision-making, someone else (e.g., his or her surrogate) may make decisions on the patient's behalf. The surrogate has the same rights in medical decision-making as the patient. A patient's surrogate would therefore also have the right to request death for the patient.

With regard to assisted suicide or euthanasia, a surrogate would not only be required to decide for the patient, but also to ensure that the chosen action occurred. Patients who are incapable of making medical decisions would also likely be incapable of self-administering a lethal medication and would therefore need someone to administer the medication to them. This would be non-voluntary euthanasia--non-voluntary because the patients can no longer decide for themselves and euthanasia because someone must act directly to kill the patients.

Once the barrier to active assistance is overcome (and euthanasia is accepted), it will be regarded as unethical to deny a patient who is incapable of decision-making the same "good." A patient who is unconscious or mentally compromised must be afforded the same consideration as one who is mentally sound and therefore must also be assisted in dying. These issues are troubling for euthanasia proponents; thus, it is not surprising that they remain hidden behind more prominent aspects of their agenda.

The agenda of euthanasia/PAS proponents is to take whatever first step they can toward achieving their ultimate goal of legalizing euthanasia, while attempting to obscure the underlying issues. However, I find their attempted "spin" to be disingenuous at best. Public opinion that drives legislation, ballot initiatives, and judicial rulings needs to be an informed opinion, shaped by all the facts--not just those favorable to "right to die" supporters. Unfortunately, advocates of euthanasia and PAS choose to ignore theory and reality and instead resort to generating fear and confusion.

Coordinated educational campaigns, led primarily by physicians and other health care professionals opposed to euthanasia and PAS, have resulted in many legislative victories in Michigan, Maine, and other states. Similar efforts are also currently underway in Vermont. However, this issue is far from decided. We therefore must all be alert to, actively oppose, and champion alternatives to measures promoting the culture of death in our society.