One of the principles of palliative care is that it neither hastens nor postpones death. Palliative care does not hasten death so euthanasia is not a palliative care practice. Palliative care does not postpone death so medical interventions that keep people alive without improving quality of life are not used.
For example, artificial ventilation and life support which are very important when people are recovering from illness or injury, should not be used when there is no chance of recovery and the intervention is only prolonging a person’s dying. It is helpful if a person has documented their wishes not to be kept alive by artificial means but it is still appropriate to take decisions to stop futile treatment without this document.
Palliative care assists people who are seriously ill and their families to enjoy good quality of life until the moment of a natural death.
The euthanasia discussion has come about partly because people do not believe that good quality of life in achievable under circumstances of illness, disability, ageing or physical decline. People do not believe that good pain control is achievable; or they believe that this is only achievable with unacceptable side effects. The reality is that good pain control can be achieved without serious side effects; that most of the initial side effects that do occur are temporary. For example, the drowsiness and confusion patients may experience when taking morphine for the first time wears off after a few days of using morphine regularly so that they can be alert and active while using pain medication.
Unfortunately, palliative care is not yet widely available in this country or worldwide; and not all doctors and nurses are trained in palliative care. It is important that doctors refer patients to palliative care or to a pain management specialist if they find they are not able to meet the patient’s care needs or manage difficult pain.
South Africa was one of the co-sponsors of the World Health Assembly resolution that palliative care should be integrated into all countries’ health systems. The South African Department of Health is developing a policy framework for palliative care in this country and recommends that all health care professionals receive training in palliative care.
We know that with palliative care, it is possible to have good quality of life with physical comfort and dignity until the natural end of life. Currently, in South Africa, less than 20% of people have access to palliative care. We should be putting all our efforts into ensuring that palliative care is available for all who need this care rather than supporting development of a law that will put the lives of vulnerable people at risk.
Why are we worried that legalization of euthanasia would put vulnerable people at risk? This is because people who are healthy and able-bodied, including our law makers, have a perception that the people who are old, disabled or seriously ill do not or cannot have good quality of life. This prejudice is held even against our future selves.
Yet the only person who can judge quality of life is the individual himself and people adapt to changing circumstances and many people still enjoy good quality of life under difficult circumstances. Good quality of life is possible, not only with good care but with family and community support so we believe that we should be putting efforts into building compassionate, caring communities. It is when we are isolated and alone either as someone who is ill or someone caring for a loved one who is ill that despair enters our lives that we consider euthanasia an acceptable option.
The current argument for euthanasia of supporting an individual’s autonomy is flawed as autonomy is compromised under circumstances of suffering and we should address the suffering to restore full autonomy. Our experience in providing palliative care to people with serious illness and a short life expectancy, is that each day is precious when time is short and once pain and other causes of distress are alleviated, people value this period of time above all. Autonomy supports informed decision-making and cannot be exercised if the person making the decision does not have full information about options for care and relief of suffering.
In addition, individual autonomy should also not be the only consideration, we should consider the impact of one person’s autonomy on another individual – relational autonomy, the impact on family, and on the community especially in South Africa where communal autonomy is an important reality.
Contrary to what we expect when we are well, research has shown that people do not request euthanasia because of unbearable pain; people request euthanasia because of hopelessness and despair and because they see themselves as being a burden on their loved ones. Research into the experience of dignity shows that if people are valued and shown respect they maintain their self-esteem and do not feel worthless or a burden on their carers; and maintain their dignity in spite of their decline.
We need to develop or maintain respect for others, not only in illness but in everyday life; in this way we learn to value people who are different from ourselves including those who are elderly, disabled or ill and we do not judge their lives as no longer being of any worth, believing death as a compassionate option. Doctors and nurses know that death is not a good treatment for any illness; and with palliative care we know we can relieve suffering whether physical, emotional or spiritual.
The critical line we should not cross is that of allowing anyone to end another person’s life prematurely under any circumstances. This is our appeal to the judges considering this case on Friday. In South Africa, we abolished the death sentence as we believe this to be an infringement of human rights. It is a gross violation of human rights to offer death instead of offering good care to relieve pain and suffering.