Tell it to the Marines

To kill or let die? To the Editor: Although I hold quite different views from Helga Kuhse' about actively terminating human life, I support her contention that such issues should be publicly examined and debated. Rather slowly, we are coming to realize the extent to which the subtle encroachment of technology on the care of seriously ill and dying patients confronts us with previously unimagined challenges to our concepts of good care. Dr Kuhse should be comforted to know that current principles of good palliative care daily assist health-care providers to find better solutions for these patients. For example, the two clinical cases she cites would be routinely and humanely dealt with on quite different lines from those she describes (and which she implicitly suggests are the best modern medicine has to offer). Perhaps it needs to be repeated that dying is not an intellectual exercise it often requires much hard work of various kinds on the part of many people who must deal with a number of others with their own rights, obligations and expectations. A number of particular points call for comment. I. It really is extraordinary that anybody should find new directions in the principle that "the duty of the physician is to act to protect the best interests of his patient" (which is not to say that this principle is always observed). We are still left with the old dilemmas of what are the "best interests" of patients at large, patients in particular groups and individual patients, and with the difficulties in discerning those interests. The "new" starting point seems not so new. Since it is axiomatic that a person's best interests ought to be determined by himself (wherever possible) and then observed as nearly as possible, having regard to the law and the legitimate rights of others (there will always be difficulties here), carrying out such wishes with expertise and compassion is a basic principle of good care. A significant shortfall in such standards would call for better education and training not new standards. 2. Kuhse's categorization of the wish to draw a moral distinction between allowing to die and killing as the pursuit of an "old myth" will be offensive to many. Such things as conscientiously held religious views and transcendental ethics may not easily be shared, but ought to be respected. At the very least, it should be conceded that it is "safer" for all men to respect human life, which is so little understood despite our frequent reluctance to admit it. 3. The rational discussion of euthanasia is hard enough, without introducing unnecessary non sequiturs. If I use, in good faith, an orthodox treatment which subsequently proves to be harmful, useless or illadvised, I am then surely using competent judgement to cease such treatment "in the patient's best interests" and, considering all relevant information, to decide whether any other (or indeed any) treatment should now be tried. It would seem misleading and even mischievous to go on describing such behaviour, when applied to some dying patients, as "passive euthanasia" as this and many similar articles do. Such a description introduces inaccurate and emotional elements into the consideration of practices which have been widely endorsed by many discussants, including the US President's Commission and the authors of the Declaration of Venice of the World Medical Association, and which quite possibly ought more widely to be practised as part of appropriate patient care. The fact that death may follow such decisions (and this is not always the case) is inherent in the severity of the pathology, but the ethical principle in decision-making is not different from that in less grave situations. 4. In most discussions of voluntary euthanasia, a large gap in logic is commonly glossed over; this gap appears also in this article. Dying patients certainly have a right to die, which, on humane grounds, obliges others both to ease the pain of death by every possible means and not artificially to prolong the process of dying. It is quite misleading glibly to equate such a right to die with an asserted right to be killed (ie, with voluntary euthanasia, or assisted suicide), and to maintain that there is no distinction is possibly perverse. The law realizes that consent to such action would be the sole exception under any circumstances to the principle that innocent (ie, non-aggressive) human life may not be taken. It is surely not acceptable that all the issues raised by such considerations should be treated as non-existent. Since logically every genuine human right has corresponding, definable obligations on the part of others (who may also have rights), a proposed right to be killed implies at the least a duty to kill on the part of somebody else and that calls for serious discussion, not suppression. I agree with Dr Kuhse that the way forward in further debate should hinge on the deeper exploration of "the best interests of the patient", but clearly this won't be too easy. Brian Pollard, FFARACS Palliative Care Service Repatriation General Hospital Concord, NSW 2139 1. Kuhse H. Euthanasia again: "letting die" is not in the patient's best interests. A case for active euthanasia. Med J Aust 1985; 142: 610·613.