Good Suicide versus Bad Suicide
If it looks like a duck and it quacks, then . . .
On the same day that the Victorian Legislative Council Select Committee Inquiry into end of life choices report was released, the Prime Minister foreshadowed a new inquiry into suicide and its prevention. That evening, the ABC ‘Drive’ program ran the two news items consecutively. Whether this arrangement reflected an initiative of a program arranger or was completely fortuitous, is not known but the grouping of the two items failed to elicit any comment from the usually chirpy presenter ‘PK’. Nor were any text messages from listeners received by the ABC (or at least none were aired). Perhaps this was an early indication of a general failure to recognise that the term ‘assisted dying’ had a very well established currency overseas as a polite substitute for assisted suicide and/or euthanasia. It certainly represented an emphatic acknowledgement of the success of the Select Committee in quarantining the S word from polite conversation.
The S Word
The Select Committee report was remarkable in a number of respects. Whereas the S word only appeared a handful of times (either when emphasising the potential of assisted dying for preventing ‘do it yourself’ unassisted suicide or for citing overseas legislation embodying the word), the phrase ‘assisted dying’ made in excess of 100 appearances in the course of the first 30 pages, many of which dealt with distantly related issues – an achievement of truly Orwellian proportions.
Creation of the expression ‘assisted dying’ represents one of a number of new terms to shield a variety of communities from the S word. Nomenclature such as ‘The Voluntary Euthanasia Society’ morphed into ‘Dying with Dignity’ in Australia. The Hemlock Society in Oregon has been reborn as Compassion and Choices.. In the course of a recent international competition to discover the most marketable terms to denote assisted suicide and/or euthanasia the Survey Monkey was confronted with gems such as ‘dignicide’. Assisted dying had little competition. A quite explicit account of why terms such as assisted suicide were forbidden was provided by longtime US advocate for euthanasia Dr Timothy Quill. His concerns about the use of the term ‘suicide’ arose because he perceived it as being unfavorable to community acceptance of attempts to gain respectability for assisted suicide and/or euthanasia.
Old-School Suicide Advocates Shunned
Interestingly, those advocates of assisted suicide who elect not to tailor their vocabulary to avoid the use of distressing terminology have been shunned by former colleagues. Two such individuals who come to mind are Ludwig Minelli, proprietor of Dignitas in Zurich and our very own Phillip Nitschke. Ludwig referred to suicide as a marvellous, marvellous opportunity and told a Guardian reporter that assisted suicide made good sense financially for the NHS (of the UK) because many people who failed to kill themselves when attempting unassisted suicide required expensive long-term care. This proposition elicited a rapid response of complete disagreement from a British assisted suicide/euthanasia spokesperson (a large number of British one-way-tourists have been Dignitas clients). Ludwig Minelli was interviewed by the Victorian Select Committee on 2 April, 2016.
In Nitschke’s case, a one time Victorian colleague, Dr Rodney Syme, of the Dying with Dignity organisation (formerly the Voluntary Euthanasia Society – again some adjustment of terminology)- was quoted on the ABC to the effect that he was eager to make sure the public sees that there is a huge gap between his advocacy group and the controversial views of Dr Nitschke. He is fundamentally not supported by the organizations who support Dying With Dignity, Dr Syme said (a deviation from past practice). He suggested, rather than considering Nitschke’s statements, let us argue about assisted dying.
Palliative Care’s Waning Role
A warning of things to come emerged on first reading of the Select Committee report. The first 48 recommendations related to end of life care. The only recommendation (number 49) to have received the Premier’s immediate endorsement, namely the legalisation of assisted suicide (aka assisted dying). On a second reading of the report, undue cynicism is not required to recognise the first 48 recommendations as an entrée for the main course. Whereas, originally, advocacy for assisted suicide was usually presented as a solution if available palliative care was not adequate to relieve a patient’s distress, more recent efforts, including the Victorian report, cast it as an alternative to offering palliative care at all.
One conspicuous feature of the unpredicted evolution in practice witnessed in other jurisdictions following the decriminalisation of assisting at suicide has been a change in perception of the relationship between palliative care and assisted suicide/euthanasia. In this context, it is informative to compare the views expressed in the Select Committee report and the approach to this issue in the preliminary report by Brian Owler regarding access to different services in rural Victoria.
The Select Committee report asserted that: palliative care services are not easily accessible for people living in rural and regional areas. Fast forward 12 months and the document released in July 2017 placed the priority among rural services rather differently. Feedback suggested that a register of medical practitioners who are able to assess requests for voluntary assisted dying be developed, or that other ways of dealing with accessibility issues for rural areas be considered such as visiting specialist teams. The unpredicted impact of decriminalisation on other aspects of healthcare will be examined elsewhere.
No Voice from Suicide-Prevention
The 13 months following release of the Select Committee’s report have been notable for the deafening silence of Australian suicide prevention organisations. The reason(s) for this silence are not readily apparent. Perhaps a number exist, varying between such organisations. Whether there has been confidential discussion within the suicide prevention sector remains unknown. Perhaps the likeliest explanation for lack of any comment is apprehension that, were the community to equate assisted dying with suicide, there might arise some confusion in distinguishing between ‘good suicide’ (OK according to the Victorian Government) and ‘bad suicide’ which the suicide prevention sector exists to discourage.
Reading of the chair’s foreword to the Select Committee report could leave the impression that he lacked familiarity with features of the current status of ‘bad suicide’ in the community he was elected to represent. So, for openers, he asserted that: We are living longer, fewer young people die and we have an expectation, sometimes falsely, that appropriate medical intervention can cure virtually all serious conditions. Could have been better chosen when introducing a document crafted to achieve legitimacy for ‘good suicide’; A moment’s reflection could have prompted him to recall that the commonest cause of death of young Victorians now is – you’ve guessed it – ‘bad’ suicide. Motor vehicle accidents are now running a distant second. (The gap between winner and runner up may be rather greater than figures suggest – Single vehicle, single occupant fatal MVAs are sometimes suicidally motivated).
Assessment of the influence of legitimising assisted suicide upon the frequency of its do-it-yourself equivalent is difficult to assess and disputed. There is no question that suicide (that is the bad variety) has a ripple effect and the worthwhile efforts of prevention campaigns to minimise publication of case details attests to this. As an aside, it is interesting that the most recently enacted Canadian legislation to permit euthanasia, as does its predecessor in Oregon relating to assisting at suicide, prohibits any indication of the cause of death as being suicide. Causation shall be recorded as the medical condition justifying the event (in hindsight, this may be embarrassing in the very recent Canadian case of a patient whose euthanasia was approved by a court on the grounds of osteoarthritis). Perhaps it would not be reading too much into this mandated requirement to falsify death certificates
to infer that the legislative drafters sought to avert any possibility that published information on ‘good suicide’ might inspire some of the ‘bad’ variant?
The ripple effect of suicide is especially evident when the frequency of suicides within different identifiable groups is compared. Considerably augmented rates have been recorded among gaoled prisoners during the first 12 months after release and among military personnel during the period after return from active service. The latter is currently the focus of government initiated review. Whilst considerable attention has been directed to suicide of prisoners in custody, I’m unaware of any action initiated to forestall suicide among released prisoners.
The most publicised, and in many ways the most concerning instance of the ripple effect in an identifiable group is that in Australian Indigenous communities. A series of suicides in young indigenous people in the Kimberley is currently the subject of a major coronial inquiry. In this instance, Australia is certainly not unique. It is of interest to recall the handling of this sensitive issue by those responsible for the Canadian parliamentary legislation.
Groups of suicides among First Nations and Inuit communities have been subject to considerable publicity extending beyond Canada. A 2016 New York Times headline, referring to events in a Cree community, proclaimed: Wave of Indigenous suicides leaves Canadian town appealing for help. After another cluster of suicides in a Dene community, a leader was reported as saying doctor-assisted suicide is not part of Aboriginal culture and he’s calling on the federal government to consult with Indigenous people before passing new legislation.
The manner in which this potential obstacle to the passage of Canadian euthanasia legislation was handled emerged in the media some months after the event. Indigenous representation in the Canadian parliament considerably exceeds that in Victoria. Consequently, considerable confidential negotiation was required to assuage the concerns expressed above..
Good Suicide Vs Bad Suicide
If interested in the question of coexistence of ‘good’ and ‘bad’ suicide within a jurisdiction, and especially in the status of prevention of the latter in such a situation, try googling ‘suicide prevention’ together with ‘Belgium’ or ‘Netherlands’. The results won’t detain you for too long. Prevention programs remain rudimentary.
Some comparison of attitudes towards suicide among young people in the Netherlands and in Australia is interesting. Whilst identification of Australian students at risk of suicide and intervention strategies is a high priority, their Dutch equivalents have the opportunity to participate in discussions conducted by the junior section of the Dutch Voluntary End of Life Association, the NVVE. These discussions are concerned with issues related to end of life and the autonomy of young people. Rather different in their objectives from existing Australian programs which attempt to reduce the prevalence of youth suicide. The NVVE also provides educational kits to high school students
The viability of an active suicide prevention program alongside an active system permitting ‘good’ suicide must be questionable. In the event that the Victorian legislation is enacted, how will the existing suicide prevention programs coexist with the new regime? No one knows. Perhaps, in 2027, the ABC might be postscripting some presentations along lines like these: If you, or anyone you know, are concerned after hearing anything in this program. and are not covered by the most recent revision of the Victorian regulation on eligibility for undertaking assisted dying please contact . . . .on 13….