We don't need greater access to Nembutal to achieve good end-of-life care

In recent discussions about legalising euthanasia, the drug best known under its American brand name Nembutal has been widely promoted by advocates as a convenient and effective method for people who wish to end their lives.

Despite the limited availability of pentobarbital (Nembutal’s generic name), it has been used in many cases of euthanasia or assisted suicide, such as that of Martin Burgess in Darwin in 2014.

Euthanasia activists such as Andrew Denton and Philip Nitschke claim that, despite advances in palliative care and pain relief, a substantial number of patients in the last stages of terminal illness are left to suffer severe pain or distress without effective treatment.

They argue these patients should have a right to demand they be given Nembutal, variously referred to as the “peaceful pill” or “death pill”, to bring about death.

But while it is universally agreed key aspects of the law regarding end-of-life treatment need to be clarified, this argument is based on a mistaken premise. Under present law, there is no limit to the treatment that may be given to alleviate suffering. Ironically, it is likely any legalisation of euthanasia in this country will actually hinder the care of those most in need.

Why Nembutal?

Nembutal belongs to the class of drugs known as barbiturates. Invented in the late 19th century, these act to depress various aspects of brain function. Barbiturates have been used for many purposes, including to treat sleep disorders, epilepsy and traumatic brain injury – as well as in anaesthesia and psychiatry.

Barbiturates are known to provide pleasant sedation and may be used effectively to relieve distress. In high doses, these drugs can cause suppression of breathing and death. Because of the risks associated with overdoses, they have been withdrawn from routine medical use over the last 20 years.

Now the drugs can be obtained directly from the manufacturers or from online sellers. In Australia, pentobarbital is listed as a Schedule 4, prescription-only medicine. The Therapeutic Goods Administration is considering moving it to Schedule 8, which would classify it as a controlled drug like morphine.

In end-of-life care, experienced clinicians today use combinations of multiple treatments to help ease physical and psychological suffering. These treatments may be complex because “suffering” in such settings is not an undifferentiated condition for which there is a single, universally effective therapy such as pentobarbital or morphine. In addition to drugs, counselling, support for family and many other measures are commonly required. The use of these treatments often requires considerable skill.

Not only is the argument for the need for euthanasia wrong, but legalising euthanasia, and Nembutal with it, is likely to be counterproductive. This is because it will result in limitation of access to appropriate care for the majority of patients who do not satisfy the strict criteria for euthanasia.

Two scenarios

To illustrate why this is so, imagine the case of an elderly man in the last stages of terminal cancer. The disease has spread and is in his bones, lungs, liver and brain. It is incurable and he has, at most, weeks to live.

His suffering is severe owing to a number of physical symptoms, fear and anxiety. He has said his farewells to family and advised his doctors he is ready to die.

Now consider two scenarios. In the first, the man’s doctor recognises her patient’s suffering. She consults with him and his family and decides to provide treatment either with Nembutal itself or with a cocktail of medications with a similar effect.

She administers the medication in a gradually escalating dose. The patient’s suffering is quickly alleviated. Within a few hours, he slips into unconsciousness and dies peacefully with his family beside him.

In the second scenario, the doctor responds to the request from the patient to kill him. She arranges consultations with two psychiatrists to confirm he has the capacity to make such a request.

She fills in the multiple forms of the new euthanasia bureaucracy. She overrides the concerns expressed by some of his children, arguing that mercy killing is their father’s wish.

When the psychiatrists give their approval, she prepares a lethal dose of Nembutal and administers it over two minutes. The patient’s suffering is alleviated, he slips into unconsciousness and dies peacefully with his family beside him.

The first scenario is a classic example of “double effect”, in which a good act – the relief of suffering – is associated with a foreseeable but unintended harmful consequence – the death of the patient. The second is a case of voluntary euthanasia.

Although the outcomes of the two cases – the death of the patient – appear the same, the two acts are in fact quite different.

Double effect

The principle of double effect is widely and appropriately employed in clinical practice today. The medications used to relieve suffering may include barbiturates or other kinds of drugs, such as benzodiazepines, ketamine, propofol or opiates. The relief of the suffering is the objective and outcome, even in cases where death also ensues.

Throughout history, a clear moral distinction has been recognised between double effect and the intentional taking of life. It is one of the traditions of medicine that the target of care should be the suffering of the patient, not life itself.

Most professional medical associations around the world, including in Australia, maintain this view, which is supported by most religions. The act of the doctor in treating suffering in our first scenario would therefore be widely supported.

For more than half a century, common law in Australia has recognised the principle of double effect and has accepted that whatever treatment is needed to alleviate the suffering of a patient is permissible – even if an outcome happens to be that person’s death.

It is true that some people, including doctors, lack certainty about the law. This is mainly because it has never been tested in an Australian court — despite repeated prompts to do so, as by the prominent public advocate for double effect, Dr Rodney Syme.

For this reason, many — including myself — support a precise and explicit statutory clarification, both to avoid uncertainty and to ensure no suffering person is left without adequate treatment.

Let us think more about the euthanasia scenario. As in the second case, the administration of Nembutal alleviates the patient’s suffering and he dies, an outcome that was equally achieved in the first scenario.

But there are no additional benefits. If the patient failed the test of full competency – as will be the case for the majority of patients in such circumstances, whose cognitive function will often be affected by the severity of their illness, dementia or other factors — adequate relief of suffering will be obstructed rather than facilitated. To limit appropriate sedation only to those who can consciously demand it would merely increase the burden of harm. In addition, the deliberate taking of life would be experienced as distressing to many members of society and an affront to the traditions of medicine.

In other words, legalising euthanasia by relaxing access to Nembutal or similar drugs will neither resolve the underlying problems experienced at the end of life nor enhance the care of those most in need of it. It will create harm and no further good.

If legal reform is to occur, it must focus not on the availability of one or other drug but on securing both the humane outcomes desired by the community and the moral framework its members most prize. The means to achieve this are readily available within the scope of existing legal and medical practice. The purposes of all major parties to the euthanasia debate can be most effectively served by a combination of a simple but careful clarification of the current law and an educational program to ensure it is appropriately implemented.

Paul Komesaroff has received research funding from multiple sources, including government and non-government funding agencies.