Monash Bioethics Review Vol. 17 No.4

ARTICLES

Dr Brian Pollard and euthanasia

BRENTHOWARD

October 1998

Dr Brian Pollard is the favourite son of the Australian anti legal voluntary euthanasiamovement.' In this article I examine Dr Pollard's recent response to the publication ofthe results of a survey of end-of-life decisions taken by Australian doctors' in the lightof his earlier writings.' I show that Pollard gets his facts wrong, is seriouslyconceptually confused, and displays gross inconsistencies. Given Pollard's esteemedposition within the anti legal voluntary euthanasia community this expose must reflectadversely on the credibility of this community.

Let's tackle facts first. In 1996 an end-of-life medical decisions investigationwas conducted in Australia following in the footsteps of two such investigationsconducted in the Netherlands, one in 1990 and the other in 1995. The Australianresearchers described their objective as being to "estimate the proportion of medicalend-of-life decisions in Australia, describe the characteristics of such decisions andcompare these data with medical end-of-life decisions in the Netherlands, whereeuthanasia is openly practised.?" To carry out their research the Australian teamperformed a survey using a questionnaire featuring English translations of thequestions used by the Dutch in their 1995 questionnaire survey.' Helga Kuhse and hercolleagues found that "Australia had a [much] higher rate of intentional ending of lifewithout the patient's request than the Netherlands"

Understandably this finding caused considerable distress to many opponents oflegal voluntary euthanasia. After all, one of their preferred arguments was thatpermitting active voluntary euthanasia would lead to an increased incidence ofeuthanasia without consent, a practice they viewed as a great evil. Yet here was afinding that non-voluntary euthanasia was far more prevalent in a western socialdemocratic country where voluntary euthanasia was banned than in a western socialdemocratic country where voluntary euthanasia was permitted.

Dr Brian Pollard responded by maintaining that the results from the 1996Australian questionnaire survey could not be reliably compared with the results fromthe 1995 Dutch questionnaire survey partly because (according to him) one question inthe 1996 Australian questionnaire asked about decisions to withhold or withdrawtreatment involving an explicit intention "of not prolonging life or hastening the endof life" whereas (according to him) the corresponding question in the 1995 Dutchquestionnaire asked only about decisions to withhold or withdraw treatment involvingan explicit intention "of hastening the end of life."

Here Dr Pollard conveniently ignored, or failed to understand, the obvious factthat even if he were right about the question at issue there would be no problem indirectly comparing the results from many other unrelated questions; or in showingthat the overall rate of lifeshortening decisions taken without patient consent wasalmost certainly far higher in Australia than in the Netherlands," As an example of thefirst point: There is no connection between the questions focused on by Pollard (whichpertain to passive euthanasia decisions) and calculations of the rates of active

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euthanasia, wherea doctor administers a drug with an explicit intention to hasten theend of life. And from the questionnaire data it was estimated that the rate of activenon-voluntary euthanasia was approximately five times higher in Australia in 1996than in the Netherlands in 1995. Pollard can offer no challenge to this figure bydisputing a question about passive euthanasia.

Anyhow, Pollard is wrong on the question in dispute. A reference to "notprolonging life" (expressed as "bet levee niet te verlengen") was present in therelevant Dutch 1995 question and so results from the 1995 Dutch questionnaire andthe 1996 Australian questionnaire can be directly compared for this question as wellas for others,"

I nowtum to conceptual confusion. Pollardtakes strong issuewith the inclusionof a reference to "not prolonging life" alongside a reference to "hastening the end oflife" in the question under discussion because he falsely believes there is a moraldifference between withholding or withdrawing medical treatment (ie. taking anon-treatment decision or NTD) with an intentionto not prolonglife (NFL) and doingSOwith an intentionto hasten the end of life (HTEL). The truth though is that a NTDinvolving an intentionto NPLcannot evenbe distinguished from a NTD involving anintention to HTEL factually, let alone morally, for to not prolong life via a NTDsimplyis to hasten the end of life via a NTD and, similarly, to hasten the end of lifevia a NTD simplyis to not prolong lifevia a NTD. Wejust have two different waysofdescribing the same thing and presumably the Dutch researchers added the referenceto "not prolonging life" to their 1995 questionnaire merely because some people areused to thinking in terms of "not prolonging life" rather than in terms of "hasteningthe end of life" when they decide not to treat, even though it amounts to the samething.

Suppose a patient will die at time T without treatment but live till T+N (N)O)with treatment. An intention to, via a NTD, NPLfrom T to T+N is, by definition, anintentionto HTELfromT+N (where death would haveoccurred if not for the NTD) toT. Likewise, an intention to, via a NTD, HTEL from T+N to T is, by definition, anintention to NPL from T to T+N. Even assuming, for the sake of argument, "twodifferent" intentions at an analytical level (one to NPL and one to HTEL) how couldthere be a moral difference between them given that they would both be intentions tosee death occur at time T rather than T+N via a NTD? The agent responsible wouldneed exactly the same arguments to defend intending to sacrifice a possible period oflife in both cases.

Dr Pollardgets in a tanglebecause he wants to say that it is sometimes ethical tointend to not prolong life but that it is never ethical to intend to hasten the end oflife.!O Since the "two intentions" are one and the same thing, we see that Pollard, byvirtue of his acceptance in some circumstances of an intention to not prolong life vianon-treatment, is committed to accepting as ethical in some circumstances anintention to hasten the end of life via non-treatment. We can put this in theterminology of euthanasia. Pollard claims to oppose passive euthanasia which he(correctly) thinks of as involving an intention to HTEL. However since he accepts (insomecircumstances) an intentionto NPL, and sincean intentionto NPL is necessarilyalso an intention to HTEL, he really supports passive euthanasia in somecircumstances despite his denials.

Moreover, since Pollard (correctly) does not accept that there is a basic ethicaldifference between acts and omissions (or between activeand passive euthanasia)" he

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is shown, via his acceptance of passiveeuthanasia, to be left without any fundamentalphilosophical objection to active euthanasia in certain situations either. The extent ofDr Pollard's conceptual confusion is shown by his vehement, in principle, oppositionto all active euthanasia whilst his own words, in combination with logic, in factcommit him to acceptingactive euthanasiaas intrinsicallyethical in some cases.

Dr Pollard might try to wriggle out of this conclusionby insisting that passiveeuthanasia is only acceptable when life-prolonging treatment which is "unwanted" or"burdensome" (or likely to be so) is withheld or withdrawn and that no such situationcan apply in relation to active euthanasia. However Pollard takes no such stance whenpronouncing on euthanasia. He holds that an intention to take life or hasten death isthe sole necessary and sufficientrequirementfor euthanasia (and that all euthanasia iswrong). He does not claim that if and when it involves the withholding or withdrawalof unwantedor burdensometreatment euthanasiabecomes acceptable.'?

Furthermore, we need to consider what a patient is saying when he rejectslife-prolonging treatment on the grounds that it is too burdensome. What he isdeclaring is that he would rather his life end early than endure a more extended lifewith excessive suffering. Dr Pollard is prepared (at least in some instances) to goalong with this quality-of-life-driven patient desire. Recall that he can accept anintention by a doctor to not prolong life, which amounts, as explained, to an intentionto hasten the end of life. He can then, however, have no valid reason - given hiscorrect rejection of a basic moral distinction between an act and an omission (orbetweenactive and passiveeuthanasia) - to not go along with active euthanasia wherethe patient has a similar quality-of-life-driven desire for his life to end early ratherthan endure a more extendedlife with excessive suffering.

It need hardly be mentioned that illness itself can involve at least as muchsufferingas a life-prolonging treatment for an illness so it cannot be crediblyassertedthat, in practice, people will only find treatments, as distinct from diseases, anexcessive burden. The demand for euthanasia, even from those who have receivedextensive palliative care, proves the point.13 If you are prepared not to requiresomeone to endure burdensome treatment (and hence a miserable life) how can youthen turn around and insist that they, or someone else, endure an equallyburdensome,or even more burdensome, disease (and hence an equally miserable, or even moremiserable, life)? Indeed, the question of justice arises: Why should someone who hasthe option of burdensomebut life-prolonging treatment and has a disease that will killquickly without treatment be able to escape from life soon by rejecting treatmentwhilst somebody who has no option of life-prolongingtreatment yet has a burdensomeillness that only kills slowly has no chance to escapefrom life soon?

Similar arguments to those abovecan be made in relation to "unwanted" (ratherthan "burdensome")treatmentsand diseases.

It should not be forgotten that a doctor who withholds or withdraws life­prolonging treatment causes (in combination with the disease) death to occur at thetime it does. Without her decisionto withhold or withdraw treatment death would nothave occurred till later. So it cannot be claimed that the doctor is not causallyimplicatedin the death when it occursfollowing a case of withholding or withdrawingtreatment, but is causally implicated in the case of active euthanasia. In both instancesthe doctor is responsible for the earlier than possible death of the patient which shecould have preventedby acting otherwise." When a patient wishes to go on living andhas good prospects for an enjoyable life, failure by a doctor to provide available

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life-prolonging treatment would be regarded as negligence. A doctor can never simplysay "I just let nature take its course" and expect this to be accepted as an adequatejustification for her behaviour. A large part of the function of medicine is to fightagainst the ravages of nature . The moral touchstone in not what's "natural" (howeverthat might be defined) but what is best for the patient and/or what the patient wants .And active voluntary euthanasia can be best for the patient and what the patientwants .

Pollard writes that doctors "have no duty, and no right, to impose what hasbecome needless suffering,"! but surely this is precisely what they do (in combinationwith the disease) when they deny a considered request for active euthanasia from asuffering patient with little hope of improvement. 16 By a parallel argument to the onein the previous paragraph there is no justification for simply blaming the disease forthe suffering, because it is only a combination of the disease and doctor inactivity thatproduces the suffering. With appropriate doctor action, ie. active euthanasia, thesuffering of the patient will cease.

Time now to consider some instances of Dr Pollard's inconsistencies. The mostobvious example is that Dr Pollard has screamed blue murder (literally) over Dutchfigures whilst remaining as quiet as a mouse about far worse - by his standards ­Australian figures. Pollard vigorously condemned the comparatively few cases ofactive non-voluntary euthanasia occurring in the Netherlands as "medical murder" butfailed at the same time to even mention, let alone condemn, the comparatively manycases of active nonvoluntary euthanasia occurring in Australia, where voluntaryeuthanasia is banned.I7

The second point to make is that Dr Pollard's stated view that intending to notprolong human life is ethical in certain circumstances is in stark conflict with hisdeclared "pro human life" position.

Pollard writes that "[t]he right of every innocent person to his or her life hasbeen universally recognised throughout the course of history.?" He intones that"[e]very right ever argued, claimed, granted, or denied can be viewed as an extensionof the primary right to life,"19 and asserts that "[i]f any human act has unarguablemoral significance, it is intending to take the life of a person who is guilty of nooffence.?" He states that "[t]o agree to kill an innocent person because we haveconcluded that his life had lost its inherent value is to fail to respect that life,',21 andinsists that "[t]he view which upholds the good of the community at all times is thatlife has inherent value, [and] that this is to be respected at all times.',22 If everyinnocent person has a powerful right to life and this is the most basic of all rights howcan it possibly be ethical for someone to intend to not provide another person with asmuch life as possible? If life always has inherent value which is always to be respectedshouldn't we strive to keep people alive for as long as possible in all cases (and nevermind what the patient wants or how much suffering she might endure as a result)? Ofcourse this is a bizarre doctrine , ignoring as it does issues of autonomy and welfare,but it is the only doctrine which is compatible with a genuine commitment to an equaland inalienable right to life for all humans."

What is Pollard asking us to believe? That people whose life is prolonged bymedical interventions aren't really alive and so there is no issue of life to take intoaccount here? Obviously they are alive and if your fundamental value is life you areobliged to endeavour to keep them alive for as long as possible.

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In view of the quotations cited above it was quite a revelation to see Dr Pollarddeclare in Quadrant his opposition to "prolong[ing] life unnecessarily for its ownsake.,,24 This is precisely the position of bioethicalliberals, Pollard's sworn enemies!IfPollard believes that life isn't valuable for its own sake but only instrumentally forthe enjoyable experiences or satisfied desires it can bring (or some such) then he reallyshould stop arguing with liberals because he is in full agreement with them. It seemsthat Dr Pollard both believes and disbelieves in the sanctity of human life.

At one stage, while defending the withholding or withdrawal of treatment incertain circumstances, Pollard calmly remarks that "[i]f the patient is near the end oflife, he or she may soon die whatever happens." but why then object to activeeuthanasia, which doctors estimate shortens life by less than a month in theoverwhelming majority of cases according to survey data? Pollard's sentiment appliesequally well here. To quote an excellent letter to the press:

I honestly don't know what all the fuss is about.You know, Max Bell did die. He always was going to die prematurely.

Denying him voluntary euthanasia didn't stop him dying. And it certainlydidn't stop him suffering.

The only difference between Max Bell and Bob Dent is that Bob Dent diedpeacefully, and in control. MaxBell didn't.

How then do we live with that?6

My point here though is that Pollard can't take this relaxed attitude to anypossible life forgone if he places such a high store on an equal and inalienable right tolife for all humans. That is, Pollard can't simultaneously advance a "pro human life"philosophy and accept patients being allowed to die when their lives could besustained.

Another example of Dr Pollard's inconsistent approach can readily be provided.Before publication of the 1996 Australian end-of-life medical decisions survey resultsDr Pollard frequently exploited the 1990 Dutch survey data because he - mistakenly ­believed it strengthened the case against legalising voluntary euthanasia.27 TheAustralian results however show that - judged by Pollard's own professed ethicalstandards - end-of-life medical practice is far superior in the Netherlands, whereactive voluntary euthanasia is permitted, than in Australia, where it is not. Instead ofresponding by dropping his opposition to the legalisation of active voluntaryeuthanasia in light of this empirical evidence Dr Pollard took to making false andmisleading claims about the Australian survey." However he also began raisingdoubts about the 1990 Dutch data29 - the very data from which he had tried to makesuch capital in the past! Pollard referred to a report by van der Maas and implied thatit raised significant questions about the Dutch 1990 data. In fact the van der Maasreport" serves to confirm the high quality of the Dutch data.31 Anyhow, Dr Pollardnow has a great deal of explaining to do. If he believes the 1992 van der Maas reportraised important queries about the 1990 Dutch data he must explain why:

l. In The Challenge ofEuthanasia, which was published in 1994, well after 1992, heinsisted that "the Dutch statistics cannot be refuted.,,32

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2. In The Medical Journal of Australia in 199733 he cited, without qualification,figures calculated from the Dutch data presented in the van der Maas report; andin The WeekendAustralian in 199534 he did likewise.

3. Immediately after insinuating that there were some doubts about the Dutch 1990data he turned around and tried to use comments based on this very same data tomake a case against legal voluntary euthanasia!"

It is tempting to wonder if Dr Pollard is prepared to quote uncritically whateverfigures appeal to him when he thinks doing so will advance his cause, but thenmaintain that there is uncertainly about the validity of the very same, or similarlyvalid, figures when he thinks that doing this instead will advance his cause.

When the findings of the Australian survey were not to his liking Dr Pollardinaccurately attacked the survey. Yet in responding to a query by me as to how hewould have responded to ideologically agreeable results from the very same survey hemade no mention of challenging the survey at all!36 Rather, his reply suggests thepossibility that he may merely have taken the results at face value. This invites thequestion: Can Dr Pollard not accept the obvious logical truth that if surveys are notreliable they are not reliable whether or not they happen to provide information youlike, and that if surveys are reliable they are reliable whether or not they happen toprovide information you dislike?

No survey is perfect but all three end-of-life decisions investigations, twoconducted in the Netherlands and one conducted in Australia, were highly reputableaffairs and no amount of twisting and turning can avoid the central reality that it isvirtually certain that - assessed by the standards conservatives themselves profess ­end-of-life medical decision making was clearly superior in the Netherlands in 1995than in Australia in 1996.

The argument about pressure that might be experienced by patients near the endof their lives supplies a fourth instance of the inconsistent application of principles byDr Pollard. Pollard writes, "One of the biggest problems with legalising euthanasia isthe inability to remove the possibility that the person is being pressured by others.This is a serious objection, because it would mean the decision was not thereforeautonomous..." .3? However Pollard is entirely silent on the vast antieuthanasiapressure that a significant proportion of patients and doctors are subjected to wheneuthanasia is outlawed. Today, some greatly distressed people who want fast actingvoluntary euthanasia find it impossible to access simply because of the law against it.Now that's real pressure! The law as it stands intimidates and seriously biasesdecision-making in relation to active voluntary euthanasia. If Dr Pollard weregenuinely and consistently concerned about patients (and doctors) being coerced, orsubject to influence, he would be railing against current laws banning euthanasia.

Even with euthanasia legal, patients could still be subjected to anti-euthanasiainfluence from "right-to-life" fundamentalists, friends and relations reluctant to lose aloved one, and by those who admire a courageous will to live in the face of adversity.The only way to stop people being subjected to any influence from others is to closedown society. I trust that no-one is recommending this. Of course people are capableof rejecting suggestions made to them by others and do so every day. Critically, withactive voluntary euthanasia as formerly permitted in the Northern Territory, the initialformal request, and the final decision, must both be made by the patient.

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The notionof patientautonomy is not rendered empty by the fact that patientsdonot live in solitary confinement. Autonomy is a concept developed for use within asocial context. People seldom form their ideas in splendid isolation. Indeed, if theydid, their choice set would be severely diminished because many possibilities wouldnot occur to them and because withoutco-operation poverty and limitedopportunitieswouldbe the order of the day. Frequently then, social interaction promotes effectiveautonomy.

Any person tempted to exert pressure on a patient would run the risk of beingexposed, disgraced and (if a health worker) sacked. The whistle couldbe blownby thepatient or anotherparty. Paragraph 11 subsection (l) of the NorthernTerritory Rightsof the Terminally 1// Act read: "A person shall not, by deception or improperinfluence, procure the signing or witnessing of a certificate of request. Penalty:$20,000 or imprisonment for 4 years."

Suppose, for the sakeof argument, that someone is subjected to pressure - whichmight be pro or anti euthanasia. This hardly implies that the state rather than thepatient should make the decision which critically affects the patient. In fact to handdecision-making power over to the state would constitute the most comprehensivedenial of patient autonomy possible. Influence over the patient would have becometotal. All control would be in the hands of others. One can hardly express concernabout threats to patient autonomy and then respond by obliterating such autonomyentirely!

When euthanasia is banned the state has a one-size-fits-all policy. We do noteven have a situation where state officials consider each case individually and try topaternally do what is best for each patient based on her particular circumstances.Quite how anyone could believe that a totally individual-patient-independent policysuch as a generalised ban on euthanasia could produce better outcomes - let alonemore autonomous outcomes - than allowing each patient to take her own decisionsbased on case-specific medical advice and her personal assessment of her ownsituation is beyond me.

Given:1. The philosophical absurdity of maintaining that life has value entirely independent

of experiences;2. The callousness of a serious "pro life"view;3. The fact that even leading"pro lifers" such as Dr Pollard cannot hold to a serious

"pro life" position whenpushcomes to shove;"4. The finding that there is almost certainly a far higher rate of non-voluntary

euthanasia (bothpassive and active) in Australia wherevoluntary euthanasiais notpermitted than in the Netherlands wherevoluntary euthanasia is permitted; and

5. The fact that out of 1112 Australian doctors who reported in 1996 on their mostrecentpatientdeath resulting froma terminal illness63 answered ''yes'' to both thefollowing questions: "Did your perception of the law, as it applies in.your StateorTerritory, inhibit or interfere with your preferred management of the patient andend of life decision?" and "Would enactment of laws providing definedcircumstances in which a drug may be prescribed and/or administered to patientswith a terminal illness, with the explicit purpose of hastening the end of life, haveenabled your patient to receive better and more appropriate care?" - with 92responding ''yes'' to the former question and 96 responding ''yes'' to the latter;"

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the critical issue becomes: Where now is the case against legal voluntary activeeuthanasia? Knocked out of the ring must surely be the answer.

Certainly there is nothing to be achieved by clasping at the straw that those whowould seek active voluntary euthanasia were it legally available would probably, ornecessarily, be in a disturbed mental state which could be transformed, with thetransformation leading to an abandonment of the request for euthanasia. Severalpoints can be made here:

1. The Northern Territory legislation required that the patient be examined by apsychiatrist. This psychiatrist was required to certify that the patient was "notsuffering from a treatable clinical depression in respect of the illness."Furthermore, the two other medical practitioners involved both had to be"satisfied, on reasonable grounds, that the patient is of sound mind and that thepatient's decision to end his or her life has been made freely, voluntarily and afterdue consideration. "

2. Wanting to die strikes me and many others as an entirely reasonable response tosome cases of terminal illness. Is anyone seriously suggesting that Bob Dent andJanet Mills were "not of sound mind" in the context of their sttuations?"

3. Doctors, including Dutch doctors - who, note, do not agree to most of the initialrequests for euthanasia which they receive from their patients - are not keen toperform active voluntary euthanasia. It is those whose desire for it seemssubstantially-grounded who are likely to finally receive active voluntaryeuthanasia.

4. Given that we deem virtually all terminally ill patients to be mentally competent totake a life-shortening decision by refusing life-sustaining treatment how can wedeem a significant proportion of the terminally ill incompetent to take the life­shortening decision of active euthanasia?

5. Every day we allow millions of people - of totally unassessed psychological state ­to make significant decisions, some of which shorten their lives and/or the lives ofothers. Consider the case of smoking. Why should voluntary euthanasia be treatedso differently?

6. There is another problem in that opponents of legal voluntary euthanasia acceptwithout any question a decision by a patient not to seek euthanasia while theyinsist that any choice in favour of euthanasia must be subjected to the mostrigorous of scrutiny (and then rejected!). Patients might decide against euthanasiadue to a delusion that their plight will improve. Conservatives however show nointerest in rooting out this "irrationality" .

7. A world of perfect psychological support for all is a pipe-drearn. Many medicalstaff are already over-worked and cannot reasonably be expected to do more.Increased funds would be of some assistance but there are many competing claimson the taxpayer dollar. Anyhow, no amount of money would transform health careprofessionals into miracle workers always capable of solving all problems,psychological as well as physical. Moreover, some people simply do not have asupportive network of friends and family members and such networks cannot beconjured up at will. Harsh realities must be faced, not wished away. You can'tclose off what may be the best real world choice for the absolutely worst-off whilstclaiming to be a friend of social justice.

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8. Even if, given enough time, environmental changes could in fact be made whichwould alter the thinking of the patient it must be remembered that those whorequest euthanasia almost invariably have little time left. What use is therapy orwhatever, which might produce results in X months, if the patient will die withinX weeks or daysand, whilealive, the patientwill retain her desireto die?Even if alast minute change of mind couldbe achieved if euthanasia were refused, earliervoluntary euthanasia may well still be preferable because any period whereeuthanasia is desired but not secured counts as a major moral negative. A shortperiodof desired life is unlikely to outweigh in ethicalsignificance a long periodofmisery and undesired life.

9. Unsuccessful attempts to convince a patient to rescind his request for euthanasiajust prolong his torment. Under the Northern Territory legislation a period of atleast nine days had to elapse between an initial request for euthanasia and the actitself. Columnist Paddy McGuinness was moved to write, "The NorthernTerritorylegislation is objectionable not because it permits assisted suicide, but because ithas too many obstacles built in to the making of conscious decisions by adults."?'and academic Beatrice Faust has commented that "[slo-called safe-guards imposeadditional burdenson sufferers and their carers."?

My conclusion from the analysis above is that the arguments of Dr Pollard andlike-thinkers are gravely lacking in credibility. State parliaments should thereforeproceed to introduce and pass legislation to permitactive voluntary euthanasiawithoutfurther delay. There can be no justification for governments imposing needless andsevere suffering on, and denying the centralfreedoms of, their people.

NOTES1. Robert Manne, an opponent of legal voluntary euthanasia, published two anti euthanasia articles by

Pollard in Quadrant whilehe was editor (December 1991, pp. 44 to 49, and November 1992, pp. 42 to46). The N.S.W. LaborCatholic"Johno" Johnsoncirculatespapers by Pollard. Frank Devinehas praisedPollard's book The Challenge ofEuthanasia in The Australian. 10Managing Mortality: Euthanasia onTrial (Geelong: Villamanta PublishingService, 1996) Ian Parsonsand Dr ChristopherNewell (Parsonssupports euthanasia legalisation but Newell opposes it) describe Pollard (p. 184) as "arguably theforemost Australian critic of arguments for euthanasia." Even the English "right to life" writer JennyTeichman cites Pollard in her book Social Ethics : A Student 's Guide (Oxford: Blackwell Publishers,1996, pp. 87 and 88).

2. Helga Kuhse,Peter Singer, Peter Baume, MalcolmClark and MauriceRickard;"End-of-lifedecisions inAustralian medical practice," The Medical Journal of Australia . Vol. 166, February 17 1997, pp.191-196. [MJA 17/2/97 hereafter.] For Pollard's reaction see Quadrant. October 1997, pp. 5 and 6[QP97 hereafter];and Quadrant. January-February 1998, p. 6 [QP98 hereafter].

3. I will chieflyconcentrate here on: Brian Pollard; The Challenge ofEuthanasia [CE hereafter],Sydney:Little Hills Press, 1994.

4. MJA 17/2/97, p. 191.5. In 1995the Dutch also carriedout a surveybasedon interviews as they had done in 1990. The Australian

researchers did not conduct interviews. The results obtained from interview surveys carried out in theNetherlands in 1990 and 1995 weresimilarto the resultsobtainedfromthe corresponding "retrospective"questionnaire surveys. It is resultsfromretrospective questionnaire surveyswhichare cited in thisarticle.

6. MJA 17/2/97,p. 191.7. Pollard makes various other charges in QP97. For my rebuttal of his claims see Quadrant. November

1997, pp. 8 and 9 plus the correction in Quadrant. January February1998, p. 6 [QH97 hereafter].8. Many liberals, myself included, reject the claim of many conservatives that there is a major mora1

difference betweenan act involvingan "intention"(on a narrowdefmition of this term) to shorten life anda parallel act not involving such an "intention" (on a narrow defmition of the term) to shorten life, butwhich the agent undertakes with the expectation that it will shorten life. See: Helga Kuhse; TheSanctity-ofLift Doctrine in Medicine - A Critique. Oxford: OxfordUniversityPress, 1987, ch. 3. Also:

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Peter Singer; Practical Ethics - Second Edition. Cambridge: Cambridge University Press, 1993, pp. 209and 210 .

9. There was no reference to "not prolonging life" in the corresponding question in the earlier Dutch 1990questionnaire but the reference was certainly present in the Dutch 1995 questionnaire. Pollard falls intoerror not merely due to failure to consult the Dutch 1995 questionnaire but also by misreading The NewEngland Journal ofMedicine. Vol. 335 , November 28 1996, p. 1700. Pollard asserts (QP98) that "theDutch said their 1995 study was 'identical ' to the 1990 study" but in fact the relevant passage reads: "thequestionnaires used were almost identical to those used in the 1990 study" [emphasis added] . One ofthechanges made in the Netherlands between 1990 and 1995 was the addition of the reference to "notprolonging life" in the question under review.

10. I think what Pollard ultimately does is label those decisions involving an intention to not prolonglifethasten the end of life of which he approves as decisions involving an intention to not prolong lifewhilst labelling many of those decisions involving an intention to NPUHTEL of which he disapproves asdecisions involving an intention to hasten the end of life. That is, he makes the category error of loadingmoral content into what are purely descriptive terms. Worse still, he loads radically different moralcontents into two descriptive terms ("intending to NPL" and " intending to HTEL") which are synonyms .The correct moral divide is between ethically justified NPUHTEL decisions and ethically unjustifiedNPUHTEL decisions, not between NPL intention decisions (justified, at least sometimes) and HTELintention decisions (never justified).

II. Pollard defmes euthanasia (CE, p. 17) as "intentionally taking life for compassionate motives , whether byan act or an omission" and then writes (CE, pp. 18 and 19) that, if(and only if) the intention is the same,"direct killing" is morally on a par with "ceasing medical treatment when the result is that the person willdie."

12. Pollard might respond by saying that he distinguishes acceptable cases of intending to not prolong life vianon-treatment from unacceptable cases of thesame by requiring that the former involve the withholdingof unwanted or burdensome treatment However , apart from the challenge of defending this position inlight ofhis "pro human life" stance (see below), Dr Pollard must then explain why he goes on to hold theinconsistent view that intending to hasten the end of life via nontreatment is wrong when treatment islikewise unwanted or burdensome.

13. In passing we might ask such a fervent believer in palliative care as Dr Pollard whathis solution is forthose who - in the real world - will never receive optimal palliative care. And what about those whosimply don't want palliative care (and who want death rather than life without palliative care)irrespective ofthe faith in palliative care possessed by people like Pollard? It should also be noted that DrPollard himself has made the following admission ("Risks of Euthanasia," p. 4, transcript of a speechsupplied to me by "JoOOo"Johnson) : "For some few patients with severe problems, palliative care, evenin the best hands, can fail to make life tolerable . For those near the end of life, sedation and maximumanalgesics will see them through in a kind of twilight state until the end, but the death of others may notbe so near," We might wonder why propelling a patient into a "twilight state" can be ethical whileproviding euthanasia on request cannot be. Furthermore, we should take heed of thewords of others withpalliative care experience such as Dr Roger Hunt and Dr Michael Carr-Gregg. For Roger Hunt's positionsee: Helga Kuhse (editor); Willing to Listen » Wanting to Die. Melbourne: Penguin Books, 1994, pp.115-137. Carr-Gregg's contribution to The Last Right? edited by Simon Chapman and Stephen Leeder(Melbourne: Reed Books, 1995) includes the following (pp. 35 and 36): Some [of the patients I haveworked with] have died in great and apparently uncontrollable pain. ... Even with the best hospice-trainedstaff and the most up-to-date equipment, I have still seen young people die in terrible pain.... An horrificcase study is provided and Carr-Gregg concludes : "The hospital response after many hours ofdebate wasto drug himinto a state ofunconsciousness, from which he periodically awoke, still in ferocious pain." Somuch for the joys of the "twilight state". In Rethinking Life and Death (Melbourne: Text Publishing,1994) Peter Singer recounts (pp. 139 and 140) the terrible story of Lillian Boyes whose "body could nolonger absorb the quantities of opiod pain-killers, including heroin, that [her doctor] was giving her."Singer reports that "[a] nurse was later to say 'she howled and screamed like a dog' when anybodytouched her," In his fmalletter (see The Australian. September 27 1996, p. 13) Bob Dent wrote of thedeeply disturbing side-effects of palliative drugs . Issues beside pain for patients can include : immobilityand confinement, isolation, inability to do things which once gave pleasure, dependence on others, severedifficulty breathing. dizziness, nausea, vomiting. fluid retention, bleeding. damaged skin, disfigurement,incontinence, abject weakness and exhaustion, tiredness of life, feelings that all dignity and control hasbeen lost, fear and anxiety. It would be an arrogant person indeed who would claim he could make lifeacceptable for all in all circumstances.

14. Obviously what is at issue is the time ofdeath not death per se since death is inevitable.15. CE, p. 19.16. Even for those with a suicide option - and some patients have no suicide option at all and a great many

others have only very poor suicide options (note that the overwhelming majority ofattempts at suicide fail

Monash Bioethics Review Vol. 17 No.4 21 October1998

and many of these only make matters worse for the person concerned) • denying a considered request foractive euthanasia from a suffering patient with poor prospects imposes needless suffering on the patientfor (presumably) thepatient asked for active euthanasia because they regard it as the alternative involvingleast suffering for them.

17. QP98.18. CE, p. 73.19. CE, p. 74 .20. CE, p. 74 .21. CE, p. 81.22. CE, p. 82.23. Pollard refers to the "equal and inalienable rights of all members of the human family" on p. 73 of CE

and notes that inalienable rights should not be given away.24. QP97.25. CE, p. 19.26. Fiona Drummond, Sydney Morning Herald. Letters, October 4 1996.27. Prior to the release ofthe Australian survey resultsthere was no comparable data from any nation where

voluntary euthanasia is not permitted to set against the 1990 data from the Netherlands wherevoluntaryeuthanasia is permitted. Moreover, there was no survey performed in the Netherlands prior to thedecriminalisation ofvoluntary euthanasia there in the mid 1980s . The 1990 Dutch investigation, standingalone, could not support any claim that legalising or decriminalising voluntary euthanasia led to adeterioration in end-of-life medical ethics.

28. See QP97 and QP98 plus my responses in QH97 and the first section ofthis article .29. QP97 and QP98 .30 . P. J. van der Maas, 1. 1. M. van Delden andL Pijnenborg; Euthanasia and other Medical Decisions

Concerning the End of'Life, Amsterdam: Elsevier Science Publishers, 1992.31. Pollard might quibble about how the data was labelled and grouped but the reliable basic data was there

for people to label and group in alternative ways ifthey so desired. The Australian researchers (see MJA17/2/97) usedthe same labels and groups as the Dutch so that like could be compared with like, whilealso presenting their raw data.

32. CE, p. 134.33 . Brian J Pollard; "The euthanasia debate," The Medical Journal ofAustralia Letters, Vol. 166, May 19,

1997, p. 563 .34. Brian Pollard; "Euthanasia: The right to live," The Weekend Australian. June 3-4 1995, p. 27.35 . QP98.36 . For my query see QH97. For Pollard's reply see QP98 .37. Brian Pollard; "Risks ofEuthanasia," p. 3.38 . For a comprehensive investigation ofthe inconsistencies ofthose who profess to believe in the "sanctity of

human life" see: Helga Kuhse; The Sanctity ofLife Doctrine in Medicine - A Critique:39. Harry M Nespolor', Helga Kuhse, Malcolm Clark and Keith V Woollard; "Matters Arising: Medical

end-of-life decisions and legislation," The Medical Journal ofAustralia, Vol. 167, September 1 1997,pp. 282 -283. See also the following response : Rodney R A Syme; "Medical end-of-life decisions andlegislation," The Medical Journal ofAustralia, Letters, Vol. 168, May 41998, pp. 468-469.

40. For a discussion of the principles involved here see: Joel Feinberg; Freedom and Fulfilment. Princeton:Princeton University Press, 1992, pp. 285 and 286 .

41. P. P. McGuinness; "The case for euthanasia," Sydney Morning Herald. May 31 1995 .42. Beatrice Faust; "The dying must decide," The Weekend Australian. October 5-6 1996 .

Reply to Mr Howard

BRIAN POLLARD

Mr Howard is supremely certain of the truth of all his opinions, even when theymisrepresent my position, and when they reveal his misunderstanding of elementaryethical principles. Space allows me to address only his chiefcontentions.