Seven deaths in Darwin: case studies under the Rights of the Terminally III Act, Northern Territory, Australia

Summary

Background

During the 9 months between July, 1996, and March, 1997, the provision of euthanasia for the terminally ill was legal in the Northern Territory of Australia. Seven patients made formal use of the Rights of the Terminally III (ROTI) Act;¹ four died under the Act. We report their clinical details and the decision-making process required by the Act.

Methods

We taped in-depth interviews with the general practitioner who provided euthanasia. Further information was available from public texts created by patients, the media, and the coroner.

Findings

All seven patients had cancer, most at advanced stages. Three were socially isolated. Symptoms of depression were common. Having met criteria of the Act, some patients deferred their decision for a time before proceeding with euthanasia. Medical opinions about the terminal nature of illness differed.

Interpretation

Provision of opinions about the terminal nature of illness and the mental health of the patient, as required by the ROTI Act, created problematic gatekeeping roles for the doctors involved.

Introduction

On May 25, 1995, the Northern Territory Parliament in Australia passed the Rights of the Terminally III Act 1995 (ROTI).¹ The Act became law on July 1, 1996, making the Northern Territory the first place in the world to have legalised euthanasia.² By contrast, in the Netherlands euthanasia is sanctioned and has been openly practised since 1991, but remains technically illegal.3, 4 In Oregon, USA, physician-assisted suicide was first enacted on Dec 8, 1994,⁵ but was deferred through appeals, until it was confirmed by a second referendum on Nov22, 1997.

The Northern Territory ROTI Act was appealed against in the Supereme Court, but on July 24, 1996, it was ruled valid. On Sept 9, 1996, a Member of Parliament from Victoria introduced into the Commonwealth Parliament of Australia the Euthanasia Laws Bill 1996, designed to repeal the ROTI Act. This bill came into effect on March 25, 1997. In Australia the Federal Parliament can over-rule the laws of its Territories, although it cannot over-rule State laws.

The Northern Territory has a population of roughly 180 000 spread over one sixth of mainland Australia, and one third of this population is indigenous. During the period when the ROTI Act was law, four people died under the Act, on Sept 22, 1996, and Jan 2, Jan 20, and March 1, 1997. We studied the clinical decision-making process during this period of legal euthanasia. PN was the only Darwin medical practitioner who reported euthanasia deaths. He agreed to be interviewed by DWK, a consultant psychiatrist and professor of palliative medicine, and AS, a medical sociologist. We describe seven case histories of patients who sought to use the Act. Our aim was to make overt the decision-making processes involved in their care. The report is necessarily limited by the scope of medical records and the memory of PN, but we judge that it provides a useful profile. Since we have differing views about euthanasia we have not attempted a critique of the management of these patients nor a debate about euthanasia, but we simply place the case material on the public record.

The ROTI Act, 1995,1, 2 stated that a terminally ill patient, experiencing pain, suffering, and distress to an extent deemed unacceptable, could request a medical practitioner for assistance to end his or her life. The doctor had to be satisfied on reasonable grounds that the illness was terminal and would result in the patient's death in the normal course and without application of extraordinary measures. A further requirement was that there were no medical measures acceptable to the patient which could reasonably be undertaken to effect a cure, and that any further treatment was only palliative in nature. The doctor needed to certify that the patient was of sound mind and making the decision freely, voluntarily, and after due consideration.

A second medical practitioner, a resident of the Northern Territory, was required to examine the patient to confirm the existence and terminal nature of the illness, and to give an opinion on prognosis to be recorded on the schedule used for certifications under the Act. The regulations required that this practitioner hold a qualification in a medical specialty related to the terminal illness, recognised by fellowship of a specialist college in Australia. If the first medical practitioner did not have special qualifications in palliative care, defined by the regulations as either 2 years' full-time practice in palliative medicine or not less than 5 years' general practice, a third doctor with such qualifications was required to give information to the patient on the availability of palliative care. A psychiatrist was also required to examine the patient and confirm that he or she was not suffering from a treatable clinical depression in respect of the illness. The Act required a period of 7 days to pass between the initial request to end life made to the first doctor and the patient's signing of an informed-consent form, witnessed by two medical practitioners. A further 48 h later, assistance to end life would be provided. A death as the result of assistance given under the Act was not taken to be unnatural, but a copy of the death certificate and relevant section of the medical record relating to the illness and death in each case had to be forwarded to the coroner. The coroner was subsequently required to report to Parliament the number of patients using the Act.