In Nitschke's Hands

For health and legal professionals with an interest in bioethics

In Nitschke's Hands

In Nitschke's Hands
by Michael Cook
Arena: The Australian Magazine of Left Political, Social and Cultural Commentary
December-January 2005-06

Has voluntary euthanasia been transformed from a philosophy into an open-source business venture? asks Michael Cook

After the incarceration of Jack Kevorkian, the Michigan doctor who bumped off more than 100 patients with gas, drugs and contraptions like his "Mercitron", the mantle of Doctor Death has fallen upon the broad Australian shoulders of Philip Nitschke. Such is his notoriety that the Howard Government has garlanded him with a law drafted, debated and passed specifically to keep him from his life's work. The Criminal Code Amendment (Suicide Related Material Offences) Act 2005 will soon ban giving advice about committing suicide through the internet. How often does the machinery of Parliament grind and whirr to accommodate a single citizen? Who needs knighthoods?

In the eyes of many left-wingers, Nitschke is a hero. He has convincing progressive political credentials. He opposed the Vietnam War; he lived with the Gurindji tribe in the Northern Territory and helped them with land claims; he opposed nuclear ships in Australian waters. His links with the Greens are particularly strong. He was a candidate for them in the Northern Territory in 1996. In 2001 he honoured Senator Bob Brown by giving him an award for "outstanding contributions in the right to die movement". It's no wonder that Green Left Weekly concluded a review of Nitschke's manifesto Killing Me Softly: Voluntary Euthanasia and the Road to the Peaceful Pill (Penguine, 2005) by conflating the war in Iraq and his campaign for voluntary euthanasia (VE):

Nitschke could have made more of the grossly hypocritical, anti-VE "pro-life" brigade in parliament and church, whose "moral" zealotry to prolong "bare biological existence" and defend life at all costs regardless of pain and misery, silently evaporates when they form the vanguard for criminal wars that inflict involuntary pain and death on hundreds of thousands at the drop of a carefully crafted lie.

But is Green Left Weekly right in depicting support for VE as a progressive cause? There is no doubt that progressives support it, both in Australia and elsewhere. The Australian Democrats, for instance, are broadly supportive, although Nitschke complains that they "now seem half-hearted in their commitment to a legislative turn-about". Millionaire businesswoman and arts patron Janet Holmes a Court penned a back-cover blurb for Killing Me Softly.

Nitschke as innovator

True, Nitschke does not speak for the whole VE movement. The state organisations feel that it is important to work within the law to achieve legislative change, a point of view which Nitschke has abandoned. But he is the most prominent euthanasia campaigner in Australia, perhaps in the world. Killing Me Softly, published with Fiona Stewart, outlines a new side of the VE campaigner: Dr Nitschke the innovative new-economy entrepreneur of DIY death.

Nitschke has emerged at a transitional stage in the VE movement. The public perception of voluntary euthanasia is that it is a desperate solution to unbearable pain. But in reality the days of justifying lethal injections with lurid descriptions of excruciating torment are largely over. With good palliative care patients need not suffer unbearable pain. Dying can still be an uncomfortable business marked by weakness, dependency and lack of control, but in the past these have not been accepted as sufficient reasons for euthanasia. If Nitschke had continued to jabber about people racked by excruciating pain, he would have been out of a job. But -- and this gives the measure of the man -- he swiftly adapted to the new market environment. Now he services people who are simply tired of life and wish to die. In effect, he has reinvented himself as a universal suicide provider.

His epiphany came when he met Lisette Nigot, a 79-year-old retired French academic living in Perth. When Nitschke first became involved with euthanasia, during the brief time when it was legal in the Northern Territory, all of the people he helped to die were ill, though not necessarily terminally ill. But there was nothing at all wrong with Lisette. Her pixie face was still strikingly handsome, she felt no pain and insisted that she was not depressed. She simply wanted to die. Their relationship is documented in an impressive documentary by Janine Hosking, Mademoiselle and the Doctor.

"Lisette was an important patient to me -- Nitschke writes. -- She was the first person to call my bluff. Finally, she had enough of me and my protestations that she should live. She told me to 'stop patronising' her. I was mortified to hear her allegation that I had become the type of doctor I despised. Lisette noted that I preached one thing in theory -- that a person of sound mind has a right to end their life at a time and place of their choosing -- and another in practice... I took a step back and stopped trying to frustrate and thwart her plans."

From then on, Nitschke expunged the vestiges of "sanctity of life" from his program and began to describe his work as providing do-it-yourself suicide technology and know-how. He has abjured the holistic Hippocratic tradition to become a service provider, more like a clerk in Bunnings Warehouse than a doctor. It is quite a logical step, for once the link between medical practice and the sanctity or inviolability of life is severed, doctors have no philosophical framework to work in. Their technical skills serve no higher purpose.

Nitschke as internet entrepreneur

Nitschke's key innovation has been to recognise that VE is no longer about compassionate medicine, but about providing technologies. He has effectively laid the foundation for transforming VE from a mere philosophy into an open-source internet business venture. In a 2001 interview with the right-wing US magazine National Review Nitschke even declared that ideally euthanasia -- "the peaceful pill" -- should be made available in supermarkets. He has been pilloried for this remark, but he sticks to it in Killing Me Softly: "it remains a metaphor that is useful in any discussion about universal access".

In short, Nitschke's campaign represents a radically individualistic, consumerist model which has more in common with the sanctified egotism of Ayn Rand than with conventional left-wing policies. This is where he diverges from the totalitarian, bureaucratised, state-sponsored Nazi model of VE. Nitschke represents nimble, entrepreneurial, consumer-driven VE. This accounts for his enthusiasm for the internet business model pioneered by Bill Gates and Microsoft. "Where choice in dying are concerned, the Internet is allowing us to share our ideas with other activists around Australia and the globe," he writes. It reminds me of Gates' slogans about "business @ the speed of light" and the paradise of the information society. And that's what Nitschke is: another huckstering prophet of consumer technology.

"This is why I can envisage a time when our dying will be more technologically influenced than ever before. But instead of doctors -- or politicians or legislation -- calling the shots, dying will become democratised… This heightened level of autonomy will open up new choices to the ordinary person."

Is this a compassionate doctor speaking? It sounds more like the "compassionate conservativism" so beloved by American neocons. Death, for Nitschke, has lost its existential meaning and has become an opportunity to market his weird gizmos over the internet: the Deliverance Machine, the Exit Bag, the CoGenie and the Peaceful Pill.

Nitschke as libertarian economic rationalist

As Nitschke's VE project unfolds, it becomes clearer and clearer that instead of being a left-wing progressive, he is basically a libertarian anarchist. This becomes very clear when he discusses his frustration with the law. A decade of campaigning for VE has convinced him that laws for voluntary euthanasia are useless and absurd. "In my view, such a law would have enough constraints to leave me wondering if it was at all worthwhile." Like so many other dot.com spruikers, he envisages a future in which law is effectively rendered irrelevant by technology.

"This is what I mean by the transformative potential of technology," he writes. "With knowledge at our members' fingertips, the need for a voluntary euthanasia can be questioned. Why pander to a specific medico-legal criteria about whether or not you are permitted end-of-life choices when you have all the technology you need?"

Nitschke's expertise is the technology of death. But Killing Me Softly also reveals that he is an economic rationalist in the mould of Maggie Thatcher. His argument for VE as a way of trimming fat from government budgets would make Peter Costello blush. End-of-life care is expensive. If VE lopped a mere six months off the lives of ailing elderly, immense savings would result, he muses.

"So the next time you hear a government minister trying to argue why this or that payment or welfare program for single mothers or war veterans must be cut, counter their argument with their fiscal irresponsibility on end-of-life choices."

At this point in Killing Me Softly, you have to stand up and walk around and take a few deep breaths. Is this man attempting a satire like Jonathan Swift's A Modest Proposal for solving the food shortages in Ireland by roasting and boiling the surplus of Irish babies? Or is he serious?

Nitschke's flawed vision of personal autonomy

At the heart of Nitschke's proposals is a notion of personal autonomy which is remarkably like the Cloud Cuckoo land of the perfectly rational consumer. Ceteris paribus, all other things being equal, these curves predict how stuff happens. But in real life the ceteris aren't paribus, in economics or medicine. Apart from the psychological pressure not to be a burden, patients are often depressed in ways too subtle for many psychiatrist to pick up, let alone a GP like Dr Nitschke.

Professor David Kissane, an Australian who is now head of psychiatry at Memorial Sloan-Kettering Cancer Center in New York argues that many patients who want to die may not be judged to be clinically depressed and thus "could be perceived by clinicians to rationally choose suicide as a merciful conclusion to their life." But in fact, he says, they may be suffering from what he calls "demoralisation", a separate psychiatric state which covers hopelessness, helplessness, meaningless and existential distress, and often includes suicidal thoughts. It can be caused by social isolation, declining physical health, disfigurement, disability, dependency, perceived loss of dignity and concern about being a burden to family. After reading Nitschke's folksy stories about those he helped to die, this sounds very familiar.

Remarkably, Nitschke never alludes to the fact that doctors are often tempted not to respect that autonomy. Studies of how legalised euthanasia works in the Netherlands have shown that doctors fail to fill their paperwork and lie about their euthanased patients. And then there is always the old-fashioned possibility of murder. If euthanasia were legalised, surely it would be easier for mad doctors to knock off their patients. This possibility never seems to occur to Nitschke. Significantly, the name of Harold Shipman, the British GP who may have killed more than 200 of his patients over about 20 years, is not mentioned in Killing Me Softly.

Nor does Nitschke wonder why he has helped to kill more women than men. A US study in 2000 by psychologist Silvia Sara Canetto, of Colorado State University, found that two-thirds of the victims of mercy killing in the records of the Hemlock Society, the most prominent American euthanasia group (now reorganised as Compassion & Choices) were women and 70 per cent of the killers were men.

"Many women do not have the resources, the sense of entitlement or the power and freedom to make the choice they desire, especially when they are sick or disabled... If older women are uniquely affected by the legalisation of hastened death," she said, "then policies presented as 'neutral', enhancing self-determination, dignity and choice in death, may actually be dangerous to older women."

Although Nitschke feels that he has a vocation to help autonomous elderly Australians to die on demand, he seems prepared to broaden his scope to people who may be even more depressed or demoralised. In the National Review interview he spoke about providing euthanasia for "the troubled teen". He also supports involuntary euthanasia for seriously ill newborns. He cites a slew of utilitarian philosophers in support of the view that there is no difference between a legally abortable foetus inside the womb and a legally killable infant outside it. To the practical difficulties of determining whether a child is really sick enough to deserve euthanasia Nitschke gives no thought whatsoever. Another potential market for VE is prisoners -- at least those who feel that life behind bars is literally the living end. VE, muses Nitschke, may be the "last frontier in prison reform".

The rhetoric of euthanasia

All this occurs in the midst of a culture whose rhetoric is slanted overwhelmingly in favour of VE. At this year's Academy Awards, euthanasia was applauded as the dernier cri, with Million Dollar Baby taking out four Oscars and Mar Adentro (The Sea Inside) winning an Oscar for best foreign film. The first of these, directed by Clint Eastwood, tells the story of a woman boxer who becomes a quadriplegic in her last fight. Her trainer, also played by Eastwood, is a daily Mass-going Catholic, but when he sees that she no longer wants to live he pulls the plug on her life support system. The Sea Inside is a Spanish film based on the true story of Ramón Sampedro, a former ship's mechanic who seeks help in committing suicide after 30 years as a quadriplegic.

The effect of these films is twofold: to portray the helpless, hopeless pathos of paralysis and to question an inflexible legal system which robs people of the ultimate in personal autonomy. This rhetorical strategy has not changed much since the Urquelle of euthanasia films, a German work called Ich Klage An, or I Accuse. This depicts the stunningly beautiful, vibrant young wife of a brilliant medical researcher struck down by multiple sclerosis. The climactic moment comes when her husband helps her to drink a draught of poison as her doctor's fingers ripple over a keyboard in the dimly lit room next door. Hanna says, "I feel so happy, I wish I were dead." Thomas replies, "Death is coming, Hanna." Hanna answers, "I love you, Thomas." "I love you, too, Hanna," says Thomas. There just weren't enough tissues in my box of Kleenex to watch this scene, even with my wretched German.

Ich Klage An doesn't end there, of course. The dark forces of gross hypocrisy and moral zealotry, disguised as an elderly housekeeper, denounce Thomas to the police. The film concludes in a dramatic courtroom scene with Thomas defiantly accusing the reactionaries: "Try me! Whatever the outcome, your judgment will be a signal to all those who are in the same position like me! Yes, I confess: I did kill my incurably ill wife, but it was at her request." He is acquitted.

Ich Klage An offers some telling clues about the progressive credentials of euthanasia. The script was written by Nazis in 1942 as propaganda for euthanasia of the voluntary sort. For the Nazis, there was no bright line between the two. The road to the Holocaust was paved with the involuntary euthanasia of useless eaters in a little-known program called T-4. The gas chambers and ovens were given trial runs in which an estimated 100,000 people died.

But the regime also favoured voluntary euthanasia for incurably ill patients like Hanna. The film even alludes to the possibility of an official commission to oversee such requests and prevent abuse, a system which has become a reality in the Netherlands. However, euthanasia never became legal in Germany because Hitler feared resistance from the Catholic Church. Some of the semi-secret involuntary euthanasia programs had to be suspended after a fiery sermon from the Catholic bishop of Münster, Clemens August Graf von Galen -- although Hitler vowed to "extract retribution to the last farthing" after the War for his impudence.

Lest I be accused of falling into the fallacy of reductio ad Hitlerum, or refuting an idea by associating it with Nazism, I admit that Hitler's support for VE does not ipso facto invalidate contemporary VE. Hitler also supported full employment and vegetarianism and these are wholesome concepts fully compatible with a democratic society. But the fact that both the Nazis and Nitschke use the rhetoric of maudlin compassion and the same strategy of coping with resistance to legislative change by bypassing the law raises some awkward questions. They are not, incidentally, questions which Nitschke seems ready to answer. Killing Me Softly contains a potted history of suicide, but omits a potted history of VE. He can hardly be ignorant of VE's Nazi antecedents -- his critics remind him often enough -- but there is not one entry in the book's index for "Nazi". This significant absence alone should reinforce the impression that it is at least not self-evident that VE is or should be a left-wing cause.

A diminished sense of community

Indeed what is almost entirely missing from Nitschke's account of patient autonomy -- or from most arguments in favour of VE -- is a sense of community. Most of the people whom Nitschke has helped to die are loners, classic casualties in a society afflicted by the anomie described in Emile Durkheim's classic text Suicide more than a century ago. From that point of view, it was fitting that the central figure in Mademoiselle and the Doctor is an unmarried, childless woman who fears becoming a burden. This impoverishment accounts for the VE movement's lack of interest in reforming the social structures which have created the loneliness and isolation. These are what feed the demand for euthanasia. But libertarians are like that, aren't they?

As we move into the post-baby-boomer era, the ageing of the Australian population will put great pressure on personal lives as well as government finances. There is no doubt that Nitschke's model of privatised, DIY death will become more attractive to many lonely people, especially women, who fear being dependent on others. And now that he has given his supporters an open-source model for euthanasia, even more entrepreneurial types could get involved, creating a commercial market for ingenious end-of-life devices. This is not a progressive vision for the future and this is why the left should beware of the fallacy of commutative enmity, that the enemy of my enemy is my friend. Just because all the right people hate Philip Nitschke doesn't mean that he should be adopted as a mascot for progressive thinkers.

Michael Cook is editor of the international bioethics newsletter, BioEdge. Email:mcook@australasianbioethics.org