Philip Nitschke is no stranger to controversy. As a physics student during the Vietnam war he became upset about his own, perhaps tenuous, connection with research relevant to weapons of mass destruction. To redress the balance, he headed up to Australia’s Northern Territory to take part in the Aboriginal land rights struggle. In his time he has supported nuclear disarmament and campaigned for better services for intravenous drug users. He took up medicine as a mature student and graduated from the University of Sydney aged 42. Six years later, he took up the cause of what he regards as the universal right to die. He is director of the voluntary euthanasia organisation Exit
Why did you decide you wanted to help people die?
I was working in the Darwin area running a practice that focused on the health needs of intravenous drug users. I heard the announcement of the proposed voluntary euthanasia legislation on the radio. The Australian Medical Association (AMA) reacted strongly, claiming they would ensure it never got passed. They stated emphatically that no doctor in the Territory would cooperate with such a proposal. This claim annoyed me. Apart from being untrue, it clashed with my perception of the role of the medical profession in the community, which was not to frustrate and thwart the clear wishes of the people – who were strongly behind the proposal.
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What did you do?
I took out a full-page ad in the local press and listed the names of 20 doctors who believed the politician proposing the legislation, chief minister Marshall Perron, was on the right track. So my involvement was initially political, and it was only then that patients began to seek me out in increasing numbers.
In Thomas More’s Utopia, the sick are nursed until they become an unbearable burden to themselves or those around them, when they are helped to die – but only with their consent. Are you a Utopian?
Yes, although there is a question of what constitutes help. What most people desperately want is access to information and, ultimately, access to drugs they know will give them a peaceful death. In some unusual medical circumstances, such as motor neuron disease, they may need help with administering the drugs, but they don’t generally need or want a doctor at the bedside.
In Utopia, it is the priests who decide when a person has lived too long. Who decides in a secular society?
Unfortunately we are now seeing the medical profession acting as the new priests. They have quickly set themselves up as the experts on dying and promote the idea that it is something you cannot do well without a doctor at the bedside. This medicalising of natural events – dying, childbirth – disempowers people. People now have to go cap-in-hand to the medical gatekeepers, begging for the right to die. Genuine empowerment sidelines the doctors and priests, but none of the proposed or enacted legal models that allow voluntary euthanasia – in the Netherlands, Belgium or the US state of Oregon – offers that to any significant extent.
Tell me about the deliverance machine. Is the idea to restore that power to the people?
The machine was built so that patients who were eligible to use the Northern Territory law could do so themselves. I no longer had to sit at the bedside giving them the lethal injection. True, I had to load the machine, but they were in control and I was out of their personal space – the space where only the people who matter should be. In each case, the family could hold their loved one as the machine delivered the lethal drug. I would have been very wary of a patient who said they did not want to use the deliverance machine, but wanted me to give the injection instead. I would fight for their right to die, but the decision has to be wholly theirs.
But what if a patient’s illness makes them irrational?
It is important not to get too fixated on the word rational. Rational to whom? By what standards? It’s better to use the concept of sanity as defined in law – that is to say, is a person able to give informed consent? If a person is rational by this definition, is over a certain age and is not psychiatrically unwell, and they decide that death is in their best interests, they should not have obstacles placed in their way. If they are not rational, then they come under the jurisdiction of the various psychiatric treatment acts that exist around the world. I support rational suicide as a concept and I see the vast majority of my patients as rational.
Have you ever tried to talk someone out of their decision to die?
Well, I often find myself thinking that death is not my answer to their question. But what is important is not my answer, but theirs. Increasingly, the people coming to the Exit clinics are elderly and tired of life. They have no particular identifiable pathology, certainly nothing terminal. In these cases I find myself suggesting what I think might be new and innovative life options, until they get thoroughly sick of me. They remind me that I am not them, and that until I am 80, perhaps I should keep my thoughts to myself.
Isn’t there always a chance that a person could survive a “terminal” illness, and perhaps even attain a better quality of life?
This is always a possibility, and I am forever reminding patients at the Exit clinics that miracles do happen. However, many people have spent considerable time and effort suffering in the hope of such a miracle. A point is reached when they feel the scales tip, and the permanence and peace of death become too attractive.
How would you change the existing laws on assisting suicide?
In Australia we have laws that say suicide is legal, but anyone who advises, counsels or assists a person to commit suicide can attract the most savage penalties. Two of Australia’s states still have life imprisonment for this crime. There’s no other example in law in which an act can be legal, but to advise, counsel or assist in that act is illegal. There is now a procession of people going through the courts – loving partners, occasionally children – who have helped sick people they love to end their suffering. Mostly they are treated leniently, but that is little comfort for those who find themselves caught up in these issues. And what constitutes assisting? Talking about it? Attending an Exit workshop? Is it a crime to simply sit with someone who takes that legal step of ending their life? There is no consensus.
Is it true that you give classes on how to commit suicide?
This is how our opponents describe the Exit workshops. In a four-hour session we run through the legal issues: what you can and cannot do, what the consequences might be. We talk about living wills and the medical power of attorney. We discuss psychiatric illness, particularly depression, and palliative care. We outline medical loopholes like terminal sedation – so-called slow euthanasia – and we talk about the drugs that cause death, as well as non-drug methods such as carbon monoxide generators. We finish with a discussion of death certification, inquests and autopsies.
Who attends these workshops?
They are generally well, elderly people who want to learn more about their end-of-life options. The average age is 75. It used to be the case with abortion that getting the help you needed depended on who you knew. The same is now true for getting help at the end of life. Not many doctors come to my clinics.
Have you ever been prosecuted?
The AMA has on four occasions tried to initiate disciplinary proceedings against me, but on each occasion the relevant state medical board has side-stepped the issue, claiming it is up to the police to investigate if there has been a breach of the law. So it is a strained relationship. I am quite circumspect about what I admit to, though we stick to the mantra that we neither “advise, counsel nor assist”. Death threats come in, but not very often. Euthanasia seems to be a less emotive issue than abortion, and I’m grateful for that.
You are developing a “peaceful pill”. How do you intend to test it?
The pill has to satisfy certain criteria: you have got to be able to make it yourself, and it has got to reliably provide you with a peaceful death. We’ve been looking at plants and other natural substances, but generally we are looking at reject pharmaceuticals that have been shown to be too dangerous in clinical trials. We have put a lot of effort into carbon monoxide generators, because pure carbon monoxide is very effective. Testing is obviously problematic, but ultimately we will probably rely on volunteers – people who have been involved in the project and who find themselves in a situation where they are prepared to try one of these substances.
How do your views differ from those of Ludwig Minelli, who runs the Swiss assisted suicide organisation Dignitas, and Jack Kevorkian, who is in prison in the US for helping people kill themselves?
I greatly admire Kevorkian and Minelli, but there are differences in our philosophies. As a lawyer, Minelli has taken skilful advantage of his country’s constitution, which can be interpreted to allow people access to the drugs they need to end their lives peacefully. For that he is to be applauded. However, most countries don’t provide that option. So I find myself looking for a more universal solution.
Kevorkian saw a pivotal role for the doctor, but was not an advocate for legislative change. I see the doctor as a partner, and possibly only a minor partner. Having said that, Kevorkian’s courage is undeniable, as is the injustice of his long incarceration. At the age of 74 he hardly represents a threat to society.
Do you regret anything?
Yes, there have been times when I could have expressed myself more clearly. Generally, though, they have been when opponents have chosen to deliberately misrepresent my comments. For example, in an interview with an American magazine I discussed my ideas of universal access to information and a universal right to die. This became known as the article where I advocated suicide pills on supermarket shelves for troubled teens. Not actually what I said, but the pro-life lobby continues to get mileage from it.