Should Nembutal be legalized?

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 individuals that don’t value their lives and wish to end it.

Although there are 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 assume that, despite advances in palliative care and pain relief, a substantial number of patients in the last stages of terminal illness are allow to suffer severe pain or distress without effective treatment.

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

As it is a universally agreed key aspects of the law regarding end-of-life treatment need to be clarified, this argument is depend on a mistaken premise. According to the law, there is no limit to the treatment that may be given to alleviate suffering. Basically, 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 well known to provide pleasant sedation and may be used effectively to relieve distress. These drugs can cause suppression of breathing and death in high doses, due to the risks associated with overdose, they have been withdrawn from routine medical use over the last 20 years.

 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 distress. These treatments may be complex because “distress” in such settings is not an undifferentiated condition for which there is a single, universally effective therapy such as pentobarbital or morphine. Furthermore, counselling, support for family, relatives and many other measures are commonly required. The use of these treatments often requires considerable talent.

The euthanasia is not only seen wrong from this argument, but legalising euthanasia, and Nembutal with it, is likely to be counterproductive. It is due to as a result  in limitation of access to appropriate care for the majority of patients who do not get comfortable with the strict criteria for euthanasia.

Philip Nitschke advocates that people undergoing pain at the end of their lives be given Nembutal to ease their pain. ALAN PORRITT/AAP
Two scenarios.

To demonstrate why it is so, imagine the case of an old 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 the old man has limited time to survive.

His suffering is intense 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. First case, the man’s doctor recognises her patients undergoing stress. She consults with him and his family and decides to provide treatment either with Nembutal itself or with a cocktail of medications with the same effect.

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

In the second case, the doctor attends to the request from the patient to kill him. She organises consultations with two psychiatrists to confirm he has the ability 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 patients undergoing distress  is alleviated, he slips into unconsciousness and dies peacefully with his family beside him.

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

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

Double effect

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

From 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 focus of care should be how distress the patient is, not life itself as imagine.

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 handling distress cases 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 agreed that whatever treatment is needed to alleviate the suffering or distress of a patient is permissible – even in death scenario.

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