The practice of euthanasia: more than a debate; the conviction in March of a nurse, Lesley Martin, for the attempted murder of her terminally ill mother, has highlighted the need for nurses to face up to end-of-life policy and practice dilemmas.

NURSES ARE experts on death. Or so many nurses would claim. While doctors legally certify that death has taken place, nurses are the ones who are there for the dying person and their family.

Ethical nursing practice includes the prevention or delay of death. In very rare cases, nurses retrieve people from death. When death is inevitable, they prepare the person for the best possible death. Once death has occurred, nurses carry out rituals of care on the body. Nurses and doctors do not always agree on death practices. Nurses see themselves as more accepting of death; its naturalness and inevitability. They also see themselves as advocates for people to die in the way they choose, if at all possible.

Nurses and doctors do not carry out death practices in isolation. Professional standards guide individual practice. Legal structures exist to monitor and sanction their work. The media helps to form public opinion regarding nurses' and doctors' practices.

Public surveys suggest that nurses are more highly respected than doctors. Un fortunately, respect for the person and their work is not the same thing as respect for the knowledge they are assumed to hold. While nurses may think they are the experts on death, this view is not generally shared by doctors or members of the public. Nor is it shared by the creators of legal structures regarding death practices. Hence there is a danger that legal and social judgements about nurses' death practices are based on ill-informed assumptions about nurses' knowledge and morality.

Another kind of death expertise also exists. It develops in people who have participated in the dying and death of a loved one. Many of them support the reform of professional, legal and social structures to ensure that people can die in their own chosen way and with as little suffering as possible. Three possible reforms, with that end in mind, are currently attracting attention. One provides for a doctor to assist people to kill themselves. Another proposes that the person give their consent for a doctor to kill them with, for example, a lethal injection. The third contentious reform involved the practice of "terminal sedation", whereby a person is rendered unconscious and pain-free through sedation, until death occurs. These practices are already occuring in other parts of the world.

Some New Zealand nurses would support these reforms. Some would adamantly oppose them. Regardless of what position nurses take, what stares us in the face is the recent conviction of a New Zealand nurse, Lesley Martin, for carrying out the attempted murder of her mother. This was a high profile case, not least of all because Martin published an account of the experience, but also because she sought to create publicity for the legalisation of euthanasia. The media coverage of the case bears careful analysis because it is an example of how nurses and nursing are constructed in the media. But there are deeper issues to address here. Lesley Martin's trial and conviction provide a poignant and tragic backdrop to an issue that must focus New Zealand nurses' minds and energy. First, we have to grasp a nettle or two.

Grasping the nettle

Euthanasia practices do occur in New Zealand. This has been borne out by nurses' stories and by research. It is common knowledge about an uncommon act, eg a doctor or nurse injecting morphine into a terminally ill patient, knowing that there are two likely effects--pain relief and death. Nurses and doctors carry out other practices at the end of life, where one of the known effects is the death of the patient. These practices occur in a context where legal guidance and control exist, for example, the Crimes Act 1961, the New Zealand Bill of Rights Act 1990 and the Health Practitioners' Competence Assurance Act 2003. Two sets of problems arise. First, why do these practices occur, given the legal sanctions against them? Second, why are so few cases referred to the courts? And is this a good thing? These questions are difficult but not impossible to address.

First, there are the problems arising from nurses and doctors being reluctant to seek advice and support for clinical practice decisions, from outside parties. This apparent reluctance arises from a strong belief system among many doctors and nurses about where their responsibilities begin and end. They would argue that only those who are substantially involved with each case can make a totally relevant and efficacious decision. Therefore, where an ethical dilemma about a terminally ill patient exists, they would argue, the best people to solve that dilemma are not the ethics committee, or the company lawyer or even a parliamentary statute, but the patient, the family, and the nurses and doctors who are familiar with all the aspects of the dilemma.

This arrangement could be seen as a conspiracy between the patient and all the caregivers, a conspiracy where an implicit agreement is made to support the patient and protect one another from the possibility of investigation and possible censure. This blatant assertion of clinical freedom flies in the face of increasing regulatory measures for the management of risk in the health system. Nurses and doctors participating in end-of-life practices which may be ethical but not legal, do risk investigation. All it takes is for one party to withdraw from the conspiracy of silence and report the incident.

A further set of problems arise. What harm is being done when these death practices are carried out "behind closed doors"? It does depend rather on who is behind the doors and whether they are there on a "need to know" basis; usually the patient, family members and caregivers, including those who have the authority to make decisions in a climate of trust. What a shut door also provides, however, is protection from scrutiny for a murderer, is a practitioner whose intent it is to harm a patient by killing him or her.

In 2003 a private members' Bill was tabled in Parliament, the Death with Dignity Bill. On the basis of regrettably ill-informed emotive debate, and an extremely close vote, the Bill failed to make it to the next step of the parliamentary process--consideration by a select committee. The Bill's stated aim was to allow people to request their own death with the assistance of a medically qualified person. If this Bill had become law, it would have legitimised the practices referred to above. Its implementation would also have thrown out major challenges to nurses. More nettles to grasp.

Oh nettle, where is the sting?

The thinking that nurses do about euthanasia and assisted suicide must take into account several things. First of all, nurses need to decide on their expertise about death and dying, trust and suffering, and the significance of negotiating with others. Taking responsibility for this area of nursing knowledge is the starting point to being an effective nurse of the dying person and informed participant in the euthanasia debate. The next thing to take into account is the realisation that death expertise is a contestable notion. Others will also claim to be experts on death, for example, other health care workers, ethicists, legal and policy advisers, and death policy consumer activists. These areas of expertise will be displayed and manipulated by the media. Public opinion will rest on this portrayal. Therefore, nurses' thinking will need to be communicated to the public and nursing expertise embedded in public debate about legal and ethical death and dying practices.

There is no doubt that a Death with Dignity Bill will re-surface some time in the future. If it is the will of the House of Representatives to debate the Bill and seek submissions, nurses need to be ready. We can make an informed, ethical contribution to the debate about whether the law on assisted suicide should be upheld or changed. First, we will need to engage with one an other in debate, because nurses hold a range of views about this. It may not be possible to present a unified nursing view to the public and to the relevant Select Committee. Where there is a diversity of views, the status quo is likely to remain. Whether nurses are listened to or not, depends on the select committee's willingness to accept that nurses are key practitioners here, and that they have a particular expertise. To some extent, it also depends on how honest we are prepared to be about what goes on now and how much we are willing to share our understanding about how people face death.

A further significant question must be the extent to which we are ready to have our practice openly guided and monitored by parliamentary legislation and regulations. Should such legislation be passed, we then face the task of setting up systems to make death and dying practice safe for the dying person and for nurses.

Do not underestimate the difficulty of these challenges. They will occur in a context of considerable turbulence. Even the definition of death is constantly mobile. A burgeoning "requested death movement" will be arguing for requested death, not so much on the basis of relief of unmitigated suffering, but on the basis of a desire for control over one's destiny. Individual requests for specific ways of dying will be compounded by technological advances in the ways that people can be kept alive.

On the other hand, there is continuing evidence of individuals' lives, and therefore deaths, being valued differently. Would some groups in society be more likely to be offered assisted suicide than others? Evidence suggests that this is a strong possibility. Standards, policies and guidelines will provide some supports but only if they are universally known, understood and accepted. Finally, practices around death cannot be separated out from every other realm of nursing practice. Neither should they be.

Conclusion

In other countries, where euthanasia has been de-criminalised or legalised, nurses have been thrown in the deep end and have reacted in different ways to the impact it has had on their practice. It is inevitable that nurses in New Zealand will have to address this in the future. There are two choices. Either nurses face this with determination, candour and confidence born of practice and political expertise, or they wait for this issue to rear its head again, unprepared and secretive, fearful and divided. I know which option I will go for. I invite you to join me.

* Nurses interested in debating this issue further should contact the author at: [e-mail]. A list of references is available from the author at the same email address.

--Joy Bickley Asher, RGON, RM, PhD, is a senior lecturer in the Post Graduate School of Nursing and Midwifery at Victoria University. Her PhD thesis is: A study of medical, nursing, and institutional not-for-resuscitation discourses.