Dr Death asks some painful questions

In Australia and the United States, euthanasia has replaced abortion as the big moral question of our time. There is an urgent need for proper debate, says Dr Philip Nitschke, who has helped several terminally ill people to die. He speaks to Ann Treneman

Dr Philip Nitschke is the only doctor in the world who has legally helped patients kill themselves. He helped four people to die - though some would call it murder - during the eight months in which euthanasia was legal in the Northern Territory. He says that he couldn't help but feel a bit like an executioner when he turned up on the doorstep at the appointed hour, killing machine in hand. But now that euthanasia is illegal again, he feels like a criminal as he tries to help the people who constantly ask for his help.

Executioner or criminal? Legal or back-street euthanasia? Right or wrong? It's the kind of thing that we should be debating here because - like it or not - euthanasia is a subject whose time has come. In the US and Australia it is seen as the great moral question of our time and a subject that has replaced abortion in terms of ethical talking points. Tomorrow in the far western American state of Oregon voters will decide whether it should be legal. Three Australian states are considering some sort of legislation. In Holland, where it is decriminalised but still illegal, the debate is murkier but ongoing.

In Britain, however, there is little informed discussion. Last week the High Court ruled that Annie Lindsell, a 46-year-old woman who is gravely ill with the debilitating but not usually painful motor neurone disease, could receive an injection from her doctor to make her unconscious in order to relieve her mental suffering. But do most of us really know what this means? A few days later the International Forum for Transplant Ethics headed by the former president of the Royal College came out in favour of giving lethal injections to patients who are in permanent vegetative states and then harvesting their organs. But do we have any idea what we are really talking about here?

Dr Philip Nitschke does and the story of his eight months as a practising euthanasia doctor has more than a few surprises. Part of this is because the man they call Dr Death is himself a surprise. Today he is on his way to Oregon for the vote and last week he was in London to address a Voluntary Euthanasia Society symposium. I met him and his killing machine at his London hotel room.

"Oh I've had so many problems with that bloody machine," he says as we walk towards the room. These turn out to be technical in nature and he says it's a good thing it doesn't have to be used again. In the room the laptop computer attached to a contraption of vials and a needle is all set up. The barbiturates are even loaded, as is the "Deliverance" software that enabled his terminally ill patients to tap their way through a series of steps, the last of which triggered a lethal injection. The machine still has its Qantas luggage tags attached. It is not considered hand luggage.

He invented the machine because patients said they wanted to be in control of their own deaths. By law, he only had to be in the room when they hit the button. He no longer uses it though he does admit to helping some people who would have qualified under the old law to try and get the barbiturates they want so desperately. "I find myself in the position all the time of breaking the law. I don't like it at all. One has to be constantly careful. One has to sneak around. One feels like a criminal. But if they are going to push us back into that shadowy illegal world, you will get behaviour that is more in keeping with the jungle than when we had a piece of legislation and a bit of sunlight on the issue."

Dr Nitschke was contacted by some 50 people who wanted to die and, as such, managed to build the first profile of its kind. "They were almost all terminally ill from cancer and were in the late stages after everything else had been tried. They were older, mid-sixties, and usually from the lower economic spectrum. You know, people who have money have never had trouble getting access to euthanasia. The people who contacted me were not part of the club, they did not have brothers and sisters who were doctors. One of the good things about the Territory law was that it opened things up to everyone. It was not just a matter of who you knew. It became something that people saw as one of their rights."

The law caused uproar when it came into effect on 1 July 1996. Media from all over the world made their way to the remote Northern Territory to report on a situation where local doctors were loath to give the signatures that were required under the law. The first two people to die did so in the middle of a media scrum. Whatever it was, this was not death with dignity.

"At first the law was a circus but then the situation changed. The media interest died off. It wasn't seen as a sideshow anymore. They were discreet and private affairs." When the federal government overturned the law by a two-vote margin earlier this year, Dr Nitschke had patients who were ready to die. One was Esther Wild and her story, he believes, shows the hypocrisy of the law as it now stands around the world.

Because neither he nor his machine could give her a lethal injection, Dr Nitschke could only treat Esther Wild for her pain. This is what is called the "double effect" when treatment for pain ends up hastening death. It is not illegal as long as the doctor only intends to treat the pain. This is common practice around Britain and was the crux of Annie Lindsell's case. In effect, Annie Lindsell won a widening of how the current law is interpreted and for her mental suffering to be seen as pain and treated as such.

Dr Nitschke sees this as "slow euthanasia". The idea is that the patient asks for the infusion to begin and they then slip into a coma and eventually die. In practice, of course, there can be problems. "In Esther Wild's case we started the infusion but three times in four days she woke up. One time she woke up and asked 'Am I dead? Is this death?' and I had to run in and get the infusion running again." Opponents of euthanasia praised the case as good medical practice, which Dr Nitschke finds bizarre. "To call that obscenity good medical practice just shows how far off the rails we are."

A key lesson here is that there is a demand for euthanasia and demands tend to get met, one way or the other. There is a lot of interest now in developing a "suicide pill" that would be a human version of the one used by veterinarians for animals. "This is not the way I want to see it go but in the some way as I see it as an inevitable consequence of having so much difficulty getting legislation passed," he says. "We battle, battle, battle, battle and can't get the law through. It's not surprising that people are putting effort into this kind of thing."

The idea of a suicide pill, like euthanasia, is not the kind of thing we want to think about. But think we must for this is one of the great questions of our time and how we answer affects all our lives - and deaths.