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Address on the occasion of the launching of the Arthur E Mills Oration, Gold Coast



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ADDRESS BYTHeIg OVERNOR^GENERAL \ ON THE OCCASION OF THE ARTHUR E MILLS ORATION COLD COAST. WEDNESDAY. TUNE 21 1995.

[CHECK AGAINST DELIVERY - EMBARGOED TO 8PM 21 TUNE 1995]

Let me begin by thanking the Fellows of the Royal Australasian College of Physicians for the honour you have done m e . this evening: firstly b y

admitting me as an Honorary Fellow, and secondly for having invited m e to give the annual Arthur E Mills Oration. I am highly conscious of the

privilege.

Arthur Mills was a Foundation Fellow of this College. He died in 1940, less than two years after its inauguration, yet his name lives on as a physic ian and teacher, especially among his students - and their students - w h o have

been infuse d with his spirit of true inquiry. As his biographical notice

observes, "He insisted that they keep asking the question "Why?"", a nd that they seek to u n d e r s t a n d p h e n o m e n a rather than blindly a c c e p t

conventional dogma."

I take that as the guiding principle for my address tonight - as I have, 1 hope, throughout my public life. What I would like to do is express some quite personal thoughts, and I stress that, from my own perspective as a liberal h um anist on some of those social, medical and ethical dilem mas that

confront us in these times at so many stages of our journey through life.

We live in an age of unparalleled material satisfaction and entertaining diversion. The su m of knowledge is greater than it has ever been, a n d the resources with which to develop that know-ledge are more productive a nd efficient than at any time in human history. H um an ingenuity excels itself

in meeting our wants, but is far from fully stretched. Even the poo r of the world are much less poor than say a quarter of a century ago. True, in

m o d er n history under the stirring influence of nationalism h u m a n s

murder more fellow humans than ever and, concurrently, sanctimoniously practice religions of forbearance, compassion and love. My point is not to pro p ag an d ise about our remarkable feats nor to moralise a b o u t those

dreadful shortcomings.

In spite of the abundance of knowledge, commodities and d iversio ns

humans are now able to create, it seems that the more we know a b o u t so many things the less we understand about ourselves. So many old reference points w'hich once guided the generations th ro u g h life have been

demolished, discarded or othenvise discredited and of those r e m a in in g

there are not a lot of importance unchallenged. This is in a very real sense the age of deconstruction. But it is not all bad news. Many of the old

reference points needed updating or replacing.

We are learning, for instance, that as our society becomes more liberal then unexpected consequences flow in the wake of that extended toleration. In many cases we find ourselves deeply shocked by the consequences which

flow from some initial act of o v e rd u e tolerance. Last year was the

International Year of the Family. As such it was a year of some confusion. The convenors of this great o p p o rtu n ity for talking among agreeable

companio ns found they were the targets of disagreeable criticism.

Fundamentally, the difficulty was, what is the definition of a family in this extremely pluralistic and individualistically demanding age? ■

Claims for marriage between same sex partners and custody and adoption of children proved to be a. bit more than many could take and so' the "issue of definition was sidestepped effectively. Marriage is formally a contract between heterosexual partners. It brings in its wake certain rights, duties and obligations as between the parties to it. Because we do not discriminate against same sex partnerships it is difficult to see how there can be a

sustainable objection to partnership contracts similar to marriage covering those relationships. That is, in taking the first step of accepting same sex relationships as lawful and acceptable certain consequences flowed from that and we cannot pretend otherwise. Furthermore, this contractual protection

would establish a more just basis for the rights of the partners in those

relationships at law.

The proposal that same sex partners have adoption rights came as rather shock to a lot of us. Yet if we reason our way through what, in many cases, is already happening it is evident that same sex partners frequently have custody of the offspring of one of them. If we dispute this point we are trying

to roll contemporary mores back denying equal rights to same sex partners. The adoption test for them should be the same as for other members of the community. Is the best interest of the child or children concerned being catered for by this arrangement, as against alternatives which could properly be contemplated.

For instance a w o m a n , for w h a tev e r the reason, enters a lesbian

relationship. She maintains custody of her children. They enjoy their mother's love and affection and have the protection of a secure and

emotionally supportive family life. They are far better off in that situation than being passed over to a strange and uncertain adoptive life or into the control of an orphanage. The point is, if custody is acceptable in these

circumstances so is adoption, as long as the rigorous grounds applied in such cases is consistently followed. I think the point to remember is that because someone, male or female, is homosexual, it does not mean that person is automatically a pederast any more than a heterosexual is by

definition not a pederast. In any case it is not the state's role, not in a liberal society, to invade people's personal choices unless these put others at risk.

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W h e n society took the decision to no longer re g a rd the practice of

homosexuality as a threat to established mon oga mo us heterosexual de jure marriage, regarded as the corner-stone of society for so long, certain

inevitable consequences followed. Certain rights flowed to homosexuals in the wake of that decision and unanticipated changes to commun ity

standards followed.

The notion of the family, as mentioned already, is no w much more complex and for some this is confusing. It is also irreversible: an d not just a m o n g same sex partners. De facto relations a nd the offspring of such unions, socially scorned when I was young, proliferate with community acceptance.

Expectant single mothers instead of frequently entering dreadful institutions where they were made to extirpate their sinfulness as fallen women in steaming laun dries and by scrubbing· floors-as a prelude to the ultimate

punishment, hand ing over their children for adop tion at the instant of

birth, now raise their offspring with general social approval. Society is better for these changes.

In this respect I made my own modest contribution. I introduced the Single Mothers' Allowance, later to become the Single Parents’ Allowance, more than twenty years ago as Minister for Social Security.

In-vitro fertilisation programmes and surrogacy have, similarly, transformed the notion of the conventional family. These have not been w ith o u t their

controversies. Moral, theological, militant feminist and of course financial objections have been raised. As a liberal humanist I find myself guided by the principle that people have a right to choose their life style, provided that others are not genuinely harmed, as distinct from being upset or resenting that choice,

the state does not have a right to intervene.

My own feeling is the guidelines set down by the Victorian Parliament in 1984 legislation provide adequate controls and cater sufficiently for the interests of participant parties, regulate the scientists without being a stifle and in particular protects the infant delivered of IVF.1 The practice of abortion, after so many years of controversy, is virtually sanctioned by society in practice. Abortion is abo ut

unwanted children. IVF and surrogacy are about wranted children, about creating and nurturing new life, and accordingly have a superior claim for c o m m u n ity sanction.

For me moral concerns are met by my liberal humanist values. People of a

particular religious faith have a perfect right to personally object to IVF and surrogacy and not to use it as they have to reject abortion. Australia, however, is altogether too religiously pluralistic for any one set of religious values to be imposed on all of the community. Some militant feminists oppose surrogac>r on neo-Marxist grounds; that it reinforces gender roles by perpetuating a state of false consciousness, that the surrogate mother is exploited as a means to som eone

else's ends, that commercial surrogacy constitutes alienated labour.

Altruistic surrogacy is an act of noble support for others whose desperate wish for n child is understandable and driven by more than notions of cultural oppression o f women imposing subordinated gender roles on them. In the case o f commercial surrogacy, rather perversely, some feminists support it because il challenges the myth o f the maternal

instinct and society's gender norms. Some even laud surrogacy because the non-coital collaborative procreation it offers increases the methods and range o f reproduction available to a woman. Others oppose it, generally on strained ideologicaJ grounds, at the same time asserting a woman’s right to be in control of her body where abortion is concerned, without a blush at the obvious inconsistency. In practical terms, surrogacy contracts in Australia arc unenforceable and accordingly have the potential to be the source of much confusion, emotional despair and heartbreak. Moreover, in a number o f

Australian jurisdictions, certain activities in connection with commercial surrogacy contracts attract the sanction of the criminal law. The law therefore obstructs those who wish to be involved in a surrogacy arrangement. In a. liberal society, this obstruction

should perhaps be reexamined. Properly regulated to ensure protection o f the interests of the parties involved, surrogacy can be seen as a fundamentally pro-life action central to the private affairs o f those who feel it is their only practical option.

Given the very low conception ar.d even lower birth rates from various forms of artificial Insemination, Justification of the total cost has been questioned. The only figure I have seen is $30M. for 1VF programmes, of which more than half was met by federal taxpayers. It is several years old. It however gave an average

cost of something like $40,000 per live baby taken home. But then in ou r society we are prepared to make extraordinary efforts to preserve h u m a n life. Thus, treatm en t of certain premature underweight babies, which fail to sur vi ve

intensive care costs nearly $700,000 each. Liver transplants cost a r o u n d $60,000 per person and the total cost - direct and Indirect - of treating an AIDS patient

a p p r o a c h e s $ l.OM.2 From an economists point of view with the heavy

u n d e rp i n n i n g of utilitarianism their training gives them the t e n d e n c y is to

question the cost of these procedures as against using the resources elsewhere to better the life expectancy of humans. They seek to quan tif y things and to

measure co mparative aggregate outcomes from given levels of inputs. Their calculations are also often based on incomplete knowledge a nd of course Ignore Intangibles. The happiness of an infertile family having a child is immeasurable. That does not mean by the way expenditure on such pro g ram m es therefore can

be unlimited.

I do recall, however, while in parliament, a constituent family a p p ro a c h e d me about assisting them obtain government funding to take their infant son to the USA for a renal transplant. For some reason the procedure then could not be

done here- The father was an air force corporal, by definition a family on modest income. My training inclined me strongly towards the Finance D e p a r t m e n t view the cost could not be Justified because then survival rates from this procedure were low. I am glad my sentiment for fellow humans got the better of me. The

family eventually got some help. The child lived until a few years ago giving incalculable, blessed happiness to that family.

V wo y e a r s a g o I h a d t h e h o n o u r !o o p e n a n e w m e d i c a l b u i l d i n g a t t h e R o y a l

C h i l d r e n ’s Hos pi t a l, Brisbane. I was informed the su rv iv al rate for liver

transplants among children was · 0 per cent. The early high costs were Justified by the way techniques, and the stork of happi ness in the wor l d- to use utilitarian

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jargon - had been improved by that earlier pioneering work. This is not to

dismiss the need for rigour in resource allocation between competing sectors. On the other hand bigger savings couid be achieved elsewhere and that is where the exercise should start, even if politically it is intimidating.

I hope I am not considered an ungrateful guest by mentioning that, combined with fee for service remuneration and the incentives it provides, the increase in the number of doctors in recent years and the lowering of the doctor patient ratio has been associated with a concomitant increase in the incidence of pa ti en t medical servicing. Mostly practitioner initiated. In some important cases the mystical hand of the market works perversely. The remedy for this rests not with

fewer doctors but in different payment systems.3

With the extraordinary range and complexity of organ transplants, the life sustaining support these procedures offer arid, in cases, an excess of d e m a n d to supply - some 20 percent of donor applicants die while still on waiting lists - there have been suggestions of treating organs as a community resource. For this read

the adoption of co-ercive- powers over next-of-kin and arbitrary autho rity to remove organs, where suitable for transfer, from deceased. If the tabloid press is to be believed there have been instances of this practised in some Australian hospitals. The community will not accept that view. In particular, not in this age of elevated individualism where community duty is, unfortunately, so inferior

in its rating. :

It is depressing to reflect so many younger lives are deprived of further years of productive and enjoyable life because of prevailing attitudes denying a greater supply of organs. The case for organ transplants for the old seems less well founded given the full life behind them and the limited life expectancy ahead of

them. This because of the high costs to federal taxpayers of most of these

procedures. They should not even be contemplated for the elderly where there are young people in need. The British National Health System, for instance, applies an upper age limit to the provision of certain life extending procedures.

The great d e m a n d for mor^ donors does seem a c a s e 'for intense, persuasive public education. Whether we like it or not we are, to some important degree of liability, our brothers' and sisters’ keepers. This does not justify the compulsory acquisition of organs, practised in at least one European country, if an explici: opting out procedure as a donor has not been formally entered into. That is back door authoritarianism.

Which reminds me of one other topic before 1 move on to my final subjec

tonight. There is ongoing difference between some of ihe medical profession anc the gay lobby on a key aspect of the issue of privacy. Should patients be blooc tested so that medical practitioners and nurses will be aware when to take greate: care, in the interests of their welfare, attending to patients with potentially letha

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conditions such as HIV /Aids and strains of Hepatitis. While I u n d e r s t a n d the apprehensions of the gay movement on this issue, I have never been co nv in c ed of the correctness - I might add nor the fairness - of their position. As in di v id u a ls they certainly have rights to privacy. That is unchallengeable. What is e qua lly

incontrovertible is that medicos and nurses have certain rights too. The

incontrovertible right to be reasonably and adequately informed of any pot ential for being confronted with a life-threatening situation. It is u n p e r s u a s i v e to

declare that in attending to all patients doctors and nurses should do so w it h the same level of intense alertness to their own welfare. ·

To apply a quite inadequate metaphor, we always seek to drive our m o to r vehicle with due care and diligence. That is not the same as saying we always drive with an equally, high degree of care and diligence. On quiet subu rban ro ad s , along scarcely used rural by-ways, we are inclined to drive with less i n t e n s i v e

application to the task than say on high speed, heavily used traffic lanes in a big city. That is human nature and it is a practice we carry across a wide range of w h a t we do. The higher the risk, the more we are aware of it and informed about it, the more care we take.

The intensity of pressure, the long hours and heavy workloads whic h se e m

common for many practitioners in the medical services, especially in hospitals, must lead to tiredness, to a diminution of alertness to personal prec aut io ns at times in dealing with patients. Doctors and nurses have a right to know the risks they take in their work and thus to be more alert, for themselves as m u c h as

anything else, when an identifiable high risk occurs. 1 am u n a w a r e of any

evidence that knowledge of an AIDS sufferers' condition has caused ostracism by medical staff in hospitals and hospices.

On the contrary. Dallas and I, sadly, have been associated with the h a r r o w i n g deaths of a few friends from AIDS. What struck us in every case was the deeply committed care, the compassion and the personal involvement of nu rse s and other medical staff to -their patients. We rather thought it was above and be y o n d

the call of normal duty and represented the best that we h u m a n b e ings are

capable of when our fellow humans are gripped by wretched adversity. It was, in a word, inspirational. Now it strikes me that if that is their response in the awful terminal stages of this affliction, the care of members of these professions for patients in the earlier stages of the infection will be no less.

Finally, there is the issue of euthanasia, passive or active. Passive e uth an asia is already sanctioned by law. The Catholic church, furthermore, with its impressive concern for human life, accepts the practice of double effect and proportionate and disproportionate means, within certain strict guidelines.4 Pope Paul VI ha; stated, "The duty of the physician consists more in striving to relieve pain thar

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in p r o l o n g i n g as long as possible with e very available mea ns a life t hat is no

longer fully human and that is naturally c omi ng to its conclusion."5

The N o r t h e r n Territory has recently l egi sl at ed to p e rmi t active i n t e r v e n t i o n

ha st eni ng de at h for the terminally ill, practised within strict guidelines. O p i n i o n polls reveal three out of four res pondent s s u p p o r t active euthanasia. W it h i n the past s everal weeks there has been comment f rom within nearl y every p a r l i a m e n t in A u s t r a l i a that a pri vat e member ' s bill will be i n t r o d u c e d to l egalise the

practice. I w o u l d anticipate that this form of legislation will be Austral ia w i d e

before the turn of the century. It is a d e v el o p m e n t which I w o u l d su pp or t . It is

h u m a n e a n d preserves the right to death wi t h dignity for those wh o choose it or

who, t h r o u g h a living will, have a rr an g e m e nt s in place for the deci si on to be

compe t e nt ly taken on their behalf. · ■ .·. ; .

Palliative care, prolonging life through the difficult terminal stages of a medi cal condi t ion is a compassionate response. So is passive euthanasia. The p r e f e r r e d option for some of us - most people according to those polls - woul d be the choice of active euthanasia. In principle I fail to see any difference between passive a n d

active euthanasia. By consciously deciding n ot to do s ome t hi ng of whi ch I am

capable a n d another p e rs o n ’s death ensues - a death otherwise avoidable at that point - I a m actively collaborating in b r i ngi ng about that person' s de at h. The

distinct ion between that and my actively interveni ng to meet a d yi ng pe rs on' s

wishes to avoid distress and effect a speedy and dignified end to that person's life seems to me rather n a r r o w at most. What I am di scsussing is the ethics of

ha st eni ng death in certain conditions.

The u t i l i ta r i a n j u d g m e n t s of, for instance, the economists a n d m a n y health

workers cannot be totally ignored in this discussion in spite of the sanctity which our society invests in h u m a n life. For instance, US studies disclose that people over sixty-five use medical services at 3.5 times the rate of those younger, t hat the 11 p e r cent of popul at ion over sixty-five us e d nearly 40 per cent of s h or t - s t a \

hospital days, and the 4.4 per cent over seventy-five used 20.7 per cent.

People over eighty c onsumed on average 77 per cent more medical benefits thar those b e t w e e n sixty-five a nd seventy-nine. For US Medicare recipients, whi cr covers the aged a nd some low income groups, those who di ed were only 5.9 pe cent of enrolees but they accounted for 27.9 per cent of p rogr amme expenditures. The un d e ni ab l e fact is that "a unit of medical care c onsumed late in life will hav

m u ch less effect in p r es e rv i n g life and m ai n t a i n i n g n o r ma l s peci es-t ypi ca

function t han a unit of medical care c onsumed at a younger age." Prima facie th case for more spending on preventive care and on direct assaults on specifi diseases would allow more people to live a normal life span and in good health.

Attitudes to death, of course, are a product of social conditioning.

The Inuits left their aged to float away on ice flows, the Trobriand Islanders celebrated the impending departure of their aged with a feast an d entertainment. The aged then went away to quietly die in the bush from the effects of their food which had been poisoned, as they well knew beforehand. The elderly among the

ancient Japanese retreated to a mountaintop for the same purpose. Certain nomadic tribes people abandoned their aged and infirm by the side of the trail.

The Greeks on the island of Ceos, while it was under siege, required people sixty- five years of age and on to commit suicide. The Stoics of Greece and Rome, such as Senecca, proposed suicide as the responsible act of a wise m an instead of attributing excessive importance to mere life itself. .Rather it was better,, they believed, to establish a level of disengagement and w i s d o m allowing one to calmly end one's life at the appropriate time. Now this all seems rather primitive

and brutal by our standards. It made good practical sense for the times and the people concerned.

Thus there are some in our community who, denied the choice of medically administered, painless voluntary euthanasia, would wish to exercise the de ath option themselves. Several years ago a former Governor of the Reserve Bank and his wife both quite healthy, did just that according to newspaper reports of

the time. Having concluded they had lived a full and satisfying life, that there was little ahead of them but to wait for the emptiness of death, they dr an k a

draught of whisky and swallowed some pills, lay do w n and went to sleep for ever. I speak only for myself in saying the following.

1 view the prospect of the closing days of my old age with apprehension. I have visited too many nursing homes, seen too many vegetating old people who were once vigorous, vivacious personalities now depen dant on their middle-aged children much as when infants those children were d e p e n d a n t on them. This loss of personal control, of autonomy, of human personality for me w o u ld

destroy my sense of human dignity. Moreover, having h ad a full and satisfying lifetime there is a point when the succeeding g e n erations deserve to be

disencumbered - to coin a clumsy word - of some unproductive burdens. That is why 1 supp or t voluntary, medically assisted euthanasia and the provision of a living will. In the absence of these I would, like those Trobriand Islanders prefer to leave the community early rather than too late, go out and find my place of lasting rest in forest glades. Perhaps I may want to do that earlier even, at a point after a full life has been lived and before the breakdown of body and mind take

over a once sentient personality.

In summary, I have been talking tonight about certain key principles in a liberal democracy. The right to choose one’s life style, provided it does not h a r m others; the right to be autonomous and free; to be a responsible citizen by exercising choice an d not have the state co-ercively impose a narrow, pre-determined form of morality by which all are supposed to conform. It has also been about accepting

the- consequences which come in the wake of choice, including radical change in values and to accept that if we had not properly thoug ht o ur way throu gh those consequences beforehand, that is our fault. The deter minists, of course, w o u l d challenge this view and there is something in their argument. But for people like me who have spent most of their life autonomously determining their fate alibis

for failure cannot be found in blaming someone or something else. In short, I m u st rule myself by my own judgment and my conscience. The authentic life is led from the inside, by what one genuinely and decently believes, rather than having those things imposed from the outside either by social convention, which

can be badly flawed where true personal freedom and autonomy are concerned, or by government fiat.

Aquinas probably said it best; "If a (person) acts according to his (or her,

conscience and ... conscience is right, well and good: if ... conscience is mistaker b u t throug h no fault of (that person), then his (or her) action is not morally

b a d . "7 And this is, really, where I started. The pace of change, the complexity o. our social relationships, the rapid re-shaping of o u r values, the increasing

autonomy of individuals all mean greater responsibility to make choices. They imply we m ust re-define our relationships so that we can understand an d make our social system function satisfactorily, and I trust fairly. The challenge to do thi: can be confusing, even disturbing. We have been used to social guideposts whici hitherto se em ed perm anent markers, but which h ave been u p r o o t e d anc

replaced in this modern age. We are at the existentialist point of making

ourselves by our choices, of being responsible for ourselves. The more who fail tc do this the smaller the group who will make the decisions for them. A n d tha w o u ld be a most unfortunate consequence: for it w o u ld be neither liberal no democratic.

(© Hayden - Canberra - 1995)

Infertility Medical Procedures Act 19S4 Charlesworth M, Bioethics in A Liberal Society, pp 126-130, CUP National Health Strategy Paper No 5, Richardson J, The Effects of Consumer Co­ payments in Medical Care, in particular Ch 4 pp 40-55.

Declaration on Euthanasia, Congregation for the Doctrine of the Faith, Rome, 19S0. Quoted in Charlesworth M, Life, Death. Ccr.cs and Ethics, pc<0, ABC 19S9 Boyer Lectures, pub I9S9 NSW.

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6 Baltin MB The Least Worst Death - Essays in Bio-ethics on the End of Life, pp59-60, 63, OUP NY 1994 .

7 Nicomachenn Ethics, Book III Ch. I.