Kindness without risk? Voluntary Assisted Dying.

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There is again a move in Australian jurisdictions to implement legislation creating a patients’ right to access a humane medical process to end their life at a time of their choosing.

The Victorian legislation will allow some of those with short life expectancy and a terminal illness to obtain a lethal drug mixture that they can use at their discretion. The WA government has signalled that it will introduce a bill in 2019 and has appointed an expert advisory committee to assist in drafting. Politically, passage will depend on the balance of the vote in the Legislative Council.

The kindest thing we can do is try to make sure patients, doctors and the community base their decisions about such laws on considered discussion of all the facts, rather than anecdotes. Stories are important, but seeing each other’s perspective as a whole and understanding detailed consequence is essential for forming safe legislation.

We all understand that no-one wants suffering for themselves or others more than absolutely necessary in life and in dying. Any story that conveys the difficulty of a loved one’s or patient’s death is important and should be heard, and is a reason to try to move forward. But these stories do not often help us consider the complexities of access to healthcare for the vulnerable which underscore the reluctance on the part of many doctors to sanction Voluntary Assisted Dying (VAD).

These laws will not just apply to those who have had excellent primary and palliative care, including well resourced nursing during a terminal illness. VAD must not become a substitute for resourcing anyone and everyone in society to get the opportunities that are available in cities to relatively wealthy people who can advocate for themselves.

An example of the physician anxiety as regards the elderly is that many nursing home residents, more than 30% in some studies, receive no visitors. The rate of abuse of the elderly by carers is unfortunately estimated to be more than 8% in Australia. A Royal Commission is underway with some terrible examples of lack of basic care coming to light. In this context, the concept of VAD for the elderly terminally ill patient is fraught with ethical and practical difficulty.

The AMA has been through an extensive consultation process and I was involved as a member of the Federal Council’s Ethics and Medicolegal Committee in revisiting the policy in this area in 2016. There was a survey of members, which showed a spread of opinion in the profession not dissimilar to that in the community.

The AMA policy is grounded in the belief that:

doctors should not be involved in interventions that have as their primary intention the ending of a person’s life. This does not include the discontinuation of treatments that are of no medical benefit to a dying patient.

The doctrine of double effect supported by the AMA and by the law currently in Australia means that doctors can already lawfully treat a patient to make them comfortable in a way that might hasten death, where death is not the primary intention of the treatment. For example a high dose of morphine to treat pain is not unlawful even if death is brought forward as a secondary effect of the pain relief. Administering a paralysing drug or massive overdose of morphine though would not be aimed to reduce suffering and thus is clearly unlawful in the current context.

There is detailed discussion in the policy with guidance on

  • Good quality end of life care and the relief of pain and suffering
  • Patient requests for euthanasia and physician assisted suicide
  • AMA position on euthanasia and physician assisted suicide

AMAWA should act to ensure the discussion around the proposed WA Bill highlights need for good preventive, primary and palliative care options for all, with much work to be done especially for disadvantaged community groups. This must happen whatever the outcome for Voluntary Assisted Dying.

The AMA Policy further states that

if governments decide that laws should be changed to allow for the practice of euthanasia and/or physician assisted suicide, the medical profession must be involved in the development of relevant legislation, regulations and guidelines which protect:

  • all doctors acting within the law;
  • vulnerable patients – such as those who may be coerced or be susceptible to undue influence, or those who may consider themselves to be a burden to their families, carers or society;
  • patients and doctors who do not want to participate; and
  • the functioning of the health system as a whole.

Doctors respect that society has the final say on laws, but we should fight to ensure that they are based on facts and not assumptions, and that doctors who work with dying patients every day are the ones whose voice is heard loudest. The front line clinicians deserve our respect and support, as they are the ones closest to those that need our kindness the most – patients and their complicated families.

Photo by Gus Moretta on Unsplash

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