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THE parliament of Victoria passed a Bill on 3 December 2017 to allow voluntary assisted dying. It brought that state alongside jurisdictions in several nations or individual states of Europe and North America where similar legislation has been enacted. Twenty previous attempts in Australian state parliaments to legalise “euthanasia” (as it is commonly termed) had failed. Only in the Northern Territory had such a law passed, in 1995, and been overturned in the following year by the federal parliament.
In Victoria, the Bill came to the parliament with a number of salient advantages. It was introduced not by a private member (as had usually been the case in earlier attempts), but by the incumbent Labor government, with the full support of the Premier and Cabinet. Over the previous 2 years, the issue of assisted dying had been under close consideration — first, by a committee of the Legislative Council, which had undertaken wide consultation and detailed review of many related issues. The Committee’s Report in 2016 made numerous recommendations, including that palliative care services be strengthened and that the law be changed to allow assisted dying.
The Minister for Health and Community Services sought, from an expert advisory panel of seven members, further advice about how that recommendation might be achieved. The panel met regularly through the first half of 2017, and its report in June 2017 presented 66 recommendations and 68 safeguard provisions, which established a framework for the drafting of the Bill. The Minister presented the Bill to parliament in September 2017 as a comprehensive and complete package, embodying a conservative approach — its stringent, detailed requirements making it resistant to amendment. It was agreed that all members be granted leave to speak to the Bill, and an individual conscience vote was allowed by all parties.
Assiduous preparation did not protect the Bill from intense controversy and objection in the media and in parliament. Debate in the Legislative Assembly stretched through 26 continuous hours and considered over 100 proposed amendments, all of which were rejected when the Bill finally passed by 47 to 37 votes. It went to the Legislative Council, where debate again required night-long sittings. Several relatively minor amendments were agreed, touching on matters of timing and referral, and on the safe-keeping of the lethal dose of medication to be employed. The amended Bill returned to the lower house and was passed without further change.
The Bill disappointed many established advocates of euthanasia in its clear exclusions, its stringent and restrictive eligibility criteria, and its necessary diligent processes of referral, reporting and oversight. Relatively few dying persons will be eligible to access voluntary assisted dying. Continuing protest must be expected also from the many individuals and special interest groups that have been consistently adamant in opposition.
The legislation now enters an implementation phase and will not be proclaimed until details are finalised on how voluntary assisted dying will operate in practice. Delay into 2019 will allow interested parties to consider how the availability of voluntary assisted dying will affect individual decision making, professional practice and institutional policy.
In opposition to the Bill palliative care services carried considerable weight, with warning to of the legislation’s deleterious effects on palliative care. Spokespersons voiced the claim that assisted dying would be seen as a cheap and quick alternative to the expense of providing palliative care among a number of other objections along these lines:
- palliative care’s charter is to ensure comprehensive comfort to dying persons, with no interventions to either extend or shorten life;
- the provision of appropriate comprehensive care for a dying patient is a special skill. Only palliative care services are equipped to do it effectively and the assisted dying alternative threatens erosion of that expertise;
- gaps in palliative care services will force persons unable to access their care to rely on assisted dying;
- the public is better served by an urgent strengthening of palliative care than by investing in assisted dying;
- the introduction of assisted dying is an affront to palliative care, implying unjustly that its services cannot adequately meet the needs of dying patients;
- assisted dying runs counter to the values consistently affirmed by palliative care to sustain quality of life and never to kill; and
- assisted dying will lead inevitably to a “slippery slope”, and vulnerable persons – individuals who are poor and disadvantaged or have disabilities – unable to access expensive health care, will be encouraged to request assisted dying by families and by doctors prepared to bend the rules.
Many staff in Victoria’s palliative care services have been drawn to this specialty’s special characteristics: its offer of holistic care that attends to spiritual as well as physical and emotional concerns, and its patient-centred approach that seeks to avoid medical hubris and inappropriate therapeutic activism. Also, important to many is its close historical association with Christian charitable and moral intent. Palliative care favours asking a dying patient “what matters most to you?”, and frames a responsive plan of management that can include measures far removed from conventional hospital investigations and drug prescriptions, though they will not be ignored. The presence of a compassionate caring person and attention to simple nursing measures for comfort can be as effective as prescribed drugs. Nurses, in particular, are drawn to this type of care – “This is why I did nursing”.
The arguments against assisted dying from palliative care workers usually avoid mention of underlying ideological and religious considerations, important to the sector. The Roman Catholic Church, in particular, has accepted a major role in opposing assisted dying. It has a proud tradition of pioneering care for dying persons. Orders founded by remarkable 19th century women – Mary Aikenhead’s Sisters of Charity in Ireland and Mary Potter’s Little Company of Mary in Britain – brought to Australia their concern that the souls of dying persons should have the best preparation for purgatory, and recognised the importance of physical care in the nurture of the soul. In this tradition, suicide is a mortal sin; killing is worse, and assisted dying is killing. Throughout Australia, Catholic hospitals, hospices and aged care facilities provide the majority of inpatient beds available for palliative care, and also promote associated community home care programs. Church spokespersons state that assisted dying cannot occur within Catholic facilities and that their staff will not provide it, which raises significant difficulties for both assisted dying and palliative care. Other care options such as a public hospital or home care placement will need to be sought if a person receiving care in a Catholic facility requests assisted dying.
Palliative care professionals recognise a common defensive stance in the care offered by specialist colleagues in other disciplines to persons with a terminal illness. Too often there is continuation of futile therapies and delay in referral to palliative care services. A common message heard is: “He’s not ready for you yet”.
Palliative care has its own defensiveness, however, based on its claim of being special, both in its skills and in the caring relationships maintained with its client families. It brings not only effective symptom relief, but also a care founded in compassion and commonly directed with Christian conviction. This encourages a view that “only we can do it”, that the care it offers is essentially “good” and accords with the commandments of God.
In countries where assisted dying has been introduced, palliative care has continued to flourish and grow. It is reasonable to expect a similar improvement in Victoria, as assisted dying becomes available. The Victorian Government has made a clear commitment to strengthen palliative care services. The Bill just passed requires that palliative care is acknowledged and recommended to all persons requesting assisted dying.
Neither professional bodies nor religious foundations can claim absolute exemption from charges of coercion or abuse, yet they point to the threat of these with assisted dying. The continuing involvement of palliative care in all settings is one of the strongest safeguards for a dying person against any such risk.
Personal religious conviction helps govern and guide individual choice, and conscientious objection to personal participation in assisted dying is acknowledged and respected by the Victorian legislation. Its weight, in matters of policy and law in a secular and multi-ethnic community such as the state of Victoria, is more open to question. Individual conviction should not impose its religious values and views on others. Those who hold such convictions should be prepared to declare them openly. A Catholic institution clearly is entitled to exclude assisted dying from its facilities. How it will manage a request for assisted dying remains unclear, but health authorities and the public need to be confident that palliative care will continue to play its major role in care for all terminally-ill persons, including those who have opted to request assisted dying. That reassurance needs to be heard from those palliative care staff who oppose assisted dying.
What lies ahead for assisted dying and palliative care? The acknowledged dedication to best practice among palliative care staff feeds confidence that palliative care and voluntary assisted dying will find separate and complementary but not competitive roles, respecting each other in a common focus on the care of persons who experience major discomfort in progressive, advanced terminal illness.
Emeritus Professor Ian Maddocks was appointed to the pioneer Chair of Palliative Care at Flinders University of South Australia in 1988, and subsequently elected foundation president of both the Australian Association for Hospice and Palliative Care (now Palliative Care Australia), and the Australian and New Zealand Society of Palliative Medicine. Study of theology during medical undergraduate years fostered interest in ethical and religious issues, and 14 years in Papua New Guinea encouraged understanding of ethnic diversity. Since retirement in 2015, he has continued to comment on health care, community medicine and medical ethics. In 2017, he was a member of the Ministerial Advisory Panel established by Victoria’s Minister for Health and Human Services to help prepare legislation for voluntary assisted dying.
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Let us hope that the Victorian Legislation for VAD, restrictive as it is, gets up and is fully implemented. I agree with most of Keith Anderson’s comments above. However for myself I feel Australia has been too weak in standing up to conservative forces such as Churches, some Medical Organisations and strangely I hadn’t realised Pallative Care as well. We patients deserve the human right and dignity to be able to choose the manner of our death, not be brow beaten into suffering and by suffering I don’t just mean ‘pain’. For me as an elderly dignified lady, the loss of modesty, of choking, of undignified circumstances, or perhaps sharing wards with men or seeing others in worse circumstances, or being seen by others – all of that is never taken into account by the medical establishment but is simply tormenting to me! I saw a friend die in hospital by being put into a coma using morphine and allowed to starve and dehydrate to death. It is dreadful and not a good way to die. I would rather jump off a bridge!
Dr Maddocks, who was on the Victorian Inquiry which recommended “voluntary assisted dying”, lacks perspective on this issue. He attempts to merge Palliative Care and “VAD”, which we should call physician assisted suicide, because that is what it is. Fudging words is one of the techniques advocates for assisted suicide and euthanasia use to hide the real impact of their policy.
The RACP draft policy states: “Medical assistance in dying must not be seen as part of palliative care – these are distinctpractices.
Legitimate concerns exist around protection of vulnerable individuals or groups. Government,society and physicians must ensure that specific groups have equitable access to palliative and end of life care. All physicians must also affirm the value of all patients’ lives, exploring reasons for requests for medical assistance in dying, whilst remaining alert to any signs of coercion and reduced capacity.”
The consequences of physician assisted suicide will inevitably be elder abuse, pressure from families suffering carer fatigue, creeping criteria, and ultimately gradual reduced funding for Palliative Care, and chemotherapeutic/ radiotherapy in certain circumstances, because assisted suicide is “ cheaper”.
This retrograde policy is contrary to all the tenets of medicine I learnt and have practiced, is contrary to World Medical Association policy, and should be opposed by all medical organisations who want to be considered ethical.
I’m just a Joe the Goose concerned citizen, but that also means I’m a prospective customer of the medical system. The comments from Health…sayno, items 12 and 14, remind me of the puzzles about islands populated by truthers and liars. Accusing Prof Maddocks of being a liar does not make him a liar. Applying a simple sanity check to the claims of Health…no, I find:
“right to self determination … not relieve” Wrong. Of course it will. One of the big problems your prospective customers face as we age, is loss of self determination. Often, it is not our illness that makes PAD attractive, but escape from health experts wanting to treat us like medical conditions. Simply asking “what do you want?” can deliver a much greater sense of dignity than any bucket of morphine or magic elixir. Conversely, “Relax while I shove this tube here”, makes dignity elusive.
“not medical treatment… extension of Palliative care” This might be the way some medical experts see the world, but it is not the way their customers see it. I’ve seen quite a few friends and relatives die, and I’ve followed the debate thoroughly, including reading the submissions from both sides to at least two inquiries: Tasmania and Victoria. For many customers, end of life palliative care is best when it is indistinguishable from PAD, and a pain in the rectum (sometimes literally) when it isn’t. It is important to remember that the V in VAD means “voluntary” and medical people who want not to provide this service are allowed by all legislation to refrain from providing it.
“inaccurate summary” If Dr Maddock’s summary seems inaccurate to members of Hel…no, then it is probably the members of that organization who need to read more and pontificate less.
“dignity of its vulnerable” This verges on hypocrisy. Concerned citizens like me want PAD to be available as we age precisely so we can be protected from groups like Hel..no when we become vulnerable. As I face death, probably the most harm I am likely to suffer, I want the law to protect me from the harmful details from which I want to be protected, not from the details from which I don’t want to be protected.
“no choice to the majority” You’ve got to be kidding. The Victorian legislation is all about more choice, not less. It is about preventing interfering busybodies like Hel…no from interfering. The reference to “prioritised” seems to be a red herring fished from a murky imagination. The Victorian legislation places the patient, the customer, at the top of the pecking order. Probably, members of Hel…no are complaining because they cease to enjoy top priority.
I’m only a Joe the Goose concerned citizen, and I’ve already had more then my fair share of comment, so I’ll skip to the end.
“damage has been done” No. It hasn’t. A problem has been fixed. Prof Maddocks has not indulged in rhetoric, but has explained the situation carefully, thoughtfully and accurately. He has righted quite a lot of wrongs, and I know who I’ll ask to discover how to get off this island and out of this puzzle.
Dr Mewett would like us to not speak truths and instead call physician assisted suicide the valid option, as well as accept all that he and Prof Maddocks say on face value. He dismisses our comments to what is needed for more appropriate care provision as rhetoric, and expects “compliance”. He severely misses the point.
It is not time to “move on”, but time to continue to lobby to governments to provide and consolidate what is actually needed, and what is best practice to assist the alleviation of suffering in our society, rather than pretend “VAD” is the answer as a “choice” instead. Justice and legality, in this instance, do not equate. Therefore is definitely not time to move on as we continue to try and advocate for what is really needed to care for those who come to us for assistance. We know that requests for assisted suicide are often a cry for help by those who’s burdens are not addressed with appropriate care.
No amount of rational argument or well-considered opinion will change the minds of the previous 2 contributors.
They are entitled to their views but remember that both houses of the Victorian Parliament held a conscience vote after exhaustive debate and passage of some amendments to the Bill. Support was bipartisan.
Accusations of “vote buying” and “horse trading” are meaningless unless backed up by evidence.
So to Healthprofessionalssayno.info I say that your rhetoric cannot change the fact that the legislation has been passed, that it has had the support of the clear majority of the public (over multiple polls), that it will become law on June 19th 2019, and, like it or not, we will all need to live with it as a legally-available, valid option for the minority of terminally-ill people who will access VAD.
Instead of continuing to argue and bicker about the pros and cons of such legislation, it is now time, for those of us who are interested (medical and non-medical), to turn our minds to ensuring that the implementation of VAD is successful, respectful of all views (including the legislated liberal conscientious objection provisions), accessible for those that want it and is absolutely compliant with the letter of the legislation.
Time to move on, I reckon!
A right to self determination used as the premise for PAS ( and masked by ill-conceived and purely arbitrary conditions ) will not relieve societal suffering nor restore a sense of dignity to those suffering or burdened by loneliness, aged conditions, ill-health, disabilities and mental illness. Assisting suicide is not a medical treatment, nor an extension of Palliative Care, and Dr Maddocks’ rationalisations and inaccurate summary will not change these facts. The power of the therapeutic relationship cannot be overestimated in the outcomes produced, and should be instead used to encourage all appropriate measures to assist restoration of a sense of dignity, individual worth and quality, through access to and provision of appropriate and best practice measures in aged care, palliative care, suicide prevention and social services. The duty of governments is to protect the dignity of its vulnerable and act for the common good of all its citizens through provision of these measures and services, and supporting those who try to provide them. The Victorian result provides no choice to the majority, as appropriate processes were not prioritised. The Andrews’ government instead chose to throw the baby out with the bathwater; it has ignored best practice service provision and maligned major healthcare service providers who provide such care, to undermine and silence the alternative positions and voices. The outcomes in Victoria represents political games and has resulted in a lack of appropriate measures for its citizens, hiding as it did so, behind the coat tails of so-called “experts”, to legitimise what is not with constantly changing and arbitrary boundaries. The damage has been done, and Prof Maddocks’ rhetoric cannot change all these facts, nor right any wrongs.
Do you know that in Oregon,a “terminal illness” can be ANY chronic disease that without usual treatment ,eg insulin dependent diabetes,will likely cause the patient’s death within 6 months? People can just stop taking any of their life preserving meds.
I’m not sure that was how it was sold to our legislators and the public in Victoria.Professor Maddocks?
As well,authorities destroy all records within 2 years of death ,so who’s going to know what’s going on there?
And doctors must be hopeless with their prognoses there because a large percentage of people killing themselves under their legislation are doing it much later than 6 months and sometimes years after the original request.
In fact ,up to nearly 3 years.
I suppose Victorian euthanasia doctors will be much more accurate and conservative with their prognoses.Everyone can accurately predict the prognosis of a COPD ,CVS,cancers of the myriad of types.Can’t they?
The Victorian euthanasia bill is a gift to the Phillip Nitschkes(?) of the world and a tragic injury to the Palliative Care community.
Professor Maddocks has made an awful mistake.
Dr Mewett- I am not surprised about the comments by anonymous about palliative care. Most of the medical doctors, surgeons,GPs in Australia think like that (at least in my regional city). I am not at all surprised …
This is the same for many things including VAD…they have not got a clue…and don’t want to listen as well if it is not in line with their narrow view.
I’m sorry Anonymous, but your understanding of modern palliative care is sadly deficient if you think that is what we do! There is so much more to palliative management of a suffering patient than the administration of opioids such as morphine.
I’m sorry that you have had the experience you describe with respect to nursing home care, but the “old school” technique that you describe is so illogical (pharmacologically), inhumane (IM injections!) and is ,in any case, not euthanasia by any definition.
The new VAD legislation gives consenting, competent people the reasonable option, in my opinion, of medical assistance in dying but it by no means alters what is good, modern palliative care, which will be the option most people will choose near the end of life.
Palliaive care is wrong in giving large doses of subcutaneous morphing. This inevitably causes severe irritation an prolongs life long enough for a patient to need to spend their final days in a nursing home with just a once a week visiting doctor who may not understand palliative care. The patient is then left to starve to death! Before the days of palliative care our parptients were given 6 hourly intramuscular morpine in a legal dose of 10-15mg IMI with anti emetic and usually died within 48 hrs in peace and with relatives present.
Allowing politicians and lawyers to determine end of life decision making is a mistake that we in the medical profession will live to regret. It is a small step to make it illegal or unprofessional for doctors to exempt themselves from the process. Deliberate killing negates our whole charter and codes of ethics. Fundamental trusts will be lost, and our profession will be the loser.
My life is MY life. It is not saleable, rentable, has no economic value to anyone but me. It is a form of slavery to deny me the right to decide for myself when I wish to end it.
As a palliative care physician who has recently, with two eminent colleagues, written publicly in support VAD, I say to Dr Scott and Dr Stephen Parnis:
– the legislation has been passed so sour grapes will not be of benefit to anyone.
– the implementation process (just begun) will be exhaustive and grapple with a range of practical issues.
– it is ridiculous for Dr Parnis to criticise the lack of Victorian doctors on the Ministerial Advisory Panel. Palliative care input by experienced palliative care physicians surely is non-parochial!
– the “small minority” in our palliative care profession that agree with this legislative change is around 15% but that figure is 3-4 years old. At any rate, palliative care opposition in itself does not mean the legislation is wrong ,as judged by the majority of our population.
People with various opinions will, quite rightly, continue to speak out about this significant change in our society’s law and we should all indeed be vigilant as the legislation comes into effect on June 19 2019. However, we cannot deny that it will be law. People, particularly doctors, can conscientiously object to involvement with it but we should respect those who do wish to pursue VAD as an end of life option and respect the right of some doctors to be involved in what will be a legally available.e medical procedure.
Both my husband and I want the right to choose how our lives end and are in favour of assisted dying. We have discussed the issues at length with our children, both over 25, and have clearly articulated at what point we want to “pull the plug”. Why should anyone else have a say in the matter?
Absolutely no one should be coerced under any circumstance into taking the irreversible step of an assisted death; but similarly no one should be forced against their will to exist in a world of unbearable suffering when they desire nothing more from life than their own assisted death, under strict parameters and rules.
Around the world there are a number of successful and well regulated programmes offering this option. Is Australia so arrogant to assert that they are wrong, don’t care about some of their most vulnerable citizens or that we can not make an informed decision about our own right to an assisted death should we really need one? I believe that Australia can, that Australia should and that Australia will introduce nationwide assisted dying under a strict but fair, properly regulated and controlled system to help those who should not be forced to desperate and often unsuccessful attempts to die.
Professor Maddocks is incorrect in saying that there was full support within the Victorian Cabinet for the Voluntary Assisted Dying Legislation. The Deputy Premier led a small but significant minority of government MPs who were vocal in their concerns that society’s vulnerable will be put at significant risk of coercion – the notion of a “laudable exit” for those who have become a burden upon their loved ones (if they are not alone) or society in general. The author fails to mention that the bill would have failed to pass the Upper House had two MPs voted the other way. The political horse trading, promises and threats made to ensure passage of this bill underline a ruthlessness to establish these laws, irrespective of the price to be paid in achieving such a goal.
The expert panel which advised on the legislation did not contain a single Victorian doctor, and I suggest was handpicked on the premise of strong support for the principle of the legal availability of lethal medication. Euphemisms such as “the most conservative legislation in the world” sought to distract from the inherently radical nature of this legislation, which crosses a legal and ethical rubicon in Australia.
It seemed clear during the Victorian debate, that any prominent voice to oppose the Voluntary Assisted Dying Bill was shouted down as some sort of religious zealot, devoid of independent thought or legitimate concerns. Opposition to the practice of assisted suicide and euthanasia is opposed by people from a vast range of perspectives, be they Atheist, Christian, representatives of the Disability Community, or others. I say that the practice and provision of any medical care in the absence of an ethical framework is dangerous and profoundly misguided. With regard to the Palliative Care Sector, there is no doubt that the vast majority of those who work with the dying on a daily basis are opposed to these measures, placing Professor Maddocks in a small minority within his own specialty.
Few would dispute the fact that the delivery of palliative care in the State of Victoria is patchy. Much is based on inadequate resourcing, but consideration must also be given to inadequate education and expertise across the medical and other health professions, as well as poor community awareness, in a society that has grown comfortable feeling quarantined from mortality. It remains to be seen whether the changes required to address these shortfalls are addressed as the priority they should be.
There are many unanswered questions about fundamental details relating to the operations of these laws, and it is essential that the process of enactment be subject to transparency and scrutiny. I remain unconvinced of the adequacy of the safeguards.
I also suggest vigilance in other parts of Australia, where proponents of these laws will seek to apply a Victorian formula in their quest for nationwide legalisation assisted suicide and euthanasia.
The author uses a straw man argument to dismiss the real concerns of palliative care physicians. They are not all religious and their opposition, as well as the opposition from the AMA and atheist doctors like myself is not due to religious reasons that we have “avoided mention” of. This bill can help a very small number of people who could not be helped by palliative care. It conceivably could be useful for people with motor neuron disease or similar who would prefer to end their life instead of waiting for pneumonia etc. It does not help anyone with dementia as they cannot consent. It does not help anyone with pain/nausea/distress as these are already controllable with palliative care including use of terminal sedation. I’m sure you would say not all pain can be controlled with palliative care etc. etc, but that is simply not true. If someone is distressed with pain, giving them 10000mg of IV morphine will ease their pain, and have the secondary function of causing their death. This is perfectly legal and practiced often under existing laws. So is the use of terminal sedation for psychological distress. The patient feels nothing during good terminal sedation – it is only the family that suffers while waiting for them to die. If you want to ease the suffering of the family then call it for what it is, don’t pretend that it’s for the patient. This bill does not help those with intractable psychiatric illness as again that is excluded. So very few people can actually benefit. The harms of this include serious cases of misuse, such as those listed by Michael Gannon in his article on this site. The so called slippery slope has been proven true in the Netherlands and elsewhere with children, non-terminal and psychiatric cases being included and decreasing rates of involvement from palliative care and specialists. There is a real (but unmeasurable) effect on the general population that pressures the (often vulnerable) patients towards assisted dying by having that as a legal option. I believe these harms and risks outweigh the very few people who would genuinely benefit from this bill. By all means dismiss the churches and their wishes to control society but don’t paint all palliative care physicians and other opponents as being driven by “unmentioned religious ideology”. If you have to resort to that type of straw man argument then your argument is just as weak as the churches’ nonsense.