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DOCTORS participating in the Victoria voluntary assisted dying system have highlighted concerns about safeguards which may be preventing access for otherwise eligible patients, prompting experts to call for a review.
Voluntary assisted dying became lawful in Victoria in June 2019 when the Voluntary Assisted Dying Act 2017 (Vic) (the Act) commenced operation. To 31 December 2020, there had been 224 deaths under the Act. Other Australian states have already or are likely to legalise voluntary assisted dying in the near future.
Professors Lindy Willmott and Ben White, from the Australian Centre for Health Law Research at the Queensland University of Technology, and colleagues conducted semi-structured interviews with 32 doctors who had participated in the voluntary assisted dying system during its first year of operation.
Three major themes related to problems during the first year of operation of the Act were identified by the research, which is published by the MJA:
- The prohibition of health professionals initiating discussions with their patients about voluntary assisted dying – the policy aim of this prohibition was to guard against undue influence by health professionals.
“Some doctors expressed concerns this could prevent a patient making an informed choice about treatment options, particularly patients from non-English speaking backgrounds or people with poor health literacy,” wrote Willmott and colleagues.
Some participants felt this prohibition was an appropriate safeguard against unduly influencing patients.
“Doctors described patients as [therefore] inevitably self-selecting. For some, this made the conversation easier.”
- The Department of Health and Human Services guidance that all doctor‒patient, doctor‒pharmacist, and pharmacist‒patient interactions be face-to-face – this guidance reflects concerns that doctors and pharmacists might breach federal law should they use a “carriage service” (eg, telephone, email, or telehealth facilities) to discuss “suicide”, even if acting lawfully under the Act.
“Many participants criticised the burden this requirement placed on doctors, pharmacists and patients, particularly patients in rural and remote areas, a burden exacerbated during the COVID-19 epidemic,” wrote Willmott and colleagues.
“Doctors spoke of the immense burden for very sick patients required to travel, sometimes for hours and several times, for eligibility assessments. Some also noted the burden on already busy doctors who travelled long distances to undertake assessments. Others saw merit in stipulating at least one face-to-face consultation.”
- Aspects of implementation, including problems with the voluntary assisted dying online portal, obtaining documentary evidence to establish eligibility, and inadequate resourcing of the Statewide Pharmacy Service.
“They felt that the portal was badly designed, counterintuitive in its layout, and difficult to navigate. Concerns were also expressed about technical problems with uploading documents, with implications for busy clinicians,” reported Willmott and colleagues.
“Doctors described difficulties in generating required documentation for assessing eligibility, particularly proof that a person was an Australian citizen or permanent resident and had been ordinarily resident in Victoria for the 12 months before making a first request for voluntary assisted dying.
“Some felt this effectively locked out patients who had lived in Victoria throughout their adult lives but could not provide documentary proof of these requirements.
“Third, after a permit for voluntary assisted dying has been issued by the Department of Health and Human Services secretary, the Statewide Pharmacy Service liaises with the doctor when the required prescription is written and meets with the doctor or patient (according to what is appropriate) when the medication is delivered,” they wrote.
“While participants praised the quality of their interactions with the Statewide Pharmacy Service, they generally believed that it was inadequately resourced and that this caused considerable delays.”
Willmott and colleagues concluded that although safeguards ensured that systems for providing voluntary assisted dying were safe for patients and communities, “the system must also be efficient and help doctors navigate the process”.
“It is therefore important to consider the perceived shortcomings reported by participating doctors. While some problems might be resolved by amending the legislative framework, others might be more readily remedied by practical support for doctors, including clear guidance about using the voluntary assisted dying portal, particularly during their initial use of the system, and adjustments in system design.”
Also online first at the MJA
Research: Self‐collection cervical screening in the renewed National Cervical Screening Program: a qualitative study
Creagh et al; doi: 10.5694/mja2.51137 … FREE ACCESS permanently.
Podcast: Associate Professor Julia Brotherton, Medical Director of the VCS Foundation, and Miss Claire Zammit, Research Assistant at the Centre for Health Policy at the University of Melbourne, and Research Officer at the VCS Foundation … FREE ACCESS permanently.
Research letter: Opioid medication prescribing in Queensland, 1997‒2018: a population study
Adewumi et al; doi: 10.5694/mja2.51115 … FREE ACCESS permanently.
A belated apology to Randall for accidentally posting my critical comments of his post as “Anonymous”. My mistake.
However this “Hippocratic” view of so-called “medical ethics” (in reality, a “Code of Conduct”) is now considered largely outdated by most clinical ethicists, due to the inevitable evolution (like it or not, Randall) of social values and priorities, with the attendant increased focus on autonomy and patient-centered care.
There was no discussion with patients when Hippocrates et al wrote their historic Oath.
There is now wide acceptance in our community for such things as contraception choice, abortion, assisted reproduction and now assisted dying. That doesn’t mean all doctors will agree or feel the need to participate in these practices but they should not portray doctors who do so as being “unethical”, given the very broad approval of such things by our society at large.
A great example of the shift in “medical ethics” over time is that FIGO (International Federation of Gynaecology & Obstetrics) opposed abortion for many decades until, in 1998, it adopted the position that all women must have access to safely performed abortion and that “…neither society, nor members of the health care team responsible for counselling women, have the right to impose their religious or cultural convictions regarding abortion on those whose attitudes are different”.
And so, in my opinion, this will inevitably occur with voluntary assisted dying as it becomes accepted and legal practice throughout Australia and NZ.
If ‘Anonymous’ is going to sneer at my sincerely held views on and concerns about VAD then he should be prepared to put his name to his comments . My “version” of medical ethics is that which has been tightly held in Western Medicine for hundreds of years, and which we adulterate or dilute at our peril. I submit that voluntary assisted dying may progress to suggested or encouraged suicide in some situations, and there is evidence that this has happened overseas. Legal safeguards put in place are already being questioned by some protagonists. The “train may have left the station” but I will not be on it. I fear that those doctors who promote and take part in VAD risk damaging fundamental trust in our profession., particularly amongst the elderly, chronically ill or disabled .
The “safeguards” were put in place presumably to minimise the risk of making fatal mistakes in this very vulnerable group of patients.Only 2 years later ,after hundreds more euthanasia cases than the Victorian Government had predicted, there is an argument that the “safeguards” are now “impediments” so that the coterie of euthanasiasts will therefore increase the risk of making fatal “mistakes”.So sad but so predictable.The profession is significantly diminished because of its members’ involvement in this death crusade.
Oh dear Randall!
Opponents of VOLUNTARY assisted dying (emphasis intended) once again trotting out terms like “suicide” , “killing”, “euphemisms” ( the term euthanasia is a euphemism!), “medical ethics”, “indication creep” are all just somewhat irrelevant in the current climate of VAD legislation occurring throughput Australia and NZ.
The VAD train has well & truly left the station and you might not want to be on it, nor like where it is going, but the people are speaking through their elected representatives and are collectively driving the train.
Your version of medical ethics is not every doctor’s, and they will be involved or not depending on their views, but no amount of carping will change the legislation.
Find another cause to get heated up about, like climate change or domestic violence. That’s 2 areas where human ethics and morality need robust expression!
In reply to “Anonymous’ it is certainly not my experience that 80% of doctors support VAD, I base this on countless interactions and discussions with colleagues. We all know results of surveys depend very much on how the question is framed. In my view there is a medical duty of care to relieve pain and suffering, there is no duty of care to assist the patient to kill themselves. VAD is a euphemism for euthanasia or assisted suicide, no matter how affronting ‘Anonymous’ may find this. VAD, like capital punishment is irreversible if mistakes occur or circumstances change. Estimates of life expectancy are notoriously unreliable, and diagnostic mistakes can occur. Malfeasance may play a part in some circumstances. In terms of “indication creep’ there have been numerous examples of this overseas where medical euthanasia has been practiced for many years, and it is naive to think it will not happen here.
Support in the adult community for VOLUNTARY assisted dying has been reliably assessed at 80% or more over a long period. Does it truly matter what the precise level of support is among medical practitioners? Those number willing to take part in the process is more cogent – if the numbers are not sufficient to make the provision of VAD workable, the community will eventually act to reduce the required level of medical practitioner involvement…
There is a duty of care responsibility for doctors to provide this service to their patients, but it is voluntary on both sides of the relationship – if the person doesn’t want it for whatever reason, they will not ask for it and if the doctor doesn’t want to be involved they will not be, apart from informing their patient that that is the case – they are not even obliged to identify another practitioner who is willing to progress their patient’s wishes.
Calling the process “assisted suicide” is an affront.
By its nature, this is controlling the manner and setting of the person’s approaching, inevitable death, preserving their dignity and the integrity of their bodies and allowing their loved ones and friends to adjust to and respect their choice, whist allowing them to forego the possibility of prolonged decline and lingering suffering.
The alternative of true suicide requires stealth and deception, is not reliable and generally is traumatic to the person and distressing to those who love, care for and know them.
As for “indication creep”, it is inevitable that there will be problems discovered as any new process operates, and those involved in the mechanics of VAD will have the best insight into those, and a duty to raise them with the regulatory authority, as well as making informed suggestions about rectifying them.
The large pool of spectators and multiple participants in the process, as well as rigorous regulatory and parliamentary scrutiny, will make any changes conform tightly to the wishes of the whole community.
I am more concerned about “indication creep”, the gradual liberalisation of VAD ( essentially assisted suicide) as it becomes normalised in our communities.. There have been numerous examples of carefully considered and regulated processes progressing gradually and surreptitiously almost to “on demand”. This article illustrates that some doctors involved in VAD already want to change safeguards in the legislation. If you survey doctors supportive of VAD naturally they are going to give these sorts of views. I would be interested to know what percentage of Australia’s medical practitioners (a) support VAD and (b) are prepared to take part in the process. Personally I prefer our long held and cherished medical ethics and good palliative care . “Thou shalt not kill, but needst not strive, officiously, to keep alive. “