Cultural safety crucial in Northern Territory voluntary assisted dying

The Northern Territory was once Australia’s leader in voluntary assisted dying (VAD), passing legislation in 1995 before it was overturned in 1997.

Now, they are the only Australian jurisdiction without VAD legislation.

In August 2023, an independent Expert Advisory Panel was established by the Chief Minister of the NT to inform development of VAD legislation. The expert panel undertook extensive public consultation, with a public report released in 2024.

A perspective published in the Medical Journal of Australia reflects on the challenges highlighted in this report with respect to meeting the health care needs of Aboriginal and Torres Strait Islanders in the NT’s remote communities.

“The recent NT consultation process revealed strong preferences for equity of access but also the need to carefully calibrate services to make them culturally safe,” Dr Geetanjali Lamba and co-authors wrote.

“Central to the NT context will be Aboriginal input into the governance, design, implementation and iterative evaluation of VAD.”

The complexities of cultural safety

The perspective authors note that diverse views were expressed by Aboriginal and Torres Strait Islander organisations and individuals in the advisory panel.

“Despite agreement that health services, including VAD, should be accessible to all Territorians, concerns existed about how VAD would be implemented in practice,” the authors wrote.

“Potential conflicts between VAD and cultural beliefs were also outlined, including possibilities that some Aboriginal people, particularly elders, were struggling to reconcile VAD with their spiritual, cultural and religious views.”

While the need for cultural safety was widely agreed upon in the report, there was also acknowledgement that each person’s cultural needs are unique.

The perspective authors argue VAD implementation must be co-designed with Aboriginal and Torres Strait Islanders to ensure cultural safety is upheld.

“Risks to cultural safety are associated with power imbalances, medication safety, potential cultural misunderstandings and misconceptions regarding the role of remote PHC [primary health care] services,” the authors wrote.

“Co-design approaches can help address power dynamics, and ensure Aboriginal perspectives are preferenced.”

The potential role of telehealth

While providing VAD via telehealth is currently illegal in Australia, many participants in the advisory panel spoke of its importance in overcoming VAD access issues for remote patients.

Telehealth could improve equity issues for patients too unwell to travel, help overcome limited availability of medical practitioners outside Darwin, and improve access to interpreters.

However, telehealth has its limitations, including inadequate clinical and interpreter workforce in remote clinics, and issues with internet connectivity and technology literacy.

Panel participants also expressed preference for in-person consultations to build therapeutic relationships, which suggests telehealth would be most effective as an adjunct to face-to-face consultations, not as a replacement for them.

Investment and co-design

The perspective authors note that the NT has the fewest trained medical practitioners relative to disease burden nationally, and implementing VAD services will be difficult without additional investment.

“Equitable access in the NT requires adequate resourcing,” the authors wrote.

The authors emphasise that Aboriginal and Torres Strait Islander organisations and individuals must remain directly involved in VAD service development and delivery to ensure cultural safety is upheld.

“Co-design and Aboriginal governance will ensure integration of cultural knowledge and safety, allow continuous adaptation of services based on community feedback and facilitate safe involvement of cultural brokers and interpreters,” the authors wrote.

“It will also ensure health care providers receive appropriate cultural competence training on using telehealth for VAD, assuming that telehealth for VAD will become legal in Australia.”

“If it does, safe and voluntary involvement of cultural brokers and interpreters needs to be considered and communication channels with on-the-ground health care workers need to be clear.”

Read the perspective in the Medical Journal of Australia.