Why I Support Voluntary Assisted Dying
For almost 40 years, it was my privilege to watch and medically assist mothers (and many fathers) to prepare for a new life. However, it is my belief that the medical profession is not doing enough to assist us at the other end of life. Sure, we have excellent palliative care services that are generally available but, even with the best of these, at least 5% of us are destined to experience a painful or undignified death that can be avoided if there is access to voluntary assisted dying (VAD), often called euthanasia.
After more than 37 attempts across Australia to introduce Voluntary Assisted Dying Laws, NSW became the last State to pass legislation that permits this option for its residents on the 19th of May 2022.
The NSW Voluntary Assisted Dying Act 2022 was assembled on the back of similar legislation in the other States and most similar to the Queensland Voluntary Assisted Dying Act. The key points are:
Eligibility
* The person must be 18 years or over
* Be a resident of NSW for at least 12 months and an Australian citizen/permanent resident
* Have decision-making capacity in relation to voluntary assisted dying
* Act voluntarily without coercion of any sort
* Be diagnosed with an incurable disease, illness or medical condition that is advanced, progressive and will cause death and is expected to cause death within 6 months (or 12 months with a neuro-degenerative condition).
Application
* A person has to make one verbal request and two written requests
* Eligibility to be confirmed by two senior doctors who are independent of each other
* There is a minimum of five days between the initial request and final approval.
The person must make the request themselves. Nobody else is authorised to make the request, and the request cannot be made via an advance care directive.
Access
* The person must maintain decision-making capacity
* A person may opt for self-administration or a medical practitioner to administer the drug.
Doctors and Institutions
* Doctors and other healthcare workers are permitted to raise the option of assisted dying with their patients, if all other treatment options are also discussed
* Participating health practitioners must complete training for voluntary assisted dying
* Any healthcare worker may decline to participate for any reason, without penalty
* Institutions may decline to participate but must not hinder access to VAD.
Oversight
* A Review Board receives assisted dying reports, assesses reports, and can refer cases to disciplinary or prosecuting authorities
* Parliament will periodically review the law and issue summary reports.
The legislation will become operative in November 2023.
However, our work is not yet complete.
We need to:
* Defend VAD legislation already passed; opponents have pledged not to stop until they “overturn them all”
* Champion the voices of dying people (despite it being their legal right, some institutions try to make people’s VAD choice difficult)
* Support Australians to make their own, informed choices at the end of life.
* Support doctors and others who are training for and/or provide VAD and seek better remuneration for these services.
VAD Limitations and Possible Future Legislation – The Problem of Dementia
Any discussion about VAD quickly turns to the problem of dementia. Existing legislation, enacted in Australia and in most places around the world, has a primary requirement for the diagnosis of a terminal illness to be made before this option can be considered and a secondary requirement that the applicant has, and maintains, capacity. The grim statistics about dementia say that it affects one person in three over the age of 90 and it is now the leading cause for women. Of course, it can occur much earlier and most of us know of the thousands of elderly living in a vegetative state or worse in our nursing homes.
There is also an issue if a person who would otherwise qualify for VAD, loses capacity for some reason or other during their terminal illness that, under current legislation, prevents them giving consent to the process in the manner required. Statistics and experience suggest that this could be as many as 50% of those who have elected a VAD pathway.
Finally, there is the problem for a person who, throughout their life, has clearly indicated their preference for VAD but who, for any of a number of good reasons, have not formalized this either by way of an Advanced Care Directive or an application for VAD.
Here is a Discussion Paper, written by a doctor who is part of an organization active across Australia and New Zealand and called “Health Professionals for Assisted Dying Choice”, that explores these issues and describes possible legislative changes that may overcome them. One of his proposals is an ethically-operating Community Granted Assisted Dying option.
Here is a drafted Advanced Care Directive that includes VAD for dementia.
Given the years it took, and the continuing fierce opposition to current VAD legislation, I am not holding my breath for any workable amendments within my lifetime! As with abortion law in the US, it is always possible for opponents of VAD to wind back the clock. What is certain that they will continue to fight against “going down the slippery-slope to Nazi-style euthanasia” as they see proposals such as these.
Because I consider that life is a terminal illness, I have an Advanced Care Directive that seeks to anticipate future legislation that would enable me to access VAD by stating now what my wishes are and opting out of the requirement that capacity at the time of assisted dying is required.
Click here for a version of my Advanced Care Directive that anticipates the problem of dementia.
A Message to Doctors
Somewhat surprisingly, whilst upwards of 85% of the general community supports VAD, this falls to as few as 40% when doctors are surveyed. The reasons are complex.
I support the following values and principles:
- Every human life has equal value.
- A person’s autonomy should be respected.
- A person has the right to be supported in making informed decisions about the person’s medical treatment, and should be given, in a manner the person understands, information about medical treatment options including comfort and palliative care.
- Every person approaching the end of life should be provided with quality care to minimise the person’s suffering and to maximise the person’s quality of life.
- A therapeutic relationship between a person and the person’s health practitioner should, wherever possible, be supported and maintained.
- Individuals should be encouraged to openly discuss death and dying and an individual’s preferences and values should be encouraged and promoted.
- Individuals should be supported in conversations with the individual’s health practitioners, family and carers and community about treatment and care preferences.
- Individuals are entitled to genuine choices regarding their treatment and care.
- There is a need to protect individuals who may be subject to abuse.
- All persons, including health practitioners, have the right to be shown respect for their culture, beliefs, values and personal characteristics.
These are taken from the Discussion Paper by Irish Doctors in support of Medical Assistance in Dying (MAiD) whose complete text I can recommend. It includes the most contemporary analysis of current practice that I have found.
You can help by joining Health Professionals for Assisted Dying (HPAD) Choice, see https://www.hpadchoice.org.au/join_hpad
Further Resources
Go Gentle Australia: Committed to making VAD available to all terminally ill Australians
Dying with Dignity NSW: Committed to making VAD available as a Choice in NSW
Violet: Free information and support focusing on the last stage of life and the grief and loss that accompanies it.
Christians Supporting Choice for Voluntary Assisted Dying
End of Life Law for Clinicians
Advance Care Planning Australia
Voluntary Assisted Dying Australia and New Zealand Offering resources for anyone involved in the provision of VAD services.
NSW Voluntary Assisted Dying Care Navigator Service – the service by NSW Health for everyone including health practitioners and providers.
Navigating the Topic of Voluntary Assisted Dying in Advance Care Planning conversations – information for doctors that addresses their obligations and how to fulfill them.
Max Brinsmead
Updated February 20 2024