Are we truly ready for voluntary assisted dying?

The Victorian government has made progressive movements towards reforming the laws around physician-assisted dying in the last 12 months, forming a lively and interesting debate amongst physicians, politicians and ethicists. With the bill passing the legislative assembly, we are set to see a tight vote in the legislative council, potentially seeing the reform come into action by 2019.

Physician-assisted dying is a term defined as a doctor providing the means for a patient to self-administer a lethal dose of prescribed medication.

Although the idea seems contemporary, this concept has formed the centre of heated debate in the field of medicine for thousands of years, dating back to Ancient Greek times.

Despite the Hippocratic Oath opposing forms of euthanasia or physician-assisted dying – “Nor shall any man’s entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so” – poison hemlock was often used for euthanasia in Ancient Greece. Even in 1936 King George V’s physician had hastened his death with the use of a concoction of drugs, noting in his diary that he had acted to preserve the dignity of the king and to prevent further strain on his family.

In 1942, Switzerland decriminalised assistance in death for any case that was deemed without “selfish motives”, leading the way for slow but steady amendments surrounding the laws on assisted dying.

Over the next 70 years, this pattern became a common trend in many countries across the world, with Canada and a number of European countries legalising assisted dying. Several states in the United States of America have also legalised physician-assisted dying, with Oregon’s Death with Dignity Act allowing doctors to prescribe end-of-life medication for patients requesting such care.

Given this context, though, where does Australia stand? Turns out our relationship with assisted dying goes back a bit before the current Bill in the Victorian parliament.

In 1995, in fact, the Northern Territory’s Chief Minister, Marshall Perron, was the first person in the world to introduce and pass legislation legalising voluntary euthanasia. Perron drafted the Rights of the Terminally Ill Act, however, the Act was soon voided by the Commonwealth’s Euthanasia Laws Act 1997, introduced into the federal parliament by Liberal Party backbencher Kevin Andrews.

Until recently, there had been no new law reforms in Australia legalising euthanasia or physician-assisted dying since 1997. However, recent undertakings by the Victorian Labor government may see physician-assisted dying legalised and provided in Victorian hospitals by 2019, pending approval from the state’s upper house.

Victoria’s premier, Daniel Andrews, who had previously stated there would be no changes to legislation outlawing assisted dying, had a recent change of mind after watching his father take his last breath in April, 2016.

His father had lost his long and agonising battle with cancer and Andrews had told The Sunday Age that his father’s quality of life had deteriorated long before he had passed and felt that Victoria’s laws needed change.

Labor’s anticipated changes have been met with mixed feelings. Several palliative care doctors have voiced warnings in response to Labor’s swift move to reform the law.

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Reports stated that patients requesting physician-assisted dying would have consultations with psychiatrists, independent case workers and at least two physicians.

Ultimately, the major concern raised by palliative care physicians was that this proposed level of care for patients opting for assisted dying was of better quality than the care currently given for those requesting palliative management. Therefore, doctors were concerned that this disparity would greatly influence patients and their decision making in their final months of life.

As we move closer to the prospect of a drastic change in end-of-life treatment, do we, as a society, have expectations that match the realistic outcomes of physician-assisted dying?

Professor Peter Hudson, from St Vincent’s Health, thinks that the public have not had the needed in-depth discussions on these procedures. Further, he notes that less than 1% of patients with terminal illnesses desire physician-assisted dying.

Despite a push from pro-euthanasia advocacy groups and parliamentary reports, a number of palliative care physicians are calling for increased funding to palliative care and better resource allocation, hoping for improvements in patient outcomes and decision making as opposed to legalising an ethically challenging procedure.

The proposed psychiatric care plan with assisted dying outlined in the Victorian parliamentary recommendation would serve to identify and prevent mental health deterioration as a driving factor in patient decision making. However, most palliative care physicians are still stating that these procedures are too easily seen as a ‘quick fix’ to end-of-life complications, are too emotionally taxing on families, and are often more clinically problematic than the public understands.

Some experts have also stated that it can become clinically problematic when physician-assisted dying is legalised without euthanasia as the doctor is restricted in their ability to be actively involved in the process.

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If physician-assisted dying is legalised and euthanasia is not, then a physician can only assist a patient in obtaining the means for self-administration. A Dutch study that interviewed 405 physicians across multiple specialities in 1990 and another 405 physicians in 1995 found that physician-assisted dying often became problematic in patients with neurological illness that prevented them from self-administering due to issues with swallowing, using their hands or peripheral weakness.

One of the parliamentary recommendations to the bill states that if a patient cannot self-administer the medication, a physician’s assistance in doing so may be appropriate. However, this directly conflicts with the act of self-administration needed to represent the voluntary nature of the dying process.

The physicians involved in the aforementioned Dutch study also reported assisted dying becoming problematic due to longer-than-expected durations between the patient self-administering and the ensuing death. Indeed, 21 of the 114 cases of physician-assisted dying resulted in the physician deciding to administer the lethal dose due to these clinical complications.

Will the changes being proposed by the Andrews government lead to more problematic outcomes in palliative care? Or will it be able to work closely with physicians to introduce a successful and progressive new end-of-life treatment for terminally ill patients, setting the stage for the future of Australia? Only time will tell, but one thing’s certain: the nation will be listening.

The views and opinions expressed in this article are those of the author and do not necessarily represent those of the Doctus Project.