The “voluntary Assisted dying” legislation appears set to pass both lower and upper houses in Victoria. However, let us call it “assisted suicide and euthanasia legislation”, because that is what it is.
One of the problems with this whole debate has been with the corruption of language. The aim of language changes has been to try to associate it with respected medical palliative care. Palliative care is a sub-speciality of medicine which focuses on relief of symptoms at end of life, together with psychological and social care, whose aim is to help people to live as fully as possible until they die: a quite different goal from assisting suicide.
Language change has also been used to appropriate the “dying with dignity” mantra, as if the only way to die with dignity was by having a legislative change for assisted suicide and euthanasia: obviously not the case.
Good quality palliative care is adequate, although not perfect, to relieve end-of-life distress. The difficulty in Victoria is that it is under-funded and patchy in its distribution. Also, your average doctor and nurse may have little experience in end-of-life care.
The insistence of advocates on ‘choice’ (without much attention to the price to be paid by the community in the erosion of ethical standards) was crucial. Some seem to think ‘choice’ trumps all else in this day of quick fixes and superficial thinking.
The Victorian legislation was minimally amended, but its basic flaws remain. You cannot turn a dog into a racehorse by tying a ribbon around its neck. There is much that could be said about the pros and cons of this debate, but for the moment let us leave that aside, and note some issues about the process of how this has been debated in the Victorian Parliament, and then, the consequences of this law change we may expect.
Dr Michael Gannon, the Federal President of the AMA, was criticised for observing that some parliamentarians were using this debate to discuss their own emotional reactions to family death. While family death can obviously often be very upsetting (and in fact highlights the importance of this whole area), many parliamentarians seemed to miss the point that their role was to make good Law, which serves the “common good” of the community.
Daniel Mulino, an ALP Member of the Legislative Council, opposed (to his credit) the stance of most of the members of his side of politics, and put the view that this legislation is going to do more harm than good. Opposition to it has been little to do with religion, despite attempts to label and dismiss opposition as being on religious grounds only.
Many upper house members were also roundly criticised by the government for filibustering, but in fact, there were 141 clauses to be discussed. Opponents clarified the flaws in this attempt to put complicated medical and psychological issues into black and white legislation.
It has been notable also that the experience of experts has been rejected by those who voted for this legislation and decided in favour of “personal choice”, despite the significant cost to the community of such choice.
So what should we watch out for in coming years as a consequence of this legislation? There are three main areas where its effect will be seen, but not immediately:
Firstly, it will waste millions of taxpayer dollars, which would be better used for funding palliative care. There will be an extensive Board set up which will be toothless, not have the power to investigate anything, and merely be a collection point for paperwork, data, and information. It will make a nominal report to parliament annually. Additionally, there will be the costs of state government bureaucrats who will have to sign off on “permits” for participating doctors. It will be expensive.
Secondly, there will be elder abuse in families and nursing homes, when ill people will be coerced, implicitly or explicitly, into signing up for assisted suicide. Paul Keating, as part of his severe criticism of this legislation, made the observation that it is “utopian”. It indeed assumes that all families are benign and supportive, which is far from the case. In modern Australia, many families of ill people are intolerant, impatient, and even eager to get their hands on whatever inheritance might be going.
Coercion need not be plainly explicit, but subtly implicit in terms of the attitudes of family members. Many of these cases will go unreported because the main witness will be dead! In other instances, we are bound to see legal action taken by one part of the family against another on the basis of “You made my mother sign up to change her will and suicide”.
It has been reported that elderly people in nursing homes are apprehensive about this legislation, because they are concerned that they will be pushed. This legislation excludes people with dementia, but in early dementia it is common to find people having “good days” when they are quite lucid, and “bad days” when they obviously are not. On a good day, someone could have sufficient testamentary capacity to be persuaded to sign up. People with disabilities are similarly apprehensive that they will be discriminated against.
Thirdly, there will be a significant change to medical practice. It has always been a part of good medical practice that doctors do not participate in taking the life of their patient or aid them to do so, such that the World Medical Association statement on assisted suicide and euthanasia clearly considers it unethical. If doctors are involved in the taking of life, it will affect the trust that people have in their medical practitioners.
The legislation also leaves open the possibility of the doctor administering euthanasia if the patient is unable to take the lethal dose voluntarily by mouth. This opens the door to intravenous euthanasia, as happens in The Netherlands. Indeed, in The Netherlands that is documented to occur on an involuntary basis.
It is possible that we will see suicide clinics set up, possibly by outliers in the medical profession. Most palliative care physicians, and many others involved in terminal care, have said they will refuse to participate in this process. AMA official policy is that doctors should not be involved.
Medical students and graduate doctors will be taught how to take lives. Pharmacists will be taught how to formulate lethal poisons. How long will it be before we see the first accidental overdose from an unsupervised fatal preparation in someone’s home?
There is at the moment no clear mechanism for payment for medical services for assisted suicide and euthanasia, so we may see a Medicare Item number created for assisted suicide and euthanasia – your taxes at work!
A more insidious consequence, but inevitable in my opinion, is the attitude of some health bureaucrats who will take the view “It is cheaper for you to have the lethal suicide dose than for us to have to pay for your palliative care or chemotherapy”. This has already occurred in Oregon, which is supposedly the model for the Victorian legislation; although by allowing direct doctor euthanasia it is, in fact, more like The Netherlands model where most euthanasia is done by intravenous injection.
In the future, it is probably inevitable that this legislation will be broadened. Some have already been advocating for the criteria to be broadened before they have even been established. There will be cries of discrimination and attempts to widen the legislation to include those not immediately terminally ill, those with mental illness and those who have dementia. Philip Nitschke believes anyone should be able to ask for Euthanasia for any reason. If you take into account the expenses of an ageing population and the growing numbers of people needing dementia care, it is obvious that this proposal will be made.
Why would medical students and GPs bother to get palliative care training if the management of severe illness becomes assisted suicide or euthanasia? Why would decision-makers about research grants devote money to currently incurable illness if euthanasia becomes widely used?
There are many who regard these changes not as “progressive” but “regressive”. I have been honoured to be a member of the medical profession for the last 47 years. I have always seen it as a noble calling, but along with many colleagues who have opposed these changes vigorously, I am concerned about the future of medical care in Australia.
This legislation has been rejected in South Australia, Tasmania, and most recently New South Wales. It will be a regrettable day for quality medical practice if the Victorian decision spreads to the rest of Australia. Widespread quality palliative care is the better alternative. The wish for choice by some carries too great a price for the community.
Dr John Buchanan is a former Chair of the Victorian Branch of the Royal Australian & New Zealand College of Psychiatrists. He has worked as a physician, then medical director, at Citimission Hospice Program and after training in psychiatry as a liaison psychiatrist, oncology and palliative care, in Melbourne. In 2013 he was the recipient of the RANZCP Medal of Honour.
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