New euthanasia/assisted suicide law in Australia

Victoria’s Voluntary Assisted Dying Act 2017

Sean Murphy*

Introduction
On 19 April, 2018, the legislature of the State of Victoria, Australia, passed the Voluntary Assisted Dying Act 2017, which will come into force in June, 2019.  It is currently the most restrictive euthanasia/assisted suicide (EAS) legislation in the world, running to 130 pages.  In brief, the law authorizes physician assisted suicide for terminally ill adults, but permits euthanasia by physicians only when patients are physically unable to self-administer a lethal drug.  In both cases a permit must be obtained in advance.  The main elements of the law are set out below, followed by consideration of its protection of conscience provisions. . .  [Full Text]

Why I will be a conscientious objector to Victoria’s assisted dying law

A palliative care specialist laments the unrealistic individualism and elitism of the euthanasia movement

MercatorNet

Adrian Dabscheck

During a recent period of enforced rest, I had time to reflect on my attitude to the recently enacted voluntary assisted dying legislation in Victoria and consider my response.1 I will detail my reaction to the Act and why I have chosen to become a so-called conscientious objector.

In his essay Western Attitudes Toward Death,2 French historian Philippe Ariès illustrates the evolution of our attitudes to death.

Initially, and for millennia, there had been a general resignation to the destiny of our species for which he used the phrase, Et moriemur, and we shall all die. This was replaced in the 12th Century by the more modern concept of the importance of one’s self, and he used the phrase, la mort de soi, one’s own death.

Ariès then notes that in the 18th Century man gave death a dramatic and disquieting meaning. Man became concerned with the death of the other person, la mort de toi. Death was no longer familiar, nor were the dead. The dead had been torn from life; death had become an important event. By the 19th Century mourning had become difficult and thy death, la mort de toi, is more feared than la mort de soi, one’s own death.

Following this slow evolution in Western attitudes towards death, from being ubiquitous and familiar, with industrialisation, came the concept of the forbidden and shameful death. Life was now meant to be happy and this happiness was interrupted by the emotional disturbance of death and dying. Death was not spoken of, as illustrated by Tolstoy in “The Death of Ivan Ilyich”.3 Death was moved from home to hospital, from the care of one’s family to the sanitised, technical care whereby it is difficult to tell when the dying process actually began due to the interference of modern medicine. Death became part of the medical industrial-movement.

In a 2013 article reviewing the situation in Flanders where euthanasia is embedded in palliative care,4 it was noted:

Healthcare professionals note that family members and proxies tend, much more than before, to consider the dying process as undignified, useless and meaningless, even if it happens peacefully, comfortably and with professional support. Requests made by family members for fast and active interventions from healthcare professionals regarding elderly parents are often very coercive, with little nuance or subtlety. End-of-life interventions such as euthanasia are seen as an instrument to end a process of disease (or old age) that is demanding and difficult to bear, instead of letting it follow its course.’

We could not be further removed from Ariès’ phrase, Et moriemur, and we shall all die. Happiness is now the ultimate goal; we can no longer accept the place of death in our life. Ariès wrote in L’Homme devant la mort:5 “Death must simply become the discreet but dignified exit of a peaceful person from a helpful society. A death without pain or suffering, and ultimately without fear.” Thus the idealised ‘good death’.

Unfortunately, for most, society is unable to achieve such utopian goals, hence the need for the modern palliative care movement. As David Roy noted in the third edition of the Oxford Textbook of Palliative Medicine,6 it is up to society to allow the palliative care movement to flourish, to remove barriers to care, to develop the broad tapestry of interconnected people, resources, services and institutions to care for those who suffer in the face of death.

For this to be successful there must be an effective ethic of care. An ethic that allows relationships to flourish, an ethic that acknowledges the vulnerability of people and views autonomy from a relational rather than an atomistic perspective. Autonomy is a product of our personhood, our development of interests and values gained by interactions with others. None of us can make decisions which are free from influence. Our decisions relating to ourselves are made in the context of relationships. We commence our life completely dependent on others to sustain us. We depend on the non-judgemental love of others to care for us, to allow us to become independent, to become autonomous in the context of family, friends and society.

I continually ask myself, how have we allowed our ethical boundaries to move to such a degree that a law allowing doctors to take life as a way of relieving suffering has been passed by our state legislature? How have we allowed our view of the individual to become so individualistic and self-gratifying, so removed from an acknowledgement of our dependence on others, so self-centred or dare I say narcissistic?

Perhaps we can learn for the world of art and aesthetics. Hans van Meegeren was an accomplished forger of Vermeer, such that Vermeer experts accepted as originals what are obvious from our current perspective as forgeries. David Roy asks:6 “What process was at work that could so distort the faculties of aesthetic perception and poor judgement? It was a process of incremental adaption to incrementally poor forgeries.”

The Netherlands introduced the Termination of Life on Request and Assisted Suicide (Review Procedures) Act in 2001. In 2005, of all deaths, 0.4 percent were the result of the ending of life without an explicit request by the patient.7 In 2013 euthanasia was performed for 97 patients with dementia and 42 patients with psychiatric diseases (percentages not reported).8 Have ethical perceptions been distorted such that incremental creep allowed this to happen, as it did with aesthetics and van Meegeren?

In an article published in May 2017 in the New England Journal of Medicine discussing the experience of the University Health Network in Toronto after the introduction of medical assistance in dying (MAiD) in Canada,9 the authors noted:

[T]hose who received MAiD tended to be white and relatively affluent and indicated that loss of autonomy was the primary reason for their request. Other common reasons included the wish to avoid burdening others or losing dignity and the intolerability of not being able to enjoy one’s life. Few patients cited inadequate control of pain or other symptoms.

I would like to question if the possible consequent good of allowing a highly selected population of privileged people the ability to request and be administered medical assistance in dying is sufficient to overturn millennia of accepted medical practice. Medicine has long been perceived by society to be beneficent and is trusted to avoid actions which would deliberately hasten death. The intent of palliative medicine is the relief of pain and suffering, not the taking of life. Should we risk the incremental creep of our values for the sake of a privileged few?

Do we wish to allow our society to become similar to Belgium, where we are so removed from the human experience that we consider the dying process useless, meaningless and undignified?

In my own city, Melbourne, we can all witness the inadequate provision of palliative care and other health services to more economically challenged sections of our society. A similar picture emerges in rural settings. Can we as a society justify allocating resources to voluntary assisted dying, when basic palliative care and health care are so lacking?

Should we really allow the values of our society to be so radically altered for the few who are so removed from an acceptance of the frailty of the human experience, from an acceptance that we are all dependent on others and vulnerable?

It is for the above reasons that I will be a so-called conscientious objector when the Voluntary Assisted Dying Act comes into operation on 19 June 2019. I will continue to practise medicine as it has been practised for millennia, for the relief of pain and suffering. I would encourage all doctors to in Victoria to do likewise.


Adrian Dabscheck is a Palliative Care Consultant from Victoria

References

1.  Voluntary Assisted Dying Act 2017 (Vic).

2.  Ariès P. Western Attitudes Toward Death from the Middle Ages to the Present. Johns Hopkins University Press, 1974.

3.  Tolstoy L. The Death of Ivan Ilyich. Published in 1886.

4.  Vanden Berghe P, et al. Assisted Dying – the current situation in Flanders: euthanasia embedded in palliative care. European Journal of Palliative Care 2013;20(6):266-272.

5.  Ariès P. L’Homme devant la mort (The Hour of Our Death). Published in 1977.

6.  Doyle D, et al. (eds.) Oxford Textbook of Palliative Medicine. 3rd Edition. Oxford University Press, 2005.

7.  Van der Heide A, et al. End-of-Life Practices in the Netherlands under the Euthanasia Act. New England Journal of Medicine 2007;356:1957-1965.

8.  Radbruch L, et al. Euthanasia and physician-assisted suicide: A white paper from the European Association for Palliative Care. Palliative Medicine 2016;30(2):104-116.

9.  Li M, et al. Medical assistance in dying – implementing a hospital-based program in Canada. New England Journal of Medicine 2017;376:2082-2088.


This article is published by Adrian Dabscheck and MercatorNet under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to MercatorNet. Commercial media must contact MercatorNet for permission and fees. Some articles on this site are published under different terms.

Medical Euthanasia in Canada: Current Issues and Potential Future Expansion

Psychiatric Times

Mark S. Komrad

Dr Mark Komrad explores the relatively new Medical Aid in Dying (MAID) law in Canada, and how it may be on the verge of opening medical euthanasia to certain qualified psychiatric patients, similar to practices in Belgium and The Netherlands (see A Psychiatrist Visits Belgium: The Epicenter of Psychiatric Euthanasia).

He also brings out specific worries about the emerging ethical and legal trends in Ontario, to stop conscientious objecting physicians from refusing to refer cases of patients seeking euthanasia to colleagues who might be willing to provide it.

Dr Komrad is a clinical psychiatrist and an ethicist. He just finished a 6-year tenure on the APA Ethics Committee and also serves on the APA Assembly. In those contexts, he helped to craft the current current APA position on Medical Euthanasia for non-terminally ill patients [PDF]. He is also on the teaching Faculty of Psychiatry at Johns Hopkins, Sheppard Pratt, and the University of Maryland. Dr Komrad’s opinions are his own, and he is not officially representing the APA in this article, nor any of the institutions where he is on the faculty. . . . [Go to Psychiatric Times for Podcast]

 

Health service unable to cope with demand if abortion legalised, medics claim

GP says referendum campaign has led to ‘fundamental divisions’ within profession

The Irish Times

Sorcha Pollak

The State’s health system will be unable to cope with the demand for additional surgical procedures if access to abortion is legalised, a group of anti-abortion doctors, nurses and midwives has said.

The medics told an event hosted by the Save the 8th campaign on Monday that the Government had not carried out a full assessment of the cost and logistics of law changes arising from the potential repeal of the Eighth Amendment after the May 25th referendum.

Ann Flynn, assistant director of nursing at St Vincent’s hospital, Dublin, said Minister for Health Simon Harris was “asking us to introduce an abortion regime that cannot be introduced” into the health system he leads. . . [Full Text]

Are organ donors really dead?

BioEdge

Xavier Symons

What does it mean for a human being to “die”? This question is more complex than one might think. In the domain of vital organ procurement, there is significant disagreement about the criteria that we should employ to assess when someone has died.

The standard criterion for several decades has been the “brain death” criterion, according to which a patient can be pronounced dead once “whole brain death” has occurred. Whole brain death refers to the comprehensive and irreversible cessation of brain function, typically caused by trauma, anoxia or tumor.

Yet transplant surgeons have in recent years employed a different, more ethically contentious definition of death, the so-called “circulatory criterion for death”. “Circulatory death” refers to the permanent cessation of cardiopulmonary function, after which point brain tissue quickly begins to deteriorate (if it hasn’t already).

According to proponents of the circulatory criterion, a patient’s heart will never spontaneously restart after 2 or so minutes of pulselessness. As such, it is seen as ethically permissible to begin organ procurement once this short time period has elapsed. There are in practice different time periods specified by healthcare regulators for when organ procurement can begin (typically between 75 seconds and 5 minutes).

Yet several scholars have criticised the cardiopulmonary definition of death, arguing that the impossibility of autoresuscitation does not necessarily indicate that death has occurred. Critics point out that CPR could still restart a person’s heart even when autoresuscitation has become an impossibility.

The most recent criticism came from Kennedy Institute for Ethics bioethicist Robert Veatch, who wrote an extended blog post on the topic this week. Veatch states:

If one opts for requiring physiological irreversibility, death should be pronounced whenever it is physiologically impossible to restore brain function. Autoresuscitation is completely irrelevant. If autoresuscitation can be ruled out before physiological irreversibility, one must still wait until that point is reached. On the other hand, if it becomes physiologically impossible to restore function before autoresuscitation can be ruled out, death can be pronounced at the earlier point. Either way autoresuscitation is irrelevant.


This article is published by Xavier Symons and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact BioEdge for permission and fees.

‘Intentionally ending the life of an innocent baby does not treat any illness’

Nurses say proposed abortion legislation could mean nurses giving up jobs on conscience grounds

The Irish Times

Patsy McGarry

Proposed abortion legislation could force nurses and midwives out of a job, it has been claimed.

Campaigners for a No vote in the referendum on the Eight Amendment say the conscience clause promised by the Government in legislation if the measure passes is inadequate.

“We are concerned about freedom of conscience and have seen how Scottish midwives lost their case in the UK not to be involved in abortions,” said Mary Kelly Fitzgibbon, of Nurses for Life, a nurse, midwife and a lecturer. . . [Full Text]

World Medical Association to consider policy changes on abortion, euthanasia, assisted suicide

Debate planned for ethics conference in October in Iceland

Sean Murphy*

Following a meeting of the WMA Council in Riga, Latvia, the WMA issued a statement noting that a revised version of the WMA abortion policy would be presented for approval at the WMA annual General Assembly in Reykjavik, Iceland.

In addition, the WMA has announced that there will be a further “open debate” on changing the Association’s policy against physician participation in euthasnasia and assisted suicide.  The debate will occur during a WMA conference on medical ethics taking place at the same time and place.  Formal presentations on euthanasia and assisted suicide will be given on 4 October, 2018, but informal discussions among delegates are likely to be important.  The debate appears to be a consequence of lobbying by the Canadian and Royal Dutch Medical Associations to convince the WMA to drop its condemnation of the practices

It is not clear whether or not WMA members appreciate the relationship between abortion policy and euthanasia policy.  Compulsory referral for abortion is essentially a dress rehearsal for compulsory referral for euthanasia and assisted suicide, something clearly demonstrated in Canada.  Accusations of “patient abandonment” formerly aimed at those refusing to refer for abortion1 are now, in addition, being levelled at those who refuse to refer patients to someone willing to kill them or help them commit suicide.2

In 2011, a Royal Society of Canada panel of experts chaired by Udo Schuklenk  recommended legalization of assisted suicide and euthanasia.3  The experts insisted that health care professionals unwilling to provide euthanasia help patients commit suicide must refer them to someone willing to do so.4 This was justified, they said, because it was agreed that objectors are obliged to refer for “reproductive health services.”5  It really was not agreed: the Canadian Medical Association had, in fact, rejected this claim five years earlier6 after it was made by Jocelyn Downie,7 one of Schuklenk’s colleagues on the Royal Society Panel.

By 2015 Schuklenk was arguing that objecting physicians should not be accommodated at all. Among his arguments was that referring for abortion or euthanasia is not a compromise because it involves moral complicity in the act, “barely reduced” by the act of referral.8  This implied that physicians should be forced to provide abortion and euthanasia, notwithstanding religious or conscientious convictions to the contrary, a position Schuklenk explicitly adopted over the next two years.9, 10

At the same time, Ottawa law professor Amir Attaran was insisting that physicians should be forced to kill eligible patients themselves.11 He claimed that this was required by human rights law,12 describing effective referral as an unacceptable form of illicit discrimination.13

In considering changes to euthanasia, assisted suicide and abortion policies in October, WMA delegates will have to take great care to consider not only the most obvious ethical issues of life and death, but less obvious yet important issues like the distinction between acceptable cooperation and unacceptable collaboration, which play out in disputes about mandatory referral for abortion and euthanasia.


Notes
1.  “According to the prevailing norm of beneficence therefore, as well as those of trust, patient autonomy, and not abandoning patients, physicians should refer patients for abortions.”  McLeod C. Referral in the Wake of Conscientious Objection to Abortion. Hypatia, Vol. 23, No. 4 (October-December, 2008) at p. 36 (Accessed 2018-08-022).

2.  Cook M. Canadian court tells doctors they must refer for euthanasia. Mercatornet, 2 February, 2018

3. Schuklenk U, van Delden JJM, Downie J, McLean S, Upshur R, Weinstock D. Report of the Royal Society of Canada Expert Panel on End-of-Life Decision Making (November, 2011)[“Royal Society“] p. 96 (Accessed 2014-02-23).

4.  Royal Society, p. 69, 101.

5.  Royal Society, p. 62.

6.  Blackmer J. Clarification of the CMA’s position on induced abortion. CMAJ April 24, 2007 vol. 176 no. 9 doi: 10.1503/cmaj.1070035 (Accessed 2017-12-12).

7.  Rodgers S. Downie J. Abortion: Ensuring Access. CMAJ July 4, 2006 vol. 175 no. 1 doi: 10.1503/cmaj.060548 (Accessed 2017-12-12).

8.  Schuklenk, U. Conscientious objection in medicine: private ideological convictions must not supercede public service obligations (2015) 29:5 Bioethics ii, DOI: 10.1111/bioe.12167

9.  Schuklenk U, Smalling R. Why medical professionals have no claim to conscientious objection accommodation in liberal democracies (2016) 43:4 J Med Ethics 234, DOI: http://dx.doi.org/10.1136/medethics-2016-103560.

10. Savulescu J, Schuklenk U. Doctors have no right to refuse medical assistance in dying, abortion or contraception (2017) 31:3 Bioethics 162, DOI: 10.1111/bioe.12288

11.  Though conceding that a lethal drug might be administered in the physician’s presence by a delegate, and that referral might be necessitated by technical incompetence. Attaran A. The Limits of Conscientious and Religious Objection to Physician-Assisted Dying after the Supreme Court’s Decision in Carter v Canada (2016 ) 36:3 Health L Can 86 [“Attaran“], p. 87-88, 96.

12.  “[W]hen a doctor refuses to assist a patient who is disabled by a ‘grievous and irremediable medical condition’, just because the patient wants death rather than something else, that arguably discriminates against the disabled patient.” Attaran, p. 89.

13.  Attaran, p. 91–93.

Abortion: INMO calls for conscientious objection safeguards

Nurses union has had no discussions to date with HSE about the implications of repeal

The Irish times

Barry Roche

The Irish Nurses and Midwives Organisation expects the same conscientious objection protections that exist for nurses under the Protection of Life in Pregnancy Act to be afforded to nurses and midwives in any forthcoming legislation in the event of the Eighth Amendment being repealed.

INMO director of social policy and regulation Edward Matthews said that nurses and midwives are afforded the same protections as medical practitioners when it comes to conscientious objection to carrying out a termination of pregnancy. . . [Full Text]

Isle of Man abortion reform bill passed by House of Keys

BBC News

Plans to change the Isle of Man’s abortion laws have been approved by the House of Keys by a margin of 22-2.

The Abortion Reform Bill would allow women to have terminations within the first 14 weeks of their pregnancy, with other restrictions also being eased.

Under existing Manx law, abortions can only be carried out if a pregnancy is the result of rape or because of mental health concerns.

Members of the Legislative Council will now consider the bill. . . [Full text]

    • Note: the Abortion Reform Bill as passed by the Keys includes a simple  protection of conscience provision covering all “relevant” professionals (registered medical practitioners, nurses, or midwives) and pharmacists.  It requires objecting practitioners to provide information, but not  referral.

Conscientious objection to participation in abortion by midwives and nurses: a systematic review of reasons

Valerie Fleming Lucy Frith, Ans Luyben, Beate Ramsayer

Abstract

Background

Freedom of conscience is a core element of human rights respected by most European countries. It allows abortion through the inclusion of a conscience clause, which permits opting out of providing such services. However, the grounds for invoking conscientious objection lack clarity. Our aim in this paper is to take a step in this direction by carrying out a systematic review of reasons by midwives and nurses for declining, on conscience grounds, to participate in abortion.

Method

We conducted a systematic review of ethical arguments asking, “What reasons have been reported in the argument based literature for or against conscientious objection to abortion provision by nurses or midwives?” We particularly wanted to identify any discussion of the responsibilities of midwives and nurses in this area. Search terms were conscientious objection and abortion or termination and nurse or midwife or midwives or physicians or doctors or medics within the dates 2000–2016 on: HEIN legal, Medline, CINAHL, Psychinfo, Academic Search Complete, Web of Science including publications in English, German and Dutch. Final articles were subjected to a rigorous analysis, coding and classifying each line into reason mentions, narrow and broad reasons for or against conscientious objection.

Results

Of an initial 1085 articles, 10 were included. We identified 23 broad reasons, containing 116narrow reasons and 269 reason mentions. Eighty one (81) narrow reasons argued in favour of and 35 against conscientious objection. Using predetermined categories of moral, practical, religious or legal reasons, “moral reasons” contained the largest number of narrow reasons (n =  58). The reasons and their associated mentions in this category outnumber those in the sum of the other three categories.

Conclusions

We identified no absolute argument either for or against conscientious objection by midwives or nurses. An invisibility of midwives and nurses exists in the whole debate concerning conscientious objection reflecting a gap between literature and practice, as it is they whom WHO recommend as providers of this service. While the arguments in the literature emphasize the need for provision of conscientious objection, a balanced debate is necessary in this field, which includes all relevant health professionals.


Fleming V, Frith L, Luyben A, Ramsayer B. Conscientious objection to participation in abortion by midwives and nurses: a systematic review of reasons. BMC Medical Ethics. 2018;19:31. doi:10.1186/s12910-018-0268-3.