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High stakes in voluntary assisted dying debate

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The tragedy occurred half a lifetime ago, but for Coralie Richmond the memory remains acute.

Called to her parents' home in the Blue Mountains suburb of Lawson by her distraught mother one day in 1981, Richmond found her father Geoffrey on the floor, bleeding.

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The 72-year-old had been enduring great pain as a consequence of asbestosis he had developed from exposure to the deadly fibres while building houses.

That morning – the day after a doctor instructed him to take a series of X-rays to Westmead hospital – Geoffrey had put a shotgun to his temple and pulled the trigger.

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"I had to ring the ambulance then I had to ring the police because a gun had been discharged," Richmond recalls. "The police asked, 'Is the gunman still around?' I told them, 'Look, it was my father, he's tried to take his own life'."

Richmond's father spent about a week in Westmead Hospital before he died.

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A Christian and member of the Salvation Army, Richmond is a long-time advocate for voluntary assisted dying laws, including legislation due for debate in the NSW Parliament next week.

She can't say for sure, but Richmond believes her father would have been likely to take a more peaceful path had such laws have been in place, avoiding the trauma experienced by her and her family.

"I think he said, 'I'm so ill, I'm in so much pain, I have to do something about it'," she says.

A high-stakes moment

With bills before the parliaments of the two largest Australian states, NSW and Victoria, the issue of physician-assisted dying is prompting national debate not seen since the Northern Territory became the first jurisdiction in the world to legalise such laws (later nullified by the Commonwealth).

In NSW, MPs will on Thursday debate a private member's bill devised by a cross-party working group that would create a law, supporters argue, containing some of the most stringent safeguards of any such legislation globally.

To be eligible a patient must be at least 25 years old and suffering from a terminal illness from which they are expected to die within 12 months.

The decision must be signed off by two medical practitioners, including a specialist, and the patient assessed by an independent psychiatrist or psychologist.

There is a 48-hour cooling-off period, the patient may rescind the decision at any time and close relatives can challenge patient eligibility in the Supreme Court. A seven-person medical board would oversee all assisted deaths in NSW.

MPs will be given a conscience vote, but Premier Gladys Berejiklian and Opposition Leader Luke Foley have said they are opposed to the laws.

Without expected support from key crossbenchers and deep divisions in both major parties, the vote is expected to be a photo-finish in the upper house.

Should it pass and be referred to the lower house, its passage there is viewed as even more uncertain.

But supporters hope for some momentum from voluntary assisted dying laws being debated the Victorian parliament's upper house. Unlike in NSW, the Victorian bill has been introduced to the parliament by the government and has the support of Premier Daniel Andrews. 

The bills differ in important ways: in Victoria the age limit is 18, there is no requirement to consult a psychiatrist or clinical psychologist and no appeal right for relatives. 

Proponents say both laws are, by international standards, extremely conservative regimes modelled on the first American state to pass such laws: Oregon, in 1997. 

But Michael Gannon, the national president of the Australian Medical Association, which is opposed to the law, says that the passage of a bill through one parliament would be a signal to the nation's others.

The high stakes have mobilised the Catholic Church and even former prime minister Paul Keating, bringing debate on the ethics and practicalities of medically assisted dying to a level not seen in Australia for 20 years.

The arguments for voluntary assisted dying

People are suffering "bad" deaths

The most prominent argument for assisted dying laws highlights the consequences of not having them: often violent suicides that traumatise family and friends.

The Victorian state coroner gave evidence to a parliamentary inquiry last year that between January 2009 and December 2013 there were 2879 suicide deaths in Victoria. In 240 of these cases there was "evidence that the deceased had experienced an irreversible deterioration in physical health due to disease or injury". The most common suicide methods were by poisoning, hanging and firearm.

Dr Rodney Syme, who has supplied the drug Nembutal to terminally-ill patients in Australia, also points out that simply knowing the option of voluntary assisted dying is available can offer significant psychological comfort to a person anxious about the circumstances their death.

Palliative care cannot alleviate suffering in all cases

Palliative care is defined by the World Health Organisation as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering".

However, research has found even high-quality palliative care cannot relieve significant pain and suffering in some cases. Surveys conducted by the University of Wollongong's Palliative Care Outcomes Collaboration between 2008 and 2011 found "patients can still experience high levels of pain and other symptoms despite the involvement of a specialist palliative care service".

The surveys found that 58 per cent of patients reported mild levels of pain and 25 per cent severe pain.

The legislation is based on a long-standing law in the US state of Oregon

The NSW voluntary assisted dying legislation is modelled on law in force in Oregon since 1997.

Under the Dying With Dignity Act, Oregonians can "obtain and use prescriptions from their physicians for self-administered, lethal doses of medications". To be eligible a patient must be aged at least 18, an Oregon resident, mentally competent and suffering from a terminal illness that will lead to death within six months.

In Oregon, 1749 people have had prescriptions written under the Act and 1127 patients have died from taking the medications. In 2016, there were 204 deaths under the Act, with 80.4 per cent of patients aged 65 and over. The rate of Dying With Dignity Act deaths for that year was 37.2 per 10,000 total deaths.

Advocates say the state of Oregon is evidence that conservative models for physician-assisted suicide can be maintained without gradual expansion. That state's strict laws affording euthanasia drugs only to patients facing death within six months have not been amended for nearly two decades. 

 

The arguments against voluntary assisted dying

The slippery slope

Only seven states around the world have legalised voluntary euthanasia, including the Low Countries, Switzerland, Colombia, Canada and some American states.

Opponents say their experience shows laying down terms such as "unbearable suffering" in law leads to future blurring of their meaning. The director of palliative medicine at RPA Hospital, Dr Maria Cigolini, says: "Once you change a criminal law [allowing] people to be killed, then it can be extended beyond just being terminally ill and to include psycho-social reasons."

A 2006 review of international cases found "psychological, existential and social reasons" figured more often than medical symptoms when patients asked for a hastened death. 

Euthanasia has been extended to include cases involving children in both Belgium and the Netherlands but laws in America have remained stable.

Alcoholism, mental illness caused by sexual abuse, botched gender-transformation surgery and paralysis have all been used as reasons for euthanasia in Europe. But in Belgium official statistics list cancer as behind more than 70 per cent of requests and psychological reasons in fewer than 5 per cent. 

Medical ethics

A number of major medical bodies have refused to endorse euthanasia because they believe a doctor hastening the end of life undermines the foundation of medical ethics. The World Health Organisation, the Royal Australian College of Physicians and the Australian Medical Association all believe that more palliative care is the ethical policy response.

Opponents also believe that euthanasia presents muddy issues relating to patient consent. Some physicians who specialise in end-of-life medicine, such as Dr Cigolini, say the desire for death is often transient.

One attempt to quantify this phenomenon, a 1999 study in the medical journal Lancet, measured the will to live of about 150 elderly patients in the advanced stages of terminal cancer and found it fluctuated even between intervals as short as 12 hours. 

Safeguards

Many in the state parliament voting against the bill worry that no legislation, however well designed, can protect vulnerable people from feeling like a burden to their families and seeking to end their lives. 

A 2013 attempt to introduce euthanasia in the NSW parliament was defeated easily. Some MPs who then voted no are now leading the charge for this bill, which they argue has stronger safeguards.

Shadow health minister Walt Secord will remain a no voter. He stresses his objections are not religious but were shaped by three years working for the federal aged care minister, which convinced him it would be "almost impossible" to design a policy that could protect their residents from manipulation.

Former NSW deputy premier John Watkins, who chairs Calvary Healthcare agrees: "There are too many examples of elder abuse and inheritance impatience before our Guardianship tribunals to comfortably ignore this risk."


Lifeline 13 11 14; MensLine 1300 789 978; Beyondblue 1300 224 636
 

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