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Ethical Challenges About Voluntary Assisted Dying

By Ian Haines

Much of the focus on new voluntary assisted dying laws is centred on patient autonomy, but it is only one of the four pillars. Does the legislation also satisfy the other three tenets of beneficence, non-maleficence and justice?

Will voluntary assisted dying (VAD) legislation provide compassionate physician-assisted dying, as hoped, or are we providing state-sanctioned euthanasia and assisted suicide? It certainly raises some important ethical questions.

Many of the submissions in Victoria were about tragic cases of desperate and suffering people with incurable illness who had taken or attempted to take their lives in sometimes very horrific circumstances. There was also a focus on high-profile celebrities and politicians who had watched on feeling helpless as a loved one suffered and died.

Many of us would want to put these people “out of their misery” as soon as possible, wouldn’t we? But is it what the patients themselves would choose if they had access to high-quality palliative care and psychosocial intervention, which are their right under the other tents of ethical care?

There is every indication from the written submissions that this was often not offered or provided. Also, none of the high-profile celebrities and politicians indicated that their loved ones had strongly requested VAD when they were still capable of providing informed signed consent, or that their loved ones had received optimal palliative and psychosocial care.

When my own father died of advanced cancer he was like most of us and most of the thousands of patients with cancer that I have cared for until the end. He wanted to be spared a death with suffering. However, he was also desperately keen to stay alive for the first Brisbane Lions AFL premiership in 2001. He shared this, fully alert and “in the moment” of euphoria and joy from his inpatient palliative care bed, surrounded by 29 of his family. He was then “ready to go”, and the combination of modern palliative care, terminal sedation and the law of “double effect’ – which protects doctors if a medication given to relieve suffering or distress also contributes to a quicker patient death – allowed him to die very peacefully 7 days later.

My mother, a powerful advocate for euthanasia, developed severe dementia years later and would have been unable to consent to the new laws. However, when she developed pneumonia, we instituted modern comfort care only and she also died quickly and peacefully surrounded by family.

Patient autonomy is vitally important, but what about the autonomy of the physicians and nurses who just want to provide optimal, modern comfort care for suffering patients? We can achieve this for most patients, and for the remainder we have terminal sedation and the protection of the law of double effect.

What about the justice and non-maleficence principle of protecting patients from the pressure and coercion that comes from relatives who want their inheritance? I have observed this pressure in more than a dozen cases in my 35 years of full-time oncology and palliative care, and it is chilling to observe and challenging to deal with.

What about the strict auditing of the use of the suicide pills and the recovery of the unused ones so that they don’t get into the hands of relatives and friends who want to harm themselves or others? None of these requirements are properly provided for in new and proposed legislation.

What about the patients who have not received optimal care but request VAD? A 1998 study in the Lancet of the four patients who received euthanasia in the Northern Territory when it was legal from 1996–97 revealed that one was depressed, another was socially isolated, only one had seen a specialist palliative care physician, and none had uncontrolled pain .

What about the difficulty of predicting if a patient has less than 6 months to live? Doctors are consistently very poor at this and I am certainly not much better at it now than when I started 35 years ago.

Surely improved funding and provision of optimal palliative care rather than state-sanctioned euthanasia should be the focus of any ethical, modern, wealthy, liberal, secular and pluralist society?


Dr Ian Haines is a medical oncologist and Adjunct Clinical Associate Professor of Medicine at Monash University.