Article Text

Download PDFPDF
Eligibility and access to voluntary assisted dying: a view from Victoria, Australia
  1. Rosalind J McDougall1,
  2. Danielle Ko2,3
  1. 1 Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
  2. 2 Department of Palliative Care, Austin Health, Heidelberg, Victoria, Australia
  3. 3 Department of Patient Safety and Clinical Excellence, Austin Health, Heidelberg, Victoria, Australia
  1. Correspondence to Dr Rosalind J McDougall, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC 3010, Australia; rmcdo{at}unimelb.edu.au

Statistics from Altmetric.com

In their analysis of the eligibility criteria for assisted dying in Canada, Downie and Schuklenk put forward a strong argument for the ethical defensibility of including mental illnesses and disabilities as underlying conditions driving a person’s request for assisted dying.1 In this commentary, we add a view on these debates from our home state of Victoria, Australia, where voluntary assisted dying has been legal since June 2019. We highlight the more conservative approach to eligibility in our setting compared with Canada, and argue for debates about eligibility criteria to be conceptualised as part of a broader discussion about access to assisted dying that includes clinicians’ roles and perspectives. In our view, clinicians’ perspectives may have a significant impact on individuals’ ability to access assisted dying, regardless of legislative or other changes made to any system. ‘Voluntary assisted dying’ (VAD) is the terminology used in our context, rather than Medical Assistance in Dying (MAiD), so we will use that term when referring to the Victorian system.

There are several key differences between the Canadian and Victorian approaches that are important in relation to the debates addressed by Downie and Schuklenk. First, the emphasis in Victoria is on patient self-administration of the VAD medication. In Victoria, physician administration of VAD is only allowed in circumstances where the patient is physically unable to self-administer or digest the medication (section 48 (3) (a)),2 unlike Canada where only a very small proportion of MAiD deaths are via self-administration.3 Victoria’s legalisation of VAD contributed to momentum for legislative change in other Australian states, where similar legislation for allowing VAD has recently passed through several other state parliaments, with the same focus on patient self-administration of VAD.

Second, in comparison with the Canadian situation, the eligibility criteria for accessing VAD in Victoria are substantially more limited. The Victorian eligibility criteria for accessing VAD, outlined in section 9 of the Act, require that a person must:

  • Have a medical condition that is ‘incurable’, ‘advanced’ and ‘progressive’.

  • Have a prognosis of no longer than 6 months (or 12 months in the case of neurodegenerative disease).

  • Be experiencing suffering caused by the relevant condition, that ‘cannot be relieved in a manner that the patient deems tolerable’.

  • Have decision-making capacity in relation to VAD.2

There are further requirements in relation to residency, the request process, etc.2

The Victorian eligibility criteria are thus far more restrictive than the current Canadian requirements. While the Canadian Parliament’s Bill C-7 removed the requirement that ‘natural death has become reasonably foreseeable’, in Victoria eligibility is limited not only to people with terminal illness, but to people for whom death from their illness is likely within 6 months for most conditions. People for whom mental illness or disability is the underlying condition causing their suffering are specifically excluded from eligibility for VAD in the Victorian system (section 9 (2), (3)).2 These very tight eligibility criteria were presented as a strength of the Victorian approach, with the Victorian government consistently referring to the system as ‘the safest and most conservative’ in the world.4

However, even with these restrictive criteria and the emphasis on self-administration of the VAD medication in the Victorian system, there have been significant challenges for eligible patients attempting to access VAD in Victoria. The specific limited group of people delineated in the Victorian regime—the terminally ill and suffering, within the last months of life—would presumably be the least controversial group in terms of the ethical justifiability of their eligibility for VAD. However, in Victoria, even this group of patients found accessing VAD difficult in many cases. A key reason was the shortage of doctors willing to be involved—particularly specialists in the patient’s particular disease (whose involvement is a necessary condition for access to VAD under the Victorian law) as well as participating doctors in rural and regional areas.5

The experience in Victoria highlights that eligibility under the law is only one element of access to assisted dying. Doctors’ willingness to participate in VAD is a further critical aspect. The small number of Victorian doctors willing to participate in VAD, including in highly affected specialties such as neurology and oncology, was a key barrier to accessibility for eligible patients.6

Further, even doctors willing to participate in VAD make their own nuanced individual decisions about the specific types of patients for whom they are willing to be involved. Participating doctors make their own ethical decisions about the subset of legally eligible people whom they would be comfortable assisting. For example, some participating doctors are only comfortable with assisting patients with whom they have had a long-term therapeutic relationship. Some are only comfortable with assisting patients who can self-administer the medication. Others will only assist those patients whose families are supportive of the patient’s choice, citing not only concerns of future legal action but also the potential for harm and complicated grief for remaining family members.

From the Victorian experience, eligibility under the law is only one aspect of enabling access to assisted dying for particular groups of people who may seek it. Clinicians’ willingness to facilitate VAD for members of the particular group is also necessary. Establishing the ethical defensibility of including mental illness and disability as eligible conditions for MAiD is therefore one important element of debates about access for members of these groups. Understanding whether clinicians would be comfortable in supporting members of these groups is another crucial aspect.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors RJM and DK conceptualised the article. RJM wrote the first draft and DK made substantive revisions.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests DK is a member of the Victorian Voluntary Assisted Dying Review Board. She has engaged in this research in her role as a clinical ethics researcher and palliative care specialist and not in her role as a member of the board. Any views expressed in this paper are not to be attributed to the board.

  • Provenance and peer review Commissioned; internally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles

Other content recommended for you