10 June 2021

SA passes voluntary assisted dying

Aged Care TheHill

The laws are expected to mimic Victoria’s system, warts and all.

The South Australian parliament became the latest in the country to pass voluntary assisted dying laws early this morning and is set to implement a system very similar to Victoria’s – including various aspects criticised by doctors.

Following 16 failed attempts spanning more than two decades, the bill passed both the upper and lower houses, and is now awaiting the upper house to ratify various amendments.

Voluntary assisted dying laws, which allow terminally ill patients to request access to fatal doses of medication, have been passed by a growing number of jurisdictions and countries over the last several years.

Victoria, the first state to legalise voluntary assisted dying in Australia, has now had the laws in action for approximately 18 months.

These laws differed from those in other parts of the world in several key ways, according to clinical ethics researcher and endocrinologist Professor Paul Komesaroff.

“The debate [over voluntary assisted dying] has been very polarised, and sometimes the arguments have been very bitterly contested,” he told The Medical Republic.

“So the Victorian government and the Victorian parliament were very well aware of the division in the community, and they sought to allay the fears of people who were strongly in opposition to the concept of voluntary assisted dying by building in multiple safeguards.”

These come in the form of procedures – such as the provision which prevents doctors initiating discussions about voluntary assisted death – which has led some GPs to criticise the system as being overly bureaucratic.

“If a patient says, ‘What are my options?’, a doctor isn’t allowed to say, ‘One of your options is voluntary assisted dying’, the doctor has to wait until the patient raises that question,” Professor Komesaroff said.

“A lot of people have said the secrecy provision in the Victorian legislation doesn’t really work, but in spite of that it’s been included pretty well unchanged in the South Australian legislation.”

The clause was also included in laws passed in Tasmania but was removed from the legislation in Western Australia.

Other process-heavy provisions in the Victorian law includes the requirement for doctors to go through a pre-approval process before acting on a voluntary assisted dying request, in addition to the standard retrospective oversight.

Currently, the only other system with those requirements worldwide is Colombia.

Given that the Victorian voluntary assisted dying system is still in its infancy, there is still a dearth of data on how the extra checks and balances affect care for end-of-life patients.

In one of the first studies on the subject researchers from the Queensland University of Technology Australian Centre for Health Law Research collected qualitative data from 35 Victorian doctors with involvement in voluntary assisted dying.

Their findings, which were published in BMJ Supportive and Palliative Care, included that although many doctors experienced frustration in the application process, they were also very satisfied that the system was robust and secure.

A frequent theme identified by the researchers was concern around the time taken from beginning an application for voluntary assisted dying to receiving approval.

“The doctors described a process where they submitted a form and had to wait for it to be considered by the secretariat of the voluntary assisted dying review board,” lead author Professor Ben White told The Medical Republic.

“The system wouldn’t allow them to progress to the next stage until that form had been returned.

“If there was a problem with a form [such as a name spelled incorrectly] then it came back to the doctor, which they had to then fix, and then resubmit again.

“Each of these steps took time, and as a result one of the concerns overall, the doctors said, was that the period of time this process took was unnecessarily long, in their view.”

According to Professor White, these hold-ups were considered potentially dangerous due to the advanced stages of illness which the patients requesting voluntary assisted dying were in.

This led the research team to conclude that system design was almost as critical to get right as the legal framework.

“These findings about the Victorian system raise questions about whether its prospective oversight and approval process may be an unjustified barrier to assisted dying,” they wrote in BMJ Supportive and Palliative Care.

“This may be due to the nature of the Victorian law, and perhaps particularly how it has been implemented, rather than prospective approval itself being problematic.”

On the flip side, Professor White said some clinicians appreciated the level of oversight.

“There was some appreciation from doctors about having this system which protected them, that if they followed the process, that if they stepped through the processes required, they would be protected and supported,” he told said.

To date:

  • Victoria has legalised and implemented voluntary assisted dying;
  • Western Australia and Tasmania have legalised voluntary assisted dying;
  • South Australia is awaiting ratification, then it will be legalised;
  • Queensland has a bill going through parliament;
  • The Northern Territory and the ACT are banned from passing legislation on voluntary assisted dying by the federal government but are actively campaigning for this right to be restored.

BMJ Supportive & Palliative Care 2021, June 6