Questions and answers on the Victorian “Voluntary Assisted Dying Bill 2017”
To be debated in the Victorian Legislative Council (late 2017)
Dr Peter McCullagh MD (Melb), D Phil (Oxon), MRCP (Lond) *
Q Has the frequency of euthanasia cases stabilised in Belgium following legalisation in 2003?
A Hardly. Despite an initial expectation that this would occur after a ‘backlog’ had been processed, there has been a steady increase from 235 in the first year to 1807 in 2013. Source
Q Is this increase likely to occur in other places such as Victoria?
A The Canadian Supreme Court addressed this question asserting that the “permissive culture” prevailing in Belgium would not be replicated in Canada. When the tally reached its first thousand, Dr Ellen Wiebe, who had been personally responsible for 40 cases proclaimed that Canada would rapidly attain the frequency, for its population, equivalent to Belgium. This was very different from the testimony provided to the Court by her pro-euthanasia colleagues.
Q How effective has the regulated requirement for reporting cases been in Belgium?
A Not too flash. Interviewing of practitioners by a university based research group found that, in 2010, approximately 50% of cases had not been reported. Source
Q Were there any features which distinguished reported from non-reported cases?
A Unreported cases were dealt with less carefully. One third of unreported cases in Flanders were undertaken without patient request.
Q Wasn’t decriminalisation of euthanasia in Belgium intended to reduce the frequency of unreported cases?
A That was predicted but, in reality, this did not occur.
Q Are there any implications in this outcome, for Victoria?
A There could be. The Legislative Council Select Committee heard evidence, based on surveys, that some 7% of practitioners in NSW and ACT had admitted to researchers that they had intentionally taken steps to end patients’ lives.
Q Have there been instances of investigation of Belgian cases not complying with the ‘robust’ regulatory system.
A Of course. To date, there has been one (out of the roughly 5000 cases). In this instance, the son of a deceased elderly lady raised an objection. It is of some interest that the practitioner involved is the chair of the Belgian regulatory committee.
Q How will ‘assisted dying’ be monitored?
A This will be dependent on self reporting by practitioners.
Q Is there some mechanism for a designated authority to check and, when necessary, ensure that every case is detected?
A This will be completely dependent on people other than the participating practitioner ‘dobbing in’ him or her. Informants could be another healthcare person or a relative or friend of the ex-patient.
Q Will this work?
A Consider, as an example, another system in which the primary responsibility on a person entails self reporting. The Australian Taxation Office requires each citizen receiving an income to self report on that. It’s not unknown for self reporting to the ATO to be ignored by some individuals and, absent additional checks, this system would regularly fail. The ATO has, however, quite a few other mechanisms for detecting unreported transactions. These ensure a high degree of exposure of non compliance. The regulatory model incorporated in the Bill has none apart from the ‘dob in a mate’ provision.
Q Have the eligibility criteria for euthanasia in Belgium changed since decriminalisation?
A Yes. Generally, criteria have been loosened by modification of the original legislation as a response to the occurrence of these modifications in practice.
Some examples include the extension of eligibility to people under 18 years of age. In the case of children aged between 12 and 16, parental agreement is required. The legislated change was preceded by vigorous advocacy by paediatricians at the Queen Fabiola Hospital with explicit request to remove practitioner liability.
Another example was extension of eligibility to include people with dementia. In this situation, an existing limit of 5 years on operation of an advance directive was quashed.
Q Are there suicide prevention programs in Belgium?
A Rudimentary. Try googling this.
Q The Select Committee assured us that there was a ‘vigorous examination mechanism’ regulating euthanasia in the Netherlands. How vigorous is the examination?
A As early as 2009, the annual report of the official regulating body stated ‘the 5 regional committees have reached the limits of their capacity’. This was attributed to the increasing numbers of candidates.
Q A question prompted by the previous one – how has the frequency of cases changed?
A The number of deaths has steadily increased at a rate of 15% per year. Euthanasia has changed from being a last resort to a default mode of dying. In 2002 the tally was 1882 but by 2012 this had increased to 4188. Source
Q Aren’t those Dutch practitioners who provide the service also trained in palliative care?
A Certainly. Their association, SCEN (Support and Consultation in Euthanasia in the Netherlands), provides a 24 hour training course in all aspects of the service. 3 hours of this deliver instruction in palliative care (in order for an Australian practitioner to acquire PC recognition, several years of training and experience are necessary).
Q A frequently mentioned precaution of Dutch practice is that the participation of a patient’s general practitioner, who knows the patient, will occur. Doesn’t this ensure that the GP will have a good knowledge of the patient?
A Yes, but circumstances are rapidly changing. Mobile euthanasia services (dial a jab) are replacing the GP’s. The KNMG (the Royal Dutch Medical Association) has opposed this but to no avail.
Q How efficient is Dutch reporting of euthanasia cases?
A The Lancet reported in 2010, on the basis of interviewing practitioners, that 23% of cases went unreported. Source
Q Are there any other discrepancies in the actual operation of Dutch euthanasia practice?
A Yes. For instance, it was reported in NEJM (New England Journal of Medicine) that, of 2410 deaths in 2005, 560 occurred without explicit patient consent. Source
Q Surely the regulatory requirement that the officiating practitioner must consult a second physician will ensure good practice?
A In 2007, it was reported in BMJ (British Medical Journal) that, in 35% of cases of involuntary euthanasia, a second physician was not consulted. Source
Q Apart from changes in the numbers of patients involved, have there been changes in the nature of practices?
A Yes, a number of significant variations from what was originally legislated. A few examples:
Original legislation precluded individuals from exercising a right to decline a treatment which was potentially beneficial in order to claim then that their consequent condition rendered them eligible for euthanasia. This caveat has been removed.
Whilst individuals affected by a mental health condition were required to have psychological assessment to determine their competence to make decisions, mental health conditions are now grounds for eligibility.
The Dutch government has undertaken to introduce legislation in 2017 to make ‘completed life’ (aka being at least 70 years of age) conferring eligibility for euthanasia.
Q Are suicide prevention programs operative in the Netherlands?
A Poorly developed. Try googling. There are active programs intended specifically to normalise suicide. NVVE Jongeren, the youth wing of the Dutch euthanasia organisation, runs ‘Dead Normal Café’ at which young people are encouraged to discuss suicide in the context of normal life choices (rather different from Victorian programs like Beyond Blue and Headspace).
Q The Select Committee has described the regulatory system in Oregon as ‘robust.’ Is this an accurate description?
A Oregon has decriminalised assisting at a suicide but euthanasia remains illegal. Description of its regulatory process as ‘robust’ is questionable for a number of reasons:
Reporting is not compulsory.
No applicable penalties for failure to report a death.
No information is available on the frequency of non-reporting.
In a series of 61 consecutive cases of assisted suicide, the independent 2nd physician was a member of ‘Compassion and Choices (formerly the Hemlock Society). ‘Independent’ of what?
* Peter McCullagh MD (Melb), D Phil (Oxon), MRCP (Lond)- Spent his first 24 years in Victoria, graduating in Medicine from the University of Melbourne in 1961 and practising as a Resident Medical Officer in a hospital until 1963 when he left for Oxford on a Rhodes Scholarship. Returning to Australia in 1966, he undertook research into the immune system for 35 years at the Australian National University.
While the majority of his career was laboratory based, with clinical responsibilities, he has had several decades of participation in community organisations concerned with disability, most notably as Chair of the National Brain Injury Foundation. Whilst no longer a Victorian resident, he has retained strong associations with medical colleagues there.