Originally published in New Zealand Doctor, February 2018
by Rosalie Evans
I agree that all doctors should read the End of Life Choice Bill. However, unlike Dr Havill et al, I do not believe it is inevitable that this bill will become law, writes GP Rosalie Evans.
Dr Havill et al “cherry-picked” a few submissions to the health select committee which promoted a change in the law, as evidence for their viewpoint
Far more jurisdictions have rejected moves to legalise euthanasia than have passed them. In November 2017, the New South Wales upper house rejected a bill to legalise assisted suicide, while in Victoria, a euthanasia bill was passed. It was the strong opposition of palliative care doctors in NSW that has been credited as one of the main reasons the bill was defeated there.1
I would also encourage all read the health select committee’s report on Petition 2014/18 of Hon Maryan Street and 8974 others2 and Prof Grant Gillet’s report3 (commissioned by the NZMA) on euthanasia. These documents discuss the many ethical and practical considerations involved when a jurisdiction considers legalising euthanasia and/or physician-assisted suicide (EAS).
I take issue with the assertion that 35-50 per cent of New Zealand doctors support voluntary assisted dying4. This figure is based partly on Dr Havill’s survey of one geographical area of New Zealand and the responses of a mere 78 doctors5. The study was criticised previously by Professors D Richmond6 and A D Macleod7 who pointed to the low response rate, the use of euphemisms and the combining of the two end-categories in a five-point scale.
The second study referenced8 has a number of methodological flaws. The issues with online surveys (multiple responses from the same person, responders other than doctors or nurses) are highlighted in the fact that four days of survey results were removed after they received notice that two results were from a TVNZ journalist (who was not a health professional)9.
The sampling is unlikely to be representative because a number of organisations declined to forward the survey to their members, including the New Zealand chapter of the Australia New Zealand Society of Palliative Medicine (ANZSPM) and Palliative Care Nurses New Zealand (PCNNZ).
Currently, NZ Nurses Organisation’s position statement, referenced by Dr Havill et al in their letter, is still in draft form10. It was released in this form before consultation with its members had taken place. No specific input was requested from nurses who specifically work in palliative care, and who overwhelmingly oppose euthanasia11. The final version, post-member consultation, has not yet been released.
Doctors opposing law change
Dr Havill et al “cherry-picked” a few submissions to the health select committee which promoted a change in the law, as evidence for their viewpoint. Yet they ignored the fact that 80 per cent of the general submissions2, and 85 per cent of the submissions from those who identified themselves as doctors, were against a law change. The Australia and New Zealand Society of Palliative Medicine13 and Palliative Care Nurses New Zealand11 both made submissions which strongly opposed the legalisation of euthanasia and assisted suicide.
The NZMA has just released its submission to the justice select committee on the End of Life Choice Bill12. In it, the NZMA has reaffirmed its position that euthanasia is unethical and unnecessary to achieving a good death, and that no legislation can ever make it safe from abuse.
NZMA admits there is a range of views on this issue and over the past few months it has been asking its members for their views on these issues which helped to inform the submission.
Australian study
My experience as a young doctor working in the community and also as a registrar in hospital wards (eg in ED, general medicine, ICU and rural hospitals) does not support the assertion that patients are often dying with unmanageable physical symptoms as implied in the letter4.
Personally, I cannot recall a single situation where a patient’s symptoms were unmanageable following consultation with the palliative care team and after the titration of analgesic medication. There were a few cases where family members felt uncomfortable with the length of time that death was being awaited despite the absence of any evidence that the dying patient was in pain.
I also find it reassuring that a prospective Australian study of 18,975 patients found that only 4.2 per cent experienced severe pain at the time that they were diagnosed as dying14.This does not mean that these patients died with pain, but rather that their symptoms needed urgent attention from skilled medical practitioners. Half of those had no distressing symptoms at the time dying was diagnosed which is very different to the public’s perception of the dying process.
Another point of interest is that 10.8 per cent of those who were diagnosed, by experts in palliative care, as being terminally ill and expected to die within days did not die within the expected timeframe14. This highlights the difficulty doctors face in making accurate diagnoses during the dying process.
I believe that the care of those who are suffering or who are terminally ill is a very important issue for New Zealanders in general, and for doctors in particular, to consider. We, as health professionals, need to think about how euthanasia and assisted suicide, if legalised, would affect both our most vulnerable patients and ourselves.
Submissions due next week
Human dignity is innate to every person. It is not defined by a person’s abilities or by an individual’s contribution to society. I refute totally the premise that a person’s dignity is diminished according to that person’s degree of dependency on others for her or his care.
I encourage my fellow health professionals who feel strongly (whatever their viewpoint) to consider making a submission to the justice select committee regarding the ELCB prior to 6 March, 2018 (note, this is a two-week extension on the original date).
Even if you support assisted suicide in particularly hard cases, it doesn’t mean that it’s in the public’s best interest to enshrine these practices into law. It also doesn’t mean that doctors need to be the ones performing it or that the End of Life Choice Bill would make a good law.
Those doctors who feel strongly, as I do, that they do not want to be part of euthanasia or assisted suicide should visit www.doctorssayno.nz and join the over 550 others who have signed this open letter.
Dr Rosalie Evans (FRNZCGP, FDRHMNZ) is a GP and rural hospital doctor, currently working in Otago.
References
1. Nicholls S. Palliative care experts warn NSW assisted dying bill ‘unsafe’. Brisbane times. 15 Nov 2017. Available from: https://www.
2. Health Select Committee, Fifty-‐first Parliament. Report on Petition 2014/18 of Hon Maryan Street and 8,974 others. August 2017. Available from Wellington NZ: https://www.parliament.nz/
3. Gillett, G. A report on Euthanasia for the NZMA. 2017. New Zealand Medical Association. Wellington. Available from: https://www.nzma.org.nz/
4. Havill J, Smales L, Sparrow M, Johnson L, et al. Letter: Group of doctors urge colleagues to read the End of Life Choice Bill. NZ Doctor. 9 Feb 2018. Available from: https://www.nzdoctor.co.
5. Havill J. Physician Assisted Dying – a survey of Waikato general practitioners. NZ Med J 2015;128(1409):70-71, 20 Feb 2015.
6. Richmond, D. Re: Physician-assisted dying—a survey of Waikato general practitioners NZ Med J 2015;128(1417):57-58, 3 Jul 2015.
7. Macleod, A D. Euthanasia and physician-assisted dying: editorial comment and reply to the Waikato GP survey findings by Dr Havill. NZ Med J 2015;128(1409):9-11, 20 Feb 2015.
8. Oliver Pam, Wilson M, Malpas Phillipa. New Zealand doctor’s and nurses’ views on legalising assisted dying in NZ. NZ Med J 2017;130(1456): 2 June 2017.
9. Malpas, P., M. Wilson, and P. Oliver. “Attitudes of New Zealand Doctors and Nurses Towards Legalising Assisted Dying – Report to New Zealand Medical and Nursing Associations.” Auckland: The University of Auckland, May 2016.
10. New Zealand Nurses Organisation. Guidelines: Professional challenges – Assisted dying position statement [Draft]. Avilable from: https://www.nzno.org.nz/
11. Palliative Care Nurses New Zealand Society Inc. Submission: ‘Health Select Committee: Petition of Hon Maryan Street and 8,974 others. Available from: https://www.parliament.
12.New Zealand Medical Association. End of life Choice Bill Submission to the Justice Select Committee. Feb 2018. Available from:https://www.nzma.org.nz/_
13. The Australian and New Zealand Society of Palliative Medicine. (2015). Submission: Investigation into Ending One’s Life in New Zealand. Available from: http://www.
14. Clark, K., Connolly, A., Clapham, S. et al. (2016). Physical symptoms at the time of dying was diagnosed: a consecutive cohort study to describe the prevalence and intensity of problems experienced by imminently dying palliative care patients by diagnosis and place of care. J Pall Med, 19(12):1288-1295. doi:10.1089/jpm.2016.0219.