Voluntary assisted dying: peak bodies must provide practical guidance.

Despite widespread reform in Australia, the Australian Medical Association (AMA) remains ethically opposed to voluntary assisted dying (VAD). This article argues that the AMA should abandon its opposition to VAD to fulfil better its mandate of providing the best outcomes for doctors, patients and the community. A neutral stance enables peak bodies to engage more fully in implementation and support diverse perspectives.

Introduction

‘The AMA acknowledges that laws in relation to euthanasia and physician assisted suicide are ultimately a matter for society and government’.

By 2023, approximately 97% of the Australian population will live in a jurisdiction in which voluntary assisted dying (VAD) is a legal option. VAD is one type of end‐of‐life choice, in a spectrum of choices, designed to alleviate a dying person's suffering by allowing them to choose the manner and timing of their death. It involves the administration of a prescribed lethal substance, either by self‐administration or by a health practitioner at the request of the person, with the purpose of bringing about the person's death.

The degree of VAD reform across Australia in the past 5 years has been striking; since 2017, Victoria, Western Australia, Tasmania, South Australia, Queensland, and New South Wales have all enacted VAD legislation (Table 1). There are also efforts to reinstate territorial power to legislate on VAD. Despite this extensive reform, the Australian Medical Association (AMA) has not revisited its 2016 position statement which is ethically opposed to VAD. This paper argues that the AMA should now update its statement and abandon its opposition.

Table 1

Australian states that have passed voluntary assisted dying laws (as of 27 May 2022)

State	Legislation	Date operational
Victoria	Voluntary Assisted Dying Act 2017 (Vic)	19 June 2019
Western Australia	Voluntary Assisted Dying Act 2019 (WA)	1 July 2021
Tasmania	End‐of‐Life Choices (Voluntary Assisted Dying) Act 2021 (Tas)	By 23 October 2022
South Australia	Voluntary Assisted Dying Act 2021 (SA)	March 2023 (proposed but not confirmed)
Queensland	Voluntary Assisted Dying Act 2021 (Qld)	1 January 2023
New South Wales	Voluntary Assisted Dying Act 2022 (NSW)	27 November 2023

Diverse views on VAD in the medical profession

Assessing attitudes towards VAD can be challenging, as survey results can be influenced by framing effects, and vary in their sampling methodology and response rates. , Nevertheless, data have demonstrated broad trends. In Australia, surveys suggest there is strong public support for VAD, with the majority (~70–80%) of the community in favour of legalisation. , However, the medical profession historically has been divided on VAD (although doctors' degree of support varies by country ).

In Australia, a 2016 online survey of AMA members (conducted when VAD was illegal across the country) found divergent views in response to various questions about ‘euthanasia’ and ‘physician‐assisted suicide’. , , The AMA did not publicly release the full survey results; although it published a report of the results for its members, it only commented on select outcomes in the media. , The survey received approximately 4000 responses (12% response rate) and respondents' attitudes to VAD varied based on the question. A key question reported on publicly was the AMA's existing position that ‘doctors should not be involved in interventions that have as their primary purpose the ending of a patient's life’. The survey found that 50% of respondents agreed with this position, 38% disagreed and 12% were undecided. , , However, in a separate question querying whether ‘euthanasia can form a legitimate part of medical care’, 52% of respondents agreed, 38% disagreed and 11% were neutral. Most respondents indicated that if VAD were legalised, doctors should be the ones to provide it. ,

Surveys from Australian medical colleges have also found mixed attitudes towards VAD. In 2018, the Royal Australasian College of Physicians (RACP) conducted extensive consultation and found its members had a range of views on VAD, from strong opposition to strong support. Similarly, in a survey of its membership (response rate of 55%), the Medical Oncology Group of Australia (a specialist society of the RACP) could not reach a clear majority position: 47% of respondents disagreed with VAD; 36% agreed with VAD and 17% were neutral. A 2017 online survey of Australian and New Zealand Society for Geriatric Medicine members (20% response rate) found that 53% opposed the legislation, 24% supported it and 23% were undecided.

College position statements with a neutral stance on VAD

As a result of the diverse views in the medical profession, several medical colleges have adopted a neutral stance on VAD. Our recent analysis of VAD policies found the RACP, the Royal Australian College of General Practitioners (RACGP) and the Royal Australian and New Zealand College of Psychiatrists (RANZCP) have all adopted a neutral position. The RACP statement notes:

The RACP respects and supports all its members and does not believe it is appropriate or possible to enforce a single view on a matter where individual conscience is important. … Our members are not unanimous in their support of or opposition to legislative change.

The RACP statement ‘recognises that legalisation of voluntary assisted dying is for governments to decide’ and maintains it:

‘…will continue to advocate for patient and physician well‐being, in order to support our members and contribute our expertise as medical specialists who care for dying patients.’

Similarly, the RACGP position statement recognises that GPs are integral to a patient‐centred approach to VAD and aims:

‘…to provide frameworks and commentary to ensure that both patients and GPs are supported when legislation for voluntary assisted dying comes into the clinical setting.’

The RANZCP position statement on VAD was issued after VAD was legalised in Victoria and WA and states it was developed ‘to provide a psychiatric perspective on VAD’. The statement discusses the ways psychiatrists could be involved in VAD, including seeing patients who might be considering VAD, and providing consultations for the purpose of a VAD assessment.

While these college position statements are tailored to their respective medical specialties, they have several broad factors in common. First, the RACP, RACGP and RANZCP statements are all explicitly neutral and clarify that providing a perspective on VAD should not be construed as support for legalisation. Second, all use the legislative terminology ‘voluntary assisted dying’. The RACP statement indicates the Working Party that informed the policy ‘considered (the) language (of euthanasia and physician‐assisted dying) to be loaded, and to lead to polarised thinking and a stalemate’, and it was ‘most practical to use the prevalent legal language, accepting that all the terminology is to some extent disputed’. Last, another common factor is that rather than engaging in political advocacy, all statements are focussed on recommendations for policymakers to consider when legalising and implementing VAD, including adopting a patient‐centred approach, ensuring access to quality end‐of‐life care and protecting doctors' right to choose whether or not to be involved in the VAD process.

The AMA's position on VAD remains unchanged

The AMA Position Statement: Euthanasia and Physician Assisted Suicide 2016 stands in contrast to these college position statements. The AMA statement was last revised in 2016, prior to the passage of VAD legislation in Victoria (the first Australian state to legalise VAD). The AMA has a long history of opposition to VAD. When the AMA last revised its statement in 2016, it softened its stance somewhat, stating for the first time that it ‘acknowledges that laws in relation to euthanasia and physician assisted suicide are ultimately a matter for society and government’. The statement also foreshadowed that if VAD was to be legalised in Australia, it was imperative that the medical profession be involved:However, despite recognising that the legalisation of VAD was a matter for democratically elected legislatures, the AMA reiterated its ethical opposition to VAD in the 2016 revision, retaining the language that:

…in the development of relevant legislation, regulations and guidelines which protect:

all doctors acting within the law;

vulnerable patients – such as those who may be coerced or be susceptible to undue influence, or those who may consider themselves to be a burden to their families, carers or society;

patients and doctors who do not want to participate; and

the functioning of the health system as a whole.

3.1 The AMA believes that doctors should not be involved in interventions that have as their primary intention the ending of a person's life…

The AMA statement remains unchanged since 2016, despite the passage of VAD laws across most of the country. This creates a conflict between the ethical obligations for doctors set out in section 3.1 of the statement and the legal frameworks established by VAD legislation in Victoria, Western Australia, Tasmania, South Australia, Queensland and New South Wales. While the AMA statement advocates for high‐quality end‐of‐life care (section 1) and endorses other end‐of‐life choices that can relieve suffering (section 2.2), its opposition to VAD is clear and has subsequently been reiterated in public statements and parliamentary submissions.

International comparators

In contrast to the AMA's continued ethical opposition to VAD, medical bodies internationally have adopted an explicitly neutral stance ahead of the prospect of legalisation. The Canadian Medical Association (CMA) abandoned its opposition during the landmark Carter v Canada case, in which the Supreme Court struck down the prohibition on medical assistance in dying (MAiD). The CMA determined it was important to be involved if the law changed, and while the Carter case was still being litigated it conducted broad consultations on MAiD and end‐of‐life care with its members and the public. In a BMJ commentary, Dr Jeff Blackmer, part of the CMA leadership, noted ‘(a)lthough views were divergent, the consensus was clear: Canada needed a framework to protect vulnerable patients’. Blackmer described the CMA's policy change as ‘a watershed moment, enabling the association to lead national discussions’ and take an active role in implementing MAiD across Canada. This role included meeting with legislators, regulators and federal and provincial government stakeholders to ‘represent the wide ranging perspectives of the medical profession’.

The British Medical Association (BMA) (which had opposed VAD since 2006) also recently adopted a neutral stance on VAD, prior to parliamentary debate that commenced in October 2021. The policy change came following a debate at the BMA's annual meeting in September 2021, which found 49% in favour of adopting a position of neutrality, 48% against it and 3% declining to vote. The debate was informed by the BMA's first‐ever survey of its members conducted in 2020 (19% response rate), which found 40% of respondents thought the BMA should actively support attempts to change the law, 33% favoured opposition and 21% thought the BMA should adopt a neutral stance. In its commentary on the shift to neutrality, the BMA stated it would not support or oppose efforts to change the law but would advocate ‘…to represent our members' interests and concerns in any future legislative proposals’.

An active role in implementation benefits doctors, patients and the community

Policy work takes time, particularly in controversial areas such as VAD. It is possible that the AMA is currently considering its position in light of the new legal landscape in much of Australia. Indeed, in September 2021, the Chair of the AMA Ethics and Medicolegal Committee was quoted in the media as voicing broad support for the New South Wales VAD bill. It is also possible that the AMA intends to leave its policy in its current form.

We urge the AMA to issue a revised statement which abandons its ethical opposition to VAD and, like the college statements discussed above, adopts the legislative language ‘voluntary assisted dying’. The RACP, RACGP, RANZGP positions and the experience of the CMA and BMA, illustrate a key advantage of not opposing VAD; namely, this facilitates contribution to VAD implementation and regulation by supporting diverse perspectives.

The AMA's mandate is broad:

Representing doctors, the AMA works with governments to develop and influence health policy to provide the best outcomes for doctors, their patients, and the community.

Being formally opposed to a practice that is lawful (or will soon be) across most of Australia, is supported by a large majority of the public, and on which there are diverse views within the medical profession, hampers the AMA's ability to achieve this mission. Abandoning opposition provides greater scope for medical professional organisations to provide practical guidance on VAD to protect practitioners, promote patient‐centred care, and support the safe functioning of the health system (see Table 2 for examples of the practical guidance that could be provided).

Table 2

Key questions about which medical professional organisations can provide guidance for states that have legalised voluntary assisted dying (VAD)

Supporting doctors What supports are needed for doctors and other health professionals who participate in VAD and for those who do not (including organisational supports, professional supports, and self‐care)? What practices support doctors to assess VAD eligibility criteria and prescribe or administer the VAD substance? What protections are needed for conscientious objection and what duties do doctors have when they conscientiously object to VAD? What guidance is needed for junior doctors who may encounter requests for VAD (whether or not they conscientiously object)? What guidance is needed to support respectful professional relationships when VAD is integrated into practice (in particular, for those who participate in VAD and those who object to it)? What supports are needed for doctors who care for patients who have chosen VAD but are not directly involved in the process (e.g. specialists who treat co‐morbidities, and those who are present when an individual self‐administers a VAD substance)?

Supporting patient‐centred care What is needed to support patient‐centred care for persons seeking VAD? How can patient awareness of VAD as an option be improved? How should factors like voluntariness, coercion and an enduring request be assessed and monitored in practice? What can be done to support patients who choose VAD? How can the health system facilitate patient access to VAD where institutions may object? What supports are needed for Aboriginal and Torres Strait Islander peoples, and culturally and linguistically diverse patients and their families? What education is needed for doctors to understand palliative care better so that they can better advise patients on all palliative and treatment options?

Supporting the community and health system How can access to VAD in rural/remote areas be better supported? In what circumstances can telehealth be used for VAD, and what practices are needed to support doctors and patients to ensure safe and effective practice? What research is needed to ensure that the VAD system is appropriately monitored, and functions as intended? What aspects of system design can be improved to support medical practitioners better (including those who participate in VAD and those who do not)? How can the health system ensure that those who assess and provide VAD receive appropriate financial remuneration?

For doctors, best outcomes regarding VAD include health policy that supports all involved, including those who provide VAD, those who do not, and those who are neutral or undecided. For doctors participating in VAD, the current AMA position may be perceived as suggesting that their lawful conduct is unethical. Evidence from other jurisdictions demonstrates inter‐professional dynamics are a challenge when VAD is implemented. A neutral position would better reflect the lack of medical consensus about VAD's ethical acceptability and would enable the AMA to better support doctors to navigate these challenging issues in a respectful and professional way.

For patients, best outcomes involve access for those who are eligible and make this choice, as part of holistic, integrated end‐of‐life care. It also involves ensuring those who are ineligible, or do not want VAD, continue to be supported and receive optimal end‐of‐life care. The AMA's focus on patient‐centred care should include making VAD safe yet accessible for eligible people. A neutral position would help drive policy to ensure all patients are supported, regardless of their end‐of‐life choices. Additionally, as the RACP recognises, adopting the terminology ‘voluntary assisted dying’ reflects the legislative language and would help reduce the polarising effect associated with terminology such as ‘euthanasia’ and ‘physician‐assisted suicide’.

For the community, the AMA's role in influencing VAD policy includes protecting the vulnerable and improving the functioning of what is now part of the health system. This could occur in a variety of ways including promoting rigorous research into VAD, commenting on VAD Review Board Reports, or furthering broader efforts to ensure high‐quality, integrated end‐of‐life care, including promoting access to palliative care. A neutral position by the AMA can help ensure that a diverse range of community views are promoted in these activities at a national level. It could also help promote standardised practice (to the extent possible given variations in local laws) across Australian jurisdictions.

Conclusion

With the passage of VAD legislation in most of Australia, society and government have spoken. The AMA should now revisit its position on VAD to better reflect diverse views of its members, the medical community and the broader public. Implementation of VAD is ongoing and continues after laws commence as the system is evaluated and refined. A shift to a position of neutrality (which has occurred for other Australian medical bodies including the RACP, the RACGP and the RANZCP) could enhance the AMA's ability to guide policy and practice in this complex arena.