Last November, Victoria passed the Voluntary Assisted Dying Act, becoming the first Australian State to legalise assisted dying.
The Act comes into force on 19 June 2019.
How will a person lawfully use the Act? This post provides a brief walk through the procedure established by the Act.
This is not the first time Victoria has been at the vanguard of law reform on a hotly contested bioethical issue. In 1988, Victoria introduced Australia’s first advance directives legislation, the Medical Treatment Act (it was repealed on 12 March 2018, replaced by the Medical Treatment Planning and Decisions Act 2016). Earlier, in 1984, Victoria passed the Infertility (Medical Procedures) Act 1984, the world’s first legislation regulating IVF and human embryo research, now replaced by the Assisted Reproductive Treatment Act 2008.
Can’t talk about it
Prior to the Parliamentary vote, former Prime Minister Paul Keating argued passionately against the Act, writing that “The experience of overseas jurisdictions suggests that pressures for further liberalisation are irresistible”.
The Act is said to contain 68 safeguards to guard against abuse.
One of the most interesting safeguards is section 8(1), which states that a medical practitioner must not initiate a discussion with a patient that is “in substance about voluntary assisted dying”.
A doctor who does so engages in unprofessional conduct under (Victoria’s version of) the Health Practitioner Regulation National Law.
Section 75 of the Act also imposes mandatory notification requirements [to the Australian Health Practitioner Regulation Agency] on a medical practitioner who reasonably believes that another registered health practitioner has initiated a discussion about voluntary assisted dying, or offered to provide voluntary assisted dying in a manner that is not in accordance with the Act.
Mandatory notification requirements are imposed on an employer in the same circumstances (s 76).
Before assisted dying was legalized in Victoria, there was nothing unlawful about talking to a terminally ill person about assisted dying. The topic was not “off the table”, so long as no action was taken.
But now, drawing a person’s attention to a lawful course of action under an Act of Parliament apparently amounts to reportable misconduct, in order to ensure that zealous health care workers do not nudge sick and distressed, aging or disabled people towards “euthanasia”.
Right to opt-out
There is no obligation on a medical practitioner to assist a patient to die under the Act.
Under section 7, a medical practitioner who has a conscientious objection to voluntary assisted dying has the right to refuse to provide information about assisted dying, to participate in the process the Act establishes, and to supply drugs or be present at the time an assisted dying substance is administered.
A complex process
With 143 sections, the Voluntary Assisted Dying Act is a complex piece of legislation.
This is intentional: the legislative requirements that must be satisfied before assistance in dying can lawfully be given are intended to act as safeguards against misuse.
Victoria’s assisted dying regime is only open to adults who have been resident in Victoria for at least 12 months – this is clear from section 9 [s 9(1)(b)].
This is intended to prevent Swiss-style euthanasia tourism – the kind of tourism illustrated in the film “Me before You” starring Emilia Clarke and Sam Claflin.
A person doesn’t meet the eligibility criteria for assistance unless they are suffering from an incurable disease that has reached such an advanced state that death is expected within 6 months, and the disease is causing suffering that is intolerable to the person [s 9(1)(d)].
One exception to this is in s 9(4), which allows a person to access assistance if they have a neurodegenerative disease that will cause death within 12 months.
Coordinating medical practitioner
The process of assisted dying under the Act begins when a person makes a “first request” for access to voluntary assisted dying to a registered medical practitioner (s 11).
This request may be verbal. The medical practitioner may accept or refuse the request, but if they accept they must record the request, and become the patient’s coordinating medical practitioner (ss 13-15).
A coordinating medical practitioner must be either a medical specialist, or a vocationally registered general practitioner.
[A vocationally registered GP attracts higher Medicare rebates and special Medicare item numbers. There are a variety of pathways to accessing these higher rebates, including through membership of the Royal Australasian College of GPs, or by meeting requirements for vocational registration by the General Practice Recognition Eligibility Committee.]
The coordinating medical practitioner must carry out approved assessment training and then assess whether the patient meets the eligibility criteria set out in s 9. (Approved assessment training must be approved by the Secretary of the Department of Health and Human Services [see s 114]).
In order to be eligible for voluntary assisted dying, a person must have “decision-making capacity” in relation to voluntary assisted dying: s 9(1)(c).
The term “decision-making capacity” is defined in s 4, and it requires a person to be able to understand information, retain it, and use it or weight it in order to reach a decision. The person must also be able to communicate their decision to a medical practitioner.
The coordinating medical practitioner must be satisfied that the patient is acting voluntarily and without coercion, and that their request for assistance to die is enduring (s 20).
If they are assessed as eligible, the coordinating medical practitioner must report to the Voluntary Assisted Dying Review Board (established under s 92 – see s 21) and refer the patient for a consulting assessment (s 22).
The consulting medical practitioner who carries out the this assessment must have completed “assessment training” (s 26) and must be a specialist or vocationally registered GP with at least 5 years’ experience and have “relevant expertise and experience in the disease, illness or medical condition expected to cause the [patient’s] death” (ss 23-24).
If the consulting medical practitioner concludes that all the eligibility criteria are met, they must notify the person and also notify the Board (s 30).
Formal written request
At that point, the patient may make a written declaration requesting access to voluntary assisted dying which meets the requirements set out in s 34.
This request must be signed by the patient in the presence of 2 witnesses and the coordinating medical practitioner.
Witnesses need to meet requirements set out in s 35 and must also sign a certificate dealing with matters set out in s 36.
The patient may then make a final request under s 37. This final request must be at least 9 days after their first request (made under s 11), and at least one day after they were assessed by the consulting medical practitioner as eligible (s 38). However, the requirement for at least 9 days of reflection following the first request may be shortened if the person’s death is imminent and they are likely to die within that 9 day period.
Following the final request, the patient must then appoint a contact person who, amongst other things, must return unused assisted dying drugs to pharmacists (ss 39-40).
The coordinating medical practitioner must then review all the documentation and certify that the request and assessment process complies with the Act. They must give the completed final review form to the Board (s 41).
Voluntary assisted dying permits
This enables the coordinating medical practitioner to apply for a “voluntary assisted dying permit” for the patient (s 43).
There are 2 kinds of voluntary assisted dying permit.
The coordinating medical practitioner can apply for a “self-administration permit” under s 47 if the patient is physically capable of self-administering the drug or poison. The drug in question must be specified in the permit.
Under s 45, a “self-administration permit” authorises the coordinating medical practitioner to prescribe and supply a quantity of drug for self-administration by the patient in sufficient quantity to cause death. It also authorises possession of the drug by the permit holder, and possession by the contact person of unused drug – for the purposes of returning it to a pharmacist.
Alternatively, the coordinating medical practitioner can apply for a practitioner administration permit where the patient is physical incapable of self-administering or ingesting the poison or drug (s 48).
As you might expect, a practitioner administration permit authorises the coordinating medical practitioner to administer the drug in the presence of a witness only if the patient is physically incapable of doing so and the patient has decision-making capacity at the time the request for administration of the drug is made (s 46(c)).
This means that a patient cannot make an advance directive for assisted dying.
The decision to issue a permit is made by the “Secretary” ie the Head of the Department of Health and Human Services, doubtless under delegation (s 49).
Section 57 sets out the information that the coordinating medical practitioner must give the patient before prescribing a drug under a self-administration permit. This includes information about how to self-administer the “voluntary assisted dying substance”, and the fact that the person is under no obligation to fill the prescription or to use it. The drug itself must be stored in a locked box that satisfies prescribed specifications.
The Act also contains labelling and storage requirements, and requirements imposed on pharmacists.
Section 64 states that the patient may make an administration request to the coordinating medical practitioner, in the presence of a witness, to administer the drug specified in a practitioner administration permit.
The person making the request must be the subject of the permit, they must have decision-making capacity in relation to voluntary assisted dying, and they must understand that the drug is to be administered immediately after the request is made.
The coordinating medical practitioner will only have a practitioner administration permit if the person is physically incapable of self-administering the drug to themselves (s 46).
The drug can then be administered.
The witness and the coordinating medical practitioner must jointly fill out a form called the “coordinating medical practitioner administration form”, which must be sent to the Board (ss 65-66).
After the death
The death must be reported as voluntary assisted dying under the Births, Deaths and Marriages Registration Act 1966 (s 67). The Coroner must also be routinely informed of such deaths (s 67(2)).
Section 80 protects a medical practitioner who acts in accordance with the Act from any kind of liability, including liability for unprofessional conduct or professional misconduct.
Part 8 of the Act includes a range of offences for people who take actions otherwise than in accordance with the Act.
Will doctors choose to participate in the process?
It remains to be seen whether Victorian medical practitioners regard the procedures established by the Act as so complex or cumbersome that they prefer to provide assistance informally, rather than triggering the Act’s processes and subjecting themselves to scrutiny.
I’d be surprised if there were not at least a few doctors who adopt this course of action.
The legislation is complex. Doctors may also – again, for reasons of self-protection – confine themselves to traditional forms of palliative care. Those who take a conservative view on the legalization of assisted dying may urge doctors to do this.
For example, if a coordinating medical practitioner administers a drug to a person who is the subject of a practitioner administration permit otherwise than as authorised by that permit, they are liable to life imprisonment (life or such other term as fixed by the Court) (s 83).
It is an offence to fail to give copies of forms to the Board (s 90) and for a contact person to fail to return the unused portion of a euthanatic drug to the pharmacist who dispensed it (s 89).
Using this new legislation is not for the faint-hearted. Doctors who choose to do so will need to know what they are doing.
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