Accessing assisted dying in Victoria: how will it happen, exactly?

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  In 1988, Victoria introduced Australia’s first advance directives legislation, the Medical Treatment Act (it was repealed on 12 March 2018, replaced by the Medical Treatment Planning and Decisions Act 2016).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.

Eligibility

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).

Consulting assessment

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.

Final request

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.

Administration requests

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.

Are you interested in health law?  Sydney Law School offers a Master of Health Law that is open to lawyers, health professionals and other qualified applicants.  Click here and here for more information, or click here for information on the units of study on offer in 2018 and 2019.

Abortion law reform on the horizon in NSW and Queensland

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Contrary to popular belief, abortion is not available “on demand” in NSW.

The Crimes Act 1900 (NSW) contains three criminal offences relating to abortion.

Section 83 creates an offence for unlawfully administering a drug or using any instrument or other means to procure a woman’s miscarriage,

Section 82 creates an offence for a woman to unlawfully procure her own abortion (eg by taking abortion drugs), while section 84 creates an offence for unlawfully procuring drugs for the purposes of an abortion.

The scope of these offences reflect the limits of the law’s protection for the life of the foetus in the face of a decision by the pregnant woman to terminate her pregnancy.

However, the question of whether the doctor’s actions – or those of the woman or another person – are “lawful” has been left to the common law.  The leading decision is a District Court case from 1971 called R v Wald ([1971] 3 DCR (NSW) 25).

According to Wald, lawfulness turns on whether the jury (or judge) accepts that the person who performed the abortion believed on reasonable grounds that their actions were: “necessary to preserve the women…from serious danger to their life, or physical or mental health, which the continuance of the pregnancy would entail” (going beyond the usual dangers of childbirth), and secondly that the actions taken were not out of proportion to that danger.

Courts have elaborated on a number of issues that emerge from the principles set out above.

For example, in CES v Superclinics (Australia) Pty Ltd [1995] NSWSC 103, Justice Kirby wrote that the economic and social stresses that pregnancy and, in due course, motherhood might impose on the woman were relevant to the doctor’s conscientious belief on reasonable grounds that the abortion was necessary to preserve the physical or mental health of the mother (thereby negativing an offence under section 83 of the Crimes Act).

 

Removing abortion from the criminal law

Greens MP Mehreen Faruqi MLC has introduced the Abortion law Reform (Miscellaneous Acts Amendment) Bill 2016 into the NSW Parliament.

The Bill seeks to do four main things.

Firstly, the Bill would remove abortion from the Crimes Act 1900 (NSW) by repealing the three criminal offences in the Act that relate to abortion.

Secondly (to the extent that it exists), the Bill would abolish any remaining rule of common law creating an offence for procuring a woman’s abortion.

 

Abortion and the duty to refer

Thirdly, having banished abortion from the criminal law, the Bill would impose new requirements on doctors that would take effect through the Health Practitioner Regulation National Law – the statutory framework through which the medical profession enforces norms of professional conduct against medical practitioners.

Section 139C of the National Law, in its application to NSW, sets out the matters which may constitute “unsatisfactory professional conduct”.

Under the Greens Bill, a doctor who was approached by a patient seeking advice about abortion would be guilty of “unsatisfactory professional conduct” if they:

  • failed to tell the person about any conscientious objections to abortion that they had;
  • failed to refer the person in a timely manner to another health practitioner who the doctor knew did not have a conscientious objection to abortion, or to the local Woman’s Health NSW Centre, in order to ensure the woman had “full information about all of the person’s options in relation to the pregnancy”.

The intention of this amendment is appropriate.  It ensures that women are not kept in the dark about their options in ending a pregnancy because the doctor morally disapproves of their choice.  Victoria’s Abortion Law Reform Act 2008 contains a similar provision (s. 8).

Nevertheless, under the Greens Bill, a doctor would apparently be in breach of their professional obligations if they failed to refer the woman to someone who had no objections to abortion, irrespective of the woman’s circumstances and the reasons why she wanted the abortion.

So, to take an extreme example, a pro-life doctor would (obviously) be in breach of their professional obligations if they refused to provide a referral for a pregnant teenager who had been raped.

But so would a pro-choice doctor who nevertheless felt it was wrong to help a woman achieve an abortion because she wanted a boy, but had ended up pregnant with a girl.

This last scenario recalls the experience of Dr Mark Hobart, a Melbourne GP who was investigated for potentially breaching section 8 of the Victorian Act for failing to cooperate in an abortion.

“They wanted the abortion because they wanted a boy and they found out it was a girl” Dr Hobart told Ben Fordham on radio 2GB.

The woman was 18 and a half weeks pregnant.

As it turned out, Dr Hobart held a conscientious objection to all or perhaps most abortions.

In his words: “I guess I believe that life begins at conception, that human life is sacred….I know that other people [don’t hold views as strong as that] but that’s what I believe, I find it a big problem if someone asks me to refer them for an abortion”.

When I documented an “underground” in illicit euthanasia among health professionals working in HIV medicine in the late 1990s, in the book Angels of Death, one of the common ways that doctors, nurses, psychologists and others facilitated euthanasia was by referring people who requested it to others whom they knew would provide it.

Those who facilitated euthanasia in this way might have felt it was the right thing to do.  But they didn’t pretend they weren’t morally involved.

Impediments to access to abortion services are real (see eg Heather Rowe et al, “Considering Abortion: A 12 Month Audit of Records of Women Contacting a Pregnancy Advisory Service” (2009) 190 Medical Journal of Australia 69-72).

But requiring a doctor who has explained that they feel morally conflicted in facilitating the abortion in the circumstances of the case – to help the patient achieve it elsewhere – smacks of triumphalism.

The decision a woman reaches about her pregnancy should be respected.

But doctors should not be treated as moral slaves to their patients, especially in the case of this procedure, the moral character of which is notoriously contested.

There ought to be room for a more sensitive balance between the freedom that a woman ought to have to make decisions about her pregnancy, and the sincerely felt moral beliefs of the clinician.

It’s possible that euthanasia may be legalised in an Australian State within the next few years, if not sooner.  Will it also be “unsatisfactory professional conduct” for a doctor who has moral objections to euthanasia to fail to refer a patient to a colleague who is willing to provide a hot-shot?

 

Safe access zones for abortion

The fourth thing the Greens abortion law reform Bill would do is to implement a 150 metre “safe access zone” around abortion clinics.

A similar exclusion zone exists under the Victorian legislation.

Safe access zones were introduced to protect women who wish to access abortion services, and the staff of abortion clinics, from harassment, obstruction and humiliation by protestors.  In some cases, these protests have been carried on for decades.

 

Abortion law reform in Queensland

Two Bills to amend Queensland’s abortion laws have also been introduced into the Queensland Parliament.

Like NSW, Queensland has criminal prohibitions for “unlawfully” performing an abortion, unlawfully supplying drugs or instruments to procure an abortion, or in the case of a woman herself, unlawfully administering any “poison or noxious thing” to procure a miscarriage (sections 224-226).

However, the common law’s articulation of the circumstances in which an abortion is lawful is considered to be narrower in Queensland than in NSW.

In 2010, a young woman and her boyfriend were prosecuted under section 225 for procuring and self-administering RU486.  It took less than an hour for a jury to find them not guilty.

Two years earlier, in a remarkable judgment, a Justice of the Queensland Supreme Court found that parents lacked legal capacity to authorise an abortion for a 12 year old girl who was 18 weeks pregnant.  Rather, court approval was required.

The first Bill, the Abortion Law Reform (Woman’s Right to Choose) Amendment Bill 2016 (Qld) would effectively take abortion out of the criminal law by repealing sections 224-226 of the Queensland Criminal Code.

The Health (Abortion Law Reform) Amendment Bill 2016 then sets out a new regulatory regime for abortion within the Health Act.

The Bill states that abortion procedures must only be performed by qualified medical practitioners, assisted by qualified nurses who may administer drugs at the written request of a doctor.

No limitations are imposed on the performance of abortions before 24 weeks: these procedures would effectively be available upon demand from a willing medical practitioner, as in Victoria.

Abortions after 24 weeks could only proceed when a doctor had consulted with at least 1 other doctor and both believed that continuing the pregnancy would involve “greater risk of injury to the physical or mental health of the woman than if the pregnancy were terminated”.

Nor is there any duty imposed on a medical practitioner to perform or assist in an abortion (except in an emergency, in order to save the woman’s life or to prevent serious physical injury).

The Bill provides protection from harassment, intimidation and obstruction for persons entering or leaving an abortion facility which the Minister has declared to be a protected area.

The Bill also prohibits protests, “by any means”, between the hours of 7.00am-6.00pm or for such other period   as the Minister declares.  The protected area must extend outwards at least 50m from the abortion facility.

In summary: I would be surprised if either the NSW or Queensland Bills are successful.  Already, a Parliamentary Committee of the Queensland Parliament has recommended that the Abortion Law Reform (Woman’s Right to Choose) Amendment Bill 2016 should not be passed.

Rather than seeking to reverse all the perceived problems of current law in a single legislative episode, abortion law reformers may find it more effective to adopt an incremental approach.

In jurisdictions where the public mood remains more conservative, it might be wiser for law reformers to set out to achieve less.

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Muzzling health and welfare professionals in the name of national security: Australia’s Border Force Act 2015

Posted by Roger Magnusson and Cameron Stewart

This is the view from the top of Table Mountain in Cape Town, South Africa.  Take it in.  It helps to have a sense of perspective.

The view from Table Mountain, Cape Town (1)
The view from Table Mountain, Cape Town (1)

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The view from  Table Mountain, Cape Town (2)
The view from Table Mountain, Cape Town (2)

It’s now more than 21 years since apartheid ended.  These days, few people would criticise anyone for having broken those racially motivated laws that were part of South Africa’s statute book during the period of white minority rule.  But why do people feel that way?

For some, it may be the patent absurdity of discriminating against entire classes of people based on the colour of their skin, or whether or not they passed the “pencil test” .

For others, it may be the fact that laws constructing systematic racial discrimination were inconsistent with a higher moral law, or with international human rights instruments that give protection from discrimination on grounds such as race, colour, sex, language, religion, and national or social origin .

With apartheid in mind, let’s return to Australia.  The Box below describes some key features of the Australian Border Force Act 2015 (Cth).  The application of this Act to health and welfare professionals caring for children in immigration detention has attracted a great deal of attention.

Rightly so.

As law professors, health law specialists, and parents, we know we are not alone in believing that whatever sense of obligation we feel to obey the law is eclipsed by the moral imperative to protect children from harm.  Some of the worst abuses of children, causing lifelong harm and distress, are the result of institutional indifference to instances of abuse.  If you think you care about children, or if you have any children of your own, then consider how the Australian Border Force Act will impact on them.

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The Act creates the Australian Border Force, integrating immigration and customs functions into a single entity within the Department of Immigration and Border Protection.

Amongst other things, the Act appears designed to improve the control of information, to prevent leaks, and to reduce unwelcome media scrutiny of the operation of immigration detention facilities arising from public disclosures by Immigration and Border Protection workers.

The Act creates an offence, carrying a penalty of imprisonment for 2 years, if an “entrusted person” makes a record of, or discloses “protected information” (s. 42).

An “Immigration and Border Protection Worker” includes government employees, as well as consultants – doctors, nurses, social workers – engaged by the Department to work inside immigration detention centres.  “Protected information” means “means information that was obtained by a person in the person’s capacity as an entrusted person”.

The Act authorizes the Secretary of the Department to authorize an entrusted person (let’s say a doctor) to disclose protected information (let’s say allegations of sexual assault against a child in immigration detention) to the Department, to police, or to any other authorized body or person.  However, the Secretary may attach written conditions to the permission to make such disclosures (s. 44).

The Act does authorize disclosure of protected information to “prevent or lessen a serious threat to the life or health of an individual” (s. 48).  However, this would not extend to disclosures to the media relating to the systemic conditions in which children are living in detention, or the impact of incarceration on their mental and physical health and wellbeing.

In summary, the Act appears designed to muzzle health and welfare professionals from reporting any information they obtain in the course of their duties (extending, for example, to allegations of sexual assault against children in immigration detention), except with the permission of a bureaucrat.

The culture operating within the Department of Immigration and Border Protection is likely to mean that Secretarial permission will rarely, if ever, granted.

The likely result of the Act is that it will become more difficult for the government’s accountability for the health, welfare and protection of children in immigration detention to be tested in the political arena.

Whatever you think about the merits of mandatory detention of the children of asylum seekers, the constraints on health and welfare professionals appear to strike at the heart of freedom of speech.  The Act might well infringe the implied constitutional freedom of political communication that all Australians enjoy.  No doubt this will be tested soon.

The Australian Border Force Act does not mention the Public Interest Disclosure Act 2013 , but if – as the government asserts – the former Act is subject to the latter , persons speaking out would need to navigate a thicket of statutory conditions in order to escape prosecution.  The intent of the Australian Border Force Act is to change the culture within which services are delivered to persons in immigration detention: that much seems clear.

It is not surprising that health and welfare professionals have pointed to the contrast between the Australian Border Force Act and the protections that apply to Australian children outside immigration detention.

In NSW, the Children and Young Persons Care and Protection Act 1998 imposes mandatory reporting on health and welfare professionals when they have reasonable grounds to suspect a child is being abused or is at risk of significant harm .  On the other hand, unless the Secretary gives their permission, doctors and welfare workers could be committing a criminal offence if they reveal anything at all about the conditions in which children in immigration detention are living.

Writing in the Guardian, over 40 “entrusted persons” have called for civil disobedience:

“We have advocated, and will continue to advocate, for the health of those for whom we have a duty of care, despite the threats of imprisonment, because standing by and watching sub-standard and harmful care, child abuse and gross violations of human rights is not ethically justifiable”.

As law professors employed by one of Australia’s oldest law schools, we live and breathe law, and care about the rule of law.  Frankly, however, we don’t care about it enough to stand by while government tries to muzzle dedicated professionals working in difficult conditions to protect the safety and dignity of children.

Parliament makes the rules.  It decides what is lawful and unlawful.  But when the moral compass goes astray and laws are designed to ensure that the public never even gets to hear about the harm that children are suffering in immigration detention, then that is a step too far.

The President of Australia’s Human Rights Commission, Professor Gillian Triggs, points out that Australia is alone in the world in indefinitely locking up the children of asylum seekers. The Commission’s Forgotten Children report found that this practice violates the right to health that children enjoy under the Convention on the Rights of the Child.  It also ignores the substantial body of evidence of the harm that immigration detention is causing to children.

“Entrusted persons” face difficult choices in the months ahead.  In deciding how to reconcile their professional ethics, moral intuitions and legal obligations, they can at least stand assured that there can be no moral obligation to stand by and do nothing while children are being harmed.

The Australian Border Force Act 2015 needs a radical overhaul.  Otherwise it belongs in the bin.  Both parties ought to think again.

Take another look at the view from Table Mountain.  In the distance you can see Robben Island, where Nelson Mandela spent 18 of his 27 years of imprisonment.

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