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It’s time for doctors to start thinking about the End of Life Choice Act review

It’s amazing how fast five years can go. Although it doesn’t seem like half a decade since the End of Life Choice Bill was making its way through Parliament, it’s already time for the post-enactment review that was promised when the Bill became law. By November this year, the Ministry of Health must have completed a review of the Act, considered whether any law changes are “necessary or desirable,” and reported to the Minister.

Most doctors opposed the Bill before it became law, and there’s still a majority against it even after enactment. There’s a good chance the majority’s concerns are going to be sharpened by the review. To see how, let’s look at two main issues and the way they could interact.

The first issue is that proponents of the law want to see it expanded. Eligibility for assisted dying depends on having a terminal illness and a prognosis of six months or less to live. David Seymour, the law’s architect and now Associate Health Minister, has made no secret of his personal belief that denying euthanasia or assisted suicide to people with longer to live is “cruel”. The media campaign is also underway, with some advocates calling for eligibility to extend to degenerative illnesses and against the background of a coming “dementia tsunami”.

That would make our law more like Canada’s, which allows euthanasia or assisted suicide where a patient has a “grievous and irremediable medical condition”, comprised of a “serious and incurable” illness, an “advanced state of irreversible decline”, and “enduring physical or psychological suffering”. While our law and our experience wouldn’t exactly map Canada’s, their direction of travel is clear: the number of cases is growing at over 30 percent each year, and four percent of all deaths were “medically assisted” in 2022, up from 2 percent in 2019. That accounted for 13,000 Canadians in 2022 and 45,000 in total since 2016.

The second issue is that there seems to be little sympathy for New Zealand practitioners who don’t want to participate in assisted dying.

Earlier this year, we asked the public whether a doctor who doesn’t want any involvement with euthanasia for religious or moral reasons should still be legally required to tell patients how to access those services. A clear majority, 67 percent, said they should have to give this information. Never mind that anyone who wants to can find that information themselves with a quick Google (“i want assisted dying” will get you there in two clicks, ironically after you’ve scrolled past promotions for Lifeline and the Suicide Crisis Helpline at the top of the search page).

Now put these two issues together. Expanding the law to cover more conditions will generate more conscience concerns for doctors fielding requests for assisted dying. Let’s start with the current position. Some doctors may already feel that the Act’s conscience provision is too burdensome when it says that a doctor with a conscientious objection must tell their patient they can find a replacement doctor through the SCENZ (Support and Consultation for End of Life in New Zealand) Group. Other doctors may not object to assisted dying in principle, or may have no objection to the SCENZ requirement. But they may be concerned about the difficulty of complying with the Act’s requirements when one of their patients requests the option of assisted dying. This includes their obligation to give a definite prognosis, to ensure the patient “has had the opportunity to discuss their wish with those whom they choose,” and to attempt to ensure the patient’s request is not affected by pressure from others. Doctors who feel these requirements aren’t realistic may already want to opt out of involvement in assisted dying, whether they think of that as a conscience issue or simply a practical concern.

Expanded eligibility criteria are likely to increase these concerns. They will certainly sharpen the concerns for doctors who already object to participating in assisted dying, whether that’s on principle or out of concern for safety under the Act’s existing requirements. Expanded criteria may also create new conscience issues for doctors who don’t currently object.This cohort of practitioners may, for example, be perfectly happy providing assisted dying in some cases, like end-stage cancer, but object to providing it in others, say, if the law was extended to the kind of “grievous and irremediable” conditions covered in Canada, which includes neurological conditions like Parkinson’s disease, multiple sclerosis, and dementia. Doctors, and others, may also oppose the broader cultural message that expansion would send—that living with some kind of impairment or disability reduces the value of that person’s life or society’s commitment to providing them with care and treatment.

At the same time as doctors may have more conscience concerns, the polling suggests many members of the public will see these concerns as hindering their access to the life-ending procedures they want. The combined effect may be increased friction between doctors who worry about where the end-of-life regime is taking us, and the public who apparently see doctors more as providers of consumer services than as conscientious professionals.

If doctors are at all concerned about this, now is a good time to start engaging with the upcoming review. Doctors may have ideas about its terms of reference and want to share them with the Minister. They may want to get together with colleagues to discuss how to constructively share a medical perspective with the review. They may have concerns about the various pressures that can already influence patients to consider assisted dying, like economic or sector constraints that can limit vulnerable patients’ access to services. They may be concerned that the review could increase pressure on hospices or other institutions to help patients access assisted dying. Or doctors may have observed the current practice of euthanasia and assisted suicide and have stories they think the review, and maybe the public, should hear.

Whatever the concerns, the review is a chance to inform policy and practice, and to speak into the suggestions of law change. Nearly 800 New Zealanders have received euthanasia or assisted suicide since November 2021. It would be a shame to let the review pass us by and to find ourselves, in another five years, wondering where the last half-decade went, and what happened to that opportunity to engage.

Read "Students and Social Transition"
Alex Penk
June 10, 2024
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