The assisted dying debate needs to move on from binary questions

by Stephen Child, The Spinoff, 27 August 2016

Dr Child is the President of the New Zealand Medical Association.

In jurisdictions where euthanasia and assisted laws exist, concern is growing about the impact on palliative care, where those seeking euthanasia are referred first to palliative care for assessment. This has led to confusion in patients as to the role of palliative care and – in some instances – patients who are opposed to euthanasia declining palliative care services.

The profession as a whole has also echoed concerns about the accuracy of diagnosis and prognosis, as well as the lack of certainty around measuring the capacity of patients facing terminal illness, who often also have reactive depression, altered brain physiology from medications or metastases, as well as potential external coercion factors.

For the profession, as well as ethical considerations, physician-assisted dying raises issues of:

  • potential impacts on palliative care delivery
  • potential changes to a doctor-patient relationship
  • difficulties with adequate training, assessment and regulation of the profession
  • potential negative impact on health providers participating in such acts.

Principles of autonomy and self-determination are, of course, central to this debate. The NZMA respects and supports patient autonomy but is concerned about relying on these principles to enact euthanasia or assisted suicide. Principles of autonomy demand full knowledge of risks and alternatives, and consent must be free of coercion, duress or undue influence.

An absolute guarantee that those who choose assisted dying are doing it voluntarily would be extremely difficult to establish in legislation and ensure in practice. Doctors are often not in a position to detect subtle coercion – as is also the case when trying to identify signs of emotional or financial abuse of elders more generally. Coercion also extends to assumptions of being a burden, giving rise to a sense of an “obligation” to die.

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