Voluntary assisted dying

Purpose

Voluntary assisted dying (VAD) continues to be widely debated across jurisdictions in Australia and New Zealand. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has developed this position statement to provide a psychiatric perspective on VAD.

The RANZCP acknowledges the wide range of views regarding VAD and encourages discussion about relevant ethical considerations.

Key messages

• Psychiatrists may be involved in assessing and offering treatment for people who have symptoms of mental illness as part of a terminal illness, and in supporting people with irremediable suffering.
• Priority should be given to ensuring that all individuals at the end-of-life have access to appropriate, high-quality palliative care.
• Capacity assessment is a minimum safeguard for any voluntary or physician assisted dying process.
• Psychiatrists must be afforded the right to refuse to participate in voluntary or physician assisted dying.

Definition

The RANZCP acknowledges that there are a range of different terms used for VAD. These alternative terms include ‘physician assisted dying’, ‘physician assisted death’ or ‘physician aided dying’. The terminology used in this position statement is based on the psychiatric and medical literature.

VAD refers to situations where doctors prescribe ¹ lethal substances to informed patients who have a terminal illness or a grievous and irremediable medical condition. These individuals must possess the legal capacity to decide that they wish to end their own lives at a time of their own choosing.

Background

Recent surveys suggest that around 80% of Australians and 70% of New Zealanders support the legalisation of some kind of VAD, although these numbers vary depending on details of the proposed scheme.  [1-3] Medical opinion is more divided, with the Australian Medical Association, New Zealand Medical Association and World Medical Association considering that doctors’ involvement in VAD may in some cases be inappropriate or unethical. [4]

VAD was legalised in Victoria in 2017 and Western Australia in 2019; for an incurable medical condition that one is suffering from and who is experiencing intolerable suffering. Debate around the legalisation of VAD is at varying stages across other Australian and New Zealand jurisdictions. VAD has been legalised in some international jurisdictions across Europe and the United States. Even where VAD is illegal, some patients may request VAD from their doctors.

All medical practitioners involved in the administration of any stage of the VAD process should be familiar with the relevant legislation and regulations of their jurisdiction(s). [5]

The role of psychiatrists

During the assessment process for VAD applications, psychiatrists may be asked to see individuals who are considering or wish to discuss VAD. In these circumstances psychiatrists will, through the identification and treatment of mental illness, make recommendations about mental health treatment and care irrespective of VAD considerations. Psychiatrists may also be involved in providing consultative support to colleagues in relation to VAD; such as general practitioners, palliative care specialists and psychologists, and this should be recognised within health services. [6]

Psychiatrists may also be involved in assessing a person’s capacity to decide about VAD. Assessment of capacity in this context is challenging and requires an evaluation of the person’s thought processes and the effect that emotional factors have on their capacity. It is important to note the issue of capacity as a critical consideration in the application for and administration of VAD. An assessment of capacity is not diagnosis-specific but rather is focused on a person’s ability to make the decision. [7] An assessment of capacity does not necessarily require a psychiatrist, and the role of the psychiatrist will not usually be as a capacity assessor.

The motivation to access VAD in terminally ill people is likely to reflect multidimensional distress in relation to end-of-life suffering. In addition to physical suffering, people in this situation may experience depression, anxiety, organic mental disorders and delirium, as well as psychological distress. A psychiatrist’s specific skills in the diagnosis and treatment of psychiatric illnesses, and their expertise at differentiating those illnesses from adjustment reactions to extreme personal circumstances, are particularly relevant in terminally ill patients. Psychiatrists should also be aware that an individual’s cultural and religious beliefs may influence their decision to access VAD. Psychiatrists can play an important role in ensuring that health services are aware of any necessary protocols important to that individual and/or their community. [8]

The RANZCP affirms that it is a right of medical practitioners to choose whether they wish to be involved in VAD and to determine the extent of their involvement. Psychiatrists must never be required (i.e. mandated) to participate in the VAD process.

Recommendations

The RANZCP recommends that discussions about VAD include consideration of:

• the primary role of medical practitioners to facilitate the provision of good-quality, comprehensive and accessible healthcare, including end-of-life care.
• the need to consider mental health as a core factor in comprehensive end-of-life care.
• the role of psychiatrists in end-of-life care to assess and treat mental health conditions that are contributing to suffering, and to treat those conditions in the first instance.
• the importance of medical practitioners being allowed to make their own ethical decisions with regard to their involvement with VAD, in line with relevant legislation.

¹ Note in some jurisdictions, clinicians may administer where recipients are unable.

Responsible committee: Committee for Professional Practice

References

1. Cartwright C. FactCheck Q&A: do 80% of Australians and up to 70% of Catholics and Anglicans support euthanasia laws? The Conversation. 2019.

2. Gendall P. Euthanasia support dependent on circumstances - Massey University. 2010.

3. Hurley E. Newshub poll: Most New Zealanders support euthanasia. Newshub. 2018.

4. Australian Medical Association. Euthanasia and Physician Assisted Suicide. 2016.

5. Department of Health and Human Services (Vic). Voluntary Assisted Dying Bill: Discussion Paper.

6. Australian Commission on Safety and Quality in Health Care. National Consensus Statement: Essential elements for safe and high-quality end-of-life care. 2015.

7. Stewart C, Pesiah C, B. D. A test for mental capacity to request assisted suicide. Journal of Medical Ethics. 2011;37: 34–9.

8. Queensland Health. ‘Sad News, Sorry Business: Guidelines for caring for Aboriginal and Torres Strait Islander people through death and dying’. 2015.

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.