What you need to know about voluntary assisted dying

Voluntary assisted dying is available in all Australian states. Picture: Getty Images

Voluntary assisted dying is emotional territory, traversing medical ethics, religion and the general unease about death and dying.

And it is a live issue around the world. Just last month the UK parliament narrowly voted in favour of VAD in a private member’s bill after a heated debate.

Those in favour argued it reduced the suffering of the terminally ill and let them control their own death, while those against raised concerns vulnerable ill people would take the option out of fear of being a burden to their families, or worse, being coerced into it.

Britain is some distance behind Australia, with VAD now available in all states, and the ACT set to have access from November next year.

Victoria’s VAD regime has been in place the longest, operating from June 2019. The other states have followed progressively, NSW being the last to become operational in November last year.

What has been the uptake so far?

According to advocacy group Go Gentle’s 2024 State of VAD report published in August, “since VAD first became legal in Victoria in June 2019, more than 7200 terminally ill people in Australia and New Zealand have sought to access this end-of-life choice and 3242 have died using a VAD substance, supported by more than 1200 health professionals”.

Updated figures by the various state VAD boards to June 30, 2024, and in Queensland’s case September 30, push the total beyond that.

Across the nation more than 9100 people have formally begun the VAD assessment process with 3840 dying after being administered a VAD substance.

Victoria has recorded 1282 deaths and Queensland 1140 despite the regime starting in January 2023.

In NSW, where voluntary assisted dying has only been in place since November last year, there have already been 1141 people seeking VAD in the seven months to June 2024, with 398 deaths.

In WA more than 700 have died so far through VAD, nearly 200 in South Australia and 87 in Tasmania.

The typical VAD applicant in Australia is aged 70-79, more likely male, and has been diagnosed with cancer.

Sally Cockburn, president of Voluntary Assisted Dying Australia and New Zealand, the peak body for VAD practitioners, said VAD had quickly become “well accepted as an end of life option in Australia”.

“I think even those who may not agree with VAD for themselves do respect that this is a personal decision for an individual and that all the laws have safeguards to prevent coercion,” Dr Cockburn said.

But a spokeswoman for the Catholic Archdiocese of Sydney said there were better options for those at the end of their life.

“Every person deserves the best possible care available, including physical, psychological, social and spiritual support,” the spokeswoman said. “We can do better for Australians at the end of their life than offering them lethal drugs.”

Specialist oncologist Cameron McLaren, who practices in Victoria and has supported a number of patients through VAD, said in his state the numbers had outstripped predictions.

“Once it became available there were a lot of people who sought out VAD as their preferred end-of-life option,” Dr McLaren said.

Oncologist Cameron McLaren supports patients through the voluntary assisted dying process in Victoria. Picture: David Geraghty/The Australian

“Those initial concerns were that things would go wrong, or that society would be in some way inexorably changed, but what we’ve seen in practice is that these fears have simply not come to pass.

“The demand shows that this is what patient-centred care really is. A lot of my colleagues may still be uncomfortable about it, but it’s what dying patients want,” he said.

“I think that there are similarities with the gay marriage laws, a lot of debate in the lead-up, but since being introduced it has become broadly accepted as something people want to have available.”

What are the objections to VAD?

The arguments against VAD broadly include the religious position that the inviolability of human life prohibits intentional killing.

The notion of a “slippery slope” is also often raised, in that once entrenched the practice could expand over time to include voluntary assisted dying in wider circumstances than currently legislated, for example where a person’s quality of life may be considered too poor to continue.

Another is that palliative care already appropriately supports people in their final weeks and days.

There is also an argument made that it may place pressure on people to end their lives to reduce their burden on a family.

The recent British vote has been a real-time exploration of the morality and ethics of VAD.

Laws giving effect to the right to VAD were passed in the British parliament in late November, but only just, 330 votes to 275, and not before a lengthy and emotional debate.

British Prime Minister Kier Starmer voted for the reform, but his health secretary Wes Streeting voted against, raising the slippery-slope argument.

That concern was similarly raised by the Archbishop of Canterbury Justin Welby, before his recent resignation, who said the notion of assisting people to die was “dangerous and sets us in a direction which is even more dangerous, and in every other place where it’s been done, has led to a slippery slope”.

“I worry that even the best intentions can lead to unintended consequences, and that the desire to help our neighbour could, unintentionally, open the door to yet more pain and suffering for those we are trying to help,” Archbishop Welby said.

The Catholic Church is also broadly opposed to assisted suicide and euthanasia, with the Vatican issuing a statement in 2020 saying they were “intrinsically evil” acts in all circumstances.

During the recent UK debate Cardinal Vincent Nichols, head of the Catholic Bishops of England and Wales, argued the nation needed to “be careful what you wish for”.

In a letter he said the circumstances in which assisted dying was available across jurisdictions where it was in place had been “widened and widened”, making it “more available and accepted”.

Cardinal Nichols also said the laws may create pressure from others or “even from themselves, to end their life in order to take away a perceived burden of care from their family, for the avoidance of pain, or for the sake of an inheritance”.

But revealing the complex nature of the debate, former archbishop of Canterbury the Right Reverend Lord Carey has backed the new laws.

“At what point should we say ‘Thou shalt suffer on against thy will,’ and when say ‘You can let go and return to God’? Which is the more compassionate or religious response?”, he wrote ahead of the vote.

“For those who worry that this is ‘playing God’ — think again. We play God every time we see a person having a heart attack and decide to put them on a defibrillator or give CPR rather than let nature take its course.

“Should we stop doing that? If we play God to lengthen life, we can also do so to relieve pain and indignity at the end of life,” Lord Carey wrote.

Are older people really being pushed into VAD?

Dr Cockburn rejects this outright. While the laws are there to protect against it anyway, in practice it is more likely families are trying to talk a loved one out of going through VAD.

“I think the concerns voiced about coercion into VAD have been shown to be unfounded,” she said.

Sally Cockburn, president of Voluntary Assisted Dying Australia New Zealand.

“Indeed, it has been reported that the opposite may occur – with attempts to coerce people out of their desire to access VAD by some relatives, healthcare professionals or others involved in their care.

“Interestingly along with penalties for coercion into VAD, the law in the latest jurisdiction to legalise VAD, the ACT, imposes financial penalties for those attempting to block a person’s access to their legal VAD choice.”

Who is actually taking up VAD?

The typical VAD applicant in Australia is aged 70-79, more likely male, and has been diagnosed with cancer.

People in rural and regional areas make up a higher proportion of VAD applicants than the general population distribution, with one reason postulated that country people are more pragmatic about death and assisted dying.

Do VAD laws differ depending on where I live?

The laws in each state are similar, but there are some important differences.

In all jurisdictions, eligibility requires a person to be at least 18, to be within six to 12 months of dying as assessed by two medical practitioners, to have decision-making capacity throughout the process, to make at least three separate requests for VAD including a written request, and to be acting voluntarily and without coercion.

When the ACT system kicks in it will require one medical practitioner and one nurse practitioner.

Dr McLaren said one of the issues Victoria faced that was different from other jurisdictions was that one of the two medical practitioners has to be a specialist relevant to the applicant’s condition.

“In many cases this will be a specialist oncologist, and this means access can be limited, especially in rural and regional areas,” he said.

Another difference is the amount of time medical professionals deem a person has left.

In Victoria, WA, South Australia and Tasmania the laws require that a person’s illness, medical condition or injury is advanced, progressive and will cause death within six months (or 12 months if you have a neurodegenerative disorder, such as motor neurone disease).

In Queensland it is 12 months, in NSW within six to 12 months and in the new ACT laws that are yet to begin there is no specific time frame until death.

A common feature of the various VAD systems around Australia is that medical professionals are entitled to opt out or conscientiously object to advising on VAD or supporting a patient through the process.

But states differ on whether medical professionals can raise VAD as an option for a patient. In Victoria and South Australia, along with New Zealand, health practitioners are banned from initiating such a conversation.

Dr Cockburn is pushing for legal changes to have these so called “gag clauses” removed in those jurisdictions, noting the proportion of VAD deaths in WA, while still small at 1.4 per cent of all deaths, is substantially higher than in Victoria at 0.65 per cent.

“One likely explanation for this difference is that in Western Australia health practitioners are permitted to initiate a conversation with a patient about VAD while in Victoria only the patient can initiate such a discussion,” Dr Cockburn said.

“While the clause was no doubt put in place to protect patients, it could be having the opposite effect.

“Patients expect their healthcare professional to give them the appropriate range of options open to them and healthcare professionals should be trusted to deliver these options sensitively.”