Australian Medical Association Updates Advice to Doctors with Conscientious Objections

News Release

Australian Medical Association

The AMA has released its updated Position Statement on Conscientious Objection 2019 (replacing the Position Statement on Conscientious Objection 2013). The policy was reviewed as part of the AMA’s routine, five-year policy review cycle.

A conscientious objection occurs when a doctor, as a result of a conflict with his or her own personal beliefs or values, acknowledges that they cannot provide, or participate in, a legal, legitimate treatment or procedure that would be deemed medically appropriate in the circumstances under professional standards.

A conscientious objection is based on sincerely-held beliefs and moral concerns, not self-interest or discrimination.

AMA President, Dr Tony Bartone, said today that doctors are entitled to have their own personal beliefs and values, as are all members of the community.

“However, doctors have an ethical obligation to minimise disruption to patient care and must never use a conscientious objection to intentionally impede patients’ access to care,” Dr Bartone said.

The AMA advises that a doctor with a conscientious objection should:

  • inform the patient of their objection, preferably in advance or as soon as practicable;
  • inform the patient that they have the right to see another doctor and ensure the patient has sufficient information to enable them to exercise that right;
  • take whatever steps are necessary to ensure the patient’s access to care is not impeded;
  • continue to treat the patient with dignity and respect, even if the doctor objects to the treatment or procedure the patient is seeking;
  • continue to provide other care to the patient, if they wish;
  • refrain from expressing their own personal beliefs to the patient in a way that may cause them distress;
  • inform their employer, or prospective employer, of their conscientious objection, and discuss with their employer how they can practise in accordance with their beliefs without compromising patient care or placing a burden on their colleagues; and
  • always provide medically appropriate treatment in an emergency situation, even if that treatment conflicts with their personal beliefs and values. 

Changes since 2013

The tone and emphasis of the Position Statement has been amended. Rather than taking a prescriptive line, the Position Statement now takes a reflective approach where a doctor is asked to focus on what really should matter the most: the impact of their decisions on the patient in front of them.

A new statement has been included that an objecting doctor should be aware that certain treatments or procedures are time critical.

A new section on institutional conscientious objection has been included. It advises institutions that do not provide particular treatments or procedures due to institutional conscientious objection to inform the public of this so (potential) patients can seek care elsewhere. This section also advocates that a doctor working within such an institution should be allowed to refer a patient (already admitted) who seeks such a service to another doctor outside the facility.

The AMA Position Statement on Conscientious Objection 2019 is at https://ama.com.au/position-statement/conscientious-objection-2019


CONTACT:        John Flannery                     02 6270 5477 / 0419 494 761

                            Maria Hawthorne               02 6270 5478 / 0427 209 753

Victoria’s voluntary assisted dying law: clinical implementation as the next challenge

Ben P. White, Lindy Willmott, Eliana Close

The Voluntary Assisted Dying Act 2017 (Vic) (VAD Act) will become operational on 19 June, 2019. . . . While some have written on the scope of, and reaction to, the VAD legislation, there has been very little commentary on its implementation. Yet, important choices must be made about translating these laws into clinical practice. These choices have major implications for doctors and other health professionals (including those who choose not to facilitate VAD), patients, hospitals and other health providers. This article considers some key challenges in implementing Victoria’s VAD legislation.


White BP, Willmott L, Close E. Victoria’s voluntary assisted dying law: clinical implementation as the next challenge. Med J Australia. 2019 Mar;210(5):207-209.e1

Euthanasia rollout challenges Vic doctors

Daily Mail

Australian Associated Press

Doctors will have to ensure Victoria’s complex voluntary assisted dying laws don’t prevent eligible candidates from accessing the scheme.

It’s one of several legal and ethical challenges doctors will face when the country’s first euthanasia laws come into affect in June, experts have said.

“Translating this complex law into appropriate clinical practice will be challenging,” lead author Professor Ben White and colleagues said in an article published in the Australian Medical Journal on Monday. . .[Full text]

Queenslanders asked if voluntary euthanasia should be allowed for under-18s

Brisbane Times

Felicity Caldwell

Queenslanders will be asked whether voluntary euthanasia should be available to people aged under 18.

The Health, Communities, Disability Services and Domestic and Family Violence Committee released an issues paper as part of its 12-month inquiry into aged and palliative care, end-of-life and voluntary assisted dying on Thursday.

People will be asked whether they think voluntary euthanasia should be allowed in Queensland, whether it should be limited to people aged 18 and over, and if doctors should be allowed to conscientiously object. . .[Full text]

Conscientious objection to abortion, the law and its implementation in Victoria, Australia: perspectives of abortion service providers

Louise Anne Keogh, Lynn Gillam, Marie Bismark, Kathleen McNamee, Amy Webster, Christine Bayly, Danielle Newton

Abstract

Background

In Victoria, Australia, the law regulating abortion was reformed in 2008, and a clause (‘Section 8’) was introduced requiring doctors with a conscientious objection to abortion to refer women to another provider. This study reports the views of abortion experts on the operation of Section 8 of the Abortion Law Reform Act in Victoria.

Methods

Nineteen semi-structured qualitative interviews were conducted with purposively selected Victorian abortion experts in 2015. Interviews explored the impact of abortion law reform on service provision, including the understanding and implementation of Section 8. Interviews were transcribed verbatim and analysed thematically.

Results

The majority of participants described Section 8 as a mechanism to protect women’s right to abortion, rather than a mechanism to protect doctors’ rights. All agreed that most doctors would not let moral or religious beliefs impact on their patients, and yet all could detail negative experiences related to Section 8. The negative experiences arose because doctors had: directly contravened the law by not referring; attempted to make women feel guilty; attempted to delay women’s access; or claimed an objection for reasons other than conscience. Use or misuse of conscientious objection by Government telephone staff, pharmacists, institutions, and political groups was also reported.

Conclusion

Some doctors are not complying with Section 8, with adverse effects on access to care for some women. Further research is needed to inform strategies for improving compliance with the law in order to facilitate timely access to abortion services.


Keogh LA, Gillam L, Bismark M, McNamee K, Webster A, Bayly C, Newton D. Conscientious objection to abortion, the law and its implementation in Victoria, Australia: perspectives of abortion service providers. BMC Medical Ethics201920:11.

Mobile euthanasia service to launch for terminally ill patients

Melbourne’s Alfred Hospital says it will deliver lethal drugs to patients across Victoria

AusDoc.PLUS

Euthanasia drugs will be delivered directly to patients using a mobile delivery service when Victoria’s voluntary assisted dying scheme starts later this year.

The Alfred Hospital in Melbourne, which has been given sole responsibility for importing, storing, preparing and dispensing the medications, says it will deliver the drugs to patients living in rural Victoria or who are too sick to travel to pick up the drugs themselves. . . [Full text]

New euthanasia/assisted suicide law in Australia

Victoria’s Voluntary Assisted Dying Act 2017

Sean Murphy*

Introduction
On 19 April, 2018, the legislature of the State of Victoria, Australia, passed the Voluntary Assisted Dying Act 2017, which will come into force in June, 2019.  It is currently the most restrictive euthanasia/assisted suicide (EAS) legislation in the world, running to 130 pages.  In brief, the law authorizes physician assisted suicide for terminally ill adults, but permits euthanasia by physicians only when patients are physically unable to self-administer a lethal drug.  In both cases a permit must be obtained in advance.  The main elements of the law are set out below, followed by consideration of its protection of conscience provisions. . .  [Full Text]

Why I will be a conscientious objector to Victoria’s assisted dying law

A palliative care specialist laments the unrealistic individualism and elitism of the euthanasia movement

MercatorNet

Adrian Dabscheck

During a recent period of enforced rest, I had time to reflect on my attitude to the recently enacted voluntary assisted dying legislation in Victoria and consider my response.1 I will detail my reaction to the Act and why I have chosen to become a so-called conscientious objector.

In his essay Western Attitudes Toward Death,2 French historian Philippe Ariès illustrates the evolution of our attitudes to death.

Initially, and for millennia, there had been a general resignation to the destiny of our species for which he used the phrase, Et moriemur, and we shall all die. This was replaced in the 12th Century by the more modern concept of the importance of one’s self, and he used the phrase, la mort de soi, one’s own death.

Ariès then notes that in the 18th Century man gave death a dramatic and disquieting meaning. Man became concerned with the death of the other person, la mort de toi. Death was no longer familiar, nor were the dead. The dead had been torn from life; death had become an important event. By the 19th Century mourning had become difficult and thy death, la mort de toi, is more feared than la mort de soi, one’s own death.

Following this slow evolution in Western attitudes towards death, from being ubiquitous and familiar, with industrialisation, came the concept of the forbidden and shameful death. Life was now meant to be happy and this happiness was interrupted by the emotional disturbance of death and dying. Death was not spoken of, as illustrated by Tolstoy in “The Death of Ivan Ilyich”.3 Death was moved from home to hospital, from the care of one’s family to the sanitised, technical care whereby it is difficult to tell when the dying process actually began due to the interference of modern medicine. Death became part of the medical industrial-movement.

In a 2013 article reviewing the situation in Flanders where euthanasia is embedded in palliative care,4 it was noted:

Healthcare professionals note that family members and proxies tend, much more than before, to consider the dying process as undignified, useless and meaningless, even if it happens peacefully, comfortably and with professional support. Requests made by family members for fast and active interventions from healthcare professionals regarding elderly parents are often very coercive, with little nuance or subtlety. End-of-life interventions such as euthanasia are seen as an instrument to end a process of disease (or old age) that is demanding and difficult to bear, instead of letting it follow its course.’

We could not be further removed from Ariès’ phrase, Et moriemur, and we shall all die. Happiness is now the ultimate goal; we can no longer accept the place of death in our life. Ariès wrote in L’Homme devant la mort:5 “Death must simply become the discreet but dignified exit of a peaceful person from a helpful society. A death without pain or suffering, and ultimately without fear.” Thus the idealised ‘good death’.

Unfortunately, for most, society is unable to achieve such utopian goals, hence the need for the modern palliative care movement. As David Roy noted in the third edition of the Oxford Textbook of Palliative Medicine,6 it is up to society to allow the palliative care movement to flourish, to remove barriers to care, to develop the broad tapestry of interconnected people, resources, services and institutions to care for those who suffer in the face of death.

For this to be successful there must be an effective ethic of care. An ethic that allows relationships to flourish, an ethic that acknowledges the vulnerability of people and views autonomy from a relational rather than an atomistic perspective. Autonomy is a product of our personhood, our development of interests and values gained by interactions with others. None of us can make decisions which are free from influence. Our decisions relating to ourselves are made in the context of relationships. We commence our life completely dependent on others to sustain us. We depend on the non-judgemental love of others to care for us, to allow us to become independent, to become autonomous in the context of family, friends and society.

I continually ask myself, how have we allowed our ethical boundaries to move to such a degree that a law allowing doctors to take life as a way of relieving suffering has been passed by our state legislature? How have we allowed our view of the individual to become so individualistic and self-gratifying, so removed from an acknowledgement of our dependence on others, so self-centred or dare I say narcissistic?

Perhaps we can learn for the world of art and aesthetics. Hans van Meegeren was an accomplished forger of Vermeer, such that Vermeer experts accepted as originals what are obvious from our current perspective as forgeries. David Roy asks:6 “What process was at work that could so distort the faculties of aesthetic perception and poor judgement? It was a process of incremental adaption to incrementally poor forgeries.”

The Netherlands introduced the Termination of Life on Request and Assisted Suicide (Review Procedures) Act in 2001. In 2005, of all deaths, 0.4 percent were the result of the ending of life without an explicit request by the patient.7 In 2013 euthanasia was performed for 97 patients with dementia and 42 patients with psychiatric diseases (percentages not reported).8 Have ethical perceptions been distorted such that incremental creep allowed this to happen, as it did with aesthetics and van Meegeren?

In an article published in May 2017 in the New England Journal of Medicine discussing the experience of the University Health Network in Toronto after the introduction of medical assistance in dying (MAiD) in Canada,9 the authors noted:

[T]hose who received MAiD tended to be white and relatively affluent and indicated that loss of autonomy was the primary reason for their request. Other common reasons included the wish to avoid burdening others or losing dignity and the intolerability of not being able to enjoy one’s life. Few patients cited inadequate control of pain or other symptoms.

I would like to question if the possible consequent good of allowing a highly selected population of privileged people the ability to request and be administered medical assistance in dying is sufficient to overturn millennia of accepted medical practice. Medicine has long been perceived by society to be beneficent and is trusted to avoid actions which would deliberately hasten death. The intent of palliative medicine is the relief of pain and suffering, not the taking of life. Should we risk the incremental creep of our values for the sake of a privileged few?

Do we wish to allow our society to become similar to Belgium, where we are so removed from the human experience that we consider the dying process useless, meaningless and undignified?

In my own city, Melbourne, we can all witness the inadequate provision of palliative care and other health services to more economically challenged sections of our society. A similar picture emerges in rural settings. Can we as a society justify allocating resources to voluntary assisted dying, when basic palliative care and health care are so lacking?

Should we really allow the values of our society to be so radically altered for the few who are so removed from an acceptance of the frailty of the human experience, from an acceptance that we are all dependent on others and vulnerable?

It is for the above reasons that I will be a so-called conscientious objector when the Voluntary Assisted Dying Act comes into operation on 19 June 2019. I will continue to practise medicine as it has been practised for millennia, for the relief of pain and suffering. I would encourage all doctors to in Victoria to do likewise.


Adrian Dabscheck is a Palliative Care Consultant from Victoria

References

1.  Voluntary Assisted Dying Act 2017 (Vic).

2.  Ariès P. Western Attitudes Toward Death from the Middle Ages to the Present. Johns Hopkins University Press, 1974.

3.  Tolstoy L. The Death of Ivan Ilyich. Published in 1886.

4.  Vanden Berghe P, et al. Assisted Dying – the current situation in Flanders: euthanasia embedded in palliative care. European Journal of Palliative Care 2013;20(6):266-272.

5.  Ariès P. L’Homme devant la mort (The Hour of Our Death). Published in 1977.

6.  Doyle D, et al. (eds.) Oxford Textbook of Palliative Medicine. 3rd Edition. Oxford University Press, 2005.

7.  Van der Heide A, et al. End-of-Life Practices in the Netherlands under the Euthanasia Act. New England Journal of Medicine 2007;356:1957-1965.

8.  Radbruch L, et al. Euthanasia and physician-assisted suicide: A white paper from the European Association for Palliative Care. Palliative Medicine 2016;30(2):104-116.

9.  Li M, et al. Medical assistance in dying – implementing a hospital-based program in Canada. New England Journal of Medicine 2017;376:2082-2088.


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Victoria’s Voluntary Assisted Dying Act 2017

Sean Murphy*

On 19 April, 2018, the legislature of the State of Victoria, Australia, passed the Voluntary Assisted Dying Act 2017, which will come into force in June, 2019.  It is currently the most restrictive euthanasia/assisted suicide (EAS) legislation in the world, running to 130 pages.  In brief, the law authorizes physician assisted suicide for terminally ill adults, but permits euthanasia by physicians only when patients are physically unable to self-administer a lethal drug.  In both cases a permit must be obtained in advance.