Ahead of this week’s parliamentary vote on the divisive Assisted Dying Bill, Maya Dhillon spoke with three GPs in New Zealand, where assisted dying has been legal for three years.
In 2020, the people of New Zealand were faced with a double referendum. The questions? Whether to legalise recreational cannabis and assisted dying. The first one didn’t pass, but the second did – with 66% of voters opting to legalise assisted dying. In the year between the result and legislation being passed, doctors had to decide if they would opt to be a part of the ‘Assisted Dying Service Team’.
Drs Stanley Koshy and David Wilson were two such GPs.
Dr Koshy, a GP in Hamilton working primarily with older people and those suffering with terminal illnesses, had known he would be involved from the moment talk of the bill first arose in 2018. His father had suffered from cancer: ‘I had just one wish: I don’t want to watch him suffer. Fortunately, he passed away before things got too bad. But I figured that I could not have been the only person who didn’t want to watch their loved one wither and waste away.’
For Dr Wilson, a GP working in rural care homes, the decision wasn’t as instantaneous. He voted for the bill but ignored it after, even as the deadline crept closer. ‘It was only a few months before it became law that a patient in the care home I worked at said: “David, please do it for me. Promise me.” That was the first time I properly considered it.’
How it works: criteria and process
The eligibility criteria for assisted dying in New Zealand closely resembles those proposed for England and Wales. In both instances, the patient must be: over 18, suffering from a terminal illness which will likely end their life within six months; in an advanced state of irreversible decline in physical capability; competent to make an informed decision; and make the decision voluntarily, without coercion.
In New Zealand, the process begins with the patient contacting the Ministry of Health to express their wish for an assisted death. The ministry assigns an attending medical practitioner (AMP), who conducts an in-person assessment to confirm eligibility. This includes reviewing medical records and speaking with the patient’s family. If satisfied, the AMP submits the paperwork to the ministry.
A second, independent doctor – chosen randomly by the ministry and unknown to the AMP – then assesses the patient. This can be done virtually. This doctor runs through the same process as the AMP to make sure that their judgement was correct and the patient does still want to die.
Once approved, the AMP discusses the preferred method (intravenous or oral) with the patient, and a date and location are set. The ministry vets the submission before the registrar gives final approval. The AMP then arranges for the prescription, which is delivered by courier. On the chosen day, the AMP takes the prescription to the patient, and remains with them until ‘life is extinct,’ reporting back to the ministry.
Again, this is similar to what has been laid out here – most countries tend to follow each other when setting up legislation. However, an extra step being included in the England/Wales legislation is that following the two independent doctor reviews, the application must then be heard by a High Court judge. The judge must hear evidence from at least one of the doctors, and may also choose to hear from the patient who submitted the application.
The insertion of the High Court bolsters proposer Kim Leadbeater’s assertion that this bill would ‘ensure the strictest safeguards anywhere in the world.’ But, Dr Wilson believes this step seems ‘unnecessary.’ He explains: ‘In New Zealand, the ministry goes through each case to ensure the rules are followed, and that seems to have worked here.’
He also cautions that judicial involvement could slow the process, and presumably add an extra cost. The latter point is pertinent, as health secretary Wes Streeting – who is opposing the bill – has said that providing an assisted dying service will mean cuts for other NHS services. It is unclear at this point where funding for assisted dying would come from, but Dr Koshy notes that in New Zealand, funding for the service was allocated separately and has not affected existing health care services.
The slippery slope: coercion, collusion and burdens
The High Court step is included to prevent any coercion or collusion occurring. These have both been salient concerns ever since the subject of assisted dying was introduced. Nobody wants a situation where someone who doesn’t want to die is pushed into it by family, friends or others. There have also been concerns over someone voluntarily choosing to end their life, but with the primary motivation of not being a burden to family, friends or the health service.
But those who have been involved with the process indicate this has not been an issue. The independent doctors who review the patient will be on the lookout for ‘red flags’ – like a patient referring to themselves as a ‘burden.’ Something that is also neglected in discussions of coercions and burdens is that doctors can decline applications – not everyone who applies is granted an assisted death. The last quarterly report showed that the ministry received 287 applications for an assisted death, but 117 did not proceed for reasons including: the individual’s application didn’t comply with the criteria; they withdrew their application; or were found incompetent to give consent.
Dr Wilson says that in his three years of working in assisted dying, he has never come across an instance of someone being pushed into it. Dr Koshy reinforces this: ‘Anyone can deceive a medical practitioner, and I will admit I have been deceived on many occasions in regular general practice. But not with assisted dying. To the best of my knowledge, there has not been any situation where two separate practitioners have agreed to allow someone to die just because they felt they were a burden or they were coerced. The ‘slippery slope’ argument has been made before and is invalid.’
Where does the system go from here?
With three years of assisted death, what has New Zealand got right, and what could be improved?
Dr Koshy is clear that it isn’t a perfect system, pointing out compromises made to get the bill through the system. He brings up the ‘gag clause’ restricting doctors from initiating conversations about assisted dying – patients must be the first party to bring it up. This means that those that are more literate will know about it and will suggest it, but others won’t have that opportunity: ‘Given the suffering they are going through, this option may not be foremost in their mind, and then as their doctor it becomes tricky.’ The draft legislation here has no ‘gag clause.’ Instead, practitioners can use ‘professional judgement to decide if, and when, it is appropriate to discuss the matter with a person’.
Another improvement from Dr Koshy is to mandate public institutions to allow their patients to have an assisted death, if they wish to. Many care homes, including those run by religious orders or have such affiliations – will not allow patients to have an assisted death. ‘Once a person moves into a rest home, they no longer have their own home – they might have sold it off. If the rest home says they cannot have an assisted death, even if they want to, then finding a place for them becomes exceedingly difficult.
‘I have had to carry out assisted deaths in a paddock in the back of a utility van. I wish the Government had been more emphatic and said public institutions had to allow it. The restriction is limiting people’s choice and that is terrible. There are probably a lot of people who want this, but cannot access it simply because of where they are. It is unfair.’
There are currently 154 medical practitioners and 15 ANPs on the Support and Consultation for End of Life in New Zealand (SCENZ) list. It is not a huge number, and is a reminder that the service is opt-in, as it would likely be here. The BMA – neutral in its assisted dying stance – is clear that if the bill went ahead, it would support a system where ‘only those doctors who positively choose to participate’ are involved.
Though part of a small cohort of doctors, Dr Koshy points out that this does not mean that all other doctors are against assisted dying. ‘You meet all kinds of practitioners doing this work. There are those that, because of their conscience or religion, actively oppose it. But there are a lot of people sitting on the fence – some practitioners have said to me: ‘I don’t have the gumption to do it, but I am glad you do.’
A change of heart
A third GP, ‘Dr A’, voted against the bill, for religious reasons and because he believed there was a high likelihood assisted death would be seen as an ‘easy’ and ‘cheaper’ option for the health system, rather than ‘fully funded palliative care to the taxpayer.’ Having been a GP in a rural area for 30 years, Dr A was often the only provider of palliative care in his community and had been with many patients in their final moments. Even though he had witnessed many deaths characterised by suffering, the idea of giving someone a medication that ended their life provoked a ‘guttural negative reaction’ within him.
When the vote went through, Dr A was in a job that meant he couldn’t avoid the topic of assisted dying; he had to know the process and protocol. As he learned more about it, he wondered, given that he’d seen so many patients suffer, whether this was something he could be a part of. He was also concerned about access to the service for rural communities – especially Māori (the indigenous population of mainland New Zealand): ‘If people like me did not get involved, who would be there to help people who were suffering?’
Dr A took part in online learning and attended a two-day in-person training course before the legislation came into effect. He explains: ‘Understanding the checks and balances, the process, the medication and delivery helped resolve any concerns and assumptions about the technicalities for me.’ He has been involved with assisted deaths ever since.
‘It is not our job to maintain life at all costs‘
Both Drs Wilson and Koshy say that the sense of gratitude that the patient and their loved ones feel both during and after the assisted death process is a key part of their decision to keep going. Dr Wilson maintains that the gratitude is beyond anything he has ever done in ordinary general practice. When Dr Koshy checks in with the family a week after the death, so many say the same thing to him: ‘The day you first spoke to mum/dad/whoever changed them – they became better because they knew their suffering was going to end. Suddenly, they wanted to do whatever they could with the little time they had left.’
When faced with the almighty question ‘Why participate in a process that extinguishes life, when the role of a doctor is to sustain it?’ the answers come easily to the doctors we spoke to. It is a common – though not unimportant – query.
Dr Koshy acknowledges that ending someone’s life is not part of the job description, but he points out that in these cases, the disease process has pretty much ended their life. ‘All you are doing at this point is making that ending a little more pleasant. Given half a chance, most people would rather live than die, and all medical practitioners would go out of their way to make sure that life is sustained.
‘Contrary to popular perception, people are not in a queue waiting to die. This is a very considered decision and is not taken lightly. I think assisted death is a great thing for people to have as an option, so that they know their last days will not be filled with misery and agony. People who don’t want an assisted death, do not have to have one. But for those people that do want it, you cannot deprive them of the option to have this as their final treatment.’
‘It is not our job to maintain life at all costs,’ argues Dr A. ‘It is far more accurate to say our role is to help people deal with suffering. Not everyone feels able to be involved in helping those who need an abortion, and not everyone will feel able to provide a person with an assisted death.
‘My hope would be that enough people do consider this as part of their ethical duty to respect people’s autonomy: to apply beneficence in easing suffering; to avoid maleficence by providing care in the way it is needed; and to apply the principle of justice in using all the extensive skills and experience they have gained in this very complex area of care.’
its clear that this works well. Lets hope our MPs show compassion and common sense and allow this bill to progress for more detailed work. I’m shocked how hysterical the anti lobby have become with their scaremongering.
Finally parliament gives the go ahead to bring about a new law and a new paradigm. I predict we will look back in ten years and wonder why 275 MPs were so against this sensible and compassionate change. It seems the baby boomer generation changes the laws as they go through their lives….