There is a great deal of misunderstanding about dying with dignity and physician assisted dying (PAD). Some misunderstanding is the result of lack of information, while other misunderstanding is the result of deliberate misrepresentation by conservative opponents.

These FAQs answer the most commonly asked questions about PAD, particularly in regard to DWDV's initiatives for law reform.

DWDV promotes death, right?

Wrong. DWDV promotes the right for a mentally competent, terminally ill adult with intolerable suffering to choose whether to persevere or to ask a doctor for assistance to die peacefully. Current Victorian law denies the sufferer that right to choose, despite the overwhelming majority of Victorians wanting that choice for more than 25 years.

If a terminally ill sufferer wishes to continue living as long as is possible, DWDV completely supports and commends that person's choice and right for themselves. What is not acceptable is for anyone but the sufferer to determine their course of action.

DWDV absolutely agrees that there should be and is a fundamental right to life. Sufferers must have available to them all reasonable medical treatment they wish to accept. However, equally, if a terminal sufferer wishes assistance to depart a little earlier in order to maintain dignity and avoid horrendous suffering, then DWDV firmly believes that right should exist. Others have no right to force their views on the sufferer.

What are the "four principles"?

DWDV's legislative charter is based on four important principles:

Do you support doctors "killing" patients?

No. DWDV's legislative charter specifies that the form of requested assistance given to terminally ill sufferers to die peacefully is to provide an oral dose of medication that the patient may consume voluntarily. This is physician assisted dying (PAD). In order to maximise safeguards, DWDV's legislative charter does not embrace the broader approach where a doctor administers a lethal dose to the sufferer by injection. The key intention is to relieve suffering, although hastening of death may also occur.

Why "PAD" and not "VE"?

We use the expression Physician Assisted Dying (PAD) rather than Voluntary Euthanasia (VE) for several reasons.

Why not "suicide"?

Suicide is an emotive word that is often equated with irrational, regrettable acts. However, this is not the case for the terminally ill.

A professional study published in the Australian medical literature shows that 93% of doctors believe that a request by a terminally ill patient for assistance to die can be rational.

Rather than "punish" the patient for a rational act, DWDV believes it is more important to recognise the intolerable and unrelievable suffering that caused the patient to make the request. That is compassionate, while "blaming" people without thought for their circumstances is not.

For this reason, DWDV's draft Bill stipulates that the death certificate is to record the patient's underlying illness, not suicide, as the cause of death.

Aren't doctors coping quite well already?

No. It is currently an offense to assist anyone to die, regardless of their circumstances, although it is legal to provide medical care in the knowledge that it "may" shorten life--the principle of the "double effect".

A 1997 professional study published in the Australian medical literature showed that nearly 1 in 50 deaths is already physician assisted dying; but these doctors risk prosecution as the intention to shorten life is illegal, regardless of the patient's circumstances. The law is opaque, depending on the ability to establish "intention" or not of shortening life.

The secret mental life of the doctor is currently the
"decider" as to the legality of shortening a patient's life. But it cannot be reliably tested, meaning there is
currently no regulation in practice.
 

Another 1997 professional study published in the Australian medical literature found that 45% of physicians did not believe that present arrangements are adequate, 68% believed that physician assisted dying can be an act of caring, and 45% wished to have the option of physician assisted dying.

Should doctors decide who dies?

No. Nor should relatives. The only person who should decide whether a terminally ill sufferer dies with medical assistance is the sufferer alone. This is what DWDV's legislative charter specifies. It also means that the sufferer must be mentally competent and well informed to make that decision. If the sufferer is not mentally competent, no decision can be made, except subject to any wishes documented in an advance directive (living will) made previously by the sufferer, or with the advice of the Public Advocate.

Isn't palliative care always enough?

Palliative care is an excellent modern medical practice, and in many cases can provide relief for the terminally ill. However, this is not always the case, which most palliative care specialists would acknowledge. In about 5% of terminal cases, palliative care simply is unable to provide relief from intolerable suffering. While hardly cheerful, the following are facts:

• A motor neuron disease (MND) sufferer becomes progressively paralysed. Late in the disease, breathing can be seriously hindered. Many MND sufferers fear suffocating to death more than anything else and would prefer to go in a dignified manner whilst being able to say goodbye to loved ones, rather than desperately gasping for breath.
• Asbestosis sufferers not only gasp desperately for breath, but breathing is extremely painful.
• A sufferer with cancer of the spine may have pain so severe that it can only be relieved by terminal sedation (TS).
• For many patients, suffering is not just about pain. Suffering can include other factors such as loss of control of wits, bowels or bladder, or such weakness that they are completely dependent on others for every intimate part of their daily care.
• A 2007 study published in the Journal of Clinical Oncology shows that despite the availability of good palliative care, one quarter of late-stage cancer patients experience moderate to severe suffering.

Aren't palliative care and PAD incompatible?

No. Palliative care provides many sufferers with adequate relief from pain, distress and suffering. But for some sufferers, it is unable to and they may suffer terribly unless the doctor is prepared to increase the dosage to a point that will induce coma, which may have the side effect of hastening the patient’s death.

In fact, palliative care specialists already have a term for the process of inducing a profound coma before death: terminal sedation (TS). Some doctors insist that it is the practitioner's intention (to relieve suffering rather than to cause death) that makes the profound difference. In fact, if the primary intention is to hasten death, the doctor may be charged with murder under current Victorian law.

DWDV firmly believes that a mentally competent sufferer deserves the respect to make that decision of time until death for themselves. And indeed, under existing Victorian State law, maximum palliation even if it hastens death may be specifically and legally requested by the sufferer.

But isn't knowingly hastening a death morally wrong?

We each have to determine for ourselves what is right and wrong, especially in life and death situations. But those decisions are ours alone.

As Dr Ronald Dworkin, Professor of Jurisprudence
at Oxford University said, "Making someone die in a way that others approve, but the dying person believes a horrifying contradiction of his life, is a devastating, odious form of tyranny."

Don't PAD supporters just want to save the health system money?

This is a highly offensive claim of conservative opponents; an attempt to shut down the dying with dignity debate with which they are so uncomfortable.

DWDV makes no consideration whatever as to any possible economic impact of the right to choose either way. The only aim is to give terminally ill sufferers the right to full self-determination, a right they currently don't have.

Suggesting or claiming that DWDV wants people to die faster because it will save the health system money is defamatory and may lead to legal action.

Wouldn't PAD be open to abuse?

No—because of strict and effective safeguards.

When PAD is legal, it is mandatory that there is a formal, safe and secure process in place to prevent its abuse. DWDV's legislative charter proposes highly effective safeguards, modelled on successful Oregon law. Formal annual reviews of the Oregon law as applied in practice over nine years have clearly demonstrated an absence of abuse.

With such safeguards, claiming that doctors or relatives will force the sufferer to choose to die, are spurious and without foundation.

Won't doctors be forced to participate against their own beliefs?

Definitely not. Under DWDV's legislative charter, a doctor has the right to decline to act on a sufferer's request for assistance to die if it is against the doctor's own beliefs.

The charter also specifies that private medical institutions may also make a ruling that such practices may not be carried out in or using their own services or premises. Ultimately, it's about choice for everyone.

A sufferer who has specifically made requests for PAD and passed the necessary due safeguard process sees the process as "relief and release," and not in any way "killing."

Wouldn't there be an avalanche of deaths?

The factual evidence shows this is not the case at all.

Formal annual reviews of the Oregon laws in practice show clearly that there has been no significant increase in physician assisted dying at all. These reviews have been conducted for nine years now. DWDV's legislative charter is modelled on Oregon law.

In fact, many patients (such as Steve Guest) report that a great weight is lifted off them when they have a real choice, and there is no necessity to "rush" into an early death by one means or another. So, choice often prolongs life rather than shortens it.

A real consequence of lack of choice to die in a dignified manner with medical assistance is that some sufferers attempt to take their own lives anyway while they believe they still can, often by violent and undignified means. And they don't always succeed, ending up in a worse state than ever before. This is a tragic but factual consequence of the lack of legal choice.

Wouldn't those with access act hastily?

This common objection mistakes access with use: that is, it is assumed anyone who is granted access then immediately goes on to use it. This perception is quite wrong. Formal statistics from nine years of operation in Oregon show that only a minority of sufferers actually go through the process to obtain permission for medical assistance to die. One third (34%) of those who receive the prescription actually never use it, showing restraint and careful thought.

The Actual Oregon PAD Statistics 1998-2006

 
What happens in practice is that people who obtain access feel a profound relief at having control back over their end of life, but do not feel compelled in any way to end it right now. It is this control that itself is very good palliative care, and helps relieve some of the very significant (existential) suffering.

Granting of permission to assist actually removes the necessity to act hastily, including taking one's life by violent means (e.g. jumping in front of a train) because one doesn't have to "take action" while one is still physically able to move about freely.

This means that objections that highlight Mr or Mrs So-and-so who was given three months to live and was alive and well five years later, are irrelevant. It is only when the patient's situation becomes truly hopeless and the suffering severe and unremitting that those with access finally decide to use medical assistance to die on their own terms.

Shouldn't we allow religious leaders or politicians to decide this moral issue for us?

If a terminally ill sufferer wishes to seek religious counsel to help make a difficult end of life decision for themselves, DWDV absolutely supports that.

Suffering at the end of life is a very personal experience. Individuals should be free to consult whoever they want to help them make their own choices. However, the view of religious leaders or politicians should not overrule the right of the individual to make their own informed decision.

In addition to this, the 2006 census shows that close to 1 in 5 Australians (19%) have "no religion", so it doesn't make sense for religious leaders to make decisions for everyone. (To put this in perspective, the number of "no religion" Australians now exceeds the number of Anglican Australians, though not the number of Catholic Australians.)

Don't you just use "horror stories" to shock people into agreeing with you?

This is an offensive claim by conservatives who oppose self-determination. It exposes ignorance at best and a profound lack of compassion at worst. It trivialises the suffering that such individuals have been forced to endure.

All our stories are real stories about real people. We present them as factual evidence as to what actually happens when people are not given a legal choice.

Isn't this just the start of a slippery slope?

The "slippery slope" argument is a scare tactic used by conservative opponents to shut down the dying with dignity debate so that the law continues to conform with their views.

An official review of nine years of Oregon (USA) PAD statistics shows a modest number of people--not an "avalanche" requesting PAD. Fully one third of those who receive a PAD prescription end up not using it. Clearly, restraint is exercised.

DWDV has published a legislative charter in plain English that spells out exact proposals for legislative reform. Nothing more. Nothing less. If it doesn't appear in the legislative charter, it's not proposed. And DWDV's Charter is based on the Oregon law.

Individuals and groups can easily determine the scope of the proposal and decide whether they wish to support it, debate it, or oppose it.

A number of politicians and respected organisations have already endorsed and shown support for DWDV's legislative charter.

You can support it too by signing DWDV's petition to State Parliament.

Won't the depressed and people with disabilities be next?

Absolutely not. This is an extension of the discredited "slippery slope" argument. DWDV believes firmly that those suffering depression in the absence of a terminal illness with intolerable suffering should be directed to proper psychological care. A choice to die because of intolerable and unrelievable suffering near the end of life can be rational, but a choice to die because of psychological illness alone is not.

Nor are people with disability per se ever intended to be covered by medically assisted dying laws. DWDV opposes that firmly, and its legislative charter specifically makes these points abundantly clear.

In any case, DWDV's recommended process stipulates that the decision and action to die with medical assistance is the patient's alone and not of any third party. This means that involuntary euthanasia is specifically excluded and forbidden.

Is it wise to legislate for "exceptions"?

The claim is that terminal suffering that cannot be adequately addressed by palliative care is very rare and therefore at best is not worthy of legislative effort and at worst exceptions are just too "tricky". This is another false argument.

Firstly, it is wrong in law. Much law attempts to legislate the exceptions. Speaking of dying, the average annual murder rate in Australia is approximately 0.002% (or 1 in 50,000). That's very much the exception to normal behaviour. Yet legislate against it we do, and rightly so.

Terminal illness suffering cannot be adequately palliated to the sufferer's satisfaction in around 5% of cases, yet we have not legislated for choice in more than 25 years of an overwhelming majority of Victorians wanting it. And because modern medicine is so effective at keeping people alive, around 85% of us will die in hospital of a terminal illness rather than "passing away quickly and peacefully in our sleep" at home. This means that the 5% is growing in absolute numbers of people.

Secondly, it shows a breathtaking lack of compassion for sufferers. The issue is not about the technics of palliation. It's about the experience and beliefs of the sufferer who, if mentally competent and with sound medical and other advice at hand, deserves the respect of self-determination.

What about "suicide tourism"?

"Suicide tourism" is a highly offensive expression. It completely trivialises the deep and unrelenting suffering experienced by many terminally ill people. To suggest that people go on a "happy holiday" to die, a long way from home, family and friends, lacks insight and compassion.

Nevertheless, DWDV believes that it would be inappropriate for the State of Victoria to support PAD for those whose only purpose in visiting is to die. PAD would be available only to residents of Victoria.

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