The Northern Territory parliament recently passed legislation to legalise voluntary assisted dying (VAD), making it the last jurisdiction in the country to do so. But supporters say there are still too many barriers to accessing VAD.
Currently, Federal law prohibits using a carriage service, such as a phone, video link or email, to counsel or incite suicide or provide instructions on a method of suicide, where the required intention exists. Supporters of telehealth VAD are therefore lobbying Federal Parliament to permit telehealth VAD.
The Catholic Weekly asked Sydney physician John Obeid to comment on this contentious issue.
Why do you think that amending current legislation to permit telehealth for VAD is unwise?
There are a number of reasons why it would be unwise to permit telehealth for voluntary assisted dying.
Despite the attempts to sanitise the language used to describe it, voluntary assisted dying (VAD) is in fact just another form of suicide. In most overseas jurisdictions, VAD is called “physician assisted suicide.” The Federal Government has long prohibited the use of carriage services to promote or induce suicide, because there is a well-founded concern that doing so will induce more people to choose suicide as an option.
The concern for doctors is that extending carriage services (such as telehealth) to VAD, will induce more people to end their own lives.
Furthermore, no honest clinician believes that telehealth consultations are as effective and as comprehensive as an in-person assessment. For one, you cannot do a physical examination on a patient. How is it therefore possible to exclude treatable conditions, which might only be diagnosable by physical examination?
In addition, it is frequently not possible to get a full appreciation of a person’s non-verbal communications, such as agitation or anxiety (which might only be picked up by observing a person’s movements in a chair or by noticing movements of their hands or feet all of which could be out of view of the assessor).
The government has long recognised this issue with telehealth. For example, the Australian Health Practitioner Regulation Agency told the ABC that telehealth is not appropriate for every consultation because the lack of in-person interaction can limit a practitioner’s ability to provide safe and effective care. Therefore, if a doctor should not use telehealth to prescribe a common diabetes medication, how can a doctor use telehealth to make life-and-death decisions about a patient? There can be no doubt that telehealth for VAD is totally inappropriate.
The other significant concern of undue influence or pressure being put on older people to end their lives, so as not to be a “burden” on others.
Herein lies the problem of using telehealth for assisted suicide – there is no way of being sure that another person in the room (or just outside the room, or who otherwise has influence over a person) is not exerting pressure on the person at risk of assisted suicide/VAD. A remote assessor (that is, the doctor who is to approve VAD for the patient) has no way of appreciating what might have happened just before the telehealth consultation and has no way of being sure that undue pressure has not been brought to bear on the patient.
Isn’t telehealth VAD needed to give rural and remote patients equal access?
This is completely false. Already people in rural and remote areas are over-represented in the statistics of patients being approved for VAD. So, there are proportionately more people requesting and receiving VAD than is the case for the general population. That argument just does not hold water.
Telehealth VAD is unnecessary, given that it is available elsewhere in person. Whilst it might involve some travel, it is a well-accepted principle that patients sometimes need to travel for important appointments or procedures.
For example, state health departments have not set up centres in very remote locations for cardiac surgery or renal transplantation or even palliative care, despite the fact that they are essential services. People in outer west NSW even have to travel just to see a dentist. Patients have always travelled for these assessments, procedures, or essential services.
Furthermore, if telehealth is allowed for VAD in remote locations, what is to stop it being introduced in non-remote locations? Inevitably, it will also be introduced even for people in large towns and cities. People in large towns and outer suburbs where VAD is readily available may well allege discrimination, because some people can access telehealth VAD and they cannot.
Don’t most doctors support telehealth VAD?
Very few medical practitioners support telehealth VAD. In one survey, it was below 10 per cent.
Major specialist medical colleges representing doctors who care for people at the end of life are not calling for the introduction of telehealth VAD. The peak professional bodies of medical specialists looking after older people (the ANZSGM) and people using palliative care services (the ANZSPM) have not called for telehealth VAD. We do not see it as a valuable contribution to the care of the patients we serve.
A significant issue we are already seeing in our early experience with VAD is that it is undermining the efforts of medical practitioners who advocate for enhancements to palliative care and geriatric medical services in rural and remote areas.
If telehealth VAD “takes off in a big way”, what incentive is there for governments to enhance rural and remote palliative care services in these communities? It has been suggested and observed by many of us working in the field that palliative care services have not been appropriately funded in rural areas. Allowing telehealth VAD will only make this worse.
What is the most compassionate avenue for end-of-life care for people in remote and regional Australia?
The gold standard of care for people approaching the end of their life is high-quality palliative care and geriatric medicine services. This means state governments must properly fund specialist multidisciplinary teams (including medical, nursing, social work, psychology, pastoral care, and community support services) at the local level to properly care for people with the greatest need.
It does not mean offering a quick “over the phone” assessment and then posting out life-ending suicide drugs.
But academics supporting VAD argue that there are no substantial problems with telehealth VAD.
Some academics supporting VAD conclude that the benefits outweigh the risks, but I do not believe their research gives sufficient weight to issues encountered at the clinical coalface. The biggest problems we clinicians care about – adequately funded services – are seldom considered by some of the “studies” which claim that there are “no substantial problems” with rolling out telehealth VAD.
Furthermore, none of the studies supporting telehealth VAD consider the issues of undue influence, accuracy of assessments, or the effects on palliative/aged care service provision.
It’s like doing a study on the potential risks of anti-inflammatory medications but not including stomach ulcers and kidney problems as an end-point.
A recent study argued for telehealth VAD because “telehealth allows flexibility that can also reduce health professionals’ travel time, allowing them to consult more patients and more often… Using telemedicine eliminated stressful travel costs, time, and discomfort for both patients and assessors.”
It seems to me that they were more concerned about making things as easy as possible to induce more patients into having VAD, rather than providing good quality clinical care.
Dr John Obeid is a consultant physician and geriatrician, working in Western Sydney. He is an Associate Professor of Medicine at the University of Notre Dame Australia. His major interests are dementia, delirium, aged care rehabilitation and medical student education.
