UCA Synod of and response to the introduction of voluntary assisted dying legislation in Victoria

A report and proposals based on the Synod’s consultation and review process

Voluntary Assisted Dying Section C1.9 1 Response report to Synod 2019 20 May 2019

Prepared by: Dr Jessica Hateley-Browne Senior Advisor, Centre for Evidence and Implementation Mr Tom Steele Research Assistant, Centre for Evidence and Implementation

Centre for Evidence and Implementation Melbourne | | Singapore | London Web: ceiglobal.org Twitter: @CEI_org

Voluntary Assisted Dying Section C1.9 2 Response report to Synod 2019 Contents

1. Glossary...... 4 2. Introduction ...... 5 2.1. Project background ...... 5 2.2. Project purpose and scope ...... 5 2.3. This report ...... 6 3. Victoria’s Voluntary Assisted Dying legislation ...... 8 3.1. Background to the legislation ...... 8 3.2. Understanding the legislation ...... 9 3.2.1. What it is ...... 9 3.2.2. What it is not ...... 9 3.2.3. What it is not likely to be ...... 9 3.2.4. Eligibility criteria ...... 10 3.2.5. Process ...... 10 4. Theological reflection on voluntary assisted dying ...... 12 5. Review and consultation process ...... 14 5.1. Review scope and approach ...... 14 5.2. Consultation scope and approach ...... 14 6. Review findings ...... 17 6.1. Voluntary assisted dying around the world ...... 17 6.1.1. Trends in voluntary assisted dying ...... 17 6.2. Views and values of people of Christian faith regarding assisted dying ...... 20 6.3. Responses to voluntary assisted dying from other Christian denominations in ...... 21 6.3.1. Catholic Church in Australia ...... 21 6.3.2. The Anglican Church in Australia ...... 22 6.3.3. The Salvation Army in Australia ...... 22 6.3.4. The Baptist Church in Australia ...... 22 7. Consultation findings ...... 24 7.1. Consultation with UCA members in Victoria ...... 24 7.1.1. Presbyteries ...... 24 7.1.2. UCA ministers from Culturally and Linguistically Diverse Backgrounds ...... 25 7.1.3. 2017 open consultation with UCA members ...... 25 7.2. Consultation with Uniting AgeWell ...... 26 7.3. Consultation with Uniting (Vic&Tas) ...... 27 7.4. Consultation with Epworth Healthcare ...... 28 7.5. Consultation with Uniting Church chaplains ...... 28 7.6. Additional consultations ...... 29 8. Proposals ...... 30

Voluntary Assisted Dying Section C1.9 3 Response report to Synod 2019

Appendices

Appendix A Draft pastoral resources ...... 32 Appendix B Legal implications and recommendations for congregational pastoral carers and ministers ...... 50 Appendix C Victorian Government’s Voluntary Assisted Dying Factsheet ...... 53 Appendix D Theological reflections on voluntary assisted dying ...... 59 Appendix E Summary table of assisted dying legislation around the world ...... 64 Appendix F JIM Unit Consultation Paper ...... 68

Voluntary Assisted Dying Section C1.9 4 Response report to Synod 2019 1. Glossary

Voluntary assisted dying Assistance to die provided in a medical context to someone who makes a voluntary, fully informed choice to die. ‘Physician assisted dying’ or ‘medical aid in dying’ are commonly used interchangeably with ‘voluntary assisted dying’.

Euthanasia An umbrella term that covers a range of practices or interventions undertaken with the intention of ending a life to relieve suffering. can be passive (e.g. withdrawing treatment) or active (e.g. taking or administering a lethal substance); voluntary (at the patient’s request) or involuntary (not at the patient’s request).

Assisted suicide The intentional act of killing oneself, aided by another person or persons. Note however that it is generally considered preferable not to use the term ‘suicide’ to refer to voluntary assisted dying or euthanasia, though ‘voluntary ’ is the term most often used in the USA.

Palliative care Care that aims to improve the quality of life of people with an active, progressive disease who have little or no chances of being cured, and their families.

Voluntary Assisted Dying Section C1.9 5 Response report to Synod 2019 2. Introduction

2.1. Project background To date, the Uniting Church Synod of Victoria and Tasmania (Synod) has not made a definitive statement regarding voluntary assisted dying or euthanasia. In 1995, the then Synod of Victoria considered euthanasia, decided at the Synod meeting that it was not yet ready to express an opinion about whether it would support or oppose active euthanasia legislation in Victoria. In 2016, the Presbytery of Tasmania addressed the issue of euthanasia in their submission to the Tasmanian government’s consultation on a Dying with Dignity bill, stating that the UCA was neither for nor against the introduction of the bill. Then, the 2017 meeting of the Synod resolved (17.6.6.1):

a. In the event of the Parliament of Victoria passing legislation to allow assisted dying/suicide, to request the Synod Standing Committee to initiate a process including, but not necessarily limited to, consultation with Uniting AgeWell, Uniting Victoria-Tasmania, the faculty of Pilgrim Theological College and the Assembly Standing Committee, and taking into account the feedback from the wider Church through the current consultation process in relation to this matter being conducted by the Justice and International Mission Unit, to present a report with proposal(s) to the 2019 Synod meeting regarding the Uniting Church in Victoria and Tasmania’s response to the assisted dying/, including a position on how the Synod and relevant UCA institutions and staff should be asked to respond to such legislation; and

b. To support the recommendation of the Victorian Government Ministerial Advisory Panel on Voluntary Assisted Dying that any voluntary assisted dying legislation include a broad provision to allow all health professionals and facilities the right of conscientious objection to participation in such legislation. On 29 November 2017, the Victorian Parliament passed the Voluntary Assisted Dying Act 2017, which comes into effect on 19 June 2019. The Act gives provision for Victorians at the end of life who meet the extensive eligibility criteria to request access to voluntary assisted dying. The Synod engaged the Centre for Evidence and Implementation (CEI) to undertake a process of consultation and review, guided by Synod resolution 17.6.6.1. The project was led by Dr Jessica Hateley-Browne, Senior Advisor at CEI, who is also a UCA member. 2.2. Project purpose and scope The purpose of the review and consultation project was to resource the Synod with: - information about the voluntary assisted dying legislation in Victoria; - summaries of the diverse Christian responses to this issue; and - reflections on the theological, pastoral, policy, and practice implications for the Synod and relevant UCA institutions. This project included the development of proposals, presented to the Synod in the final section of this report, that recommend a position for decision at the 2019 Synod meeting. Any resolution(s) by the Synod about responding to Victoria’s Voluntary Assisted Dying legislation will inform policy and practice directions within the relevant UCA agencies (Uniting AgeWell and Uniting) and Epworth HealthCare (Epworth), which is a UCA-affiliated organisation (Epworth’s roots are in the Methodist Church). Uniting AgeWell and Uniting are wholly owned subsidiaries of the Synod and as such, their organisational responses to Victoria’s Voluntary Assisted Dying legislation need to be guided by the relevant Synod resolution(s). The establishing Act for Epworth specifies undertaking: “treatment of each patient in a manner that accords the respect due a person before God, according to the beliefs of the Uniting Church”.

Voluntary Assisted Dying Section C1.9 6 Response report to Synod 2019 Consequently, the Synod must give direction to Epworth on the beliefs of the UCA in Victoria regarding voluntary assisted dying. Synod’s resolution about how to respond to Victoria’s Voluntary Assisted Dying legislation will naturally also inform pastoral responses and resourcing within the Church. This work is essential, as the issue will affect Church members, their families and loved ones, regardless of whether or not voluntary assisted dying will be permissible within/under the care of the relevant UCA agencies (Uniting AgeWell and Uniting) and Epworth Healthcare. Thus, the key questions for consideration by the Synod are: 1. Will it be permissible for a patient, resident or client of the UCA agencies (Uniting AgeWell and Uniting) and the UCA-affiliated hospital (Epworth HealthCare) to access voluntary assisted dying (according to the law) while living in and/or receiving care and/or services from these organisations? 2. How will the Church in Victoria respond pastorally to individuals who are exploring or accessing voluntary assisted dying (in accordance with the legislation), and their family and loved ones? The key considerations for the Synod in reflecting on these questions are: 1. Theological: What Christian theological convictions can inform a response to voluntary assisted dying? 2. Pastoral: What are the pastoral and spiritual care implications of allowing or disallowing voluntary assisted dying within the UCA agencies and affiliated hospital? How will the Synod resource the Church to offer a compassionate pastoral response to people who are exploring or accessing voluntary assisted dying (and their families and loved ones)? 3. Policy and practice: What are the policy and practice implications for UCA agencies and affiliated hospital if Synod resolves to permit voluntary assisted dying within their facilities and service contexts? What are the implications if voluntary assisted dying is resolved to not be permissible in UCA agencies and the affiliated hospital by the Synod? 4. Pragmatics: The legislation has already been passed and will be in force from 19 June 2019 in Victoria. Should the Synod restrict access to the legislation within the context the UCA agencies and affiliated hospital, and if so, how? The Synod should note that there is no current UCA national position on voluntary assisted dying, and that is it permissible for a Synod to develop its their own response. This reflects the need to offer nuanced responses to the specifics of state-based legislation on issues of bioethics. A ‘blanket’ national UCA position is unlikely to be appropriate given that, if voluntary assisted dying legislation is developed and passed in other Australian states and territories in the future, we can predict, based on observations from the United States for example, that the specifics of the legislation may vary significantly on important details (e.g. eligibility criteria, safeguards), relative to the Victorian legislation. While any resolution(s) passed by the Synod would, by default, also apply to the Church’s response to any potential future legislation in Tasmania, such legislation would need to be checked for comparability to the Victorian legislation to determine whether a separate response (and additional review and consultation work) would be necessary. Note that while the development of pastoral resources relating to voluntary assisted dying is outside the scope of this project, a parallel project has been undertaken by the Synod Ethics Committee to commence the development of such resources. CEI and the Synod Ethics Committee have worked in close collaboration throughout the life of both projects to share resources and avoid duplication. Draft examples of the pastoral resources developed by the Synod Ethics Committee are provided in Appendix A. Relatedly, draft legal considerations and recommendations for ministers and pastoral care workers are provided in Appendix B. 2.3. This report This report provides an overview of Victoria’s Voluntary Assisted Dying legislation, followed by a summary of key theological reflections that are intended to support the Synod’s decision-making. Following this, the review and consultation approaches and findings are each described in turn.

Voluntary Assisted Dying Section C1.9 7 Response report to Synod 2019 Finally, this report presents proposals to the Synod that follow from the findings of the review and consultation activities. Most sections in this report are supported by detailed appendices, which are named and referenced in the relevant places in the text.

Voluntary Assisted Dying Section C1.9 8 Response report to Synod 2019 3. Victoria’s Voluntary Assisted Dying legislation

A detailed factsheet about Victoria’s Voluntary Assisted Dying legislation has been developed by the Victorian Government, and we commend it to you as essential reading. It is provided in Appendix C. A summary of the key information is included in this section of the report. 3.1. Background to the legislation In November 2017, Victoria became the first Australian state to pass voluntary assisted dying laws1. The Voluntary Assisted Dying Act 20172 provides a legal framework for people who are dying and suffering to take a medication prescribed by a doctor that will bring about their death at a time they choose. The law comes into effect in Victoria on 19 June 2019. The legislation followed an extensive ministerial inquiry into end of life choices, which consisted of reviews of 1037 submissions, and a program of site visits, public hearings, and international visits to jurisdictions elsewhere in the world where voluntary assisted dying, in a range of different forms, is legal. Some key findings from the review were as follows: • Death has become taboo in our society, which inhibits end of life care planning and may result in a person’s wishes not being known, or not being followed. • The Victorian palliative care system is overburdened and needs more government support. • For most people, palliative care will give them the support needed at the end of life. • A small minority of people who are dying experience suffering that is unacceptable and intolerable to them, even with the best palliative care. Prohibition of assisted dying for such people is resulting in significant pain and suffering and, in some instances, is resulting in them taking their own life prematurely and/or in distressing and traumatic ways. • Assisted dying accounts for a very small proportion of deaths each year in jurisdictions where it is legal (see section 6 of this report). • There were inconsistencies in end of life care legislation in Victoria (prior to the introduction of the Voluntary Assisted Dying Act 2017) which was leading to uncertainty amongst health practitioners. • There was evidence that unlawful and unreported assisted dying was occurring, and because it was unregulated, this left vulnerable people without safeguards. • In Victoria and across Australia, courts have not imposed heavy penalties on people who have assisted a loved one to die. People are not sent to prison because voluntary assisted dying is not seen to present a danger to society, and it seen as an act of compassion. • Internationally, government funding for palliative care services has not declined following the introduction of assisted dying legislation. • End of life care needs are different for everyone, and Victoria should have a system in place that caters to this wide variety of needs while upholding important safeguards to protect vulnerable people.

1 The Rights of the Terminally Ill Act was passed in the in 1995 which gave provision for a medical practitioner to end the life of a person who was dying at their request, however this was repealed by the federal government in 1997. 2 The Voluntary Assisted Dying Act (2017) can be accessed at http://www.legislation.vic.gov.au/Domino/Web_Notes/LDMS/PubStatbook.nsf/f932b66241ecf1b7ca256e92000e23be/B3 20E209775D253CCA2581ED00114C60/$FILE/17-061aa%20authorised.pdf

Voluntary Assisted Dying Section C1.9 9 Response report to Synod 2019 3.2. Understanding the legislation

3.2.1. What it is According to the Victorian Voluntary Assisted Dying legislation, voluntary assisted dying means that a person in the late stages of advanced disease can take a medication prescribed by a doctor that will bring about their death at a time they choose. In most cases, the person will administer the medication themselves. A person’s decision to access voluntary assisted dying must be: • Voluntary – their own choice. • Continuing and enduring – staying the same over a set period of time. • Fully informed – the person must be well-informed of their illness, treatment and palliative care options. Voluntary assisted dying will only be available to people who meet strict eligibility criteria as assessed by two independent doctors, which includes having an advanced disease that will cause their death and experiencing suffering that is unacceptable to them. As such, voluntary assisted dying is a choice between two ways of dying, not a choice between life and death. Voluntary assisted dying will only be accessible if the person and their doctors follow a set process as outlined by the law, which includes numerous safeguards to protect vulnerable people and the wider community. The Victorian Government has described Victoria’s Voluntary Assisted Dying legislation as the safest and most conservative assisted dying legislation in the world.

3.2.2. What it is not The Victorian Government has been clear that the Voluntary Assisted Dying legislation is not an alternative to palliative care for Victorians. It is a requirement of the legislation that a person who requests access to voluntary assisted dying is also informed about their treatment and palliative care options. The Palliative Care Funding Model Review Report3 (published October 2018) has recommended enhancements to the existing funding model to position Victoria’s palliative care service system to become an “exemplar of excellence” (p. 10), which further reflects a commitment to maintain and possibly boost investment into inpatient and community palliative care services. Internationally (in Belgium, The Netherlands), improvements to the quality of and access to palliative care has followed legalisation of assisted dying, because such services were seen as essential supports for assisted dying. Voluntary assisted dying, as defined and permitted by the Victorian legislation, is not permissive of passive euthanasia. That is, it cannot be ‘done to’ someone. A person must explicitly request and choose to enact voluntary assisted dying themselves; it cannot be requested or decided for them by another person (i.e. family member, doctor). In most cases, the person will administer the lethal dose of medication themselves. Voluntary assisted dying, as defined and permitted by the Victorian legislation, is not only the withdrawal or withholding of medical treatment at the request of the person who is dying. Rather, voluntary assisted dying is the choice of a person who is dying to request, access and take a lethal dose of medication according to the process outlined by the law.

3.2.3. What it is not likely to be Based on data and information from other countries where assisted dying is legal, we can make the following predictions about Victoria’s Voluntary Assisted Dying legislation:

3 The Palliative Care Funding Model Review Report can be accessed here: https://www2.health.vic.gov.au/hospitals-and- health-services/patient-care/end-of-life-care/palliative-care/palliative-care-funding-review

Voluntary Assisted Dying Section C1.9 10 Response report to Synod 2019 • It is not likely to be a “slippery slope” to involuntary assisted dying that puts vulnerable people at risk. Studies in jurisdictions where assisted dying is legal have shown that vulnerable people are not more likely to access assisted dying than the general population.4 • The legislation is not likely to be liberalised. Changes in practice or to the law that would extend access to voluntary assisted dying to people beyond the initial scope of the legislation (e.g. to children) are not likely. The legislation was drafted following extensive consultation with the community, including experts, and the law as it stands reflects the values and preferences as expressed by those who took part in the consultation. The safeguards that are built in to the Victorian Voluntary Assisted Dying legislation are enforceable by law, and any changes would require a lengthy parliamentary process.

3.2.4. Eligibility criteria To access voluntary assisted dying in Victoria, a person must meet all of the following criteria: • be aged 18 years or more; and • be an Australian citizen or permanent resident; and be ordinarily resident in Victoria for at least 12 months; and • have decision-making capacity in relation to voluntary assisted dying; and • be diagnosed with a disease, illness or medical condition that: o is incurable; and o is advanced, progressive and will cause death; and o is expected to cause death within weeks or months, not exceeding 6 months (12 months for people with a neurodegenerative condition); and o is causing suffering that cannot be relieved in a manner the person considers tolerable.

3.2.5. Process The following is a brief summary of the process a person must go through in order to access voluntary assisted dying according to the law. More details are provided in Appendix C. • A person must make three separate requests to a medical practitioner (combination of oral and written), at least 9 days apart. o Only the person wishing to access voluntary assisted dying can make the request. No-one else can make the request on their behalf. o A medical/health practitioner cannot initiate a conversation about voluntary assisted dying while providing a health service. • Following the first request, the person must undertake two independent assessments by medical practitioners to determine whether the person: o meets the eligibility criteria; o understands the information provided; o is acting voluntarily and without coercion; and o has an enduring request. • Permits are then obtained by a medical practitioner from the government (self-administered medication and practitioner-administered medication permits are available).

4 EJ Emanuel, BD Onwuteaka-Philipsen, JW Urwin, and J Cohen. ‘Attitudes and Practices of Euthanasia and Physician- Assisted Suicide in the United States, Canada, and Europe’. JAMA 316, no. 1 (2016), 79 – 90.

Voluntary Assisted Dying Section C1.9 11 Response report to Synod 2019 • A medical practitioner then prescribes the appropriate medication. A range of medications have been secured for use in Victoria, but the details of these will not be made available to the public. • A single dispensing pharmacy service will be available at Alfred Hospital, with provision for transportation of the medication to rural and regional areas. • This same pharmacy at the Alfred Hospital will be responsible for collecting and/or receiving and disposing of any unused voluntary assisted dying medications.

Note that a medical/health practitioner is not obliged to participate. Medical/health practitioners can conscientiously object by refusing to: o Provide the requesting patient with information about voluntary assisted dying, and/or o participate in the request, assessment and application process, and/or o supply, prescribe, dispense or administer the lethal medication, and/or o be present at the time of administration of the lethal medication.

Voluntary Assisted Dying Section C1.9 12 Response report to Synod 2019 4. Theological reflection on voluntary assisted dying

A summary of some key theological ideas is offered in this section, with a more detailed theological paper provided in Appendix D.5

The vast majority of us will not have the opportunity to choose or control our manner of dying. However, Victorian Voluntary Assisted Dying legislation offers the possibility for some people to make more active and legal choices about the manner of their death where death is already inevitable and, in most cases, imminent. This raises significant questions for people of faith. The life of faith is inescapably messy. While the Bible affirms the value of human life and witnesses to the promise that death is not the ultimate end, it does not remove life’s complexities or offer simple answers to the ethical challenges we face. Some of the most difficult of such challenges are those that relate to death. There are many long-held theological convictions in the Christian tradition that can inform our thinking about the complex issue of voluntary assisted dying.6 There are two theological convictions that are particularly relevant here, which are distinct yet bound up together: The sanctity of human life For most Christians, the strongest theological argument against euthanasia is that it represents a direct affront to the sanctity of human life. All human life, it is argued, is a gift of the Creator and so is simply not ‘ours’ to end. The Catechism of the Catholic Church judges that ‘intentional euthanasia, whatever its forms or motives, is murder. It is gravely contrary to the dignity of the human person and to the respect due to the living God, his [or her] Creator’.7 By and large, Protestants share this view – that ‘it is for God and God alone to make an end of human life’.8 But not all draw from this claim an absolute to be applied in all situations. Some argue that faith does not mean blindly following unassailable and predetermined laws but rather calls for listening for, discerning, and obeying God’s voice in every new situation. Here, human freedom is inescapably bound up with real risk, and with the responsibility to assess every situation and to make a real choice. This opens the door to the possibility that one might – in faith – make a responsible decision to end one’s life as an act of obedience. People of faith live, die, and make their judgements where no certainties abound and where they navigate concrete and immediate life with real limits, trusting that ultimately God alone takes responsibility for us. Commitments to the sanctity of human life wrestle also with questions of life’s quality: Is life to be equated with mere existence, or is life defined by other realities in which the quality of a life becomes a critical factor? Are people of faith morally required to avail themselves of every available technology in order to postpone or to hasten death? Life is certainly to be respected, but we must not make an idol of it. When life is preserved as an end in itself, with disregard for the quality of that life, then the result may serve an idolatry which has nothing whatever to do with religious obedience. Discerning when in fact this may be the case, however, is difficult, especially in the kinds of situations envisaged by Victoria’s Voluntary Assisted Dying legislation.

5 Paper from the Synod Ethics Committee, written by Rev Dr Jason Goroncy with Rev Dr Robyn Whitaker. 6 See Jason A. Goroncy, ‘Euthanasia: Some Theological Considerations for Living Responsibly’. Pacifica 29, no. 3 (2016), 221–43. 7 Catholic Church, Catechism of the Catholic Church (Homebush: Society of St Pauls, 1994), §2324. 8 Karl Barth, Church Dogmatics III.4, trans. A. T. Mackay, et al. (Edinburgh: T&T Clark, 1961), 425.

Voluntary Assisted Dying Section C1.9 13 Response report to Synod 2019 Arguably, it is possible, even desirable, that theologians defend ‘not only the sacredness of human life but also the sacredness of death. Sometimes death is the best that life has to offer, the moment when we return the gift of our life to God’.9 It might be argued that this represents the kind of decision that religious believers are free to make and to hasten as they face their own end.

Autonomy and Community Responsibility Those who have welcomed Victoria’s Voluntary Assisted Dying legislation uniformly argue that at issue here is a person’s ‘moral right’ to choose how they will die: ‘It is, after all, the patient’s life, and as long as the patient is capable of reaching an informed decision, then who better to decide whether life is worth living? Doesn’t the patient have a right to ask for this help and, if a doctor is willing to give it, why should the law stand in the way?’10 Here, individual agency is prized above all other concerns. This argument is theologically relevant because of the weight that religious traditions place on human persons being responsible for their own decisions. Critics of this rationale warn of that ‘autonomy has become an imperative; that which we cannot control, our belief in autonomy teaches us to hate. Thus, we learn to hate our ageing bodies; and we learn to hate those others who are sick and dying. We even learn to hate those we would define as “permanently dependent”, exactly because they will always need our care’.11 A theological defence of the moral right to choose argument underscores human responsibility for life before God. Indeed, at the very centre of the Christian story lies a voluntary act of giving up life for the other. Without such freedom, there would be no human life as we know it at all. It might be argued that assisted dying might not always be the ultimate form of individualism, but rather might be judged to be an act of responsible freedom and love for the other, a mode of glorifying God with one’s body (1 Cor 6:20). Of course, the counter argument here is that such a decision robs the other of the opportunity to themselves love and to bear together the burden of life’s uncertainties and ambiguities beyond the limits that one might choose to set for oneself. Human responsibility for life is exercised not only before God. It is exercised also before and with others with whom one is called to ‘bear one another’s burdens’ (Gal 6:2). Assisted dying, by its very definition, is not a private matter. It involves, requires, and has an impact upon a wider public and society. It ought not, therefore, be reduced to being about a patient’s rights alone. In religious communities, for a person to claim the as an individual right can be a form of individualism that contradicts the communal and relational nature of God and God’s people. But what if the decisions made around death were undertaken not by the individual alone but rather with a community that was committed to bear the burden of the decision together? This would mean that whether or not the path led towards or away from voluntary assisted dying, there remains the opportunity to die accompanied by the presence, prayers, and confessions of others. For Christians, it offers the opportunity to die accompanied by those sacraments we have been rehearsing – Baptism and Eucharist. Baptism, that symbol of death with which the Christian journey begins; and Eucharist, where Christians remember and anticipate that the tragedy of the grave is not territory of which God is unfamiliar.

9 D. Dixon Sutherland, ‘From Terri Schiavo Toward a Theology of Dying’, in Resurrection and Responsibility: Essays on Theology, Scripture, and Ethics in Honor of Thorwald Lorenzen, ed. Keith D. Dyer and David J. Neville (Eugene: Pickwick Publications, 2009), 246. 10 Peter Singer, Rethinking Life and Death: The Collapse of Our Traditional Ethics (Melbourne: The Text Publishing Company, 1994), 132. 11 Carole Bailey Stoneking, ‘Receiving Communion: Euthanasia, Suicide, and Letting Die’, in The Blackwell Companion to Christian Ethics, ed. Stanley Hauerwas and Samuel Wells (Malden: Blackwell Publishing, 2004), 379.

Voluntary Assisted Dying Section C1.9 14 Response report to Synod 2019 5. Review and consultation process

5.1. Review scope and approach Three separate desktop or literature reviews were conducted in order to identify and synthesise information and data to inform this report and the associated proposals. Each review process is briefly described in turn below.

1. Scoping review of literature summarising the theology of voluntary assisted dying. A review of popular and academic literature about the Christian theology of end of life issues, most particularly voluntary assisted dying, was conducted. This review informed the scope and nature of the theological reflections used as a basis for discussion during the consultations (see section 5.2). 2. Rapid review of Christian people’s beliefs and attitudes towards voluntary assisted dying (and related concepts such as euthanasia). A ‘rapid review’ is a review of previous literature reviews. It is an efficient method for identifying and synthesising a wide range of studies on a specific topic that have been published in the academic literature. Three large journal databases (Scopus, Web of Science, PsycInfo) were systematically searched for relevant reviews, which identified four previously published reviews of studies that explored Christian beliefs and attitudes towards end of life issues such as voluntary assisted dying and euthanasia. None of these reviews focused substantively on Australian data, nor were any of these reviews conducted by Australian researchers. Thus, the findings from these four reviews were supplemented with Australian survey data about the support or otherwise for voluntary assisted dying amongst Christians from mainline denominations. 3. Desktop review of the official responses of other Christian denominations in Australia to voluntary assisted dying. A review of the public and/or official statements from other mainline Christian denominations on voluntary assisted dying (and related concepts such as euthanasia) was conducted. This was undertaken by visiting denominational websites, searching media articles, and approaching key stakeholders to request information and input. The scope of this review was focused on mainline Christian denominations in Australia.

5.2. Consultation scope and approach The aim of the consultation process was to gauge and summarise the views of the members, staff, and leadership of the UCA, UCA agencies, and UCA-affiliated organisations about how the Synod should respond to the introduction of Victoria’s Voluntary Assisted Dying legislation. Consultation with external experts and consumer groups12 were out of scope of the current project on the basis of this being an internal consultation to inform Synod’s decision-making. The consultation plan was designed to take into account a wide variety of perspectives from across the UCA, including theological, pastoral, policy, and practice perspectives, as well as pragmatics. It was developed in collaboration with key leaders from the Synod of Victoria and Tasmania, various committees of the Uniting Church in Victoria, Uniting, Uniting AgeWell, Epworth Healthcare and the UCA Assembly. Table 1 outlines who was consulted, for what purpose, and by what method. The consultation scope and approach were reported to the Synod Standing Committee in the early phases of this project. Note that while all presbyteries were invited to take part in the consultation, only four presbyteries accepted the invitation: Yarra Yarra, Loddon Mallee, North Eastern Victoria and Western Victoria. The Western Victoria

12 It is strongly acknowledged that consumer groups will add enormous value to discussions about how voluntary assisted lying legislation should be implemented within UCA agency / UCA-affiliated organisation sites and services (if it is decided by the Synod that this would be permitted) and will also helpfully inform the development of any pastoral resources for the Church.

Voluntary Assisted Dying Section C1.9 15 Response report to Synod 2019 consultation event was ultimately cancelled on account of not receiving any affirmative RSVPs, and so the table below summarises the details of only three presbytery consultations. It is also important to note that while consultation with the Uniting Aboriginal and Islander Christian Congress was highly desired, it was deemed not feasible on the basis that there are currently no Aboriginal people in leadership roles in the Victorian Congress. The articles and papers identified through reviews 1 and 2 (see section 5.1) were screened in an attempt to identify any research that related specifically to the views and perspectives of Aboriginal people, however none were identified.

Table 1. Summary of voluntary assisted dying consultation activities.

Organisation / Council Who Purpose Method / Committee Uniting AgeWell Mission Committee To understand the needs and Combined 90-minute Voluntary Assisted Dying preferences of the UCA agencies workshop with Mission Implementation Taskforce and affiliated organisations Committee, regarding if/how to make access Implementation Taskforce, Board members to voluntary assisted dying and Board members. Senior managers permissible within their facilities, services and programs. Survey data from Uniting AgeWell’s internal consultation with senior managers. Uniting Director of Mission Two-hour workshop Mission and Ethos Partner (Western VIC and TAS) Executive Officer (Eastern Melbourne) Aged Care Senior Manager Justice Campaign Manager Pastoral Care Worker Epworth HealthCare Executive Director – One-on-one discussions Academic and Medical and UCA representative on the Board Presbyteries Presbytery of North To provide opportunities for the One-hour presentation and Eastern Victoria broader church to contribute to table group discussions the discussion, so this can be fed during February presbytery back to the Synod to inform meeting. Option of sending decision making a written submission by email Presbytery of Loddon 1.5-hour presentation and Mallee table group discussions during February presbytery meeting. Option of sending a written submission by email Presbytery of Yarra Yarra 45-minute presentation and table group discussions during February presbytery meeting. Option of completing written submission on the spot by completing a structured,

Voluntary Assisted Dying Section C1.9 16 Response report to Synod 2019 Organisation / Council Who Purpose Method / Committee open-ended questionnaire, or sending by email

Ministry & Mission Committee of the Synod To ensure project processes and 45-minute presentation and Standing Committee outputs were meeting the needs discussion of the Synod

CALD community Eleven CALD community To ensure the paper and 90-minute workshop with ministers in the Uniting proposals are informed by option of completing Church in Victoria perspectives that represent the written submission on the diversity of the UCA spot by completing a structured, open-ended questionnaire, or sending by email Hospital chaplains Two (one current, one To understand the needs and Structured, open-ended former) Uniting Church desires of the chaplaincy staff questionnaire chaplains in Victoria response to VAD legislation, so this can be fed back to the Synod to inform decision-making Pilgrim Theological Biblical scholars and To provide theological input into Request input in the form College theologians project activities and outputs, of literature and papers ensuring these issues have been given due consideration Synod Ethics All To resource the project by Regular discussions with Committee providing literature and Chair to prepare and inform connections to relevant people work plan, and stay abreast of developments To prepare a theological ‘primer’ for inclusion in Synod report

To activate parallel pieces of work to resource the broader church (e.g. pastoral and liturgical resources) eLM Representatives Social Justice Senior To ensure project outputs are One-on-one discussions to Advocate informed by previous and explore any current or Disability Inclusion Officer current work of the Synod (eLM) planned activity in this space Co-Director Relationships and Connections UnitingCare Australia National Director and To keep the national body Input and comment on Board Chair abreast of the work and create draft version of this report opportunities for mutual learning.

UCA Assembly Assembly General To keep the national Church Input and comment on Secretary abreast of the work and create draft version of this report opportunities for mutual learning

In addition to the consultation activities outlined in Table 1, the current report also summarises and draws upon the findings of the 2017 Synod consultation on voluntary assisted dying (led by the then Justice and International Mission Unit).

Voluntary Assisted Dying Section C1.9 17 Response report to Synod 2019 6. Review findings

6.1. Voluntary assisted dying around the world Medical assistance in bringing upon a person’s death is legal and practiced in numerous jurisdictions across the world. Regulations and legislation vary markedly across jurisdictions, which themselves may be at a National or State/Provincial level, as is the case for Victoria. The previously mentioned Victorian Government ministerial inquiry into end of life choices included committee visits to the following international jurisdictions for the purpose of providing detailed summaries of assisted dying legislation in these jurisdictions: • The Netherlands (law commenced 2002) • Canada (2016)13 • Québec Province, Canada (2015)13 • Oregon State, USA (1997) • Switzerland (1942)14 The Victorian Government ministerial inquiry also provided an overview of the legislations in Belgium (2002), Luxembourg (2009) and Washington State, USA (2009), as additional jurisdictions where assisted dying is legal15. A summary table outlining the particulars of the legislation in each of these jurisdictions is provided in Appendix E and demonstrates that there is substantial variation in the laws. Of all of these, the laws in Oregon and Washington in the USA are most comparable to Victoria’s Voluntary Assisted Dying legislation. That is, the laws have similar (though not exactly the same) eligibility criteria and safeguards. In the following section, data that relates to the observed impact of assisted dying legislation over time in these North American jurisdictions is compared with data from The Netherlands and Belgium which have much more liberal legislation (less restrictive eligibility criteria and fewer safeguards) but have had the legislation in force for comparable lengths of time with data available to portray trends over a minimum of 10 years.

6.1.1. Trends in voluntary assisted dying One of the key concerns raised in opposition of voluntary assisted dying is the ‘slippery slope’. That is, there is concern that the introduction of voluntary assisted dying legislation will lead to an expansion of intentionally ending people’s lives, often with a particular focus on doing so without their request, and the consequent risks to vulnerable groups. While the slippery slope debate continues, the data from international jurisdictions suggest that this concern has not been fully realised. This is especially true for jurisdictions where the original legislation was explicitly written to emphasise the voluntary and consensual nature of assisted dying for those in the late stages of disease.

13 Québec initially had a provincial level legislation. Following a high-profile court ruling, this was since expanded to the Federal level, but still in preliminary stages at the time of the report. For our purposes, the Federal legislation can be considered inclusive of Québécois law. 14 Swiss legislation is unique in nature, as it prohibits assisted suicide “unless it is provided ‘without selfish motives’”. Eligibility criteria and safeguarding are uncertain and not clearly articulated, making it challenging to compare with other legislation. 15 Since the ministerial inquiry report was published in 2016, other jurisdictions (Colombia and the states of California, Colorado and Vermont in the United States), also have also passed and approved laws permitting and voluntary assisted dying respectively.

Voluntary Assisted Dying Section C1.9 18 Response report to Synod 2019

6.1.1.1 Diagnosed illness Across the world, data from the past 20 years consistently indicate that most people accessing assisted dying (in its various legislative forms) have cancer. However, the proportion of people accessing assisted dying who have cancer is decreasing over time. This indicates that more people with conditions other than cancer are dying in an assisted manner. 6.1.1.2 Proportion of deaths Data from Belgium, The Netherlands, Oregon and Washington all indicate an upward trend in assisted deaths over time following the introduction of relevant laws. Figures 1-4 present the trends over time in assisted deaths and mortality rates in these four jurisdictions. The following observations can be made: • In Belgium and The Netherlands, increases in the proportion of assisted deaths have been in the order of 1.6% and 2.4% respectively over more than a decade, which predominantly reflects changes in the legislation over time which have broadened the eligibility criteria16. • Oregon and Washington (with legislation similar to Victoria’s) have both seen only very small increases over extended periods of time: 0.3% in both jurisdictions, over a period of 18 years and 7 years respectively. • In all four jurisdictions, the death rates have remained constant (between 0.7-1.0%). This suggests one or both of the following: o 1) the introduction of assisted dying laws does not lead to substantially more deaths per year, but rather the laws offer a different mode of death; o 2) the number of assisted deaths each year is so small that it does not impact the mortality rate.

Figure 1. Assisted dying and mortality rate trends in Belgium (2003-2015)

Belgium 4.5 4.0 3.5 Deaths attributed to 3.0 VAD (%) 2.5 % 2.0 National 1.5 mortality rate 1.0 (%) 0.5 0.0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year

16 For example, the Dutch legislation was adapted in 2005 to broaden eligibility to children and infants who are “gravely ill, suffer birth defects or have a hopeless prognosis”. This criterion was also introduced in Belgium in 2014.

Voluntary Assisted Dying Section C1.9 19 Response report to Synod 2019

Figure 2. Assisted dying and mortality rate trends in The Netherlands (2002-2015)

Netherlands 4.5 4.0

3.5 Deaths 3.0 attributed to VAD (%) 2.5 % 2.0 1.5 National 1.0 mortality rate (%) 0.5 0.0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year

Figure 3. Assisted dying and mortality rate trends in Oregon USA (1998-2016)

Oregon 1.2

1

0.8 Deaths attributed to % 0.6 VAD (%)

0.4 State mortality rate 0.2 (%)

0 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016

Voluntary Assisted Dying Section C1.9 20 Response report to Synod 2019

Figure 4. Assisted dying and mortality rate trends in Washington USA (2009-2016)

Washington 1.2

1

0.8 Deaths attributed to % 0.6 VAD (%)

0.4 State 0.2 mortality rate (%) 0 2009 2010 2011 2012 2013 2014 2015 2016 Year

6.2. Views and values of people of Christian faith regarding assisted dying 1. Opposition to assisted dying Many studies and reviews exist around end of life care and situations encompassing voluntary assisted dying and euthanasia. Generally, when assessing attitudes, these are conducted as opinion polls and surveys, to which the major Christian opposition to both voluntary assisted dying and other related concepts such as euthanasia can generally be attributed to Catholicism. A qualitative study conducted with clergy in the United States and found that Catholic clergy held less favourable attitudes towards voluntary assisted dying than those from other Christian denominations17. Less recent information is available in Australia; one study from 1997 described the Catholic position in their research as “opposition to such a legislation”, relative to other denominations as “voices in disagreement”18. These views have also been expressed by Christian (specifically Catholic) healthcare professionals. A systematic review of research investigating attitudes towards assisted dying among healthcare professionals found that Catholic nurses and doctors had lower rates of acceptance of, agreement with, and willingness to participate than those who did not identify as Catholic.19 This has also been reflected in the Australian context, albeit historically, with a 1995 survey of 1238 Australian doctors finding that Catholic practitioners were opposed to voluntary assisted dying at a rate significantly greater than others.20 2. Support for assisted dying Findings from the literature have also indicated support for assisted dying amongst those of Christian faith, both locally and abroad. A 1997 opinion poll15 not only portrayed a diversity of opinions among Australian Christians, but anonymously, the majority were supportive of assisted dying (74-83% of responses). Support has also come from Christian medical professionals; 92% thought that the use of drugs in lethal doses on the

17 Karen Mason, Kim Esther, W. Blake Martin, and Rashad J. Gober. ‘The Moral Deliberations of 15 Clergy on Suicide and Assisted Death: A Qualitative Study.’ Pastoral Psychology 66, no. 3 (2017), 335 - 351.

18 Andrew Dutney. ‘Christian Support for Voluntary Euthanasia’. Monash Bioethics Review 16, no. 2 (1997), 15 – 22. 19 R Chakraborty et al. ‘A Systematic Review of Religious Beliefs about Major End-of-life Issues in the Five Major World Religions.’ Palliative and Supportive Care 15, no. 5 (2017), 609 – 622. 20 P Baume, E O'Malley, and A Bauman. ‘Professed Religious Affiliation and the Practice of Euthanasia.’ Journal of Medical Ethics 21, no. 1 (1995), 49 – 54.

Voluntary Assisted Dying Section C1.9 21 Response report to Synod 2019 explicit request of the patient is acceptable in the case of terminal illness with extreme uncontrollable pain/other distress.21 There is also evidence of support for assisted dying amongst clergy. A survey of 1,665 Christian clergy (representing at least 5 denominations) in the United States found that mainline/Liberal Christian clergy were more likely to approve of the morality (56%) and legality (47%) of assisted dying, while approval rates amongst clergy from other denominational groups were substantially lower (6 and 17% for morality and legality respectively).22 3. Impact of religiosity Implicated in the literature is a relationship between individuals’ attitudes towards assisted dying and the degree to which they are devoted to a religious faith. This was summarised in a review of 31 papers which found that the “self-reported importance of religion in life” correlated negatively with supportive attitudes towards assisted dying. In other words, the more important religion is to a person, the more likely they are to hold attitudes that are unsupportive of assisted dying in any form.23 6.3. Responses to voluntary assisted dying from other Christian denominations in Australia

6.3.1. Catholic Church in Australia The Catholic response locally (in Victoria) has been consistent with the international stance; the Catholic Church is against Voluntary Assisted Dying and euthanasia in all its forms. The then Archbishop of Melbourne, Denis Hart, summarised the stance in their response to the passing of the legislation in November 201724: • Euthanasia and assisted suicide represent the abandonment of older and dying persons25.

• Voluntary assisted dying is not part of the practice of Catholic healthcare workers and incompatible with the provision of quality palliative care. Therefore, Catholic health and aged care providers will not provide assisted suicide.

• No one should be forced to act against their conscience. It is believed that a burden will be imposed on medical professionals, conflicting with their medical commitment to “do no harm” to patients.

The Catholic Church believes the introduction of voluntary assisted dying will create a lower threshold of care and civil protection afforded to the sick, suffering and vulnerable. They believe that such a law would not only normalise suicide, but would serve to exploit vulnerable people, exposing them to further risk26. There is also a concern that eligibility criteria will expand to include individuals without a terminal illness, which is possible in Belgium and the Netherlands.

Importantly, paralleling the response from the Catholic Church has been their advocacy for increasing support for palliative care to provide the best possible care for those in the last stages of their life. This commitment by extension includes all Catholic-affiliated residential aged care facilities.

21 E Inghelbrecht, J Bilsen, F Mortier, and L Deliens. ‘Nurses’ Attitudes Towards End-of-life Decisions in Medical Practice: A Nationwide Study in Flanders, Belgium.’ Palliative Medicine 23, no. 7 (2009), 649 – 658. 22 Michael J Balboni, Adam Sullivan, Patrick T Smith, Danish Zaidi, Christine Mitchell, James A Tulsky, Daniel P Sulmasy, Tyler J VanderWeele, and Tracy A Balboni. ‘The Views of Clergy Regarding Ethical Controversies in Care at the End of Life.’ Journal of Pain and Symptom Management 55, no. 1 (2018), 65 – 74. 23 J Gielen, S van den Branden, and B Broeckaert. ‘Religion and Nurses' Attitudes to Euthanasia and Physician Assisted Suicide.’ Nursing Ethics 16, no. 3 (2009), 303 – 74318. 24 http://cathnews.com/media-releases/media-releases-2017/1126-171129-melb-arch-statement-from-the-archbishop-of- melbourne-denis-hart-on-euthanasia-and-assisted-suicide-in-victoria/file 25 http://shgc.vic.edu.au/_uploads/_cknw/files/CAM_Archbishop_euthanasia.pdf 26 http://melbournecatholic.org.au/Portals/0/Victorian%20Bishops%20-Pastoral%20Letter%20on%20euthanasia.pdf

Voluntary Assisted Dying Section C1.9 22 Response report to Synod 2019 6.3.2. The Anglican Church in Australia Melbourne Anglican Archbishop Philip Freier has previously expressed his objections towards voluntary assisted dying, with the Church submitting a plea for the Victorian Parliament to reject voluntary assisted dying and euthanasia, and for it to remain illegal27. As part of their submissions, the Church expressed a concern for the potential “change in attitude” that the legislation could instigate, at a time when the government is also trying to reduce youth suicide28. There has also been apprehension from the medical professionals that identify with the Anglican Church that the legislation may harm the reputation of their profession and their duty to preserve life29. To this end, the potential for the current legislation to expand to include individuals without a terminal illness, as witnessed overseas is a concern, one that in the views of the Anglican Church is not adequately safeguarded by the current bill.

Concordant with the Catholic statements and stance, the Anglican Church has also used their response to the Voluntary Assisted Dying legislation as a call for greater emphasis on palliative care and improved funding in this space, which would make “palliative care a safer and more compassionate way to address ‘bad deaths’” that may currently fit into the eligibility criteria of the legislation.

6.3.3. The Salvation Army in Australia The Salvation Army Australia follows that Church’s international leadership from the United Kingdom, which is opposed to euthanasia and assisted suicide in all its forms. This position has been official locally since 2016 and was based on The Salvation Army International’s Positional Statement: Euthanasia and Assisted Suicide, 201330. These are: • All people deserve to have their suffering minimised in every possible way consistent with respect for the sanctity of life. • It is not suicide for people to choose to refuse or terminate medical treatment. • It is not euthanasia for healthcare professionals to withhold or withdraw medical treatment that only prolongs the dying process. • To provide supportive care for the alleviation of intolerable pain and suffering (e.g., by way of analgesics) may be appropriate even if the dying process is shortened as a side effect.

Their theological belief in the sanctity of life underpins the view that society cannot use anyone’s suffering as a justification in causing their death, or in judging a person’s life as not worth living. They also state that whilst they prize human autonomy, they believe that “human beings do not have the right to death by their act or by the commissioning of another person to secure it”.

The Salvation Army believes that issues which cause people to consider euthanasia can instead be addressed by increasing the role of the Church in providing support to dying people, as well as through increased support provided by palliative care services.

6.3.4. The Baptist Church in Australia The Australian Baptist Ministries is the national cooperative network of over 1,000 churches, which is the representative body of the Baptist Church in Australia. Each individual church is an autonomous entity, however all policy, organisational, and administrative functions for the Baptist Church are undertaken at the state and territory union level (e.g. The Baptist Union of Victoria). The topic of assisted suicide and euthanasia was a topic that was addressed by the Australian Baptist Ministries at their national council meeting in 2010. A national level resolution was outlined, which detailed their opposition to euthanasia and assisted suicide, which included:

27 http://www.anglicanprimate.org.au/press/assisted-dying-law-cause-for-lament/ 28 http://acl.asn.au/please-reject-euthanasia-church-to-victorian-parliament/ 29 http://www.anglicanprimate.org.au/press/assisted-dying-law-cause-for-lament/ 30 https://www.salvationarmy.org/ihq/ipseuthanasia

Voluntary Assisted Dying Section C1.9 23 Response report to Synod 2019 • To accept the Biblical teaching that all human persons are precious and of intrinsic worth since they are made in the image of God, and that death is a normal and natural part of every human life; • Whilst opposing euthanasia, their belief is that it is morally acceptable to not prolong life with futile or burdensome treatments; • They called on the Prime Minister and other political leaders to oppose all initiatives to legalise euthanasia and assisted suicide; and, • They called upon federal, state, and territory governments to encourage alternatives to euthanasia and to increase funding for pain management and palliative care.

At a state level, the Baptist Union of Victoria has not expressed an explicit position on euthanasia or voluntary assisted dying. However, Baptcare, a Baptist-affiliated organisation operating residential and community facilities for older and other disadvantaged community members, has stated in its social policy paper31 that it is “committed to reviewing the practices currently in place within its service provision to assist a person to exercise their preferences and to be respectful of individuals’ end of life choices. This includes encouraging advance care planning, the role of active palliative care, and, where appropriate, assisted dying”. Currently, Baptcare operates 14 residential aged care facilities across Victoria, which would be impacted by the Voluntary Assisted Dying legislation, which according to the statement, appears likely to make accessing voluntary assisted dying permissible at these sites.

31 http://www.baptcare.org.au/__data/assets/pdf_file/0016/20059/BC0794-RESEARCH-ASSISTED-DYING-SocialPolicy-A4- 4pp-INFOSHEET-WEB-2.pdf

Voluntary Assisted Dying Section C1.9 24 Response report to Synod 2019 7. Consultation findings

7.1. Consultation with UCA members in Victoria

7.1.1. Presbyteries As outlined in section 5 of this report, while all presbyteries were invited to take part in this consultation, only three did: Yarra Yarra, North Eastern Victoria, and Loddon Mallee. As there were no notable differences in the findings from each of these three consultations, they have been summarised together here. Key insights from the presbytery consultations were as follows: A wide range of views were expressed by Church members about death and dying, and how to improve the experience of people at the end of their lives. Consultation participants generously shared their own professional and personal experiences with death and dying, and explored together how these experiences, alongside their theology and ethics, shaped their personal views. The sanctity of life, free will and autonomy, and non-judgemental and non-discriminatory pastoral and health care were raised as issues for discussion and reflection by consultation participants at each presbytery. It is possible to differentiate between support for voluntary assisted dying, and support for an individual’s legal right to access voluntary assisted dying. Meaning, most consultation participants considered it possible to support a person’s legal right to access voluntary assisted dying within UCA agencies (Uniting AgeWell and Uniting) and the UCA-affiliated hospital (Epworth Healthcare), even if one’s theological, moral and/or ethical beliefs lead them to a personal position of being against voluntary assisted dying. There is a responsibility on the Synod to make a clear and timely decision at its July 2019 meeting about whether or not voluntary assisted dying will be permissible within the UCA agencies and affiliated hospital. There was consensus within all of the presbytery consultations that Synod must take a position on this issue at its July 2019 meeting, and that is was not fair on the staff, residents, patients and clients of UCA agencies (Uniting AgeWell and Uniting) and affiliated hospital (Epworth Healthcare) to delay decision-making and/or avoid giving clear direction. There was strong, though not unanimous, support for voluntary assisted dying being permissible within UCA agencies and UCA-affiliated hospital. Most, though not all, consultation participants supported the notion that it be permissible to access legal voluntary assisted dying within UCA agencies (Uniting AgeWell and Uniting) and affiliated hospital (Epworth Healthcare) in Victoria. That is, most were in favour of not restricting access to voluntary assisted dying for patients, clients and residents of these organisations. Many held the view that denying access to voluntary assisted dying was neither pragmatic nor pastorally responsible: voluntary assisted dying is already legal in Victoria and denying a person’s right to access it would be a likely cause of considerable distress at an already extremely difficult time. Many expressed concerns about the implication of an aged care resident needing to move out of their home, or a palliative care patient needing to move hospitals, in order to enact voluntary assisted dying if it was not permissible within the context of UCA agencies and affiliated organisations. A small minority expressed the view that voluntary assisted dying should not be accessible within UCA agencies and affiliated organisations. A small proportion of consultation participants believed it would be against the teaching of the Bible for voluntary assisted dying to be permissible within the context of UCA agency (Uniting AgeWell and Uniting) and affiliated hospital (Epworth Healthcare) facilities and services, and they were therefore not supportive of voluntary assisted dying being permissible in these contexts. There was a consistent emphasis on wanting to ensure that all people, and their families, would receive a compassionate pastoral response from the Church regardless of how or where they choose to die. Pastoral and spiritual care at the end of life was seen to be of great importance. There was no support for the notion of withdrawal of pastoral and spiritual support for those accessing voluntary assisted dying, and their families. There was a recognised need to give provision for conscientious objection. Noting that the Voluntary Assisted Dying legislation provides for healthcare professionals to conscientiously object, consultation participants

Voluntary Assisted Dying Section C1.9 25 Response report to Synod 2019 urged the UCA agencies (Uniting AgeWell and Uniting) and affiliated hospital (Epworth Healthcare) to develop clear policies and procedures for staff and volunteers to opt-out of any form of participation in voluntary assisted dying, including being present while a person takes a lethal dose of medication. Some also expressed the importance of UCA ministers, deacons, chaplains, and other relevant workers opting-out of providing pastoral care and/or a funeral liturgy if they felt they were unable to do so in ‘good conscience’. In this instance, the suggestion was that a referral should be made to another worker who is willing to provide such support.

7.1.2. UCA ministers from Culturally and Linguistically Diverse Backgrounds Key insights from the consultation with UCA ministers from Culturally and Linguistically Diverse Backgrounds were as follows: People from collectivist cultures are likely to respond to the issue of voluntary assisted dying in different ways to those from individualistic cultures. People from collectivist cultures that emphasise family or community goals, needs and desires above those of the individual are likely to be challenged by Victoria’s Voluntary Assisted Dying legislation which gives primacy to individual autonomy. The dominant, though not the only, view was that voluntary assisted dying should not be permissible within UCA agencies (Uniting AgeWell and Uniting) and UCA-affiliated hospital (Epworth Healthcare). The sanctity of life, the distinction (or possible lack thereof) between voluntary assisted dying and suicide, and the meaning and purpose of suffering were all key theological reflections that informed this perspective. A minority of CALD ministers expressed support for allowing voluntary assisted dying within UCA agencies (Uniting AgeWell and Uniting) and UCA-affiliated hospital (Epworth Healthcare). While a small number of consultation participants believed it should be permissible for voluntary assisted dying to be accessed and enacted within the UCA agency and affiliated hospital facilities and services, the level of support varied. For example, while some fully endorsed facilitating access to voluntary assisted dying, others believed that while access should not be denied, it should not be permissible for medical or healthcare professionals employed by the UCA agencies or affiliated organisations for participate in voluntary assisted dying. There was a strong desire for tailored, culturally-responsive educational and pastoral resources about voluntary assisted dying, in community languages. Consultation participants were directed to a Victorian Government website that provides information sheets about the voluntary assisted dying legislation in a range of languages, and in Easy English32. However, it was apparent that more was needed, including educational resources in additional languages that reflect the cultural and linguistic backgrounds of UCA members in Victoria, and tailored pastoral resources that are responsive to the needs, values and customs of different cultural groups within the UCA.

7.1.3. 2017 open consultation with UCA members In September 2017, the then Justice and International Mission (JIM) Unit produced a consultation paper on voluntary assisted dying for presbyteries, congregations and individual members of the UCA in Victoria and Tasmania. The purpose of the paper was to resource a Synod-wide consultation process to gauge whether the Synod should take a position on voluntary assisted dying, given new legislation was proposed in Victoria (though not yet passed as law at the time). The paper outlined the recommendations arising from the Victorian government’s ministerial inquiry, reviewed the relevant resolutions that had previously been passed by the then Synod of Victoria, offered detailed theological reflections on voluntary assisted dying from a range of perspectives, summarised the views of other churches, provided case studies, and described the nature and impact of assisted dying and euthanasia laws elsewhere in the world. The full paper is available as Appendix F. The JIM Unit invited submissions in response to the issues raised in the consultation paper from individuals, congregations, or other groups. In particular, submissions were invited (though not obliged) to address the following questions:

32 http://healthtranslations.vic.gov.au/bhcv2/bhcht.nsf/PresentDetail?Open&s=Voluntary_assisted_dying

Voluntary Assisted Dying Section C1.9 26 Response report to Synod 2019 1. Should the Synod take a position on the proposed laws the Victorian Government plans to introduce on voluntary assisted dying/suicide? If so, what should that position be? 2. If the laws are passed through the Parliament, should the Synod allow people to end their lives in Synod facilities, such as aged care facilities, if such action by the person complies with the requirements of the laws? 3. If the laws are passed through the Parliament, should people ultimately employed by a Synod body be permitted to assist or facilitate people using the laws to end their lives while they are employed by the Synod? Fifteen submissions were received in total: 10 from individuals, couples or pairs; four from congregations; one from Uniting AgeWell. Of the ten submissions that addressed question 1 above, eight recommended the Synod take a position on the (then proposed) voluntary assisted dying laws while two recommended the Synod not take a definitive position. Two submissions recommended the Synod take a position of supporting the legislation, four recommended a position of opposing the legislation, and the remaining two offered mixed views or made no specific recommendation to the Synod about what stance to take. Of the six submissions that addressed questions 2 and 3 above, all indicated support for allowing voluntary assisted dying within ‘Synod facilities’ (e.g. Uniting AgeWell aged care facilities), and all indicated support for allowing Synod employees to facilitate access to, or support a person as they accessed, voluntary assisted dying. 7.2. Consultation with Uniting AgeWell Key insights from the consultation with Uniting AgeWell Board members, Mission Committee members, and executive were as follows: There was unanimous support for allowing voluntary assisted dying within Uniting AgeWell facilities. The Uniting AgeWell Board members, Mission Committee members, and executives that participated in the consultation reached unanimous agreement in support for facilitating a resident’s / client’s end-of-life choices within Uniting AgeWell facilities, including voluntary assisted dying (in accordance with the law). This was seen to be consistent with Uniting AgeWell’s identity statement, which names in particular “support for each person in their uniqueness” as a key Christian belief-in-action that drives how the organisation undertakes it work. This was seen to include respecting a resident’s / client’s autonomy and choice at all stages of their life to the greatest extent possible, facilitating access to the full range of end-of-life choices legally available to a person according to their preferences, and reducing suffering with compassion. Note that while this view was expressed and/or supported by all consultation participants, Uniting AgeWell has not formulated an official, public position on the issue. Palliative care needs to be recognised as critical to alleviating suffering at the end of life and should be resourced accordingly by both the government and by Synod. For most people who are dying, palliative care will meet their needs and alleviate their suffering at the end of their life. Palliative care needs to continue to be a real option and choice, especially within the context of legalised voluntary assisted dying. The government and the Synod should be prioritising more funding, staff and support services and maintain, expand and strengthen palliative care in Victoria. There was concern about the care, quality of life, and risk implications for Uniting AgeWell residents / clients if the Synod decided that voluntary assisted dying would not be permissible. Consultation participants explained that once a person moves in to a residential facility, it becomes their legal home. Therefore, there was concern about the implication that a resident would need to move out of their own legal home at the residential facility to access voluntary assisted dying if the Synod decided it was not permissible within Uniting AgeWell facilities. This would threaten security of tenure and cause significant distress and upheaval. There was also concern that ‘banning’ voluntary assisted dying from taking place within Uniting AgeWell facilities might lead to residents taking their own life in traumatic ways, non-disclosure of medication on behalf of residents (i.e. residents do not make the required declaration that the lethal medication is in their possession) and / or risk of actual or perceived discrimination against potential future residents who already have the lethal medication in their possession. It was believed that clear and transparent policies and procedures to

Voluntary Assisted Dying Section C1.9 27 Response report to Synod 2019 facilitate safe and legal access to voluntary assisted dying within Uniting AgeWell facilities would be preferable to these implications and risks. The Synod needs to give clear direction to the UCA agencies and affiliated organisations on whether or not voluntary assisted dying will be permissible following the July 2019 meeting. Uniting AgeWell consultation participants are looking to Synod for a clear and timely decision on whether or not it would be permissible for people to access voluntary assisted dying within the UCA agencies and affiliated organisations. While Uniting AgeWell has undertaken significant preparatory work in order to be ready for the introduction of the legislation, much remains to be finalised (e.g. policies, procedures, staff and resident communications) in light of the Synod’s decision. The implementation of any decision will be complex, and a clear and timely Synod decision will enable Uniting AgeWell to progress with essential next steps. There was a recognised need to give provision for conscientious objection. Uniting AgeWell has previously undertaken its own internal consultation, in the form of an online survey, to explore the extent to which its service managers support voluntary assisted dying. The results indicated that almost two-thirds of survey respondents were in favour of voluntary assisted dying being accessible within Uniting AgeWell facilities, and the same proportion indicated they would be comfortable supporting a client who has decided to access voluntary assisted dying. While this indicates likely willing participation and support from the majority of staff, it also indicates that some staff will likely conscientiously object to participation (there is provision for this in the law). This points to a clear need to develop processes and procedures to address the needs of Uniting AgeWell staff (and volunteers) who do not feel comfortable providing support for, or facilitating access to, voluntary assisted dying. 7.3. Consultation with Uniting (Vic&Tas) Key insights from the consultation with Uniting (Vic&Tas) staff were as follows: There was unanimous support for allowing voluntary assisted dying within the context of Uniting services. Consultation participants were unanimously of the view that it would not be consistent with Uniting’s client- centred approach to deny a client’s legal right to access voluntary assisted dying or withdraw care or support upon their decision to enact voluntary assisted dying. There was a strong preference amongst participants that it be permissible (not mandatory) to care for, support and refer any Uniting clients who request or are considering requesting voluntary assisted dying and to care, support and participate with any clients who have decided to legally access voluntary assisted dying. Participants believed that respecting a client’s end-of-life care choices offers dignity, non-judgemental compassion and a sense of control, and that this approach is consistent with Uniting’s values (Compassionate, Respectful, Imaginative, Bold). Note that, at the time of writing, Uniting (Vic&Tas) were undertaking their own internal consultation activities and had not yet formulated an official, public position. There was a recognised need to give provision for conscientious objection. Consultation participants recognised that it was essential that Uniting staff and volunteers were resourced and supported to make their own decisions about whether or not to participate in, or facilitate access to, voluntary assisted dying. An environment that supported not only the choices of clients, but also the choices of staff, was seen to be the ideal. It was apparent that significant work would be required to develop clear policies, procedures and communications about how to conscientiously object (amongst a myriad of other implementation issues). Clear systems and procedures were seen to offer protection (legal, spiritual, moral) to staff and volunteers. It was noted that developing and establishing these policies and procedures would require time and resourcing, but that it needed to be prioritised. There was a sense of urgency for the Synod to make a clear decision about the permissibility or otherwise of voluntary assisted dying. Consultation participants wanted to urge the Synod to make a clear decision on this issue during the July 2019 meeting to enable Uniting to undertake implementation preparations in a timely manner.

Note that Uniting (Vic&Tas) is finalising an official position statement, which is likely to reflect support for the Voluntary Assisted Dying legislation (on the basis that it provides people at the end of their life with the option

Voluntary Assisted Dying Section C1.9 28 Response report to Synod 2019 to self-determine when and how they will die) and an intention to support clients’ rights to exercise choice and control within the bounds of the legislation. 7.4. Consultation with Epworth Healthcare It became evident through consultations with two key individuals (Executive Director – Academic and Medical and UCA representative on the Epworth Healthcare Board) that Epworth Healthcare had already undergone extensive internal consultation, exploration and planning by the time the Synod’s review and consultation project was initiated. Thus, consultation workshops to explore views and preferences for response to the Voluntary Assisted Dying were not undertaken with Epworth Healthcare staff and Board members for the purposes of this project and instead, the official position of Epworth Healthcare is summarised here. Throughout 2018, the Epworth Board reviewed and considered the requirements and implications of the Victorian Voluntary Assisted Dying legislation. At a special meeting in December 2018, the Epworth Board decided, in principle, to support Epworth patients requesting information and assistance with understanding and accessing voluntary assisted dying, and the degree of those services Epworth would provide was dependent on the capacity of each organisation to provide them (NB: Epworth HealthCare constitutes numerous hospitals and specialist centres). The Epworth Board considered that this position was consistent with its values, and supported the goal of offering holistic, empowering patient-centred care, recognising the importance of patient choice and autonomy. The Board also stated its commitment to the provision and facilitation of palliative care services as an integral component of end-of-life care. The Board recognises that there are Epworth HealthCare doctors and other staff who do not support voluntary assisted dying, and thus there will be clear provision for conscientious objection, and those who do so will not be asked to participate or assist in any way. The Board notes that the Epworth HealthCare position statement will be updated periodically, including being informed by the Synod’s decision following its meeting in July 2019. 7.5. Consultation with Uniting Church chaplains Two experienced UCA chaplains (one current, one former) provided detailed input into the consultation process through written submissions, the content of which are summarised here. Chaplains will likely play an important role when the topic of voluntary assisted dying is raised by a resident, client or patient. Chaplains working in the UCA agencies (Uniting AgeWell and Uniting) and UCA-affiliated hospital (Epworth Healthcare) practice person-centred care, grounded in the UCA’s workplace ethos and values and, ultimately, in the love of God. They seek to listen respectfully and act to maintain the dignity and value of each person. Chaplains offer a compassionate and non-judgemental33 presence to residents, clients, patients (and their families), as well as staff. As such, chaplains are likely to be a key ‘touch point’ for discussions about voluntary assisted dying within UCA agencies and the UCA-affiliated hospital. It is important that UCA agencies (Uniting AgeWell and Uniting) and the UCA-affiliated hospital (Epworth Healthcare) develop clear policies and procedures around voluntary assisted dying, and that they are resourced to do so. These policies and procedures need to go beyond the context of healthcare provision and include guidance for chaplains as well. Ideally, such polices would be developed with the input of chaplains. Chaplains should be able to refer on, but not refuse spiritual care. Provision needs to be made for chaplains to refer to another support person within the organisation if they consider themselves unable to provide spiritual and pastoral care to those wanting to explore or access voluntary assisted dying (and their families/loved ones). However, it is not advisable that spiritual and pastoral be outright refused or withdrawn

33 Spiritual Health Victoria, Spiritual Care in Victorian Health Services: Towards Best Practice Framework, 2016, 12, accessed Dec 29, 2018, http://www.spiritualhealthvictoria.org.au/standards-and-frameworks.

Voluntary Assisted Dying Section C1.9 29 Response report to Synod 2019 from those wanting to explore or access voluntary assisted dying as this would not be consistent with provision of compassion, non-judgemental care. The two consultation participants differed in opinion as to how the Synod should ultimately respond to the legislation. One recommended that Synod disallow voluntary assisted dying within UCA agencies (Uniting AgeWell and Uniting) and UCA-affiliated hospital (Epworth Healthcare), while allowing for and resourcing staff to provide spiritual and pastoral support, information, and referral to options beyond the organisations for those exploring or seeking to access voluntary assisted dying. Conversely, the other recommended that the Synod allow voluntary assisted dying within UCA agencies and the UCA-affiliated hospital, on the basis of wanting to provide compassionate, non-judgemental care, and out of concern about the implications of disallowing it, including: the possibility of an aged care resident needing to move out of their home in order to enact voluntary assisted dying, instigating a religious dilemma (where it may otherwise have been a matter of individual conscience), and sending the message that the Church insists life continue when suffering is all that remains. 7.6. Additional consultations The following additional consultations were undertaken for the purposes of resourcing the project with key documentation or ideas, and/or for the purposes of reporting project progress and seeking feedback on its direction: • Theologians and biblical scholars from Pilgrim Theological College provided key readings, reflections and insights that were used to inform the development of consultation materials for use with presbyteries, and one Pilgrim Theological College staff member was a co-author on the theological reflections paper provided in Appendix A. • Consultations included discussions with key equipping for Learning and Ministry (eLM) staff to resource this project with the findings from the previous consultation process led by the JIM team, to seek feedback on the consultation strategy, and to explore whether any other consultation activity was planned or underway (none was) to avoid any duplication. • A presentation and project progress report were made to the Ministry and Mission Committee (sub- committee of the Synod Standing Committee) that gave input into the theological considerations that need to be addressed and who reflected on and responded to the key ideas being reflected in the presbytery consultations. • UCA Assembly and UnitingCare Australia have been given the opportunity to review a draft version of this report.

Voluntary Assisted Dying Section C1.9 30 Response report to Synod 2019 8. Proposals

It is proposed that the Synod resolves: 1. to affirm that: a) all human life, regardless of circumstance, is precious to and has dignity before God; b) life is both a gift of God, and a responsibility that requires active decision-making, balancing individual needs and desires with those of the community; c) ‘loving the other’ means reducing their pain and suffering as far as possible, recognising that a Christian vision of a good and purposeful life is more than just the absence of pain and suffering; d) in the context of the hope the Christian faith offers, death does not equate with defeat, and suffering and sickness do not equate with meaninglessness. 2. to acknowledge that: a) there is a wide range of views and beliefs about voluntary assisted dying within the Synod, and within the wider community. b) as of 19 June 2019, it is a legal right for all Victorians who meet the eligibility criteria and follow the set process as outlined in the relevant legislation to access voluntary assisted dying. 3. that it is in accordance with beliefs of the Church (including those affirmed in clause 1 above) to support the permissibility of voluntary assisted dying under the conditions described in the Victorian Voluntary Assisted Dying Act 2017. 4. to give permission within Victoria to UCA institutions (Uniting Vic&Tas and Uniting AgeWell) and the UCA-affiliated hospital (Epworth HealthCare) to make voluntary assisted dying allowable within the context of their facilities and services for their patients, clients and residents. 5. to request that the relevant UCA institutions (Uniting Vic&Tas and Uniting AgeWell) and the UCA- affiliated hospital (Epworth HealthCare) in Victoria ensure they develop and adopt clear policies and procedures that allow staff and volunteers to conscientiously object to participating in voluntary assisted dying, in accordance with the provisions outlined in the relevant legislation. 6. to commit to the provision of a compassionate pastoral response to all people associated with the councils of the Church, and UCA institutions (Uniting Vic&Tas and Uniting AgeWell) and the UCA- affiliated hospital (Epworth HealthCare), and their families, who choose to explore or access voluntary assisted dying within Victoria. 7. to request the Synod Ethics Committee: a) to continue to develop and disseminate resources related to voluntary assisted dying to support UCA ministers, lay leaders, chaplains, pastoral care workers and others who wish to offer spiritual and pastoral support to people who are exploring, accessing, or who have accessed voluntary assisted dying, and their families; b) to consult with the Assembly’s Transforming Worship Panel regarding the development of suitable funeral liturgies that address pastoral responses to death resulting from the practice of voluntary assisted dying; and c) to work with relevant equipping Leadership for Mission Unit (eLM) staff to pursue translation of these resources into languages other than English. 8. to write to the Victorian Premier, Leader of the Opposition, relevant government ministers, and shadow spokespeople:

Voluntary Assisted Dying Section C1.9 31 Response report to Synod 2019 a) to call on them to continue to invest in active palliative care as the primary means through which end of life care is offered and delivered; and b) to encourage them to engage with culturally and linguistically diverse communities using educational resources / activities about voluntary assisted dying in community languages.

Voluntary Assisted Dying Section C1.9 32 Response report to Synod 2019 Appendix A Draft pastoral resources

Voluntary Assisted Dying Section C1.9 33 Response report to Synod 2019 An Abundant Life: pastoral care resources for conversations around voluntary assisted dying

DRAFT 7 25 March 19

Introduction ‘Every decision about death is a judgement about life. The claim of the Christian community is that, despite a great deal of evidence to the contrary, life – its beginning and its ending – is made most intelligible by reference to God as life’s creator, sustainer, and end. More particularly, the Christian community’s view of life and death has been a persistent exegesis of the Easter events as the primary text for interpreting life. This does not, however, make the world a place in which certainties abound. On the contrary, the life of the world and indeed the universe appears to be characterized by profound and inescapable risk and contingency. This seems to be God’s own experience too. Death is not a way to escape life. No one gets out of life alive.’ Rev Dr Jason Goroncy in his article ‘Euthanasia: Some theological considerations for living responsibly’, published in Pacifica 2016, Vol. 29(3) 221–243. As Christians, we believe that our human physical life is not the end of all things but the continuation of our life with God, or the beginning of something different with God. Obviously, we do not know what that might be, but our faith points us to something beyond this present human existence. Voluntary assisted dying (VAD) has become a reality for the state of Victoria. As people undertaking pastoral care within the Uniting Church context, you need to be aware of legal information and practical information to enable you to lead people to reflect theologically on their lives, including the end and to support them. These resources are intended to be read alongside the VAD report to synod, particularly the theological reflection. Please note the language used in the legislation is voluntary assisted dying (VAD).

Voluntary Assisted Dying Section C1.9 34 Response report to Synod 2019 Code of Ethics and Ministry Practice From the UCA ‘Code of Ethics and Ministry Practice’, please pay attention in particular to: 1.2 Ministers have a particular place within that community (the Church). They touch people's lives at many points of joy, pain, celebration, grief and vulnerability. They are responsible for providing leadership in the community's task of worshipping, proclaiming the good news of Jesus, providing pastoral care, standing with those who suffer, and working for justice and peace. They minister within a pastoral relationship in which they seek to enable other people to focus on God as the source of healing, restoration and wholeness. 1.4 It is the seriousness of the pastoral relationship, and the vulnerability of people in that relationship, which make it necessary for Ministers to appreciate their unique position and the way they touch people’s lives. They exercise considerable influence and power. It is essential that each individual Minister recognises the power they have and understands the boundaries that the church requires to be observed within their ministry.

3.8 SELF CARE Ministers shall take responsibility to: (a) address their physical, spiritual, mental and emotional health needs and, where appropriate, seek assistance from a qualified professional; (b) participate in supervision; (c) give adequate priority to their relationship with their family; (d) nurture personal relationships which assist them in their wholeness; (e) take appropriate and regular leave, and time off from work for recreational activity.

3.9 SUPERVISION (a) Ministers have a responsibility to recognise that they are also vulnerable, requiring them to maintain their professionalism in difficult circumstances. (b) Ministers shall keep appropriate pastoral records (eg. details of appointments and referrals and a journal of critical incidents). (c) Professional supervision means the relationship Ministers have with another professional whereby the Minister is assisted to maintain the boundaries of the pastoral relationship and the quality of ministry (as per the definition at the commencement of the Regulations) including competencies, time management, priorities and any difficulties arising in ministry. (d) Ministers have a responsibility to ensure that they receive regular professional supervision. Such supervision is intended to assist Ministers to maintain the boundaries of the pastoral relationships and quality of ministry. (e) Ministers shall discuss with their supervisor any ongoing situations of conflict in which they are involved in the course of their work. (f) Where applicable, Ministers shall maintain membership requirements of any relevant professional association (e.g. psychologists or counsellors.)

Voluntary Assisted Dying Section C1.9 35 Response report to Synod 2019 Victorian Voluntary Assisted Dying Legislation The main points of Victoria’s VAD legislation are34: • to allow a person in the late stages of advanced disease to take a medication prescribed by a doctor that will bring about their death at a time they choose • to allow access to voluntary assisted dying is limited to people who meet specific requirements • there are many steps that must be followed to access voluntary assisted dying • there are safeguards in place to make sure that voluntary assisted dying is the person’s own decision and that no one is pressuring them

People choosing to access voluntary assisted dying must meet the following requirements: • they must have an advanced disease that will cause their death and is: o likely to cause their death within six months (or within 12 months for neurodegenerative diseases like motor neurone disease) and o causing the person suffering which that person decides is unacceptable

• they must have the cognitive ability to make a decision about voluntary assisted dying throughout the process

• they must also: o be an adult 18 years or over o have been living in Victoria for at least 12 months o be an Australian citizen or permanent resident.

Be aware of the following pastoral possibilities: • anyone requesting VAD needs to speak to 2 doctors and needs to pass through the 6 different decision stages. Not everyone who requests VAD, therefore, will be eligible which will result in other pastoral conversations

• some people may request VAD, may be eligible, may even obtain the medication to administer, but they may not actually decide to take them. There are protocols around the supply and return of all VAD medication

34 Taken from the Victorian Government’s Better Health website: https://www.betterhealth.vic.gov.au/health/servicesandsupport/voluntary-assisted-dying

Voluntary Assisted Dying Section C1.9 36 Response report to Synod 2019 Additional resources There are resources produced by the Victorian government to help people to understand the legislation, to guide those people who might be eligible, and to support health practitioners. There are also resources which discuss the ethics and/or theology dealing with the how and why of VAD.

A good place to start is: Rev Dr Jason Goroncy, ‘Euthanasia: Some theological considerations for living responsibly’, published in Pacifica 2016, Vol. 29(3) 221–243. This readable paper is available from the Dalton-McCaughey Library at the Centre for Theology and Ministry. https://www.dml.vic.edu.au/ eLM has produced DIY toolkit modules on various aspects of pastoral care. These can be downloaded at: http://www.ctmresourcing.org.au/digital-downloads/

The Victorian state government has a website where you can find frequently asked questions about voluntary assisted dying: https://www.betterhealth.vic.gov.au/health/servicesandsupport/voluntary-assisted-dying

The Victorian Department of Health and Human Services has a very clear fact sheet for the public: https://www2.health.vic.gov.au/Api/downloadmedia/%7B16E71848-1A55-4FA4-B5C5-293D659F62A3%7D

Additional articles you might find helpful include this one by Rev Dr Robyn Whitaker and Rev Dr Jason Goroncy of the University of Divinity: https://theconversation.com/voluntary-assisted-dying-is-not-a-black-and-white-issue-for-christians-they-can- in-good-faith-support-it-81671

And this by Dr Rosalind McDougall of the Melbourne School of Population and Global Health, University of Melbourne https://www.abc.net.au/news/2018-11-09/euthanasia-assisted-dying-in-victoria-enabling-choice-for- dying/10478420

Voluntary Assisted Dying Section C1.9 37 Response report to Synod 2019 Self-reflection Please refer also to the theological reflection written as part of the 2019 Synod Report on VAD.

1. Autonomy Autonomy, within the concept of voluntary assisted dying, refers to the right of a patient to choose when and how to die. There is a belief in some parts of society that we have autonomy of our lives and so should have the same autonomy over our deaths. • how do you understand death? • do feelings of guilt, fear and hope sit within your understand of death? • how did you develop your understanding of death? • when Jesus struggled in the Garden of Gethsemane, he made his decision in relationship with God and the Holy Spirit (Luke 22:30-42). How are our decisions about death and dying made in relation to others beyond us as individuals? • if we cannot exercise autonomy, do we feel out of control? Who is in control? • God has made the whole of life a human responsibility - does that include death?

2. Sanctity of life Sanctity of life refers to the belief that life is a gift that is simply not ours to end. We cannot make decisions about death even though ‘passive euthanasia’ such as withdrawal of life support may be supported under certain conditions. • where do you see sacredness in life and in death? • what does it mean to say God alone has the right to end life, that God is the creator and sustainer of all life? • can we say all human life is sacred? • is sacredness present in and around death? • what is the relationship between sanctity of human life and the idea that we are created in the image of God? • if medicine cannot provide the desired life, can we look to medicine for the desired death?

3. Abundant life John 10:10 I came that they may have life, and have it abundantly. • how do we define an abundant life? • can abundant life be present if the basics of earthly life are absent? • what is our role in ensuring the abundance of God is shared with all? • what is the place of the following in an abundant life: health and pain, relationships, sense of usefulness? • the German 19th century philosopher Friedrich Nietzsche said, “To live is to suffer, to survive is to find some meaning in the suffering.” What does this say about abundant life?

Voluntary Assisted Dying Section C1.9 38 Response report to Synod 2019 4. Death is not the ultimate enemy or the ultimate end • for some people, death is seen as an ending rather than a new beginning, it is regarded as something to be fought rather than embraced. Is there a time when death would be fought and when death should be embraced? • in Uniting Church funeral services, we say that death is the end of this mortal life and marks a new beginning in our relationship with God. What do you understand this to mean? • our role as pastoral carers is to help people prepare for death and following death, if that’s something they would find useful – to support someone thinking through different medical interventions, decisions about different treatments or no treatment, how and when to die, the funeral service, the burial and perhaps even ethical decisions around the environmental practices of funerals. When have you ministered to people in this role?

Jason Goroncy: ‘It is the Christian community’s claim that we are made for life – life that neither precludes nor dulls the actuality of death. Death – whether biological, emotional, or relational – may indeed be life’s enemy. But it is an enemy that, like the strange promise of resurrection, is woven into the warp and woof of life in God’s world.’

Death café is a movement that began in 2010 in the UK with the objective 'to increase awareness of death with a view to helping people make the most of their (finite) lives'. https://deathcafe.com/

“Dying to know” is an organisation whose aim is to ‘activate conversations and curiosity, build death literacy and help grow the capacity of individuals and community groups to take action toward end of life planning.’ www.dyingtoknowday.org/

Some references from Scripture which may be useful: John 14:1-3 Matthew 28:5-8

5. Everything in life has a time, including death • when is ‘the time’? • how do we know when the time is? • what is meant by God’s time? • we intervene medically from birth through to death but what about autonomy? Is there a God-given right to take control?

Voluntary Assisted Dying Section C1.9 39 Response report to Synod 2019 Case study about resisting treatment: A patient is diagnosed with cancer. Treatment will be painful and incredibly debilitating but it may prolong life for up to 6 months. The patient decides not to accept treatment but to be made comfortable. The patient can now decide to end life. Does this make a difference? What does this tell us about time and autonomy?

Some references from Scripture which may be useful: Ecclesiastes 3:1-8 John12:23-24 Luke 22:40-42 Romans 14:8

6. Death and dying, and the fear behind each, are very different • are you fearful of the process of death? • is your hope primarily for a pain free death? • how do you feel about the loss of identity, of self, of agency, of ‘dignity’, of ageing?

The myth of a good death is seen in Gen 25:7-8. This is the length of Abraham’s life, one hundred and seventy- five years. Abraham breathed his last and died in a good old age, an old man and full of years, and was gathered to his people. • what does dying actually mean? • if you were asked, ‘what has been the meaning of my life’, how would you answer? • what do you think ‘meaningful ageing’ means? • some people fear the state of non-existence – how do you understand this?

The ‘story of my life’ work undertaken in Uniting Age Well is not only designed for the individual but also for family and the community as it creates a social history as well as helping a person make sense of the life lived.

Some references from Scripture which may be useful: Rev 21:3-4 Luke 12:13-21

7. The reality of human suffering • is it easier to face one’s own suffering and more challenging to face the suffering of someone else? Does this inform VAD discussions? • death is the end of human physical life and a new beginning in our relationship with God – is this where the hope is to be found? Does choosing VAD equate with lack of hope or embracing a profound hope? • what is the place of palliative care in suffering?

Voluntary Assisted Dying Section C1.9 40 Response report to Synod 2019

The state government has produced some resources and frequently asked questions on the Better Health Channel website addressing the issue of where palliative care sits in the area of voluntary assisted dying. VAD is not an alternative to palliative care, indeed those entering into the discussions about VAD with the doctors will often already be receiving palliative care. https://www.betterhealth.vic.gov.au/health/servicesandsupport/voluntary-assisted-dying

Some references from Scripture which may be useful: Romans 8:38-9 Romans 12:1-2 Psalm 22

Liturgical Resources for VAD

These are offered in addition to the prayers and services set out in Uniting in Worship 2.

Prayer with one utilising VAD legislation Merciful God, your Son, Jesus Christ, commended his spirit into your hands in his last hour. He asked for compassion and release in his hour of need. Seeking that same compassion and care, we commend your servant N. Death is coming, O God, and N seeks a gentle and purposeful journey to meet you. Open your gates to eternal life, And bring N into your everlasting presence. Bring the release that N seeks, and surround him/her in these final moments with the faithfulness and love which has blessed his/her life. In hope we pray, Amen.

Voluntary Assisted Dying Section C1.9 41 Response report to Synod 2019 Adapted from pastoral prayer in Uniting in Worship 2:

God of mystery, at this time of decision, I bring to you my fears and concerns. Hear me as I pray. Help me to hear your voice above the other voices present now. Help me to remember your unconditional love. Thank you for Jesus who understands what it is to be human and to suffer. I place my trust in you, and await your guidance and your peace. Amen

Voluntary Assisted Dying Section C1.9 42 Response report to Synod 2019

An example of an opening to worship (adapted from UIW2)

Good afternoon and welcome. I feel safe in saying that none of us want to be here today, and we wish we were off living our relatively normal lives, but we have come together today because we loved NAME, and there is nothing normal in the reality of her/his no longer being in our midst. But here together today we celebrate the life s/he lived among us, we will honour the generous and loving life that s/he lived; and we will also offer comfort to each other as we thank God for the place s/he has in our lives, in our memories and in shaping who we are because of her/him.

We come today believing that all human life is valuable, that the truth and integrity and hopefulness, which lies in each life, lives on. We come, believing that N’s life, which we remember today and for which we now experience great loss, is joined with all life, stretching into the past and into the future. Her/His life was lived in its uniqueness with us and now rests secure in the loving hands of God.

And while we are here to honour that truth, it needs to be reinforced. Death, in all its forms is inevitable, and heartbreaking for those who are left behind. N was facing inevitable death, and chose in the end to control that death in what he/she believed to be the best way for them. But her/his death in no way defines her/his life, which was (insert appropriate words eg; generous, full of love), but also burdened at the end with struggle and illness.

No matter our questions, doubts or uncertainties we might be facing in this moment, this I know to be true – God’s love surrounds him/her in this life and the next; our love surrounds him/her in this life and the next; and his/her love for his/her family and friends blesses us in this life and the next.

Voluntary Assisted Dying Section C1.9 43 Response report to Synod 2019 In Paul’s letter to the Romans, we are blessed with some of the greatest wisdom in scripture- he writes: For I am convinced that neither death, nor life, nor angels, nor rulers, nor things present, nor things to come, nor powers, nor height, nor depth, nor anything else in all creation, will be able to separate us from the love of God in Christ Jesus our Lord.

I know some of you here today won’t be followers of the Christian faith or another faith. Some of you may bring hurt which prevents you from believing anything at all. Whether you reach out to God, the universe, or to your fellow brothers and sisters in humanity, love is the greatest and infinite divider of barriers, and that cannot be diminished, not even today.

Voluntary Assisted Dying Section C1.9 44 Response report to Synod 2019

Selections from a funeral service which could be adapted Adapted from (waiting for Stephen to send reference)

We meet in the presence of Jesus Christ, who died and was rose again for us.

We come together now to mourn and weep for ______, to honour her/his life and death, and to thank God for it, to entrust ______into God’s hands, and to bid our own farewells to ______’s body.

We come together now also for // ______// (partner/next of kin) (and ////______//// others, such as children, parents, etc), to stand beside them in their time of grief. May our being here for them today be a commitment to be there for them into the days ahead.

And, in a real sense, we come here today also for ourselves, because ______’s death reminds us that we too one day will die, however that may be. And so we come face to face with own mortality, and questions about life and death, and what each means.

This service speaks to each one of us gathered here today. It assures us that death is not the end, but the beginning of a new relationship with God.

Suggested readings: Psalm 23, Psalm 139, John 11:17-45

Voluntary Assisted Dying Section C1.9 45 Response report to Synod 2019 Prayers

Psalm 121 (NRSV) 1 I lift up my eyes to the hills— from where will my help come? 2 My help comes from the Lord, who made heaven and earth.

3 He will not let your foot be moved; he who keeps you will not slumber. 4 He who keeps Israel will neither slumber nor sleep.

5 The Lord is your keeper; the Lord is your shade at your right hand. 6 The sun shall not strike you by day, nor the moon by night.

7 The Lord will keep you from all evil; he will keep your life. 8 The Lord will keep your going out and your coming in from this time on and for evermore.

From psalm 130 (NRSV) 1 Out of the depths I cry to you, O Lord. 2 Lord, hear my voice! Let your ears be attentive to the voice of my supplications!

3 If you, O Lord, should mark iniquities, Lord, who could stand? 4 But there is forgiveness with you, so that you may be revered.

5 I wait for the Lord, my soul waits, and in his word I hope; 6 my soul waits for the Lord more than those who watch for the morning, more than those who watch for the morning.

7 O Israel, hope in the Lord! For with the Lord there is steadfast love, and with him is great power to redeem. 8 It is he who will redeem Israel from all its iniquities.

Voluntary Assisted Dying Section C1.9 46 Response report to Synod 2019

Prayers for self-reflection on VAD choices God of grace, I grieve all that I have lost: the life I once lived, the life I hoped to live, the death I hoped to die. At this time, I sit with disappointment and frustration. From where will my hope come? I seek guidance in my decisions. I seek peace for those who love me. I seek healing in whatever form it can take at this time and in this reality. I want to feel close to you, God of grace, so that my final choice brings relief, either in life or death. Amen

God of mercy, I don’t want to live and I don’t want to die. I don’t want to live like this, But I’m not sure how I want to die. I’m not sure I can decide. Your mercy was shown to rich and poor alike, to those who were sick and those who were dying. Show me your mercy now, guide me to the right decision for me and mine. Cry as we cry, hold us together as we seek answers. And bind us forever in your love. Amen

Voluntary Assisted Dying Section C1.9 47 Response report to Synod 2019 God of eternal life, I want to die. I cannot live this life that I have now. But others want me to live it, urge me to live it, however that life may look to me or to them. I am confused, I am disturbed, I long for peace. But how will I find peace – in life or in death? Or is there somewhere in between? God of life, show me where my life should lead now, guide my words as I share how I feel with those whom I love. Take my fear and clear my mind. Amen

Voluntary Assisted Dying Section C1.9 48 Response report to Synod 2019 Prayers with the family around VAD

God of grace, We gather in the sure and certain knowledge that you are with us and will never desert us. You know of our reality, the decisions for which we must prepare. Help us to recognise everything N has done in life and in death. Help us to see that death does not define who and what we are in life. Help N to live on in us through our memories, our stories and our love. Amen

We are here, God, and we don’t want to be. We respect all that N has been in life to us, all that he/she has achieved, all that he/she has shown us and shared with us. Be with us as we release N into your eternal care knowing that you will always be with us and her/him. We are here because we love N and because we have been present in his/her life, so it is only fitting we are present, too, in death. Beyond this life, beyond this death, we trust in your eternal love. Help us not be overwhelmed but be able to speak of this time together. Amen

Voluntary Assisted Dying Section C1.9 49 Response report to Synod 2019 Prayers for discernment

Suscipe - St. Ignatius of Loyola Take, Lord, and receive all my liberty, my memory, my understanding, and my entire will, All I have and call my own. You have given all to me. To you, Lord, I return it. Everything is yours; do with it what you will. Give me only your love and your grace, that is enough for me.

Philippians 4:6 Do not worry about anything, but in everything by prayer and supplication with thanksgiving let your requests be made known to God.

Voluntary Assisted Dying Section C1.9 50 Response report to Synod 2019 Appendix B Legal implications and recommendations for congregational pastoral carers and ministers

DRAFT 10 MAY 2019

End of life discussions, although challenging, are part of the role of ministers and pastoral carers in whichever context they work. Legal advice offers clarification about what we, as professionals, can and cannot do and say.

Obligations of registered health practitioners – application to pastoral care Ministers, chaplains and pastoral carers are not registered health practitioners. Accordingly, they will not be subject to the limitations placed upon registered health practitioners. However, it is possible that some ministers, chaplains and pastoral carers will ALSO be registered health practitioners. 18. This legal guidance is provided on the basis that minsters, chaplains and pastoral carers engage in discussions only in their capacity as the Church’s religious leaders and representatives, and not in their capacity (if any) as registered health practitioners.

Although it is apparent that minsters, chaplains and pastoral carers do not fall into the category of registered health practitioners, we consider it is appropriate to be guided by the Act’s requirements (where possible) when engaging in discussions with individuals about VAD in the context of pastoral care.

For example, we suggest that ministers, chaplains and pastoral carers do not instigate conversations with individuals to whom they are providing pastoral care about VAD. If such a discussion is instigated by the individual, the minister, chaplain or pastoral carer may engage and respond in the ordinary way (this may include, for example, discussion about theological concepts). They should abstain from providing the individual with any legal or medical advice as to their eligibility for VAD or as to their prospects of a successful application for VAD.

There is no legal obligation to engage in discussions about VAD. If a minister, chaplain or pastoral carer does not wish to take part in these conversations, they must advise the person for whom they are caring in a pastorally appropriate way.

Prohibitions under the Act

The majority of the Act’s requirements and obligations apply specifically to registered health/medical practitioners and pharmacists. However, there are certain provisions in the Act which operate more broadly (that is, beyond health/medical practitioners) to prohibit certain conduct or activity. For example, a person will engage in a criminal offence if it shown that the they induced another person to make a request for VAD by dishonesty or undue influence. This offence is punishable by up to 5 years’ imprisonment and/or a fine of $96,714.

Meaning of “Undue Influence”

1. The exercise of undue influence is an important consideration for the Church in the context of the offence discussed above. We note the following passage taken from the pastoral care resources that you provided to us.

It is the seriousness of the pastoral relationship, and the vulnerability of people in that relationship, which make it necessary for Ministers to appreciate their unique position and

Voluntary Assisted Dying Section C1.9 51 Response report to Synod 2019 the way they touch people’s lives. They exercise considerable influence and power. It is essential that each individual Minister recognises the power they have and understands the boundaries that the church requires to be observed within their ministry.

2. Searches of relevant cases indicate that there are a number of factors for consideration in determining whether undue influence has been exercised by one individual in relation to another. Such factors include, but are not limited to:

a. A strong relationship of trust and confidence between the parties; b. The use of physical coercion; c. The intelligence, education, character of the other person; d. , state of health of the other person; e. The strength of character and personality of the other person; f. The period of closeness of parties and their relationship; g. The vulnerability of other person.

3. The Act does not define the term “undue influence”. Traditionally, the concept of undue influence has been applied in contexts involving financial contracts, wills and testaments, and property-related disputes. However, the concept has a “much broader application.”35 The precise meaning and application of the concept in the context of VAD in Victoria it not entirely clear.

4. In a 2010 Article entitled “A Test for Mental Capacity to Request Assisted Suicide” published in the Journal of Medical Ethics, the authors provided the following guidance on the meaning of undue influence in the context of assisted suicide:

“While patients will still be able to make competent decisions when they are highly dependent on others for care, their decisions must truly be ones that they have made, rather than decisions which they have been forced to make or feel they should make to relieve others of burden. Undue influence must be assessed by having regard to both the patient’s strength of will and level of pressure being placed on the patient by others to commit suicide.”36

5. Case law indicates that in order for influence to be undue, it must be shown that Person A has applied more than just pressure on Person B and that Person B’s will has been overborne. The South Australia Supreme Court in the case of H Ltd v J [2010] held that undue influence means that a person has been prevented from an independent exercise of that person’s volition.

6. For example, the NSW Supreme Court found in Dickman v Holley [2013] that undue influence was exercised over a woman in relation to the distribution of her estate in light of her extreme age, her physical weaknesses and her emotional liability. The Court did not consider that the woman was capable of exercising her own will and standing up to pressure imposed by others.

Undue influence in the context of elder abuse 7. As stated above, section 5 of the Act provides that there is a need to protect individuals who may be subject to abuse. The elderly are especially vulnerable to the risk of abuse. Accordingly, concepts relevant to elder abuse are important considerations in the context of the broader VAD discussion.

35 Wand, Pesiah, Draper et al, [2017], Macquarie Law Journal: https://www.mq.edu.au/about/about-the- university/faculties-and-departments/faculty-of-arts/departments-and-centres/macquarie-law-school/macquarie-law- journal/mlj-vol.18/The-Nexus-between-Elder-Abuse,-Suicide-and-Assisted-Dying_-The-Importance-of-Relational- Autonomy-and-Undue-Influence.pdf 36 Stewart, Peisah and Draper [2010], Journal of Medical Ethics file:///C:/Users/Dora.cosentino/Downloads/StewartetalMentalcapacityforassistedsuicide%20(1).pdf

Voluntary Assisted Dying Section C1.9 52 Response report to Synod 2019 8. According to the World Health Organisation, elder abuse can be defined as a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person. One means of incurring harm is to adversely influence decision making.

9. The Macquarie Law Journal Article, The Nexus Between Elder Abuse, Suicide, And Assisted Dying: The Importance Of Relational Autonomy And Undue Influence,37 (the Article) provides some useful commentary on why elders may be more likely to suffer abuse in the context of VAD:

“elderly individuals are particularly vulnerable to abuse under the Act given…the frequently dependent nature of their relationships and comparatively greater health burden, combined with other psychosocial factors such as perceived burdensomeness influencing decision making.”

10. The article reiterates that there are a number of factors relevant to determine whether an elder is being unduly influenced. These include the relationship between the individual and the person with whom they are discussing VAD, the individual’s social circumstances (such as the risk of family conflict or loss of favour) and the individual’s physical capacity.

Informing discussions about VAD

11. Ministers, chaplains and pastoral carers must ensure that they do not cause an individual’s independent will to be overborne. This is particularly relevant in the context of discussions with individuals who appear to have compromised decision-making capacity, and/or vulnerabilities that make them susceptible to the influence of others.

Keeping notes of conversations about VAD

It is wise to make a note in your diary or pastoral care files that the conversation took place at the request of the person. If the person instigating the conversation about VAD is characterised as vulnerable (for example, is suffering from dementia), the conversation should cease. Ensure that appropriate and comprehensive notes are taken.

Best Practice Recommendations

‘Best practice’ approach, when providing pastoral care, may include: 1. Avoiding instigating conversations about VAD; 2. Ceasing conversations about VAD if it is apparent that an individual has characteristics of vulnerability; 3. Not providing individuals with any legal or medical advice as to their eligibility for VAD or as to their prospects of a successful application for VAD; and 4. Exercising great caution when discussing VAD with individuals so as to ensure that the minister, chaplain and pastoral carer does not induce the individual to request VAD (either by dishonesty or undue influence). 5. Keeping notes of discussions with individuals about VAD.

37 Wand, Pesiah, Draper et al, [2017], Macquarie Law Journal.

Voluntary Assisted Dying Section C1.9 53 Response report to Synod 2019 Appendix C Victorian Government’s Voluntary Assisted Dying Factsheet

Voluntary Assisted Dying Section C1.9 54 Response report to Synod 2019 Understanding voluntary assisted

dying Community and consumer information

1. Summary

Victoria’s voluntary assisted dying law allows a person in the late stages of advanced disease to take a medication prescribed by a doctor that will bring about their death at a time they choose. Under Victoria’s Voluntary Assisted Dying law, access is limited to people who: • have an advanced disease that is expected to cause death within 6 months (or within 12 months for neurodegenerative diseases like motor neurone disease) • have the ability to make a decision about voluntary assisted dying • are adults 18 years and over and have been living in Victoria for at least 12 months. There are several steps to access voluntary assisted dying. The law has many safeguards to make sure that it is the person’s own decision and that no one is under any pressure to access voluntary assisted dying.

2. Introduction

In 2017, legislation was passed to allow voluntary assisted dying in Victoria. The law will start from 19 June 2019. Voluntary assisted dying means a person in the late stages of advanced disease can take a medication prescribed by a doctor that will bring about their death at a time they choose. Only people who meet the requirements and follow the steps set out in the law can access voluntary assisted dying. A person’s choice to access voluntary assisted dying must be: • voluntary (the person’s own choice) • continuing (their choice stays the same) fully informed (the person is well-informed about their disease, and their treatment and palliative care options). End of life issues can be distressing and difficult for many people. There is also a range of views in the community about death and dying and how to improve the experience of people at the end of their lives. For these reasons, a Parliamentary Committee considered issues about palliative care, advance care planning and voluntary assisted dying. There was a lot of consultation with people in the community including experts. The Committee recommended that voluntary assisted dying should be made law. An expert panel then consulted on what the law should look like before the Bill was brought into the parliament. Across this time, many people said they wanted genuine choices at the end of life. They wanted to make decisions about the treatment and care they needed. They also wanted to choose where they die. Some people also wanted to decide the timing and manner of their death. Most people will find palliative care and end of life services give them the support they need at the end of their life. Palliative care and end of life services help to improve the quality of life for people with advanced disease. They also provide support to their family and carers.

Voluntary Assisted Dying Section C1.9 55 Response report to Synod 2019 But even with the best care, some people approaching the end of their life experience suffering that is unacceptable to them and may want to access voluntary assisted dying. Some of these people will now have the choice to control the timing and manner of their death by taking medication that will bring about their death. The choice must be the person’s own. Only the person accessing voluntary assisted dying can ask for it. It is against the law to pressure someone to ask for voluntary assisted dying.

3. Frequently asked questions

4. What is voluntary assisted dying? Victoria’s voluntary assisted dying law allows a person at the late stages of advanced disease to take a medication prescribed by a doctor that will bring about their death at a time they choose. Only people who meet the requirements and follow the steps set out in the law can access voluntary assisted dying. A person’s choice to access voluntary assisted dying must be: • voluntary (the person’s own choice) and • continuing (their choice stays the same) and fully informed (the person is well-informed about their disease, and their treatment and palliative care options).

5. Who can access voluntary assisted dying? People choosing to access voluntary assisted dying must meet the following requirements: 1. They must have an advanced disease that will cause their death and is: • likely to cause their death within 6 months (or within 12 months for neurodegenerative diseases like motor neurone disease) and • causing the person suffering that is unacceptable to them. 2. They must have the ability to make a decision about voluntary assisted dying throughout the process. 3. They must also: • be an adult 18 years or over • have been living in Victoria for at least 12 months • be an Australian citizen or permanent resident.

6. Can someone with a disability or mental illness access voluntary assisted dying? People with a disability or mental illness who meet all of the requirements to access voluntary assisted dying have the same right to access voluntary assisted dying as other members of the community. However, having a disability or mental illness is not sufficient reason in itself for a person to access voluntary assisted dying. Like anyone else, people with a disability or mental illness must also have an advanced disease likely to cause death within 6 months (or 12 months for neurodegenerative diseases) and have the ability to make a decision about voluntary assisted dying throughout the process.

Voluntary Assisted Dying Section C1.9 56 Response report to Synod 2019 7. Can someone with dementia access voluntary assisted dying? When dementia affects a person’s ability to make a decision about voluntary assisted dying, they will not meet the requirements to access voluntary assisted dying. To access voluntary assisted dying, a person needs to have the ability to make decisions throughout the process.

8. Can a person request assisted dying in an advance care directive? A person cannot make a request for voluntary assisted dying in an advance care directive. The law says that you cannot include anything about voluntary assisted dying in an advance care directive.

9. How does someone access voluntary assisted dying? There are several steps to access voluntary assisted dying. This process makes sure only people who meet the requirements can access voluntary assisted dying. The first step for a person choosing to access voluntary assisted dying is to ask their doctor about it. It is likely that most people will have a conversation with their doctor to get more information before they decide to go ahead. To access voluntary assisted dying, the person needs to tell the doctor that they want to go through the steps that would allow them to access voluntary assisted dying. After a person has asked their doctor, there are several more steps before they can access voluntary assisted dying. These steps include being assessed by two doctors to make sure they meet the requirements. Both of these doctors must have completed approved training in assessing people for voluntary assisted dying. Each doctor must make sure the person is fully informed about their disease, and their treatment and palliative care options. Both doctors must also assess that voluntary assisted dying is the person’s own choice. The doctors must let the person know that they can change their mind about accessing voluntary assisted dying at any time. To make sure the decision is not rushed, the process to access voluntary assisted dying cannot be completed in less than 10 days, unless the person is expected to die within 10 days.

10. How will a person take the medication? In most cases, people will take the medication themselves, by swallowing it. If a person cannot swallow or cannot otherwise physically take the medication themselves, they can ask the doctor who first assessed their request to administer medication that will bring about their death. This request must be made in person. The doctor must then apply for a special permit to allow them to administer the medication.

11. Who can provide access to voluntary assisted dying? Only a doctor can provide access to voluntary assisted dying. Other health practitioners, such as nurses, and residential aged care staff, can give support but cannot give the person access to the medication.

12. Can someone’s doctor suggest they access voluntary assisted dying? No, it is against the law for a doctor to suggest a person accesses voluntary assisted dying. A doctor cannot talk about voluntary assisted dying unless the person raises it first. If the person asks about it, a doctor is then able to give information about voluntary assisted dying and can discuss it with them. Once a person has asked to access voluntary assisted dying, the doctor needs to follow the process set out in the law. During the process, they cannot persuade a person to access voluntary assisted dying. The doctor will remind them that they don’t have to go ahead if they change their mind along the way.

Voluntary Assisted Dying Section C1.9 57 Response report to Synod 2019 13. Do all doctors or other health practitioners have to participate in voluntary assisted dying? No, the law protects doctors and other health practitioners, such as nurses, who do not want to participate in voluntary assisted dying because they have a conscientious objection. This means they cannot be forced to: • Provide information or support about voluntary assisted dying • Assess a person for voluntary assisted dying • Supply or give the medication used for voluntary assisted dying

14. Can someone’s family member (or carer or friend) ask for voluntary assisted dying for them? No, only the person choosing to access voluntary assisted dying can ask for it. This is an important part of making sure the person’s choice is voluntary. A person may ask their family, friends or carers to go with them when they visit the doctor. At the visit, the doctor may want to talk to the person on their own first, and then altogether with their family, friends or carers.

15. If a person has a medical treatment decision-maker, can that decision- maker ask for voluntary assisted dying? No, only the person choosing to access voluntary assisted dying can ask for it. A medical treatment decision maker can make decisions about a person’s treatment only when a person cannot make a decision for themselves, for example, they are unconscious. But a person accessing voluntary assisted dying needs to be able to make their own decisions throughout the process.

16. What if someone needs an interpreter or assistance with communication? People who speak a language other than English, or need communication assistance because of a disability, can use an interpreter or people with skills in communication aids to ask for voluntary assisted dying. The interpreter must be independent and approved by a professional body. Family members cannot be interpreters. During the doctor’s visit, the interpreter can help the person to ask for voluntary assisted dying. They can also support the person to understand information given by the doctor.

17. Can someone be pressured into accessing voluntary assisted dying? There are strong safeguards to make sure a person’s choice to access voluntary assisted dying is their own choice, and that they are not pressured by others. Only the person choosing to access voluntary assisted dying can ask for it. Their family, friends or carers cannot ask for them. Also, a doctor cannot suggest a person accesses voluntary assisted dying. They can only respond when a person asks for it. As part of the process to access voluntary assisted dying, two doctors must decide the person is well- informed about their disease and their treatment and palliative care options. Both doctors have to assess that no-one is forcing or influencing them to do this. Both of these doctors must have completed approved training in assessing a person for voluntary assisted dying. Even after a person has started the process, they can change their mind at any time. A person cannot complete the steps to access voluntary assisted dying in less than 10 days, except in some very special circumstances.

Voluntary Assisted Dying Section C1.9 58 Response report to Synod 2019 18. Is there a danger someone will access voluntary assisted dying because they can’t get palliative care? Voluntary assisted dying is not an alternative to palliative care services. Palliative care and end of life services are widely available in Victoria. Most people who access voluntary assisted dying will be supported by palliative care and end of life services and will be encouraged to receive this support if they are not already using these services.

19. Who will oversee Victoria’s voluntary assisted dying law? The Voluntary Assisted Dying Review Board will oversee voluntary assisted dying in Victoria. The Board will make sure the law provides a compassionate outcome while addressing the concerns of the community. It will review every case of voluntary assisted dying in Victoria and make suggestions for changes or improvements in the law. There are also other organisations, such as Victoria Police, the Coroner and the Australian Health Practitioner Regulation Agency that make sure that laws and professional standards are observed.

20. The law will start in June 2019. Will there be more information available for people considering voluntary assisted dying? Yes, detailed information is currently being written for people considering voluntary assisted dying. This information will explain more about the process for accessing voluntary assisted dying and the support available. It will be available in early 2019, before the law starts on 19 June 2019.

21. I find end of life issues distressing. Who can I talk to? Some people find it upsetting to think about their death and end of life care. If reading this information has raised issues of grief, stress or personal crisis, the services listed below can provide telephone support and counselling 24 hours a day, 7 days a week. They may also provide online assistance: Lifeline Tel: 13 11 14 Australian Centre for Grief and Bereavement Tel: 1800 642 066

Date of publication: August 2018

Voluntary Assisted Dying Section C1.9 59 Response report to Synod 2019 Appendix D Theological reflections on voluntary assisted dying

Voluntary Assisted Dying Section C1.9 60 Response report to Synod 2019 Voluntary Assisted Dying: Some Theological Considerations A paper from the Synod Ethics Committee, written by Rev Dr Jason Goroncy with Rev Dr Robyn Whitaker

A good death – an ideal death – is pre-planned, perfectly timed, excretion-free, speedy, neat and controlled. Birth is not like this. Life is not like this. And yet we think we have a right to ask it of death. We want a caesarean-section death. The only way we could come close to meeting all these criteria for a good death would be to put people down when they reach a predetermined age, before the chaos of illness sets in.38 What do you have that you did not receive? And if you received it, why do you boast as if it were not a gift?39

The vast majority of us will not have the opportunity to choose or control our manner of dying. However, Victorian Voluntary Assisted Dying legislation offers the possibility for some to make more active and legal choices about the manner of their death where death is already inevitable and, in most cases, imminent. This raises significant questions for people of faith. The life of faith is inescapably messy. While the Bible affirms the value of human life and witnesses to the promise that death is not the ultimate end, it does not remove life’s complexities or offer simple answers to the ethical challenges we face. Some of the most difficult of such challenges are those that relate to death. Thankfully, there are many long-held theological convictions in the Christian tradition that can inform our thinking about this complex issue.40 There are two of particular relevance which are discussed below. One concerns convictions about human responsibility, raising difficult questions about how we value and appraise (modern) ideas of individualism, autonomy, and rights. A second concerns convictions about the sanctity of life, and especially of human life. While distinct, these two concerns are inescapably bound up together.

The sanctity of human life For most Christians, the strongest theological argument against euthanasia is that it represents a direct affront to the sanctity of human life. All human life, it is argued, is a gift of the Creator and so is simply not ‘ours’ to end. The influential thirteenth-century theologian Thomas Aquinas wrote: ‘It belongs to God alone to pronounce sentence of death and life … Therefore to bring death upon oneself in order to escape the other afflictions of this life, is to adopt a greater evil in order to avoid a lesser’.41 Likewise, the Catechism of the Catholic Church judges that ‘intentional euthanasia, whatever its forms or motives, is murder. It is gravely contrary to the dignity of the human person and to the respect due to the living God, his [or her] Creator’.42 By and large, Protestants share this view – that ‘it is for God and God alone to make an end of human life’.43 But not all draw from this claim an absolute to be applied in all situations. Some argue that faith does not mean blindly following unassailable and predetermined laws but rather calls for listening for, discerning, and obeying God’s voice in every new situation. As the German theologian Dietrich Bonhoeffer argued, ‘Responsible action is neither determined from the outset nor defined once and for all; instead, it is born in the

38 Karen Hitchcock, Dear Life: On Caring for the Elderly (Carlton: Black Inc., 2016), 64. 39 St Paul, in 1 Corinthians 4.7. 40 See Jason A. Goroncy, ‘Euthanasia: Some Theological Considerations for Living Responsibly’. Pacifica 29, no. 3 (2016), 221–43. 41 Thomas Aquinas, The ‘Summa Theologica’ of St. Thomas Aquinas, trans. Fathers of the English Dominican Province (London: Burns Oates & Washbourne, 1920), Q 64, Art 5. 42 Catholic Church, Catechism of the Catholic Church (Homebush: Society of St Pauls, 1994), §2324. 43 Karl Barth, Church Dogmatics III.4, trans. A. T. Mackay, et al. (Edinburgh: T&T Clark, 1961), 425.

Voluntary Assisted Dying Section C1.9 61 Response report to Synod 2019 given situation’.44 Such listening continually puts one’s whole life in question. Here, human freedom is inescapably bound up with real risk, and with the responsibility to assess every situation and to make a real choice. This opens the door to the possibility that one might – in faith – make a responsible decision to end one’s life as an act of obedience. Martyrdom, for instance, assumes such a possibility. Might not such an action – of casting one’s life into the mercy and love of God’s mysterious future – be an act of faith, an expression rather than a denial of religious hope and of the sanctity of life, and a form of love, however broken? Certainly, all human action and every human response forms part of what Bonhoeffer called the ‘penultimate’ rather than the ‘ultimate’ realm of which we only ever experience as a ‘dawn’.45 People of faith live, die, and make their judgements where no certainties abound and where they navigate concrete and immediate life with real limits, trusting that ultimately God alone takes responsibility for us. Commitments to the sanctity of human life wrestle also with questions of life’s quality: Is life to be equated with mere existence, or is life defined by other realities in which the quality of a life becomes a critical factor? Are people of faith morally required to avail themselves of every available technology in order to postpone or to hasten death? Life is certainly to be respected, but we must not make an idol of it. When life is preserved as an end in itself, with disregard for the quality of that life, then the result may serve an idolatry which has nothing whatever to do with religious obedience. Discerning when in fact this may be the case, however, is difficult, especially in the kinds of situations envisaged by Victoria’s Voluntary Assisted Dying legislation. Arguably, it is possible, even desirable, that theologians defend ‘not only the sacredness of human life but also the sacredness of death. Sometimes death is the best that life has to offer, the moment when we return the gift of our life to God’.46 Writing almost two centuries before the Christian era, the Jewish scribe Ben Sira stated that ‘Death is better than a life of misery, and eternal sleep than chronic sickness’ (Sirach 30:17). It might be argued that this represents the kind of decision that religious believers are free to make and to hasten as they face their own end.

Autonomy and Community Responsibility Those who have welcomed Victoria’s Voluntary Assisted Dying legislation uniformly argue that at issue here is a person’s ‘moral right’ to choose how they will die: ‘It is, after all, the patient’s life, and as long as the patient is capable of reaching an informed decision, then who better to decide whether life is worth living? Doesn’t the patient have a right to ask for this help and, if a doctor is willing to give it, why should the law stand in the way?’47 Here, individual agency is prized above all other concerns. This argument is theologically relevant because of the weight that religious traditions place on human persons being responsible for their own decisions. Critics of this rationale warn of the ‘medicalisation of autonomy’,48 and that ‘autonomy has become an imperative; that which we cannot control, our belief in autonomy teaches us to hate. Thus we learn to hate our ageing bodies; and we learn to hate those others who are sick and dying. We even learn to hate those we would define as “permanently dependent”, exactly because they will always need our care’.49 This seems to be a particular burden for those who have exercised the greatest control over decisions made in other parts of

44 Dietrich Bonhoeffer, Ethics, trans. Reinhard Krauss, Charles C. West, and Douglas W. Scott (Minneapolis: Fortress Press, 2005), 221. 45 Bonhoeffer, Ethics, 168. 46 D. Dixon Sutherland, ‘From Terri Schiavo Toward a Theology of Dying’, in Resurrection and Responsibility: Essays on Theology, Scripture, and Ethics in Honor of Thorwald Lorenzen, ed. Keith D. Dyer and David J. Neville (Eugene: Pickwick Publications, 2009), 246. 47 Peter Singer, Rethinking Life and Death: The Collapse of Our Traditional Ethics (Melbourne: The Text Publishing Company, 1994), 132. 48 Daniel Callahan,‘Organized Obfuscation: Advocacy for Physician-Assisted Suicide’, Hastings Center Report 38, no. 5 (2008), 32. 49 Carole Bailey Stoneking, ‘Receiving Communion: Euthanasia, Suicide, and Letting Die’, in The Blackwell Companion to Christian Ethics, ed. Stanley Hauerwas and Samuel Wells (Malden: Blackwell Publishing, 2004), 379.

Voluntary Assisted Dying Section C1.9 62 Response report to Synod 2019 their life – i.e., those who enjoy comparative social, economic, professional, educational, and other privileges. Many simply wish to die as they have lived – in charge, and independent. A theological defence of the moral right to choose argument underscores human responsibility for life before God. Indeed, at the very centre of the Christian story lies a voluntary act of giving up life for the other. Without such freedom, there would be no human life as we know it at all. As Bonhoeffer once argued: ‘The freedom to risk and to give one’s life as a sacrifice is the counterpart of the right to life’.50 Following Bonhoeffer, it might be argued that assisted dying might not always be the ultimate form of individualism, but rather might be judged to be an act of responsible freedom and love for the other, a mode of glorifying God with one’s body (1 Cor 6:20). It is these fundamental moral actualities that might, for example, lead a young parent with upper motor neuron disease to exercise the right to end their life prematurely so that their children’s memory of them is one unmarked by a debilitating disease. Of course, the counter argument here is that such a decision robs precisely those same loved ones of the opportunity to themselves love and to bear together the burden of life’s uncertainties and ambiguities beyond the limits that one might choose to set for oneself. This is one place where liberalism has not served well our lived experience. It is founded on a definition of liberty wherein humans might be free to pursue whatever they desire, undetermined by and disconnected from history, tradition, family, kin, body, land, culture, religion, ancestral and civic concerns, or any authority external to the self-authored identity. Moreover, it has trained us to ‘think first and foremost of the self as a finished and self-contained reality with its own fixed needs and dispositions’.51 But to journey with another facing the decision to end their own life is to embody, confess, and protest the fact that liberalism has not delivered what it promised. Matters of personal autonomy and community responsibility are further complicated by the fact that we are steadily identified as consumers rather than citizens. Our governments have shown themselves impotent against the brute forces of consumer demand for an increasing number of end-of-life options beyond pain relief, palliative care, and the cessation of various treatments, even those undertaken with the direct intention of hastening death. As the populations of many countries steadily age, and as managerialised death targets and escalating healthcare costs become par for the course, it is unsurprising that the subject of euthanasia should be raised as often as it is. While some identify such a trend with a growing respect for human life, others identify such a trend with an eroding respect for human life. Human responsibility for life is exercised not only before God. It is exercised also before and with others with whom one is called to ‘bear one another’s burdens’ (Gal 6:2). Assisted dying, by its very definition, is not a private matter. It involves, requires, and has an impact upon a wider public and society. It ought not, therefore, be reduced to being about a patient’s rights alone. In religious communities, for a person to claim the right to die as an individual right can be a form of individualism that contradicts the communal and relational nature of God and God’s people. But what if the decisions made around death were undertaken not by the individual alone but rather with a community that was committed to bear the burden of the decision together? This would mean that whether or not the path led towards or away from voluntary assisted dying, there remains the opportunity to die accompanied by the presence, prayers, and confessions of others. For Christians, it offers the opportunity to die accompanied by those sacraments we have been rehearsing – Baptism and Eucharist. Baptism, that symbol of death with which the Christian journey begins; and Eucharist, where Christians remember and anticipate that the tragedy of the grave is not territory of which God is unfamiliar. ⍭⍭⍭

50 Bonhoeffer, Ethics, 197. See also Philippa Foot, Virtues and Vices and Other Essays in Moral Philosophy (Oxford: Clarendon Press, 2002), 40. 51 Rowan Williams, ‘On Making Moral Decisions’, Anglican Theological Review 81, no. 2 (1999), 297.

Voluntary Assisted Dying Section C1.9 63 Response report to Synod 2019 Death, in whatever form it takes, may indeed be life’s enemy. But it is an enemy that, like the strange promise of resurrection, is woven into the warp and woof of life in God’s world. Christians affirm that even death has been transformed by God who alone is our end. Whatever our manner of dying, we die into God’s care.

In life, in death, in life beyond death, God is with us. We are not alone. Thanks be to God.52

52 ‘A New Creed (1968)’, The United Church of Canada, accessed 8 March 2019, https://www.united-church.ca/community- faith/welcome-united-church-canada/new-creed.

Voluntary Assisted Dying Section C1.9 64 Response report to Synod 2019 Appendix E Summary table of assisted dying legislation around the world

Voluntary Assisted Dying Section C1.9 65 Response report to Synod 2019 Summary of assisted dying legislations worldwide (adapted from Appendix 4 of the Final Report on the inquiry into end of life choices, Victorian Parliament, 2016) Netherlands, 2002 Belgium, 2002 Luxembourg, 2009 Canada, 20161 Oregon, USA, 1997 Washington, USA, Victoria, 2017 2009

Name of legislation Termination of Life on Act on Euthanasia Law of 16 March 2009 Bill C-14 Death with Dignity Act Washington Death with Voluntary Assisted Request and Assisted on Euthanasia and an Act to amend Dignity Act Dying Act Suicide Act Assisted Suicide the Criminal Code and to make related amendments to other Acts (medical assistance in dying)

Eligibility Criteria: must the applying person…

… be an adult? No- in 2005, the law No- a 2014 Yes Yes Yes Yes Yes was amended to amendment to make euthanasia for the law made permissible for euthanasia legally infants with possible for all “hopeless prognosis minors. and intractable pain”.

…be cognitively No No Yes Yes Yes Yes Yes competent?

… have an advanced No No No No- ‘at the end of Yes Yes Yes disease that will cause life’, with their death? ‘grievous and irremediable medical condition’ i.e. a serious and advanced incurable illness, disease or disability in irreversible decline.

Voluntary Assisted Dying Section C1.9 66 Response report to Synod 2019 Netherlands, 2002 Belgium, 2002 Luxembourg, 2009 Canada, 20161 Oregon, USA, 1997 Washington, USA, Victoria, 2017 2009

… be experiencing pain Yes Yes- must be in a Yes- must show Yes- condition No- this is considered No- this is considered Yes- the and/or suffering that is ‘medically futile ‘constant and must cause implied by the advanced implied by the advanced (disease/diagnosis) must unacceptable to them? condition of unbearable physical or enduring physical disease that will cause disease that will cause cause ‘suffering that is constant and mental suffering, or psychological death criteria death criteria unacceptable to them’ unbearable without prospects of suffering that is physical/mental improvement’ intolerable and suffering that cannot be relieved cannot be under conditions alleviated’ patient considers acceptable

…have an estimated No No No No- see Yes- six months or less Yes- six months or less Yes- six months or less2 prognosis from their description of medical team? ‘advanced disease that will cause their death’

Safeguards

Medical 2 doctors 2 doctors- a third 2 doctors 2 doctors or nurse 2 doctors 2 doctors 2 doctors- who must involvement/assessment may be required if practitioners make an assessment of request patient is not that the individual expected to die ‘in meets the eligibility the near future’ criteria, understands the information provided, is acting voluntarily and without coercion and has an enduring request

Request is enduring? Not specified Doctor must have Doctor to have held Yes- 15 days Yes- 15 days between Yes- 15 days between Yes- A person must had several several interviews with between request initial and verbal initial and verbal make three separate conversations patient at reasonable and requests. 48hrs from requests. 48hrs from requests to a medical over a ‘reasonable intervals with regard to administration of signing written request signing written request practitioner period of time’ the patient’s condition drug to prescription of to prescription of (combination of oral medication medication and written), at least 9 days apart3

Voluntary Assisted Dying Section C1.9 67 Response report to Synod 2019 Netherlands, 2002 Belgium, 2002 Luxembourg, 2009 Canada, 20161 Oregon, USA, 1997 Washington, USA, Victoria, 2017 2009

Person is informed? Yes- ‘informed of the Yes- patient Yes- informed of state Yes- informed that Yes- informed of Yes- informed of Yes- Each doctor must situation they are in, informed about of health, life natural death is diagnosis, prognosis, diagnosis, prognosis, make sure that: and their prospects’ health condition, expectancy, therapeutic reasonably risks of taking the risks of taking the life expectancy, and palliative foreseeable. Also medication and medication and The person is fully possible palliative possibilities and informed that alternative treatment alternative treatment informed about their and therapeutic consequences request may be options. Patient is also options. disease, treatment and courses of action withdrawn at any offered the opportunity palliative care options and their time to rescind the request Voluntary assisted dying consequences before the prescription is the person’s own is written choice Th person understands that they can change their mind about their decision at any time. The decision is not rushed4

1 For purposes of this summary, only the Federal Canadian legislation has been included, and can therefore be considered inclusive of provincial Québécois legislation.

Voluntary Assisted Dying Section C1.9 68 Response report to Synod 2019 Appendix F JIM Unit Consultation Paper

Provided separately.

Voluntary Assisted Dying Section C1.9 69 Response report to Synod 2019 Voluntary Assisted Dying/Suicide

CONSULTATION PAPER for Uniting Church Synod of Victoria and Tasmania Presbyteries, Congregations and Individuals Voluntary Assisted Dying Section C 1.9 Appendix 1 Response report appendix Justice and International Mission Unit Synod of Victoria and Tasmania Uniting Church is Australia 130 Little Collins Street Melbourne, Victoria 3000 Phone: (03) 9251 5271 Fax: (03) 9251 5241 Email: [email protected] Cover Image Credit: Garth Jones September 2017

Voluntary Assisted Dying2 Section C 1.9 Appendix 2 Response report appendix CONTENTS

Introduction 4 Victorian Parliamentary Inquiry into end of life choices 5 Submissions to this Consultation 7 Questions for consideration 7 Ministerial Advisory Panel Recommendations 8 Existing Uniting Church Synod of Victoria Resolutions 20 Theological Reflections on the Issue 22 The Views of Other Churches 38 The Justification for Assisted Dying/Suicide Laws 49 Other Jurisdictions 52

Voluntary Assisted Dying Section C 1.9 Appendix 3 3 Response report appendix INTRODUCTION

Over the past 20 years there have been more than 30 bills made in state and territory parliaments to introduce legislation to allow euthanasia/assisted dying, most without success. The Northern Territory Act on euthanasia/assisted dying, the Rights of the Terminally Ill Act was passed on 25 May 1995, but was subsequently overturned by a federal law in March 1997. In response to a cross-party Parliamentary Committee’s findings that the current medical system does not adequately provide for the pain and suffering some people experience at the end of their life, the Victorian Government proposes to introduce legislation for voluntary assisted dying/suicide in Victoria in the second half of 2017. It is proposed that people with decision-making capacity who are experiencing unbearable pain and suffering at the end of their life be able to access medical intervention to end their lives in certain and limited circumstances. The then Synod of Victoria had previously considered the issue of euthanasia/assisted dying/suicide in 1995 and the Synod meeting decided, “That it is not yet ready to express an opinion on whether to support or oppose legislation to provide for active euthanasia in Victoria.” There was clear division in the views of church members on the issue. This consultation paper is to determine if church members have reached a new view after prayerful discernment. The role of the Justice and International Mission Unit is to try and gauge if the Synod should take a new position. The JIM Unit is not proposing any specific position be taken. Further, the JIM Unit recognises there will be strongly held views to support or oppose laws to actively assist in dying/suicide. This paper attempts to provide an overview of the diversity of Christian responses to this issue. The language used by those who already hold strong views differs markedly. Those who are supportive use terms such as “assisted dying” and “dying with dignity”. Those opposed to such measures use language such as “euthanasia” and “suicide”. Wherever possible, in sections written by the JIM Unit and not by other parties, the language of both sets of views is used in an attempt to make it clear the JIM Unit is not taking sides in the discussion and is seeking guidance from the church members. If the Victorian Parliament passes the proposed legislation, the Synod must make decisions about how its own bodies will respond. For example, will the Synod allow people to end their lives within its facilities, such as aged care facilities? Will the Synod allow employees of Synod bodies to assist or facilitate someone ending their life under the new law? The following details the timeline of consultation processes and reporting undertaken by the Victorian Government to date.

Voluntary Assisted Dying4 Section C 1.9 Appendix 4 Response report appendix VICTORIAN PARLIAMENTARY INQUIRY INTO END OF LIFE CHOICES

On 7 May 2015, the Parliament of Victoria’s Legislative Council agreed to the following motion: That pursuant to Sessional Order 6 this House requires the Legal and Social Issues Committee to inquire into, consider and report, no later than 31 May 2016, on the need for laws in Victoria to allow citizens to make informed decisions regarding their own end of life choices and, in particular, the Committee should: (1) assess the practices currently being utilised within the medical community to assist a person to exercise their preferences for the way they want to manage their end of life, including the role of palliative care; (2) review the current framework of legislation, proposed legislation and other relevant reports and materials in other Australian states and territories and overseas jurisdictions; and (3) consider what type of legislative change may be required, including an examination of any federal laws that may impact such legislation. In June 2016, the Legal and Social Issues Committee of the Parliament of Victoria’s Legislative Council published its report on the “Inquiry into End of Life Choices”. The full report and a summary booklet can be found online here: https://www.parliament.vic.gov.au/lsic/inquiry/402

The Victorian Government response to this report was tabled in Parliament on 8 December 2016 and can be found online here: https://www.parliament.vic.gov.au/lsic/article/3098

On 25 January 2017, following the Parliamentary Committee’s Inquiry into end of life choices, the Victorian Government appointed a Ministerial Advisory Panel to develop voluntary assisted dying/suicide legislation for introduction into Parliament in 2017. This discussion paper sought feedback on the Parliamentary Committee’s recommendations to help create a safe and practical voluntary assisted dying/suicide framework (not on opinions for or against assisted dying/suicide). The discussion paper was published in January 2017 and feedback was sought until Monday 10 April, 2017. In May 2017, the Victorian Government released the Interim report of the Ministerial Advisory Panel: Consultation overview – Voluntary Assisted Dying Bill. On 21 July 2017, the Victorian Government released the Ministerial Advisory Panel on Voluntary Assisted Dying: Final Report. The Discussion Paper, the Interim Report and the Final Report can all be found online here: https://www2.health.vic.gov.au/about/health-strategies/voluntary-assisted-dying-bill

The final report sets out the Panel’s recommendations for a voluntary assisted dying/ suicide framework for Victoria. It follows from the Panel’s interim report, released in May, which outlined the key themes that have arisen from the consultation process with stakeholders. The proposed framework provides access to voluntary assisted dying/suicide for adult Victorians who are at the end of their lives and suffering.

Voluntary Assisted Dying Section C 1.9 Appendix 5 5 Response report appendix There are 66 recommendations put forward in the report, which address the details of how voluntary assisted dying/suicide would work in practice. The report explains the detailed considerations of the Panel in making its recommendations. The starting point for each of the discussions is the voluntary assisted dying/suicide recommendation set out by the Parliamentary Committee. The Panel considers the consultation feedback, and reviews the research, evidence and experience of other jurisdictions where this is relevant. In terms of next steps, the Victorian Government will consider the Panel’s Final Report in shaping its Voluntary Assisted Dying Bill. The bill is due to be introduced to Members of Parliament for a conscience vote later in 2017. The preparation of the Voluntary Assisted Dying Bill (the Bill) will be supported by expert legal advice and a Ministerial Advisory Panel (the Panel) that will provide advice on the practical and clinical implications of the Bill. If the bill passes, the Panel has recommended an 18-month period prior to commencement to allow sufficient time for establishment of the voluntary assisted dying/suicide framework. The Medical Treatment Planning and Decisions Act 2016 (Vic), which is due to come into operation on or before 12 March 2018 aims to simplify the existing legislative framework for medical treatment decision-making in Victoria. Among other things, the Act repeals the Medical Treatment Act 1988 (Vic); provides for binding advance care directives; and replaces powers of attorney (medical treatment) with medical treatment decision-makers. The new laws will not affect the operation of the voluntary assisted dying/suicide framework.

Voluntary Assisted Dying6 Section C 1.9 Appendix 6 Response report appendix SUBMISSIONS TO THIS CONSULTATION

You are invited to make submission to the Justice and International Mission Unit in response to the issues raised within this consultation paper. You are free to address the questions included in the consultation paper, but you are no way constrained to respond simply to these questions. Submissions will be accepted up until Friday 20 October 2017 and can be sent to:

End of Life Options Submission c/- Justice and International Mission Unit Uniting Church Synod Centre 130 Little Collins Street Melbourne VIC 3000 Email: [email protected]

Submissions can be in any written format that you choose. Submissions will be made public unless confidentiality is requested. The submissions will help shape the Synod’s response to this important issue. The JIM Unit is happy to visit Presbytery meetings, Congregations and/or small groups to hear people’s views on the issues raised by the consultation paper. To arrange a time, please call (03) 9251 5271 or email [email protected]

Questions for consideration The following are questions that you, your faith group or your congregation might like to use to guide your discussion of this issue: • Should the Synod take a position on the proposed laws the Victorian Government plans to introduce on voluntary assisted dying/suicide? If so, what should that position be? • If the laws are passed through the Parliament, should the Synod allow people to end their lives in Synod facilities, such as aged care facilities, if such action by the person complies with the requirements of the laws? • If the laws are passed through the Parliament, should people ultimately employed by a Synod body be permitted to assist or facilitate people using the laws to end their lives while they are employed by the Synod?

Voluntary Assisted Dying Section C 1.9 Appendix 7 7 Response report appendix MINISTERIAL ADVISORY PANEL RECOMMENDATIONS

The final report of the Government’s Ministerial Advisory Panel puts forward 66 recommendations, which address the details of how voluntary assisted dying would work in practice. Guiding Principles Recommendation 1 That the following principles are included in the legislation to help guide interpretation: • Every human life has equal value. • A person’s autonomy should be respected. • A person has the right to be supported in making properly informed decisions about their medical treatment and should be given, in a manner that they understand, information about medical treatment options, including comfort and palliative care. • Every person approaching the end of life has the right to quality care to minimise their suffering and maximise their quality of life. • The therapeutic relationship between a person and their health practitioner should, wherever possible, be supported and maintained. • Open discussions about death and dying and peoples’ preferences and values should be encouraged and promoted. • Conversations about treatment and care preferences between the health practitioner, a person and their family, carers and community should be supported. • Providing people with genuine choices must be balanced with the need to safeguard people who might be subject to abuse. • All people, including health practitioners, have the right to be shown respect for their culture, beliefs, values and personal characteristics.

Voluntary Assisted Dying8 Section C 1.9 Appendix 8 Response report appendix Part A: Eligibility Criteria Recommendation 2 That to access voluntary assisted dying, a person must meet all of the following eligibility criteria: • be an adult, 18 years and over; and • be ordinarily resident in Victoria and an Australian citizen or permanent resident; and • have decision-making capacity in relation to voluntary assisted dying; and • be diagnosed with an incurable disease, illness or medical condition, that: -- is advanced, progressive and will cause death; and -- is expected to cause death within weeks or months, but not longer than 12 months; and -- is causing suffering that cannot be relieved in a manner the person deems tolerable. Recommendation 3 That the capacity test in the Medical Treatment Planning and Decisions Act is used to assess a person’s decision-making capacity in relation to voluntary assisted dying.

Recommendation 4 That when an assessing medical practitioner is in doubt about whether a person has decision-making capacity in relation to voluntary assisted dying, a referral must be made to an appropriate specialist for assessment.

Eligibility Considerations Recommendation 5 That mental illness does not satisfy the eligibility criteria for access to voluntary assisted dying, nor does mental illness exclude a person from eligibility to access voluntary assisted dying.

Recommendation 6 That disability does not satisfy the eligibility criteria for access to voluntary assisted dying, nor does disability exclude a person from eligibility to access voluntary assisted dying.

Voluntary Assisted Dying Section C 1.9 Appendix 9 9 Response report appendix Part B: Request and Assessment Process

Initiating a request for voluntary assisted dying Recommendation 7 That a request for access to voluntary assisted dying, or for information about voluntary assisted dying, can only be initiated by the person. Requests cannot be initiated by others, including family and carers.

Recommendation 8 That a health practitioner cannot initiate a discussion about voluntary assisted dying with a person with whom they have a therapeutic relationship.

Recommendation 9 That a request for information about voluntary assisted dying does not constitute a first request.

Recommendation 10 That the person may withdraw from the voluntary assisted dying process at any time. When the person withdraws from the voluntary assisted dying process, they must commence the process from the beginning if they decide to make a subsequent request for voluntary assisted dying.

Receiving a request for voluntary assisted dying Recommendation 11 That the legislation support access to voluntary assisted dying for people who are from culturally and linguistically diverse backgrounds and for people who require alternative means of communication, by allowing appropriately accredited, independent interpreters to assist them to make verbal and written requests for voluntary assisted dying.

Recommendation 12 That two medical practitioners must undertake independent assessments of a person’s eligibility for voluntary assisted dying.

Recommendation 13 That the roles of the two assessing medical practitioners be clearly defined as: • the coordinating medical practitioner; and • the consulting medical practitioner.

Recommendation 14 That both the coordinating medical practitioner and the consulting medical practitioner must be qualified as Fellows of a College (or vocationally registered); and • at least one of the medical practitioners must have at least five years post fellowship experience; and • at least one of the medical practitioners must have expertise in the person’s disease, illness or medical condition.

Recommendation 15 That both the coordinating medical practitioner and the consulting medical practitioner must complete specified training before undertaking an assessment of a person’s eligibility for access to voluntary assisted dying.

Voluntary Assisted Dying10 Section C 1.9 Appendix 10 Response report appendix Recommendation 16 That the specified training comprise of obligations and requirements under the legislation including: • assessing the eligibility criteria under the legislation; • assessing decision-making capacity in relation to voluntary assisted dying and identifying when a referral may be required; and • assessing the voluntariness of a person’s decision to request voluntary assisted dying and identifying risk factors for abuse.

Recommendation 17 That the coordinating medical practitioner or the person may request that the role of the coordinating medical practitioner for the voluntary assisted dying process be transferred to the consulting medical practitioner.

Recommendation 18 That a health practitioner may conscientiously object to participating in the provision of information, assessment of a person’s eligibility, prescription, supply or administration of the lethal dose of medication for voluntary assisted dying.

Making a request for voluntary assisted dying Recommendation 19 That the person must make three separate requests to access voluntary assisted dying: a first request, followed by a written declaration of enduring request, and then a final request.

Recommendation 20 That the formal process for requesting voluntary assisted dying proceeds for the person as follows: • The person makes their first request to a medical practitioner. • The person undergoes a first assessment by the coordinating medical practitioner. • The person undergoes a second independent assessment by the consulting medical practitioner. • The person makes a witnessed written declaration of enduring request to the coordinating medical practitioner. • The person makes a final request to the coordinating medical practitioner.

Recommendation 21 That the coordinating medical practitioner and the consulting medical practitioner must ensure that the person is properly informed of: • their diagnosis and prognosis; • treatment options available to them and the likely outcomes of these treatments; • palliative care and its likely outcomes; • the expected outcome of taking the lethal dose of medication (that it will lead to death); • the possible risks of taking the lethal dose of medication;

Voluntary Assisted Dying Section C 1.9 Appendix 11 11 Response report appendix • that they are under no obligation to continue with their request for voluntary assisted dying, and that they may withdraw their request at any time; and • any other information relevant to the person’s needs.

Recommendation 22 That the coordinating medical practitioner and the consulting medical practitioner undertake independent assessments to form a view as to whether: • the person meets the eligibility criteria; • the person understands the information provided; • the person is acting voluntarily and without coercion; and • the person’s request is enduring.

Recommendation 23 That the final request may only be made after a period of at least 10 days has passed since the first request.

Recommendation 24 That there is an exception to the 10 day requirement when the coordinating medical practitioner believes that the person’s death is likely to occur within 10 days and this is consistent with the prognosis provided by the consulting medical practitioner.

Recommendation 25 That the final request cannot be made on the same day that the second independent assessment is completed.

Recommendation 26 That a person’s written declaration of enduring request must be in writing, be signed by the person, and be witnessed by two persons in the presence of the coordinating medical practitioner. The two witnesses must certify that the person appears to be voluntarily signing the declaration, to have decision-making capacity, and to understand the nature and effect of making the declaration.

Recommendation 27 That one of the witnesses to the written declaration of enduring request must not be a family member. The two witnesses must be 18 years and over and cannot be: • a person who knows or believes that they are a beneficiary under the will of the person making the written declaration of enduring request, or a recipient, in any other way, of a financial or other material benefit resulting from the person’s death; or • an owner or operator of any health care or accommodation facility at which the person making the written declaration of enduring request is being treated or any facility in which the person resides; or • directly involved in providing health or professional care services to the person making the written declaration of enduring request.

Recommendation 28 That the written declaration of enduring request allows the person to make a personal statement about their decision to access voluntary assisted dying.

Voluntary Assisted Dying12 Section C 1.9 Appendix 12 Response report appendix Completing the voluntary assisted dying process Recommendation 29 That the person appoint a contact person who will take responsibility for the return of any unused lethal medication to the dispensing pharmacist within 30 days after the person has died and act as a point of contact for the Voluntary Assisted Dying Review Board.

Recommendation 30 That, to conclude the assessment process, the coordinating medical practitioner complete a certification for authorisation to confirm in writing that they are satisfied that all of the procedural requirements have been met.

Recommendation 31 That the prescription of the lethal dose of medication requires an authorisation process.

Recommendation 32 That at the point of dispensing the lethal dose of medication, the dispensing pharmacist must: • attach labels clearly stating the use, safe handling, storage and return of the medication; and • provide the person with information about the administration of the medication and the likely outcome.

Recommendation 33 That the person be required to store the lethal dose of medication in a locked box.

Recommendation 34 That the legislation not preclude health practitioners from being present when a person self-administers the lethal dose of medication if this is the preference of the person.

Recommendation 35 That there be protection in the legislation for health practitioners who are present at the time a person self-administers the lethal dose of medication, including that the health practitioner is under no obligation to provide life-sustaining treatment.

Recommendation 36 That not being able to self-administer is defined as being physically unable to self- administer or digest the lethal dose of medication.

Recommendation 37 That if the person is not able to self-administer, the coordinating medical practitioner may administer the lethal dose of medication.

Recommendation 38 That, in the rare circumstance the person loses the capacity to self-administer the medication after it has been prescribed, they must return to their coordinating medical practitioner if they wish to proceed with voluntary assisted dying. After the previously prescribed medication has been returned to the pharmacist, the coordinating medical practitioner may undertake the process to administer the medication.

Voluntary Assisted Dying Section C 1.9 Appendix 13 13 Response report appendix Recommendation 39 That, in the rare circumstance where both the coordinating and consulting medical practitioners conscientiously object to administering the lethal dose of medication, the coordinating medical practitioner can refer the person to a new consulting medical practitioner willing to administer the medication. The new consulting medical practitioner must conduct their own independent assessment, after which the coordinating medical practitioner may transfer the role of coordinating medical practitioner to them.

Recommendation 40 That, if the coordinating medical practitioner administers the lethal dose of medication, a witness who is independent of the coordinating medical practitioner must be present. The coordinating medical practitioner and the witness must certify that the person’s request appears to be voluntary and enduring.

Voluntary Assisted Dying14 Section C 1.9 Appendix 14 Response report appendix Part C: Oversight

Monitoring after death Recommendation 41 That the death certificate of a person who has accessed voluntary assisted dying identifies the underlying disease, illness or medical condition as the cause of death.

Recommendation 42 That accessing voluntary assisted dying should not affect insurance payments or other annuities.

Recommendation 43 That the medical practitioner who certifies death must notify the Registrar of Births, Deaths and Marriages if they are aware that the person has been prescribed a lethal dose of medication or if they are aware that the person self-administered a lethal dose of medication under the voluntary assisted dying legislation.

Recommendation 44 That the Registrar of Births, Deaths and Marriages and the Voluntary Assisted Dying Review Board share information relating to voluntary assisted dying.

Recommendation 45 That a death by means of voluntary assisted dying in accordance with the legislative requirements not be considered a reportable death for the purpose of the Coroners Act.

Voluntary Assisted Dying Review Board Recommendation 46 That a Voluntary Assisted Dying Review Board be established under statute to review every case of voluntary assisted dying and report on the operation of voluntary assisted dying in Victoria.

Recommendation 47 That the role and functions of the Voluntary Assisted Dying Review Board be: • reviewing each case of voluntary assisted dying and each assessment for voluntary assisted dying to ensure the statutory requirements have been complied with; • referring breaches of the statutory requirements to the appropriate authority to investigate the matter such as Victoria Police, the Coroner, or the Australian Health Practitioner Regulation Agency; • collecting information and data, setting out additional data to be reported and requesting additional information from medical practitioners or health services, for the purpose of performing its functions; • monitoring, analysing, considering and reporting on matters relating to voluntary assisted dying, • supporting improvement by facilitating and conducting research relating to voluntary assisted dying and maintaining and disseminating guidelines to support the operation of the legislation, in collaboration with other agencies and professional bodies and services; and • any other functions necessary to promote good practice.

Voluntary Assisted Dying Section C 1.9 Appendix 15 15 Response report appendix Recommendation 48 That the membership of the Voluntary Assisted Dying Review Board be appointed by the Minister for Health, and that the appointments reflect the appropriate knowledge and experience required for the Board to perform its functions.

Monitoring of voluntary assisted dying Recommendation 49 That there is mandatory reporting by medical practitioners to the Voluntary Assisted Dying Review Board within seven days of: • completing the first assessment (regardless of the outcome); • completing the second independent assessment (regardless of the outcome); • completing the certification for authorisation (which will incorporate the written declaration of enduring request and appointment of contact person forms); and • when the lethal dose of medication is administered by a medical practitioner.

Recommendation 50 That, in order to monitor the lethal dose of medication, there is mandatory reporting within seven days to the Voluntary Assisted Dying Review Board: • by the Department of Health and Human Services when the prescription is authorised; • by the pharmacist when the prescription is dispensed; and • by the pharmacist when unused lethal medication is returned by the contact person.

Recommendation 51 That reporting forms are set out in the legislation to provide certainty and transparency about the information that is collected. That these forms include a: • first assessment report (which includes record of first request); • second assessment report; • written declaration of enduring request; • appointment of contact person; • certification for authorisation; • dispensing pharmacist report; • administration by medical practitioner report; and • return of medication notification.

Recommendation 52 That the Voluntary Assisted Dying Review Board report to Parliament: every six months in the first two years after commencement, and thereafter annually.

Recommendation 53 That the voluntary assisted dying legislation be subject to review five years after commencement.

Voluntary Assisted Dying16 Section C 1.9 Appendix 16 Response report appendix Protections and offences Recommendation 54 That the legislation provides clear protection for health practitioners who act in good faith and without negligence to facilitate access to voluntary assisted dying under the legislation.

Recommendation 55 That a health practitioner must notify the Australian Health Practitioner Regulation Agency if they believe that another health practitioner is acting outside the legislative framework.

Recommendation 56 That any other person may notify the Australian Health Practitioner Regulation Agency if they believe that a health practitioner is acting outside the legislative framework.

Recommendation 57 That there be offences for: • inducing a person, through dishonesty or undue influence, to request voluntary assisted dying; • inducing a person, through dishonesty or undue influence, to self-administer the lethal dose of medication; • falsifying records related to voluntary assisted dying; and • administering a lethal dose of medication to a person who does not have decision-making capacity.

Voluntary Assisted Dying Section C 1.9 Appendix 17 17 Response report appendix Part D: Implementation

Voluntary assisted dying in the context of existing care options Recommendation 58 That the implementation of voluntary assisted dying should occur within the context of existing care available to people at the end of life, and ensure voluntary assisted dying activity is embedded into existing safety and quality processes.

Implementation planning and governance Recommendation 59 That work to establish the Voluntary Assisted Dying Review Board begin at least 12 months before the commencement of the legislation and is supported to develop a clear work plan to meet its legislated obligations including collection requirements and processes for receiving and recording data, procedural requirements related to its review, reporting and quality functions, and protocols for engaging and sharing information with other partners (such as the Department of Health and Human Services, Safer Care Victoria, and services and providers) for quality improvement purposes.

Recommendation 60 That the Department of Health and Human Services establish and support an Implementation Taskforce to investigate and advise on the development of voluntary assisted dying. The Implementation Taskforce should have the coordinating role in overseeing and facilitating the work set out in these implementation recommendations.

Recommendation 61 That the functions proposed by the Parliamentary Committee for End of Life Care Victoria be subject to a gap analysis in relation to existing entities and their functions to determine a clear role for the proposed agency.

Implementation support Recommendation 62 That appropriate workforce support, information, clinical and consumer guidelines, protocols, training, research and service delivery frameworks to support the operation of the legislative framework are developed in a partnership between Safer Care Victoria, the Voluntary Assisted Dying Review Board and the Department of Health and Human Services in consultation with key clinical, consumer and professional bodies and service delivery organisations.

Recommendation 63 That the Implementation Taskforce establishes a collaborative coordination process across responsible agencies to periodically review the resources and frameworks that support the operation of voluntary assisted dying.

Research Recommendation 64 That the Implementation Taskforce provide advice to the Department of Health and Human Services on engaging with a university to undertake research on the best practice identification and development of medications for use in voluntary assisted dying.

Voluntary Assisted Dying18 Section C 1.9 Appendix 18 Response report appendix Recommendation 65 That a collaborative research program is developed with existing research entities to identify key clinical, policy and practice issues and align research with these priorities.

Commencement Recommendation 66 That, in order to prepare for implementation, there is an 18-month period between the passage and commencement of the voluntary assisted dying legislation.

Voluntary Assisted Dying Section C 1.9 Appendix 19 19 Response report appendix EXISTING UNITING CHURCH SYNOD OF VICTORIA RESOLUTIONS

The relevant Synod of Victoria resolutions that have been made on this issue to date are detailed below:

1992 Re: Euthanasia, Abortion 92.5.1.1 The Synod resolved: That the Synod Commission for Mission be requested to ensure that the issues of euthanasia and abortion are appropriately addressed, and report to Synod 1993.

1994 Re: Euthanasia, Abortion, Genetic Engineering 94.4.2.10 The Synod resolved: (a) To request the Synod Commission for Mission to reproduce and distribute to each Presbytery and Parish in the Synod the report on Euthanasia and Abortion of the Bioethics Committee for the information of members of the Church, together with a study guide. (b) To encourage Presbyteries and Parishes to respond to the Bioethics Committee no later than 30th June 1995. (c) To request the Synod Commission for Mission to ensure that in the future work of the Bioethics Committee, particular attention is given to ways in which genetic engineering and genetic mapping relate to bioethics.

1995 Re: Euthanasia 95.6.9.5.2 The Synod resolved: (a) That it is not yet ready to express an opinion on whether to support or oppose legislation to provide for active euthanasia in Victoria. (b) To request the Commission for Mission to continue its program of research, study and debate on issues relating to euthanasia and after seeking assistance from the Committee on Doctrine and Liturgy to develop further its statement on euthanasia within a broad theological context. (c) To inform the Victorian Government that the Synod is actively encouraging discussion on the issue of euthanasia and asks to be consulted about any proposed legislation in the future. (d) To make strong representation to the State and Federal Ministers for Health urging: (i) that an increased range of quality palliative care services be made accessible and affordable to all in the community; and (ii) that increased resources be made available for specialist training in palliative care for health care professionals. (e) To request the Synod Commission for Mission, in consultation with the Commission on Education for Ministry, to develop and promote further

Voluntary Assisted Dying20 Section C 1.9 Appendix 20 Response report appendix training opportunities for specialist and lay pastoral carers, including staff of Uniting Church aged care facilities for ministry in palliative care. (f) To request the Commission for Mission to produce and distribute information and study material on The Medical Treatments Act 1988 with encouragement for the wider use of the provisions of the Act. (g) To encourage members of the church to offer strong pastoral support to doctors, nurses, chaplains and others who care for terminally ill patients and their relatives and friends.

The Uniting Church Synod of Victoria and Tasmania has yet to make a definitive statement regarding voluntary assisted dying/suicide or euthanasia. A response submitted by the Presbytery of Tasmania in 2016 considered the complexity of the issue as part of the Tasmanian Dying with Dignity submissions, and stated that the Church was neither for nor against the introduction of the Bill. In addition to the Synod of Victoria resolutions, in 1996 the Synod of Queensland passed a resolution to oppose “the legislation of active voluntary euthanasia”.1

1 Synod of Queensland resolution 96.100.

Voluntary Assisted Dying Section C 1.9 Appendix 21 21 Response report appendix THEOLOGICAL REFLECTIONS ON THE ISSUE

In order to resource discussions among Uniting Church members, we have sought theological reflection from people who have already been involved in thinking and practice around the issues of dying, assisted suicide and euthanasia. We have attempted to ensure that a diversity of positions are represented.

A good death

Rev. Lauren Mosso

‘We do not live to ourselves, and we do not die to ourselves. If we live, we live to the Lord, and if we die, we die to the Lord; so then, whether we live or whether we die, we are the Lord’s. For to this end Christ died and lived again, so that he might be Lord of both the dead and the living.’ Romans 14:7-9

As a Pastoral Carer in a hospital setting, the presence and possibility of death is around us all the time. Patients and families are anxious, holding that possibility whether spoken or unspoken, even with the knowledge that the health care they are receiving is excellent. Life-changing events happen to people in completely unexpected ways. Sometimes there is a long, slow progression of disease which still takes people by surprise when the end is near. The pain of anticipating the death of a loved one can make it very difficult for family members to discontinue medical treatment. We cannot imagine the final parting, and feel we are somehow failing our loved one if we do not continue to fight for them. Sometimes we hear from patients that they have ‘had enough.’ We are often privileged to hear a ‘life review’ from a patient as he or she sums up what they have accomplished in their life, moving toward a sense of completion. Sometimes we hear of unresolved issues and broken relationships. Mostly we hear about love that has sustained the person in their life. It is comforting to know that the person has come to a place of acceptance that death is coming. This is a key ingredient of a good death. Conversation about the end of life is important, and can alleviate stress and worry. Yet we are so reluctant to ‘go there’. Another key ingredient is the family/carer’s acceptance that death is coming. This painful realisation can be softened when medical staff give clear reasons as to why further treatment is no longer an option. When treatment is withdrawn, care does not cease. The nursing team, whether in hospital or in community palliative care, treat the person with dignity and respect ensuring as far as possible that they do not experience pain. Gentle care and support is offered to the family, who are encouraged to be fully present with their loved one as they share in this sacred liminal time. We are privileged to gather with families in their loved one’s last days. Stories are shared, tears are shed, and deep connections of love and support strengthen the bonds that will hold them in the coming days and into the future.

Voluntary Assisted Dying22 Section C 1.9 Appendix 22 Response report appendix Offering ministry in a hospital setting has made me aware of my own mortality. I now realise that we fool ourselves into thinking that we are in control. In fact, very little is within our control! A compassionate response is needed when life becomes ‘out of control’. We as a society need to ensure that all are cared for with dignity and respect at the end of life, and that a good death happens wherever possible. To that end we are invited to have the difficult conversation, make our wishes known through ‘Advanced Care Planning,’ and live each day to the full. Whether we live or whether we die, God is with us.

Rev. Lauren Mosso is a Uniting Church Minister of the Word, currently serving as a Uniting Church Chaplain. Before that time, Lauren was the Synod’s Ethical Standards Officer, based at the Centre for Theology and Ministry in Parkville.

Voluntary Assisted Dying Section C 1.9 Appendix 23 23 Response report appendix Love is stronger than death

Rev. Gordon James Bannon

Love is born With a dark and troubled face When hope is dead And in the most unlikely place Love is born: Love is always born. (Michael Leunig)

It may seem strange to begin this conversation by quoting a Leunig prayer about birth and love, but I believe that love should be at the centre of this conversation about assisted dying. This prayer also encapsulates for me that acts of love are sometimes fraught and difficult and painful, yet love can still be born in those spaces of darkness and hopelessness. I want to ground my argument in the teachings of Jesus who told us to live by two basic commandments. “Love the lord your God with all your heart mind and soul and to love your neighbour as yourself”. These two commandments are supposed to sum up all the ‘law’ and the second in particular gives me a guide to moral behaviour when I relate to the issue of assisted dying. My argument is focussed on allowing people to find a way to end their own life when faced with a painful and prolonged death. It is an argument for people to take their own lives only when it is their will and when other pathways to a peaceful and dignified death have been exhausted. Sadly, the current law of the land and our ethics, defines this act as illegal both by the person themselves and by those assisting. This puts both the person wishing to die, and those wishing to care for them (in many cases doctors and nurses) in the position of either acting deceitfully to enable a dignified and peaceful death (and thereby becoming a criminal) or to mindlessly prolong a life of agony and distress to fulfil the law. A passive form of euthanasia is already happening in hospitals everywhere as medical practitioners find a way to surreptitiously end life by withholding medical intervention or by giving pain relief at a dosage which is likely to end life. It is wrong that these medical practitioners or relatives (or the person themselves) has to do this in a way which has them being seen as performing an immoral and illegal act. When they are helping someone die in accordance with their wishes and in a manner that brings relief to their suffering, then I believe they are acting with mercy and with love. I would go so far as to say that they are showing the love and mercy of God in such acts. If we are to live a compassionate life, I believe that can mean not standing in the way of someone finding a way of ending their own life if they are in unbearable pain. I find myself asking, what does the parable of the Good Samaritan mean in this context? If I am travelling with someone who is facing months or years of unbearable pain and I am able to open the way for them to die and end their suffering, then I feel that it can be a loving act to enable their death. Arguably, to do nothing or to take away the sufferer’s power over their own life, is (at best) to be like the priest and walk by on the other side of the road, and at worst, to be one who continues their suffering needlessly. As the parable implies, not to act, is still to act. As far as I am aware the Bible does not explicitly forbid suicide. St Augustine used the argument that suicide was illegal because it was against the 6th commandment. (I find it interesting that very few of those who make this theological argument are pacifists.)

Voluntary Assisted Dying24 Section C 1.9 Appendix 24 Response report appendix This is an argument still used against assisted dying, yet the sixth commandment actually forbids murder, which I would argue is quite different to either the taking of one’s own life or assisting another to end their suffering. Pope John Paul II has said that suicide or assisted dying are a rejection of God’s gift of life and love. This to me implies an image of God as one who is happy to stand by and watch someone suffer horrible and long-lasting pain rather than be given the gift of a merciful and peaceful death. John Paul’s very statement implies that whilst life is a gift, death is not. Yet in death we are promised a greater union with the divine and, as people of faith, we believe that death is not an end. Part of our faith is the understanding that life is a journey with God that does not have death as an absolute end, but a pathway into a different way of being with God. This does not mean that we are to seek death, but it also means that we are asked not to fear it. Some opponents to assisted dying see euthanasia and suicide as mortal sins which have God condemning them to eternal punishment. I do not believe that suicide is a mortal sin and I do not believe that the scriptures portray a God who wants us to suffer needlessly. I do not believe in the kind of Divine being who condemns a person to eternal damnation for taking their own life, but rather see the divine as looking with mercy and love on those who suffer. I know that the issue is not a simple one and I have sympathy for those who are concerned that any change in the law is the ‘thin edge of the wedge’ in regards to the value of human life. And I feel strongly that it is vital to set legal boundaries that guard as much as possible against abuses of any law that allows a person to end their own life. Nevertheless it seems wrong to stand by and let someone suffer an agonising death when we are able to alleviate their suffering and it is their will to do so. As the writer of the Song of Solomon so famously said “Love is stronger than death.” No more starkly is that statement portrayed than in the agony of considering the death of someone we love, yet at times I believe that to allow death can be an act of greater love than to prolong a life of great agony.

Gordon Bannon is a Uniting Church Minister of the Word, and the Presbytery Minister – Pastoral Care for the Loddon Mallee Presbytery. Gordon is also an Ambassador for Dying with Dignity Victoria.

Voluntary Assisted Dying Section C 1.9 Appendix 25 25 Response report appendix The Christian conscience that permits assisted death or Yes to Voluntary Assisted Death (VAD)

Rev. Kenneth Ralph

With voluntary euthanasia law reform now unstoppable in western democracies it is no surprise that it has landed on Australian shores. In the spring of 2017 it is very likely the Victorian State Parliament will approve a voluntary assisted death proposal which means Victorians will be able to access its death hastening provisions somewhere in 2019. Some will see this as an overdue day of natural justice and compassion, others as a day of shame and folly. So how will our Uniting Church respond to the pastoral challenges presented by such a Bill? Will it, for example, refuse to conduct the funerals of terminally ill persons who do accelerate their dying? Probably not. But what about this more problematic issue: will it say yes to those clergy who have intimated that they are prepared to enter the room of the dying patient with the sacrament of the church at the same time the doctor enters it with her or his death hastening liquid or pill? And this: will it compose appropriate last-rite liturgies for those who elect to take up the provisions of the new law. I imagine that if the ebullient and much loved Desmond Tutu, Bishop of Durham were asked about these possibilities he would likely endorse them all. He recently indicated that now he is 85 and ‘closer to the departure hall than the arrival,’ he has reversed his lifelong opposition to assisted death. He now believes that dying people ‘should have the right to choose how and when they leave Mother Earth.’ Alongside the ‘wonderful palliative care that exists,’ he states, dying people’s choices ‘should include a dignified assisted death.’ Bravo say some. Bad form say others. But Tutu has done nothing novel or extraordinary in this thing. Oodles of clergy and laypersons have endorsed the moral right of an individual to accelerate a bad dying that makes no sense to them and involves them in suffering and/or indignity that is intolerable to them. Death control, like birth control, they have argued, is entirely consistent with a Christian conscience. Ever since the first voluntary euthanasia bill was introduced into a western democracy in the House of Lords in 1936, this movement has benefitted from Christian input. Clergy and lay became chairpersons or committee members in scores of local, voluntary euthanasia movements throughout the world. Over twenty clergy once marched in the streets of New York banners aloft in advocacy of voluntary euthanasia law reform. Some wrote significant ethical material that under-girded the world wide Right to Die ethical platform. Books by the score have flowed from the pens of Christians worldwide. Thousands of Christian have argued the case for the self-elected hastening of death in the public domain through speeches, news presentations, sermons, letters to editors, and TV appearances. These Christian leaders have never been audacious enough to say that their view is the only one in Christendom. They speak of a diversity of viewpoints. Some also remind us that in the 1990s the Ethics committee of the UCA Synod of Victoria noted that three views existed within Christendom regarding voluntary euthanasia. When a motion was put to have it resolved that the view of the Synod be that voluntary euthanasia be condemned this was defeated. A cluster of big themes have been held in common by those Christians who over the centuries have supported the option of voluntary assisted death

Voluntary Assisted Dying26 Section C 1.9 Appendix 26 Response report appendix • the minimisation of non-beneficial suffering • the right of the individual to self-determination • a vision of an empathic, nurturing, respectful deity who wills only good for humans • a rejection of the view that life possesses absolute value No Christian in modern times has championed these views more than the Reverend Dr Hans Kung, for a long time one of the Roman Catholic Church’s most esteemed religious thinkers. In his co-authored book A Dignified Dying he argued that terminally ill people have the right to determine the timing and manner of their dying. In 2014 he followed this up with a public statement that he intended to seek suicide in a Swish clinic if his medical condition continued to worsen, suffering as he then was from Parkinson’s, hearing loss and osteoarthritis. Early in his career Kung accepted the teachings of his church that God as unconditional lord and owner makes the end-time decision. But watching his brother die badly over twelve months with an inoperable tumour had a big influence on changing Kung’s thinking from No to Yes on voluntary euthanasia. First he rejected the notion that all suffering is bearable or has value or purpose – if not now then in some after life. Second he came to believe that God wants human beings to be ‘free responsible partners.’ God not only gave humans life, Kung claims, but ‘the utter right to self-determination.’ The whole of life is under our responsibility, he writes and this responsibility ‘applies to the last phase of our lives.’ Prominent Australian philosopher, Roman Catholic layman and voluntary euthanasia supporter Max Charlesworth was of the same view. He wrote about what he called ‘an autonomous death, a death I have as a moral agent, after serious reflection, determined for myself.’ I sometimes play a fantasy game in my mind that if Kung were to a time travel backwards he would have had some good chats with the Reverend Dr. Leslie Weatherhead minister of the City Temple Church in London. In 1965 he wrote that helping a person to die who was enduring ‘a long, incurable, useless and intolerable painful illness’ far from being ‘cowardly or selfish,’ was reasonable, liberating and altruistic.’ Perhaps Kung might have persuaded Weatherhead to be with him in that final end of life moment at that Swiss suicide clinic, for it was Weatherhead who wrote that provided proper safeguards were drawn up he would be more than willing ‘to give the patient the Holy Communion and stay with him while a doctor whose responsibility I would thus share, allowed the patients to lay down his useless body and pass in dignity and peace into the next phase of being.’ And perhaps Kung could call to his bedside another pro-euthanasia clergyman, American Dr Joseph Fletcher – who argued that death control at one end of life lies as much in the hands of humans as birth control lies at the other. Fletcher who claimed to coin the phrase ‘bio-ethics’, wrote numerous papers on voluntary euthanasia, spoke often at Right to Die rallies and conferences. He was not of the view that ‘life as such is the highest good.’ He called that the ‘vitalist fallacy.’ He quoted with approval the words from a submission made by a group of New York clergymen in support of euthanasia law reform: ‘We believe in the sacredness of personality, but not in the worth of mere existence of length of days.’ Dignity, meaning, self-awareness, control of one’s own existence, inter-personal capacity, these are what give value to life, according to this way of looking at things. Fletcher certainly would have agreed with James Gustafson, Professor of Divinity at the University of Chicago, when he wrote ‘sometimes the powers that bear down

Voluntary Assisted Dying Section C 1.9 Appendix 27 27 Response report appendix on a person can be greater than the powers that sustain them.’ In his view the conscientious choice of an individual to kill themselves ‘in the face of unrelievable and unbearable suffering,’ may be a ‘reasonable choice.’ To these deaths ‘one must consent,’ he wrote. Gustafson has little time for those who argue that even if life is a burden we have to hold on to it as a gift from God. He claims that if God does not guarantee some good out of the afflictions or provide the conditions of possibility for a way out, then we must raise questions about the assertions that God is benevolent and beneficent. So there we are – a brief selection from a large range of Christian writers – all promoting the right of the terminally ill person to call a halt to a distressing dying that no longer makes sense to them. For myself, a long term, active supporter of accelerated assisted death and an Ambassador to Death With Dignity Victoria (DWDV) my own view on this issue is summed up in brief by two affirmations. I am sure I have modified them from other individual’s originals but I can’t recall who they were. Here they are. (1) We do not have to live for as long as we can but only for as long as we choose. (2) All should be free to access assisted death, but none should be obliged to.

Kenneth Ralph is an author, counsellor and retired Uniting Church Minister of Religion. His latest book is Your Final Choice. Hastening your death when terminally ill - eight questions to ask yourself.

Voluntary Assisted Dying28 Section C 1.9 Appendix 28 Response report appendix Playing God with Death

Rev. Prof. Andrew Dutney

Excerpt from Dutney, Andrew (2001), “Playing God: Ethics and Faith”, Harper Collins, Melbourne, Australia How do patterns of Christian support for voluntary euthanasia, and especially the theological explanations of that support, reflect the influence of the social and historical context within which Christians seek to live out their faith? In this discussion, then, my primary interests are twofold. First, I want to register the fact of the presence of voices in the Christian churches. It seems to me that simple honesty, as much as the integrity of the church, requires that they be recognised. Second, it particularly interests me that Christian support for voluntary euthanasia has been supported by the way modern Christians have come to think about God. Changes in society that have no obvious theological relevance can enable members of society who are Christians to think differently about God and their relationship with God. These new theological insights are non-denominational or trans-denominational and can have a significant bearing on Christian bioethical activity. This is demonstrated in the spiritually and theologically serious way in which large numbers of Christians came to support voluntary euthanasia in the twentieth century.

Christian Support for Voluntary Euthanasia As it happens, Christians have always been active in the modern voluntary euthanasia lobby. Among the founders of the American Euthanasia Society, in 1945, were prominent Christians such as Henry Sloane Coffin, the President of Union Seminary in New York, and Harry Emerson Fosdick, the minister of the Baptist Riverside Church in New York.

Theological Support for Voluntary Euthanasia Among the experts and authorities there is also a diversity of opinion. Catholicism has an official position of unqualified opposition to any form of euthanasia. According to the Catechism of the Catholic Church, “Intentional euthanasia, whatever its forms or motives, is murder. It is gravely contrary to the dignity of the human person and to the respect due to the living God, his [sic] Creator.” Nonetheless there are Catholic voices expressing disagreement with that position. The philosopher Max Charlesworth is one. He takes a position that has been characteristic of Christian supporters of voluntary euthanasia, affirming that God has created human beings to make their own decisions and to accept responsibility for themselves and their neighbours. Hans Küng, a Catholic theologian, has taken a similar position. In his view, “God, who has given men and women freedom and responsibility for their lives, has also left to dying people the responsibility for making a conscientious decision about the manner and time of their deaths.” Similar views have been expressed by Protestant Christians. Kenneth Ralph, a Uniting Church minister, argued that, “self-determination is central to what it means to be a human being or person”, and that “Christianity has always been a champion of this position. The great German historian and liberal theologian, Adolf Harnack (1851-1930) crystallised the faith of the age at the turn of the twentieth century:

Voluntary Assisted Dying Section C 1.9 Appendix 29 29 Response report appendix In the combination of these ideas – God the Father, Providence, the position of men [sic] as God’s children, the infinite value of the human soul – the whole Gospel is expressed.

For Harnack these were inseparable ideas. The man [sic] who affirms that “the being who rules heaven and earth” is his divine Father, that he is God’s child, and that they can have utter confidence in the benevolence of this divine ruler is beginning to grasp how greatly God values his individual soul. From this message, this Gospel, he can then live confidently, positively and prosperously – just as the project of nineteenth century liberalism proposed he might. The American theologian Reinhold Niebuhr (1892-1971) belonged to a later generation. The experiences of the twentieth century – especially the Great War, the horrors of Nazism and Stalinism, and the nihilistic madness of the nuclear arms race – had given the lie to the optimism of the liberal project. Niebuhr was one of the most influential theologians of his generation. He earned particular fame for his contribution to social ethics – reinstating the doctrine of original sin and developing a model of prophetic social engagement known as “Christian realism”. Yet even as he distances himself from the discredited liberalism of the previous generation the unqualified value of the individual remains the organising principle of his thought – the heroically defiant individual, the vulnerable individuality of the citizen, the paradox the individual’s freedom. John Cobb, a Methodist theologian, has made a similar point in a more careful way. He maintains that, “Theologically, few would now accept the view that one range of actions belongs wholly to the sphere of human free will and another wholly to God. God is at work everywhere, but in a way that does not set aside the decisions of the creatures. Instead God makes such decisions possible and works in and through them.” It is his contention that God does not lay exclusive claim to decisions about ending one’s life. It is not a special case. In this as in all things, we may find ourselves having to be in partnership with God. We even find ourselves playing God – but just because we must. We were created for this, in Cobb’s view. And the developments in biotechnology that have so suddenly increased our burden of responsibility for our own lives and destinies need not be viewed as sinister, or as corroding our relationship to the Creator. Rather they may be interpreted theologically as an opportunity to give fuller expression to the image of God within us.

Liberalism and Christian Support for Voluntary Euthanasia It is helpful to recognise that such Christian expressions of support for voluntary euthanasia are consistently couched in the language of “liberal” theology. “Liberalism” as a social or political philosophy emphasises the value of the individual and, in particular, the rights of the individual to personal freedom and autonomy. Liberalism has been the dominant philosophy in modern western societies, and especially in Australia. “Liberal theology” describes those styles of Christian thought, which evolved in partnership with the liberal society, rather than in isolation from it (as did eastern Orthodox theology) or in resistance to it (as did Roman Catholic theology, some evangelical, and fundamentalist theologies). The strength of liberal theology has been the way it speaks about God and the nature of human life in the same language as the surrounding (liberal) society. That is, it is a theology that makes sense to people. The members of our churches are also members of Australian society, a liberal society. It would be expected that they would tend to understand God and human life in liberal terms. And from this historico-cultural

Voluntary Assisted Dying30 Section C 1.9 Appendix 30 Response report appendix perspective it is no surprise that a majority of them support voluntary euthanasia, nor that the theological articulation of that support uses the language of liberal theology. But, at the same time, a weakness of liberal theology has been the way it has served the enculturation of Christianity in a (liberal) culture that many now regard as being in decline. If liberalism is failing, liberal theology is failing with it.

Post-Liberal Theology For some decades a “post-liberal” approach to theology has been in formation. Two features of these theologies are relevant to this discussion. First, whereas liberal theology elevated the value of the individual in the doctrine of the human person, post-liberal theologies have given more emphasis to the way personhood is relationally constituted. That is, the “image of God” in the human person is located not so much in the exercise of autonomy (being “like” God in authority) as it is in building relationships and being-in-relationship (being “like” God in mutuality and love). This shift is related to the marked movement from the effectively monistic doctrine of God in liberal theology to explicitly trinitarian theologies in the critique of liberal theology. In Trinitarian theology, the being of God is to be found in the dynamic relations between the persons of the Trinity – the mutuality of self-giving love between the Father, Son and Holy Spirit. As the theologian Colin Gunton would have it,

The persons are what they are by virtue of what they give and receive from each other. As such, they constitute the being of God, for there is no being of God underlying what the persons are to and from each other. God is a being in relation, without remainder relational.

There is no God anterior to the living relationship of the persons of the Trinity. The being of God is all the inter-personal mutuality of love. A second feature of post- liberal theologies is related to this: the recognition of the importance of community. “Individualism” and “libertarianism” have become pejoratives, especially where their ready acceptance by liberalism has been seen to rebound on the weakest members of society. Instead “solidarity” has become a leitmotif in the various types of post- liberal theological ethics. It needs to be acknowledged that post-liberal theologies have tended to line up against voluntary euthanasia. But my specific purpose here is to recognise and interpret patterns of Christian support for voluntary euthanasia. And, with the decline of liberalism, it is important to register the fact that there is support of a post-liberal variety too.

Post-Liberal Theology in Support of Voluntary Euthanasia For example, the Anglican theologian Duncan Reid argues from a Trinitarian position that the practice of voluntary euthanasia can be ethically legitimate for Christians. Reid draws attention to the way Trinitarian anthropology critiques the individualist models of the human person that have been characteristic of modern thinking. A Trinitarian anthropology, he says, “suggests an ethic of relationality and care rather than one of rights.” So he insists,

We can no longer argue for euthanasia on the basis of the right of the individual to decide, nor against euthanasia on the basis of the right of biological human life to be preserved in abstraction from consideration of the personhood associated with that life and other persons connected to it.

Voluntary Assisted Dying Section C 1.9 Appendix 31 31 Response report appendix In addition, Reid sees Trinitarian theology as a critique of “a lordship model of God” as the one who unilaterally withholds or gives life, preserves or ends life. Rather, the Trinitarian emphasis on the inter-personal dynamic of mutuality as constitutive of the being of God – perichoresis to use the theological term for it – “opens up a relational view of a generous God who invites our adult and generous response and interaction.” From this perspective voluntary euthanasia does not represent a usurping of the exclusive prerogative of God. Kenneth Vaux, a Reformed theologian and ethicist, is somewhat more provocative. Vaux accepts the arguments of liberal theology in support of voluntary euthanasia, but he sees them as partial and inadequate to the fullness of the human person. Instead of reiterating arguments based on autonomy and personal freedom he is determinedly focussed on the church, the communal matrix of Christian life. For him, it is not just that the individual has the moral and spiritual authority to make choices about the manner of his or her death, but that church has to become the kind of community that helps its members (and others) to deal well with death and dying. So he says to local churches, “let us not only preach and teach on a regular basis about dying, death, and God’s purposes through these culminating events, but let us also have planning sessions: opportunities to lay out our wishes and enlist others to safeguard those wishes against any who would override them.” This will help the local church to be prepared for when any of its members is dying. The solidarity of the well and the sick can be expressed in “helping, consoling, grappling for meaning, providing meals, caring for children and guests who arrive from around the country, and just distracting to allow relief.” An absence of this solidarity is a religiously and morally flawed as wresting the right to choose from a dying person.

Conclusion In its submission to the Senate inquiry into the Euthanasia Laws Bill 1996, the Board for Social Responsibility of the NSW Synod of the Uniting Church seemed to catch journalists off balance. The Board was critical of “politicians claiming the high moral ground without commensurate moral responsibility for the human beings who are affected by their decision.” It expressed its concern at the way opponents had misused the inquiry “to promote criticisms which are based on simplistic and inaccurate views of euthanasia and of the Northern Territory legislation”. In the Board’s view, “There is no simple right and wrong in this situation.” However, such is the level of general ignorance of the diversity of Christian opinion on this and other ethical issues that the press could only deal with the Board’s moderate and cautionary comments under the exaggerated headline, “Church rift emerges on euthanasia legislation.” The article then opened with the extravagant claim that the Uniting Church had “attacked other Christian churches for their opposition to voluntary euthanasia”. The belief that Christians and churches are united and unambiguous in their opposition to voluntary euthanasia is false. There is in fact strong support for voluntary euthanasia among both nominal and active church members. There are also numerous Christian thinkers and theologians who have set about to show that the holding of Christian faith and doctrine is consistent with supporting voluntary euthanasia. Liberal theology has been dominant in Christian statements of support for voluntary euthanasia, identifying autonomy and personal freedom as integral to the “image of God” in the human person, and emphasising human partnership with God in decisions about death. More recently some post-liberal constructions of Christian faith have introduced new emphases in the patterns of Christian support for voluntary euthanasia, especially the inherent relationality of the human person and the communal nature of Christian existence.

Voluntary Assisted Dying32 Section C 1.9 Appendix 32 Response report appendix None of this is to say that Christians should support particular initiatives to legalise voluntary euthanasia – only that they may. It is high time that church authorities and experts gave more attention and respect to the perspectives and insights of ordinary Christians, who daily test their faith against the realities of the world in which they must live and allow their faith to light a way through the world. It is not good enough that when the discussion gets serious – as did the discussion on voluntary euthanasia in Australia in the mid-nineties – they are ignored, talked over or bullied into silence. In any case, the really interesting thing that emerges when we focus on Christian support for voluntary euthanasia is the way our understanding of God is not static but is constantly being reconsidered, revised, retrieved and renewed as the Christian community makes its journey through history within societies and civilisations. And this process which we have now seen in at work in Christian reflection on the tragic decisions that people make around abortion and euthanasia we can also see in the joyous, hopeful decisions by which people become parents.

Rev. Prof. Andrew Dutney teaches Systematic Theology within the Adelaide College of Divinity and Flinders University. He is the Principal of Uniting College for Leadership & Theology. He is the immediate Past President of the national Assembly of the Uniting Church in Australia.

Voluntary Assisted Dying Section C 1.9 Appendix 33 33 Response report appendix Euthanasia in biblical and theological perspective

Associate Professor Rosalie Hudson and Rev Ross Carter

From the doctrine of creation, we learn that God is both the origin and destiny of created human life: our beginning and our end. Made in the image of God, our worth and dignity as unique persons is a gift of grace. Hence all human life is precious in God’s sight. From the doctrine of the trinity we learn that we are made for fellowship with God and with each other; we live only in relationship. From St Paul, we learn that in ‘the body of Christ’ (1 Cor.12) all members are equally important to the whole and that the weakest members are to be respected and loved. The New Testament teaches that questions of biological life and death have been decided through the death and resurrection of Jesus Christ. We cannot therefore say suffering and death are of no consequence; neither can we say death is the greatest evil. The paradox for Christians is that death must ordinarily be resisted, but death must also at some point be accepted. Christians believe that ultimately our end is not in death but in God: in the raising of Jesus Christ from the dead by the power of the Holy Spirit we also are raised to new life. The strong consensus of the church over its history has been that Christians never aim at death, as an end or a means to an end, either for themselves or others. Autonomy and dignity. Many people are concerned about autonomy and dignity, believing that euthanasia provides a choice and control over the time and manner of dying. However, vulnerable disabled and/or elderly people may be placed under pressure from relatives to request euthanasia. This may take the course of gentle persuasion or coercion towards believing this to be the preferred course of action. Allowing some people the right to choose, places an obligation on everyone to make a choice. If euthanasia were an option, it would add to the distress and guilt of those who worry that they are too great a burden on others. At present, they are protected by the fact that euthanasia is illegal, and if this protection were removed tremendous stress could be placed on them. Is the pressure of sensing that you are a financial handicap, a worthless burden or ‘having passed one’s use-by date’ compatible with being an autonomous individual? All frail or elderly people would be faced with the dilemma: ‘should I be euthanised instead of giving all this trouble to my family or adding to the burden on the health services?’ The following example illustrates the point.

A mother of a large family repeated, ‘I wish I could go to sleep and not wake up’. She had no pain and said she was comfortable. Finally, it was discovered that she was concerned that her family had gathered, some from interstate, to be with her. The staff had believed her death to be imminent, when in fact she improved and was not actually dying. She felt that she was interrupting the busy lives of her family. When they could go home and arrangements were made for her to return to the little country hospital in her home town she was contented.

It is essential to uncover what is underlying a request for euthanasia or assisted suicide. Public opinion. It is claimed that public opinion surveys show that a large majority of the population support euthanasia: therefore, it should be legalised. For many

Voluntary Assisted Dying34 Section C 1.9 Appendix 34 Response report appendix years euthanasia was regarded as necessary to prevent people from dying in pain. Opinion polls since 1946 have asked the hypothetical question, ‘If a hopelessly ill patient, in great pain, with absolutely no chance of recovery asks for a lethal dose, so as not to wake again, should a doctor be allowed to give a lethal dose or not?’ The poll question is not ‘Do you think euthanasia should be legalised?’ but ‘Would you favour dying in agony or euthanasia?’ Naturally, many people chose euthanasia. Pain relief is not given as an option, as the hypothetical patient’s pain cannot be relieved. The great advances in pain management since 1946 make this scenario extremely unlikely today, with new drugs and analgesic techniques being continually developed. This sort of question does a disservice to dying patients. It suggests that they might suffer great pain which could only be relieved by killing them. Other opinion surveys have asked ‘Should euthanasia be legalised?’ but when respondents are self-selected readers of a newspaper the results may not reflect the opinions of the general population. Whatever the case, legislation should be based on informed opinion rather than public opinion. Palliative care. Palliative care recognises that even when we can’t cure we can care. Suffering is relieved by treating symptoms and giving support to patient and family, so that individuals are helped to live as fully as possible until they die. To ‘palliate’ is derived from the Latin, meaning ‘to cover with a cloak’. In English, it means ‘to alleviate the symptoms of a disease’ or ‘mitigate the suffering of it’. Palliative care is not confined to the last stage of illness. Some people recoil from the term ‘palliative’ in the mistaken belief that it suggests ‘giving up’ or ‘no more treatment’ or ‘being left to die’. More emphasis is now being given to interventions throughout the disease process which can improve the quality of life for people whose illness is not amenable to cure, and for their families. Evidence of the benefits of palliative care earlier in the illness is becoming increasingly apparent. Benefits include improved pain control, improved symptom control, reduced anxiety, reduced hospital admissions, reduced care-giver distress, improved survival with a type of lung cancer, fewer emergency presentations, fewer days in intensive care and reduced costs. The result is better living, not just easier dying. Made in the Image of God. From the doctrine of creation, we learn that God is both the origin and destiny of created human life: our beginning and our end. Made in the image of God, our worth and dignity as unique persons is neither earned nor self-created; it is a gift of grace. Hence all human life, whether unborn child or older adult, whether healthy or malformed, is precious and underscored by the gracious commandment, ‘Thou shalt not kill’ (Deut 5:17). The same creation doctrine teaches that human life is not created in or for isolation; we live only in relationship. As the Son is one with the Father, so we are one with Christ as Christ is one with us, and we are one with each other in Christ (John 17: 20-23). This claim follows from the fact that Christ takes the part of all who, like him, share the human likeness. Therefore, the issue of one person’s life and death cannot be viewed in isolation from who we are as persons created in God’s image. St. Paul describes the church as the ‘body of Christ’ (1 Cor. 12) in which the weakest members are to be respected and loved, and where all parts are equally important to the whole. Human rights. The task of Christian theology regarding human rights is not to try to represent what thousands of experts, lawyers, legislators, and others have already accomplished. Theology’s task is different. It aims to ground human rights in God’s right to human beings. The question arises: How does the exercise of our human rights occur within the freedom given in Jesus Christ? Individuals and groups create many lists of human rights, and often one set of rights conflicts with the claims of

Voluntary Assisted Dying Section C 1.9 Appendix 35 35 Response report appendix other individuals or groups. For example, an individual’s claimed right to assisted suicide depends on the agreement of another individual. Many people react against the notion that God has a right to human beings because it is heard as an imperious claim that devalues the freedom of individuals to decide for themselves the meaning and purpose of their lives. That notion suggests that God rides roughshod over human freedom. This is an appropriate response if God is conceived as all-powerful and distant, albeit kindly and compassionate, who stands over and against human beings. But if God’s relationship to us is based on his gracious action for us, the claim that human rights should be grounded in God’s right to human beings will be heard differently. According to this understanding, God’s right is neither imperialistic nor totalitarian. It is the claim of the Creator who gives us life which we cannot give ourselves and which is not at our disposal. We may say that God has a right to us because everyday life is a gift from beyond our own resources. God’s right to us is our fortunate destiny, allowing us the freedom and the right to respond to God’s abundant goodness toward us. The tragedy is that instead of accepting the freedom to welcome others into our lives we use it to close ourselves to others, especially those who need protection and love at the beginning and end of life. For this we can only repent. Suffering. The capacity to suffer, to bear grief and misfortune, is, along with our capacity for pleasure, joy and happiness, what makes us human. Humanity cries out for the removal of suffering, especially in view of our helplessness in many situations. We may not stand idly by and watch a person suffer without intervening. The best available means of response are called for – medical, therapeutic and pastoral – to relieve unnecessary pain, together with patience and courage in the face of the suffering we cannot totally alleviate. There are two well-known views on euthanasia which deny the transcendent, redemptive aspect of suffering. One is an indiscriminate ‘pro-life’ stance that arises when sanctity of life is made a self-referencing end separated from God’s gift of grace. The result is to make life an inherent ‘good’ and biological existence to be preserved at all costs, even at the cost of profound suffering. On the other hand, ‘quality of life’ proponents strive to avoid all debilitating pain and suffering, believing that suffering is inherently ‘bad’ and must be overcome in all situations and by whatever means. Biblical faith, however, understands that suffering never removes us from the loving care and mercy of God. Thus, quality of life and sanctity of life are not opposed; in Christian terms, they are complementary. Care for others. The challenge for Christians is how to care for people who find themselves increasingly dependent on others for their needs and who perhaps more than ever before need to retain that most valuable of all self-understandings – the dignity of personal worth. What quality of care for those who are approaching death can help them find purpose and joy in whatever span of life remains? This is a challenge for individuals and congregations alike. It may be one of the ways by which Christianity demonstrates not only the compassion of Christ, but the resilience of faith in that article of the creed which states ‘I believe in the resurrection of the body’. In the face of death Christian hope is in Jesus Christ who said: ‘I am the resurrection and the life; those who believe in me, though they die, yet shall they live; and whoever lives and believes in me shall never die’ (John 11: 25, 26).

Voluntary Assisted Dying36 Section C 1.9 Appendix 36 Response report appendix Associate Professor Dr. Rosalie Hudson is an Honary Senior Fellow, School of Nursing & Social Work at the University of Melbourne and Adjunct Associate Professor at Charles Sturt University. She is a consultant/educator in palliative aged care and dementia care, Rev. Ross Carter is a Uniting Church Minister of the Word currently in placement at South Port Uniting Church Parish Mission in South Melbourne. Both Rosalie and Ross served on the Synod’s Bioethics Committee for several years.

Voluntary Assisted Dying Section C 1.9 Appendix 37 37 Response report appendix THE VIEWS OF OTHER CHURCHES Anglican Diocese of Melbourne

In 2012, The Synod of the Anglican Diocese of Melbourne passed the following motion: That this Synod reaffirms the resolutions of the General Synod of Australia (1995) concerning Euthanasia, namely: • We affirm that life is a gift from God not to be taken, and is therefore not subject to matters such as freedom of individual choice • We case doubt on whether a practice of voluntary euthanasia can be prevented from sliding into a practice of . • We affirm the right of patients to decline treatment but not to expect the active intervention by medical staff to end their lives. And calls upon (1) Members of the Victorian State legislature to vote against legislation to legalise euthanasia when such matters come before our Parliament; and (2) Governments to further improve access to high quality palliative care to ensure that all people will be able to die with dignity.

Voluntary Assisted Dying38 Section C 1.9 Appendix 38 Response report appendix Australian Catholic Bishops Conference

Real care, love and compassion Compassion for the sick and suffering is something which unites us all. Many of us have accompanied friends or family as they face the fear and uncertainty of a serious illness. Our heart goes out to them and we wish only the best for them. From time to time euthanasia or assisted suicide is proposed as the compassionate choice for people who are facing such illness. Euthanasia may be defined as intentionally bringing about death by active intervention, or by neglect of reasonable care in order to end suffering. Physician Assisted Suicide is when a person is prescribed lethal drugs with which to kill themselves, with the purpose of eliminating suffering. We hear people saying that this would allow people to ‘die with dignity’ and that it is each individual’s ‘right’ to choose the timing and manner of their death. This view, although born of compassion, is misguided and even dangerous. Killing people is wrong, and this principle is fundamental to our law. In the very few jurisdictions overseas where euthanasia or assisted suicide have been introduced, there is already ample evidence that the system is being abused and the legislated safeguards are being ignored. All Australians seek a compassionate response to illness and suffering. We ask you to consider the following myths and facts outlining why euthanasia, or government authorised killing, is never the best expression of compassion.

Myth 1: Euthanasia can be legislated for safely Fact: Euthanasia and assisted suicide can never be safe. Because terminally ill people are vulnerable to powerful feelings of fear, depression, loneliness, not wanting to be a burden, and even to coercion from family members, no law can adequately protect them from succumbing to euthanasia if it is available. Experience in other countries has shown clearly that it is impossible for government- authorised killing to be made safe. This is one of many strong reasons that the principle of prohibiting killing is so deeply embedded in our law and ethics throughout the world, recognised in international human rights documents, and basic to our common morality.

Myth 2: Dying with dignity Fact: Our dignity is not dependent on our usefulness or health, but simply on our humanity. Our society should be judged by how well we care for the sick and vulnerable. Everyone should be loved, supported and cared for until they die. There is nothing truly dignified about being killed or assisted to suicide, even when the motive is compassion for suffering. Suicide is always a tragedy. People at a very low ebb are not helped by being told by our laws that we think they would better off dead or that we would be better off if they were dead. The community is rightly concerned about the high level of suicide in Australia and much effort is put into reducing it. To then introduce government authorised killing on request, or assisted suicide, would be to create a dangerous double standard, and promote a false idea of dignity.

Myth 3: Euthanasia is an issue of personal liberty and personal choice Fact: Euthanasia always involves a second person and is therefore a public act with public consequences. One person assisting the death of another is a matter of significant public concern because it can lead to abuse, exploitation and erosion of care for vulnerable people. Euthanasia would forever change the nature of doctor

Voluntary Assisted Dying Section C 1.9 Appendix 39 39 Response report appendix patient relationships, from one of a duty to care, and heal and comfort, to one where a doctor is given the power to kill or to help you kill yourself.

Myth 4: It’s worked well in other places, like The Netherlands, Belgium & Oregon in the US Fact: The overseas models are not working well. The so-called strict guidelines are failing badly, with deadly consequences. When euthanasia was introduced in Belgium in 2002 it was considered to be only for terminally ill adults, deemed to be in their right mind, with full consent given. Doctors were required to report cases of euthanasia to a nominated authority. A little over a decade later, the Belgian parliament has now legalised euthanasia for children of all ages and dementia patients. Studies show only half of euthanasia cases are reported to the authority and in a study in Flanders, 66 of 208 cases of euthanasia occurred without explicit consent. Similarly in the Netherlands, despite the supposed safeguards, the Dutch government’s own statistics show that more than 300 people die each year from euthanasia without explicit consent. From its strictly controlled beginnings, euthanasia in the Netherlands has now grown to include the unconscious, disabled babies, children aged 12 and over, and people with dementia and psychiatric illnesses. In Oregon the legislation allows lethal drugs to be administered without oversight, leaving enormous scope for family pressure or elder abuse to be applied.

Myth 5: Euthanasia should be legalised because opinion polls support it Fact: Parliaments don’t legislate on opinion polls alone. Parliaments are elected to consider all the relevant arguments, to legislate in favour of the common good, to endorse responsible action and to protect the vulnerable, whose voices and concerns are often not heard in opinion polls. The devil is very much in the detail when it comes to euthanasia, and when parliaments across the world have had a chance to examine all the evidence and all the dangers, the great majority of them have voted against it, even in the face of strong opinion poll support.

Myth 6: Euthanasia is necessary to relieve pain Fact: Good palliative care, not killing, is the answer to relieving pain for the dying. Palliative Care Australia says that good, well-resourced palliative care gives people the ability not only to live well in their illness, but to die well too, “free from pain, in the place of their choice, with people they wish to be present, and above all, with dignity”. Great medical gains are being made in palliative care and many families speak of palliative care as providing very precious time with their loved one. But the fact is that palliative care is not offered to many dying people in Australia and in some places there would be no opportunity to receive it, even if a person in great pain asked for it. No one should be talking euthanasia in Australia until we have righted this wrong.

Author: Australian Catholic Bishops Conference Public Policy Office https://www.catholic.org.au/bishops-commission-for-pastoral-life/alternative-to- euthanasia

Voluntary Assisted Dying40 Section C 1.9 Appendix 40 Response report appendix Baptist Union of Victoria (BUV)

The Baptist Union of Victoria have released a resource kit for consultation forums which they hope will discern what God’s will for them is as a movement of churches. The forums are for any Baptist from the Victorian Baptist Church and they are especially hoping that church delegates will attend these forums, but they are open to anyone. Those who represent their Church as Delegates of the Baptist Union of Victoria, do so with a responsibility and the trust of individual congregations to represent what they have discerned God leading in each local setting. The forum opportunities are not about individual views – but for people to come together as representatives of the different parts of the one body. Their resource kit says “we set aside this time to listen to God, to each other, and to discern Gods ways, not our own preferences. We come together to seek God’s best purpose for us – together, as a movement of Baptist Churches, intent on advancing the Kingdom of God”. Each Consultation Forum will discuss issued identified through feedback from Delegates Dinners, through BUV networks, and from matters raised by churches within the BUV Office. Union Council determines each year which key issues should be addressed and discussed. The BUV discernment process timetable includes consultations, delegates dinners and gatherings taking place from February to October, and in November and December issues for broader consultation, discussion and discernment will be determined by Union Council for the next 12 months’ discernment process.

Voluntary Assisted Dying Section C 1.9 Appendix 41 41 Response report appendix Catholic Archdiocese of Melbourne

The Catholic Archdiocese of Melbourne will be releasing its’ formal statement following the tabling of the draft legislation into the Parliament later in 2017. On 18 April 2017, the Archbishop of Melbourne; Bishop of Ballarat; Bishop of Sale and Bishop of Sandhurst Dioceses wrote “A Pastoral Letter to the Catholics of Victoria”. That letter follows: There is a renewed push in Victoria and in many other parts of Australia for euthanasia and assisted suicide to be legalised. Misplaced compassion leads some to call for the deliberate ending of life by the direct action of a doctor or by a doctor helping someone to suicide. This is never justified (Catechism of the Catholic Church #2277). In this latest push the term ‘assisted dying’ is being used to describe both euthanasia and assisted suicide. While it is never easy to face the end of life of a loved one, we cannot support this kind of legalisation however it is described. Assistance in our time of dying is something that we should all want for ourselves and for others – however, this should not involve a lethal injection or offering a lethal dose. As Pope Francis recently reminded us, “The predominant school of thought sometimes leads to a ‘false compassion’ which holds that it is … an act of dignity to perform euthanasia. Instead, the compassion of the Gospel is what accompanies us in times of need, that compassion of the Good Samaritan, who ‘sees’, ‘has compassion’, draws near and provides concrete help.” Euthanasia and assisted suicide are the opposite of care and represent the abandonment of the sick and the suffering, of older and dying persons. Instead, we encourage all people of goodwill, to respond to this new challenge with truth and compassion. We wish to affirm that our task is to protect, nurture and sustain life to the best of our ability. We thank the Government for its recently increased commitment to palliative care. We encourage them, rather than taking the negative path towards euthanasia or assisted suicide, to continue to invest in the care and support of all Victorians in need. There is clearly much more work to be done. Last year a Parliamentary Committee recommended Victoria move towards legalising assisted suicide and euthanasia. This was endorsed by the Government in December with a consultation currently underway to look at how such laws can be made ‘safe’. We should be clear – there is no safe way to kill people or to help them to their own suicide. For millennia, the Church and civil society has understood such actions to be morally and ethically wrong. The commandment, ‘Thou shalt not kill’ is both a biblical and civil dictum and should remain so for very good reason. Since the Northern Territory’s brief experiment with euthanasia in 1996, euthanasia and assisted suicide legislation have been continually rejected in state parliaments around Australia. Why? Because when parliamentarians take the time to debate the issue fully and to consider all the consequences they realise that to legalise euthanasia and assisted suicide would threaten the lives of vulnerable people. During 2008, this issue was at the forefront of the public debate in Victoria. Since then little has changed. The proposals then, as now, would allow some people to be treated differently under the law, where their lives could be taken at their request. It would create a lower threshold of care and civil protection afforded to the sick,

Voluntary Assisted Dying42 Section C 1.9 Appendix 42 Response report appendix suffering and vulnerable. Such a law would serve to exploit the vulnerability of those people, exposing them to further risk. Such legislation is usually presented as being limited: only for terminal illness; only for those in the last weeks and months of life etc. However, the evidence from jurisdictions where assisted suicide and euthanasia are practiced legally show that incremental changes follow over time once the notion that some lives are not worth living becomes accepted in the community. Euthanasia for children was adopted in Belgium in 2014. Likewise, euthanasia for psychological illness is now legal in Belgium. In Holland, there is pressure to allow assisted suicide for people over the age of 70 who have simply become ‘tired of life’. We must, therefore, urge our elected representatives to resist this ‘first step’. As medical advances increasingly lead to a longer life for many people, we should view older people as a blessing for society rather than a problem. Each generation has much to teach the generation that follows it. We should therefore see care of the elderly as repayment of a debt of gratitude, as a part of a culture of love and care. The Catholic community already does much to care through our network of hospices, hospitals, aged care facilities and other services. We call on the Catholic community and people of goodwill to continue to care for the frail, elderly, the sick and the dying, at every stage of life. We ask you to continue to journey with those who are sick and in pain, to visit them, and ensure they have appropriate care, support and pain management and most of all someone to remain close to them. We thank those healthcare professionals and palliative care specialists, nurses, doctors, psychologists, pain management teams, pastoral carers, religious, volunteers and others who work every day to reduce pain as well as social and spiritual suffering, in positive and life-affirming ways. We ask Victorians to continue to love and care for those who are sick and suffering rather than abandoning them to euthanasia or supporting them to suicide. Our ability to care says much about the strength of our society. At this time we especially also want to encourage you, our sisters and brothers, to pray and to act. We commend the efforts of lay groups and associations and all people of good will who respectfully let their parliamentary representatives know of their concerns. Please do what you can to stay informed about this issue. If you would like to contribute to the efforts of your local parish, ask your parish priest how you can be involved. If you would like more information on this issue or would like to find out how you can contribute locally, contact the Life, Marriage and Family Office of the Melbourne Archdiocese on: [email protected] or (03) 9287 5587. In all our efforts, let us never cease to call on Jesus Christ and the intercession of Mary our Mother. Yours sincerely in Christ,

Most Reverend Denis Hart DD Archbishop of Melbourne Most Reverend Paul Bird CSsR DD Bishop of Ballarat

Voluntary Assisted Dying Section C 1.9 Appendix 43 43 Response report appendix Most Reverend Patrick O’Regan DD Bishop of Sale Most Reverend Leslie Tomlinson DD Bishop of Sandhurst

In addition to the pastoral letter, the Catholic Archdiocese of Melbourne has published a reflection by Dr. Caroline Ong RSM entitled“When Life is Ending: Discussing dying, assisted suicide and euthanasia”. Dr. Ong is a Sister of Mercy, a practising general practitioner and a bioethicist. A copy of that book can be downloaded from the Archdiocese of Melbourne’s website: http://www.cam.org.au/euthanasia/Be-Informed/What-is-euthanasia

Voluntary Assisted Dying44 Section C 1.9 Appendix 44 Response report appendix Salvation Army

The National Salvation Army Moral and Social Issues Council are currently discussing the issue of Euthanasia. The Moral and Social Issues Council is the body that creates Positional Statements and resources to assist Salvationists in thinking through issues of social justice.

Voluntary Assisted Dying Section C 1.9 Appendix 45 45 Response report appendix Victorian Council of Churches

At the time of writing (July 2017), the Standing Committee of the Victorian Council of Churches (VCC)* is considering making the following public statement:

Victorian Churches Condemn Lack of Consultation on Euthanasia Bill In an extraordinary move today (26 July) a majority of the major churches in Victoria have issued a joint statement condemning the Andrews Government’s euthanasia legislation. The State Government of Victoria intends to introduce “End of Life” legislation in the spring session of Parliament and the churches, through the Victorian Council of Churches (VCC), are calling for widespread community debate and discussion. “There are far-reaching consequences of such legislation” said Bishop Peter Danaher, the outspoken President of VCC. “We call for open and frank discussion across the whole community about all aspects of death and dying. There is a wide range of views and interpretations about end of life” he said. Though recent Australian Bureau of Statistics data shows a decline in faith and religion, approximately 68% of Victorians still claim some form of belief. Consultation has been limited and the churches are far from confident that the views of all members of society have been heard and taken into consideration. The churches assert that euthanasia, the deliberate talking of the life of a terminally ill person in order to bring that person’s suffering to an end, should not be legalised in Victoria. Since 1988,2 patients in Victoria have had the right to refuse life-sustaining treatment. The churches played a constructive role in the development of that legislation and they believe they should play a similar role in preserving its integrity. The churches understand that many Victorians want to uphold the current legislation which affirms that life should be preserved rather than destroyed and which supports the common law right of any individual to refuse medical treatment in certain circumstances. They also assert that consistent, universally available, high quality palliative care is the gold standard for end of life management. “Dying at our place of choice with the people we choose and with the religious and cultural practices of our choice are all important factors” said Bishop Danaher. “We claim inclusivity to be a hallmark of Victoria, but this legislation threatens the cultural sensitivities of so many. We have to allow end of life to occur with maximum respect and dignity”. The churches are calling on state politicians not to pass this legislation. * Please note, the Uniting Church Synod of Victoria and Tasmania is not a formal signatory to the above statement.

2 By virtue of the Medical Treatment Act (1988)

Voluntary Assisted Dying46 Section C 1.9 Appendix 46 Response report appendix The previous statement from the Victorian Council of Churches came in the form of a Joint Statement by the Heads of Churches on 17th July, 1995. That statement follows: “At a recent meeting of the Heads of Churches in Victoria it was agreed to release a joint statement on euthanasia: The Churches recognise that there is considerable community debate and discussion about euthanasia. The Northern Territory has responded by introducing legislation and other States have indicated that they may follow suit. The churches welcome and encourage open and frank discussion within the community about all aspects of death and dying. They recognise that there is in Australian society a wide range of views and interpretations about euthanasia. Euthanasia – the deliberate taking of the life of a terminally ill person in order to bring that person’s suffering to an end – is illegal in Victoria. However, by virtue of the Medical Treatment Act 1988 a patient in Victoria can refuse burdensome life- sustaining treatment provided certain conditions are met. The churches played a constructive role in the development of this legislation and should play a similar role in preserving its integrity. While we recognise that there are others in the community who do not hold the same views as the Churches, we believe that the vast majority of Victorians agree with the current legislation which affirms that life should be preserved rather than destroyed and which upholds the common law right of any individual to refuse medical treatment in certain circumstances. The churches affirm the following principles as they apply to euthanasia: Life is a gift from God which must be protected by all reasonable means. It should be the primary intent of law to sustain and enhance life, not to destroy it. Dying is a natural process, an integral part of the cycle of life and death. While we naturally cling to life, at some point death must be accepted as inevitable. The refusal or withdrawal of drugs and of other interventions are not of themselves euthanasia. To describe them as “passive” euthanasia causes confusion in the public debate. Optimal palliative care should be available to all people regardless of their economic or social circumstances. Economic expediency must not become the occasion for the introduction of euthanasia. Human beings are not separate, disconnected individuals. It is integral to a Christian understanding of creation that individual rights must be framed in relation to the common good. As a community we have the duty to care form and to enhance the life of an individual. The measure of society’s integrity is its capacity to care for the most weak and vulnerable. People should never be made to feel that they are a burden, and they have a “duty to die” and that they need to take measures to cause their own death. The churches believe that the current Medical Treatment Act 1988 provides a useful framework for the medical profession and the community to care for dying people with compassion and integrity whilst preserving their intrinsic rights and dignity.

Voluntary Assisted Dying Section C 1.9 Appendix 47 47 Response report appendix Signatories: The Most Revd Dr Keith Rayner, Anglican Archbishop of Melbourne; the Rt Revd David Silk, Anglican Bishop of Ballarat; the Revd Canon Alfred Austin, Administrator Anglican Diocese of Bendigo; The Revd Dr Bill Brown, President Baptist Union of Victoria; Mrs Pat Greig, President Churches of Christ; the Revd Fr Tadros Sharobeam, Coptic Orthodox Church; the Rt Revd Bishop Ezekiel, Greek Orthodox Church; the Revd Dr David Stolz, Lutheran Church; the Rt Rev R P Betts, Moderator Presbyterian Church of Victoria; The Most Revd T F Little, Roman Catholic Archbishop of Melbourne; the Most Revd R A Mulkearns, Roman Catholic Bishop of Ballarat; the Most Revd Noel Daly, Roman Catholic Bishop of Sandhurst; The Most Revd Jeremiah Coffey, Roman Catholic Bishop of Sale; Commissioner John Clinch, Southern Territory Commander Salvation Army; the Revd Dr Warren Bartlett, Moderator Uniting Church in Australia.”

Voluntary Assisted Dying48 Section C 1.9 Appendix 48 Response report appendix THE JUSTIFICATION FOR ASSISTED DYING/SUICIDE LAWS

The obvious question is why should assisted dying/suicide laws be considered at all. This section points out the reasons why such laws might be considered. One of the key reasons the Victorian Parliamentary Committee supported the introduction of voluntary assisted dying/suicide laws was due to the stories from relatives about the suffering of their loved ones at the end of life and the cases of desperate suicides committed by those who found the pain they were in unbearable. The Committee reported:3 People suffering from terminal illness and serious chronic and degenerative diseases gave evidence about the angst and frustration they feel at being unable to choose to end their irremediable pain and suffering, and to die at home surrounded by loved ones. Some people are choosing to stop having treatment, knowing that this will result in their imminent death. Others spoke to the trauma of watching seriously ill loved ones refuse food and water to expedite death and finally relieve their suffering. Family members, the Coroners Court of Victoria and Victoria Police gave evidence about how people experiencing an irreversible deterioration in health are taking their own lives in desperate but determined circumstances. The Committee also reported that:4 The Committee heard evidence from health providers that palliative care is effective in alleviating pain and suffering in the vast majority of end of life cases. For those for whom palliative care is effective, it provides comfort and support and improves the quality of life of patients and their families…. The Committee also heard from patients, carers and health practitioners that there is a proportion of people who continue to experience irremediable pain despite receiving palliative care. Ann Woodger wrote to the Committee of her father who suffered motor neurone disease and decided to cease percutaneous endoscopic gastronomy feeding so he would die of starvation and dehydration:5 While the law respected his right to decide to end his life, it gave him no help to do it and insisted that he must die slowly of starvation and dehydration… Mucous solidified in the back of his throat and needed to be regularly prized out with cotton buds, causing him to gag. His mouth was dry and could only be swabbed with water… He died after 12 days. The Coroners Court of Victoria presented evidence to the Committee that around 50 Victorians a year are taking their own lives after experiencing am irreversible deterioration in physical health.6 An example of such a death involved:7

3 Victorian Legislative Council Legal and Social Issues Committee, ‘Inquiry into end of life choices – Final Report’, June 2016, 193. 4 Victorian Legislative Council Legal and Social Issues Committee, ‘Inquiry into end of life choices – Final Report’, June 2016, 194. 5 Victorian Legislative Council Legal and Social Issues Committee, ‘Inquiry into end of life choices – Final Report’, June 2016, 196. 6 Victorian Legislative Council Legal and Social Issues Committee, ‘Inquiry into end of life choices – Final Report’, June 2016, 197. 7 Victorian Legislative Council Legal and Social Issues Committee, ‘Inquiry into end of life choices – Final

Voluntary Assisted Dying Section C 1.9 Appendix 49 49 Response report appendix A 93-year-old woman with crippling arthritis and back pain had gone into an aged care facility and smuggled a razor blade into her wallet which she then used, and she died of exsanguination with her arm dangling over the toilet bowl. Her daughter made a very compelling statement about her mother’s death. The essence of it is that, from the family’s point of view, if only there was a better way, that their loved ones did not have to die in such violent circumstances and alone. Acting Commander Rod Wilson of Victoria Police described to the Committee the effect of these violent deaths on first responders:8 … the desperation and the will of some people to take their lives have exposed our police to fairly horrific scenes of suicide. I think that the police who attended these events, like ambulance officers and others – our police are only fairly junior and inexperienced and quite young – and I think the impact of dealing with the deceased persons at those horrific scenes, and also having to prepare inquest briefs for the coroner and taking statements from family members who are clearly desperate and frustrated with the system. I would just like to say that that does have some impact on our frontline police officers. The Committee noted that it is currently lawful for doctors to provide treatment for pain and suffering even when such therapy may shorten a patient’s life.9 However, to put the matter beyond doubt the Committee recommended that Victoria introduce explicit legislation that medical professionals be permitted to administer pain relief which may have the unintended effect of ending a patient’s life, with such legislation already in place in Queensland, and South Australia.10 In addition to the examples above the following example is from a Uniting Church minister. As a Uniting Church minister, Rev Carolyn ‘Caro’ Field is perhaps more familiar with death than most people, having offered pastoral care to parishioners when they, or a loved one, is dying. She thinks that if society re-thinks ideas around death and dying, the arguments against assisted death would be different. People naturally fear death, so to hasten it seems unnatural. Since caring for her mother in the last months of her life, Ms Field has reflected on what it truly means to ‘die with dignity’. “Towards the end, it would take two hours for an Endone (painkiller) to work effectively, it was doing nothing for her”. “I would sit with her on the side of her bed rubbing her back waiting for the pain to go. She would say to me ‘This is so bloody cruel, why can’t I just die?’ “On the wall were wedding photos of her and Dad taken back in 1957. Here was this beautiful young woman full of life and here is this shell of a woman in agony just wanting it to be over. It was just so cruel.” Opponents of assisted dying often cite improvements in palliative care and pain management as options for those facing a painful death. But as Ms Field explained, even though her mother’s palliative care team was terrific, towards the end of her life her mother’s body was unable to absorb medication efficiently, so she would endure hours of unbearable pain.

Report’, June 2016, 198. 8 Victorian Legislative Council Legal and Social Issues Committee, ‘Inquiry into end of life choices – Final Report’, June 2016, 200. 9 Victorian Legislative Council Legal and Social Issues Committee, ‘Inquiry into end of life choices – Final Report’, June 2016, 201. 10 Victorian Legislative Council Legal and Social Issues Committee, ‘Inquiry into end of life choices – Final Report’, June 2016, 202.

Voluntary Assisted Dying50 Section C 1.9 Appendix 50 Response report appendix Ms Field has little doubt that, had her mother been offered the choice to continue suffering or end her life, her final days alive would have been less traumatic. But, because the legal option wasn’t available, it was something they never considered. “Mum wouldn’t do anything unless it was legally recognised or advised by a doctor”. “She would have been worried that if we’d ‘accidently’ given an overdose it could have had implications for me as her carer, and I could have been in trouble with the law.” Ms Field is also aware of the religious objections to assisted dying, but says her faith enables her to see the importance of ending life with dignity and self-determination. “I’m not going to throw around a whole lot of Bible verses, I’ll leave that to the scholars ... my reflection is more of my experience and my own personal journey of faith.” “Human life is sacred and God holds the key. The dice had already rolled; God had made the decision that Mum was going to die. Whether it was tomorrow or next week was immaterial in the scheme of things”. “It was interesting for me that I never once thought about praying for God to miraculously cure Mum of the cancer. I just thought ‘OK she’s got this cancer and it’s going to kill her’. So my prayer was for a good death. “Certainly for Mum and I both, if there had been a legal option to end her life sooner we would have both grabbed it with both hands. Because the level of suffering that she had towards the end – I’m talking the last two to three weeks – there was nothing that could be done.”

Voluntary Assisted Dying Section C 1.9 Appendix 51 51 Response report appendix OTHER JURISDICTIONS

There is much debate about what impact assisted suicide/dying would have, so an important contribution is to consider those parts of the world that have already implemented such a regime. Assisted dying/suicide has been permitted under law in the following places: • Netherlands • Switzerland • Belgium • Luxembourg • Canada • Colombia • Oregon, USA • Washington State, USA • Montana, USA • Colorado, USA • District of Colombia, USA • Vermont, USA; and • California, USA. Details of these jurisdictions are given below. Overwhelmingly the experience is that the legislation in these jurisdictions appears to function as intended. However, overwhelmingly these assessments of whether the law has been complied with, are based on a self-report of the medical professional who ended the person’s life or assisted in the person dying. It is unlikely a medical professional would report their own non-compliance with the law. That said, opponents of the laws are able to produce few cases that demonstrate the laws are not being complied with. The Victorian Ministerial Advisory Panel on Voluntary Assisted Dying asserted that the “rigorous request and assessment process provide protection from abuse”, asserting that the evidence from other countries is that the safeguards work to detect people who are not requesting assisted dying/suicide of their own free will.11 The Ministerial Advisory Panel cited only one reference from 2007 to back its claim. This study examined whether particular groups were over-represented amongst those requesting assisted dying/suicide or euthanasia, including women, the uninsured, people with low educational status, low income people, physically disabled, minors, people with psychiatric illness including depression and racial or ethnic minorities.12 The study showed these groups were not over-represented amongst those accessing assisted dying/suicide or euthanasia. However, this is not the same thing as testing if doctors are capable of assessing whether someone requesting assisted dying/suicide is really doing so freely or if they are being subject to direct or indirect pressure to do so from carers or family members. The Ministerial Advisory Panel provided no references that assessed this latter issue to back its claim that the safeguards would provide “protection from abuse”. Clearly safeguards will provide

11 ‘Ministerial Advisory Panel on Voluntary Assisted Dying. Final Report’, Victorian Department of Health and Human Services, July 2017, 88. 12 Margaret Battin, Anges van der Heide, Linda Ganzini, Gerrit van der Wal, and Bregje Onwuteaka-Philipsen, ‘Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact of patients in “vulnerable groups”’, J. Med Ethics 33, 2007, 591 – 597.

Voluntary Assisted Dying52 Section C 1.9 Appendix 52 Response report appendix a level of protection against abuse, but evidence of the level of protection was not provided by the Ministerial Advisory Panel. It needs to be noted that there is a vast difference in what the laws of different governments allow in terms of assisted dying/suicide and euthanasia. Generally European jurisdictions have the most liberal laws relating to assisted dying/suicide and euthanasia with the fewest safeguards compared to US states that have introduced assisted dying/suicide laws. Belgium stands out as allowing assisted dying/euthanasia for people who are not suffering from terminal illnesses and can be applied to children and people who are unconscious. Also, Belgium authorities appear to show little interest in ensuring the safeguards in the law are complied with and it would appear the safeguards can be breached with impunity provided the person freely wishes to die, including when they do not have a terminal illness. There is no such evidence of disregard for the safeguards in US States that have allowed such laws. European jurisdictions have generally widened the group of people who can be assisted to die or be euthanised over time, as feared by opponents of such laws. By contrast, US states have not done so. Only the governments of Belgium and the Netherlands allow children to be assisted to die/ euthanised. Only the Swiss government allows non-residents to travel to Switzerland for the purpose of being assisted to die. North American governments require that a person have decision-making at the time they seek assisted dying/ suicide, whereas some European governments allow people to make written requests for assisted dying/suicide in advance of the time it will be carried out. The European governments of the Netherlands, Belgium and Luxembourg all require that a person be experiencing some degree of suffering to be eligible to access assisted dying/suicide or euthanasia. The US state governments of California, Oregon and Washington have a requirement that a person have a ‘terminal disease’. There is no additional requirement that a person be suffering. The laws in the Netherlands, Belgium and Luxembourg do not say anything about excluding people with mental illness from assisted dying/suicide or euthanasia. The law in the Netherlands requires that a request for assisted dying/euthanasia must be ‘well-considered’. The US state governments of Oregon and Washington expressly require that an assessing medical practitioner refer a person for counselling when they are suspected to be suffering from a psychiatric or psychological disorder or depression causing impaired judgement. In Canada, a person with a mental illness may be eligible for medical assistance in dying/suicide if they meet all of the eligibility criteria. In all jurisdictions where the laws have been introduced, the number of people using the laws to end their lives has continued to increase with no sign of the number plateauing. However, the JIM Unit has not been able to find any research that definitively explains the increasing use of the laws. Largely the use of the laws for assisted dying/suicide and euthanasia are used by well-educated people with higher incomes. In the US states, ethnic minority groups are under-represented in those using the laws. Further, opponents of such laws have expressed concern that women will feel pressure to end their lives by use of the laws.13 However, the experience in the US does not support this concern, with 51.6%

13 For example this was raised by the Synod of Queensland Bio-Ethics Committee in their report ‘A Christian Response to Euthanasia’, 1996.

Voluntary Assisted Dying Section C 1.9 Appendix 53 53 Response report appendix of those who have taken their lives using the Oregon Dying with Dignity Act between 1998 and 2016 being men.14 Concerns exist that in all places where assisted dying/suicide is permitted and a palliative care specialist needs to be involved in the process to authorise the assisted death/suicide, raising questions of if people are really given accurate information about all the alternative options that exist. A concern has been raised by opponents of voluntary assisted dying/assisted suicide laws that it makes suicide generally more acceptable in the community. Data from the US state of Oregon has shown a significant increase in the suicide rate amongst the general population since the introduction of the laws. In 2012, the age-adjusted suicide rate among Oregonians was 17.7 per 100,000, 42 percent higher than the national average. 15 The rate of suicide among Oregonians has been increasing since 2000. However, the increase in suicide rate is far from uniform across the community:16 • Suicide rates among adolescents aged 10 through 17 years has increased since 2011 after decreasing from 1990 to 2010. • Suicide rates among adults aged 45 to 64 years rose more than 50 percent from 18.1 per 100,000 in 2000 to 28.7 per 100,000 in 2012; the rate increased more among females than among males. • Suicide rates among males aged 65 years and older decreased approximately 18 percent from nearly 50 per 100,000 in 2000 to 42 per 100,000 in 2012. Those ending their lives under the Oregon Death with Dignity Act are not included in the above statistics.17 However, the national suicide rate in the US has also been increasing since around 2000 and Oregon’s suicide rate has been much higher than the US national rate since 1980, almost two decades before the Death with Dignity Act started to be used. 18 That said, suicides among men and women aged 35-64 increased 49% in Oregon from 1999-2010, compared to 28% nationally.19 However, this does not prove that the introduction of the Oregon Death with Dignity Act has caused the higher rates of suicide in Oregon and other causes might be responsible, such as Oregon’s lax gun control laws.20 Other key factors may be lack of access to mental health services and an individualist culture that deters help seeking.21 Further, other states in the west of the US near Oregon have higher suicide rates than Oregon, being Nevada, Idaho, Montana, Wyoming, Utah, Colorado and New Mexico.22 Of these Colorado also has assisted dying/suicide legislation and Montana allows for assisted dying/suicide by court ruling.

14 Oregon Health Authority, ‘Oregon Death with Dignity Act. Data summary 2016’, 10 February 2017, 8, http://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/ DEATHWITHDIGNITYACT/Documents/year19.pdf 15 X. Shen and L. Millet, ‘Suicides in Oregon. Trends and Associated Factors 2003-2012’, Oregon Health Authority, 2015, 3. 16 X. Shen and L. Millet, ‘Suicides in Oregon. Trends and Associated Factors 2003-2012’, Oregon Health Authority, 2015, 3. 17 X. Shen and L. Millet, ‘Suicides in Oregon. Trends and Associated Factors 2003-2012’, Oregon Health Authority, 2015, 7. 18 X. Shen and L. Millet, ‘Suicides in Oregon. Trends and Associated Factors 2003-2012’, Oregon Health Authority, 2015, 9. 19 David Stabler, ‘Why Oregon’s suicide rate is among the highest in the country’, The Oregonian, 15 May 2013, http://www.oregonlive.com/living/index.ssf/2013/05/why_oregons_suicide_rate_is_am.html 20 David Stabler, ‘Why Oregon’s suicide rate is among the highest in the country’, The Oregonian, 15 May 2013, http://www.oregonlive.com/living/index.ssf/2013/05/why_oregons_suicide_rate_is_am.html 21 David Stabler, ‘Why Oregon’s suicide rate is among the highest in the country’, The Oregonian, 15 May 2013, http://www.oregonlive.com/living/index.ssf/2013/05/why_oregons_suicide_rate_is_am.html 22 Centres for Disease Control and Prevention, https://wisqars.cdc.gov:8443/cdcMapFramework/

Voluntary Assisted Dying54 Section C 1.9 Appendix 54 Response report appendix Looking at Washington State, there has been an upward trend in suicides since the introduction of the Death with Dignity Act in 2008, but again this does not prove that the introduction of the law caused this increase in rate. Figure 1. Suicide rate in Washington State 1980 to 2015.23

Disturbingly, US States that record the motivation for the use of the laws record that around half identify the feeling of being a burden on others as a motivation for ending their lives, although this is far from the only motivation for these individuals to make use of the laws. A small minority of people using the laws in US States that have introduced them, give the financial cost of medical treatment as a reason to make use of the laws. However, differences between the Australian healthcare system and the US healthcare system need to be considered before drawing any conclusion that a similar outcome would occur in Victoria. The JIM Unit has been unable to establish if the introduction of assisted dying/ suicide or euthanasia laws has had any impact on resourcing for other end of life options, such as palliative care, in the places where such laws have been introduced. The Victorian Ministerial Advisory Panel on Voluntary Assisted Dying used only one reference to state that in Belgium and the Netherlands, research published in 2014 suggested that the introduction of assisted dying/suicide and euthanasia has not stunted the development of palliative care, and that government funding grew at a consistent rate with countries such as the UK, that have not legalised assisted dying/suicide.24 Researching the quality of palliative care and comparing between jurisdictions is complex. For example, attempting to use cost as a proxy measure for the quality of palliative care is not simple as cost will depend on a whole range of factors such as how much health professionals are paid in the country in question, the types of illness from which people are dying as different illnesses will generate different costs to treat and if private for-profit companies run the health system and demand high levels of profit. Examining a study looking at cancer patients in their last six months of life in 2012 in seven wealthy countries, there was no correlation between the rate at which they died while being provided with acute care in hospital

23 Washington Department of Health, http://www.doh.wa.gov/DataandStatisticalReports/VitalStatisticsData/ Death/DeathTablesbyTopic#Cause 24 ‘Ministerial Advisory Panel on Voluntary Assisted Dying. Final Report’, Victorian Department of Health and Human Services, July 2017, 39.

Voluntary Assisted Dying Section C 1.9 Appendix 55 55 Response report appendix and if the government in question had allowed assisted dying/ euthanasia legislation. For countries with assisted dying laws in 2012, Belgium had 51.2% of cancer patients in the last six months of life die in acute hospital care, while in the Netherlands it was 29.4%.25 In the countries without such laws the rates were 52.1% for Canada, 44.7% for Norway, 41.7% for the UK, 38.3% for Germany and 22.2% for the US.

Netherlands In the Netherlands, a court in 1973 allowed a doctor to lawfully shorten a person’s life to prevent serious and irremediable suffering. In 1984 a court ruled that a doctor was entitled to assist a patient to die at their request under the doctrine of necessity to end unbearable and irremediable suffering. The Netherlands passed the Termination of Life on Request and Assisted Suicide (Review Procedure) Act in 2002. Assisted suicide remains a criminal offence, but doctors are not prosecuted if they report to a Regional Euthanasia Review Committee and meet all due care criteria. The due care criteria are that the doctor must: • be satisfied that the person has made a voluntary and well‑considered request; • be satisfied that the person’s suffering was unbearable, with no prospect of improvement; • have informed the person about his or her situation and his or her prospects; • have concluded, together with the person, that there is no reasonable alternative in light of the person’s situation; • have consulted at least one other independent doctor who must have seen the person and given a written opinion on the due care criteria referred to in 1–4 above; and • have terminated the person’s life or provided assistance with suicide with due medical care and attention. In addition to the ‘due care’ criteria described above, the framework under the Termination of Life on Request and Assisted Suicide (Review Procedures) Act includes the following elements: • generally accessible by adults aged 18 and over, but children aged 16–18 can also access assisted dying with parental consultation, as can children aged 12–16 with parental consent; • it applies not only to the terminally ill, but also the chronically ill and people with mental suffering; • there is no need for competency at the time of a person’s death — a doctor may provide assisted dying to a person 16 years or older, where they made the request in writing prior to losing competence; • there is no mandatory mental health assessment, but if a doctor determines that a person’s judgment may be impaired by poor mental health, they may decide the request does not meet the ‘well‑considered’ part of the due care criteria; • there is no residency requirement;

25 Justin Bekelman, Scott Halpern and Carl Rudolf Blankart, ‘Comparison of Site of Death, Health care Utilization and Hospital Expenditures for Patients Dying with Cancer’, JAMA 2016, 315(3), 272-283.

Voluntary Assisted Dying56 Section C 1.9 Appendix 56 Response report appendix • there is no mention of a specified cooling‑off period, but the doctor must be satisfied that a request is ‘well‑considered’. Assisted dying/suicide is most commonly carried out in the person’s own home. Doctors typically administer a barbiturate intravenously, which puts the patient to sleep. This is followed by injection of a lethal neuromuscular blocker. Where assisted dying/suicide occurs, doctors are required to report the death to the municipal pathologist, who then notifies a Regional Euthanasia Review Committee. These committees, which consist of a medical doctor, an ethicist and a legal expert, assess whether the doctor has fulfilled the statutory due care criteria. If the committee concludes that the criteria have been met, the doctor is exempt from criminal liability and no further action is taken. If the committee finds that the doctor has not acted in accordance with the due care criteria, it reports its findings to the Public Prosecution Service and the Regional Health Inspector. These two agencies then consider what action, if any, should be taken against the doctor. The number of deaths through assisted dying/suicide are provided in the graph below. Figure 2: Number of deaths under the Netherlands Termination of Life on Request and Assisted Suicide (Review Procedures) Act from 2002 to 2014.

In 2015, 3.75% of all deaths in the Netherlands were from medically assisted death/ suicide.26 Only 3.8% of these assisted deaths/suicides were self-administered, with the rest being carried out by medical professionals.27 Between 2008 and 2011 between 3.5% and 8.5% of requests for assisted dying/euthanasia were rejected because a lack of voluntariness was identified.28

26 https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance- dying-interim-report-dec-2016.html 27 https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance- dying-interim-report-dec-2016.html 28 ‘Ministerial Advisory Panel on Voluntary Assisted Dying. Final Report’, Victorian Department of Health and Human Services, July 2017, 87.

Voluntary Assisted Dying Section C 1.9 Appendix 57 57 Response report appendix Switzerland The Swiss assisted dying law primarily resides in the country’s Criminal Code. Assisted suicide, if done without selfish motives is legal, while assisting or inciting suicide with selfish motives is illegal. The practical effect is that assisted suicide is only a crime where the following elements are proven: (1) a suicide was committed or attempted; (2) a third party encouraged or helped in the suicide; (3) the third party acted on selfish grounds; and (4) the third party acted deliberately, with intent. Swiss law does not contain a statute with a framework of eligibility criteria and safeguards for assisted dying/ suicide. As such there are none of the usual eligibility requirements such as terminal illness or unbearable and irremediable suffering. Neither is assisted dying/ suicide restricted to citizens or residents of Switzerland. Assisted dying/ suicide in Switzerland need not be performed by a doctor; in fact the vast majority of assisted deaths that take place in Switzerland are not supervised by doctors. A doctor is required, however, if a person wants to use a lethal drug which may only be accessed by prescription. Most deaths take place in a person’s home, or at one of the premises of organisations that assist with suicide/ dying. The four most prominent organisations in Switzerland that assist people to end their lives are: • Dignitas • Exit — German Switzerland • Exit — French Switzerland • . These organisations notify the police and coroner when they assist a person to die. The police and coroner investigate to determine if any crime has taken place, in the most part determining whether there were selfish motives, but also examining any doubts about the deceased’s competence and the autonomy of their choice. If the police and coroner find no wrongdoing the death is reported as suicide. There are no official statistics on the number of assisted deaths in Switzerland. One study investigating the number of deaths assisted by Exit — German Switzerland found that between 1990 and 2000 Exit - German Switzerland assisted in 748 suicides among Swiss residents (0.1% of total deaths, 4.8% of total suicides).

Belgium Euthanasia/assisted dying was legalised in Belgium on 28 May 2002. Under the Belgium law, in the case of a patient in the final stages of his/her illness, euthanasia may take place if: • the patient is an adult or a minor who has been granted adult legal status and is deemed to be in his/ her right mind and therefore able to express his/ her wishes; • the request has been made on a voluntary, thoughtful and repeated basis and does not arise from being pressured into it; • the request has to be made in writing;

Voluntary Assisted Dying58 Section C 1.9 Appendix 58 Response report appendix • the medical situation does not allow for a positive outlook and causes constant and unbearable physical or psychological suffering which cannot be alleviated and is caused by a life‐threatening and incurable accidental or pathological illness; • the medical practitioner has talked to his/her patient on various occasions about his/her state of health, his/her life expectancy, his/her request for euthanasia; • the medical practitioner must discuss the possible options available to his/her patient regarding both therapeutic treatment of the illness and the palliative care available and the consequences thereof; • the medical practitioner has consulted another independent and competent medical practitioner who has drawn up a report setting out his/her findings; • the medical practitioner has discussed his/her patient’s request with the medical team treating the patient and with the patient’s close family, if the patient so requests; • after euthanasia, the medical practitioner fills out both pages of the form designed to ascertain the legality of the death/assisted suicide. If the patient is not in the final stages of his/her ill‐ ness, two further conditions apply: • the medical practitioner must consult a second independent medical practitioner, psychiatrist or a medical practitioner specialized in the relevant pathology; and • the period of reflection required between the patient’s written request and the assisted death/suicide has to be at least one month. In Belgium a person who is not conscious can be subject to euthanasia if: • the person is an adult or a minor who has been granted adult legal status; • the person is not conscious and the situation is irreversible according to current medical knowledge; • the person is suffering from a life‐threatening and incurable accidental or pathological illness; • the person has drawn up and signed a declaration in advance requesting euthanasia. This declaration is valid for a period of 5 years and may appoint one or several reliable individuals who have been entrusted with voicing the patient’s wishes; • the medical practitioner has consulted another independent doctor; • the medical practitioner has discussed the declaration, which was drawn up and signed by the patient in advance, with the patient’s medical team and any close family members; and • after euthanasia, the medical practitioner fills out both pages of the form designed to ascertain the legality of the death. Under the Belgium law the medical professional is the one to euthanise/assist the person to die, although cases have been reported of medical professionals providing lethal medications for the person to end their life themselves. Belgium extended the scope of its law in 2014 to allow euthanasia for minors of any age suffering from incurable diseases if they were capable of making a rational

Voluntary Assisted Dying Section C 1.9 Appendix 59 59 Response report appendix decision about their fate.29 The first child, aged 17, was assisted to die/euthanised in 2016.30 In 2010 to 2011, 2% of the cases of assisted death/euthanasia were carried out on people who were unconscious.31 In 2014 and 2015 a total of 67 people were assisted to die/be euthanised on the basis of a prior declaration, as at the time of their death they were no longer able to give consent.32 In 2010 and 2011 9 % of declared cases of euthanasia, death was not envisaged in the very short term. The most often declared illnesses mentioned to justify this type of request are first and foremost neuropsychiatric diseases, followed by degenerative neuromuscular diseases.33 By 2014 and 2015 this had grown to 15% of cases.34 Figure 3. Number of assisted deaths/suicides in Belgium under the euthanasia law between 2003 and 2015.35

In 2015 1.83% of all deaths in Belgium were medically assisted deaths/suicides.36 In 2014 and 2015 the youngest person assisted to die/euthanised was aged 40.37 29 Expatica, ‘Belgium euthanasia cases hit record high’, 27 January 2016, http://www.expatica.com/be/news/ CORRECTED-Belgian-euthanasia-cases-hit-record-high_580213.html 30 CBS News, ‘First child dies by legal euthanasia in Belgium’, 19 September 2016, http://www.cbsnews.com/ news/child-dies-by-euthanasia-in-belgium-where-assistance-in-dying-is-legal/; and NZ Herald, ‘Belgium assisted-dying case makes impact in NZ’, 18 Sept 2016, http://www.nzherald.co.nz/world/news/article. cfm?c_id=2&objectid=11712150 31 European Institute of Bioethics, ‘Euthanasia in Belgium: 10 years on’, April 2012, 3, http://www.ieb-eib.org/en/ pdf/20121208-dossier-euthanasia-in-belgium-10-years.pdf 32 Institut Européen de Bioéthique, ‘Analysis of The Seventh Report of the Federal Commission for Euthanasia Control and Evaluation of the Legislative Chambers (for the Years 2014 and 2015)’, 4, http://www.ieb-eib.org/ en/pdf/20161008-en-synthese-rapport-euthanasie.pdf 33 European Institute of Bioethics, ‘Euthanasia in Belgium: 10 years on’, April 2012, 3, http://www.ieb-eib.org/en/ pdf/20121208-dossier-euthanasia-in-belgium-10-years.pdf 34 Institut Européen de Bioéthique, ‘Analysis of The Seventh Report of the Federal Commission for Euthanasia Control and Evaluation of the Legislative Chambers (for the Years 2014 and 2015)’, 5, http://www.ieb-eib.org/ en/pdf/20161008-en-synthese-rapport-euthanasie.pdf 35 European Institute of Bioethics, ‘Euthanasia in Belgium: 10 years on’, April 2012, 3, http://www.ieb-eib.org/en/ pdf/20121208-dossier-euthanasia-in-belgium-10-years.pdf; Kennedy Institute of Ethics, Bioethics Research Library, Georgetown University, ‘Euthanasia continues to rise in Belgium’, https://bioethics.georgetown. edu/2016/01/euthanasia-continues-to-rise-in-belgium/; and Simon Caldwell, ‘Five people killed every day by assisted suicide in Belgium as euthanasia cases soar by 25 per cent in last year alone’, Daily Mail Australia, 29 May 2014, http://www.dailymail.co.uk/news/article-2641773/Five-people-killed-EVERY-DAY-assisted-suicide- Belgium-euthanasia-cases-soar-27-cent-year-alone.html. 36 https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance- dying-interim-report-dec-2016.html 37 Institut Européen de Bioéthique, ‘Analysis of The Seventh Report of the Federal Commission for Euthanasia

Voluntary Assisted Dying60 Section C 1.9 Appendix 60 Response report appendix However, the introduction of assisted dying/euthanasia legislation has not overtaken people having their lives shortened through pain relief and withdrawal of treatment as the main forms by which people die in Belgium. In 2013, the intensified alleviation of pain and other symptoms with the use of drugs with the side effect of shortening the person’s life accounted for 24.2% of deaths, while the withholding or withdrawing of life-prolonging treatment accounted for 17.2% of deaths. These remained the most prevalent end-of-life practices.38 In 2013, a survey to physicians in Belgium that had signed death certificates which had a response rate of 60.6%, found that in 73.7% of cases of assisted dying/ euthanasia it was reported that the person was receiving palliative care services, which suggests it is not an absence of access to palliative care services that drive a majority of people in Belgium to access assisted suicide/euthanasia.39 The Belgium Commission for Control and Assessment that monitors if cases of assisted dying/euthanasia have been in compliance with the requirements of the law, has been criticised for dispensing with the need for the patient to be in unbearable and unrelievable pain.40 Further, it has been alleged that the Commission has approved assisted dying/suicide for a very small number of people suffering from Alzheimer’s disease, depression and psychosis.41 In 2014 and 2015 a total of 124 people had their lives ended/ were euthanised as a result of mental or behavioural disorders.42 The Belgium Commission has included members of the Association pour le Droit de Mourir dans la Dignité (Association for the Right to Die in Dignity), which campaigns for the expansion of euthanasia, which has called into doubt the objectivity of the Commission from some quarters.43 In October 2015 the Belgium Commission for the first time referred a doctor to a public prosecutor for violating the Belgium assisted suicide/euthanasia law. On 22 June 2015, Dr Marc Van Hoey, president of the association Recht op Waardig Sterven (RWS) [Right to Worthy Dying], assisted in the suicide of 85-year-old Simona De Moor, whose death was filmed live by an Australian journalist in her report Allow me to die for the SBS Dateline program. Dr. Van Hoey provided a lethal drink to Simona De Moor who was not suffering from any particular physical or psychological illness other than depression and described an unbearable grief from the recent death of her daughter. Dr Van Hoey did not appeal to a third physician, as required by law when the person is not in an imminent end-of-life situation.44 However, it appears the

Control and Evaluation of the Legislative Chambers (for the Years 2014 and 2015)’, 2, http://www.ieb-eib.org/ en/pdf/20161008-en-synthese-rapport-euthanasie.pdf 38 Kenneth Chambaere, Robert Vander Stichele, Freddy Mortier, Jochim Cohen and Luc Deliens, ‘Recent Trends in Euthanasia and Other End-of-Life Practices in Belgium’, The New England Journal of Medicine, 19 March 2015, 1179, http://www.nejm.org/doi/pdf/10.1056/NEJMc1414527 39 Kenneth Chambaere, Robert Vander Stichele, Freddy Mortier, Jochim Cohen and Luc Deliens, ‘Recent Trends in Euthanasia and Other End-of-Life Practices in Belgium’, The New England Journal of Medicine, 19 March 2015, 1179, http://www.nejm.org/doi/pdf/10.1056/NEJMc1414527 40 European Institute of Bioethics, ‘Euthanasia in Belgium: 10 years on’, April 2012, 6, http://www.ieb-eib.org/en/ pdf/20121208-dossier-euthanasia-in-belgium-10-years.pdf 41 European Institute of Bioethics, ‘Euthanasia in Belgium: 10 years on’, April 2012, 6, http://www.ieb-eib.org/en/ pdf/20121208-dossier-euthanasia-in-belgium-10-years.pdf 42 Institut Européen de Bioéthique, ‘Analysis of The Seventh Report of the Federal Commission for Euthanasia Control and Evaluation of the Legislative Chambers (for the Years 2014 and 2015)’, 3, http://www.ieb-eib.org/ en/pdf/20161008-en-synthese-rapport-euthanasie.pdf 43 European Institute of Bioethics, ‘Euthanasia in Belgium: 10 years on’, April 2012, 6, http://www.ieb-eib.org/en/ pdf/20121208-dossier-euthanasia-in-belgium-10-years.pdf 44 Institut Européen de Bioéthique, ‘Belgium first case of euthanasia transmitted to the Public Prosecutor’s Office’, 28 October 2015, http://www.ieb-eib.org/fr/bulletins/belgique-premier-dossier-deuthanasie-transmis- au-parquet-348.html#sujet1016; and SBS, ‘Belgian euthanasia doctor could face criminal charges’, 29 October 2015, http://www.sbs.com.au/news/dateline/article/2015/10/29/belgian-euthanasia-doctor-could- face-criminal-charges

Voluntary Assisted Dying Section C 1.9 Appendix 61 61 Response report appendix public prosecutor declined to proceed with the case as there is no public reporting that the case was followed through on.

Canada Legislation to legalise assisted dying in all of Canada was introduced in the Canadian Parliament in April 2016, as required by the Supreme Court’s ruling in Carter v Canada (AG), and passed into law on 17 June 2016. In 1972, Canada decriminalised suicide, but assisted suicide/dying remained a crime. In June 2014, the Québec National Assembly passes An Act Respecting End‑of‑Life Care, which legalised assisted dying/suicide. On 6 February 2015 the Canadian Supreme Court in the case Carter v Canada (AG) unanimously ruled that Canada’s prohibition of assisted dying/suicide in certain circumstances is unconstitutional. The Court ordered the Canadian Government to introduce legislation to legalise assisted dying for consenting adults with intolerable physical or mental suffering by 6 February 2016. This was later extended to 6 June 2016 after the Canadian Government sought an extension to the time frame. The Québec National Assembly An Act Respecting End‑of‑Life Care came into effect on 10 December 2015. The Act provides for ‘medical aid in dying’ in the form of voluntary euthanasia and assisted suicide for people who are: • 18 years of age and capable of giving consent; • at the end of life; • suffering from a serious and incurable illness; • in an advanced state of irreversible decline in capability; and • experiencing constant and unbearable physical or psychological pain which cannot be relieved in a manner they deem tolerable. The Act contains the following safeguards: • two doctors must be satisfied the request is an informed one, that it is made freely and without external pressure; • the person must be informed of their prognosis and other therapeutic possibilities and their consequences; and • no specified cooling‑off period, but a doctor must verify the persistence of suffering and that the wish to obtain assisted dying remains unchanged at reasonably spaced intervals. The legislation does not specify whether depression or mental illness is a limiting factor for eligibility, however, the patient must be capable of giving consent. The Québec legislation established a Commission on end‑of‑life care to oversee the application of assisted dying. A doctor who provides assisted dying/suicide must notify the Commission within 10 days. The Commission assesses whether the doctor complied with the requirements of the Act. If at least two‑thirds of members of the commission believe the Act was not complied with, the conclusions are forwarded to the institution concerned and to the Collège des Médecins du Québec.

Voluntary Assisted Dying62 Section C 1.9 Appendix 62 Response report appendix The law was challenged in December 2015, and was temporarily suspended by Québec’s Superior Court until the federal prohibition against assisted dying/suicide was lifted. This suspension was later overturned by Québec’s Court of Appeal. Representatives from Canada’s justice ministry noted that Québec’s assisted dying legislation does not conform to the Canadian Charter due to its limitation to terminal patients. As a result of the Carter decision, Québec’s assisted dying/suicide framework will need to be extended to accommodate those who are not terminally ill. The number of medically assisted deaths/suicides under Québec legislation between 10 December 2015 and 10 June 2016 was 167.45 The number of medically assisted deaths/suicides in Canada under Québec and federal legislation between 17 June and 31 December 2016 was 803.46 Only 0.4% of the deaths/suicides were self-administered, with the rest being carried out by medical professionals.47 The average age of the people assisted in dying/suicide was 72 and the ages ranged from 69 to 74. Of those assisted to end their lives 56.8% were suffering from cancer- related illness, 23.2% from neuro-degenerative illnesses and 10.5% from circulatory/ respiratory system illness.48 The province of Alberta has rejected 36 requests for assisted dying/suicide and the province of Manitoba has rejected 20.49 From June to December 2016, 0.6% of all deaths in Canada were medically assisted deaths/suicides.50 A case has been reported in late 2016 calling into question the effectiveness of the safeguards in Canada. It was reported by a relative of the person assisted to die/ euthanised:51 My Aunt ... was just Euthanized today Nov 9, 2016 by Lethal injection at ... Retirement Home ... in BC. We were called to a meeting at ... Hospice on Nov 7, 2016 to be told for the first time that our ... Aunt had requested to be Euthanized. We were told it would take at least 10 days. My sister and I argued that our Aunt appears to only have a severe Bladder infection. The Hospice Doctor said he would look into having her urine tested for this before they proceed with Euthanasia. The same day we were sent over to our Aunts apartment to witness the doctor (that is going to give our Aunt the Lethal injection) having our Aunt sign the document to give her the permission to do the euthansia. After the Doctor read out the document to My Aunt; the doctor went and got a woman that works in the kitchen to initial all the questions for my Aunt. The Doctor brought two people to be witnesses into the room that had been witnesses for other Euthanisations. When we mentioned the urine tests we had asked to be done; the euthanising Doctor said it would make no difference because my Aunt has already signed permission for her euthanasia. The euthanising Doctor said she is going to put

45 https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance- dying-interim-report-dec-2016.html 46 https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance- dying-interim-report-dec-2016.html 47 https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance- dying-interim-report-dec-2016.html 48 https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance- dying-interim-report-dec-2016.html 49 https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance- dying-interim-report-dec-2016.html 50 https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance- dying-interim-report-dec-2016.html 51 Alex Schadenberg, ‘Woman dies by euthanasia may only have had a bladder infection’, Euthanasia Prevention , 14 November 2016, http://alexschadenberg.blogspot.com.au/2016/11/woman-who-dies-by- euthanasia-may-only.html

Voluntary Assisted Dying Section C 1.9 Appendix 63 63 Response report appendix a rush on the Euthanasia. To my even more shock the Doctor gave My Aunt the lethal injection today. It all took less than three days from start to finish. The Doctor did the three Doctor visits to my Aunt in three consecutive days. I am so upset. This was so wrong .. It is unknown if this case was reported to Canadian authorities or if any attempt has been made by Canadian authorities to investigate the case.

Oregon, USA In 1994 the Death with Dignity Act, a citizens’ initiative, was passed by Oregon voters by a margin of 51 per cent in favour and 49 per cent opposed. However, the implementation of the Act was delayed until late 1997 by a legal injunction. The Act was subject to multiple legal proceedings, including a petition to the United States Supreme Court. People who are approved in Oregon for assisted dying/suicide most commonly ingest a lethal barbiturate without the presence of their doctor or other healthcare provider. In Oregon, only assisted dying/ suicide is legalised, not euthanasia. Doctors can prescribe people who meet certain criteria a lethal medication. People who choose to take the medication must do so without assistance. To be eligible to access a lethal medication under the Death with Dignity Act, a person must: • be 18 years of age or older and ‘capable’; • be a resident of Oregon; • have a terminal disease from which they will die within six months; and • make three separate requests; an initial verbal request, a written request, then a second verbal request. The verbal requests must be separated by a minimum of 15 days. In assessing and granting a request to access lethal medication under the Death with Dignity Act, two doctors must: • confirm the diagnosis of the terminal disease; • confirm the person is capable of making and communicating health decisions; • confirm the person’s request is voluntary; • ensure that the person is making an informed decision, and in doing so inform the person of: -- their medical diagnosis and prognosis; -- the potential risks, and probable result of taking the lethal medication; and -- the feasible alternatives, including comfort care, hospice care, and pain control.

If either of the two doctors believes the person’s judgement is impaired by a psychiatric or psychological disorder or depression, the person must be referred for counselling. The person cannot be prescribed lethal medication unless the counsellor determines the person is not suffering from a psychiatric or psychological disorder or depression causing impaired judgement.

Voluntary Assisted Dying64 Section C 1.9 Appendix 64 Response report appendix Doctors must document in a person’s medical record information concerning a person’s request for lethal medication. This includes information regarding eligibility as described above, as well as all verbal and written requests for lethal medication made by a person. Doctors are required to report all prescriptions for lethal medication to the Oregon Health Authority. The Oregon Health Authority is responsible for notifying the Board of Medical Examiners of any failures in prescribing or reporting requirements. Data on activity under the Death with Dignity Act is reported annually, and published on the Oregon Health Authority website. The table below shows the number of prescriptions for lethal medications written each year and the number of patients who died as a result of taking the medication. The discrepancy in prescriptions and deaths each year is due to people not taking medication, dying of other causes and using prescriptions written during previous years. Table 1. Prescriptions and deaths under the Oregon Death with Dignity Act between 1998 and 2015. Deaths due to Percentage of total Year Prescriptions written prescribed medicine deaths 1998 24 16 0.055 1999 33 27 0.092 2000 39 27 0.091 2001 44 21 0.070 2002 58 38 0.122 2003 68 42 0.136 2004 60 37 0.120 2005 65 38 0.120 2006 65 46 0.147 2007 85 49 0.156 2008 88 60 0.194 2009 95 59 0.193 2010 97 65 0.209 2011 114 71 0.225 2012 116 85 0.235 2013 121 73 0.219 2014 155 105 0.310 2015 218 135 0.386 2016 240 133 0.372

Voluntary Assisted Dying Section C 1.9 Appendix 65 65 Response report appendix Figure 4. Deaths from prescribed medicine under the Oregon Death with Dignity Act from 1998 to 2016.52

During 2016 most of the people who were assisted to end their lives were aged 65 years or older (80.5%) and had cancer (78.9%). The median age at death was 73 years. As in previous years, decendents were commonly white (96.2%) and well- educated (50.0% had a least a baccalaureate degree).53 During 2016, no referrals were made to the Oregon Medical Board for failure to comply with the Death with Dignity Act requirements.54 Between 1998 and 2016 a total of nine people in Oregon aged 18 to 34 have been assisted to end their lives through the Death with Dignity Act.55 In that period 57 people requesting to be assisted with dying/suicide were referred for psychiatric evaluation.56 Six people have regained consciousness after taking the medication to end their life between 1998 and 2016.57 The time between unconsciousness and death ranged from one minute to just over four days.58 The Oregon Health Authority has also collected information about the end of life concerns of those that have been assisted to end their lives, which are listed in the table below.

52 Oregon Health Authority, ‘Oregon Death with Dignity Act. Data summary 2016’, 10 February 2017, 4, http://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/ DEATHWITHDIGNITYACT/Documents/year19.pdf 53 Oregon Health Authority, ‘Oregon Death with Dignity Act. Data summary 2016’, 10 February 2017, 6, http://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/ DEATHWITHDIGNITYACT/Documents/year19.pdf 54 Oregon Health Authority, ‘Oregon Death with Dignity Act. Data summary 2016’, 10 February 2017, 3, http://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/ DEATHWITHDIGNITYACT/Documents/year19.pdf 55 Oregon Health Authority, ‘Oregon Death with Dignity Act. Data summary 2016’, 10 February 2017, 8, http://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/ DEATHWITHDIGNITYACT/Documents/year19.pdf 56 Oregon Health Authority, ‘Oregon Death with Dignity Act. Data summary 2016’, 10 February 2017, 9, http://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/ DEATHWITHDIGNITYACT/Documents/year19.pdf 57 Oregon Health Authority, ‘Oregon Death with Dignity Act. Data summary 2016’, 10 February 2017, 10, http://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/ DEATHWITHDIGNITYACT/Documents/year19.pdf 58 Kimberly Leonard, ‘Drug Used in ‘Death with Dignity’ Is the Same Used in Executions’, US News, 16 Oct 2015, https://www.usnews.com/news/articles/2015/10/16/drug-shortage-creates-hurdle-for-death-with- dignity-movement

Voluntary Assisted Dying66 Section C 1.9 Appendix 66 Response report appendix Table 2. End of Life Concerns of those assisted to end their lives under the Oregon Death with Dignity Act between 1998 and 2016.59 Number of End of Life Concern % of people people Losing autonomy 1,025 91.4 Less able to engage in activities making life enjoyable 1,007 89.7 Loss of dignity 767 77.0 Losing control of bodily functions 524 46.8 Burden on family, friends/caregiver 473 42.2 Inadequate pain control or concern about it 296 26.4 Financial Implications of Treatment 38 3.4

There are issues about the cost of the drugs in the US to carry out the assisted death/ suicide. Pentobarbital in liquid form cost about US$500 until about 2012, when the price rose to between US$15,000 and US$25,000. The price increase was caused by the European Union’s ban on exports to the US because of the drug being used in capital punishment. Users then switched to the powdered form, which cost between US$400 and US$500.60 The dose of secobarbital (brand name Seconal) prescribed under Death with Dignity laws costs US$3,000 to US$5,000.61 Due to the increase in the cost of Seconal, alternate mixtures of medications have been developed by physicians in Washington state. The phenobarbital/chloral hydrate/ morphine sulfate mix produces a lethal dose that is similar in effect to Seconal. The cost of this alternate mix is approximately US$450 to US$500. A second alternative, consisting of morphine sulfate, Propranolol (Inderal), Diazepam (Valium), Digoxin and a buffer suspension costs about US$600.62 When pentobarbital or secobarbital work as intended, people drink a solution in which the drug has been dissolved and then fall into a coma within five to 10 minutes. Soon the drug depresses the part of the brain that controls respiration, which causes them to stop breathing, generally within 20 to 30 minutes. However, in rare cases there are complications include regurgitation and remaining in a coma for days – complications similar to those seen when the drugs are used for carrying out the death penalty.63

Washington State, USA The Washington State Death with Dignity Act was passed on 4 November 2008 and came into force on 5 March 2009. The Act allows terminally ill adults who are residents of Washington State and are believed to have less than six months to live to request a lethal dose of medication from medical and osteopathic physicians. The person must be competent and needs to voluntarily express their wish to die. To ensure that the person is making an informed decision the physician must inform the person:

59 Oregon Health Authority, ‘Oregon Death with Dignity Act. Data summary 2016’, 10 February 2017, 10, http://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/ DEATHWITHDIGNITYACT/Documents/year19.pdf 60 https://www.deathwithdignity.org/faqs/ 61 https://www.deathwithdignity.org/faqs/ 62 https://www.deathwithdignity.org/faqs/ 63 Kimberly Leonard, ‘Drug Used in ‘Death with Dignity’ Is the Same Used in Executions’, US News, 16 Oct 2015, https://www.usnews.com/news/articles/2015/10/16/drug-shortage-creates-hurdle-for-death-with- dignity-movement

Voluntary Assisted Dying Section C 1.9 Appendix 67 67 Response report appendix • of their medical diagnosis and prognosis; • the potential risks associated with taking the medication to be prescribed; • the probable result of taking the medication to be prescribed; and • the feasible alternatives including comfort care, hospice care, hospital care and pain control. The physician must refer the person to a consulting physician for medical confirmation of the diagnosis and for a determination that the person is competent and acting voluntarily. In 2015, 213 people were prescribed medication to end their lives and 166 died after ingesting the medication.64 Those prescribed the medication were aged 20 to 97 and 72% had cancer.65 Below the figure shows the number of deaths of people who have been prescribed lethal medication under the Washington State Death with Dignity Act between 2009 and 2015. However, these figures include those who died of other causes before taking the medication. Figure 5. Number of deaths of people prescribed lethal medication under the Washington State Death with Dignity Act between 2009 and 2015.66

Like Oregon, Washington State health authorities record the end of life concerns for people seeking assistance to end their life. The Table below provides the proportion of people for 2015 that had the concerns listed.

64 Washington State Department of Health, ‘2015 Death with Dignity Report’, 1, http://www.doh.wa.gov/ portals/1/Documents/Pubs/422-109-DeathWithDignityAct2015.pdf 65 Washington State Department of Health, ‘2015 Death with Dignity Report’, 1, http://www.doh.wa.gov/ portals/1/Documents/Pubs/422-109-DeathWithDignityAct2015.pdf 66 Washington State Department of Health, ‘2015 Death with Dignity Report’, 4, http://www.doh.wa.gov/ portals/1/Documents/Pubs/422-109-DeathWithDignityAct2015.pdf

Voluntary Assisted Dying68 Section C 1.9 Appendix 68 Response report appendix Table 3. End of Life Concerns of those assisted to end their life under the Washington State Death with Dignity Act in 2015.67

End of Life Concern % of people

Losing autonomy 86 Less able to engage in activities making life enjoyable 86 Loss of dignity 69 Losing control of bodily functions 49 Burden on family, friends/caregiver 52 Inadequate pain control or concern about it 35 Financial Implications of Treatment 13

Montana, USA On 31 December 2009, Montana’s Supreme Court ruled in Baxter v. Montana that physicians are authorised under state law to provide aid in dying: that is, to prescribe medication that a terminally ill adult can take to shorten their dying process should the suffering become unbearable. The original lawsuit was brought by four Montana physicians and Robert Baxter who was dying from lymphocytic leukaemia. The plaintiffs asked the court to establish a constitutional right ‘to receive and provide aid in dying.’ The Court found that “we find no indication in Montana law that physician aid in dying provided to terminally ill, mentally competent adult patients is against “public policy” and therefore, the physician who assists is shielded from criminal liability by the patient’s consent.”

Vermont, USA In Vermont, the Patient Choice and Control at End of Life Act was signed into law on 20 May 2013. Under the Act a physician may prescribe a person with a terminal condition medication to be self-administered for the purpose of hastening the death of the person provided: • the person made an oral request to the physician for the medication twice, at least 15 days apart; • the physician at the second request offered the person the opportunity to rescind the request; • the person made a written request for the medication that was signed by the person in the presence of at least one witness who was not an interested person. The physician needs to have determined the person: • was suffering from a terminal condition; • was capable; • was making an informed decision; and • was a Vermont resident. The physician also needs to inform the person of:

67 Washington State Department of Health, ‘2015 Death with Dignity Report’, 7, http://www.doh.wa.gov/ portals/1/Documents/Pubs/422-109-DeathWithDignityAct2015.pdf

Voluntary Assisted Dying Section C 1.9 Appendix 69 69 Response report appendix • their prognosis; • the range of treatment options available to the person; • all feasible end-of-life services, including palliative care, comfort care, hospice care and pain control; and • the range of possible results, including potential risks associated with taking the medication to be prescribed. The physician must also refer the person to a second physician for medical confirmation of the diagnosis, prognosis and a determination that the person was capable, was acting voluntarily and made an informed decision. As of 8 June 2017, physician reporting forms have been completed for 53 people being prescribed lethal medication, according to the Department of Health.68

California, USA In California, “An individual seeking to obtain a prescription for an aid-in-dying drug... shall submit two oral requests, a minimum of 15 days apart, and a written request to his or her attending physician. The attending physician shall directly, and not through a designee, receive all three requests required pursuant to this section.”

Colorado, USA Colorado, “Allows an eligible terminally ill individual with a prognosis of six months or less to live to request and self-administer medical aid-in-dying medication in order to voluntarily end his or her life; Authorizes a physician to prescribe medical aid-in-dying medication to a terminally ill individual under certain conditions; and Creates criminal penalties for tampering with a person’s request for medical aid-in-dying medication or knowingly coercing a person with a terminal illness to request the medication.”

District of Colombia, USA In the District of Columbia, to obtain the medication, “a patient shall make two oral requests, separated by at least 15 days, to an attending physician. Submit a written request, signed and dated by the patient, to the attending physician before the patient makes his or her second oral request and at least 48 hours before a covered medication may be prescribed or dispensed.”

68 CNN Library, ‘Physician-Assisted Suicide Fast Facts’, 10 June 2017, http://edition.cnn.com/2014/11/26/us/ physician-assisted-suicide-fast-facts/index.html

Voluntary Assisted Dying70 Section C 1.9 Appendix 70 Response report appendix Voluntary Assisted Dying Section C 1.9 Appendix 71 71 Response report appendix Voluntary Assisted Dying Section C 1.9 Appendix 72 Response report appendix