Q&A


The End of Life Choice Bill will legalise assisted dying in cases where individuals have a terminal illness that is likely to end his or her life within six months, or a grievous and irremediable illness, and is in an advanced state of irreversible decline in capability, and is experiencing unbearable suffering. The Bill carefully defines those eligible for assisted dying, details a comprehensive set of provisions to ensure this is a free choice, made without coercion, and outlines a stringent series of steps to ensure the person is mentally capable of understanding the nature and consequences of each of the end of life care options.

Yes. Depending on the wording of the question, polling of adult New Zealanders have typically shown around 65%-75% support in favour of legalising assisted dying with appropriate safeguards. More recently, a Reid Research Poll in July showed 71% support and 24% opposition, and a Colmar Brunton Poll in July showed 75% support and 20% opposition. A poll of 2800 persons commissioned from Curia this month on assisted dying shows 66% supporting and 20% opposed.

The Bill defines a person eligible for assisted dying as someone who:

• is aged 18 years or over
• has New Zealand citizenship or is a permanent resident
• suffers from a terminal illness likely to end their life within six months, or has a serious grievous and irremediable medical condition
• is in an advanced state of irreversible decline in capability
• experiences unbearable suffering that cannot be relieved in a manner that he or she considers tolerable
• has the ability to understand the nature and consequences of assisted dying.

A legal process will also be created for a person who asks to receive assisted dying. Two doctors will have to be satisfied that the person is eligible in terms of the criteria in the Bill. The doctors must both be satisfied that the person genuinely wishes to end their life and that he or she has chosen assisted dying free of any pressure or coercion. Should either doctor be uncertain about whether the person requesting assisted dying is competent, then the two doctors must jointly refer the person to a specialist with a relevant scope in mental health.

The Director General of Health will establish a Registrar to whom doctors must report. At each decision-making step, a prescribed form describing the actions taken and decisions made, must be sent to The Registrar. A register of all of the forms will be held by the Registrar, and the Registrar must report to the Minister each year on actions taken under the Act. A Review Committee will consider each case of assisted dying reported to the Registrar, and recommend actions in any case where the Committee is not satisfied.  In addition, the Director General of Health will appoint a Support and Consultation for End of Life in New Zealand (SCENZ) Group which will create a list of medical practitioners, specialists in mental health, nurses, and pharmacists willing to participate in assisted dying.

The protection here is that the first (the “attending”) doctor must be independent of the second – defined in the Bill as the “independent” doctor. The first doctor cannot choose the second, but must contact SCENZ, which will refer the person seeking assisted dying to a second medical practitioner. The second medical practitioner must be independent of that person and of the medical practitioner.

Yes. The doctor must provide the person with the prognosis for the terminal illness or grievous and irremediable medical condition, and inform them of the irreversible nature and anticipated impacts of assisted dying. The doctor must tell the person of their other options for end-of-life care. The doctor must also encourage the person to talk about his or her choice with family, friends and counsellors, and the doctor must ensure that the person has had the opportunity to talk to his or her choice of people. Should the person wish to proceed with their choice, the doctor must provide the prescribed form to the person.

No. No person is obligated to take a role under this Bill. One role of SCENZ will be to provide a referral to a person whose medical practitioner has a conscientious objection so that doctors and pharmacists who do not want to take part cannot be pressured into taking part.

No. Some countries allow for advance medical directives, which are documents where a person records that he or she consents to receiving care that may be required at a future time where they are incapable of giving consent to medical treatment. Such a directive may also be used to nominate one or two persons to speak on the person’s behalf at a time where he or she is incapable of giving consent to medical treatment. This Bill, however, does not provide for advance medical directives.

No, there are many protections. The Bill has detailed processes to ensure there is no coercion. The request must be made by the person concerned. A written form will have to be submitted and both the person’s doctor and the independent doctor will have to be convinced that the person is eligible under the Act. The doctors must both be convinced the person genuinely wishes to end their life, and that they have not been coerced or pressured into making the choice they have made. The person will be encouraged by their doctor to discuss their choice with their family and friends, and must be given ample opportunity to do so. If either of the doctors has any doubts, then they must jointly refer the person to a specialist with a relevant scope in mental health. The specialist must read the person’s files, examine the person, and provide their opinion about whether the person requesting assisted dying is competent to make that decision.

We are confident the Bill has sufficient protections, with up to three independent medical practitioners having to be convinced that the request for assisted dying is justified. Every decision-making step must be detailed on a prescribed form, and sent to the Registrar. The Bill also contains a requirement for a full review of the operation of this Act starting three years after commencement, to be completed within six months. The report must be presented to Parliament. Thereafter a review must be conducted every five years.

The overseas evidence shows that lower income groups are not abused by death with dignity legislation. Since 1997, 1327 people in Oregon have been prescribed life-ending medication. Of those people, the vast majority had terminal cancer. Almost all the people who asked for assisted dying were well-educated, insured, and had access to hospice care, but asked for assisted dying because of the fear of losing their autonomy and dignity.

That confuses cause and effect. It’s understandable that people with a terminal illness would be depressed at times; but that is not the same as a clinical depression. In the Bill, if a doctor has doubts about their patient’s mental capacity, the patient will be referred to a mental health professional who will determine the patient’s competence to make an informed End of Life decision.

Both the courts and psychological associations worldwide have highlighted the importance of distinguishing between suicide, which is a violent act by a disturbed or clinically depressed person, from assisted dying, which involves a well thought out decision by a rational person who is close to the end of their life. Assisted dying is about giving people with terminal illness or an irremediable illness the choice to end their suffering, in most cases affecting the date of death by just days or weeks. The select committee report in Quebec noted that “according to the people we met during the mission to Europe, euthanasia only shortens life by about 10 days on average.”

While pain can be substantially mitigated, the indignity of that final period of life remains a profound concern to many people. Many feel that we have increased the harm we inflict on people and denied them the basic comforts they most need in their final days. The loss of autonomy and dignity is a key factor here. This Bill will allow people at the end of their lives to determine how and when their life will end, if they should so choose. In practise overseas, most people have chosen to end their lives at home, with their loved ones, rather than in a medical environment surrounded by strangers.

Doctors worldwide occasionally administer more pain control medication than might be required to control the pain of patients who are suffering and close to death. This practice is acknowledged by the courts as the principle of “double effect”, where doctors may administer increasingly larger doses of medication to ensure that patients don’t experience pain. As long as the doctor’s intention is to relieve suffering, she or he will not be liable even if they are aware that doing so might have the dual effect of shortening that person’s life. That practice is not illegal even now in New Zealand.

Yes there is. A study published in the New Zealand Medical Journal in July this year (End-of-Life medical decision making in general practice in New Zealand – 13 years on, NZMJ July 2015) shows that when GPs were asked to consider the last end-of-life medical decision they were involved with, 4.5% of GPs had more or less practiced assisted dying. The report states that of the 359 GPs who reported making end-of-life medical decisions:

• 16.2 per cent withheld treatments with the explicit purpose of not prolonging life or hastening the end of life.
• 4.5 per cent (a total of 16 GPs) reported prescribing, supplying or administering a drug with the explicit purpose of hastening the end of life.

The authors note this would be generally understood as euthanasia, although the survey did not use that term. In 15 of these cases, nurses gave the drug to the patient. The link to the study can be found here: http://www.sciencemediacentre.co.nz/2015/07/24/gp-survey-explores-end-of-life-decisions-expert-reaction/

The Supreme Court of Canada summarised one of the most thorough reviews of the international evidence as follows:

Finally, it is argued that without an absolute prohibition on assisted dying, Canada will descend the slippery slope into euthanasia and condoned murder. Anecdotal examples of controversial cases abroad were cited in support of this argument, only to be countered by anecdotal examples of systems that work well.  The resolution of the issue before us falls to be resolved not by competing anecdotes, but by the evidence.  The trial judge, after an exhaustive review of the evidence, rejected the argument that adoption of a regulatory regime would initiate a descent down a slippery slope into homicide. We should not lightly assume that the regulatory regime will function defectively, nor should we assume that other criminal sanctions against the taking of lives will prove impotent against abuse.

Assisted dying has been legal in Belgium since 2002, well over ten years. It is natural that the number of people accessing this option increases as people become more aware of that option and it becomes more culturally accepted both for people to request it and for doctors to participate. And in most cases assisted dying is having only a small impact in shifting the time of death earlier of somebody who was already close to death, typically from a terminal illness like cancer.

This was a claim made by Rick Santorum in his bid to become the United States Republican Presidential Nominee in 2012, and there is not a shred of evidence to back his claim up. The Washington Post gave this assertion “Four Pinocchios” (out of a possible four) after Santorum’s Campaign Team was unwilling to defend his comments. Representatives from the Netherlands Ministry of Health, Welfare and Sport, as well as from the Royal Dutch Medical Association, have said that such bracelets do not exist.

Many of the great social issue debates in New Zealand have been decided by Parliament, and there is no reason this shouldn’t be the case for End of Life Choice. Precedents include homosexual law reform, prostitution law reform, and marriage equality. The Parliamentary process is particularly important when any change involves a very complex issue, where the established processes – a detailed select committee review, and clause by clause voting in the Committee stages of the passage of an Act of Parliament – give the opportunity to fine-tune a Bill.

In 1993 no Western democracy expressly permitted assistance in dying, although assisted dying has not been illegal in Switzerland since 1941, provided that the person assisting a death does not have a vested interest in that person’s death. The process of legalisation began in 1994, when Oregon, as a result of a citizens’ initiative, altered its laws to permit assisted dying for a person suffering from a terminal disease. Physician-assisted suicide was legalised in the Northern Territory of Australia in 1995, but was nullified by the Federal Australian Parliament in 1997. Colombia legalised in 1997, after a decision of the constitutional court.  The Dutch Parliament established a regulatory regime for assisted dying in 2001; Belgium soon after adopted a similar regime, with Luxembourg joining in 2009. Together, these regimes have produced a body of evidence about the practical and legal workings of physician-assisted death and the efficacy of safeguards for the vulnerable. At the present time, nine jurisdictions permit some form of assisted dying: the Netherlands, Belgium, Luxembourg, Switzerland, Oregon, Washington, Montana, Vermont, and Colombia. In February 2015, The Canadian Supreme Court unanimously ruled that the prohibition against assisted dying is unconstitutional. In September 2015 California legislators approved a bill that legalizes physician-assisted dying for terminally ill patients, while in the UK an assisted dying bill was defeated in the House of Commons.