IN his opinion piece in MJA InSight, Professor Emeritus Ian Maddocks proposes an integration of palliative care, euthanasia, and physician assisted suicide (EPAS). As palliative care practitioners, we know this supposed common ground is both a contradiction in terms and contrary to sound medical practice.

From our experience of caring for people who are ill and vulnerable, legalising EPAS is unnecessary and unsafe.

Despite its inevitability, dying is not a popular topic for discussion in Australia today. In the words of American surgeon Dr Atul Gawande, we have “forgotten that we are mortal”. Death is not a medical or pharmacological event. It remains instead a profound mystery and the natural end of the complex journey of life. It is universal yet unique, personal but communal. It affects us all.

Dying can be traumatic, terrifying and painful for the patient, and challenging for the grieving family. In the face of inevitable death, some patients are willing to explore improbable alternative therapies, or burdensome or experimental treatments that may have a very low success rate. If people insist that “everything be done”, they are likely to die in the medically confronting environment of an intensive care unit, possibly prolonging the process of dying itself.

Good palliative care helps patients and families avoid both overtreatment and neglect of treatment. It enhances patient autonomy and decision-making capacity by improving symptom control and empowering patients to participate in their care. We affirm the patient’s right to choose their therapy; decline futile therapy; choose the place of dying; choose who should be present; receive the best possible relief of symptoms, even, on rare occasions, deliberate palliative sedation (not terminal sedation); and refuse to prolong the dying process. Ideally, this should be readily available for all those with life-limiting illness.

Autonomy does not include the right to demand that a clinician kills the person. Contrary to public opinion, the use of therapeutic doses of analgesia or sedation in order to relieve difficult and intractable discomfort does not hasten death and is not a form of euthanasia. Appropriate end of life prescribing of analgesia is simply good clinical practice when the patient is actively dying.

Supporting people when they are dying is utterly different to intentionally causing them to die. What Professor Maddocks calls “a single effective intervention” is in fact an act of killing.

The term “voluntary assisted dying” conceals the true nature of what is proposed in the bill before the Victorian parliament. The patient’s dying is not assisted; rather, a doctor is required to kill the patient or to help the patient commit suicide. The word “voluntary” attempts to emphasise the patient’s autonomy. Ironically, EPAS legislation weakens patient autonomy by devaluing the final stages of life. Further, overseas experience has shown that supposed safeguards within these laws do not effectively guard the autonomy of those most vulnerable to the extension of these laws.

In an attempt to make EPAS publicly acceptable, its proponents sanitise the language, using euphemisms such as “voluntary-assisted dying” and “go gentle”. However, the inconvenient truth remains that at the heart of EPAS, the action of the doctor is to end a patient’s life or assist patients to kill themselves. This has profound ramifications for all health professionals. “Do not kill” has been a core ethical principle of every civilisation and the practice of medicine; we violate it at society’s peril.

Quality health care manages the causes of patients’ distress rather than ending life. In our experience, requests to terminate life prematurely are uncommon and often a cry for help. Such requests rarely spring from uncontrolled pain, but rather from despair, a sense of loss of control, or fear of being a burden to others. Evidence shows that a person’s desire for hastened death changes over time and reduces when care is good. It is illogical and immoral to even consider euthanasia legislation before ensuring there is universal access to palliative care.

The 1990 World Health Organization definition states that palliative care affirms living and dying as a normal process, and “neither hastens nor defers death”. Likewise, after extensive research and consultation, the Australian and New Zealand Society for Palliative Medicine (ANZSPM) issued a position statement on EPAS in 2013.

This statement affirmed that:

  • the discipline of palliative medicine does not include the practice of EPAS; and
  • ANZSPM opposes the legalisation of EPAS.

In the Netherlands, often quoted as a euthanasia success story, so many doctors have refused to kill their patients that the government has established mobile euthanasia teams to perform EPAS across the country. Doctors in Canada are increasingly requesting to be removed from “assisted dying” lists. The legalisation of EPAS results in great harm to vulnerable individuals, families, the community and health professionals.

Paradoxically, it is in dying naturally that many people find healing and realise what is truly important in their lives. They may experience profound personal growth and family reconciliation. Indeed, as Canadian surgeon, Professor Balfour Mount, who coined the term “palliative care” wrote: “It is possible to die healed”.

We write as an informal network of Australian and New Zealand practitioners in palliative care. We do not represent any particular organisation, institution or philosophy. Some of us have practised palliative medicine for more than 30 years. We acknowledge that death, like birth, can be distressing and messy. We are deeply concerned at the increasingly determined attempts to legalise the practice of EPAS.

We believe that these attempts may be sincere and well meaning, but unfortunately are based on ignorance and misunderstanding. The first step towards a clear understanding of the issues is to use clear, unambiguous terminology. Irrespective of whether EPAS is legalised in Australia or New Zealand, EPAS has no part in the ethical and professional practice of palliative medicine.

Professor Douglas Bridge is an Emeritus consultant at Royal Perth Hospital, clinical professor in the University of Western Australia’s School of Medicine and Pharmacology, a consultant physician with WA Country Health Service, and is past president of the Chapter of Palliative Medicine, Royal Australasian College of Physicians. He writes on behalf of the following cosignatories:

  • Dr Simon Allan, Arohanui Hospice, New Zealand
  • Dr Megan Best, University of Sydney, University of Notre Dame, NSW
  • Dr Mil Chan, North Adelaide, SA
  • Dr Louis Christie, Orange Health Service, Palliative Care Service, NSW
  • Professor Richard Chye, St Vincent’s Clinical School, University of NSW
  • Dr Maria Cigolini, Royal Prince Albert Hospital, Chis O’Brien LifeHouse, University of Sydney, NSW
  • Professor Katherine Clark, North Sydney Cancer Centre, Royal North Shore Hospital, University of Sydney, NSW
  • A/Professor Josephine Clayton, HammondCare, University of Sydney, NSW
  • Professor Sinead Donnelly, University of Otago, Victoria University of Wellington, New Zealand
  • Dr Derek Eng, University of Western Australia
  • Dr Anthony Herbert, Lady Cilento Children’s Hospital, QLD
  • Dr Annmarie Hosie, University of Technology Sydney, NSW
  • Dr Suharsha Kanathigoda, Canberra, ACT
  • Dr Martin Kennedy, Lady Davidson Private Hospital, Calvary Hospital, NSW
  • Professor David Kissane, Monash University, VIC
  • Dr Amanda Landers, University of Otago, New Zealand
  • Dr Lynn Lim, Royal Prince Alfred Hospital, Chris O’Brien LifeHouse, NSW
  • Professor Melanie Lovell, HammondCare, University of Sydney, NSW
  • Professor Roderick Macleod, HammondCare, University of Sydney, NSW
  • Dr Yvonne McMasters, palliative medicine specialist and activist, NSW
  • A/Professor Natasha Michael, Cabrini Health Monash, University of Notre Dame, VIC
  • Dr Wendy Muircroft, Southern Adelaide, SA
  • Professor Ian Olver, Sansom Institute for Health Research, University of South Australia
  • Dr Riona Pais, Royal Prince Alfred Hospital, University of NSW
  • Dr Lawrie Palmer, University of Adelaide, SA
  • Dr Laura Pearce: South Coast, NSW
  • Professor Jane Philips, University of Technology Sydney, NSW
  • Professor Peter Ravenscroft, University of Newcastle, NSW
  • CNC Joan Ryan, Royal Prince Alfred Hospital, Chris O’Brien LifeHouse, University of Sydney, NSW
  • Dr Merlina Sulistio, Cabrini Health, VIC
  • Dr Sarah Thompson, HammondCare, NSW
  • Dr Sarah Wenham, Broken Hill Hospital, NSW


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I support the concept of voluntary euthanasia for people with terminal or chronic diseases

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16 thoughts on “Palliative care, euthanasia and physician assisted suicide

  1. Robert Claxton, FRACS. says:

    Doctor assisted suicide is unethical, unnecessary and inhuman.
    It denies what is uniquely human.
    It should be strenuously opposed.

  2. Robert Claxton, FRACS. says:

    Doctor assisted suicide is unethical, unnecessary and inhumane.
    It denies what is uniquely human.
    It should be strenuously opposed.

  3. Carolynne Bourne says:

    With complete sincerity and commitment I agree with Douglas Bridges, statement: ”The term “voluntary assisted dying” conceals the true nature of what is proposed in the bill before the Victorian parliament. The patient’s dying is not assisted; rather, a doctor is required to kill the patient or to help the patient commit suicide” and ““Do not kill” has been a core ethical principle of every civilisation and the practice of medicine; we violate it at society’s peril.” “Do not kill” has been a core ethical principle of every civilisation and the practice of medicine; we violate it at society’s peril.”.

    The responses below further support these views.

    In response to ‘Why I don’t support euthanasia’, 16 January 2017

    January 16, 2017 at 5:43 pm
    “When people no longer have a voice and others speak and act for them, the rights of the individual are on a scale from being fully met and understood to not being met at all to abuse… there is a crucial abuse which is not recognised, that being ‘identity abuse’, particularly under the law with the flow on into families and society in general.

    Identity Abuse: Providing a range of care and responses to needs, sense of identity, lifestyle preferences, self-concept, priorities and choices.

    Note: ‘Identity abuse’ is not only limited to lack of respect, lack of equality and lack of dignity”.
    [Eat Bananas. Identity Abuse in the Care of Older Australians. Bourne and Associates P/L 2010. Submission to the Productivity Commission. Care of Older Australians. (

    Of note is the article, ‘Euthanasia Prevention Coalition Euthanasia Prevention Coalition: “Mild stroke led to mother’s forced death by dehydration” 31/10/16 10:56 AM’ “…in the spring of 2009, her son and her eldest daughter, with the permission and assistance of the law, because this old woman had had a mild stroke, refused her food and water. She could not swallow, so she would have needed the food and water administered artificially… And the youngest daughter could do nothing except watch her mother die slowly, and write this, in the hope that my mother’s death, like her life, will have made a difference”.

    The response a Minister of a Christian church had to the attached article is that he has seen this assisted death several times in visits to the dying and it is deeply disturbing.
    Also I’m told about the ‘fight’ a son had re his father in an aged care facility with the doctors and nurses to stop such cruelty.

    Part of this great travesty is the inability of those on mind dissociative drugs like the opioids to communicate with their families and friends in their last days and hours.

    There is no such thing as ‘dying with dignity’, there’s just dying. In my view, the phrase ‘dying with dignity’ is used to assuage the person/s effecting the death of an individual.

    It is also prudent to note that in Victoria, charges which can end in a jail sentence is where food and/or water is withheld from animals, but we condone this is OK to do it to human beings, our fellow citizens, our family.

    What of the Hippocratic oath ‘to do no harm’? Where is ‘humanity’? What of human rights? What of informed consent ie when a person does not have capacity/has capacity?

    Also my response to Rediscovering the universality of death, 23 May 2016
    May 24, 2016 at 9:08 am

    As humans, we each grow upon the earth and create our own unique mark on the lives that surround us and the environment in which we live.

    We age, grow frail and may loose neuronal capacity and become dependent upon those with whom we live, on families and on society.

    In days long ago, when one could no longer provide for oneself through injury, illness or age, one could not survive – we were abandoned.

    A time came when human life was highly valued. Humans began to empathise, to put aside self-interest, to love and to care.

    The roots of humanity grew and flourished … but what of us now!

    Statements such as “Our long-term biological interests are fulfilled by improving the future for our offspring, not by hoarding resources for ourselves” diminishes us all – whatever our age, ethnicity, language, religion, gender, health and socio-economic status we are equal – it is this that site at the core of humanity and civil liberty.

  4. JS Kilmartin says:

    I write as a doctor who practises palliative care and as one who has been very much opposed to VAD for ethical and professional reasons, including all the reasons cited in the above article. However, I would like to point out that Professor Maddocks’ article is not about justifying VAD. It is really about how we care for patients who might end up choosing VAD as an option. VAD will become a reality in our future because every bill that has been presented to either state or federal parliaments in Australia has come closer to being passed. How will we deal with VAD when it eventually becomes a reality?

    I suggest that the problem lies in binary thinking, i.e. ‘either-or’ thinking, which is very much the pattern of how our society and culture sees issues – patients with terminal conditions will be given a choice of either palliative care OR VAD. Why must this be so? Why can’t we have both ‘together-and’?

    We believe that patients are much better served by good palliative care and we worry that the patients who choose VAD may not be accorded the same quality of care before they choose the ‘single, sudden intervention’ that will end their lives. So why not subsume VAD into palliative care, forget ‘either-or’ thinking, and give EVERY patient the same quality of care with VAD being only an option within the vast suite of palliative care options and resources? Even palliative care proponents admit that there are only a small number of patients with terminal conditions that actually request VAD and that as a last desperate option. Would it be possible that if they were given the benefit of good palliation, these few might even decrease in number?

    I strongly support Professor Maddocks’ position that we should start working WITH the issue of VAD and not against it. I believe we ought to offer patients only ONE option – that of good palliative care with its range of options, including VAD, In my experience, patients mostly need reassurance that if all else fails, they have the ability to opt out. Of course, palliative care professionals know that the patient ALWAYS has the ability to opt out (of treatment, of care, of medications, and ultimately, of life) but the fact remains that most people DON’T know that and no amount of ethical argument or explanations or what good palliative care is will ever convince them of it. And sadly, most people would have heard of friends and family dying ‘horrible’ deaths and this is a deep seated fear that we will not be able to budge.

    I fear that binary thinking will get us ‘mobile VAD units’ because those of us that refuse to perform the ‘single. sudden intervention’ for good reasons will be pitted against those that will, with both sides feeling virtuous and sure of our moral ground. But where does that leave the patient? And where does our primary duty lie?

    Intuitively I feel that the ‘together-and’ approach is the most sensible and the most rational and I welcome further discussion among us as to how we could bring this about as an Australian reality.

  5. Dr Robert Marr says:

    I have been a medical practitioner for over 40 years and I believe all terminally ill people should have the right to decide how much suffering they are willing to endure at the end of their life.
    It should not be up to palliative care doctors,priests or politicians to decide how much suffering we must endure at the end of our life.
    The bipartisan Victorian bill to support Voluntary patient dying for terminally ill people is an excellent law that should be supported and includes all the appropriate safeguards .

  6. Pauline Cole says:

    I appreciate the complex nature of this debate and the validity of aspects of both sides of the dilemma. I work as a psychiatrist with difficult to treat patients many of whom have a diagnosis of borderline personality and the consequent life threatening behaviours that this disorder brings. Rightly or wrongly we now live in a world where mental health patients have been allowed to elect death.

    My opinion is that if we embark upon a debate about EPAS we have to include those people who have psychic pain from evidence based treatment resistant mental health disorders. It is a paradox that having the freedom to chose may actually reduce the rate of suicide for people with these disorders.

  7. Anonymous says:

    I do not agree with killing even for “right reason”, and remain against all assisted dying be it euthanasia, assisted suicide, or killing of innocent or ‘guilty’. working in cancer medicine, I see patients seeking help thinking they are ‘dying and thus treatment is not needed’. often, they surprise themselves with a shift of thinking as to what quality of life means even in those who are no longer able to do things they used to, and those in pain. the issue is not about patients having autonomy, but about the other pillars of palliative care / medicine at large. do we practice maleficence by offering euthanasia, in people who may change their mind with therapy. this does include those dying, but also those with mental helath issues, and those with disability.
    and the question has to be if this does become legal, whose job is it going to be. can you opt out as a doctor? or are you going to be told not to bring your ‘cultural / spiritual baggage’ and put it on your patients.
    at what stage, will we become ok with this, to extend euthanasia like Netherlands and Belgium have done to kill infants / children as long as both parents agree as they have disability.
    also, how do we protect the most vulnerable, ie patients. do we have a clause to add in advance directive that at no stage euthanasia is going to be performed, even if they are asking for it?
    i think we have a lot of soul searching on why we are doctors, and what we see ending a persons life to be. perhaps this will lead to reinstating our better part of what we are here to do.

  8. Dr R Yeow says:

    On the one hand , we have a “….junior doctor suicide crisis” Daily Telegraph, Saturday 18th March 2017 , and the medical profession is trying to prevent such tragic suicides,
    and yet some people want to facilitate what appears to be suicide ?
    I find the inconsistency between preventing suicide and facilitating suicide somewhat confusing/ disturbing .
    The article is behind a paywall but this is a dropbox link to a pdf

  9. Anonymous says:

    For our patient’s sakes, less stop suggesting that assisting the death of someone who is actively dying from an incurable, terminal illness is either ‘killing’ or ‘assisting suicide’! That is tantamount to professing that we are capable of reversing the same process! In my 30years of General practice delivering 95% of the palliative care to my dying patients, mostly very effectively, there have been hundreds of requests for an earlier peaceful end to suffering, many but not all of which I would have unreservedly considered if the law allowed. Some talk about protecting the most vulnerable. Well how much more vulnerable can you have to be dying and incapable of carrying out your own final wish to choose the time and circumstances of your own death! I don’t believe that we have the right or power to deny them. When I search my soul, I am first human then a doctor, not the divine omnipotent that some would exalt us to be.

  10. Anonymous says:

    It is exactly because we aren’t divine or omnipotent that we should not pretend to judge we know enough to take a life. EPAS is not a part of healthcare. If governments legislate for it, then the means and agents should be based in the judiciary, not in healthcare.

  11. Anonymous says:

    Health Select Committee report on submissions around EPAS ( as requested by EPAS supporters )

    78% of Submissions (16000 people) voted against.

  12. Steve Kelly says:

    “be told not to bring your ‘cultural / spiritual baggage’ and put it on your patients”

    It is way past time for this idea to be called out – everyone has “cultural/spiritual baggage”, even Richard Dawkins or Peter Singer – the so-called secular humanist ideas are frequently the only “cultural/spiritual baggage” allowed!

    We must start (and continue …. both/and) to have CIVIL discussions in the public arena, where everyone is respected WITH THEIR BACKGROUND IDEAS (at least until they might exclude themselves by not following the civility required). I disagree with the published opinions of Singer and Dawkins, but respect their right to their cultural and spiritual baggage, even if they wish to imagine they have none (of course they do, we are each too small to invent something new on this scale). They,, and I, must PERSUADE others, accepting that this may leave us in a respected difference of opinion. However, it may leave us agreeing on a path with differing views of why the same action is ‘just’ or ‘permitted’.

    In all of this, I would wish to add my name to the signatories to the above article, even if my own spiritual journey conflicts with those I agree with!

    By the way, I think the School of Jerusalem (the whole ‘Bible’) originates this idea – God leads the way in respecting those who choose NOT to be part of His project. That they fall into the consequences of their choice is the same as all who choose anything from whatever menu badly, and there are bad consequences in both the good palliative care pathway (we are unlikely to reach 100% of dying people with the best PallCare has to offer) and even more in EPAS (in denying the opportunity of relieving despair beyond the dead person – who may in fact live on beyond bodily death with the same despair – and in those denied freedom by forces too great for them, the mentally or medically or socially incapable PEOPLE killed by those around them).

  13. Paul Jenkinson says:

    I’ve been in GP for over 40 years and for several of those years had a position with a local palliative care team.As a GP ,one would perhaps care for 2-3 people per year dying in their home.As a doctor with the palliative care team ,my job was to look after patients who did not have a local doctor,their doctor for some reason would not look after them,or their doctor was seeking advice about symptom control.
    I can only remember one patient who had terminal COPD who killed himself and it came as a complete shock to our team and myself.I know I did not appreciate his existential distress as his physical symptoms seem to have been well controlled.He is someone I will feel sad about for the rest of my days.
    I could never contemplate killing someone intentionally.I cannot see any situation,especially now that we have the necessary wherewithall to relieve suffering,that killing someone fulfils the moral criteria which guides our behaviour as doctors-beneficence,non-maleficence,autonomy and justice.
    If euthanasia is permitted in our community,a “right” to die will soon become a “duty” to die amongst our most vulnerable and “exclusions” to the legislation would soon become “obstacles” to more killing.
    We live in dangerous times in the land of plenty.

  14. Charlotte Coulson says:

    I strongly disagree

  15. Tony Lynch says:

    I suffer from Motor Neurone Disease which will ultimately prove fatal. I must, with respect, say that there is a large amount of lurking “Doctor knows best” is the writings above that i find galling. At the end of the day I will be flat on my back, waiting for the end. I have no doubt that I will be comfortable and pain free. The learned signatories to the article conveniently sidestep what to me is the issue. Their focus is on the patient who is at the end and waiting to die. What about the time period before that? Today I am still relatively functional. My future will be one of increasing dependency on others and a loss of dignity and personal autonomy between now and the time that I too will be waiting to die.
    That is the process of agony and decline that I seek to avoid.
    It is said above: ” It is illogical and immoral to even consider euthanasia legislation before ensuring there is universal access to palliative care.” I disagree. Even if there was universal access to palliative care I would still wish to be spared from the disease process that gets me to that point.
    And another quote: “Paradoxically, it is in dying naturally that many people find healing and realise what is truly important in their lives. They may experience profound personal growth and family reconciliation. Indeed, as Canadian surgeon, Professor Balfour Mount, who coined the term “palliative care” wrote: “It is possible to die healed”.
    There is no reason in logic why this process cannot occur if I was able to nominate a time for my own death. I note that it is not made clear whether this process is frustrated in places where Euthanasia is permitted.
    Lastly, it is stated: “We are deeply concerned at the increasingly determined attempts to legalise the practice of EPAS.”
    Perhaps if you get diagnosed with a terminal illness you will ultimately understand why there is the current push.

  16. Deacon William Gallerizzo says:

    Physician assisted death basically says, “We have a cure for your condition, but it will definitely kill you if it works.” That is totally contrary to the purpose of medicine. It undermines medical research as it declares a finality to the search for the end of disease and infirmity. Although many will project that they might want their lives ended in light of terminal illness, the will to survive actually takes hold and most will reject the idea even in the face of pain and suffering. Studies have shown that pain and suffering is actually one of the lesser reasons for accepting PAD/PAS. The overwhelming primary reason is lack of or diminishing resources, which makes the reason for killing a patient monetary, not compassion. Compassion sees the person as a person regardless of the . Compassion does not equate the person with an evil to be eliminated; that concept equates compassion with hatred. How many of us would like to say that we hated another person for their medical condition or illness? We might hate the condition, but that is an insufficient reason to kill someone. I remember as kid seeing people with disease and trying not to breathe fearing I might get the broken arm, or the need for leg braces. That was a ridiculous fear that abated significantly as I came to know the people and the biology. To embrace PAD/PAS is to return to childish fears, and ancient superstitions that equate good people with evils we cannot understand.

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