Clinician attitudes to voluntary assisted dying: what do surveys tell us?

Abstract

The introduction of Voluntary Assisted Dying (VAD) legislation across Australia has presented challenges to clinicians, who have had to learn about new processes and, in some cases, to consider ethical and legal issues they have not previously encountered. For the most part, the adjustments have been managed smoothly, even if not all misgivings or uncertainties have been resolved. Where innovative changes are being introduced, it is important to identify and monitor concerns that arise in the community, including those of practitioners. This can be achieved by the conduct of surveys, the results of which may be used to guide further action on institutional, community and individual levels. This is especially important while the change process is getting underway, as is the case in New South Wales (NSW), where VAD legislation has only recently come into effect. The study by Light et al.1 of attitudes to VAD amongst clinicians in NSW provides such useful information. It shows – reassuringly for supporters – that most agree with the legislation. However, the value of this study is not that a majority in favour of VAD resolves the surrounding issues for all time. Rather, its main utility derives from the questions it raises but leaves unanswered and which will undoubtedly stimulate community discussion. These questions, moreover, have relevance not just for NSW but also across other jurisdictions, including Victoria, where a review of the VAD legislation is currently in progress. Light et al.'s study shows that the support for VAD amongst clinicians is not only widespread but also extends across all disciplines, even if levels of actual support vary somewhat between different areas of work, and it provides an indication of how perceptions have changed over time. Although in this case direct comparisons may be imprecise, it seems clear that acceptance of VAD amongst Australian health professionals has increased significantly over the past decade during the period in which legislation has been progressively introduced in various jurisdictions. On the other hand, it also shows that, despite such positive expressions, only a small proportion of practitioners is prepared to become directly involved, signalling potential problems for attempts to establish the expertise required to ensure the effective operation of the new system. In Victoria, this small number of participating practitioners has been shown to have an impact on the burden of care shouldered by the practitioners, as well as on the ability for patients to access their services.2 Despite the revealing nature of the figures, as with quantitative research in general, the numerical data cannot capture all consequential nuances of opinion, for which a more detailed, fine-grained analysis of qualitative investigation would be needed to fill in the details. It cannot show, for example, how or why individual clinicians make their choices, the nature of their interactions with patients and families or the impact of their experiences on their own future practice. Nor can a survey resolve ethical disagreements. This fact has not prevented polls from being used to exert political pressure on policymakers in the past: indeed, some studies have been instrumental towards this very outcome, provoking critical reflections on how the wording of a question can increase the chances of obtaining a desired outcome.3, 4 Nonetheless, the existence of a body of opinion about certain ethical issues can help clarify what is at stake and stimulate debate in affected communities. As obvious as it may sound, numerical studies cannot resolve questions of truth or ethical validity. Even widespread agreement at the level of public opinion cannot be taken as proof that a question has been, or can be, settled. High levels of unanimity cannot substitute for or circumvent ongoing, ethical discourse, in which all questions, including those claimed by some protagonists to be closed, are potentially subject to rigorous scrutiny. One of the main sources of ethical complexity about VAD arises from the multiplicity of cultural and religious perspectives within the community. Such differences can sometimes be recognised by subgroup analysis of sufficiently large quantitative data sets. However, even here, results may be misleading because responses can vary widely within population groups, which often lack homogeneity and consensus. Notwithstanding this, it is important for policymakers and health professionals to remain alert to issues of cultural sensitivity, in relation to which both principles and practices may need to be adjusted. Numerous studies have drawn attention to the array of possible concerns, which may vary according to cultural backgrounds, professional roles, religious beliefs and family contexts.5, 6 These considerations lead to an important conclusion about VAD and the ways in which it is understood, applied and evaluated. VAD is not just one thing; it is not just a piece of legislation or a single moral act. Rather, it is a focal point for a vast array of issues and concerns, ranging from the meanings attached to life and death, grief and bereavement, pain and suffering, the importance of trust, loyalty and care, and fears of abandonment and dependency. It raises questions about the relationship between law and ethics and the processes available in a society for resolving, or accommodating, ethical differences. For this reason, it cannot be summarised or evaluated in relation to just one set of variables. It is truly multidimensional, a kind of palimpsest of accumulated voices and views from multiple perspectives. For the same reason, it is worth noting that the ferment does not cease after a law has been passed. On the contrary, legislation itself should be regarded as an invitation for ongoing discussion and ethical reflection, which legislators should welcome as important for the refinement of the system. This is not always recognised, as appears to be the case at present in Victoria, where the terms of reference for the mandated review appear to have been set in a manner seeking to limit rather than stimulate public debate. So, what is the important message? That we need to continue to monitor attitudes to and beliefs about VAD, not just in the health professional community but more broadly, and to ensure that the multidimensional conversations continue. Even where VAD programmes appear to be functioning effectively, there is an unending need for ongoing review, using quantitative surveys and other research methodologies, and critical discussion. The establishment of a legal framework for VAD is not the end point: if it is successful it will open up fecund new territory within which ethical experience can continue to be deepened and enriched.