By Jodhi Rutherford

There is a copious literature on conscientious objection in voluntary assisted dying (VAD), also known as MAID, voluntary euthanasia, physician-assisted suicide, or death with dignity. Yet, there has been relative silence in the bioethics literature on what might motivate ‘conscientious participation’ in VAD, whereby clinicians may actively, morally, and purposively support the practice of VAD. VAD has been legally available in the Australian state of Victoria since 2019 and will soon become legal in a second Australian state in 2021, joining an increasing number of international jurisdictions which have legalised the practice of doctors (and in some cases, nurses) providing legal assistance to die, either through the prescribing of a lethal substance for self-administration by the applicant, whose application has met various eligibility and procedural criteria, or through practitioner-administration, where the doctor intravenously supplies the lethal substance to the person (in the case of Victoria, this is permitted only where the applicant is unable to orally administer or digest the lethal substance).

It is known that in many places where VAD is legal, most doctors choose to not provide it. This can create access barriers for otherwise eligible persons seeking VAD if they are unable to locate a willing provider. Clinicians’ right to conscientious objection is protected in most jurisdictions which permit VAD, but not all clinicians who decline to participate do so because of a conscientious objection. Many elect to not participate because of anticipated personal (e.g. emotional toll, stress, or fear) or professional (e.g. reputational stigma, conflict with colleagues) reasons. These reasons are well documented in the literature, as are clinicians’ conscientious objections.

Less well documented are the reasons that clinicians provide towards their participation in VAD. Where the potential for access barriers to VAD are high because of a short supply of willing clinicians, one important mitigation is to understand and support those factors which doctors (and nurses) say motivate them to be involved in this type of medical practice. To better identify and understand these factors, 25 doctors with no in-principle opposition to doctors legally providing VAD were interviewed in the first year of the operation of the VAD law in Victoria. This small empirical study observed that doctors commonly utilise bioethical justifications for their involvement in VAD but struggle to reconcile that approach with the broader medical profession’s opposition. Participants identify autonomy (of both patient and physician), beneficence (relief of suffering; a better way to die; the reassuring effect of legal access) and justice (effective regulation; facilitating a patient’s legal right) as ethical imperatives for conscientious participation.

Autonomy is regularly invoked in debates about VAD, particularly the conflict which can result from a clinician’s conscientious objection, however research participants suggested that doctors’ personal autonomy can also motivate involvement in VAD, particularly where they may have an intention of access VAD themselves at some future point and therefore see an obligation to facilitate it for others, or where their willingness to be involved is motivated by a previous experience of either assisting patients to die, or political advocacy toward law reform, or watching a family member or patient die a bad death.

The duty to relieve suffering is also often relied on by proponents of VAD, and a more nuanced understanding of this ethical principle emerged from the interviews, particularly around increasing options for people at the end of life, and ensuring increased reassurance for persons who secure access to VAD. This was referred to by one participant as the ‘palliative effect’ of known access. Some study participants also invoked the ethical principle of justice in terms of helping people to access their legal right to VAD, and having a regulated VAD system available instead of the ‘access lottery’ that can result where the practice is illegal.

Despite achieving ethical reconciliation about their practice of VAD, this is not the only motivator for doctors who are willing to be involved in VAD. Ethical imperatives – even where they form a core set of professional values and identity – appear highly contingent on other motivating factors, such as the personal backgrounds or organisational contexts clinicians function within.  Therefore, ethical imperatives alone cannot be relied on to determine the potential for conscientious participation, and further research is needed into the inter-personal, cultural and professional factors which motivate clinician involvement in VAD.

Paper title: Conscientious participants and the ethical dimensions of physician support for legalised voluntary assisted dying

Author: Jodhi Rutherford

Affiliations: Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Australia.

Competing interests: None declared.

Social media accounts of post author(s): twitter: @jodhirutherford