Profession split on euthanasia

3 people holding hands

A sizeable minority of pharmacists would refuse to dispense drugs used in voluntary assisted dying, an AJP poll shows

Last month, the lower house of Victorian Parliament passed Labor’s controversial Voluntary Assisted Dying bill, which would pave the way to permitting euthanasia under very strict circumstances.

If implemented, the legislation would be one of the most conservative in the world, and include 68 safeguards.

Pharmacists would be part of the process, supplying lethal medicines in a “locked box”. Their participation would be voluntary, and professional organisations have stressed the importance of this.

At this stage it is unsure what those medicines could be, though it has been suggested that a cocktail of drugs put together by specialist compounding pharmacists would be used, rather than drugs used internationally in euthanasia such as Nembutal and Seconal.

We asked readers whether, should such legislation be passed and implemented in their state or territory, they would supply drugs under these circumstances.

Over a third of pharmacists would not dispense these “locked box” drugs, our poll found: 32% (108 readers) simply said they would not provide the medicines, while another 5% (16 readers) said that while they personally supported the legislation, they wouldn’t participate.

Some wanted to know more before making a decision – 22%, or 75 readers – while the most commonly selected option, at 41% (140 readers) was “yes”.

Dr Betty Chaar from the University of Sydney, for whom a key area of interest is ethics in pharmacy, says these results are disappointing.

“Everyone is entitled to their opinion no doubt, but it is our opinions in the context of our professional roles as pharmacists that we are exploring here in depth,” says Dr Chaar.

“Being a professional means you may need to provide services that you might not entirely believe are useful or therapeutic et cetera: for example the harm minimisation policy and provision of needle exchange services or methadone.

“Evidence however, shows that the policy works despite the concerns.”

She says it’s worrying that such a large proportion of AJP readers would not take part in this service, “with no additional comment on providing continuity of care or compassion with the suffering of the patient that is requesting this.

“There is this universally recognised contemporary debate going on, about the right of the healthcare professional to decline a service in balance with respect for patient autonomy.

“It is unresolved in most parts of the world, when it comes to euthanasia, but important to note and important to build tight protocols around such concerns to ensure patient care is enacted.

“It is not an easy subject to navigate, but we will have to if it is legalised in Australia, and we as a profession will need to face the controversies and bring together all these views to develop carefully considered guidelines and standards of practice to enable pharmacists to know what to do in such cases and what to fall back on if they have a conscientious objection to what may be deemed a professional duty.”

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  1. Tania Tobias

    I’m very surprised that pharmacists will be the providers of meds. for voluntary euthanasia. I doubt that any long-term customer/patient of a pharmacy would want their intentions known to anyone but the doctor involved. Whilst pharmacists know a huge amount about their customers’ health, or lack thereof, isn’t this a case where the meds. should be supplied directly to the doctor?

    • Jarrod McMaugh

      The legislation is set up in a way that requires multiple health professionals to be involved in the process. Pharmacists – as medication experts – will need to be involved both for the ability to discuss the medication with the individual, but also to ensure that the patient is autonomously accessing the medication.

      Patients often want as few people as possible to know about their medications and health in all aspects of life (and death). Pharmacists are an integral part of accessing medications, and people accept this. VAD is no different to any other health issue that requires medication.

      • Alison Claxton

        I take your point, Jarrod, regarding separating the doctor from the direct provision of the medicines to increase transparency. (Now I am wondering if ‘medicines’ is actually the right term for these…) I wonder how a pharmacist would ‘ensure that the patient is autonomously accessing the medication’ if they are very ill and it is always relatives who pick up their prescriptions. I wonder how we would satisfactorily confirm the consent or participation of the patient in their absence.
        In many Community Pharmacies, how private would it be to hand over this ‘locked box’ and provide comprehensive counselling? Can people imagine their customers being comfortable doing this in a public setting? Or would a private clinic involving a pharmacist be preferable?
        What do you say to that person as they leave the pharmacy after the sale? Think of what you usually say to people as they go….
        These are genuine questions I am left with, not loaded statements.
        Happy to hear others’ thoughts…

        • Jarrod McMaugh

          Jill Hennessy has been provided with a framework for the dispensing of these medicines that will cover these issues.

          The provision of these medicines will require a specific process that protects the pharmacists’ right to conscientious objection (CO), while also protecting the individual from the distress of being rejected from pharmacies who are unwilling to participate due to the right to CO.

          The process of dispensing will require the pharmacist to understand the law, have the capacity to counsell the individual correctly, and assess the individual’s autonomy and current state of mind to ensure appropriate supply.

          Depending on the nature of the individual’s terminal condition, this may require the pharmacist to travel to the patient – and this would require two trips – the first to receive the prescription, and the second to return with the medication. If the individual is capable of attending the pharmacy, the pharmacist would require a private consultation room. The counselling involved, plus the requirements to determine correct supply, will require significant time and privacy. Supply to a third party (as is the case with other medications) will be inapropriate (and a breach of regulation) for this situation.

          If there legislation passes, there is an 18 month implementation phase that will include the implementation of the supply framework that covers all of these issues (plus many more) in great depth.

  2. Jarrod McMaugh

    I think it’s to be expected that there would be a high proportion of any professional who shows trepidation at the thought of delivering a new service within their scope that hasn’t been provided in the past.

    It’s also to be expected that people will be unsure about providing any intervention that is associated with the death of a person.

    This is both – on the whole I think the number of yes respondents to be relatively high. While I personally see this as a good thing, I wouldn’t condemn those who do not wish to be involved in the provision of a VAD substance.

    I think it is also sensible that a number of people responded “I need to know more”

    When (if) the legisltation passes in Victoria, there will be an 18 month implementation phase, when regulations are created. Part of this includes the creation of a VAD Board to oversee the scheme. It will be important that a practicing pharmacist is on this board. This board will flesh out the processes required to deliver the scheme within the legislation.

    I would expect to see the Board create a system very similar to the distribution methods of very toxic medications (think thalidomide), or the recording/accreditation systems of other medications that have stringent legislative requirements (misopristol/mifepristone). That is, accreditation is required, and prescribers have access to the list of all accredited pharmacists so that they can refer directly to those pharmacists.

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