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Submission to the Queensland Inquiry into
aged care, end-of-life and palliative care
and voluntary assisted dying
APS contact:
Frances Mirabelli
Chief Executive Officer
Dr Louise Roufeil
Chief Policy Officer
April 2019
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1. Executive Summary and Recommendations
The Australian Psychological Society (APS) endorses a best practice approach
to end-of-life care, requiring that patients fully understand their alternatives and the main ramifications of their decision to access voluntary assisted dying (VAD) services should they become legal outside Victoria. Ultimately,
the APS emphasises the importance of a process that is characterised by care, compassion and considered decision-making over time. The APS
envisages that such a process would include access to the full range of care options, from the highest quality palliative care and the most competent psychological assessment and psychosocial support.
Key strategies to improve how people die include education and training to
empower the health workforce, creating better infrastructure, and having more appropriate policies and protocols in place to maximise the real choices (and sense of control) available to the seriously and terminally ill.
The APS recommends that:
Recommendation 1
The Queensland Government considers the limitations of the existing
medicalised, service system to manage people’s preferences and sense of
control as they approach the end of their life.
Recommendation 2 The Queensland Government draws on (or commissions if unavailable)
robust, transparent and impartial research to examine Queensland
community views about voluntary assisted dying, and uses this evidence
base to drive future decision-making about end of life choices.
Recommendation 3
In the event VAD is legislated in Queensland, the APS strongly advocates for
increased access to psychological services to assist in:
1. Decision-making capacity assessment
2. Therapeutic interventions for patients and their families
3. Clinical supervision for the service/s delivering assisted dying services.
Recommendation 4
Future legislation should include an equity impact assessment (a process to
ensure that a policy, project or scheme does not discriminate against any
disadvantaged or vulnerable people).
Recommendation 5
Implementation of any VAD scheme needs to consider the existing and
future capacity of an appropriately skilled workforce to meet the needs of
people approaching the end of their lives.
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2. Introduction
The Australian Psychological Society (APS) thanks the Committee for the
invitation to make a submission to this Inquiry about aged care, palliative
and end-of-life care, and voluntary assisted dying (VAD) in the Queensland.
Given the broad scope of this Inquiry, this submission focuses on the context
around end-of-life care and VAD from a psychological perspective, and
highlights the importance of ensuring people approaching the end of their life
are supported by practitioners and broader support systems to access
appropriate information and care.
Psychologists have important knowledge and skills to contribute towards
addressing some of the interpersonal challenges surrounding end-of-life
trajectories. This contribution relates not only to the debate about legalising
assisted dying, but also includes broader issues relating to palliative and
end-of-life care and advance care planning.
The APS believes psychologists can and should be involved in end of life
issues in a variety of ways including:
• diagnosis, treatment and management of psychological disorders at
the end of life;
• supervision, support and ongoing education for staff teams;
• facilitating conversations and addressing stigma around death and
dying;
• contributing to policy development and best practice for care of the
terminally ill, the process of supported decision-making, and
assessment of psychological disorders and decision-making
capacity; and
• conducting research, and translation of research into practice.
While the APS is committed to supporting the health and wellbeing of older
Australians, this submission will not address aged care more generally.
However, please note that the APS will be making a submission to the Royal
Commission into Aged Care Quality and Safety, and it is pleasing to note that
the Committee will be drawing on the findings from the Commission to
inform this Inquiry.
3. Psychological Wellbeing at the End-of-Life
For people approaching the end of their life it is common to experience
shock, grief, anger, denial, demoralisation, anxiety, guilt, resignation, and
acceptance. But mostly it is the experience of loss which is predominant –
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which includes actual loss of mobility, ability to take part in daily activities
etc. but also the anticipated loss of identity, family and relationships, and a
fear of missing out.
Depression
Studies indicate up to 45% of palliative patients experience major depression
(Hotopf, et. al., 2002); other findings indicate a prevalence of 19% for major
depression and a further 36% for any depressive syndrome (Rayner, et. al.,
2010). However, depression is often under-diagnosed in palliative
populations, with clinicians believing that depression is appropriate/‘normal’
in advanced disease and palliative situations.
DSM-5 criteria for depression include numerous somatic features such as
disturbed sleep, increases/decreases in appetite, loss of energy or fatigue,
psychomotor retardation, loss of motivation and problems with concentration
and memory. However, these are all common symptoms at the end of life,
making it difficult to make an accurate diagnosis. Diagnosis of depression for
people in palliative care therefore has different criteria to diagnosis in the
general population. Endicott (1984) listed the following substitute symptoms:
• Depressed mood most of the day
• Markedly diminished interest or pleasure in all or almost all
activities most of the day
• Depressed appearance
• Social withdrawal or decreased talkativeness
• Brooding, self-pity or pessimism
• Lack of reactivity; cannot be cheered up
• Feelings of worthlessness or excessive/inappropriate guilt
• Suicidal ideation or planning (more than a wish to die).
Anxiety and delirium
Australian findings suggest 20% - 36% of palliative patients experience
anxiety to varying degrees (O’Connor, White, & Kristjanson et al., 2010).
Reasons for anxiety include existential questions, body processes (e.g.
shortness of breath), anticipation of injections/procedures, the dying
process, death itself, as well as leaving loved ones behind. Anxiety can be
pre-existing, reactive (in response to approaching end of life), as well as an
outcome of illness or treatment. Somatisation is also very common, whereby
anxiety presents as physical symptoms (e.g. pain).
Delirium is also very common in end-of-life care, experienced by up to 85%
of terminal patients (Brown & Boyle, 2002). Delirium can be caused by a
range of conditions and interventions such as medications, infection, hypoxia
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and urinary/faecal retention. Delirium is often misdiagnosed as dementia,
psychosis, depression or mania.
Common psychological interventions
There are numerous psychology-informed therapeutic approaches for people
approaching the end of their lives, as well as their carers and/or family
members. These approaches include, but are not limited to: cognitive
behavioural therapy; meaning focused therapies; interpersonal therapy;
mindfulness therapies; dignity therapy; and narrative therapy.
However, more important perhaps than treatment models are the principles
of care relevant for all people caring for people at the end of their life. This
includes staying with patients through their pain and discomfort, being active
listeners and providing compassionate presence, acknowledging that all
patients need to tell their story in their own way, and eliciting the meaning of
life that is unique to each person.
Palliative care and quality of life
The primary goal of palliative care is to optimise Quality of Life (QoL) and an
individual’s psychology is an important factor. Psychosocial wellbeing is a key
buffer and enhancer of a patients QoL (Blinderman et al., 2008; Bovero,
Leombruni, Miniotti, Rocca, & Torta, 2016; Wang, Shen, & Xu, 2011). Whilst
physical and spiritual distress certainly contribute to reduced QoL,
psychological distress has demonstrated an equal and/or greater impact
(Kutner et al., 2007; Yohannes, Willgoss, Baldwin, & Connolly, 2010).
Evidence indicates that carers need support just as much, if not more, than
patients. Family caregivers of patients with a palliative illness indicated a
greater burden on their physical and psychological QoL compared to caring
for an individual receiving curative treatment (Weitzner, McMillan, &
Jacobsen, 1999) and non-caregivers (Haley et al., 2001). Furthermore,
studies have repeatedly found that the palliative patient’s physical and
psychological distress, to varying degrees, are predictive of caregiver burden
(Bidwell, Lyons, & Lee, 2017; Grunfeld et al., 2004; Ivziku, Clari, Piredda, De
Marinis, & Matarese, 2018).
Despite psychological distress and wellbeing being such an important aspect
for palliative patients and carers, more research is needed. Evidence which
points to the efficacy of psychological interventions within palliative care is
currently limited (Ftanou et al., 2017; Kasl-Godley et al., 2014).
In summary, the APS supports a holistic approach to the care of the
palliative patient, with a particular emphasis on the role psychologists have
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to play in contributing to improved QoL of the patient AND carer. This needs
to include not just psychologists ‘on the ground’ in palliative care services,
but funding/grants available for research focused on improving the evidence
for psychology within palliative care.
4. Responding to the Terms of Reference
the delivery of aged care, end-of-life and palliative care in
Queensland across the health and ageing service systems
If asked, most people have clear preferences regarding their end-of-life care.
Seventy per cent of people want to die at home, yet only about 14% do so
(Swerissen & Duckett, 2014). Although hospitals and residential aged care
facilities (RACFs) are usually the least preferred places to die, 54% of people
die in hospital and 32% in residential aged care (Broad et al., 2013).
The major fear about end of life is not so much death itself, but the prospect
of suffering and not being in control. Palliative care is the most established
end-of-life model of care. However its capacity to prevent/alleviate severe
suffering (including pain control and refractory symptoms) is not absolute.
Furthermore, palliative care is not always available to all people who might
benefit, or equally accessible to diverse community groups (such as
residents of aged care facilities, people who have terminal illnesses other
than cancer, people living in rural and remote communities, and people from
Indigenous and culturally and linguistically diverse backgrounds). This may
be of particular concern in Queensland, where there are high proportions of
people from Aboriginal and Torres Strait Islander backgrounds, older people
living in rural and remote areas, as well as high numbers of residential aged
care facilities. Not only are there currently serious shortages of palliative
care practitioners, palliative care is not acceptable to a sizeable minority of
dying people.
Death and dying has become increasingly medicalised and thus the domain
of medical professionals. We have lost our ‘death literacy’, where once
people were naturally engaged in the care of the dying and bereavement
(Horsfall et al, 2015; Noonan et al, 2016). In addition to physical health, end
of life concerns encompass individual and shared community perceptions of
what a life worth living looks like, and how to enable people to create their
own possibilities, hope and choices. In the developed world, people are living
longer and death, now typically occurring in hospital settings, is becoming
less visible and more medicalised. There is a growing movement to challenge
the silence around these concerns, and to facilitate conversations and
communication about death and dying and promote this as everyone’s
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responsibility (Bartel, 2016). In service provision, this whole person
approach to care is known as ‘health promoting palliative care’ (Kellehear &
O’Connor, 2008).
It is pertinent to point out that the APS has not made a distinction between
‘palliative care’ and ‘specialist palliative care’. ‘Specialist palliative care’
refers to those clinicians with advanced training (e.g. a certificate in
palliative care) and they often work out of Specialist Palliative Care Services
in their respective Hospital and Health Service (there are 16 HHS’s under
Queensland Health) or Hospice settings. ‘Palliative care’ refers to an
approach which should/could be adopted by different clinicians (e.g. GPs,
assistants in nursing, cardiologists, radiation oncologists, geriatricians).
‘Palliative care’ in this sense is also sometimes called ‘palliative approach’ or
‘primary palliative care’.
In summary, there is a significant discrepancy between people’s preferences
for end-of-life care and what actually happens. There is great potential to
enhance how people die by improving training to create a better health
workforce, creating better infrastructure, and having more appropriate
policies and protocols in place to maximise the real choices (and sense of
control) available to the seriously and terminally ill.
Recommendation 1
That the Queensland Government considers the limitations of the existing,
and very medicalised, service system to manage people’s preferences and
sense of control as they approach the end of their life.
Queensland community and relevant health practitioners’ views
on the desirability of supporting voluntary assisted dying,
including provisions for it being legislated in Queensland and any
necessary safeguards to protect vulnerable persons
Queensland community views on the desirability of voluntary
assisted dying being legislated in Queensland
Numerous polls have been conducted in Australia in the last decade, and all
indicate that the majority (66 – 85%) of the community supports terminally
ill patients to legally end their own lives with medical assistance (e.g. ABC
Vote Compass 2013 and 2016, Newspoll 2012, Australia Institute 2012).
Most surveys, while self-selected, have been weighted to be representative
of the Australian population, indicating that the Queensland community is
likely to have similar views.
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As highlighted in the issues paper, it is important to take into consideration
that Queensland has a high number of older people living in rural and remote
areas and people from Aboriginal and Torres Strait Islander backgrounds.
This may impact on public opinion.
The need for robust, transparent and impartial research into community
views is critical – particularly in the context of potentially strong arguments
against VAD legislation from a religious perspective. The APS supports the
application of evidence to drive user-informed decision-making in this area.
Recommendation 2
That the Queensland Government draws on (or commissions if unavailable)
robust, transparent and impartial research to examine Queensland
community views about voluntary assisted dying, and uses this evidence
base to drive future decision-making about end of life choices.
Provisions for VAD being legislated in Queensland and any necessary
safeguards to protect vulnerable persons
The APS acknowledges that dealing with issues surrounding the choice of a
terminally ill person to request assistance from a medically qualified
practitioner to terminate their life voluntarily and humanely is complex and
challenging. This issue needs to be examined from a number of perspectives
that encompass psychological, ethical/moral, medical, legal, religious/
spiritual, sociological and political considerations.
The APS neither endorses nor opposes VAD. Rather, the APS endorses a best
practice approach to end of life care, requiring that patients fully understand
their alternatives and the main ramifications of their decision to access
assisted dying services should they become legal outside Victoria. Ultimately,
the APS emphasises the importance of a process that is characterised by
care, compassion and considered decision-making over time (Maddocks,
2014). The APS envisages that such a process would include access to the
full range of care options, from the highest quality palliative care and the
most competent psychological assessment and psychosocial support.
The APS is concerned about the potentially detrimental impact of legislative
change on the health and wellbeing of people approaching the end of their
life, their friends and family, their carers and the broader community, as well
as the health professionals involved in implementing the legislative changes.
Of most concern to the APS is the need to support and ensure that
vulnerable people have an informed voice, particularly in legal decision-
making around whether assisted dying should be permitted (Forbat, 2017).
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Many potential risks of VAD have been identified and discussed at length
(e.g. Parliament of Victoria, 2016), both nationally and internationally. The
main risks from a psychological perspective will be outlined and addressed
below along with potential safeguards.
Competence and decision-making capacity
One commonly identified risk is that an individual may not have the capacity,
or be ‘competent’, to make a decision to die.
The APS advocates best practice in terms of psychosocial support, requiring
that the person fully understands their alternatives and the main
ramifications of their decision. Importantly, the focus of capacity assessment
is not on whether the decision to die is sensible, right, or wrong; but in fact
whether the person can demonstrate an appreciation of their current
circumstances and then apply that understanding to make decisions in
alignment with their preferences and values. Demonstrating an
understanding of the consequences of their decisions, and making those
decisions freely without undue influence, are also components assessed as
part of decision-making capacity. It is also important to acknowledge and
account for the fact that decisions can change, and that variations over time
are not to be confused with ambivalence, and should not be used to
undermine decision-making capacity.
People with a disability should be provided with appropriate support to make
decisions, and having a disability does not negate their right to assisted
dying or any other service that is legal for non-disabled persons. Patients
with ‘locked-in’ syndrome, Lou Gehrig’s disease or other conditions which
impair communication will need special attention to ensure that they can
express their views.
Some doctors and mental health practitioners may regard the presence of a
decision to end life as proof that the person does not have the capacity to
make a decision. Training of doctors and mental health practitioners
regarding indicators of decision-making capacity in this context may be
required.
Conducting assessments of decision-making capacity is a specialised area
with only psychology and medicine typically conducting such assessments.
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Mental illness and competence
Despite the law which stipulates that a person retains decision-making
capacity unless proven otherwise, there is a risk around the commonly held
assumption that mental illness and/or dementia automatically deems a
person incompetent to make decisions.
The APS believes there should be a presumption of rationality on the part of
any person. Therefore, psychiatric assessment should not be considered an
automatic corollary when a person wishes to die. Likewise, people in the
early stages of dementia should be assumed to have capacity (however they
would be unlikely to meet the eligibility criteria for VAD on the basis of
prognosis).
When the person’s GP or other treating medical practitioner suspects that
the person is confused, or if other indications of psychiatric/neurological
disturbances are present which may be affecting their decision-making
capacity, a referral for assessment by a psychiatrist or psychologist may be
warranted. The US legal statutes recommend that a psychologist become
involved in ‘physician assisted suicide’ when there are concerns regarding
the person’s decisional capacity due to the presence of psychopathology,
such as depression (Johnson et al., 2014).
It is important to understand how mental illness (e.g., severe depression)
affects decision-making capacity and advance care planning, although it is
equally important to avoid the suggestion that considering ending one’s life
is a sign of depression in itself. In many cases (e.g. early stages of
Alzheimer’s), people are competent to participate in advance care planning
and decision-making. While psychiatrists and psychologists can play a key
role in diagnosis of mental disorders and assessment of decision-making
capacity, a diagnosis of depression or cognitive impairment should not
automatically negate a person’s right to access care choices available to
other patients. It is important to acknowledge, for example, that a person’s
depression may be a response to a loss of control over the situation, which
could be alleviated by the perception of choice over terminating one’s life.
Furthermore, in the debate about VAD legislation, assessment of decision-
making capacity is often limited to depression. However, there are other
psychological or neurological disorders that may influence a patient's
decision-making capacity (e.g., neurocognitive disorders, delirium, anxiety
disorders and chronic alcoholism) warranting psychological assessment.
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Coercion
There is also a risk that a person’s decision to end their life is not entirely
their own, and may be subject to undue influence by other parties, including
carers or family members. The APS acknowledges that decisions are
influenced by a range of factors, including the opinions of others, notably
family members and health professionals. For this reason, the APS
recommends that the person should be allowed to make a request in private
- i.e. away from the influence of carers/family/nursing homes/palliative care
specialists who may disagree with their decision – or in any way that ensures
that they do not feel unduly pressured by the opinions of others.
Relationships are lenses through which to examine decision-making around
assisted dying (Forbat, 2017). Furthermore, psychologists have the specialist
expertise and tools to support families, clinicians and community systems, to
help manage the suffering and distress that arises.
Also of relevance is the indirect coercion potentially experienced as a result
of living in a society that regards many vulnerable people (e.g. older people
and people with a disability) as a burden. This highlights the need for
community education which challenges our attitudes and beliefs about
whether some lives are more worthy than others.
Conscientious objectors
There is a risk that an individual who would like assistance to die may not be
able to access a practitioner who supports their decision. In the event that
VAD is legalised in Queensland, health practitioners who object to
participating in facilitating the process should be required to refer patients to
other health practitioners who do not hold such a position.
Dying people may be at the limit of their mental, physical and economic
resources and find it very difficult to locate another health practitioner who
does support assisted dying. This is particularly true for individuals living in
rural and remote areas, as well as those in residential aged care or palliative
care facilities (where patients are entirely dependent on visiting medical
practitioners who attend to them). Finding an alternative medical practitioner
oneself in these circumstances may be excessively onerous or impossible.
Impact on practitioners working with people approaching end of life
The impact of legislation on the wellbeing of practitioners is also of concern -
particularly those working in locations where assisted dying has been newly
legislated and administrative supports and professional education are in their
infancy. Evidence from Canada since assisted dying became legal in 2016
indicates that some medical practitioners are choosing not to participate in
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the scheme not only due to moral issues, but due to a lack of training in the
area and a lack of administrative efficiency and support (Upshur, 2016).
Clinical supervision and support could be important to assist doctors and
nurses to manage their potential responses to assisted dying requests and to
reflect on their own conflicting personal values, concerns over their own
psychological wellbeing and understanding their role (Forbat, 2017).
Similarly supervision could be helpful for the many other health professionals
and volunteers who may be involved directly or indirectly with VAD requests.
Adequacy and access to health care
There is a risk that the most vulnerable people in society are less likely to be
able to access adequate health care, and therefore more likely to make
requests for assisted dying services.
While Australians are increasingly wealthy on average, there is also rising
inequality. Inequality leads to poorer health outcomes and higher levels of
suicide, particularly amongst people within disadvantaged groups. The
adequacy of access to affordable and timely health care is likely to play an
important role in a person’s decision-making, such that a request for assisted
dying may follow a failure of one or more parts of the health system to
provide adequate care. Such requests may be made in the context of
serious social inequities in access to resources such as basic medical care
(APA Resolution on Assisted Dying and Justification, 2017). Inadequate
medical, palliative or psychiatric care or support may significantly influence a
request for premature death (Komesaroff, Lickiss, Parker, & Ashby, 1995).
For this reason, the APS recommends that any future legislation include an
equity impact assessment (a decision support tool designed to ensure that a
policy, project or scheme does not discriminate against any disadvantaged or
vulnerable people).
Another issue in relation to access to services is the growing number of
younger onset dementia cases. Often the disease course is rapid and
aggressive, but because of their young age, the dementia is not diagnosed
well, or early enough. This creates significant disadvantage in that these
people may already have significant cognitive impairment impacting on their
capacity to make decisions by the time they get their diagnosis. Therefore,
ensuring access to timely early diagnostic services across the State is
important. This will support self-determination in end-of-life care and
decision-making. Specifically including younger onset dementia is particularly
pertinent in any inquiry looking exclusively at aged care, given that people
are mostly under the age of 65 when symptoms appear. For this reason,
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dementia should be considered separately so as not to exclude or
discriminate against these younger vulnerable people.
A better quality, more accessible, service system should be the priority. Not
only is it likely to reduce the demand for assisted dying services, at the same
time, if assisted dying is to become legal, a strong service system is likely to
avoid any abuses and ensure it works well.
Palliative care workforce
With the potential introduction of VAD legislation, the lack of appropriately
trained health professionals is a significant risk to the effective
implementation of the scheme.
Using psychologists as an example, the APS convened a roundtable in
October 2017 to identify the implications of any legislative changes as well
as to assist the APS to develop resources to better equip psychologists to
work in this space. Changes to legislation are likely to affect the work of
psychologists, particularly if there is provision for psychologists to undertake
mental health and/or decision making capacity assessments. A key finding of
the roundtable was that psychologists are likely to require more training and
education about end of life issues to work more effectively in this space. This
is likely to be the case for many other health professionals working with
people approaching the end of their life.
Not only is the lack of training a risk, but so too is the lack of numbers of
health professionals working in end-of-life care. It is not known how many
psychologists work with people with life-limiting and life-threatening
diagnoses in Queensland nor in Australia more widely. However, from our
APS membership data we know that one per cent of members (254
practitioners and academics) self-report as having expertise in palliative
care, 46 (18%) of whom are based in Queensland. A clinical psychologist and
APS member working in a Specialist Palliative Care Service in Queensland
(which covers both inpatient and community settings) reported that over the
last 7 years psychology referrals have increased by 142% and psychology
staffing increased from 0.5FTE to 1.5FTE. With an additional two clinical
psychology placements offered per year, this amount of psychology provision
is considered to be a privilege and extremely rare.
In Europe, the European Association of Palliative Care collates data on the
number of psychologists working in palliative care, something that could be
very useful in the Australian context to inform and guide future workforce
issues. It is likely that more investment will be required to increase the
14
numbers of psychologists working in palliative care in order to maintain and
promote psychological wellbeing, and particularly if VAD is introduced.
Recommendation 3
In the event VAD is legislated in Queensland, the APS strongly advocates for
increased access to psychological services to assist in:
1. Decision-making capacity assessment
2. Therapeutic interventions for patients and their families
3. Clinical supervision for the service/s delivering assisted dying services.
Recommendation 4
Future legislation should include an equity impact assessment (a process
designed to ensure that a policy, project or scheme does not discriminate
against any disadvantaged or vulnerable people).
Recommendation 5
Implementation of any VAD scheme needs to consider the existing and
future capacity of an appropriately skilled workforce to meet the needs of
people approaching the end of their life.
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5. About the Australian Psychological Society
The Australian Psychological Society (APS) is the national professional
organisation for psychologists with more than 24,000 members across
Australia. Psychologists are experts in human behaviour and bring
experience in understanding crucial components necessary to support people
to optimise their function in the community.
A key goal of the APS is to actively contribute psychological knowledge for
the promotion and enhancement of community wellbeing. Psychology in the
Public Interest is the section of the APS dedicated to the communication and
application of psychological knowledge to enhance community wellbeing and
promote equitable and just treatment of all segments of society.
Related APS work on end of life choices
The APS has made several relevant submissions to State and Federal
Government Inquiries over the last few years:
Inquiry into end of life choices in the Australian Capital Territory Inquiry into the need for laws in Western Australia to allow citizens to
make informed decisions regarding their own end of life choices - October 2017
Victorian Government Voluntary Assisted Dying Bill Discussion Paper –
April 2017 Victorian Parliamentary Inquiry into End of Life Choices – July 2015
Senate Inquiry into the exposure draft of the Medical Services (Dying with Dignity) Bill – August 2014
The APS presented evidence at the associated hearing of the Senate Inquiry
into the Medical Services (Dying with Dignity) Bill in October 2014 and the
Inquiry into end of life choices in the ACT. We invite the Committee to read
the Hansard transcripts as well as the submissions themselves, as these
documents explain the key concerns of the APS. In summary, the APS noted
that the model proposed under the Bill was very medically oriented and did
not consider the broader psychological and psychiatric dimensions of
introducing this option into the death trajectory. The critical element of
‘mental competence’ being a threshold for access to dying with dignity
services was noted as problematic, and thus the APS submission highlighted
the need for a holistic assessment (not just medical assessment). The APS
was also concerned about the need to acknowledge and incorporate family,
cultural and gendered perspectives into the debate.
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In addition, the APS Discussion Paper Psychological Perspectives on
Euthanasia and the Terminally Ill, updated in 2008, addresses a number of
issues relevant to this Inquiry. The Paper noted that there exists:
an inherent tension between respecting individual autonomy and
relieving people from unbearable suffering while still protecting the
principle of valuing human life. Any liberalising of laws in relation to
euthanasia needs to achieve a satisfactory mechanism which balances
this tension, achieves respect for individual rights (of patients, carers
and professional health workers), and prevents abuse, without becoming
too unwieldy, bureaucratic and time consuming to be practical (p. 21).
The APS takes a similar position to that of the American Psychological
Association (APA), which neither endorses nor opposes assisted dying given
the complex multitude of issues involved. In their recent Resolution on
Palliative Care and End-of-life Issues, the APA also advocates for quality end-
of-life care for all individuals; promotes research on assisted dying; promotes
policies that reduce suffering; and supports research on ethical dilemmas
faced by clinicians and researchers. Both the APS and APA foreground the
need to protect first and foremost the wellbeing of the individual concerned.
Consideration should also be given to the needs of family members and
professionals involved.
APS members are required to abide by the ethical standards set out in its
Code of Ethics, which has been adopted and endorsed by the Psychologists
Registration Board of Australia. The Code is built on three general ethical
principles: Respect for the rights and dignity of people and peoples; Propriety;
and Integrity, all of which are relevant to this Inquiry as well as for
psychologists involved in end-of-life care. For example, respect for a person’s
rights and dignity could be seen to support their inalienable right to life, or
conversely their right to request a dignified end to that life. Similarly the
general principle, Propriety, incorporates the principle of non-maleficence (‘do
no harm’), which can be interpreted to forbid the hastening of death, or to
support active intervention in a situation intolerable to the patient.
We also draw the Inquiry’s attention to the October 2017 issue of the Australian
Psychologist, Vol. 52, No. 5 Special issue: Psychology and End of Life, edited by
Lauren J. Breen and Anna Ugalde.
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6. References
American Psychological Association (2017). APA Resolution on Assisted Dying.
http://www.apa.org/about/policy/assisted-dying-resolution.aspx
Australian Psychological Society (2008). Psychological perspectives on
euthanasia and the terminally ill. Discussion paper.
https://www.psychology.org.au/About-Us/What-we-
do/advocacy/Position-Papers-Discussion-Papers-and-
Reviews/Psychological-perspectives-euthanasia
Bartel, R. (2016) Conversations: Creating Choice in End of Life Care.
Melbourne: Australian Centre for Health Research (ACHR).
http://www.achr.org.au/wp-content/uploads/2016/02/Conversations-
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7. Acknowledgements
Dr Christopher Martin, Clinical psychologist, Specialist Palliative Care Service,
Sunshine Coast Hospital and Health Service.
Dr Alison Argo, Advanced Psychologist, Geriatric Outpatient Department,
Nambour General Hospital, Sunshine Coast Hospital and Health Service.
Professor Liz Forbat, Director for the Centre of Palliative Care Research,
Health Care Bruce and the Australian Catholic University.
Sarah Edelman, MAPS Clinical psychologist, trainer, and university lecturer;
Chair, Dying With Dignity NSW.
Dr Felicity Allen, MAPS, JP., Health Psychologist, Director RADAC P/L.
