Victoria may soon have assisted dying laws for terminally ill patients


Ben White, Queensland University of Technology and Lindy Willmott, Queensland University of Technology

An independent group of experts set up by the Victorian government has today delivered its final report outlining 66 recommendations for how voluntary assisted dying would work in the state.

Chaired by former head of the Australian Medical Association, Brian Owler, the Ministerial Advisory Panel’s role was to work out how legislation should be drafted to allow terminally ill people to receive assistance to die. The panel based its report on the recommendations of the Parliamentary committee’s Inquiry into end of life choices in December 2016.

Legislation giving effect to the report is likely to be tabled in the Victorian Parliament within a month.

Who does the law cover?

At the heart of debates about assisted dying are eligibility criteria – who can get assistance to die and who cannot. The panel’s recommendations are broadly consistent with the report of the parliamentary committee. Access is allowed for an adult who can make their own decisions, is terminally ill and their suffering cannot be relieved. They must also be a resident of Victoria.

But the panel widens the committee’s earlier recommendation that a person must be “at the end of life (final weeks or months of life)” to be granted their request. Instead, the current report states the “incurable disease, illness or medical condition” must be expected to cause death in no later than 12 months.

While we agree eligibility should be based on a terminal illness, we don’t favour time limits as they are arbitrary and difficult to accurately predict. They can also lead to people taking harmful steps to fall inside them, such as starving themselves.

But the panel’s recommendation to extend the time to 12 months is still a better approach than the committee’s, as it is likely forming a clinical view about prognosis will be more manageable in that time. Providing a set time frame also avoids the uncertainty of the vague use of the phrase “at the end of life”.

Former AMA president, Professor Brian Owler, chaired the Ministerial Advisory Panel.

Also of note is that the panel specifically stated mental illness alone and disability alone will not satisfy eligibility requirements; but nor will they exclude access to voluntary assisted dying.

What assistance can be provided?

This is primarily a physician-assisted dying model, which means the patient is expected to take the lethal dose of medication themselves. This is a narrow approach to assisted dying as it is the person themselves who takes the final step to end life, not the doctor.

The panel’s approach is consistent with the committee’s report – both are broadly along the lines of the US assisted dying model such as the one in Oregon.

There are downsides to this and we favour a more inclusive model (like in Canada or under the European model) that permits assistance to die being directly provided by a doctor as well. This choice better reflects the autonomy that underpins these laws.

But the panel (and the committee) did recommend an exception where the person is physically unable to take the medication or digest it themselves. This may not be used often but helps address potential discrimination, for example on the grounds of physical disability which prevents someone taking the medication themselves.

What safeguards are there?

The panel has proposed a very rigorous process – comprised of 68 safeguards – that involves three separate requests for voluntary assisted dying (one which is witnessed by two independent witnesses) and two independent medical assessments.

A patient seeking assistance to die must be provided with a range of information including about diagnosis and prognosis, treatment options available, palliative care, and the expected outcome and risks of taking the lethal dose of medication. Doctors involved will have to receive special training about the law and how it operates.

Other safeguards are at the systems level, with a Voluntary Assisted Dying Review Board recommended to examine each case and also to report on how the scheme as a whole is operating. The panel has also proposed a range of new offences specifically about voluntary assisted dying to deter conduct outside the scope of the regime, such as an offence against inducing someone to request assisted dying.

Will these recommendations become law?

Strong public opinion, shifting views in the health and medical professions and international trends towards allowing assisted dying mean it will become lawful in Australia at some point. But will it be in Victoria, and soon?

The politics of assisted dying are notoriously fickle and this is the latest of over 50 bills in Australian parliaments addressing this issue over the past two decades.

But as we have argued in the past, features of this law reform effort suggest it could happen. The process of examining the issue has been very careful, inclusive and thoughtful with multiple reports and engagement with expert opinion and national and international evidence.

The ConversationThis is a narrow assisted dying model with a lot of safeguards. There is also high level and public support of senior politicians on both sides of politics. But as always, the ultimate test is what happens on the floor of parliament.

Ben White, Professor of Law and Director, Australian Centre for Health Law Research, Queensland University of Technology and Lindy Willmott, Professor of Law, Queensland University of Technology

This article was originally published on The Conversation. Read the original article.

Social mix in housing? One size doesn’t fit all, as new projects show


Kate Shaw, University of Melbourne

A recent suggestion that new housing on inner-city public land should start from a presumption of 100% social housing prompted indignation in government circles. “We can’t condemn another generation of Victorians to live in housing poverty,” huffed the housing minister, Martin Foley.

It’s curious, then, that we heard barely a peep about the latest government announcement that the height of an apartment tower associated with the Queen Victoria Market makeover will be reduced by removing the original affordable housing component to a separate, smaller development.

It is tempting to conclude that both responses accord, naturally, with the interests of the developers of private housing. But that would be to over-simplify the complex issue of social mix. It is increasingly clear there is no one-size-fits-all.

The principle of social mix now routinely drives public housing estate renewals and new housing builds on surplus public land. This is usually expressed in a 50:50 mix of social (public and community) and private housing, though the social component is often much smaller. As the stock of public land is ever diminishing, and affordable housing is in such short supply, this is problematic.

I have argued before that government commitments to social mix are often disingenuous. They are more likely to be driven by an ideological imperative to privatise public assets, or at best to secure upgrades to public housing without having to fund them directly.

What does the evidence tell us?

Soon-to-be-published research by Abdullahi Jama and I on the Carlton public housing estate redevelopment supports these conclusions.

Our findings show that public and private residents on the new estate are not mixed. They are divided into separate buildings with separate gardens, explicitly with a view to increasing the value of the private apartments.

The case that normally follows from such a finding is that public and private households should be “salt and peppered” through new apartment buildings to encourage social mixing. While Abdullahi and I agree this is a necessary precondition for social mixing, this is not the entirety of our argument. We question the very basics of the policy orthodoxy on social mix.

The rationale for building upmarket private housing in low-income areas draws on the neighbourhood effects thesis, which says that concentrations of poverty exacerbate its effects.

This might be the case in large areas of disadvantage, such as the US Rust Belt cities, parts of the UK and even some outer suburbs of Sydney and Melbourne. But it doesn’t stand up in highly resourced, gentrified inner cities where community facilities and opportunities for interaction are plentiful.

Paul Watt talks about neighbourhood effects, the disputed idea that poor communities benefit from social mix in urban renewal projects.

Even where poverty is widespread, studies from Toronto, Vancouver, Amsterdam and London show that imposed social mix disrupts support networks and social structures. Involuntary displacement from a neighbourhood often has serious effects on physical and mental health.

Ranjan Balakumaran and Kam Sandhu discuss the displacement of poorer communities by ‘redevelopment’.

Minority communities may benefit from concentration in terms of safety and maintaining their cultural heritage. A substantial body of research shows that social mix policies do not replace the social capital they displace.

So, are there good reasons to introduce social mix?

The strongest argument is the reduction of stigma that for some people comes with public housing. If the public housing is indistinguishable from private housing, the public tenants’ wellbeing is considered to be improved.

It’s not entirely clear, however, whether this is due as much to the housing being new and decent as to having private residents as neighbours. Also unresolved is the question of whether stigma is felt as keenly on estates in gentrified cities, which are islands of public housing in seas of inner-city privilege, as it may be in widely disadvantaged neighbourhoods.

There is certainly evidence that, for some people, being thrust among others from different class and socio-economic groups can increase feelings of inadequacy, discomfort and sometimes hostility.

So how do we provide affordable housing?

These issues vary across place, time and individuals. What is clear is that different responses are needed accordingly.

It is also clear that, with dire shortages of affordable housing in so many cities, all opportunities should be seized to build as much affordable housing as possible. That’s not just public and community housing, but “key worker” housing, “below market rent” housing, co-op housing and community land trusts. Models for all these exist and should be encouraged and explored.

A diversity of housing types must include diverse sources of funding, with a range of support programs. Involving future residents in design and ensuring they know what they’re moving into, and enabling people to organise their own housing, are far more effective ways of building social harmony than enforcing a rigid notion of mix.

The ConversationSeparate buildings for social tenants and private residents next to the Vic Market might be a perfectly reasonable response. But it should come from nuanced public policy and optimal use of public resources, rather than the developers and their sales people.

Kate Shaw, Future Fellow, University of Melbourne

This article was originally published on The Conversation. Read the original article.

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