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https://mentalhealth.org.nz/suicide-prevention/suicide-statistics

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What's behind the numbers

The most recent year for which we have provisional suicide data is the financial year from July 2018 - June 2019.
This data showed the highest number of reported suicides New Zealand has recorded. 685 people are suspected to have died by suicide during this period.
While the number is the highest number, the suicide rate - that is the number of people who have died by suicide per 100,000 population - is not the highest.

Both are important. The total number represents each individual who is suspected to have died by suicide (or, in the official data, the number of people who have been found to have died by suicide). Each one of these people was important and deserves to be acknowledged.

However, the rate is more helpful in comparing suicide data over time because it helps to adjust for population size. It is also more meaningful in helping us to understand how suicide impacts different populations such as Māori and non-Māori. Because the number of Māori is smaller than the number of non-Māori, we need to know their rate per hundred thousand to see that the Māori suicide rate is much higher than the non-Māori suicide rate and know Maori need targeted suicide prevention initiatives.

No, but we do have the highest youth suicide rate in the world.

New Zealand sits in the middle of other OECD countries when comparing total population suicide rates. Our suicide rate is higher than Ireland's or the United Kingdom's, but lower than Australia's or the United States'.

Source: OECD (2019), Suicide rates (indicator). doi: 10.1787/a82f3459-en (Accessed on 25 August 2019)

While every person who experiences suicidal distress has their own unique story to tell, there are some risk factors that can make people more vulnerable to suicide.

Note: most people who experience these risk factors will not become suicidal. It's important to understand what can put people at risk and know how to respond but it's equally important to see people as individuals and not make assumptions about the causes of their distress.

It's important to understand most of these risk factors are out of our control. We cannot change our ethnicity or age, we often cannot change our environments.

That's why suicide prevention can be so complex - we need to understand why people of a certain age, a certain ethnicity, and/or with a certain background are more at risk and then work to reduce that risk rather than changing the person.

We don't just need more or better services - we need to tackle big issues like how we support people bereaved by suicide, racism, the legacy of colonisation, poor housing, homophobia, discrimination, barriers to education and social barriers that prevent people from feeling comfortable or safe asking for help.

However, we can help individuals who are at risk of suicide now, without waiting for these big issues to be solved. For more information, visit our Worried about someone page

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What's behind the numbers The most recent year for which we have provisional suicide data is the financial year from July 2018 - June 2019. This data showed the highest number of reported suicides New Zealand has recorded.

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Many people think of hospice as just a building, when in fact it is a philosophy of care. The hospice philosophy places equal importance on the physical, spiritual, cultural, emotional and social well-being of a person living with a life limiting condition.

Anyone with a terminal illness, not just cancer, can access hospice care and support. People with life limiting conditions such as multiple sclerosis, lung failure, motor neurone disease or dementia can benefit from palliative care.

Whilst hospice care is primarily focused on the person who is dying, services are also for the family and whanau both before and after their loved one has died.

Everything we provide is free of charge. As an essential health service the majority of funding comes from Government, the remainder comes from community fundraising. Each year hospices must raise over $77M nationally.

Death seems to have become a difficult topic for a lot of people. Many of us have lost the knowledge about what happens, what to say to each other, and the options we have for care.

We want to support people to talk about it more, in the hope they might worry about it less.

We created this animation to answer a question hospice staff are often asked - how do I know I am dying? what will happen to me? How will we know?

You can hear more experiences of end of life care by visiting our YouTube channel.

COVID- 19 information

As you will be aware the COVID-19 virus continues to be a worldwide pandemic as classified by the WHO. (World Health Organisation)

New Zealand is currently operating under an alert level system to put measures in keep us safe from the virus.

For more information on the current alert level and what this means please visit the dedicated COVID-19 website

Due to the alert levels it is really important you contact your local hospice service before going to an inpatient facility for any reason.
Pleaseto find your local service.

All hospice services and support are provided free of charge. As an essential health service, the majority of hospice funding comes from Central Government, but each year just over $77M needs to be raised nationally to bridge the gap.

Thank you for supporting your local hospice service by making a donation.

Hospices employ over 700 people nationwide through a range of roles within each hospice service.

Here you will find a list of current vacancies - both clinical and administration - listed on behalf of hospices across New Zealand.

Stay up-to-date with Hospice NZ's work and key national activities and developments.

Our newsletter, The Kowhai is published three times a year - subscribe to our email list to receive it directly to your inbox.

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Many people think of hospice as just a building, when in fact it is a philosophy of care. The hospice philosophy places equal importance on the physical, spiritual, cultural, emotional and social well-being of a person living with a life limiting condition. Anyone with a terminal illness, not just cancer, can access hospice care and support.

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More than 2 million New Zealanders say they have no religion.

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Lecretia Seales was a lawyer based in Wellington, New Zealand, who worked for Kensington Swan, Chen Palmer & Partners, the Department of Prime Minister and Cabinet, and the Law Commission, where she was a Senior Legal & Policy Adviser.

She was diagnosed with brain cancer in 2011. Her cancer was a grade 2 oligoastrocytoma. She received surgery to debulk the tumour but it could not be removed completely. Between 2011 and 2014 she received radiotherapy and two courses of chemotherapy to deal with the remainder of the tumour.

In January 2015, Lecretia's health entered a decline despite her treatments and she came to the end of her options for treating the cancer effectively.

She began to review her end-of-life alternatives. She discovered that if she was very lucky, she might die quickly, but that the more likely outcome was that she would have to undergo a drawn out, undignified death, after losing her mental faculties and all quality of life. Her other alternative was a violent, lonely and traumatic death at her own hand, which would rob her of a few precious weeks or months of life that would be worth living and stigmatise her as a suicide.

Lecretia believed there should be a gentler, more compassionate way. She would have liked the choice to receive physician-assisted death, to bring about her demise no sooner than the point that she determined she had no quality of life, and before she entered a long, pointless and wasteful period of suffering prior to her death.

On 20 March 2015, Lecretia and her lawyers filed a statement of claim with the High Court of New Zealand arguing that her GP should not be prosecuted under the Crimes Act 1961 in assisting her in her death with her consent, and that under the Bill of Rights Act 1962 she had the right to not be subjected to the unnecessary suffering of a long, cruel death. Lecretia's wish was to be able to die at a time of her choosing, surrounded by her husband and her family, whom she loved very much.

Lecretia passed away on 5 June 2015, on the same day the Seales v Attorney General judgment was released to the public. She was not assisted to die. The judge did not grant her the declarations she sought, but he made several statements in support of Lecretia's wishes, which the New Zealand parliament is obliged to respond to.

Lecretia's case brought awareness to the plight of the terminally ill, and through her hearing she both clarified the current state of New Zealand law and catalysed New Zealand politicians into engaging with the issue of assisted dying for the first time in more than a decade.

Lecretia hoped that others in similar situations would one day be able to make their own decisions about how they live and die, and to have the choice that she was denied.

The End of Life Choice Act was passed in November 2019, and if a public referendum secures 50% support, the Act will be implemented and New Zealanders will have the choice that Lecretia fought for.

In December 2015, Lecretia was named New Zealander of the Year by the New Zealand Herald, the country's most widely circulated print newspaper.

This blog is maintained by Lecretia's husband, Matt.

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Lecretia Seales was a lawyer based in Wellington, New Zealand, who worked for Kensington Swan, Chen Palmer & Partners, the Department of Prime Minister and Cabinet, and the Law Commission, where she was a Senior Legal & Policy Adviser. She was diagnosed with brain cancer in 2011.

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Who is behind the End-of-Life Choice Society?

We are an incorporated society of ordinary citizens from all walks of life. We share a common belief that it is cruel and inhumane to force someone to die in unbearable suffering against that person's will. We operate by means of annual membership fees and donations. We have been active in New Zealand for 44 years and used to be known as the Voluntary Euthanasia Society of New Zealand.

What is meant by "end-of-life choice", "assisted dying" and "voluntary euthanasia"?

These terms all refer to the same thing: the legal option for people to request a doctor to hasten their own death, should they find themselves with a terminal or irreversibly progressive disease that causes them unbearable suffering that cannot be relieved.

Why do you support assisted dying?

Many people would prefer an earlier death to a longer life of extreme suffering. Most of the Society's members have witnessed the agonising deaths of one or more people they have loved and do not want their own death to be similar, nor do they wish to see others forced to endure the same.

What specific actions do you take to support legalising assisted dying in New Zealand?

We lobby parliamentarians to make changes to the law so that assisted dying becomes available and accessible to those who need it.

We counter misinformation about assisted dying in the media, via our online presence and by providing information to the public at face-to-face events. Please see our website and Facebook page.

We maintain ongoing communication with the Ministry of Health which oversees the implementation of the End-of-Life Choice Act 2019, which comes into force on 7 November 2021. We advise the MoH on best practice implementation drawn from overseas examples.

We inform the public on the progress of assisted dying legislation in other countries and jurisdictions.

Who was involved in the End-of-Life Choice campaign? Which organisations played part in this?

The Society was very active in this campaign through articles published in the media, through its online presence and media appearances (TV/radio) and through local events providing face-to-face information.

We were supported by Doctors for End-of-Life Choice New Zealand, a group of retired and working medical professionals. This group presented arguments for and evidence of the need for assisted dying legalisation via medical journals, opinion pieces and media appearances.

Finally, we are grateful to the "Yes for Compassion" organisation which undertook a large-scale, professional media campaign designed to counter the misinformation put about during the passage of the Act through parliament and during the referendum period.

Do you support palliative care?

The Society strongly supports palliative care and believes that most people and their families find it very helpful at the end of life. We also support increased government funding for palliative care and an expansion of its services. However, we know from personal experience as well as from international research that some diseases and conditions do not respond to even the best of palliative care. Under those circumstances, we believe assisted dying is a compassionate alternative.

Do you promote Advance Directives?

The Society has promoted Advance Directives for many years. Although our current legislation does not allow assisted dying by means of an Advance Directive, we still believe it to be an excellent document for all people to have all through their adult life. It is an alternative for those who do not meet the eligibility criteria for assisted dying but who do not wish to prolong their life under certain circumstances. An Advance Directive makes use of people's legal rights to refuse or reject unwanted treatment or medication. Please download our free-of-charge Advance Directive booklet and form here "

How can I obtain an assisted death?

You will need to meet all of the following eligibility criteria, as assessed and agreed by two unrelated doctors:

Aged 18 years or over and

A New Zealand citizen or permanent resident and

Diagnosed with a terminal illness that is likely to end your life within 6 months or less and

In an advanced state of irreversible decline in physical capability and

Experiencing unbearable suffering that cannot be relieved in any manner tolerable to you and

Be uncoerced and

Be mentally competent to understand what you are asking and to understand the implications for you if you decide to go through with an assisted death.

Assisted dying is not available to those applying solely on grounds of disability or of mental illness. It is not available via Advance Directive or once mental competency has been lost, e.g. due to advancing dementia.

Please see the "Need Help?" page on our website for current information. If you believe you are eligible for assisted dying and wish to pursue this path, you must take the first step by initiating a request. It is illegal for your doctor to raise the topic of assisted dying with you, but your doctor can respond if you ask about it.

How will the Act impact disabled people?

There are two primary but opposing issues of concern for the disability community.

1. That disabled people may be at risk by the legislation because of potential coercion by family and other influencers who may wish to use the Act to hasten their death.

2. That disabled people may be denied access to the legislation because they may be wrongly assessed as not competent to make an informed decision to end their life.

We will ensure that these issues are well understood and that appropriate mitigation against these scenarios is included in the Act's policies and procedures.

What's happening overseas regarding assisted dying?

As of January 2021, assisted dying legislation covered some 250 - 300 million people worldwide. These include entire countries such as Canada, Switzerland, Holland, Belgium, Spain, but also states such as California US and the Australian states of Victoria, West Australia and Tasmania. This year, we expect our neighbours South Australia and Queensland to pass assisted dying legislation. We believe there is no turning back the tide of right-to-die movements around the globe, as practical experience explodes the fearful myths and dire predictions, giving way to the reality of a peaceful, lawful death. Our own End of Life Choice Act comes into force on 7 November 2021.

How can I support the End-of-Life Choice Society?

Become a member, or sign up to receive our newsletters or make a donation. Your support will always be appreciated - and always much needed.

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We are an incorporated society of ordinary citizens from all walks of life. We share a common belief that it is cruel and inhumane to force someone to die in unbearable suffering against that person's will. We operate by means of annual membership fees and donations.

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The legislation, if it comes into effect, would provide people with a terminal illness the option of requesting assisted dying in certain circumstances.

The Government's referendum website highlights a list of eligibility criteria, such as the individual suffering from a terminal illness likely to end their life within six months, having a significant and ongoing decline in physical capability and experiencing unbearable suffering.

"A person would not be eligible to ask for assisted dying if the only reason they give is that they are suffering from a mental disorder or mental illness, or have a disability of any kind, or are of advanced age," the website says.

Piha resident Bobbie Carroll, 67, is among those advocating for the referendum to pass.

In 2016, she was diagnosed with multiple Myeloma, a blood cancer. Back in March 2018, she appeared on The AM Show and said there was an average life expectancy of about six to six-and-a-half years.

Since she was last on the show, Carroll has relapsed.

"In particular, it is active, attacking my bones. Multi-myeloma is called multi because it can do organs or bones or whatever. I broke a rib and then spontaneously, I was in the garden, and my clavicle just exploded. It was excruciating and so I had a full skeletal MRI and my bones have degraded somewhat," she told The AM Show.

She went to the hospital, but says it took five days to get her pain under control with the morphine not having any effect.

"I am now on a new chemo drug. That will put me back into maybe a remission and then I will relapse again. The next time I relapse, the last available drug will be ready for me and I will be put on that. I will be on the final chemo drug available for me and then when I relapse again, that's when the doctors say 'Bob, you know, we have used everything in the armoury'."

Carroll was asked whether in the future, if she met the eligibility criteria, would she request assisted dying. At this stage, she says, she doesn't know. But she wants the option if necessary.

"I don't know if I will use it or not. I just want the choice. That choice will kick in depending on the state of play with my body. If it was excruciating pain like I had with the clavicle, and it wasn't under control or other things like that, I may. But there is no guarantee".

She knows how she would like it to go, however, if it was to happen.

"It is myself, [her partner] Julia, my daughter, my grandies, my stepson, and maybe three or four really close friends. I have already spoken to hospice about this. It will be in my home. It will be gentle and loving and when we are all ready," she said.

Advance voting for the election and referendums is currently open, and a Newshub-Reid Research poll out last week shows the euthanasia vote is likely to pass. It saw 61.6 percent of participants say they supported the Act coming into force, and 25.5 percent saying no. There were 11.9 percent of people who didn't know.

Carroll told The AM Show that she is "feeling a rumble of anger about people that wish to take my choice away from me".

"If you vote yes and I vote yes, and you don't want to do it, you don't have to, and I can," she said.

"But if you vote no, and if you vote no, and if you vote no, you are taking my choice away from me. Who the hell gave you that right? You don't even know me."

Opponents of the legislation have accused it of not having adequate safeguards and that people sometimes outlive their prognosis. Supporters, however, believe proper checks and balances are in place and that the emphasis is on giving people a choice, not putting the decision into others' hands.
Watch the full interview above.

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Euthanasia advocate says referendum about giving people choice in emotional interview

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The legislation, if it comes into effect, would provide people with a terminal illness the option of requesting assisted dying in certain circumstances. The Government's referendum website highlights a list of eligibility criteria, such as the individual suffering from a terminal illness likely to end their life within six months, having a significant and ongoing decline in physical capability and experiencing unbearable suffering.

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What is terminal illness? Definition of terminal illness

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Terminal illness definition - when they reach a point where their illness is likely to lead to their death. They may live for days, weeks, months or years.

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Esther Richards, 54, and Vicki Walsh, 50, both know what it's like to be given a terminal diagnosis.

But the two mothers have come to very different conclusions about assisted dying.

Richards' cancer is now in remission and she is on the committee of her local end of life choice group; while Walsh, who has publicly documented her journey with a terminal illness, said her experience changed her mind about euthanasia.

In a New Zealand first, a new study is seeking the views of the terminally ill on assisted dying.

READ MORE:
* Voluntary euthanasia bill launched by David Seymour
* Parliamentary inquiry into record euthanasia submissions: 'note' response
* Euthanasia bill consistent with right to life, conscience and freedom of expression: Attorney General
* Terminal brain cancer patient chooses life over suicide

"We should all have this choice to have a peaceful way out," Richards said.

The Tauranga woman was diagnosed with glioblastoma - an aggressive brain tumour- in October 2012 and underwent seven and a half months of radiation and chemotherapy.

Richards never considered ending her life but she did hoard pills for the worst case scenario.

Knowing there was a safe and legal option if she needed it would have relieved a huge burden, she said.

"Mentally and emotionally knowing I would have had that option when it got so bad would have eased my mind a lot more, it would have made me a lot less stressed throughout the whole thing."

"The worst thing about that is I have to do it alone, I have to not tell anyone and then someone has got to find me- that is going to be really hard on the people who love me."

In contrast, Vicki Walsh, 50 from Tokomaru, near Palmerston North, said her journey since her diagnosis had changed her mind about euthanasia.

"I feel very passionate about people like myself not being put under pressure."

​Not long after her diagnosis of glioblastoma in June 2011, when she was very unwell, Walsh decided to take her own life.

She changed her mind at the last minute.

"That was really life changing for me."

"If I had not been on my own when I made that decision and had I had the option of assisted dying, I probably would have had family members here and loved ones and they would have come to be with me while I died."

"And I wonder whether I would have backed out of it."

"Yet I've gone on to have three more grandchildren now... I would have missed out on so much."

She is concerned terminally ill people will feel like a burden and more people will feel compelled to end their lives if assisted dying is legalised.

"Twenty years ago, I probably would have told you, 'Yes, I think everyone should be allowed to end their lives when they choose to'.

"Where as being in this situation I actually feel very differently about it."

Otago University student Jessica Young is canvassing the unique perspective of people like Richards and Walsh for her PhD.

"There has been quite a bit of research in New Zealand around people's views but it tended to be with healthy adults, and I think approaching the end of life gives you a different insight into death and dying," Young said.

"I think that is a really important issue to understand from their perspective, because these are the people who would be affected by a law change."

She is seeking up to 15 New Zealanders of different age, ethnicity and religious belief, to take part in the research.

It will give those with a terminal, incurable, degenerative or progressive illness a chance to have their say, Young said.

"It is going to be a challenging set of interviews, I imagine."

David Seymour's End of Life Choice Bill - that would give people with a terminal illness or a grievous and irremediable medical condition the option of requesting assisted dying - is before Parliament.

In Australia, Victoria's upper house held a marathon debate last week on a voluntary assisted dying bill.

A similar bill was voted down in New South Wales.

* To participate in the research, contact Jessica Young: endoflifechoicestudy@otago.ac.nz or the Department of General Practice and Rural Health, University of Otago.

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Terminally ill Kiwis to have their say on euthanasia

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Esther Richards, 54, and Vicki Walsh, 50, both know what it's like to be given a terminal diagnosis. But the two mothers have come to very different conclusions about assisted dying.

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GREETINGS AND WELCOME TO THE END-OF-LIFE CHOICE SOCIETY
In 2020 we successfully pursued a change in the law that will enhance choice at the end of life. New Zealand now has legislation that enables competent adults experiencing irremediable suffering from a terminal illness to receive medical assistance to end their lives at a time of their choosing.

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End-of-Life Choice Society of NZ Inc - HOME

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GREETINGS AND WELCOME TO THE END-OF-LIFE CHOICE SOCIETY

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Assisted dying and euthanasia will be legal in New Zealand next year, with the public voting through the End of Life Choice Act.

The Electoral Commission released the preliminary results of the End of Life Choice Act referendum on Friday afternoon.

A 50 per cent majority was needed for the law to come into force - allowing terminally ill adults with fewer than six months to live to request assisted dying.

The preliminary figures show 65.2 per cent voted in favour of the act as opposed to 33.8 per cent who voted to maintain the status quo.

READ MORE:
* Euthanasia referendum: Has the End of Life Choice Act passed? We may know today
* Euthanasia and cannabis referendums: Why do we have to wait weeks for the results?
* Euthanasia referendum: Lecretia Seales' widower 'at peace' after five-year fight

One per cent - 25,073 - of the votes were "informal", or invalid votes.

More than 2.4 million New Zealanders voted in the referendum - of those, 1.57 million voted yes.

The End of Life Choice Act will come into effect in November 2021, allowing for safeguards and processes outlined in the Act to be established.

From next year, people who meet the criteria will have the option of legally asking for medical assistance to end their lives.

The End of Life Choice Act referendum was historic - the first time legislation around assisted dying has been put to public vote in New Zealand.

However, it is not the first time Parliament has attempted to legislate assisted dying or euthanasia in New Zealand, with three failed attempts since 1995.

This act, led by ACT Party leader David Seymour, was entered into a ballot in 2015 and upon being drawn, passed three parliamentary readings to get to this stage.

Yes for Compassion executive director Dr Jessica Young said it was "delighted New Zealand came together and voted for choice for their loved ones and for themselves".

Young said New Zealand was admired worldwide as a liberal democracy, and for being the first to give women the vote.

"Today's historic victory continues that tradition, providing the choice of an assisted death to terminally ill Kiwis who want and need it - saving a great deal of unnecessary suffering for individuals and their loved ones."

Young also said she wanted to remember and acknowledge the decades of work that paved the way for the End of Life Choice Act becoming law, including by campaigners who have not lived to see this day.

Stuart Armstrong, who has terminal cancer, was among those supporting the outcome at Parliament on Friday afternoon.

The 60-year-old had flown to Wellington from Lincoln, outside of Christchurch, to mark the occasion, and intended on having a "big knees up" to celebrate.

"It is such a fantastic day," he told Stuff.

"Kiwis had a chance to have their say, and have said it in resounding fashion."

Armstrong, who has campaigned for the act and stated he one day wants to die in a matter he sees fit, said he was "incredibly grateful" for those who had worked to get this result.

"I am very, very proud."

The ACT Party said it was confident it was a "resounding victory" - one that would make New Zealand "a more compassionate and humane society".

"Thousands of New Zealanders who might have suffered excruciating deaths will have choice, dignity, control, and autonomy over their own bodies, protected by the rule of law," Seymour said in a statement.

Meanwhile, conservative lobby group Family First has called the result a "sad and dangerous day for the vulnerable".

"It is one thing to say yes to a nice-sounding phrase around having 'choice', but assisted suicide is not a simple yes no answer," national director Bob McCoskrie said.

He was concerned some New Zealanders may come to feel euthanasia would be the "right thing to do".

The Salvation Army has also expressed "serious concern" over the result.

Mark Campbell, territory commander for the Salvation Army in New Zealand, said it believed many New Zealanders are "unaware of the lack of safeguards contained within the End of Life Choice Act".

He said vulnerable people, such as the elderly and those struggling with mental illness, would be "especially at risk from this law".

The Royal New Zealand College of GPs released a statement saying it was "cautious" about the outcome, which would see some doctors assisting a patient to end their life in 12 months' time.

College president Dr Samantha Murton said while the results gave clear guidance about what options people want at the end of their lives, it "doesn't make it any less complex for medical professionals".

She highlighted rural communities in particular, where some doctors are the only medical care for some distance.

"Our membership is diverse and will run the gamut on personal opinions about euthanasia. However, professionally we are steadfast; we will work within the law and continue to do what is best for our patients."

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Referendum results: End of Life Choice Act passes, legalising assisted dying

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Assisted dying and euthanasia will be legal in New Zealand next year, with the public voting through the End of Life Choice Act. The Electoral Commission released the preliminary results of the End of Life Choice Act referendum on Friday afternoon.

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At the 2020 General Election, New Zealanders had the opportunity to vote in a referendum on whether the End of Life Choice Act 2019 (the Act) should come into force. A majority of voters supported the Act.

The Act gives people who experience unbearable suffering from a terminal illness the option of legally asking for medical assistance to end their lives. However, assisted dying remains illegal until the Act comes into force on 7 November 2021.

The Act outlines the legal framework for assisted dying, and includes controls to ensure anyone who seeks assistance to end their life is making an informed decision of their own accord.

The Ministry of Health will be responsible for the Act and has developed a work programme to implement it. This will include developing policy and preparing guidance for health providers.
On this page:
What is assisted dying?

'Assisted dying' involves:

a person's medical practitioner (doctor) or nurse practitioner giving them medication to relieve their suffering by bringing on death; or

the taking of medication by the person to relieve their suffering by bringing on death.

Assisted dying is not a replacement for palliative care or health care services more generally.

Health practitioners, medical practitioners and nurse practitioners have different roles under the Act. An explanation of these roles can be found further down this page: Health practitioners, medical practitioners and nurse practitioners

Eligibility for assisted dying

Criteria in the Act set out who is eligible for assisted dying. To be eligible, a person must meet all of the following criteria:

be aged 18 years or over

be a citizen or permanent resident of New Zealand

suffer from a terminal illness that is likely to end their life within 6 months

be in an advanced state of irreversible decline in physical capability

experience unbearable suffering that cannot be relieved in a manner that the person considers tolerable

be competent to make an informed decision about assisted dying.

A person cannot receive assisted dying solely because they are suffering from a mental disorder or mental illness, have a disability, or are of advanced age.

Citizens and permanent residents who are overseas can return to New Zealand to access the service.

A person cannot use an 'advance directive' to request assisted dying. An advance directive is a statement setting out ahead of time what treatment they want, or do not want, to receive in the future. A person requesting assisted dying must be able to make that decision at the time the request is made.

Both the medical practitioner treating the person and a second, independent medical practitioner must agree that the person is eligible for assisted dying. If either medical practitioner is unsure of the person's competence to make an informed decision, a psychiatrist must also assess the person to confirm their eligibility. If the opinion is reached that the person is not eligible, the process ends.

Once the Act comes into force, a person who wishes to receive assisted dying and thinks they meet the eligibility criteria can:

Ensuring an informed choice

If at any time the medical practitioner or nurse practitioner suspects a person is being pressured about their decision to receive assisted dying, they must immediately stop the process.

The Act includes a number of measures to ensure the person is making an informed decision and it is their choice to have an assisted death:

A health practitioner cannot discuss assisted dying with a patient unless the patient raises it with them first. A health practitioner providing a health service to the person may be subject to disciplinary proceedings or proceedings for breaching patient rights if they initiate a discussion about assisted dying.

The medical practitioners involved in the process must determine that the person is competent to make an informed decision about assisted dying, which includes being able to understand, retain, use and weigh information about assisted dying to make an informed decision about assisted dying, and can communicate that decision in some way.

A person can change their mind at any time up until the medication is administered, and their medical practitioner must ensure they are aware they can change their mind.

The medical practitioner treating the person must encourage the person to discuss their wish for assisted dying with family, friends and counsellors, and must ensure the person has the opportunity to do so. However, a person who chooses to receive assisted dying does not have to discuss their wish with anyone if they don't want to.

The medical practitioner must do their best to ensure the person's decision is free from pressure from any other person by talking with:

other health practitioners who are in regular contact with the person

members of the person's family approved by the person.

The role of family

A person who chooses to receive assisted dying does not have to discuss it with their friends and family if they don't want to. Whether to apply for assisted dying is the patient's choice. Family members, whānau and welfare guardians do not have any power to make decisions on behalf of a family member.

However, medical practitioners must encourage the person to discuss their wish with family, whānau, friends and counsellors. They must ensure there is opportunity for the patient to do so.

The medical practitioner may speak to members of the patient's family or whānau as part of the eligibility process, if they have the patient's permission.

Health practitioners can opt out

Health practitioners do not have to help a person with assisted dying if they have a conscientious objection.

A Support and Consultation for End of Life in New Zealand (SCENZ) group will be established by the Ministry prior to the commencement of the Act on 7 November 2021. SCENZ will maintain a list of medical practitioners, psychiatrists and pharmacists who are willing to be involved in the assisted dying process.

If an attending medical practitioner is asked to provide assisted dying by a patient and they object to providing the service because they have a conscientious objection, the medical practitioner must inform the patient that they have a conscientious objection, and tell them of their right to ask the SCENZ group for the name and contact details of a replacement medical practitioner.

Methods for assisted dying

An eligible person who wishes to access assisted dying will be asked to choose one of the following methods for receiving the medication:

Ingestion, triggered by the person

Intravenous delivery, triggered by the person

Ingestion through a tube, triggered by the medical practitioner or nurse practitioner

Injection, administered by the medical practitioner or nurse practitioner

When an eligible person has chosen the method for receiving the medication, their medical practitioner must ensure that the person knows they can change their mind at any time. The person may also choose to delay the date they were due to receive assisted dying by up to 6 months without needing to restart the application process.

The medical practitioner must notify the Registrar if a person changes their mind, withdraws their request, or asks for more time, if this occurs. No further actions to carry out assisted dying are allowed to be taken if the person withdraws their request to receive assisted dying.

Before administering any medication, the attending medical practitioner or nurse practitioner must ask the person if they choose to receive the medication. The person may use non-verbal communication such as gestures to inform the attending medical practitioner or nurse practitioner.

Patients are able to discuss a preferred date, time and location for receiving assisted dying with their medical practitioner.

There is no 'waiting period' between when a request for assisted dying services is made and when the medication can be administered. However, there are steps that need to be followed once a request is made, and these will take time.

For example, two medical practitioners need to establish that the patient is eligible. The attending medical practitioner needs to do their best to ensure that the person's decision is their own, free from any other pressure. This includes talking with other health practitioners who are in regular contact with that person, and members of that person's family and whānau, if the patient has given permission.

The Registrar for assisted dying needs to be notified of the request. They need to confirm that all the necessary steps are complete before assisted dying can happen. These steps will take time.

Implementation and Oversight of the Act

The Ministry of Health is responsible for ensuring the Act is implemented appropriately.

The Act provides for three statutory roles within the health system to oversee assisted dying and make sure the processes outlined in the Act are followed. The three roles are:

the Support and Consultation for End of Life in New Zealand (SCENZ) Group

the End of Life Review Committee

the Registrar (assisted dying).

Read more about the programme of work implementing the Act.

Health practitioners, medical practitioners and nurse practitioners

A health practitioner is the term for health professionals who are required to be registered and hold a practising certificate, such as doctors, nurses and pharmacists.

Health practitioners are not required to help a person with assisted dying if they have a conscientious objection. All health practitioners are prohibited from raising assisted dying with a patient - this must be raised by the person seeking an assisted death first.

Some types of health practitioners have additional roles that they can perform under the Act.

1 A medical practitioner means a doctor who is registered with the Medical Council of New Zealand, and who holds a practising certificate. Determining a person's eligibility for an assisted death can only be done by a medical practitioner.

2 A nurse practitioner has advanced education, clinical training and the demonstrated competence and legal authority to practise beyond the level of a registered nurse. The administration of assisted dying medication can only be done by a medical practitioner, or a nurse practitioner.

Subscribe for updates

The Ministry will be providing further information about the implementation of the Act through-out 2021. Subscribe to our newsletter for updates.

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At the 2020 General Election, New Zealanders had the opportunity to vote in a referendum on whether the End of Life Choice Act 2019 (the Act) should come into force. A majority of voters supported the Act. The Act gives people who experience unbearable suffering from a terminal illness the option of legally asking for medical assistance to end their lives.

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In October 2020, New Zealanders will be asked if they support the implementation of the End of Life Choice Act 2019 (EoLCA): ( http://www.legislation.govt.nz/act/public/2019/0067/latest/whole.html#DLM7285905).1

This referendum has particular implications for doctors; as practitioners who may be asked to hold the syringe, there is little room to abstain. Clinicians require a good understanding of the Act and, in the interests of clarity, we have compiled a glossary of relevant terms. For the purposes of this Viewpoint, 'euthanasia' signifies both voluntary euthanasia and physician-assisted suicide (see Appendix).

Confusion regarding terminology is widespread among the public; many New Zealanders appear to falsely believe the EoLCA applies to end-of-life practices currently legal, such as turning off life-support, implementing 'do not resuscitate' requests, and ceasing active investigation and treatment.2 When people are given proper definitions, strong views on both sides of the debate soften.2

The EoLCA Referendum is also binding on an Act that has passed in parliament and received Royal Assent. Accordingly, the specifics and technicalities are finalised, highlighting the importance for voters to understand the Act's details. A link to the official Government website has been included (though this link may not be functional after the referendum): www.referendums.govt.nz/endoflifechoice/summary.html.3

A brief summary of New Zealand legal criteria is presented in Table 1, alongside those approved in other countries.

Table 1: Comparison of proposed New Zealand law with other jurisdictions.

The EoLCA additionally stipulates that euthanasia:

* must be indicated on the death certificate, along with the terminal illness that gave rise to the patient's eligibility

* cannot be requested by anyone other than the patient

* does not require:

o prior access to appropriate medical or palliative care

o a 'cooling off' period between request and implementation

o an independent witness at any stage of the process

o the individual to inform anyone of their decision

o the doctor to reconfirm competence when patients affirm the decision to proceed at the chosen time for administration of the lethal substance

Conscientious objection

Conscientious objection is defined in the EoLCA as any objection to euthanasia on the grounds of conscience. The Act requires medical objectors to inform patients of their objection and advise they can seek a replacement from the Support and Consultation for End of Life in New Zealand (SCENZ) Group, to be established by the Ministry of Health. Objectors are not required to make onward referrals.

The EoLCA is silent on objection for organisations, eg, hospices, though there has been a recent High Court case which granted limited declarations around interpretation of the Act.4 Also absent are legal requirements for nurses, pharmacists or other health professionals who may conscientiously object; overseas evidence notably indicates nurses are often approached first with enquiries about euthanasia.5

Summary of arguments

Table 2 summarises some of the more common arguments for and against euthanasia. Relevant moral and philosophical considerations are beyond the scope of this paper.6

Table 2: Arguments for and against legalising euthanasia.

Role of doctors

The role of doctors in enabling patient autonomy is evident in abortion, which, without medical assistance, may result in unnecessary harm.7 Similarly, without assistance, a patient's desire to die may result in cruder methods of suicide, risking more suffering and trauma, or decisions to end life earlier.

Many supporters believe access to euthanasia is vital in ensuring a 'right to die', despite this principle failing to be affirmed by the US Supreme Court,8 the UK Supreme Court,9 the European Court of Human Rights10 and the New Zealand High Court.11 Not all legal experts agree, however. As US Supreme Court Justice Souter said regarding assistance in dying, "There can be no stronger claim to a physician's assistance than at the time when death is imminent". Advocates also point out that legal and judicial opinion often move slower than societal shifts in attitude.

Some people from both sides of the issue contend that euthanasia should not be solely a medical decision, and instead advocate court involvement, consistent with other complex medical decisions.12 Some also posit that a separate profession should ensure that the procedure is done safely from a technical perspective, thus protecting the doctor's role as a healer.

On the other hand, consistent with NZMA's updated Code of Ethics,13 opponents disagree with any medical involvement because they see euthanasia as incompatible with the doctor's role. The doctor-patient relationship remains asymmetrical in terms of power; how doctors communicate information can determine whether a patient chooses to undergo risky investigations or treatments. Opponents point to evidence overseas that the primary motivation for requesting euthanasia is not unbearable pain but the perceived loss of dignity14,15 and note the crucial role doctors can play in addressing that. Indeed, there is often emotional asymmetry when seriously ill patients look to their doctors for guidance and reassurance. Opponents worry about the risk of subtle coercion and undue influence,7 especially in end-of-life situations, and believe that such conversations risk harming the doctor-patient relationship.

The emotional demands of euthanasia work are inadequately understood. In a qualitative study of Dutch doctors involved with euthanasia for patients with dementia (legal in the Netherlands),16 the value of investing time to improve quality of care was strongly endorsed but seen as challenging, with some choosing to work on days off. All doctors felt there could be more support for those involved, and described the work as emotionally intense, both negatively (moral distress, frustration, anger, insecurity) and positively ('feeling in control', heroism, satisfaction, relief).16

The nursing role is crucial; a Dutch study showed them to be the first point of contact in almost half of the requests.5 Nurses are actively involved in voluntary euthanasia, even when not legally sanctioned (21% in the Netherlands), cf. 59% in Belgium, where it is legal.5

Other research suggests a lack of support for nurses who may feel pressured to take part to uphold their 'duty of care', even though conscientious objection is 'legally' permissible. Both supporters and objectors voiced concern about available support and clarity regarding professional and legal requirements.17 The EoLCA is silent on some of these issues, highlighting the importance of ensuring nurses are supported, and aware of their legal obligations and protections.

Lastly, relatively little is known about the impacts of asking health professionals to participate in euthanasia. Moral distress arises when clinicians believe they are unable to act in patients' best interests and thus includes concerns about wrongly approving or withholding euthanasia. Both possibilities need to be considered and appropriately managed.

Palliative sedation is sometimes misleadingly regarded as an example of 'euthanasia' when it hastens death.18 To whatever extent this occurs, there is a strong case that palliative sedation and euthanasia remain distinct due to differences in intent (as described by the principle of double effect). Unlike palliative sedation, the doctor who carries out euthanasia will have failed if the patient survives the procedure. Of note, multiple systematic reviews showed no association between palliative sedation and reduced survival.19,20 To the contrary, 12 of the 13 studies found marginally longer survival in those sedated.

Philosophical discussions regarding the principle of double effect may be relevant for end-of-life decisions but are beyond the scope of this paper.21,22

Comparison to abortion

Despite superficial similarities, there are substantial differences between euthanasia and abortion, and they should be considered separately.23

Similarities:

* both require technical expertise to ensure physical, emotional and legal safety

* both reflect intimate and personal decisions relevant to bodily and personal autonomy

* both decisions can be subject to coercion

Differences:

* Abortion happens far more frequently (one in four women in OECD)

* Euthanasia is seen to be a personal decision, while abortion requires the mother's decision on behalf of the fetus

* Euthanasia is the end of the life of a legal person, whereas abortion involves the loss of a fetus that is yet to have legal recognition as a person

The case for autonomy

The optimisation of individual autonomy via the EoLCA is, for many, an intuitively attractive option for medical assistance at end of life, and consistent with patient-centred care. However, ensuring autonomy is not always regarded as an absolute priority, such as when it may result in harm to self or others. Restrictions on autonomy include mandatory seat belts, prohibition against drink driving, and regulations regarding organ donation; these are deemed appropriate trade-offs in our current social contract.24 This contract can be renegotiated and, indeed, the idea of organ donation euthanasia (where death follows removal of the organs under general anaesthetic, with informed consent) is a hypothetical discussed and advocated by some as consistent with maximising autonomy and contributing to a meaningful death.25,26 The doctor's role in euthanasia thus brings into sharp relief questions about the limits and social context of autonomy.

Role of law

The Act as it stands passed royal assent in November 2019. Accordingly, we are also voting on the Act's details: legal rules, technicalities, practical and cultural implications. It is also widely accepted that law has a pedagogical function and helps shape culture as well as reacting to cultural shifts.

Proponents of euthanasia argue that the purpose of law is to protect people's freedoms, empowering individuals to judge their own quality of life, and to choose when and how to die; others may also benefit from the experience and memory of a loved one's peaceful death.

Even though the UK Supreme Court could not justify authorising euthanasia, an unintended consequence was noted by Lord Browne-Wilkinson-"...How can it be lawful to allow a patient to die slowly, though painlessly, over a period of weeks from lack of food but unlawful to produce his immediate death by a lethal injection, thereby saving his family from yet another ordeal to add to the tragedy that has already struck them? I find it difficult to find a moral answer to that question. But it is undoubtedly the law...".27 Similarly, the US Supreme Court also acknowledged that the state's interest in preserving life at all cost may be outweighed by the liberty interest of those already on the threshold of death.7,28

On the other hand, opponents argue that laws exist to protect society, especially the most vulnerable. These include those from disadvantaged ethnic or socioeconomic groups and those with disabilities. They point to legal tradition in Anglophone countries that has consistently opposed assisted suicide and sought to ensure equal protection for the 'hopelessly diseased, fatally wounded, and even criminals condemned to death'.7 Developments in modern medicine have both complicated and drawn attention to issues of dignity and independence at the end of life. Legislative changes around the world have affirmed the right to refuse treatment and enable do-not-resuscitate orders and proxy decision-making, while generally reaffirming bans on assisting suicide.

The EoLCA is intended to give the terminally ill a sense of control and/or to relieve intractable suffering, but some argue this specific Act may not adequately safeguard against ending vulnerable people's lives against their wishes. Many reasons patients seek euthanasia (loss of dignity, suffering, feeling like a burden) may also make them more vulnerable to coercion, highlighting the importance of both legal and practical protections. Indeed, despite comments made by individual judges, the UK and US Supreme Courts and others have consistently ruled that the state's interest in protecting the vulnerable is sufficiently weighty to justify prohibitions against physician-assisted suicide.7,27

The 'slippery slope' is a term that has a wide range of interpretations from both sides of the discussion. This Viewpoint focuses on the anticipated expansion of legal eligibility criteria, as distinct from increased numbers approved for euthanasia each year. The latter statistic fails to distinguish between adoption of a preferable way of dying and concerns regarding expansion of eligibility criteria.

Examples of criteria expansion include:

* Belgium removing the age limit for euthanasia,29 and subsequently a nine-year-old with a brain tumour and an 11-year-old with cystic fibrosis have been euthanised;

* Colombia allowing euthanasia for children aged 6+;30

* Netherlands developing the Groningen Protocol and common law precedents for children under one year of age;31

* A proposed bill in Canada removing the requirement that death be foreseeable;32

* Oregon relaxing the required waiting/cooling-off period for those with a lesser life expectancy, and a proposed bill removing the requirement for a six-month prognosis.33,34

Once euthanasia has been legalised at central or federal level, there is at present no example of a statutory reversal or tightening of euthanasia eligibility criteria in any jurisdiction. US Supreme Court Justice Cardozo noted the tendency of a legal principle to "expand itself to the limit of its logic".35 Euthanasia seems to be no exception, with conclusions to this effect from both the US and UK Supreme Courts-that "once a legislature abandons a categorical prohibition against physician-assisted suicide, there is no obvious stopping point".7,27

Like the EoLCA, legalisation in Canada includes no description of euthanasia as a human right. However, receiving assistance for the procedure was interpreted by the Ontario Superior Court as "a constitutionally protected civil and human right".36 With this interpretation, it may be difficult to justify denying this right to:

* someone with a degenerative condition expected to lose autonomy before reaching their six-month prognosis

* someone who does not have a terminal condition but experiences intractable suffering

* someone with unbearable mental instead of physical suffering

* someone who is 17 but deemed competent

The last point is immediately relevant as the Attorney-General has concluded that the EoLCA is inconsistent with the New Zealand Bill of Rights,37 which protects all those above the age of 16 from age-based discrimination. This makes it a cogent place for advocates to challenge and expand existing criteria.

The expansion in eligibility criteria seen overseas is not necessarily a moral fault but appears likely, as above, based on both overseas experience and formal judicial commentary. While some advocates of a "right to euthanasia" praise these expansions as egalitarian, allowing more equitable access to a valuable end-of-life option, this will concern those advocating strict eligibility criteria and who believe certain groups should never have access to euthanasia.

A distinct set of 'slippery slope' concerns relate to existing euthanasia laws, how strictly they are enforced, and other legal safeguards designed to protect vulnerable patients.38 The Canadian Supreme Court reviewed these concerns and found that laws governing euthanasia could be effectively and rigorously implemented, paving the way for legalisation in that country.39

Concerns about coercion

In New Zealand contract law, determination that individual wishes are free from undue influence involves examination of witnesses, arguments by lawyers on both sides, and consideration of legal precedent. In the context of existing common law and the EoLCA, this means that:

* Similar responsibilities are to be placed on one individual doctor;

* The doctor does not have access to the powers of the court;

* The doctor is presumed to hold a position of power and influence over patients;

* These concern weightier decisions than those typical of contract law.

These challenges are further complicated in scenarios where the primary doctor conscientiously objects: the replacement doctor must assume this responsibility without the long-term relationship and knowledge of the patient and family. The doctor providing the second independent opinion also has no obligation to determine coercion. Finally, there is no requirement to ensure lack of undue influence at the time of final consent to administration of the lethal dose. Advocates point out that these responsibilities would fall within broad professional standards and governance.

Concerns have also been raised regarding the EoLCA's regulatory framework. In particular, its Review Committee does not receive demographic data such as age, gender, ethnicity and socioeconomic status, or indeed any clinical information confirming eligibility or excluding coercion, making it difficult to confirm the statutory requirement of "satisfactory compliance with the requirements of this Act".

These factors have led some to believe the EoLCA does not do enough to ensure patients are making decisions free from coercion. The High Court of England and Wales analysed a comparatively more stringent safeguard in 2017: that each case would be reviewed by the court to ensure the absence of coercion. Their conclusion (upheld by both the Court of Appeal and the Supreme Court) was that even such a process would be considered an inadequate safeguard.40

However, as was pointed out by the Canadian Supreme Court,39 the risks of coercion are already present in the existing medical system when it comes to refusal or withdrawal of life support, both of which remain lawful. Proponents highlight this inconsistency and argue that concerns regarding coercion have been overvalued and cannot justify an absolute prohibition of euthanasia. In contrast, opponents point to an additional reason why withdrawal of life support cannot be prohibited, namely that it may result in medication/life support being forced on unwilling patients.

The US Supreme Court goes beyond protecting the vulnerable from coercion and extends the state's interest to protecting disabled and terminally ill people from prejudice, negative and inaccurate stereotypes, and "societal indifference".7 In New Zealand, the absence of demographic data required by the EoLCA will make it difficult to measure the impact of the Act at a population level and identify trends, or gaps in access. The EoLCA also has no specific provisions to ensure patients receive culturally appropriate care, including kaupapa Māori considerations as mandated by Te Tiriti o Waitangi.

Mental illness and vulnerability

Depression is common in patients with a terminal illness, with up to 44% fitting a diagnosis of depressive disorder.41 However, differentiating depressive disorders from grief reactions in the setting of a terminal illness can be difficult. Undertreatment of psychiatric illness is common,41 for example up to 80% of cases among cancer patients remain unrecognised and untreated;42 cancer constitutes the largest proportion of New Zealand's deaths and proportion of completed euthanasia overseas.15,43,44 Missed psychiatric diagnoses clearly increase the risk of inappropriate or unnecessary requests for euthanasia.

The New Zealand government has prioritised reducing suicide rates while provisionally approving assisted suicide under the EoLCA. While some posit that legalising euthanasia may affect suicide rates, this is not strongly supported by the numbers; a review found no evidence for an association between suicide rates and legalisation of euthanasia in various countries.45

Cases of people who opponents would consider vulnerable being euthanised are well documented in multiple jurisdictions. A Dutch government study revealed that in 1990 there were more than 1,000 cases of euthanasia without an explicit request.7 While the situation has apparently improved, this is still an ongoing practice. The most recent data available via the Dutch government website showed that in 2015, 431 people were euthanised without explicit request46-around 0.3% of total deaths that year, assuming no underreporting. In 2018, there were 67 reported cases of patients receiving euthanasia for psychiatric indications. A notable case in 2015 was a victim of sexual abuse in her 20s diagnosed with PTSD, anorexia and depression.47

A Belgian study found that only half of cases of euthanasia were reported,30 dropping to one in five in the elderly (80+).48 The commonest reason (77%) was because physicians did not "view their act" as euthanasia, despite the definition used in the study being the same as the legal definition used in the Benelux. Another 18% stated that they did not report because it was "too much of an administrative burden", and 12% because they admitted the "legal due care requirements had possibly not all been met".48

In 2019, the United Nations Special Rapporteur on the Rights of Persons with Disabilities expressed extreme concern with Canadian legislation,49 and recommended "adequate safeguards to ensure that persons with disabilities do not request assistive dying simply because of the absence of community-based alternatives and palliative care". Her comments are relevant in light of the known gaps for access to palliative care in New Zealand, as well as the expected 50% increase in deaths in the next 20 years.50 New Zealand is a signatory of the same UN International Human Rights Treaty and expected to fulfil similar obligations.51 While the above examples do not necessarily all indicate abuse or weakness of the law, they illustrate the difficulty of ensuring safe processes, and the challenges doctors may face in protecting themselves and their patients.

Problems in implementation

As noted, there are a variety of matters that have not been adequately specified in the Act, including:

* Which doctors can legally discuss euthanasia with patients (EoLCA refers only to the requirement for practising certificates)

* Specific criteria triggering enforcement of the Act

* Guidelines regarding conscientious objection and prevention of coercion

It remains an open question whether these issues would be better addressed by modification of the Act or by other regulatory instruments and professional bodies. Either way, one set of useful considerations that could be adapted to these purposes have been formulated by Lord Wilson of the UK Supreme Court, who identified factors to assist determination that a person's wish to end their life was "voluntary, clear, settled and informed".31,52

( https://www.bailii.org/uk/cases/UKSC/2014/38.html#:~:text=As%20a%20former%20judge%20of%20the,to%20the%20judges%20of%20the%20Division)

New Zealand doctors are obliged to consider their legal and professional obligations to patients in relation to the EoLCA. The challenge of managing end-of-life scenarios brings these issues to the fore. Much evidence points to the emotional intensity and potential moral distress associated with euthanasia. Proponents argue clinicians can be part of an intimate and rewarding process enabling patient autonomy and helping them achieve a peaceful death. In contrast, opponents say euthanasia is incompatible with both end-of-life care and medical practice generally.

From a legal perspective, the EoLCA poses many challenges and unanswered questions about how to ensure the process is safe for all involved. Proponents rightly point out that many of these questions should be addressed at a professional level with training programmes, clear guidelines and access to adequate support. On the other hand, opponents point to overseas evidence of underreporting and nonvoluntary euthanasia to illustrate risks of the legislation.

Based on overseas experience, once legalised, euthanasia eligibility criteria will be challenged, and are likely to be expanded over time. Some regard this as an egalitarian progression towards a better future that includes a 'right to die', while others view this as an unacceptable risk of the EoLCA. Either way, it is difficult to imagine a more critical referendum for both our profession and New Zealand society at large.

Glossary/definition of terms

Euthanasia: a catch-all phrase for voluntary euthanasia and physician-assisted suicide (see below), both of which are options under the EoLCA; similar to Canada's "medical assistance in dying", commonly abbreviated MAiD.

Voluntary euthanasia: administration of a life-ending substance to a consenting patient.

Nonvoluntary euthanasia: administration of a life-ending substance to a patient unable to consent (eg, persistent vegetative state).

Involuntary euthanasia: administration of a life-ending substance to a patient who is able to consent but did not.

Physician-assisted suicide: self-administration of a medically prescribed life-ending substance.

Physician-assisted dying: commonly used as an alternative to 'physician-assisted suicide', and may (confusingly) include voluntary euthanasia.

Assisted dying: commonly used to include both voluntary euthanasia and physician-assisted suicide, sometimes used interchangeably with physician-assisted dying.

Palliative sedation: administration of sedative medication to relieve refractory symptoms.

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New Zealand doctors and euthanasia-legal and practical considerations of the End of Life Choice Act | OPEN ACCESS

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In October 2020, New Zealanders will be asked if they support the implementation of the End of Life Choice Act 2019 (EoLCA): ( http://www.legislation.govt.nz/act/public/2019/0067/latest/whole.html#DLM7285905).1 This referendum has particular implications for doctors; as practitioners who may be asked to hold the syringe, there is little room to abstain.

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What Is Euthanasia? Types, Legal Status, Facts, Controversy, and

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Euthanasia is practice that helps people who are terminally ill or in extreme pain end their lives. We’ll go over the different types of euthanasia, what they involve, and where they’re legal. We’ll also break down some of the controversy surrounding it and give you tips for how to make difficult end-of-life decisions.

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The Catholic Church in Aotearoa New Zealand

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Life is full of blessings, challenges and opportunities. Even dying brings its own unique blessings, challenges and opportunities. 'Dying well' is as important as reaching our potential at school and at work, or finding happiness and fulfilment within our families and with our friends. The work of dying well often involves the healing and/or deepening of relationships.

In 1995 we wrote:

"Euthanasia occurs when a doctor, not an illness, kills a patient."

At that time we drew attention to a very important distinction: it is one thing to withhold or withdraw extraordinary methods of keeping a person alive when it is no longer sensible to do so; it is another thing to do something, or omit to do something for the purpose of terminating a person's life. In the former case, we are simply allowing a person to die. In the latter case, we are killing.

Even if it is done for what seems a good reason, (e.g. to prevent suffering), and even if it is done with the patient's consent, it is still killing.

In a society in which many regard suffering as meaningless and intolerable, euthanasia is presented as a way of avoiding suffering. This can be made to look like an attractive option, or even a right. But to legalise the killing of those who are suffering would be to introduce a whole new, and dangerous, dimension to society.

What kind of society would we have if euthanasia were legalised? People with advanced progressive illnesses, or simply in old age, may well find it difficult to trust their doctors and nurses. We need to ask: What would that do for the regard we have traditionally had for the medical and nursing professions? How would this impact on the ability of doctors and nurses to help those who are not quite sure they can trust them?

The experience of those countries that have already legalised euthanasia shows that the demand for euthanasia cannot be limited to a carefully defined group. In the Netherlands euthanasia was initially only available to dying adults with terminal illness who were able to give informed consent and who repeatedly requested euthanasia. Since 1973 all of these restrictions have fallen away and lethal injections can now be given to newborns and teenagers with disabilities, as well as to persons with dementia and depression. In some of these cases there is no explicit request from the person concerned for euthanasia.

Once we allow access to euthanasia for some, the reasons for confining it to just that group begin to look arbitrary. It is quickly argued that to deprive those incapable of giving consent to euthanasia is an injustice. It is also argued that allowing it for some conditions and not others is discriminatory.

We would have to expect the same erosion of boundaries and safeguards to happen here too, especially because there is already ambivalence about people who are perceived as having little or nothing to contribute to society while 'swallowing up' large amounts of health resources. In other words, legalising euthanasia will place at greater risk the lives of those whom others might be tempted to think would be better off dead.

Abuse of the disabled and elderly is already a serious issue in our country and overseas. Legalising euthanasia has the potential to worsen the problem in a society where the numbers of elderly are growing and where pressure on the health budget is increasing.

Further, in a society in which euthanasia becomes legal, the disabled, sick and elderly may more easily come to see themselves as an excessive financial and emotional burden. The 'right to die' could very quickly become a 'duty to die'. This is not free choice. This is not real consent. The most vulnerable members of our society depend upon the protections which the legal and medical institutions currently provide.

The good news is that advances in palliative care mean there is now no need for anyone to die in pain. When treatment is no longer effective for a person in the end stages of an illness, the priority is to provide sufficient pain relief to make the person comfortable, while supporting their physical, emotional, mental, relational and spiritual needs. This can be a very important time in a person's life, involving growth and the healing of relationships.

Research also shows that persistent requests for euthanasia are not related to physical pain but to depression and feelings of hopelessness and/or a sense of social isolation. There is a deeper malaise: our society has failed to respond in a satisfactory way to the emotional, psychological and spiritual suffering that people often feel at the end of life. As we stated in 1995, "we cannot be free from blame if there are people in our communities unable to find human comfort and assistance as they approach the end of their lives."

The real moral imperative is on us all to be bearers of hope and to offer selfless care to all those who are sick, disabled and dying while ensuring that there are adequate resources for palliative care.

We have the expertise and the means to care for those who have advanced progressive illness in ways which are in harmony with their human dignity and their status as our fellow New Zealanders. The legalisation of euthanasia will undermine trust in the medical profession and put vulnerable groups in our society at risk. It will send a message that the lives of some people are not worth living. Its introduction would seriously undermine good caring and be detrimental to the growth of a caring community.

We need to ensure that our laws promote a society in which there is room for the most vulnerable - room in our hearts and room in our homes and other places of care - rather than 'showing people the door'.

True compassion calls for us all to stand alongside, and in solidarity with, all those who are suffering. We commend all those who already do so much to care for those people who are sick, elderly or disabled as well as those who are dying. The mark of a great society is evidenced in its ability to care for those who are most vulnerable.

We do not need euthanasia.

We need to promote equitable access to good palliative care for all New Zealanders.

We need to learn how to live well and die well.

+John Dew
Archbishop of Wellington
President, NZCBC

+Patrick Dunn
Bishop of Auckland
Secretary, NZCBC

+Colin Campbell
Bishop of Dunedin

+Barry Jones
Bishop of Christchurch

+Peter Cullinane
Bishop of Palmerston North

+Denis Browne
Bishop of Hamilton

+Charles Drennan
Coadjutor Bishop of Palmerston North

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The Dangers of Euthanasia: A Statement from the New Zealand Catholic Bishops

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Life is full of blessings, challenges and opportunities. Even dying brings its own unique blessings, challenges and opportunities. 'Dying well' is as important as reaching our potential at school and at work, or finding happiness and fulfilment within our families and with our friends.

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Abstract

Background: In jurisdictions that permit euthanasia or physician-assisted suicide, patients with cancer comprise the largest group to die by these methods. We investigated the personal attitudes toward these practices of patients receiving palliative care for advanced cancer.

Methods: Seventy patients (32 men and 38 women; median survival, 44.5 days) took part in a survey using in-depth semistructured interviews. The interviews were audiotaped for transcription and content analysis of themes.

Results: Most participants (73%) believed that euthanasia or physician-assisted suicide should be legalized, citing pain and the individual's right to choose as their major reasons. Participants who were opposed to legalization cited religious and moral objections as their central concerns. Forty (58%) of the 69 participants who completed the entire interview also believed that, if legal, they might personally make a future request for a hastened death, particularly if pain or physical symptoms became intolerable. Eight of these individuals (12%) would have made such a request at the time of the interview. These 8 participants differed from all others on ratings of loss of interest or pleasure in activities, hopelessness, and the desire to die (Ps<.02). They also had a higher prevalence of depressive disorders (P<.05). However, they did not differ on ratings of pain severity.

Conclusions: Many patients with advanced cancer favor policies that would allow them access to both euthanasia and physician-assisted suicide if pain and physical symptoms became intolerable. For patients who would actually make requests for a physician-hastened death, however, psychological considerations may be at least as salient as physical symptoms.

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national center for biotechnology information

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Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide - PubMed

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Many patients with advanced cancer favor policies that would allow them access to both euthanasia and physician-assisted suicide if pain and physical symptoms became intolerable. For patients who would actually make requests for a physician-hastened death, however, psychological considerations may b ...

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Our position on euthanasia and assisted dying

Euthanasia has no place in palliative care. Palliative care, as defined by the World Health Organisation, "intends neither to hasten nor postpone death". This philosophy is a cornerstone of hospice care in New Zealand. Palliative care is holistic - physical, emotional, spiritual, social and cultural needs are all valued equally.

Euthanasia and assisted suicide of any kind is currently illegal in New Zealand, and Hospice New Zealand, as an organisation, does not support a change in the law to legalise euthanasia or assisted suicide in any form.

It is important to note that hospice will continue to support people regardless of their desire for euthanasia.

We appreciate and acknowledge an individuals right to choose and acknowledge the wide range of perspectives around euthanasia.

People living with a terminal illness should be supported to live in whatever way is important to them, their family and whānau.

People should have access to good palliative care support regardless of where they live. We need to address issues of access to care, social isolation, lack of support for family carers before we give people the means to choose death.

Click to view the current HNZ Position Statement Euthanasia and Assisted Dying (2017)

What we believe:

As an organisation we appreciate that there are a range of views on this challenging and emotive topic; we respect that everyone has the right to their opinion. There are varying views from a spiritual, religious or cultural perspective which may not be the same for all individuals within a group or culture. We acknowledge the impact these beliefs will have on the way a person thinks about euthanasia.

Hospices in New Zealand believe that improving access to hospice and palliative care services should be the priority for Government. This will ensure everyone receives quality care regardless of age, gender, ethnicity, socio-economic status or location. Only when all New Zealanders have ready access to good quality end-of-life care can a balanced discussion begin.

All people should be made aware of options for hospice and palliative care, and should be offered an individual assessment of their needs to ensure that appropriate palliative care is being provided. This should be an integral part of advance care planning.

Greater education of all health professionals is needed to dispel the myths surrounding pain and symptom relief and all aspects of end-of-life care. We encourage all those prescribing medication and providing palliative care to consult with hospice specialist clinicians and other palliative care experts where necessary.

We believe that palliative care should be routinely available to all who need it, and Government should make sufficient funding available to ensure access to palliative care whether provided by a hospital, at home, in residential care facilities or by hospice teams.

Why do we feel this way?

From experience, we know that with the right palliative care a person can have a good quality of life with their dignity maintained and symptoms managed to help them feel as comfortable as possible until their death.

Legalising euthanasia and/or assisted suicide will place pressure on vulnerable people - those living with disabilities, mental health issues, terminal illness - for fear of being a financial, emotional or care burden.

Good palliative care is founded on a trusting relationship between patient, family, whanau and health professional, which is undermined by euthanasia. Dying is a natural process and part of life, we must focus on helping people to live well until they die. We would like to encourage people to talk about their wishes when it comes to the end of life, informing family and friends what is important to them.
What do others think?
As an organisation we support the thinking of many groups on this topic. Links to their websites and/or statements below:
Further information
Hospice NZ has a number of resources on this website that will be useful to inform discussion on this subject, including our Written Submission to the Health Select Committee (2016) and our Hospice NZ Submission - Justice Select Committee - End of Life Choice Bill Feb 2018

Hospice NZ would like to acknowledge and thank all those who contributed to the review of this statement.

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Euthanasia has no place in palliative care. Palliative care, as defined by the World Health Organisation, "intends neither to hasten nor postpone death". This philosophy is a cornerstone of hospice care in New Zealand. Palliative care is holistic - physical, emotional, spiritual, social and cultural needs are all valued equally.

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Class Notes