Is euthanasia a health priority for New Zealand at present?

Discussion of the euthanasia referendum has mostly been around the ethical question of whether euthanasia should be allowed. There has been little discussion about whether this is a priority for action now.

If the referendum is passed, money and time will be put into establishing a bureaucracy to deliver aid in dying, and doctors will have to provide the service. This represents an opportunity cost, as these resources cannot be spent on other aspects of the health system.

To comply with the law there is a lot to do. There are committees to be formed and policies to be written. All doctorswill need to decide if theywant to take part. All practices and hospitals will have to respond to someone who seeks assisted dying and that is likely to lead to a lot of discussion and debate.

Hospices have already said they will not do this but what about all the other providers? Whilst the financial costs will be balanced by the money saved in someone dying earlier and not requiring some pension or some care costs, the personnel resource and the time spent setting systems up needed to do all this is still problematic.

If someone seeks assistance in dying there is a lot to be done. If the person’s regular doctor provides the assistance, theywill need to read up on the requirements of the Act and learn about how to administer the fatal medication.

If the doctor providing the aid is not the patient’s regular doctor, they will have to find out about prognosis, confirm the condition is irreversible and assess whether there is any coercion.

Either doctor would have to consult with the person on several occasions, complete the necessary documentation and sit with the patient whilst they die, which from experience in Oregon, is about an hour but can be as long as 47 hours.

All this is likely to be needed promptly and the patient may not be very mobile. There is a shortage of GPs in many parts of the country, so there may bemany doctors who just do not have the capacity for this extra work.

Who pays has not been discussed. There are two extreme options.

The first would be a fully public provided service with higher opportunity cost to the state, but no patient fee. We already know that these services will not be provided from hospices. Unless DHBs are provided with explicit funding, they will probably not do it.

The second optionwould be a for-profit service as happened for provision of abortions in the past. Were this option to be developed the opportunity cost to the state would be less; limited to setting up and maintaining the bureaucracy required for accountability, but the cost to the patient would likely be substantial.

Combined with the difficulty that terminally ill people may have with travelling, this option would likely severely limit access to the service. It is likely the service would be somewhere between these two extremes, but likely closer to the for-profit end.

What is the size of the potential quality of life benefit?

If the referendum passes, we don’t know how many people would seek aid in dying. A reasonable comparisonwould bewith Oregon.

Oregon has a population of 4.2 million (New Zealand 5 million) and has had a Death with Dignity Act in force for the past 22 years. Their act is similar to ours. Their experience is that patients are older, on average 74 years (range 33-98 years).

Just over 50 per cent of patients had a university degree and 96 per cent of patients were white. In 2019 a total of 188 people were assisted to die, 0.51 per cent of total deaths.

During the first five years of the act around 25 people a year (about 0.08 per cent of total deaths) were assisted to die. Whilst there are differences between Oregon and New Zealand, we are alike enough for this to give us some idea of what might happen here.

If this level of demand is reflected inNew Zealand, then it will benefit a few people from a group who can afford the costs and who already get significant benefit from our health system.

The result of enacting this act will be to increase health outcome disparities. We will be providing an additional service to older educated white people.

The opportunity cost to the state will be higher if this is statefunded. If privately funded there will be a smaller opportunity cost to the state of running the accountability bureaucracy, but the service will only be available to those who can afford it.

Changing the status quo now will require a focus on this issue and take attention away from the much more serious issues of responding to the Covid-19 pandemic and to the Heather Simpson review of the health system.

The ethical debate is unlikely to reach consensus. However, this referendum is also about allocating scarce health care resources on providing assisted dying which will disproportionately be used by the affluent and educated.

As well as considering the ethics of euthanasia we also need to consider whether the resources needed to set up and run an assisted dying service would be better used for other priorities such as reducing disparities in cancer screening, diagnosis and care services or supporting and improving the provision of palliative care.