GUEST BLOG: Ian Powell – Euthanasia and palliative care funding: “horribly distorted”
Dr Ben Gray is a very interesting doctor and one of the few that can lay claim to being a hippie back in the day:
He is a medical graduate from the first class at the Wellington Clinical School when established as part of Otago University. Gray has worked as a general practitioner for over 30 years, first in Waitara in Taranaki and then at the Newtown Union Health Service in Wellington.
Waitara had a significant Māori population while Newtown has a very diverse population with significant numbers of refugees from many parts of the world. This has enabled Gray to experience long-term condition management, cross-cultural care and interprofessional practice.
Ben Gray joined the Department of Primary Healthcare & General Practice in 2006 as a senior lecturer where he is now an Associate Professor. He has completed a Masters in Bioethics and Health Law and is active in the Australasian Association of Bioethics and Health Law.
Questioning health priority of assisted dying
Now he has published (22 October) a thought-provoking article online by Otago University:
Gray questions whether funding euthanasia should be a health priority for New Zealand’s public health system especially when compared with palliative care. In summary, he argues that providing equity of access for assisted dying without equity of access to palliative care is to completely undermine the goals of the End of Life Choice Act. The Act’s funding mechanism means that choice is distorted towards assisted dying and away from palliative care.
Drawing on experience from the north-west coast American state of Oregon which had introduced euthanasia, Gray concludes that it is very likely that assisted dying in Aotearoa would be predominantly taken up by a small number of mostly educated white people.
Objective of funding mechanism
He then cites the recently announced objective of the funding mechanism for the new legislation which is to provide “…funding for health practitioners to deliver assisted dying services is to support equity of access to assisted dying services for eligible persons.”
For the purposes of assisting dying ‘health practitioners’ are medical doctors and nurse practitioners (the latter should not be confused with registered nurses.
In order to understand Gray’s argument it is important to appreciate that fully funded does not mean sufficiently funded. It means that there is no additional legal patient revenue stream available. Invariably and in this context fully funded means underfunded.
Privately employed doctors and nurse practitioners can claim a gazetted government fee but can’t charge patients a co-payment. District health board employed doctors and nurse practitioners can provide assisted dying services in this capacity but they can’t claim this fee.
Dr Gray correctly observes that this funding objective means that assisted dying is different from the vast majority of other services provided in general practice and hospital specialist private practice; that is, it is fully funded by government. The main exceptions to this rule are maternity services, vaccination services, and care for under 14 year olds.
From this he identifies two important issues. First, why has this fully-funded priority to ‘End of Life Choice’ been given when the Government does not fully fund many other services, particularly palliative care.
Second, the level of funding becomes critical to the implementation of the Act. If the funding does not cover the cost of provision of these services then very few can be expected to provide these services.
Gray is right to state that to fully fund euthanasia and not fully funded palliative care makes a mockery of the title of the Act. He describes the ‘choice’ between fully funded assisted dying and severely underfunded palliative care as “horribly distorted”. Responding to calls to increase euthanasia funding would be even worse in the absence of addressing the underfunding of palliative care.
Pressure on public hospitals
The referendum held in conjunction with the 2020 general election and the legislation it enabled was about making assisted dying legal. From 7 November it will be legal to provide assisted dying within the terms of the Act. Gray observes that there was nothing in the referendum, or discussion in the build-up to passing the legislation, that addressed whether this should be fully funded.
He notes that, although it remains to be seen, it is very likely to significantly limit the already limited numbers of general practitioners willing to provide aid in dying. If correct, this will leave public hospitals facing demand for assisted dying at a time when their services are already very stretched.
Gray also acknowledges the additional pressures that the Delta variant of Covid-19 is expected to create for hospitals. He asks: “Do we want our hospitals to prioritise assisted dying over cancer treatment, elective surgery for arthritis, or endometriosis?” This alarming situation has been made worse by the Government’s u-turn in its pandemic response.
Dr Gray’s diagnosis
Ben Gray’s diagnosis is that assisted dying should be available as nearly all other community services, partially-funded under the existing government capitation payments to general practice, with a patient co-payment to reflect the cost of providing the service.
He believes this would fulfil the obligation to legalise aid in dying without further increasing inequity of health funding and increasing demand on stretched public hospital services.
I find Dr Gray’s argument compelling although, as he acknowledges, the need to fully fund palliative care remains.
Currently palliative care is recognised as an essential health service. Consequently the majority of hospice funding comes from government. But hospices remain seriously underfunded and there is no charge to patients. Instead hospices must depend on regular community fundraising. Currently they must raise over $77 million nationally.
In the advocacy for a ‘yes’ vote in the referendum a common reason given was difficulties of access to palliative care. Palliative care specialists, nurses and others working in hospices provide excellent care for the terminally ill in difficult under-resourcing circumstances. But many terminally ill patients struggle to get access when they need it.
Dr Gray’s solution with a co-payment for assisted dying is logical given the “horrible distortion” he astutely identifies. But a better solution would be to fully fund palliative care including hospices. I have every reason to believe he would support this.
Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion
Thank-you Ian for bringing Dr Gray’s article to our attention. What does it say about our priorities when we fully fund assisted dying but only partially fund palliative care and ambulance services. Interesting that this fact was not highlighted at the time of the referendum.
Oh God this makes me want to reach for the gin bottle (@8.29am) I couldn’t access the article on my old laptop but your summary is a little depressing, Ian. There’s an old saying, ‘many a slip twixt cup & lip’ from the nation of tea drinkers where I was born (and not twix the chocolate bar, twixt = between) and as I lurch towards senility, far too old to be considered cool and useful, I am wondering how to get the funds to launch my ashes into space a la Hunter Thompson. Could I blackmail somebody, perhaps? or a hold up of my local MacD’s for some cash? I know my body (such as it is) parts are quite valuable in this trans-humanist environment but I do not want to be an organ donor, so hastening the cirrhosis and renal mouldering is perhaps t b a.
Palliative care is possibly as extended and demanding a process as the birthing and nurturing of infants, and to slip quietly and peacefully into the next life surrounded by love and quiet..well that ain’t gonna happen with a bunch of ghouls keeping you on life support while they chop out the lucrative entrails, (some of them even tag them with their initials beforehand but that’s, well, that’s not another story, that’s actually what they do) …and having read how the prisoners on death row take half an hour to die in tortured agony, euthanasia doesn’t really appeal.
I also find it a little strange, given the spurious lip service given by the bureaucracy to our landed gentry who actually know a great deal more about the coming and going of souls, that this funding situation exists.
Thanks for the heads up, I have to go now, the thumbnail’s giving me ptsd.
Aroha mai tatou, tena koutou katoa
Dr Gray is right it makes a mockery of our Public health system ethos to fully fund euthanasia for a few when we aren’t equitably funding palliative care and for that matter many other forms of health treatments, care and medications that can prevent premature death at the same time give many NZers a better quality of life. Whilst palliative care in NZ is currently under utilized by both Maori and PI as many prefer to still care for their own and many have a strong senses of obligation and lack of trusts and understanding of the benefits of good palliative care. Also there is very little financial help for those who choose to care for their elderly saving the state a lot of money, yet there is funding to euthanize. We have our priorities wrong and this needs to change.
That’s why I didn’t vote for Euthanasia. Legalised dying as a substitute for a working health system.
We had a referendum on this issue and the great majority of the nation voted to approve it. I get that you don’t like the referendum result, but at the end of the day “the people have spoken”.
Assisted dying is a medical procedure (just like abortion) and the choice of whether to partake in it or not rests solely with the person involved.
Simonm, haven’t you missed the whole point of the article? Nowhere does it question the right to assisted dying – it draws attention to the inequitable funding model only. Could it be that it’s ‘fully funded’ as it will be accessed mainly by privileged white folks? If was afterall the handiwork of David Seymour and that’s his support base.
No, I think I understood the point of Dr Powell’s article just fine. If his only objection to euthanasia was that palliative care was inequitably funded in comparison, he would have argued for equitable funding for both – he doesn’t.
As for the bill being entirely David Seymour’s handiwork, that’s incorrect too. I think you’ll find this woman had just as much input into it as he did; and you couldn’t find two more diametrically opposed viewpoints on just about any other issue:
https://en.m.wikipedia.org/wiki/Maryan_Street
First, I’m not a doctor. Second, views on the referendum are irrelevant to the purpose of both Dr Gray’s and my blogs. The issue is the unfair funding mechanism. Either patients should be able to be charged a co-payment (Gray) or hospices should be truly fully funded (me and possibly also Gray).
I assumed that since you were formerly the
‘Executive Director of the Association of Salaried Medical Specialists’ that you are or had been a salaried medical specialist yourself – my mistake.
If your issue is with an unfair funding mechanism for end-of-life options, could you please clarify if you support full funding for both patient-directed euthanasia and palliative care?
I support full funding (ie, at a level to ensure patient co-payments aren’t necessary for all primary healthcare, not just these two issues. But, in the absence of this, palliative care should take priority over assisted dying for the reasons outlined in Dr Gray’s article.
Agree with Peter about how unequitable it is to fully fund euthanasia when we can’t and aren’t funding other areas of health at the same level. Also the majority of NZers voted for our current government but that hasn’t stopped many right wingers, the rich and many business people from rubbishing them at every opportunity they get and we know these people get many. A referendum is majority rules not exactly fair to the TOW partner and other disadvantaged groups like PI peoples.
Agree with Peter about how unequitable it is to fully fund euthanasia when we can’t and aren’t funding other areas of health at the same level. Also the majority of NZers voted for our current government but that hasn’t stopped many right wingers, the rich and many business people from rubbishing them at every opportunity they get and we know these people get many. A referendum is majority rules not exactly fair to the TOW partner and other disadvantaged groups like PI peoples.
“Privately employed doctors and nurse practitioners can claim a gazetted government fee but can’t charge patients a co-payment.’
The gazetted fee is $1087. Is this not sufficient payment for the paperwork and carrying out a relatively simple medical procedure? And, of course, doctors aren’t only motivated by money. A significant number will see helping a person die when they are getting close to death to be a humane act (like the vast majority of humans who don’t believe their lives belong to someone else’s God and that only He can shorten it).
Furthermore, the terminally ill chew up an extraordinary amount of money and resources in their final months and weeks. Patients wanting an assisted death are mostly going to have this done at home, depart slightly earlier, and are going to take up far fewer resources than palliative care generally will when taken right to the bitter end. For some (including me) selecting an assisted death will be partly motivated by altruism — so that younger, fitter people can get treated rather than them (and me) gobbling up medical resources at a time when our time is clearly up.
Has this difference been factored into the argument? I suspect apples are not being compared to apples here.
Also, the sly reference implying that VAD is only likely to be used by educated whites may (or may not) be true, but it shouldn’t be taken as evidence Maori don’t support it. A survey last last year showed majority support in all seven Maori electorates.
https://www.stuff.co.nz/national/health/euthanasia-debate/300133192/euthanasia-referendum-poll-shows-majority-of-mori-voters-support-assisted-dying
The medical procedure may be “relatively simple” but the work undertaken before isn’t including time for sensitive discussions and diagnosis.
The reference to ‘educated whites’ wasn’t “sly”. It was Dr Gray reported on the experience of assisted dying in Oregon. It might be uncomfortable or concerning but not sly.
“According to U.S. Census data, 4.1 million people were living in Oregon as of July 2017. … Among people living in Oregon in 2016, 76% identified as white, 13% Latina(o), 5% Asian and Pacific Islander, 2% African American, 1% American Indian and Alaska Native, and 3% two or more races.”
Mystery solved I think.
Not quite. Dr Gray’s comment on Oregon and ethnicity are further elaborated in an earlier blog of his. The white identified population of the state is 77%. White patients accessing assisted dying is 96%,
https://blogs.otago.ac.nz/pubhealthexpert/is-euthanasia-a-health-priority-for-new-zealand-at-present/
The next largest population segment in Oregon is identified as ‘Latina(o) at 13%. I worked with lots of Mexican people in California and 99.9% were practicing Catholics. They would never have utilised assisted dying or abortion services because of their religious beliefs. This is entirely their choice to make. However, one person or ethnicity’s right to make their own medical decisions doesn’t preclude other people or ethnicities from making their own personal end-of-life or reproductive choices.