Palliative care seeks to relieve pain and symptoms of patients, and is a critical part of medical practice at the end of life. Tensions can arise however where palliative medication, despite being administered with the intention of relieving a patient’s pain, has the unintended effect of hastening a patient’s death (the doctrine of double effect). This webpage explores the law relating to palliative medication and the doctrine of double effect, as well as the issue of terminal sedation.
What is palliative care?
The legal definition of palliative care varies between each Australian State and Territory. Generally however palliative care is an act or omission, medical procedure or other measures to maintain or improve the comfort of a person who is, or would otherwise be, subject to pain and suffering.
Some definitions also refer to it as the relief of pain, suffering and discomfort.
In practice, palliative care is broad and can include pain medication, oxygen, intravenous or nasogastric feeding, delivery of blood products, anti-nausea medication and anti-anxiety medication. Counselling and spiritual interventions may also provide palliative care.
What is the doctrine of double effect?
In the final stages of life, there may be concerns that palliative medication may have the unintended effect of hastening a patient’s death. In this situation the ‘doctrine of double effect’ may apply. This recognises that giving medication (usually by a health professional) to a person to relieve pain is lawful even if it could hasten death.
The most critical element of double effect is intention. If the primary intention is to relieve pain and symptoms, not cause death, the person who gave the medication will not be criminally responsible for a death which follows, even if it is foreseen.
Double effect is likely to apply only when the patient is near death – the law is unlikely to protect the provision of medication when the patient’s death is not imminent. In South Australia, it will apply only when the patient is in the terminal phase of a terminal illness.
The person administering the medication does not need to be a doctor for double effect to apply, but the law is likely to require that there is appropriate medical authorisation and supervision of the medication plan. This is specifically required by the legislation in some States and Territories
Does the doctrine apply in Australia?
The doctrine of double effect originated from moral theology, and the extent to which it is part of Australian law is uncertain. To date there has not been a court case in Australia which has specifically confirmed that the doctrine of double effect is part of Australian law. However, the doctrine has been applied by courts in similar legal systems such as the United Kingdom, the United States, Canada and New Zealand. For this reason, it is likely to be part of Australia’s common (or judge-made) law, and applies to health practitioners throughout Australia.
In practice, the doctrine has generally been accepted in the legal and medical professions, and by medical professional bodies. However, some doctors consider that properly administered palliative medication does not hasten death, and that the doctrine is not needed.
It is very likely that the doctrine will only apply to a person who is near death. The better the patient’s prognosis, the less likely the doctrine will protect health professionals if death is hastened.
Queensland, South Australia, Western Australia and the Australian Capital Territory are the only States and Territories that have introduced legislation containing versions of the doctrine of double effect. Further information about the legislation in those jurisdictions is detailed below.
Double effect in South Australia, Queensland, Western Australia and the Australian Capital Territory
South Australia, Queensland, Western Australia and the Australian Capital Territory have legislation containing versions of the doctrine of double effect. These States (but not the Australian Capital Territory) recognise that if the doctrine of double effect applies, the person who provides the medication will not be liable under the civil or criminal law for the patient’s death (provided certain criteria are met).
In the Australian Capital Territory, the legislation is framed as a right to palliative care in certain circumstances so how it excuses criminal liability is less clear. This is discussed further below.
Under the Consent to Medical Treatment and Palliative Care Act 1995 (SA) section 17, a medical practitioner or someone supervised by a medical practitioner, who hastens a person’s death through medical treatment or care is not liable in civil or criminal law for the person’s death if:
- it is consented to, administered without negligence and in good faith with the intention of relieving pain or distress;
- it is provided in accordance with proper professional standards of palliative care; and
- the person is in the terminal phase of a terminal illness (i.e. the person has an illness or condition that is likely to result in death, and there is no real prospect of recovery or a remission in symptoms).
The Criminal Code (Qld) section 282A states that a doctor, or someone authorised in writing by the doctor, who hastens a patient’s death through palliative care, is not criminally responsible for the patient’s death if the palliative care is:
- to maintain or improve the comfort of a person who is subject to pain and suffering; and
- provided in good faith and with reasonable care and skill, and is reasonable and in accordance with good medical practice.
There is no specific requirement that the person be near death for the section 282A excuse to apply. However, their condition, including whether they are close to death, would be relevant when the health professional considers whether providing the palliative care is ‘reasonable’.
The Criminal Code (WA) section 259 states that a person who hastens a patient’s death through medical treatment (including palliative medication) is not criminally responsible for that patient’s death if the treatment:
- was provided in good faith;
- was provided with reasonable care and skill; and
- was reasonable, having regard to the patient’s state at the time and all the circumstances of the case.
The legislation does not require that a patient be terminally ill. However, this will be relevant in considering whether providing the palliative medication is reasonable, and the patient’s state at the time. The Western Australian excuse will apply where the need for palliative care arises because the patient has refused life-sustaining treatment (see the case of Brightwater Care Group v Rossiter below).
Australian Capital Territory
The Medical Treatment (Health Directions) Act 2006 (ACT) section 17 and the Powers of Attorney Act 2006 (ACT) s86 provides a right for a person to receive ‘relief from pain, suffering and discomfort to the maximum extent that is reasonable in the circumstances’. These provisions will apply only where a person is under the care of a health professional and has given a health direction directing medical treatment be withdrawn or withheld, or where the person's attorney has made this decision. The effect of this law is uncertain but the legal position in the ACT is likely to reflect the common law (i.e. the doctrine of double effect).
The legislation does not specifically require that a patient have a terminal illness in order to apply.
Does the patient have to be terminally ill for the doctrine of double effect to apply?
As discussed above, it is very likely that the doctrine will only apply to a person who is near death. This has been the state of patients in the cases that have come before the courts to date. The better the patient’s prognosis, the less likely the doctrine will protect health professionals if death is hastened.
The law on this issue in the States and Territories which have legislation (Western Australia, South Australia, Queensland and the Australian Capital Territory) is detailed in the previous section. South Australia's law specifically requires that the person must be in the terminal phase of a terminal illness for the section 17 excuse to apply.
Who can administer the medication?
The legislation in Western Australia refers to a ‘person’ providing the palliative medication, and therefore a doctor is not the only person able to administer the medication. In Queensland however a doctor must order the care, and the doctor must give written authorisation. In South Australia, the treatment may be given by a ‘medical practitioner responsible for the treatment or care of a patient’, or a person supervised by that medical practitioner who participates in the person’s treatment or care.
In terms of the common law, health law academics argue the doctrine should be available to those who are authorised by doctors to administer palliative medication. This would include nurses, but also others such as non-professional carers and family members, given palliative care is increasingly being provided in the community.
How do you know whether the health professional intends to relieve pain and suffering, or intends to hasten a patient’s death?
It is very difficult to prove that a health professional intended to kill a patient or hasten his or her death. Examples of behaviour which may suggest this include where:
- a health professional gives the patient a drug that has no pain-relieving properties; or
- a drug is prescribed at twice the lethal level.
What if the health professional was negligent in providing palliative medication, but did not intend to cause the patient’s death?
The doctrine of double effect may still apply where a health professional is negligent and does not intend to cause death.
However, if the health professional was grossly negligent or careless, such as administering a grossly careless medication overdose, then the doctrine of double effect may not excuse the health professional, and he or she may be criminally liable for the patient’s death (i.e. may be prosecuted for murder or manslaughter).
Special provision: Palliative care in Victoria
In Victoria, the Medical Treatment Planning and Decisions Act 2016 (Vic) (which commenced on 12 March 2018) recognises that a health professional may give palliative care (including palliative medication) to any person who does not have capacity despite any decision of the person’s medical treatment decision-maker. However, in making the decision to provide palliative care, the practitioner must consider any preferences or values of the person, whether or not given in a Values Directive in an Advance Care Directive, and must consult with the person’s medical treatment decision-maker.
What is palliative sedation?
Palliative sedation is defined by the European Association for Palliative Care as ‘the use of medications intended to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family and health-care providers’.
It is used in palliative care for several reasons, including to manage refractory symptoms (symptoms which cannot be otherwise adequately controlled) at the end of life. The primary purpose of palliative sedation is to sedate a patient near the end of their life in order to relieve their symptoms, not to cause or hasten their death.
Is palliative sedation legal in Australia?
Whether or not palliative sedation is legal in Australia has not been considered by the Courts. However, it is likely that legality will depend on the circumstances of each individual case. For example, it would be lawful to use palliative sedation so long as it is performed to manage refractory symptoms, with the intention of relieving pain and suffering, not hastening or causing death, and the patient continues to receive nutrition and hydration.
Voluntary palliated starvation
What is voluntary palliated starvation?
Voluntary palliated starvation (VPS) or Voluntarily Stopping Eating and Drinking (VSED) occurs when an adult with capacity refuses to eat or drink and receives palliative care to relieve any suffering she or he experiences from dying due to a lack of food (nutrition) and water (hydration). Some patients may refuse hydration and nutrition as an alternative to physician-assisted suicide.
Is voluntary palliated starvation legal in Australia?
The legal status of VPS has not been decided by the Australian courts, and the law on this practice in Australia remains unclear, particularly in relation to issues such as whether the person’s substitute decision-maker can continue to refuse food and drink for the person once they lose capacity; and whether a person can make a binding Advance Directive refusing food and drink. Under Australian common law however patients have the right to refuse food and drink, even if it results in death.
Some legal commentators believe that in some circumstances a death resulting from a competent patient's decision to cease eating and drinking may be lawful for both the patient and doctors involved, and it can be lawful and ethical to provide palliative care to reduce the suffering associated with VSED.
VPS will undoubtedly continue into the future, and consideration will need to be given to the legal implications of such practices, and how the legal and health systems respond.
Brightwater Care Group v Rossiter  40 WAR 84
Note: The Court in this case did not consider the doctrine of double effect. However, this case illustrates how the excuse in section 259 of the Western Australian Criminal Code might work in practice.
Mr Rossiter was a quadriplegic who was kept alive by receiving artificial hydration and nutrition through a tube into his stomach. He had decision-making capacity, and decided he no longer wanted to receive this treatment. He asked the facility that was caring for him to withdraw the tube. The Supreme Court was asked to make declarations about the rights and obligations of the facility towards Mr Rossiter.
The Court decided that as Rossiter had capacity he could refuse the treatment. A declaration was made that the facility caring for Rossiter could lawfully withdraw the treatment. The Court also declared that the provision of palliative care would be lawful, even though Rossiter would be dying because of his refusal of life-sustaining treatment, so long as that palliative care was provided in accordance with section 259.
R v Adams (Bodkin) (Unreported, Central Criminal Court London, Devlin J, 9 April 1957)
Dr Adams was a family doctor who was charged with the murder of an elderly female patient, Ms Morrell. The Crown argued that the very large quantities of medication given to Morrell showed that Adams must have intended to kill her. The Crown gave evidence that Adams was involved in changing Morrell’s will to make him a beneficiary (about which he lied). However, there was also conflicting evidence about Morrell’s level of pain, and that the doses of medication given could have been medically appropriate. Adams was acquitted by the jury. Justice Devlin famously stated:
‘if the first purpose of medicine – the restoration of health – could no longer be achieved, there was still much for the doctor to do, and he was entitled to do all that was proper and necessary to relieve pain and suffering even if the measures he took might incidentally shorten life by hours or perhaps even longer’.
R v Cox (1992) 12 BMLR 38
Mrs Boyes, an elderly lady, was in agonising pain from rheumatoid arthritis. She had known Dr Cox for 13 years and he said she would not suffer. After many unsuccessful attempts to control her pain Mrs Boyes begged Dr Cox to kill her. Dr Cox administered a large dose of potassium chloride and Boyes died shortly after. Cox was charged with attempted murder. (The Crown was unsure if they could prove the drugs killed Boyes or she died from her other conditions. Boyes’ body had been cremated and therefore there was no scientific evidence the potassium chloride killed her).
During the trial the jury was instructed on the doctrine of double effect: Cox could only be convicted if his primary intention was to cause her death. Significantly in this case, the potassium chloride did not have any curative or pain-relieving properties and was estimated to be twice the legal dose. The jury convicted Cox of attempted murder (Cox received a suspended sentence of one year imprisonment and was allowed to return to his medical duties under supervision).
Re Baby D (No 2) (2011) 45 Fam LR 13
Baby D was an infant with a catastrophic brain injury, who need an endotracheal tube in order to breathe. The infant’s parents and doctors believed it was in Baby D’s best interests for the tube to be removed and that life-sustaining treatment should not be provided. However, if the tube were removed, there was concern Baby D would make attempts to breathe, which would likely be unsuccessful and would cause her distress. It was proposed palliative care (morphine) be given to Baby D to relieve this distress, but medical evidence showed that this treatment would be likely to suppress her breathing and hasten her death (although this was not intended). The key issue in this case was whether it would be lawful to do this.
The Family Court did not directly consider the doctrine of double effect. However, it authorised the provision of palliative care that was ‘necessary and proper’, on the basis of the medical evidence presented. The Court’s approach in this case suggests the doctrine of double effect is likely to be part of Australian law.
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Andrew McGee and Franklin Miller, Advice and care for patients who die by voluntarily stopping eating and drinking is not assisted suicide (2017) 15(222) BMC Medicine
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