Wednesday, 29 October 2025

Clause 6 further considered (10:38)

The DEPUTY SPEAKER: I remind the house that when we finished last night we were on clause 6; we still are. I understand that the member for Kew has amendments to circulate in substitution for the amendments she circulated yesterday. I invite the member to circulate these amendments now.

Jess WILSON: I seek to substitute the amendments that I circulated yesterday and ask that they be circulated to the house.

The DEPUTY SPEAKER: I call on the member for Broadmeadows to move amendment 3 in her name. I advise that if her amendment is not agreed to, she cannot move her amendments 4 and 10 to 12 as they are consequential. Therefore I advise her to address the principles of all those amendments when speaking to amendment 3.

Kathleen MATTHEWS-WARD: I move:

3.   Clause 6, line 33, omit ‘Secretary.”.’ and insert “Secretary.”.

One of the issues I feel most strongly about is the provision of information that is only about VAD, nothing more, nothing less, as mentioned in the second-reading speech, and how this could be interpreted by some vulnerable people. As the member for Monbulk said, feeling like you can access VAD is far different to feeling like you should access VAD. I strongly believe that any information given to a terminally ill person should include an explanation of palliative care and the options available, including assistance with personal care; discussion of the psychological impacts of terminal diagnosis and the psychological supports available; information about advanced care directives; information explaining the difference between symptom management interventions and life-prolonging interventions and the right to refuse interventions, which I do not think enough people understand; information about elder abuse, informed consent and the supports available; consumer affairs-related material, including power of attorney and will making; information about My Aged Care, NDIS and carer supports, and we know how tough this period can be on carers, and I think that actually plays into people’s decision on VAD, so it is important that people know that carer supports are available; contact details for referral pathways and navigation for all of these services; and that this information is offered in all languages. I think the provision of additional information would help people feel a stronger sense of autonomy, agency and value, importantly, and help with discussions with loved ones.

While we currently have a VAD navigator, we do not have a navigator for people diagnosed with terminal illness. Having worked in finance, elder abuse, aged care and policy for ageing Victorians, representing both multicultural and vulnerable communities – including having the lowest literacy in the state in Broadmeadows – as well as personal experiences with caring, death, terminal illness, palliative care, disability and the medical system, I am acutely aware of how difficult many people find it to navigate services and know where help is available. I think everyone deserves help getting the information, advice and help they need to fully understand and weigh up their options. I am also particularly concerned about the lack of psychological supports that are offered to people upon receiving terminal diagnosis. I understand that within the first six to 12 months of terminal diagnosis is when people are most likely to have suicidal ideation, and they deserve to know that supports are available and that they are not alone on their journey.

I am also acutely aware of the general lack of understanding in the community of advanced care directives and each person’s right to refuse life-prolonging interventions. I have seen time and time again people’s wishes to die not being respected by those around them and life-prolonging treatment being administered against their wishes. Sometimes they do not have the strength to talk up when they want to be heard or even have the language. The experts also spoke of the many times that people have changed their mind on VAD when they properly understood what palliative care was available. I think it is important that people have choice, and we have spoken about that, and they need to understand those choices. I think this information would help that. I think the provision of information, in addition to the VAD navigator contact number, is actually quite a small ask, and I would appreciate the house’s support on this very humble amendment.

Brad ROWSWELL: I also rise in support of the member’s amendment to clause 6. I think it is entirely sensible, the amendment that she is proposing. I think the circumstances which she has outlined in relation to her amendment are absolutely true, and I believe if there is an opportunity to provide resources to those at the end of their life, with as much information as possible about what their options are and the supports and care that are available for them, then I think that is an obligation which we should agree to and that this legislation must encapsulate and embrace. So I rise in support of this amendment and commend it to the house.

Iwan WALTERS: I rise in support of the member for Broadmeadows’s – as the member for Sandringham said – reasonable and moderate amendment. The member for Broadmeadows brings a significant amount of lived experience, both of the systems and structures around voluntary assisted dying and the current operation of those laws. Also, as the member for Broadmeadows she represents a community like mine in Melbourne’s north, which does have very high levels of English-as-a-second-language households, very culturally diverse communities and, in part because of those characteristics, relatively low health literacy, where the provision of information is important to ensure that patients – or indeed their families; whoever it might be – have active and informed choice and indeed control over their treatments.

I have made this point in different contexts, but I feel that this amendment becomes necessary because of the inherent ambiguity in clause 6, in the context of the information that is to be provided by the secretary not being made explicit. Yes, it is in the explanatory memorandum and the minister’s second-reading speech, but I note again that it has not been made clear in the bill. I will return to this in a subsequent contribution – I want to focus on the amendments – but because of that uncertainty amid both the practitioner community and also the patients about precisely what information the secretary may deem appropriate to be shared, I think it is appropriate that the member for Broadmeadows has sought to be additionally prescriptive and very descriptive about the nature of the information that would be shared with patients who are seeking information or for whom a clinician would be sharing information. On that basis I rise in support of the member for Broadmeadows’s amendments.

Chris CREWTHER: I also rise in support of the member for Broadmeadows’s amendment. I agree that it is reasonable, and they are moderate amendments that come from her substantial lived experience in this area. We of course need to ensure that people are given the best information and have increased control and choice in this matter if we are to go down the path we are going down with this bill. So I do want to add my short remarks in commending the member for Broadmeadows’s amendment.

Daniela DE MARTINO: I too rise in support of the member for Broadmeadows’s amendment. At the end of the day holistic health care is incredibly important for all of us, and this actually takes quite a holistic approach in terms of the information to be provided. I think the explanation of palliative care; information about special personal care options; information about the psychological impacts of being diagnosed with an incurable disease, illness or medical condition that will result in death; and information about psychological support options are all incredibly important. So too is information about advanced care directives and information explaining differences between treatment options that manage symptoms and treatment options that prolong life, and the right to refuse medical treatment as well; information about informed consent, the risks of elder abuse and available support options; information about powers of attorney and the process for making a will; information about aged care options, assessments and services; information about the NDIS; information about support options for carers; and contact details and referral information for services that offer care or treatment described.

Furthermore, I commend the member for Broadmeadows for also ensuring that information is available to be given in languages other than English. I think the prescriptive nature of this, as mentioned by the member for Greenvale, is pretty important to be contained in this act. I think a lot of people, generally, do not do death terribly well in our culture. We do not speak about it until it approaches us or it is there already, and it is too late sometimes for people to truly understand and appreciate what is available for and to them. I think the member for Broadmeadows’s deep consideration of this and thorough treatment of the amendment she puts forward shows the level of depth, compassion and passion that she has put into this, as well as her experience working in this area and this field prior to being a member of Parliament. I think it shows, again, a holistic approach to enhancing the act and ensuring that we provide as much information as possible to people who are in that situation – a time of great grief and challenge for them.

I completely commend this amendment to the house. It would be wonderful to see it incorporated into the act to ensure that this information is provided to people comprehensively. I commend the member for Broadmeadows on this.

James NEWBURY: I rise in opposition to the amendment. It is important to understand in this debate that the legislation was modelled on best practice from two other states in relation to this clause. I can understand why members – and I do not want to reflect – have found, especially in this clause, a place to express perhaps a broader opposition to this legislation. It does concern me that the reflections contained in amendments proposed to this clause somehow seek to undermine the capacity of non-elected individuals. I understand that there are concerns around appointments and who holds particular roles, but in seeking to amend this legislation in this way, there is a reflection being made on the secretary of the department. We have to go into these debates with a view that the public service will do their best and are always trying to do their best. Any amendment that is being moved in relation to this matter unfortunately could be seen by some as a straw man argument against broader concerns around this bill. If that is the case, I think it is easier to simply say, ‘I’m seeking to amend here because I don’t support the bill’ rather than saying, ‘I’m seeking to move an amendment because I’m concerned about the behaviour of this particular public servant.’

Last night I voted against a proposal in a similar way. It is a difficult thing to be the only member of your side not to be voting for an amendment, but I believe very strongly that the legislation in its current form should be supported, so I will not be supporting this amendment.

Nathan LAMBERT: Just briefly, to respond to the member for Brighton’s remarks, which I thought were an extraordinary characterisation in the debate we have been having, last night I rose and spoke in favour of the member for Caulfield’s amendment. I made it very clear in those remarks that the intention was simply to align the bill with the explanatory memorandum and the second-reading speech, and that is a broad principle of value for all of us who rely on those summary documents to have some fidelity to the bills. For the member for Brighton to somehow claim that is speaking against the bill defies logic. Without reflecting too much on him, I think he was clutching at straws to find something to say on this topic. His remarks were inaccurate and unwarranted.

Iwan WALTERS: I similarly rise just to briefly touch upon the comments of the member for Brighton. To suggest that a concern about this particular provision in the bill is being utilised as a broader straw man is a problematic reflection on the way this debate is being conducted. I think those of us who are speaking in support of this amendment are specifically focused on this provision, and in doing so we are seeking to improve the bill.

To suggest that somehow a concern with the drafting of legislation that grants a specific power to the secretary is therefore a reflection upon either the person or the office of the secretary I find truly extraordinary. The issue that I have with that provision is that that person is not an elected member of this chamber, and the information that they may approve to be provided in the context of end-of-life care and voluntary assisted dying in Victoria is not therefore immediately subject to this Parliament. That is a fairly substantive principle that has been around for many centuries and has evolved over many centuries. As a member of this house elected by the people of Greenvale I would wish the capacity to have a democratic level of oversight of that information.

To suggest that it is a personal reflection upon a secretary, a public official who absolutely will be working to the best of their ability and in good faith, is not the point. The point is that the information is not specified in this bill and that the house does not have the capacity to scrutinise it. I suggest that is why we are debating this point: we are seeking to improve upon the bill, not in fact reflecting upon the bill as a whole.

Kathleen MATTHEWS-WARD: I am quite disturbed by the member for Brighton’s insinuation that I am using this clause to undermine the bill. That is absolutely not my intention. If you have a listen to my speech, then maybe you would be free to comment. There are parts of the bill I support, and the information given to somebody –

James Newbury interjected.

Kathleen MATTHEWS-WARD: You also do not understand my community at all. You have probably never been there. Somebody in a state of terminal diagnosis is getting information in a very vulnerable state. I know a lot of older people, particularly in their 80s and 90s and in multicultural communities, who see doctors and others as very authoritative figures who they do not feel comfortable questioning. If they are handed information about VAD only, I absolutely see the risk that they could see that as a suggestion for where they should go and what they should decide. We have talked about autonomy so much in this house over the last 24 hours, and to me autonomy is only real when you are fully informed and know what your choices are. All I am asking for is extra information in this so that people understand their choices, understand they also have the right to refuse treatment and understand what an advanced care directive is – so many people do not understand that. I think it is not unreasonable to ask that extra information is provided.

Mary-Anne THOMAS: We do not support this amendment. End-of-life discussions are a normal part of health care happening every single day, and it would be completely inappropriate for an act of Parliament to seek to define the conversations that should be held between a treating health practitioner and their patient. I have full confidence in our highly qualified, highly experienced and compassionate healthcare workforce to always have the best interests of their patients at heart.

The SPEAKER: The house is considering the member for Broadmeadows’s amendment 3 to clause 6. The question is:

That the expression proposed to be admitted stand part of the clause.

All of those supporting the amendment should vote no.

Assembly divided on question:

The DEPUTY SPEAKER: I just remind members that the style is a bit more conversational and rebuttal is completely fine on other members, but please direct your comments through the Chair.

Brad ROWSWELL: Just briefly, if I could ask the minister, please. I am advised, Minister, that you have indicated that no new offence is created in relation to a breach of this clause, but I am keen to get your understanding and, frankly, acknowledgement that compliance with civil law is a normal requirement for the purposes of insurance, registration and employment contracts for healthcare practitioners, so the penalty for conscientiously objecting to VAD is that potentially a healthcare professional could lose their job or their ability to earn a living.

Danny Pearson: On a point of order, Deputy Speaker, with the indulgence of the house, we have just had a division on clause 6. The member for Sandringham is raising –

Members interjecting.

Danny Pearson: On the amendment. My apologies.

The DEPUTY SPEAKER: We are debating clause 6 now. We just had the division on the amendment.

Danny Pearson: Could I ask if the member for Sandringham could just briefly paraphrase his question to the minister? There was a bit of audible discussion in the chamber. I was having trouble hearing the member. I am not trying to drag this out, but I just want to make sure we are responsive to the member’s questions.

The DEPUTY SPEAKER: We have had members making a bit of noise. If the member would like to start again, I will let it go.

Brad ROWSWELL: I am happy to on the basis that it is my first crack. I am in complete agreement with the minister that we do not want to draw this out. I am advised, Minister, that you have indicated that no new offence is created in relation to a breach of clause 6. I am inviting your acknowledgement that compliance with civil law is a normal requirement for the purposes of insurance, registration and employment contracts for healthcare professionals, so the actual impact or penalty of conscientiously objecting to VAD, in this case, is a potential loss of job and the ability to earn a wage for a healthcare professional.

Mary-Anne THOMAS: In response I might repeat what I have already said in this house. When it comes to conscientious objection, our government absolutely respects the right of healthcare providers to hold a conscientious objection. However, we agree with the Australian Medical Association’s position on conscientious objection, which states that medical practitioners ‘have an ethical obligation to minimise disruption to patient care and must never use a conscientious objection to intentionally impede patients’ access to care’.

Brad ROWSWELL: Just a short, sharp question: was the change, as expressed in the government’s amendment to clause 6, recommended by the VAD five-year review?

Mary-Anne THOMAS: I have already explained at length that the five-year review was only one of the elements that led to my consideration of the need to make changes to the Voluntary Assisted Dying Act.

Chris CREWTHER: I just want to add to some of the conversation yesterday in the general consideration in detail (CID). Why has the government left the decision about what information conscientious objectors will be required to provide to an unelected official, particularly an unelected official without parliamentary oversight?

Mary-Anne THOMAS: I have already provided answers to these questions.

Will FOWLES: I still have concerns about the rural and regional access issues that attach to much of this bill. I am interested, Minister, in how the government will ensure that this information approved by the secretary provides a clear and consistent pathway to support, particularly for people in rural and regional areas who do not have the same access to specialists under the government’s scheme.

Mary-Anne THOMAS: As a regional Victorian myself, I have always had at the front of my mind how to improve access to health care for people living in rural, regional and indeed remote Victoria. As I have said a number of times, the advice that should be provided by a conscientious objector is advice on how to access the statewide navigator service and the Department of Health website, which is equally available to rural and regional Victorians.

Chris CREWTHER: I just want to add to my question from before. I know that there was some information given last night with respect to information being provided by an unelected official, but I would appreciate further information, if that can be given, about the reason why parliamentary oversight has not been given with respect to that person. I think there needs to be a further elaboration with respect to that.

Mary-Anne THOMAS: I thank the member for his question. I have already responded to this question here on the floor, but also this is outlined in the bill, the explanatory memorandum, the second-reading speech and my summing-up of the second-reading debate yesterday.

Iwan WALTERS: I touched upon this in the discussion around clause 1 yesterday, but I do want to revisit appendix 6 of the Review of the Operation of Victoria’s Voluntary Assisted Dying Act 2017 and the stakeholder feedback regarding legislation. In my question yesterday I sought to get some further detail regarding the evidentiary base about how the changes to clause 6 have come about and why the minister has deemed it to be necessary for information to be provided as a threshold issue, noting again that the review appeared to broadly suggest that there is support for conscientious objection, and I know that the minister has reiterated that now. But appendix 6 of the review does point to cases of patients being pressured not to proceed with VAD by health practitioners who conscientiously object, and I understand that that is inconsistent with the act’s principles. But I would be keen to get some sense of how significant a challenge this is, because from the perspective of people in my community – doctors and others – the threshold question is a concerning one, particularly because of the ambiguity about what specific information may be provided as a consequence of it not being in the bill. Given the significance of this change, is the minister able to provide some information about the scale of the challenge that this change is seeking to address?

Mary-Anne THOMAS: As I have stated a number of times already in this place, the bill that is before the house seeks to better align Victoria’s laws with laws that already exist in other states and territories, and the requirement for registered health practitioners who conscientiously object to provide minimum information would align us with WA, Tasmania, Queensland and the ACT. For the member’s information, the way it is expressed in this bill most closely aligns to Queensland and the ACT.

Will FOWLES: Minister, I have a concern about the narrowness, or rather the obliqueness, if you like, of this information approved by the secretary. Were there to be an LNP government or, heaven forbid, a DLP government in Victoria, would the information provided by the secretary be able to be distorted by the minister of the day to be functionally useless? And if that were the case, why not specify in legislation with greater detail what information the secretary ought to provide?

Mary-Anne THOMAS: I have already canvassed in some of my responses why I do not think it is appropriate to include website information in legislation. As I advised the house earlier, the model that we are presenting is closely aligned with what is currently working in Queensland and the ACT.

Nicole WERNER: The minister continues to refer to VAD as a form of care. Could the minister explain where in the act voluntary assisted death is defined as a form of care?

Danny Pearson: On a point of order, Deputy Speaker, it is not clear to me in relation to the question that the member is asking how this relates to clause 6. I might be missing something, but if the member can draw her point back to clause 6, I think that would be helpful for the minister.

The DEPUTY SPEAKER: Member for Warrandyte, if you could relate your question to clause 6.

Nicole WERNER: This is pertaining to the answers already received from the minister that she has referred to, so I am just seeking clarification of answers she has already provided on clause 6 and others.

Danny Pearson: On a separate point of order, Deputy Speaker, we are still on clause 6 and it is important that we stay on clause 6. The member is asking for the minister to talk about issues that go beyond clause 6, and I do not think that is in order in relation to where we find ourselves at this point in time in the debate.

The DEPUTY SPEAKER: Member for Warrandyte, I appreciate that you are relating it to responses given by the minister, but you need to relate your question to the remit of clause 6. If you can do that, then I am happy for you to ask again.

Brad Rowswell: On the point of order, Deputy Speaker, just a point of clarification, and we are all learning through this process, I contend that the member for Warrandyte’s question should be considered in order. The minister is offering a response to questions that are asked specifically in relation to clause 6. If the minister uses language consistently in her responses to questions specifically in relation to clause 6, is there or is there not the opportunity to reference and seek clarity on the minister’s language if the minister chooses to use the language she uses in response to questions specifically in relation to this clause?

The DEPUTY SPEAKER: On the point of order, as I was saying, I am mindful that words can be used in an answer to a question that does not necessarily open up the context of further points so that we are revisiting clause 1. I am trying to ask the member for Warrandyte if she can relate her question to clause 6, which is about conscientious objection of registered health practitioners. That would assist the house.

Nicole WERNER: I will move on to my next question, which does pertain to clause 6. I am wanting to know what training the government is offering or requiring for the huge number of registered health practitioners who will now be captured by this bill and the specific requirement conveyed in clause 6. This is inclusive of podiatrists, optometrists, Chinese medicine practitioners and dentists.

Mary-Anne THOMAS: Let me be clear. We are talking about conscientious objectors, and conscientious objectors are only required to provide minimum information to patients who ask a question about VAD. They are absolutely not required to initiate any conversation at all.

Tim BULL: My question relates to the provision of information in clause 6. There have been concerns raised by a number of members both last night and today in relation to what the type of information provided is and whether that can be changed by the secretary at some stage in the future. We have had some divisions on that, and the votes have been quite split. Whilst they have not been successful, it has been clear that there has been a reasonably high level of support in the chamber for them. I believe there are a number of members who wish to support this legislation and believe in this legislation – I am one of those – but would like a little bit more reinforcement in that area. So my question to the minister is: given that there are some concerns raised by a large number of members in this chamber, can we get a commitment between chambers to perhaps sit down with the minister and try and find a suitable pathway forward? It might not appease all, but I think it could with a bit of discussion. I think this is how our Parliament works the best – when we work together. Can we have that discussion and get a commitment from the minister to maybe put some tweaks or some greater safeguards in place to the satisfaction of a lot more MPs in this chamber? I just ask the minister simply if she would be prepared to make that commitment.

Mary-Anne THOMAS: I appreciate the question from the member for Gippsland East; however, my responses to previous questions in relation to this hold. I do not support the amendment. I do not support the proposal as it has been articulated by the member for Gippsland East.

Tim BULL: I did not actually move an amendment. I simply asked for a commitment to discuss this further between chambers to see if we can find some common ground.

Danny Pearson: On a point of order, Deputy Speaker, the minister has been at the table for hours both last night, this morning and now today. The minister has provided a second-reading speech. The minister has provided the summing up of the second-reading debate. The minister has responded to answers in relation to clauses. The minister has been very clear that when it comes to questions like this, you cannot put a website into a piece of legislation. The process is you have got legislation, you have got regulations and you have got statements of expectations that ministers can provide to their secretary, their office, and provide further guidelines. I think what the minister has done to date has been very clear in relation to the position of the minister in relation to these matters. The member has sought an undertaking to have a conversation between houses. Obviously when this bill – assuming it is –is transmitted to the other place there will be opportunities to explore these matters in further detail.

The DEPUTY SPEAKER: Points of order are not an opportunity to debate. I am not quite sure it was a point of order in the start. But either way, if it was, it was not. And if the minister wishes to respond to the member for Gippsland East, the minister can do that.

Mary-Anne THOMAS: I do not want the member for Gippsland East to misconstrue my statements. As I indicated yesterday, I have continued to have very productive conversations with the opposition spokesperson on health in the other place Ms Georgie Crozier.

I note that the Greens spokesperson for health Sarah Mansfield from the other place is a person whom I have also had conversations with, particularly through the Leader of the Greens, and I have had the opportunity to have a conversation with the Leader of the Nationals. I will continue to have conversations, however, and I will leave it at that.

Emma Kealy: On a point of order, Deputy Speaker, consideration in detail is an opportunity for the house to seek further information regarding legislation that is before us and particularly, obviously, clause by clause, to go through that. While the minister has referred in her response to private discussions she has had, she has not put that information on the public record and made that available to the entirety of the house, which is what consideration in detail is all about. I ask you to request that the minister review and perhaps add to her contribution to the house and make that information further available to all of us.

The DEPUTY SPEAKER: On the point of order, I cannot direct the minister or any member on the content of the debate, so there is no point of order in this case.

Iwan WALTERS: In the first question I asked to the minister I sought to really dwell on the threshold question of conscientious objection of registered health practitioners and sought to contextualise that in the setting of my electorate, and also of palliative care specialists with whom I have had conversations in the run-up to today’s and this week’s debate. The second part of the question that I would like to ask the minister does pertain to this issue that we are continuing to dwell upon, which is the specification of which information is actually to be relied upon and to be shared by practitioners with patients. The reason I am asking that is that the threshold issue is a concern for some doctors and health practitioners, but it is the uncertainty about what specifically that might be, again noting the minister’s comments in the second-reading speech, noting the explanatory memorandum, but also noting that the bill itself remains unamended as a consequence of those which have been put up.

I place this contribution in the context that conscientious objection and the provision of information and the obligations on doctors in the context of abortion services in Victoria are reasonably well understood, I think, and the system functions in accordance with law. Practitioners entering into medical training have an understanding about what would be required of them should they wish to go down a gynaecological or obstetric training pathway in terms of referral to another clinician should they have a conscientious objection. Where there is concern among palliative care specialists, geriatricians and others who are working in end-of-life care is that they do not fully understand precisely the threshold at which their conscience will be engaged. I again note that the minister has given undertakings and it is included in the explanatory memorandum the type of information that will be provided. But because it is not in the bill, because it has not been in the draft legislation that has been shared with the medical community and indeed with other medical practitioners, there is that uncertainty that clinicians who are currently in the specialism have that they do not know the threshold at which their conscience will be engaged. That, in the context of the feedback I have received, is a source of acute concern and distress. It is not that people wish to impede the lawful access of Victorians to particular forms of treatment, whether that be VAD or anything else, but because they do not know exactly upon which the threshold their conscience will be engaged, that is causing concern.

In turn it causes concern for me if the implication of that means that people who are currently – as I alluded to in my second-reading speech yesterday – drawn into those specialisms out of a deep concern and empathy for the infirm, the elderly, those to whom the measures of the VAD act would be most relevant, will be obliged, as the member for Sandringham suggested, or compelled as a consequence of the interaction of this measure with the Australian Health Practitioner Regulation Agency (AHPRA) preregistration, with professional indemnity insurance and those kinds of dimensions, to leave that profession or it curtails the choice that people have upon entering it.

I note that we have something of a deficiency in palliative care specialists, and I note your comments yesterday, Minister, about the difficulty of defining those. I think we have about 1.1 palliative care specialists, according to some research, per 100,000 compared with international estimates that it should be two per 100,000. Anything that shrinks that workforce or curtails the pipeline would be a concern to me. The question I have is: is the minister able to provide assurance to those practitioners? It is similar to the contribution of the member for Gippsland East as to whether there is capacity to review this to ensure that it does not have unintended consequences for palliative care practitioners either now or into the future.

Mary-Anne THOMAS: The member has sought some clarification on when a conscientious objector’s conscience would be engaged in relation to the act. The answer to that is quite simple: it is if that conscientious objector is seeing a patient who requests information on voluntary assisted dying. Voluntary assisted dying is always patient-led – it is only at that point that that practitioner’s conscience would be engaged. The requirement of the bill – protecting their conscientious objection but balancing that with the needs of the patient – is that there is the provision of information that will direct that patient to the statewide navigator service or the Department of Health website.

Assembly divided on clause:

Clause 7 (11:49)

The DEPUTY SPEAKER: I call on the member for Preston to move amendment 2 in his name. I advise that if his amendment is not agreed to, he cannot move his amendments 3 to 5, as they are consequential. Therefore I advise him to address the principles of all those amendments when speaking to amendment 2.

Nathan LAMBERT: I move:

2.   Clause 7, line 9, omit “may” and insert “must not”.

I will make a case that I have already made earlier in this debate, but it has not proven especially compelling yet, so I suppose I will try and make it in slightly more detail. As I have said previously, I think that explanatory memoranda and second-reading speeches are very important documents not only for the operation of this house but for the operation of Victorian democracy. I certainly try hard to read every bill in full, but I think any of us, if we are honest, realistically admit that that is not possible. All of us rely on second-reading speeches or the explanatory memoranda in order to not only make our contributions but, quite importantly, to explain things to our constituents, who often have questions about bills that we might not anticipate. That is not only true of those of us in this chamber of course. Certainly in my time as a public servant it was true of most public servants, who did not have time to read legislation in full. It was true of my time working in non-government organisations that worked with government. I imagine it is true of all the NGOs that many of us deal with. Some of us have work experience students or parliamentary interns. As far as I can work out, many of them get ChatGPT to find the answer for them, and ChatGPT relies on explanatory memoranda and second-reading speeches. I reiterate again that I think it is an important principle that those three documents, the two conventional summary documents and the bill itself, align. Of course the summary documents are summaries, so they cannot contain all the information, but I think it is a very important principle that the information they contain is an accurate representation of the bill.

I say all that to come directly to the particular clause that we have in front of us. The summary documents all make it clear that the intention is to allow discussions about VAD to be raised by health practitioners, provided that the discussion is in the course of a discussion about end-of-life care and that the practitioner takes reasonable steps to ensure that the person knows about their treatment options and palliative care options. The member for Broadmeadows, on the previous clause, spoke very eloquently about that. I will not repeat her points. More importantly, the minister at the table, the Minister for Health, spoke, I thought, eloquently about exactly the same point in her contributions on the previous clause.

The amendment I have moved is simply to ensure that the bill in front of us does exactly that. At the moment the bill says that practitioners may raise VAD subject to the conditions I have just set out and is silent on the circumstances in which they may not raise it. The normal way that we draft these clauses is that we say you may not raise it unless the conditions are fulfilled. That is all my relatively simple amendments 2 through 5 do. For the benefit perhaps of the member for Brighton in particular, these amendments do not seek to, through some straw person argument, vote against the entire bill. They are, I repeat, an attempt to ensure that the bill before us meets the intention of the minister and indeed the intention of all of us. I recommend these amendments to the house.

Iwan WALTERS: I rise very briefly in support of the member for Preston’s amendments, similarly not out of a straw man endeavour but because I agree with that principle of consistency and accuracy. I think it does align with the points that I made in the second-reading debate yesterday about the process by which this bill has arrived here and the opportunity for further consultation, for wider consultation and for things like an exposure draft and all of the steps that were present in 2017 to ensure that legislation of such consequence for life, death and the process of dying is properly considered and properly understood and therefore the drafting of it properly reflects both intention and reality.

Chris CREWTHER: I rise in support of the member’s amendments, which will change the wording of the bill to ensure that a discussion around voluntary assisted dying does not occur unless the discussion is in the course of a discussion about end-of-life care. Basically, the prohibition on practitioners initiating discussion of voluntary assisted dying was included in the original legislation to avoid the implicit practitioner recommendation of assisted suicide. If permitted to initiate discussions of voluntary assisted dying, it will almost be inevitable that many frontline doctors raising the subject will not have a good knowledge of palliative care or of the patient’s condition, yet their raising the subject will be taken as an implicit recommendation by the patient. This includes people like podiatrists, dentists, physiotherapists, Chinese medicine practitioners, chiropractors, optometrists, osteopaths and others providing such advice to a patient about voluntary assisted dying, including those without training or with little training at all. I support the amendment moved by the member.

Mary-Anne THOMAS: We do not support this amendment. Fundamental to the amendments in this bill is that there should be no wrong door for patients who are receiving end-of-life care. Therefore if a person has a life-limiting disease or illness and they are receiving care, that will most likely be from a care team. What this clause seeks to do is to enable registered health practitioners who are providing end-of-life care to use their professional judgement and potentially advise that voluntary assisted dying is a lawful end-of-life care choice here in the state of Victoria. But let me be very clear: they are absolutely obligated to then refer that person to a medical practitioner or a nurse practitioner as the most appropriate person with whom to have that conversation. I want to see a health service system where registered health practitioners are able to provide relevant information to support people to make their own decisions. Let us be clear: the patient leads this journey at every step of the way.

There are two protections in relation to this. First there is that contained within the bill itself and in the act, but the second comes by virtue of the definition of a registered health practitioner – that is, someone who is registered with AHPRA and as a consequence has a range of obligations under the Health Practitioner Regulation National Law, and all registered health practitioners are required by their codes of conduct to work within the limits of their skills and competence.

Nathan LAMBERT: Just for clarity, the minister referred to the important principle that there should be no closed door and the important principle of patient-led care. Nothing in my amendment seeks to adjust or change either of those things, but I do recognise that the minister has made a good point with respect to the fact that I understand that perhaps what I am seeking to do here may be done through the following clause, clause 2, though I am moving amendments because I do put to the house that that is still somewhat ambiguous.

The DEPUTY SPEAKER: Because this amendment deletes a word from the clause, the question is:

That the word proposed to be omitted stand part of the clause.

All those supporting the member for Preston’s amendment should vote no.

Assembly divided on question:

The DEPUTY SPEAKER: The members for Kew and Monbulk both seek to omit the word ‘may’ from clause 7, page 9, line 2. I will call on the member for Monbulk to move amendment 1 in her name. I advise the members for Kew and Monbulk that if the amendment is not agreed to the member for Kew cannot move her amendments 2 to 5 and 7 to 9 and the member for Monbulk cannot move her amendment 2, as they are consequential. Therefore I advise both members to address the principles of those amendments when speaking on the member for Monbulk’s amendment 1.

Daniela DE MARTINO: I advise the house that I wish to withdraw my amendment and will speak to the amendment of the member for Kew as circulated this morning.

Jess WILSON: I move:

2.   Clause 7, page 9, line 2, omit “may” and insert “must not”.

Thank you to the member for Monbulk for her cooperation in seeking to align the two amendments that we had previously circulated. These amendments go to clause 7 and look at, in the course of initiating a discussion about end-of-life care, removing the ability for a registered health practitioner to be able to provide advice in that context. Instead, a registered health practitioner would have to ensure that they refer the person in question who has initiated the discussion about end-of-life care to a registered medical practitioner, a doctor or a nurse practitioner who is responsible for the person’s medical care or any other registered medical practitioner or nurse practitioner.

Speaking to this amendment, I spoke in my speech about the concern I have around delegating authority to raise voluntary assisted dying to healthcare practitioners who do not have the same degree of medical expertise as doctors and nurse practitioners. When we are talking about health practitioners in the context of the definition within the bill, it would be a very, very broad definition to include, for example, specialists in their own right – whether it be optometrists, podiatrists, osteos or chiropractors – but not necessarily experts in end-of-life care, and the definition of a registered health practitioner who is not a medical or nurse practitioner, as I said, is incredibly broad and it does raise concerns about the discussions taking place in potentially inappropriate settings. I believe that these conversations should only be had with medically trained professionals and very specifically with doctors and nurse practitioners, ensuring that these conversations are navigated very sensitively and in a manner that is sensitive to the person’s diagnosis and appropriate to that diagnosis. For that reason I seek to work with the member for Monbulk to encourage members in this place to consider the broad drafting of the current bill and to seek to remove health practitioners’ ability to provide advice about voluntary assisted dying and to limit that referral to a medical practitioner, a doctor or a nurse practitioner. I commend the amendment to the house.

Daniela DE MARTINO: I thank the member for Kew for her collaboration in combining our two amendments. Essentially we had both considered that it would be inappropriate for AHPRA-registered health practitioners – obviously with the exception of medical and nurse practitioners – to be able to initiate conversations with their clients or patients, depending on how they refer to them. I did read into Hansard during my speech the list of people captured by this, and I think for the purposes of those considering this, I will do so again: acupuncturists, Chinese herbal medicine practitioners, Chinese herbal dispensers, chiropractors, dentists, dental therapists, dental hygienists, dental prosthetists, oral health therapists, diagnostic radiographers, nuclear medicine technologists, radiation therapists, registered and enrolled nurses – as opposed to nurse practitioners, who have a master’s degree minimum – midwives, occupational therapists, optometrists, osteopaths, paramedicine practitioners, pharmacists, physiotherapists, podiatrists and psychologists.

I have spoken with several health practitioners who practise in the field, one of whom is a lecturer in Chinese medicine as well. They have expressed their concerns with the capacity for their colleagues to be able to initiate these conversations. They get very, very little training in being able to actually have conversations. In fact they do not get training to initiate conversations about end-of-life care or death or dying. They are also not privy, in most instances – in fact the majority of instances – to actually having the diagnostic information to hand from that person’s medical practitioner, which explains exactly what disease or terminal illness they may be afflicted by.

They also do not have any technical expertise in prognosis. Prognosis itself, we know, is a very inexact science, but more so for those who have no familiarity with it at all. For a health practitioner to be able to initiate the conversation with a patient puts something into the mind of the patient that they may not have wanted. But this change does not stop that patient or client who has had a good relationship with that health practitioner. I may say I have several in my life that I have more of a relationship with than my general practitioner, who I have known for years and I trust. I would like the capacity and I would like the capacity for others to be able to say to that person, ‘What do you think about voluntary assisted dying?’ And I would like that person to be able to say, ‘I’m not an expert in that, but I really think you should speak to your medical or nurse practitioner,’ and if you do not have one that you can have that conversation with, there are other medical and nurse practitioners out there that you can have that conversation with.

I think it is important we do not gag them from being able to have that conversation, which is how it stands now in the bill. That gag can make people feel shame when they raise it. We should never, ever have anything that makes a person feel shame for asking a question about a legal method they may choose to end their lives from their position of choice. This is about the power dynamics in a client-patient relationship with their practitioner. When one asks the question of someone else, they are initiating that conversation, they have asked for it and they are ready to receive the information. If they have not asked the question and someone has suggested to them, ‘Have you thought about voluntary assisted dying?’ – because this person may be unwell, they may have expressed they are terminal; we do not even know what that conversation looks like –they are not in a position of power. They may receive a shock when that is put to them. And if multiple health practitioners they see have the capability to initiate this conversation, there can be a layering effect of many people putting this to them. How, then, does that impact them psychologically? I hope we all ponder that when we consider whether or not health practitioners, who are neither trained nor skilled to have these conversations, should initiate them. Actually the ones I have spoken to are unwilling to initiate it but have concerns that some of their colleagues may do so and do so clumsily and result in mental injury to their client or patient for having raised it in the first instance. I think we need to consider this one incredibly carefully. Furthermore – and I will speak to it because I know we will have another 5 minutes – many have expressed their concern about mental injury to themselves as health practitioners if they go down the path of initiating this and not understanding that they may have had a shocking effect on the person receiving the information, who, once again, had not sought it from them.

Will FOWLES: I oppose this amendment from the member for Kew that was just spoken on by the member for Monbulk. I think we have gotten trapped here in the very narrow scope of what the bill proposes here. We are talking about a discussion about VAD that may be initiated by a registered health practitioner – may be initiated. I do not think we can credibly talk about injury to that health practitioner when in fact that discussion is at their option. It is not a compulsion to have that discussion, it is merely a protection should they go down that path. Should they opt in to have that discussion, they would, as a result of this amendment to the act, as a result of this section of the bill, be protected legally if they go down that path.

Additionally, it does not say that they all of a sudden assume seniority in any way as the practitioner in discussing VAD or other end-of-life treatment with the patient – far from it. They are only protected by this clause if in fact they make clear to the patient that the appropriate person for that patient to speak to is the registered medical practitioner who is responsible for the person’s medical care or any other registered medical practitioner. That is medical practitioner as opposed to health practitioner – that is, doctor as opposed to osteopath. I am entirely comfortable with the bill as drafted because it is very, very narrow. It does not mandate the discussion, it says you may have the discussion. And it says you can only initiate the discussion – not that you must initiate the discussion – about voluntary assisted dying if the discussion is in the course of a discussion about end-of-life care.

Let us think about just how narrow the operation of this clause is. I have not had any conversations about end-of-life care with my osteopath, my chiropractor or my acupuncturist. That would be pretty weird. Frankly, it would be very, very weird for anyone to be having those conversations with those allied health professionals if they were not already in a position of significant distress and talking about end of life. In those circumstances, should that practitioner so choose – no compulsion, but should they so choose – they become protected to be able to talk about voluntary assisted dying, as long as they advise the person that the most appropriate person to discuss VAD with is their doctor. That is a perfectly appropriate legislative response.

We know that people have contact with various health professionals over the course of their lives, and that it might well be that that intervention comes at an appropriate time. If you are suffering acute pain because of your terminal illness, if you are seeing an acupuncturist on that basis and if you do not know anything about VAD, then simply that practitioner is allowed to say, ‘VAD is a thing. Go and have a chat to your doctor about it.’ What, frankly, could be more benign than that? That is a protection for a very, very low-level intervention, an intervention that is entirely sensible, that supports patient choice, that supports patient welfare and that does so in a way that is cast very narrowly and cast entirely with optionality – that is, there is no compulsion on the practitioner to even walk into the room on a VAD discussion. But if they so choose to, there is a very clear process laid out under the bill. I support the bill as it stands, and I urge members to oppose the amendment.

Kat THEOPHANOUS: I rise in support of the amendment proposed by the member for Kew, who has worked in very close collaboration with the member for Monbulk to put this forward. In essence, it gives consideration to the risks around allowing broader AHPRA-registered health practitioners to initiate conversations about voluntary assisted dying, as opposed to medical specialists and nurse practitioners, owing to the differentials in experience and setting in which those two cohorts operate.

I want to say at the outset that I am supportive of end-of-life choices and the ability of each individual to make informed decisions about voluntary assisted dying in a way that is not coercive, either overtly or cumulatively. That is a matter of autonomous choice and freedom of will, which I had the opportunity to study extensively from an existential perspective when I completed my honours in philosophy. Indeed, my final thesis was on the topic of free will. It is a principle that I hold very dear and inviolable as an element of our human condition, which is both our blessing and our burden. That is why I am a supporter of VAD as a choice in the circumstances outlined in the bill.

Inherent in that ability to make an autonomous choice about VAD must be the ability to access appropriate information on the availability of VAD, and I am sensitive to the need to expand that access. The current gag clause, as they call it, is problematic in my view. Now, the members have put forward a balanced approach which preserves in the bill the proposed expansion to enable registered medical practitioners and nurse practitioners to initiate discussions about voluntary assisted dying in the context of end-of-life care. That, to me, is appropriate and represents a significant change in the current settings. It means that when those critical conversations are being had between a patient and their medical practitioner and nurse practitioner about diagnosis, about palliative care options and about what happens next, VAD can be included proactively in those discussions.

What this amendment does is prevent this proactive initiation also being expanded to a vast list of other AHPRA-registered practitioners when they are neither trained nor experienced to have such conversations. This includes health practitioners like acupuncturists, dental hygienists, optometrists, podiatrists, pharmacists and herbal medicine dispensers. As the member for Monbulk outlined, many in the medical profession are concerned about this expansion and the risk it poses not just for patients but for potential mental injury to the practitioners themselves.

Like many in this chamber, my community is home to a large, ageing, multicultural population, many with English as a second language and many with cultural norms that elevate the opinion and authority of health practitioners. A single poorly framed or uninformed conversation could leave a person feeling that voluntary assisted dying is the recommended option, that they are a burden on society or that this is the expected pathway.

Without access to diagnostic details and an understanding of disease progression or expertise in diagnosis, even well-meaning practitioners could inadvertently instil fear or despair simply through a lack of skill in these sensitive discussions. Importantly, the amendment preserves the right of these health practitioners to provide information on VAD at the patient’s request and to advise that person that the most appropriate person with whom to discuss voluntary assisted dying or any treatment or palliative care options available is a registered medical practitioner or nurse practitioner.

It is incredibly important to me that strong checks and balances remain in this legislation, particularly against unintended or intended coercion. Equally, it is important to me that patients have access to the information they need to make informed choices. That balance is appropriately struck in this amendment.

Kathleen MATTHEWS-WARD: I rise to support the amendment put forward by the member for Kew, supported by the member for Monbulk and spoken so eloquently about by both and in particular by the member for Northcote. Everything you have just said is exactly how I feel, and you said it so well, particularly the understanding in multicultural communities and the different attitudes to people in authority or who they see as people in authority and how that suggestion could be potentially misinterpreted.

I will list the health practitioners this clause includes: Chinese medicine, chiropractors, dental practitioners, medical radiation practitioners, midwives, OTs, optometrists, osteopaths, physios and podiatrists, as well as others. I do not think they have the training or expertise to sensitively enough initiate discussions about voluntary assisted dying, nor do they have the context of everything else that a medical practitioner would have. In my view discussions about VAD with someone who is terminally ill should only be had by doctors, nurse practitioners and those with extensive experience in palliative care. That is essentially why I support this amendment. Any end-of-life discussion should be held in a supportive, holistic manner, which includes the offer of psychological support. I do not think that is possible in a dentist’s surgery, to be honest. I think there are often people waiting. It is not set up for that kind of discussion or advice.

I also do not think the peak bodies have been consulted on this. A number of the health practitioners I spoke to had no idea that this was coming. In the list of consultations in some of the information I read AHPRA and others were mentioned with consultation but not peak bodies for all of these health practitioners. It also includes very junior practitioners. There are years of experience that are required to be a nurse practitioner or a doctor, but those years of experience are not the same for many junior health practitioners.

I also am quite concerned about how AHPRA will even monitor or enforce this. While the bill says it has to be in the context of an end-of-life discussion, how on earth would that be monitored? It also says all of that information about elder abuse and all of the other training that goes there. What is the mechanism to get all of that information to all of those health practitioners, all of those peak bodies and make sure they have all read it? To me, there is no appropriate process around this suggestion.

For that reason, I entirely support the member for Monbulk. I appreciate the incredible work she has done on this, the number of conversations she has had and how entirely considered she has been on this, and the member for Kew as well. I support everything they have both said, absolutely share their concerns and thank them for their deep consideration of this issue.

Mary-Anne THOMAS: I do not support the amendment. I have confidence in the model that has been operating safely in Tasmania since 2021 and from which this provision is lifted. I am confident that we have the right combination of safeguards, offences and consequences to protect patients at all times.

These are contained in this bill but also apply as a consequence of a person being a registered health practitioner in Australia and therefore having a range of consequences and restrictions that apply to them within a clearly defined scope of practice which they cannot operate out of, because to do so would actually put their registration to act as a health practitioner at risk.

Nathan LAMBERT: I thought the member for Northcote and the member for Broadmeadows just spoke very well. I want to endorse their comments and then just very briefly address the comments made by the minister. I think the minister probably has a fair point – that we would expect, as she made the point earlier – that the Health Practitioner Regulation National Law would deal with some of the concerns that have been raised. Obviously the bill before us goes to a great deal of trouble to separate out the roles of medical practitioners, nurse practitioners and health practitioners, and in new sections 8 and 8A we are doing the same thing. But having said that, I reiterate a similar point to my earlier point, which is that whilst I appreciate that the Health Practitioner Regulation National Law will probably act as the minister has just said it will, I think it is always best in these things to be clear, and we will be supporting the amendment on that basis.

Brad ROWSWELL: I briefly rise in support of the member for Kew’s amendment. I am also thrilled that the member for Monbulk and the member for Kew have been able to reach a cooperative point on this amendment. I understand that there is a range of medical professionals that engage with a patient as part of a holistic care approach, but the reality is that some are better qualified to have conversations about quite literally matters of life and death than others. I think it is an obligation upon us as legislators to recognise that important difference. It is not to underestimate or undermine the professional nature of other health professionals, but unless there is specific training offered or undertaken by the suite of allied healthcare professionals stipulated or enabled in this bill, then I think that the amendment should be supported. I would encourage the government to consider – I am not sure they have to this point – what training they might be able to provide to a broader grouping of healthcare professionals if in fact this amendment by the member for Kew does not pass.

Chris CREWTHER: I concur with the words of the member for Sandringham and others who have spoken. I support this amendment, and I would like to thank in particular the members for Monbulk and Kew for their work in this regard. It is indeed the most marginalised and disadvantaged patients or those with low to no health literacy who are the most vulnerable and dependent on their doctors for advice and most at risk of interpreting a doctor’s raising of the subject as an implicit recommendation. Where the discussion of voluntary assisted dying is initiated by a registered medical practitioner or nurse practitioner, they must take reasonable steps to ensure the person knows about the treatment and palliative care options and likely outcomes. There is nothing to ensure, though, that the practitioner has good knowledge about those options or to avoid the risk of an inexperienced practitioner giving poor or limited advice on treatment and palliative care options while suggesting the option of voluntary assisted dying instead.

To make matters worse, a registered health practitioner is anyone registered to practice a health profession under the Health Practitioner Regulation National Law. That can include podiatrists, dentists, physiotherapists, Chinese medicine practitioners, chiropractors, optometrists, osteopaths and others who may provide such advice. In particular a number of them might have little to no training in this area at all, which I believe is a risk to patients, particularly our most vulnerable and disadvantaged and particularly those who are at risk of potential elder abuse as well.

Iwan WALTERS: I rise briefly in support of the amendment effectively proposed by the members for Monbulk and Kew, and I thank them for their work on this. I think this is an amendment which improves clause 7. I would retain concerns with even an amended clause 7, and I obviously reserve my right to ask questions on that in due course to the minister, principally because of the philosophical challenge that the member for Northcote set out about agency autonomy and free will and people from my community potentially having that trammelled as a consequence of these issues being initiated by a health practitioner.

I will confine those comments, however, to a subsequent part of the debate on clause 7.

In this instance the minister indicated earlier, correctly I think, that patients at the end of their life are likely to have a care team that will no doubt include a range of allied health professionals. I can entirely understand how podiatrists, optometrists, OT et cetera could be involved in those discussions. But I do have concerns noting that even in the context of medical training, there is very limited time afforded to end-of-life care, that allied health professionals do lack the formal training in palliative medicine and potentially the experience of the complexities around ethical and medical criteria surrounding assisted suicide, euthanasia – the VAD system more broadly – and the risk that the member for Northcote articulated of no doubt well-meaning but inadvertent harm being created as a consequence of an initiated conversation in the context of a community like mine, like that of the member for Broadmeadows and others, where members of our community do have, I think, a power imbalance with health professionals; it is real. I support the amendment, but I do note that I retain concerns with the clause more broadly.

Daniela DE MARTINO: In summary, I would like to note that although Tasmania does allow for the initiation of the conversation by health practitioners, both Queensland and WA do not allow for it – they allow only for medical practitioners and nurse practitioners to initiate the conversation, which I think is wholly reasonable. I support medical and nurse practitioners being able to raise this. I do believe that it allows the patient to have a list – an array, an understanding – of the options before them. And I think when it is raised by professionals in that regard, they are better equipped to have those conversations. They are better skilled, they are better trained for it and they have greater experience of dealing with people in end-of-life care and an understanding, as I say again, of the diagnosis and the prognosis and the medical information to hand. That is in contrast to health practitioners, which this clause seeks to amend, who do not have access to that information to hand.

Although the member for Ringwood says it is permissive with the ‘may’ – I do take that, member for Ringwood, and I understand that – the conversations I have had with health practitioners, some of whom train other health practitioners, is they are very, very concerned about the ability for others to raise this. They may not have necessarily the tact to do so. They may feel that they should raise it with that person out of a position of compassion or care, but they may not have adequate skills, knowledge and tact to have a very, very delicate conversation with someone who is at their most vulnerable at that point in time when speaking about end-of-life care.

That is why they have reservations and have expressed serious concerns to me about the capacity that this legislation creates. The question they asked me was: will it then become a bit of an expectation down the track that we may need to? We cannot answer that here, and we would hope that is not the case, but that speaks to some of the anxieties of health practitioners when they realise that this is something that they will be allowed to traverse. Previously no-one was allowed to initiate this, so it really is in Victoria uncharted territory.

I take the minister’s point that this was lifted from Tasmania and it has been in effect there for a few years, but these are seriously held concerns and fears by health practitioners themselves, who I have done my utter best to seek out and speak with. There was something else I sought to amend, and when engaging with experienced VAD practitioners in the field I stopped my amendment because they had told me they were comfortable with that change, so I left it there. Every conversation I have had with medical practitioners, every conversation I have had with nurse practitioners in the field and every conversation I have had with health practitioners – I have experienced as a patient and as a mother with my children interactions with a minimum of 35 different health practitioners.

I started listing them all and stopped when I got to that. Some have been marvellous. They are still health practitioners in my life. Some have been pretty good. Others have not been wonderful at all. The way they have indelicately raised matters with me or my children has had deleterious effects on us over the time as well as our engagement and how we have felt about things too. The conversations we have – the words we use, how we use them, the context in which we use them and, more importantly, that power dynamic – are key to this.

I fully support the patient being able to ask their practitioner, ‘What do you think about VAD?’ I fully support that health practitioner having the capability to say, ‘It’s legal here. Speak to your medical practitioner or your nurse practitioner. Get the information from them. I’m not qualified to have the conversation, but thank you for asking me.’ What this amendment seeks to do is to just limit it to that so that when that discussion happens with those two people in the room, it is only from a point of empowerment of the patient asking the question, rather than receiving it when they may not expect it necessarily. That is my concern: that they then walk away not thinking VAD is something that they could use and that could be good for them, but that they may come away feeling perhaps it is something they should use. The difference is important, and the difference can have profound consequences.

Will FOWLES: I want to thank the member for Monbulk for carefully and gently explaining her reasoning and how she arrived in concert with the member for Kew with this amendment. I think the member for Monbulk is going about this in a very mature fashion and a very thoughtful fashion, and I commend her engagement on this, because it has been better than others, who I suspect have been a bit more inclined to wreck rather than engage. I do nonetheless disagree with the member for Monbulk on the substantive issue, which is that almost every perceived ill of this bill is cured by silence on behalf of that allied health professional – they simply say nothing, and these problems, these perceived risks, do not arise. This is not a mandate to engage, it is simply permission to engage. I suspect the overwhelming majority of registered health practitioners – not medical practitioners, registered health practitioners – simply will not engage on this because they probably will not feel like it is their place or they have not got anything particularly to add. But for those that do, they are given some protection under the bill. I think that is, frankly, entirely appropriate.

One other thing I would say is I would not want readers of Hansard down the line to assume that because there have been a great many speakers in support of this amendment, that is the way the chamber is going. For reasons that baffle me a bit, there are many, many, many members of the government who are not actually contributing anything on these amendments. I do not know why they are not standing up in defence of their minister’s bill. I do not know why they are not choosing to engage more fulsomely in the debate. I wish they would. I wish they would offer a bit more vocal support to their minister and their bill, rather than sitting there keeping shtoom, because I think, as I indicated at the outset of the process, that overwhelmingly this is a good bill. It is simply a bill that can and should be improved by the amendments that I have proposed.

But again, this amendment does not, I think, address the ills that have been identified by speakers in favour of the amendment. The issues that they perceive might arise are meant to be cured simply by the registered health practitioner not playing and not entering the room, if you like. For that reason, I think the amendment should be defeated and the clause should stand as drafted by the government.

Kathleen MATTHEWS-WARD: I think I have mentioned at least once in this house during this debate the number of people I have spoken to over the last week. I absolutely took my job seriously to fully consult with as many people as I could, including experts on this. I have spoken to oncologists who have administered VAD, the head of palliative care in a large public hospital, nurses, nurse practitioners, palliative care doctors and nurses, doctors who conscientiously object, geriatricians, aged care workers, people with a neurodegenerative disease, people with terminal cancer, community leaders, older people, friends, carers and widows.

Many of them support the bill and are concerned that some of us might have been thinking of repealing VAD. They had that misperception. But they had no idea that this range of health practitioners was going to have any role in VAD or in suggesting it to people. Not one of them thought it was a good idea. They were shocked to hear this. They were shocked to hear that dentists, podiatrists and Chinese medicine people – I have listed them before, the range of health practitioners, who I absolutely, truly respect for their expertise in their roles. But they were very shocked to hear that that was part of this bill. So I support the amendments put by the members for Kew and Monbulk.

Mary-Anne THOMAS: I want to assure the member for Monbulk that the model that we have chosen here in Victoria, as she indicated, is based on Tasmania’s and has a restriction, which is registered health practitioners. This is different to the model that operates in New South Wales and the ACT, which allows health workers to initiate VAD.

In relation to some of the issues raised by the member for Broadmeadows, I can assure her that health practitioners are well in support of this and that I have had the opportunity or my department has had the opportunity to consult with the Australian College of Nursing, the AMA, the Australian Nursing and Midwifery Federation, the Australian and New Zealand College of Anaesthetists, the Royal Australian College of General Practitioners and the voluntary assisted dying practitioners network of Australia and New Zealand.

The SPEAKER: The house is considering the member for Kew’s amendment 2 to clause 7. The question is:

That the word proposed to be omitted stand part of the clause.

Those supporting the amendment should vote no.

Assembly divided on question:

Iwan WALTERS: In the brief contribution I made in the context of the amendments being proposed by the members for Monbulk and Kew, I did flag that I retained some concerns, even if the clause was amended, about the removal of what is termed the gag clause more broadly. Contrary to some aspersions being bandied around the place, this is as a consequence of concerns about that clause specifically and the way in which it would manifest in a community like mine and like that of the member for Broadmeadows, where health literacy is low and where that power imbalance between a doctor and a patient is particularly, I think, acute. The risk, as I articulated in that contribution on the amendments, is that the initiation of these discussions in relation to either assisted suicide or euthanasia, or the broader spectrum of voluntary assisted dying as a framework, could be considered less as part of a palette of options that may be available for a patient to avail themselves of – noting again the principles of choice, control and autonomy – and more in fact as a prescription that is what a patient should avail themselves of. I know that is not the intention, but in the context whereby English proficiency may be low and where the power imbalance between a health specialist and a patient is real, I think that principal issue is a material one, and so I retain that concern.

The minister has spoken about the fact that she – without wishing to characterise her words – believes that concern is addressed. I return to the point that in 2017 this provision was an essential safeguard precisely because of the situation that I am articulating. I do not think it is an entirely abstract one. I think it is something that is real and is material, particularly in the context of communities where health literacy is low, where levels of engagement with the health system are perhaps lower, where levels of social capital are lower and, again, where a health specialist initiating a conversation could be interpreted as a prescription.

In addition to that threshold issue that I spoke about, I think the risks of clause 7 are particularly acute in the context of the amendments that just failed. So my question in the context of the capacity in the bill as it stands for allied health practitioners to initiate conversations regarding palliative medicine, euthanasia, assisted suicide – the spectrum of those end-of-life discussions – is: Minister, what is planned to improve the training and the experience that allied health practitioners have in the context of those end-of-life discussions? I note, before I finally frame my question, that you have articulated a confidence in clinicians’ capacity to discharge their obligations – and I am sure that is the case – but in the absence of training, that is inevitably harder. So what plans does the government have to work with colleges to provide funding – and I want to be specific about the question – to improve the capacity of allied health practitioners to work within the context of end-of-life discussions and to be fully apprised of the different dimensions, ethical and otherwise, in that realm?

Mary-Anne THOMAS: In response, I would say this: there is no obligation on any registered health practitioner to raise voluntary assisted dying with their patients.

Nathan LAMBERT: I just want to address the remarks made earlier by the member for Brighton, where he very strongly implied that people seeking to amend a clause were therefore automatically opposing the clause or indeed opposing the whole bill. For his benefit, perhaps everyone’s benefit, I remind people the entire point of consideration in detail is that people may seek to amend a clause and then may also vote in favour of it, and that is what I intend to do.

Assembly divided on clause:

Clause 8 (13:13)

Will Fowles: On a point of order, Deputy Speaker, if I was in court, which I am not, I might say now is an appropriate time. I am not confident that we are going to get through clause 8 and my amendments to it prior to the break, so I wonder whether now might be an appropriate time.

The DEPUTY SPEAKER: Thank you for the point of order. It is not a point of order, and we are going to push through a little bit longer. Let us kick on. The members for Ringwood, Richmond, Melbourne and Broadmeadows have all circulated amendments to clause 8. I first propose to test whether the house agrees to the member for Broadmeadows’s amendment 5. If the house does not agree to the amendment, the member for Broadmeadows’s amendment 5 will fail and she will not be able to move her amendment 6, because it is consequential.

Kathleen MATTHEWS-WARD: I move:

5.   Clause 8, line 3, omit “(1)”.

I support half of clause 8. The residency requirements I think were put in place at a time when it was necessary to stop VAD tourism coming to Victoria. I do not think they are needed anymore. In fact the only constituent who has ever come to me was a friend of mine, about a friend of hers who could not access VAD and was very, very distressed by that because of these residency requirements. I support the removal of the residency requirements.

Will Fowles: On a point of order, Deputy Speaker, I understand the member’s amendment goes to the six-month eligibility for access to VAD, not to residency requirements. I wonder whether we have not skipped ahead somewhat.

Kathleen MATTHEWS-WARD: On the point of order, Deputy Speaker, if you look at the first amendment, member for Ringwood, you will see that it actually talks about number 1 because it has to be removed.

The DEPUTY SPEAKER: There is no point of order.

Kathleen MATTHEWS-WARD: So I am happy with residency. What I also very much support is the existing 12-month provision for neurodegenerative disease. I think we all know exactly how important that is. I also, for the record, seek to remove the requirement for the third specialist for prognosis for neurodegenerative disease. That is not in this clause, but that is something that I do support.

But I am concerned about opening it up to a 12-months prognosis for everyone. Accurate prognosis is very, very difficult for physicians, and we all know stories of people whose prognosis has changed considerably – someone who was given months to live only to exceed that and, very sadly, vice versa. My uncle, who was eligible for VAD, had declined the offer to store the substance at home. He said:

I’m awfully glad I did … because there have been times I would have taken it. I really would have. And I would have missed out on that wonderful day in December when I was told of my progress.

Due to some wonderful advancements in treatment, including immunotherapy, my uncle’s prognosis changed considerably, and he was no longer within the 12 months. Prognosis is really imprecise and it is really difficult, and that gets even more so the further away death is.

As I have said earlier, I also remain particularly concerned about the lack of psychological supports that are offered to people upon receiving a terminal diagnosis. I was told that the within the first six to 12 months of terminal diagnosis is when people are most likely to have suicidal ideation. They deserve to know that supports are available and they are not alone on their journey. But it also opens the risk that access to voluntary assisted dying will not be used in the original intent of the law.

The proposed amendments are not modest. Moving from six months eligibility to 12 months is effectively doubling the current access, and in my view that goes completely against the original intent of the law, which was to give people access to voluntary assisted dying in the last few months and weeks of their life. As I have noted before, I do support people with terminal neurodegenerative disease to remain eligible regarding the current 12 months life expectancy, and I note that is not changing. Except for Queensland, no-one else has this 12-month prognosis in operation, I understand.

Increasing the timeframe to 12 months also increases my ongoing concern about elder abuse and coercion. Having worked in finance, elder abuse, aged care and policy for ageing Victorians, I have seen instances of what is called inheritance impatience, and I would hate to open the doors to more risk of coercion through this clause. There are plenty of people who are not vulnerable to elder abuse. They are empowered, they can self-advocate, they have researched all of their options and they choose VAD. My concern is not for them. My concern is for the many older people who feel unheard, unseen and unvalued. Our job as legislators is to ensure we have safeguards in place to avoid them being exploited.

Chris CREWTHER: I also support this amendment moved by the member for Broadmeadows with respect to the first amendment, removing residential requirement changes, and the second amendment, removing changes from six months to 12 months. As we know, prognoses can change, and six months to live or 12 months to live can potentially become years. Some people can live many, many years, even decades, after a prognosis. That is even less certain 12 months out as against six months out.

As I mentioned, prognoses can change, but also treatments, relief and even cures can sometimes be found within timeframes in some – although sometimes rare – circumstances. This change I believe opens up voluntary assisted dying to a range of cases where prognosis uncertainty and the risk of wrong prognosis is even greater than when a six-month prognosis is required, indeed often making prognosis a matter of conjecture. This amendment increases the risk that patients will choose voluntary assisted dying on the basis of a wrong prognosis when otherwise it would have turned out that the patient would have had potentially many years of life ahead free of pain or other distressing symptoms. In those circumstances I support the amendment from the member for Broadmeadows.

Paul MERCURIO: I just want to quickly rise and say that I do not support this amendment. It goes back to what I spoke about in my debate – it feels like it was last week, but it was only yesterday – and that is that this whole legislation is about giving people who are terminal the absolute best quality of life up until they take their last breath. We cannot change if someone is terminal, but we can assist them in having a quality of life that is, as best as possible, worthwhile. As I also said yesterday, we heard from people who applied for VAD, got VAD and upon getting it their comment was, ‘Now I have my death sorted I can now get on with living.’

I do not have a problem if this amendment is for 12 months. It gives people time to spend chasing VAD – almost we could say spending their life energy and force chasing VAD – so that they can have a quality of life. Once they have got it, they then have the time to enjoy what life they can in what way they can. This idea that people can only really get VAD a month or a couple of weeks before they die is preposterous. I think we as humans must give people – fellow humans – the absolute opportunity to have hope in their heart and to have a life that is worth living under incredibly distressful, painful, intolerable situations of being terminal. I do not support this amendment.

Iwan WALTERS: I am glad to follow the member for Hastings and his contribution. I think in some respects this clause is the most difficult to deal with. There is nothing I disagree with in the member for Hastings’s characterisation of the intent of either the existing assisted suicide and euthanasia framework or indeed his characterisation of the intent of the change to move from six months to 12 months.

The part of his contribution with which I disagree relates to that point around defining what is terminal and what is not. The alleviation of suffering we agree upon. The desire to ensure that everybody, irrespective of their circumstances, is able to live and indeed die in dignity and without pain I think is a uniform thing. Words matter and it is important to get them right, so I am going to try and be really precise; forgive me if I correct myself. But the reason I have misgivings about this change is because the prognostication for death is extremely difficult in even the most clinically experienced medical hands. I have talked with a number of senior clinicians in the context of preparing for this debate. They have talked about the way in which a prognostic assessment of anything shorter than a few weeks, even in the most expert of hands, can in effect be a bit of a guess.

None of that has any bearing on the reality of what the member for Hastings and others are talking about in terms of the real suffering. I do not want this to be an abstraction, but I do note that there is an evidentiary base borne out by research that puts – and the member for Broadmeadows has talked about this – perhaps the false positive and the false certainty of diagnosis at a reasonably high level. I am not going to commit to a number, because I think it is a contested one and I am not an expert in this space, I have merely spoken to experts in this space. Suffice to say I am concerned that by increasing this across the board for all conditions from six months to 12 months necessarily amplifies that risk and that uncertainty and in doing so increases the risk of creating a circumstance whereby people prematurely end their lives on the basis of incorrect information.

I also sought in my second-reading speech at this point, in the context of this increase from six months to 12 months, to talk a little bit about something that I have been grappling with in my own mind, which is, as I perceive it, something of a philosophical and conceptual inconsistency. I do so, I hope you understand, with the intent of deep sensitivity. Mine is not a family untouched by the ravages of suicide and the impact that has. As a state we reflect those ravages and as a society we reflect those ravages by seeking to limit and reduce the number of people who take their own lives as a consequence of mental distress and other circumstances in parts of their life. We are committed to a welfare-oriented model that in effect diminishes people’s autonomy in the act of committing suicide in other stages of life. But in our framework of end-of-life care we accept that it is about the alleviation of intolerable suffering. I want to make this very clear – I think there was some confusion yesterday – that conceptually and societally we have a different approach and that in the context of end-of-life care, assisted suicide and euthanasia, the outcome may be same but the intent and the process is different. This bill recognises that personal autonomy and choice is important, so therefore that supersedes the welfare dimension of seeking to prohibit death in all circumstances. All I wish to reflect upon is that the longer the horizon between anticipated death and the time at which death would happen irrespective of intervention, the greater that tension between those two policy approaches becomes. I do not have a question for the minister, but I just seek to explain my concern.

Mary-Anne THOMAS: In response to the member for Greenvale, who noted in his contribution that words matter: words do matter. We do not have an assisted suicide framework. We do not have a euthanasia framework. We have a voluntary assisted dying framework here in the state of Victoria that seeks to give dignity and compassion to people who are seeking choice at their end of life. This is not about whether to die but how, where and with whom. And I would ask respectfully that the member for Greenvale, in his contributions, reflect on the hurt that his words are causing to some in this chamber and consider how he discusses this for the remainder of the debate.

Sitting suspended 1:30 pm until 2:02 pm.

Business interrupted under standing orders.

The SPEAKER: I acknowledge in the gallery former MLC Neil Lucas.