Ethics

The Australian health system has the potential to evolve and advance sexual and reproductive health care so that all people can choose if, how and when to parent

Catriona Melville · Bonney Corbin

Thomas Cueni · Elizabeth Somer

If female doctors receive less pharmaceutical industry funding, gender-based differences in prescribing patterns could result

Barbara Mintzes · David B Menkes

Both law and practice should be refined to better satisfy the wishes of people approaching the end of their lives

Roger W Hunt

Organ donation after VAD in Australia appears to be both legally and clinically feasible

Jan Bollen · Courtney Hempton · Neera Bhatia · James Tibballs

Adequate support for doctors, navigators, and other facilitators is vital for the effective functioning of voluntary assisted dying processes

Ben P White · Ruthie Jeanneret · Eliana Close · Lindy Willmott

The Australian Government should review its position and support intellectual property waivers in the pandemic accord

Deborah Gleeson · James Scheibner · Dianne Nicol

Growth in Aboriginal and Torres Strait Islander health research requires urgent investment in Aboriginal and Torres Strait Islander ethical governance

Michelle Kennedy · Janine Mohamed

To the Editor: Haining and colleagues discuss compensation for medical practitioners in supporting patients through the voluntary assisted dying process, which requires much time and effort.1 We want to inform you how the Netherlands, where euthanasia has been performed since 2002, has dealt with this challenge. A Dutch physician who performs euthanasia must evaluate whether a patient is suffering hopelessly and unbearably, is adequately informed, has no reasonable alternatives available, and is making a voluntary and well considered request. A second independent physician also needs to evaluate the patient, which often requires multiple house visits. Six weeks after the procedure, a review committee establishes whether all due diligence requirements were fulfilled. In 2021, 7666 people underwent euthanasia in the Netherlands, mostly performed by general practitioners for patients suffering from a malignancy.2 Everyone who lives or works in the Netherlands is legally required to have health insurance. Insurance companies finance the health costs through premiums and an income‐related contribution, collected through the government's tax on wages. On a side note: for religious reasons, it is possible to choose an insurance company that does not reimburse the costs of euthanasia or abortion. Every patient needs to be registered with a specific GP, who receives a registration payment every three months from the health insurer of between €18.76 and €51.86 (AU$30.37 and AU$83.96 at 3 April 2023), depending on age. When the patient visits the physician, an additional €11.51 (AU$18.63) is paid.3 However, as euthanasia is a time and effort consuming trajectory, the physician is entitled to additional compensation. Several home visits are required to investigate and explore the euthanasia request, for which the physician receives €88.85 (AU$143.84) per visit. On the day euthanasia is performed, the GP receives €269.99 (AU$437.09) from the health insurer. The second, independent physician receives €602.27 (AU$975.01) for their efforts. The pharmacist who prepares and processes the return delivery of the euthanasia drugs can invoice €274.00 (AU$443.58). Here, we have provided some insight into the compensations for physicians and pharmacists who facilitate euthanasia in the Netherlands, and we hope this can contribute to the discussion on the remuneration of this important work in Australia.

Stefan Leus · Jan Bollen

To the Editor: The article by Williams and colleagues1 is a narrative review of prostate cancer care from a urological perspective. However, developing recommendations for prostate cancer screening requires complementary perspectives, including population health, general practice, and the wider community. Population‐based prostate‐specific antigen (PSA) testing to screen asymptomatic men for prostate cancer is not supported by the references cited by Williams and colleagues or by systematic reviews, which identify and account for bias.2 The Royal Australian College of General Practitioners (RACGP) has assessed the current evidence and has advised against prostate cancer screening.3 The RACGP guidelines specifically state that GPs have no obligation to offer prostate cancer screening, and advise against adding PSA to a battery of pathology tests. The RACGP and the National Health and Medical Research Council have developed information sheets drawing attention to the numbers of men with screen‐detected prostate cancers who would never know they had cancer if they had not undergone screening, as well as to the impotence, incontinence and bowel problems that prostate cancer diagnosis and treatment can cause, whether necessary or not.3,4 Between 42% and 66% of screen‐detected prostate cancers would not have been diagnosed without screening. Prostate cancer is discovered at autopsy in 36% of men of European ancestry and in 21% of Asian men aged 70–79 years.5 As Williams and colleagues note, prostate cancer screening can lead to earlier diagnosis of aggressive cancers, and modern techniques enable individualised patient‐centred treatment.1 However, for the men whose cancers would never have been detected without screening, any treatment is unnecessary and potentially harmful.5 Prostate cancer screening does not meet the aim of reducing overall mortality.2 After 11 years of annual screening, four of 1000 screened men compared with five of 1000 unscreened men have died of prostate cancer. Among the screened men are 87 cases with a false positive PSA test result, of whom 28 have complications of biopsy, including 0.5 extra heart attacks. Both groups have lost 190 men from all causes.3 Australia's GPs manage a growing demand for evidence‐based primary health care, and the RACGP supports them by developing standards and guidelines. These are based on unbiased approaches and, with the current evidence, they cannot recommend prostate cancer screening.3

Rosalie Schultz

System-wide racial discrimination and inequitable access to justice impedes Indigenous rights to health and wellbeing

Pat Dudgeon · Abigail Bray · Roz Walker

To the Editor: A recent survey found that 65% of Australians choose cremation over burial, and that, in the context of the coronavirus disease 2019 (COVID‐19) pandemic, cremations could be increased fourfold.1 It seems appropriate to look at the various roles of the medical practitioner in approving cremations. The first crematorium was built in England in 1878.2 Medical practitioners were at the forefront of the movement in Australia, and argued that cemeteries were already overcrowded and in disrepair, that a fear of being buried alive was common, and that cremation was a hygienic way to dispose of the dead when it was still believed that cemeteries were a source of disease in the living.2 The first Australian crematorium was established in Adelaide in 1903, after which progress halted due to ongoing debate;3 however, objections were overcome and many were constructed in the interwar years (Box 1). The most cogent reason for rejecting cremation was that it could be employed to hide homicides. The contrary argument was that having a medical practitioner verify the cause of death would both prevent undetected crime and advance medical knowledge.4 To provide for this verification step, each Australian state and territory introduced legislation setting out a process for the approval of cremations. Where the cause of death is suspicious or unclear, permission is withheld and referral made to a coroner. In Queensland, Tasmania and Victoria, any medical practitioner who did not complete the death certificate may issue a cremation permit (Box 2). In the Australian Capital Territory, New South Wales and Western Australia, only government‐appointed medical referees may issue a permit. Some states and territories also require assessment of cremation safety, verifying that there is no implanted battery‐operated device, which may explode and damage the cremator, and that the deceased has not received radioisotopes, which may create a public health risk during cremation. At the Public Health Unit, we manage the appointment of medical referees for the NSW Ministry of Health. As part of the review of the effectiveness of our procedures, in 2020 we developed a short questionnaire to identify reasons why medical referees may refuse permission to cremate and to seek suggestions for improvement to this administrative process. We emailed it to a 10% random sample of NSW medical referees (n = 77) and received 46 responses (60%). Of these, 29 respondents (63%) had served in the role for more than 15 years, nine (20%) for five to 15 years, and five (11%) for less than five years. The number of permits issued in the previous 12 months ranged widely: 25 had signed zero to ten, and at the other extreme, two provided estimates of 780 and 1200 permits. This large variation is most likely related to varying demands on medical referees by local funeral directors. The reasons for rejecting applications included inconsistencies in the forms (ten), incorrect or unclear cause of death (seven), a reportable death (four), uncertain identity of the deceased (one), and a retained battery‐powered device (one). No suggestions for improvement were made, but three respondents suggested we provide some medical referee training — we have undertaken to develop an online education module. Although roles differ between Australian jurisdictions, medical practitioners have an important responsibility for verifying that a body is suitable for cremation, a decision that they must make independently of the practitioner who certifies the cause of death. Box 1 – Woronora Crematorium, Sydney, constructed in 1934* * Courtesy of Woronora Memorial Park. Box 2 – Roles of medical practitioners in approval of cremation under current legislation for each Australian state and territory State or territory Legislation Final approver of cremation Name of permit Comments Who assesses cremation risk Australian Capital Territory Cemeteries and Crematoria Regulation 2003 Medical referee, a medical practitioner appointed by the Director‐General Certificate of medical referee The medical referee must view and be satisfied with the “Certificate of medical attendant” The “Certificate of medical referee” must state that there is no medical reason why the remains should not be cremated New South Wales Public Health Regulation 2022 Medical referee, a medical practitioner appointed by the Secretary Medical referee's cremation permit The medical referee must be independent of the applicant and of the medical practitioner who attended the deceased A medical practitioner must provide cremation risk advice concerning battery‐operated implanted devices and radioactive treatment Northern Territory Cemeteries Act 1952 Crematorium manager Cremation permit A permit can only be issued by the cremation manager if the certificate provided is signed by two medical practitioners stating that death was due to natural causes No reference to assessment of cremation risk Queensland Crematorium Act 2003 Independent doctor Permission to cremate (independent doctor) The independent doctor is a doctor who has not signed the cause of death certificate or the “Cremation risk certificate” Any other medical practitioner may complete the “Cremation risk certificate” South Australia Burial and Cremation Act 2013; Burial and Cremation Regulations 2014 Registrar of Births, Deaths and Marriages Cremation permit Registrar of Births, Deaths and Marriages must consider the “Death from natural causes certificate of second doctor” Second doctor certifies that there is no reason why the body of the deceased should not be cremated Tasmania Burial and Cremation Regulations 2015; Burial and Cremation Act 2019 Medical practitioner Cremation permit The medical practitioner who issues the permit must not be a partner, employee or relative of the medical practitioner who issued the medical certificate in respect of the deceased person The medical practitioner who signs the permit must be satisfied that any implanted medical device has been removed Victoria Cemeteries and Crematoria Act 2003; Cemeteries and Crematoria Regulation 2015 Registered medical practitioner Certificate of registered medical practitioner authorising cremation The registered medical practitioner is someone who is not the medical practitioner who completed the notice in respect to the death of the deceased The funeral director must take note of any battery‐operated implanted device mentioned on the “Medical certificate of cause of death” Western Australia Cremation Act 1929; Cremation Regulations 1954 Medical referee, appointed by the Governor Permit to cremate The medical referee must not issue the certificate of cause of death or be in partnership with the medical practitioner who does so The “Certificate of medical practitioner” covers battery‐operated implanted devices and radioactive treatments

Mark J Ferson · Reannon Johnson · Toni Cains

Does pregnancy change a person’s medical values and preferences?

John J Bockxmeer · Casey M Haining · Andrea Atkinson

To the Editor: The metaverse is a virtual environment merging physical and digital realities.1 Once the thing of movies, metaverses are tipped to be worth $800 billion by 2024.2 They have potential to revolutionise digital health care delivery, access, education, and patient outcomes.3 Artificial intelligence (AI)‐enabled health care, with metaverse enhancement, could create virtual hospitals,4 transform clinical workflows and accelerate the diagnosis and treatment of conditions relating to mental health,5 cardiology,6,7 ophthalmology,8 and oral health,9 for example. AI‐enabled technology demonstrated potential during the pandemic by predicting the incidence of coronavirus disease 2019 (COVID‐19)10 and helping to identify sites for vaccine trials.11 Yet in the absence of strong national and global health governance and accountability mechanisms, digital health ecosystems create risk for medical confidentiality and privacy breaches12 resulting in data sharing13 and use/reuse by corporations or governments outside its intended purpose and the bounds of patient consent.14 For example, a National Health Service (NHS) Foundation Trust in the United Kingdom established patient data sharing with the international technology company DeepMind to develop machine learning‐based management tools,15 but British patient data moved to the United States when Google acquired DeepMind.14 Repurposing health‐related biometric and genomic data that cannot be altered is similarly concerning, and can result in racial profiling16 and privacy violations in the absence of appropriate legislation. Metaverses also have potential to accelerate discriminatory practices. Bias may be embedded in data used to train AI models through lack of community representation or participation.17 Structural inequalities may be reflected in health care datasets, creating risk for discriminatory outcomes.18 For instance, racial bias in a health care therapy algorithm resulted in the discriminatory underestimation of health risk for millions of American citizens, precluding access to vital treatments.19 Prioritising protections for underserved populations and their right to access safe virtual health care is crucial,20 especially for Australians at the intersection of inequities driven by poverty, disability, gender, homelessness, Indigeneity, and for the 11% highly excluded from accessing digital technologies.21 We recommend that the Department of Health and the Australian Digital Health Agency partner with the Australian eSafety Commissioner's work examining metaverse deployment,2 to ensure the highest ethical standards are upheld as planning moves forward and regulatory frameworks are developed.

Caitlin Curtis · Claire E Brolan

The increase in e-cigarette use by younger people who smoke or have recently quit reflects their presentation and marketing

Becky Freeman · Katherine Owen · Sandra Rickards · Alecia Brooks · Philip J Clare · Anita Dessaix

To the Editor: When statutes govern clinical activity, doctors need to know exactly what those legislative provisions mean. Nahm and colleagues1 address this in their article on eligibility for Australia's voluntary assisted dying (VAD) laws.1 However, in our opinion, the authors misinterpreted the relevant provisions, risking reduced access for eligible patients. Generally, a statutory provision should be given its “ordinary and natural meaning”;2 in other words, a plain English interpretation. As the authors note, each of the VAD Acts uses a particular form of words to set eligibility around a terminally ill person's life expectancy. In Victoria, for example, a coordinating medical practitioner must conclude their patient has been “diagnosed with a disease, illness or medical condition that … is expected to cause death within weeks or months, not exceeding 6 months”.3 Nothing in that wording refers to a probabilistic estimation of the percentage chance that the patient will die within 6 months nor any estimation of the best‐case scenario, as Nahm and colleagues suggest. If the Victorian Parliament had wanted this type of estimation, wording reflecting it could have been inserted into the Voluntary Assisted Dying Act 2017 (Vic). Instead, what is needed is that doctors have an expectation, based on the patient's clinical condition, that the illness will result in death within weeks or months, with the proviso that the number of months that the expectation of death will occur within is 6 or fewer. That clinical judgement is the beginning and end of this criterion. Although that judgement might be informed by knowledge about survival times and even by knowledge about doctors’ accuracy judging survival times, doctors need only certify that they expect that the patient's illness will cause death within 6 months. Nahm and colleagues are wrong to conclude that this wording might mean that people eligible for VAD would be “those with an expected survival time of 2 months”. That is not what the legislation says, and it is a mistake to introduce elements that are not there. Such an interpretation could, in practice, convert the 6 months test to 2 months for some patients, with the risk of narrowing access to VAD for patients the Parliament intended to be eligible.

Christopher J Ryan · Ben P White · Cameron L Stewart

Medical practitioners are poorly compensated for their time and services in supporting patients through the voluntary assisted dying process

Casey M Haining · Lindy Willmott · Simon Towler · Ben P White

The largest health workforce has the greatest research potential; investing in nursing and midwifery researchers is an investment in better care and cost outcomes

Marion Eckert · Claire M Rickard · Deborah Forsythe · Kathleen Baird · Judith Finn · Andrea Gilkison · Richard Gray · Caroline SE Homer · Sandy Middleton · Stephen Neville · Lisa Whitehead · Greg R Sharplin · Samantha Keogh

Barriers that limit the oversight of and participation of Indigenous people in Indigenous health research should be overcome

Luke J Burchill · Aneta Kotevski · Daniel LM Duke · Jeanette E Ward · Megan Prictor · Karen E Lamb · Michelle Kennedy

To the Editor: The concepts presented by Coman and colleagues1 parallel international trends within anatomical societies, where attitudes on human remains used for educational purposes are under scrutiny.2 Illuminating issues around legacy collections, and pressing for further clarity, transparency and appropriate cultural and ethical solutions, is important for the proper treatment of these precious resources. It is also necessary given recent events that have raised concerns within the public about how human remains and anatomical collections are treated under the guise of education.3 We strongly support the points made by Coman et al around development of repatriation policies for privately held bones, but we respectfully suggest additional considerations. The suggestion “Medical ethicists assert that in the absence of consent, anatomical specimens … should be destroyed”1 is not congruent with current suggestions and practice.4 Anatomical collections that have no provenance or consent are often used as teaching resources and represent the tangible legacies of histories of this field of science. As such, they serve the additional educational purpose of eliciting discussions on contemporary ethical and professional practice.5 There are also benefits associated with using real bones as opposed to three‐dimensional or plastic copies that do not retain the same weight, detail or nuanced anatomical features. Arguments do exist for disposition of unconsented collections, but these should be considered against the educational value these remains deliver and the social, ethical and cultural concerns around their ongoing use. In proposing consultation across various groups to clarify appropriate practice around “managing the legacy of human bone use in education,“1 we suggest it is necessary to include other specific interest groups to ensure community‐appropriate practices are developed. It is essential that community input is acquired, with indigenous representatives contributing knowledge and perspective. In addition, input from organisations that contribute expertise specific to national and international standards and practice are necessary. This should include local organisations, the Australian Institute of Anatomical Sciences and the Australian and New Zealand Association of Clinical Anatomists, and globally, the International Federation of Associations of Anatomists ethics committee. Such broad input is necessary to ensure guidelines are fit for purpose in a global education community.

Jon Cornwall · Sabine Hildebrandt · Thomas Champney