Ethics

Genomic tests present additional challenges compared with other pathological investigations

Michaela Cormack · Kathryn B Irving · Fiona Cunningham · Andrew P Fennell

We need to investigate more than which interventions may be better: implementation research is important for optimising outcomes

Jai N Darvall · Toby Richards

Voluntary assisted dying is now lawful in all Australian states, with territories likely to follow.1 As this new end‐of‐life choice becomes more widely available and known, we should anticipate it arising during end‐of‐life care discussions with patients. In Australia, unlike some international models,2,3 voluntary assisted dying is not available to people without decision‐making capacity. Therefore, patients cannot request voluntary assisted dying through an advance care directive or other advance care planning document. However, some competent adult patients undertaking advance care planning may want to discuss voluntary assisted dying. Reflection is needed to prepare patients, clinicians and health services for discussions about voluntary assisted dying during advance care planning. Advance care planning is conceptually different from voluntary assisted dying As voluntary assisted dying was being debated and legalised across Australia, efforts were made to distinguish it from advance care planning.4 This conceptual work is important because the implementation of voluntary assisted dying is often accompanied by confusion and anxiety,5,6 and the two concepts are often misunderstood and conflated.7 We support educative efforts that define and distinguish voluntary assisted dying and advance care planning because this clarity enables patients to make informed choices. Advance care planning is a “process of planning for future health and personal care whereby the person's values, beliefs and preferences are made known to guide decision‐making at a future time when that person cannot make or communicate their decisions.”8 By contrast, in Australia, voluntary assisted dying provides assistance to die for adults with decision‐making capacity who meet strict eligibility criteria, for example, if the patient is expected to die within 6 or 12 months from an advanced, progressive medical condition.1 A critical difference is that voluntary assisted dying in Australia is available only to adults with decision‐making capacity, while advance care planning focuses on decision making about future care at a time when capacity is lost. Because access to voluntary assisted dying requires a person to retain decision‐making capacity throughout the process, advance requests for voluntary assisted dying cannot be given in an advance care directive (or any other advance care planning document). Nor can a person's substitute decision maker seek voluntary assisted dying on the person's behalf. This distinction is clearly reflected in law (indeed, some medical decision‐making legislation expressly excludes voluntary assisted dying) and guidance across Australia.9,10,11,12,13 Advance care planning practices and systems need to recognise voluntary assisted dying Although voluntary assisted dying is not the focus of advance care planning, clinicians and health services undertaking advance care planning need to be prepared for this topic. A pragmatic reason is voluntary assisted dying will inevitably be raised by some patients in their end‐of‐life planning. Attempts to exclude voluntary assisted dying are impractical as patients see end‐of‐life choices holistically and are unlikely to partition advance care planning and voluntary assisted dying. An ethical reason to prepare for voluntary assisted dying discussions during advance care planning is it may sometimes be appropriate to inform patients about their potential or future eligibility for voluntary assisted dying.14,15 Some patients, as with end‐of‐life discussions generally,7 may be waiting for health practitioners to initiate voluntary assisted dying discussions. Other patients may not be aware of voluntary assisted dying or their potential eligibility. Where it is legally possible to raise voluntary assisted dying (Box 1) and clinically appropriate, informing patients of all possible end‐of‐life choices would facilitate decisions that align with the values, beliefs and preferences at the heart of advance care planning. We emphasise this must be done sensitively, within the law, and guided by good clinical practice about end‐of‐life care discussions.18 Three critical issues for advance care planning systems and practices to consider Restrictions on raising voluntary assisted dying If a patient raises voluntary assisted dying during an advance care planning discussion, health practitioners are free to discuss it. However, if not initiated by a patient, Australian law (Box 1) is unusual internationally because it regulates whether, and how, a health practitioner can raise voluntary assisted dying with a patient. In Victoria and South Australia, law prohibits registered health practitioners from raising voluntary assisted dying with a patient or initiating a discussion about it. No other lawful health care option is prohibited from being raised in this way.19 Victorian doctors and family caregivers have reported confusion and access barriers as a result of this restriction.20,21 Advance care planning programs in these states should ensure health practitioners are aware of this legal duty but make it clear that voluntary assisted dying can be discussed once raised by a patient. This includes understanding when voluntary assisted dying has been raised, given reports that patients struggle to know the “right words”21 to successfully raise this topic, and the need for open questions to facilitate a lawful discussion. In all other states, doctors can raise voluntary assisted dying, as can some or all other health practitioners, depending on the state, but this is subject to providing certain information at the same time (Box 1).1 Again, advance care planning programs in these jurisdictions need to ensure their practitioners understand these laws. Individual conscience and institutional objection Advance care planning programs must address conscientious objection, which is legally protected. Some opposed health practitioners may be willing to engage in advance care planning discussions that include voluntary assisted dying, but others may not.22 However, objecting practitioners must still be aware of potential legal duties. For example, voluntary assisted dying laws in some states require that patients making a first formal request for voluntary assisted dying be provided specific information about it, including about practitioners or voluntary assisted dying services (Box 2). Professional and ethical duties imposed by bodies such as the Medical Board of Australia and the Australian Medical Association also include not hindering access to voluntary assisted dying.23,24 Institutions objecting to voluntary assisted dying can also affect advance care planning. While institutions may object to a range of practices,25,26 relevant here is an objecting institution whose advance care planning program does not permit discussion of voluntary assisted dying. Complex laws about institutional objection to voluntary assisted dying exist in New South Wales, Queensland and South Australia1 and can affect implementation of local advance care planning programs. Accessing voluntary assisted dying requires planning and time If advance care planning discussions do include voluntary assisted dying, they should ensure patients know that accessing voluntary assisted dying takes time, and requires planning20,21 (although it can be expedited in urgent cases).1 The most recent Victorian Voluntary Assisted Dying Review Board report advises voluntary assisted dying is not an emergency procedure, with a median time from first request to dispensing medication of 34 days (interquartile range, 23–53 days).27 This need to plan arises from: the time needed for the rigorous assessment and approval process; eligibility criteria that mean a person is expected to die within 6 or 12 months, and so is on a trajectory to death and reduced physical (and potentially mental) capacity; and the possibility of voluntary assisted dying requests being made late in a person's illness.21 Preparing advance care planning programs and practices for voluntary assisted dying Voluntary assisted dying will increasingly arise in advance care planning discussions now that it is legal in all Australian states. The palliative care sector has been proactive in addressing voluntary assisted dying in end‐of‐life discussions, with Palliative Care Australia, Australia's peak palliative care body, developing a position statement and guiding principles to support people providing care for individuals with a life‐limiting condition who may wish to access voluntary assisted dying. These principles state that individuals and their families and carers “must be treated with dignity and respect and supported to explore options available to them, which may include [voluntary assisted dying]”.28 Advance care planning programs, policies and practices must also explicitly recognise the impact of voluntary assisted dying, including addressing the three issues outlined above. Much of the work to date has focused on differentiating advance care planning and voluntary assisted dying. This is important, but efforts must now extend to support optimal advance care planning in the context of new voluntary assisted dying laws. This requires health systems and advance care planning programs to adapt advance care planning policies, guidelines and information to engage with how voluntary assisted dying will be discussed in advance care planning conversations (see Box 3 for a framework for such conversations). Health practitioners undertaking advance care planning should receive training on the impact of voluntary assisted dying on these discussions. Conversation guides can also help navigate lawful and patient‐centred advance care planning discussions that include voluntary assisted dying where appropriate. Processes for health practitioners to access support or escalate for advice are also needed. These responses should harness existing voluntary assisted dying resources and services where possible, such as health department voluntary assisted dying guidance and voluntary assisted dying care navigators in each state (Box 4). Advance care planning is centred on respecting a person's values, beliefs and preferences, which may now include a choice for voluntary assisted dying. Existing approaches to advance care planning must adapt to reflect this, requiring thoughtful engagement at the system, program, and practitioner level. Box 1 – Permissibility of registered health practitioners initiating discussions about voluntary assisted dying in Australia* New South Wales Queensland South Australia Tasmania Victoria Western Australia Doctors Yes, provided they inform at same time of available treatment and palliative care options and their likely outcomes Yes, provided they inform at same time of available treatment and palliative care options and their likely outcomes No Yes, provided they inform at same time of available treatment and palliative care options and their likely outcomes No Yes, provided they inform at same time of available treatment and palliative care options and their likely outcomes Nurse practitioners Yes, provided they inform at same time that palliative care and treatment options are available, and that the patient should discuss these with their doctor As above No Yes, provided they inform during discussion that a doctor would be the most appropriate person with whom to discuss the VAD process and care and treatment options No As above Other registered health practitioners As for nurse practitioners No No As for nurse practitioners No No * Note: Some voluntary assisted dying legislation also regulates the conduct of discussions by health care workers. Table adapted from Waller et al,1 Voluntary assisted dying in aged care: roles and obligations of medical practitioners,16 and Voluntary assisted dying in aged care: roles and obligations of registered nurses.17 Box 2 – Doctors’ conscientious objection obligations to patients who make a first request* for voluntary assisted dying New South Wales Queensland South Australia Tasmania Victoria Western Australia Provision of information – Contact details of a medical practitioner or service who can assist or the details of the care navigator service – Information sheet about voluntary assisted dying, and contact details of the Voluntary Assisted Dying Commission – Information sheet about voluntary assisted dying Timeframe to notify the patient of refusal of first request Immediately Immediately Within 7 days Within 7 days (plus 48 hours to decide) Within 7 days Immediately * A first request is a formal part of the voluntary assisted dying request and assessment process where a patient makes a clear request to a doctor for voluntary assisted dying. Table adapted from Waller et al1 and Voluntary assisted dying in aged care: roles and obligations of medical practitioners.16 Box 3 – Framework for discussion of voluntary assisted dying (VAD) in advance care planning (ACP) Box 4 – Selection of voluntary assisted dying health practitioner guidance relevant for advance care planning State Resource Care navigator (or equivalent) service details New South Wales NSW Voluntary Assisted Dying Clinical Practice Handbook: https://www.health.nsw.gov.au/voluntary‐assisted‐dying/Pages/practitioner‐handbook.aspx NSW Voluntary Assisted Dying Care Navigator Service: https://www.health.nsw.gov.au/voluntary‐assisted‐dying/Pages/navigator.aspx Queensland Advance care planning and voluntary assisted dying: https://www.health.qld.gov.au/clinical‐practice/guidelines‐procedures/voluntary‐assisted‐dying/information‐for‐healthcare‐workers/advance‐care‐planning‐and‐vad Queensland Voluntary Assisted Dying Support Service (QVAD‐Support): https://www.health.qld.gov.au/clinical‐practice/guidelines‐procedures/voluntary‐assisted‐dying/support/qvad‐support Queensland Voluntary Assisted Dying Handbook: https://www.health.qld.gov.au/clinical‐practice/guidelines‐procedures/voluntary‐assisted‐dying/information‐for‐healthcare‐workers/handbook Conversation guides for GPs: Voluntary assisted dying: https://www.health.qld.gov.au/__data/assets/pdf_file/0034/1195675/Conversation‐guide‐on‐voluntary‐assisted‐dying‐for‐GPs.pdf South Australia Voluntary Assisted Dying Clinical Guideline for Health Practitioners: https://www.sahealth.sa.gov.au/wps/wcm/connect/e148edcb‐134b‐449d‐8e57‐9c3f7ad21eb2/FINAL+Voluntary+Assisted+Dying+Clinical+Guideline+for+Health+Practitioners+v2.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE‐e148edcb‐134b‐449d‐8e57‐9c3f7ad21eb2‐oK80Khi South Australian Voluntary Assisted Dying Care Navigator Service (SAVAD‐CNS): https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/services/primary+and+specialised+services/voluntary+assisted+dying/support+services/south+australian+voluntary+assisted+dying+care+navigator+service+savad‐cns Tasmania Voluntary Assisted Dying Navigation Service: https://www.health.tas.gov.au/health‐topics/voluntary‐assisted‐dying/voluntary‐assisted‐dying‐services/navigation‐service‐voluntary‐assisted‐dying Victoria Voluntary assisted dying – Guidance for health practitioners: https://www.health.vic.gov.au/publications/voluntary‐assisted‐dying‐guidance‐for‐health‐practitioners The Statewide Voluntary Assisted Dying Care Navigator Service: https://www.health.vic.gov.au/patient‐care/voluntary‐assisted‐dying Western Australia Western Australian Voluntary Assisted Dying Guidelines: https://www.health.wa.gov.au/Articles/U_Z/Voluntary‐assisted‐dying/Resources‐for‐health‐professionals Western Australian Voluntary Assisted Dying Statewide Care Navigator Service: https://www.health.wa.gov.au/Articles/U_Z/Voluntary‐assisted‐dying/Statewide‐Care‐Navigator‐Service See also “How to do advance care planning: a quick guide for health professionals” for general information about advance care planning: https://end‐of‐life.qut.edu.au/advance‐care‐directives.

Ben P White · Madeleine Archer · Casey M Haining · Lindy Willmott

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