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General medicine

Environmental health Expanding the evidence base in digital health 31 March 2019 Open Access

Gathering data for decisions: best practice use of primary care electronic records for research

Despite most Australians having most of their health‐related interactions in the primary care sector, primary care‐based research is disproportionately low. Access to quality EMR data, lack of resources to remunerate GPs, and a lack of understanding among some GPs of the value and importance of secondary use of EMR data are barriers to data sharing. Data extraction tools that enable ethical, secure and privacy‐protected access to routinely collected datasets nationally have been developed. The task now is to build trustworthy primary care data repositories for research that will provide researchers with timely access to quality‐assured general practice data. Linkage with other datasets could enable significant scale‐up of primary care‐based research in Australia, contributing new knowledge in public health, health promotion, economics and evidence‐based clinical care. Technologies that allow consumers to have greater control over how their data are used can provide better options to policy makers, hence investment in this area is essential. Educating clinicians and the public about the need for, and existence of, research based on de‐identified patient medical records has the potential to generate greater social licence and acceptance of this emerging area of study. This has the potential to generate significant gains in terms of service delivery, economics and patient health. We can “do the right thing” now, but we must never become complacent.

Rachel Canaway · Douglas IR Boyle · Jo‐Anne E Manski‐Nankervis · Jessica Bell · Jane S Hocking · Ken Clarke · Malcolm Clark · Jane M Gunn · Jon D Emery

Health services administration Research 25 March 2019 Free

Cultural respect in general practice: a cluster randomised controlled trial

The known: The gap in life expectancy between Indigenous and non‐Indigenous Australians remains large. Urban Indigenous Australian‐controlled health services are under‐resourced, and mainstream primary care services are often not culturally sensitive.

Siaw‐Teng Liaw · Vicki Wade · John S Furler · Iqbal Hasan · Phyllis Lau · Margaret Kelaher · Wei Xuan · Mark F Harris

Mja2 50031
Ethics Letters 21 January 2019 Free

Medical assistance in dying: a disruption of therapeutic relationships

To the Editor: The Perspectives article by William1 states that medical assistance in dying may disrupt therapeutic relationships and will challenge beliefs. Concern is expressed about countertransference of feelings and attitude between doctors and patients. However, such concern must surely exist with or without the availability of assisted dying laws. What guides our practice is not just codes of medical ethics, professionalism and law, important as those are. It is also a natural and nurtured feeling of compassion and oneness with our patients. Doing no intentional harm (non‐maleficence) does not rule out, or cast doubt on, the application of voluntary assisted dying. Cutting short intolerable pain, suffering and indignity, as specifically requested by the patient, is not maleficence. The suggestion that people requesting medical assistance in dying challenge our beliefs about the meaning and value of who we are and what we do is not something that applies to all of us. Some physicians would feel that assisting a patient's firmly held wish to hasten death is among the most compassionate of acts that can be undertaken, and would experience it as such, along with the patient and family members. Changing the law to something that is better than currently exists does not present a dilemma. It does not contravene medical ethics. It has nothing to do with non‐maleficence or justice (except to introduce an element of justice to those individuals seeking such change). As for education, skills and insights, these can all be honed to a new and better balance in the future. With regards to death anxiety, it may be true that much can be achieved through human engagement, but it is also true that providing the means of assisted dying can itself significantly reduce anxiety and allow any remaining time to be better enjoyed.2 Finally, the suggestion that medical assistance in dying will have a negative influence on the development of teamwork is overly pessimistic. It fails to recognise the positive and complementary potential of assisted dying laws. Alleviation of suffering is surely a noble aim, attainable in a high proportion of cases.

Peter G Beahan

Mja2 12104
Ethics Letters 21 January 2019 Free

Medical assistance in dying: a disruption of therapeutic relationships

To the Editor: We commend William1 for his perceptive review of the complex issues involved in euthanasia and assisted suicide (EAS).1 In contrast to the euphemisms in the popular media, he confronts us with some uncomfortable realities: EAS is the intentional taking of a person's life (E) or facilitating suicide (AS); doctors considering EAS may be (unconsciously) demonstrating “countertransference of their helplessness onto the patient;” and relief of all suffering is a fantasy beyond the ability of doctors, politicians and lawyers. Similar concerns are expressed by seven Canadian physicians in a critique entitled “Euthanasia in Canada: a cautionary tale”.2 Contrary to the rosy predictions of its proponents, within 2 years, the Canadian experiment with EAS has left physicians aghast. “The introduction of euthanasia in Canada has caused doubt, conflict and crisis.”2 The passing of the Voluntary Assisted Dying Bill 2017 by the Victorian Parliament marked a seismic shift in medical practice, overturning 2500 years of medical ethics: the Hippocratic prohibition on killing patients. We note the increasing pressures, internal and external, on medical associations to declare neutrality on this issue. We believe that such a stance is a mistake. Equally, it is a lost opportunity to educate the public. As stated in a 2018 review, “doctors are not agents of the state and organized medicine cannot afford to be ‘neutral’ on a topic that touches medicine at its very core”.3 Furthermore, the Australian and New Zealand Society for Palliative Medicine4 and the Australian and New Zealand Society for Geriatric Medicine all have position statements that oppose EAS.5 As the peak physician organisation in Australasia, we urge the Royal Australasian College of Physicians to make an unambiguous statement to the general public, the medical profession and politicians that: EAS is not part of health care; EAS should not require involvement of doctors; and EAS creates irreconcilable conflicts with our responsibilities to our patients. If a medical association declares neutrality on this important issue, it squanders the precious role such associations have in providing guidance to the public and political sphere. That squandering comes at precisely the time this debate would be immeasurably enhanced by the expertise and wisdom of those members of the community most involved in the care of patients with serious illnesses.

Douglas T Bridge · Sinead M Donnelly · Frank P Brennan

Mja2 12105

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