Interviewer: Torrin Wilkins

Interviewee: Alex Greenwich MP

Torrin Wilkins: My name is Torrin Wilkins, the Director of Centre Think Tank, and today I am joined by Alex Greenwich, Member of Parliament. We will be discussing his experiences of assisted dying within Australia and the legislative process within New South Wales.

Alex is an independent member for Sydney and has been in the New South Wales Legislative Assembly since 2012. He introduced the Voluntary Assisted Dying Bill 2021 to the Legislative Assembly in New South Wales. The bill had 28 co-sponsors from across both houses, the greatest number of cosponsors ever achieved in Australia for a piece of legislation. This bill became law after it received Royal Assent in May 2022. So thank you so much for joining me today, Alex.

Alex Greenwich: Thank you.

Torrin Wilkins: For my first question, an issue like assisted dying is complex and requires politicians to make a large number of decisions around a whole host of issues, including choice, dignity, protecting against coercion, funding, and even related services such as hospices and palliative care. So, how are we able to ensure all of those issues can be discussed properly?

Alex Greenwich: Well, I think all of those issues are critical for parliaments to address and to deal with in a meaningful and caring way. The journey to a scheme for some people to be able to access voluntary assisted dying in New South Wales was indeed quite a long one, with advocates campaigning for decades for it. In New South Wales, there had been previous legislative attempts that had not succeeded. There had been previous parliamentary inquiries that had looked at safeguards. And there had been other jurisdictions around Australia and indeed the world that had legislated for voluntary assisted dying.

So we were able to draw upon a great deal of evidence, expert information, and also feedback from the wider community, who overwhelmingly supported this reform. The process was about turning all the expert advice, looking at the different legislative frameworks around Australia and the world, and putting it into a model that I was prepared to present to the New South Wales Parliament as one that would work for us and allow it to take its time to get through the Parliament to be able to address all those concerns. And ultimately, you know, a two-thirds majority of the Parliament agreed with the premise that some people have an illness which is terminal or where the death is just so cruel, painful, and undignified that there must be a better option.

So, essentially, voluntary assisted dying provides a very small number of people with a death better than their illness would otherwise provide them with. And the journey to be able to access care is very rigorous. Decision-making capacity is at the heart of it. Making sure a person is not being coerced in any way is at the heart of it. And having, you know, rigorous checks and balances across the whole way has ensured that in New South Wales, people have confidence that the voluntary assisted dying scheme is working and it is working well.

Also, critically, it is about really diverting people away from lonely, messy, traumatic, and horrific suicide because we got evidence in New South Wales from the coroner, which spoke about the number of people with a terminal illness diagnosis, who rather than talk to a medical practitioner about their options, take their life in gruesome ways. So I knew that we could do better than that. And I wanted to make sure we had a system which diverted people to a medical professional to be able to talk about all of their options, which is what the framework in New South Wales now does. 

Torrin Wilkins: And I mentioned at the start as well the size of the coalition that you can create to get that through Parliament. So, how did you build that coalition? 

Alex Greenwich: Yeah, look, in terms of getting meaningful reforms through a parliament or to get them to have the backing of a wider community, you must make sure your support base is as broad as possible. And this was a reform that, whether it was first responders, people like ambulance workers, whether it was lawyers, parents, faith leaders, members of the left or the right of politics, everybody valued and saw the importance of. So I wanted to make sure that we brought everyone together so we could really have an expert-led discussion. We could have the parliamentary inquiries hearing from those ambulance workers about arriving on-site at a gruesome suicide of a person with a terminal illness, who wanted that person to be able to discuss all of their options through to medical legal experts who can talk about decision-making capacity and how to put that in legislation. So we are able to do all of that and develop a model which addresses the strong desire of the wider community to legislate for voluntary assisted dying and does so in an appropriate, sensible and rigorous way. 

Torrin Wilkins: So it sounds like a lot of that was about getting the bill right effectively, and then support follows if you get the fundamentals of the bill correct. 

Alex Greenwich: Oh, look, I think, I do not think it is that straightforward. I think, if you polled the wider community, do you support Voluntary Assisted Dying? You know, before anyone saw the text of my bill, we knew that the support was about 75 % of the community. And, you know, just the principle of it was supported, you know, in some areas. It is actually when you get into the details of the legislation that the whole process, and rightly so, gets more complicated. And you need to explain to people how it works, who would be able to access this reform, who would not be able to access this reform, and the rigorous steps in place. So they go kind of hand in hand. The principle of access to Voluntary Assisted Dying is one that the public supported, getting the details on the process right, which was an important part of that, and obviously, ultimately saw the bill pass. 

Torrin Wilkins: And one of the discussions at the moment happening in the UK is also around how long should be left for the implementation period should be. So, how did implementation happen in New South Wales? 

Alex Greenwich: Look, the implementation period is critically important. And it is something in which your health system will need time to implement. But it obviously cannot be something that is so long in an attempt to appease people who were never going to support the bill in the first place. So in New South Wales, we had an 18-month implementation period, actually, it may have been longer than that. The bill passed in 2022, and it came into effect at the end of 2023, which was a sufficient amount of time for our health system to be able to implement voluntary assisted death.

A key part of our system is the care navigator service, which supports people wanting to access voluntary assisted death with all of the information required. That cohort is to be trained. Doctors are required to be trained. It required the establishment of a board and making sure that those were the right qualified people. So there are a number of really important steps. And I think an implementation period of around 18 months to three years is appropriate. Health systems can move fast when they are given the directive of legislation.

Just the final point on that in terms of the time frame. We have got to realise that the sooner we can implement these laws and, you know, with all of the rigorous safeguards in place, the sooner that peace and dignity will be delivered to people with a terminal illness. 

You know, there will be people today in the UK with motor neurone disease who know that their decline is going to happen. There will be people with bowel cancer who will, you know, be scared that their death may end in them choking on their own faeces. It is for this very small cohort of people with advanced and cruel terminal illnesses that this law gives them dignity; delaying it too long takes that dignity away from them. 

Torrin Wilkins: And something of particular interest is how Australian states and territories learn from each other on these kinds of bills. So, how did you learn from other states, including states like Victoria, which has a gang clause in place? 

Alex Greenwich: Yeah, you know, New South Wales was the state that legislated last for voluntary assisted dying. And I would argue we did it the best in terms of being able to look at what has been working in the other states and what has not been working. Things like not being able for a doctor to talk about voluntary assisted dying with a patient. The gag clause that you referenced was something that really put up a lot of barriers within Victoria, and their review of their act has also shown that. In New South Wales, we wanted someone with a terminal illness to have a fulsome conversation with their doctor and not have it limited. So that was one element in terms of the timeframe of the last 12 months or the last six months, if it is a neurodegenerative disease. That is pretty consistent with where a lot of states and territories landed.

In terms of the conscientious objection provisions, those were also all quite consistent across the board. However, in some states which required a specialist in that specific terminal illness to be involved as one of the doctors, we saw that in New South Wales it was far too limiting. Instead, we legislated for an additional referral path for a doctor; should they need a specialist in this, they would be able to access one.

The other really consistent thing across all of the states was that with voluntary assisted dying has come an increase in funding for palliative care. Because just the debate of the legislation opens politicians minds to the reality that we are all going to die, and some people do not die well. The option which most people will access, whether you have access to voluntary assisted dying or not, is going to be palliative care. And that needs to be well-funded and readily accessible. So all of the states had a good conversation about that. In New South Wales, we enshrined the right to good quality palliative care in the legislation.

Torrin Wilkins: Yes, and you previously said that, and I quote, you baked into the principles of our legislation access to palliative care for citizens of New South Wales. So, how did you do that? And what was the impact on palliative care of assisted dying?

Alex Greenwich: Those are actual words in our Act, and they compel the government to then back those words up with expenditure. And soon after the legislation passed, the government announced record funding, a $700 million increase in funding to palliative care. The current government is honouring that and expanding it as quickly as they can. And it is an ongoing journey, a workforce journey as well. It is the words in legislation backed up by the funding and the resourcing from the government that occur here.

Torrin Wilkins: And it is interesting when you say with funding. So is the funding itself, was that sort of directly a result of the assisted dying bill or was it a bit more complex in terms of?

Alex Greenwich: Look, we have always funded palliative care in New South Wales, but the increase in funding was directly linked to the legislating of voluntary assisted dying.

Torrin Wilkins: And of course, in the UK, I mean, some groups are uneasy or perhaps opposed to the bill, just like there were in New South Wales, for instance, disability campaign groups. So, how did you work with those groups to sort of reassure them about what the bill would and would not do?

Alex Greenwich: Yeah, well, look, we did not have objections from disability groups in New South Wales. Disability groups main concern was that a person with a disability should be able to access voluntary assisted dying just as they should be able to access any other law in the state or any other form of healthcare in the state.

It is important to note that this law reform is not for people with a disability. It is for people with a terminal illness, of which a cohort will be people with a disability. It is very specific in terms of legislation in New South Wales, in every Australian state, and in the UK bill that access to voluntary assisted dying is limited to someone with a terminal illness in the last six or 12 months of their life, of which disability is not a terminal illness. And indeed, the disability advocates were particularly concerned and upset with some politicians using their community for political purposes without engaging with them.

Torrin Wilkins: And when the bill that you proposed was being debated, what were the main concerns raised before the vote? So, were there things like coercion and lack of funding for palliative care raised? And what happened when any of these concerns were put to the test after the bill passed?

Alex Greenwich: Interestingly, my bill was the first time legislation had passed without the support of the Premier and the leader of the opposition, both of whom argued that we should not have access to voluntary assisted dying, but that we need better palliative care. I was able to put to them that there is strong support for voluntary assisted dying. It is separate from what palliative care is. If you so strongly support it, let us fund it properly. And that is obviously what happened in that space.

In terms of all of the other concerns that were raised, whether it was about coercion, whether it was about decision-making capacity, those were all addressed by putting in the legislation and strengthening them actually through the amendment process, with clear safeguards which make it clear that if you are being coerced, you cannot access voluntary assisted dying. If you do not have decision-making capacity, you will not be able to access voluntary assisted dying.

And the reviews of the Act, the two that have a voluntary assisted dying scheme that has been placed, the two that have occurred show that it is a small number of people who are accessing voluntary assisted dying, that people are being rejected access to it at various steps for those reasons of those safeguards and that the system is working.

Torrin Wilkins: And since the law itself was implemented, has public opinion visibly shifted at all? You mentioned before just how high the levels of support were before implementation, though.

Alex Greenwich: Yeah, look, I think support continues to be strong. I would say support for it has grown amongst doctors. We have had a large number of doctors take up training for voluntary assisted dying because they know the important care and compassion that this reform can provide to some people. And I have to tell you some of the most heartwarming correspondence I received as a member of Parliament has been from the family members of people with a terminal illness who have accessed the scheme to talk about the peace, the dignity, the calm, how their loved one was able to choose the time and to be around loved ones when they died, rather than it being a decision made for them by a doctor at the cruel pointy end of an advanced terminal illness.

Torrin Wilkins: And for my final question, of course, the UK may soon legalise assisted dying with a law that has quite a few similarities to those implemented in Australian states and territories. So given that and the existing cooperation, which goes on with groups like VADANZ, do you think the UK and Australia, for instance, could cooperate and learn from each other on assisted dying?

Alex Greenwich: Oh, I think it is really important for all jurisdictions to share information and to share experiences. Every jurisdiction has their legal framework and their own health system. But I think that New South Wales probably has a great deal of information and insight to share with the UK, if and when you do, hopefully, implement voluntary assisted dying. And I know that New South Wales Health would be happy to provide any knowledge or expertise and share experiences with the UK on how to implement the laws. New South Wales learned from other jurisdictions as well. This is a really delicate area of law reform, and it is a very important part of healthcare to make sure you get it right. Learning from people who have already successfully implemented it is critically important, and I am sure that Australia and Australian jurisdictions would be able to learn from the UK as well, should you have a scheme up and running

Torrin Wilkins: Well, thank you so much for taking the time to join me today, Alex, and for discussing the system of assisted dying used in New South Wales.

Alex Greenwich: Absolute pleasure, thank you so much.

Note on interview transcripts:

All interviewees gave informed consent for their quotes to be used within the publication and for their interviews to be published separately. They also had the opportunity to review, approve, and suggest edits to the final transcript before publication to ensure clarity. These interviews have also been edited for grammar by the interviewer. This written version of the interview is the final and definitive version.