Interviewer: Torrin Wilkins

Interviewee: Dr Paddy Glackin

Torrin Wilkins: My name is Torrin Wilkins, the Director of Centre Think Tank, and I am joined by Paddy Glackin. We will be discussing the system of assisted dying used in Western Australia. Paddy was an inner-city general practitioner in central London for 20 years and was the Deputy Chair of the British Medical Association Medical Ethics Committee from 1996 to 1999.

He brought a motion to the British Medical Association Conference in 2005, calling for it to change to a neutral position on changing the law to permit assisted dying. He then moved to Australia in 2014, becoming a general practitioner. He is now a voluntary assisted dying practitioner and the Western Australia Country Health Service Clinical Lead for Voluntary Assisted Dying. Thank you so much for joining me today, Paddy.

So my first question is whether any system which provides assisted dying also needs to avoid and detect any form of coercion that may be within it. So, what measures are within your system to do this?

Dr Paddy Glackin: Yeah, I think that is an absolutely valid concern to have, especially when in the process of setting up your assisted dying structure. So I think it works at several levels here in Western Australia. The first one is that the person must be dying. So our legislation is very clear that on the balance of probabilities, the person must have an advanced progressive disease which is likely to kill them and from which they are likely to die within six months. That is extended to 12 months for neurodegenerative diseases. And so, the first protection is that our assisted dying option here is only available to people who are actively dying and are going to die soon.

The second one is in terms of our practitioners. So we have a relatively small number of voluntary assisted dying practitioners in Western Australia, just over 100. So there is quite a rigorous process for being selected for that.

So the first one is that you have to be a senior doctor. You have to be on the specialist register, and you have to have been on the specialist register for more than a year. There is a provision for non-specialists, but they need to be quite senior as well. There is a minimum number of hours that any doctor must practice in a year to maintain their registration here, and you need to have done double those hours. So that ensures that we have doctors who are in active practice.

The actual process of becoming accredited is, they say it is eight hours of training. I would say it takes quite a bit longer. In my case, it probably took about 16 hours spread over a period. And then there is a tough exam with a 90% pass mark. And you are only allowed one or two resets. So again, that is relatively strict. And then you have to repeat that every three years. So you are only ever accredited for three years at a time. So the process of selecting our doctors is relatively strict.

And then finally, and I think the one that works for us here, probably because of the size of the population and the number of assisted dying cases that we have, we have got two doctors involved. We have got the coordinating practitioner who organises everything, and then the consulting practitioner who is the second doctor who comes in to ensure that everything is being done correctly.

They cannot simply decide each step in the process, which has to be driven by the patient. It has to be approved by the Voluntary Assisted Dying Board, which is the statutory body. So there are prescribed online forms, which must be completed and signed and sent in. And at that point, the board then scrutinises the information that it has got and it permits the next step in the process.

So I certainly feel, after three and a half years, I am very confident that we have a system that protects people from coercion in the direction of assisted dying.

Where we do see quite a bit of coercion, it has been in the board reports, and many of us have seen that, and our patients report it. If any coercive behaviour is happening, it is in the opposite direction. It is coming from institutions that claim institutional conscientious objection. And we have seen the institutions that have specifically forbidden their employees from sharing prognostic information. We have seen doctors who have refused to take part in case conferences and multidisciplinary team meetings if they have any concerns that the information that they share might be used for the purposes of assisted dying.

We see lots of individual patients who come under more or less pressure from their oncologists, their palliative care physician, the haematologist, and family members trying to push them away from pursuing the assisted dying option.

In terms of people who would be coerced into assisted dying, I have not seen any evidence of that.

Torrin Wilkins: So, in terms of a few words to say, raise a concern, say you had a concern about someone going through the process, how would that be raised? Would that go to the board, or what would be your next step to saying, well, I have a concern about this person?

Dr Paddy Glackin: I mean, for me, as a voluntary assisted dying practitioner, one of the things that I really satisfy myself of is that the person, that their wish to access assisted dying, that it is that they, and again, there are a whole series of things that we have to state to confirm when we are submitting the paperwork, that the person understands what they are doing, that it is entirely of their own free will, that it is consistently held the position, that they understand they are going to die and that they are free of coercion.

So what I will generally do is I really do like, wherever possible, having these consultations in the patients home because that gives you the opportunity to really see the context and see who else is present and just to ask them why and hear what they have got to say for themselves.

I have done some educational events through the College of Physicians here, which were interesting because there were some very adamant conscientious objectors present who said that they had concerns about cases where they felt that the patient possibly did not meet the prognostic criteria. And what I have said to them is that those should absolutely be reported to the board. You can lift the phone, or you can send an email. I would be very happy to have a conversation with the doctor in that position who had those concerns, because it is absolutely crucial to the integrity of the process that if people have concerns, those are escalated and elevated. If we do not have a process where everybody is very confident that patients are safe and secure with it, then it will fall apart.

Torrin Wilkins: So, is it easy then for a member of the public to come forward and say, “I have concerns about this person that I know or this person that is involved in the process.” Is that quite a straightforward process for them?

Dr Paddy Glackin: That is an interesting question. It is not something I have encountered. WA is a small place; it is easy to make phone calls. Yeah. And certainly, all of these assisted dying practitioners that I know, if they have concerns raised to them, would take them very seriously.

Having said that, I mean, for example, prognostication is notoriously difficult. Yeah. And so it is very much a balance of probabilities. I have seen a patient who was referred to me for a consulting assessment, and I work in a small country town. I used to be the medical director of the hospital; I have lots of colleagues who I know very well. And I went to speak to them, called your colleagues to say, what are you thinking about this patient in terms of, you know, six months on the balance of probabilities, and they said, oh, well, we will know when we are getting the next scan. And I am like, okay. So I went to see the patient, and he had been a GP for 35 years. This patient was not going to live to the next scan.

I understand that we have colleagues who are relentlessly positive and there are genuinely good-faith disagreements about what a patients likely prognosis is. But I think if somebody had real concerns, and I would have thought for family members as well, it would not be difficult to be able to raise your concerns to the board.

Torrin Wilkins: And so one quite distinctive aspect of the Australian system is, of course, the statewide care navigator services, which are set up in each state. What are the main functions of the service? How well do they function, and how useful are they for people going through the process?

Dr Paddy Glackin: Well, I can only speak to Western Australia. I do not have first-hand experience in the other states, but they are absolutely crucial. Absolutely crucial. There are relatively high numbers of doctors with conscientious objection. We have entire regions in WA. So the Goldfields region is the size of France and Germany put together; it has one VAD practitioner. Wheatbelt, a huge region, 700 kilometres all around Perth, does not have any VAD practitioners. So the statewide care navigators are there to explain and support patients through that process.

Because again, one of the very important parts of the legislation here is that nobody prompts you at any stage to go to the next step in the process. The patient has to drive this at every point, the entire way through. But the care and advocate is very happy to have a conversation to inform people about what it is that they need to do next if they want to proceed.

The other really vital function that they have in such a huge place as Western Australia, it is something from here to Connaught; it is three and a half thousand kilometres by road, and you leave the state at any point, is that they match patients with practitioners because it can be very difficult.

We have also Commonwealth legislation going back over 20 years to a very different context, which greatly limits what we can and cannot talk about over a carriage service is the legal term. Telephone, fax, and email are all legally considered to be carriage services. And so it means that some parts of the process have to be conducted face-to-face. So they have a really good role in finding doctors who are willing and able to go and support individual patients, especially those in very remote rural and remote communities.

Torrin Wilkins: And I also know one of the other things is the statewide pharmacy service. Yes. Well, that is involved. And that has certainly been something that has been pointed out as quite useful. So what kind of role does that play, especially in your day-to-day operation of the system?

Dr Paddy Glackin: They are kind of almost invisible to the doctors involved, other than if you are involved in a practitioner-administered, actual assisted dying itself. But they perform a really important role. Again, they are the only people who manage the substances. They transport the substances, and once you get to know them, you can spot them. They have got these little country flights that fly around, and we have got a little 33-seater that takes us from here to Perth. And I often see people coming on with the red box; I know what that is. And they are on their way down to see somebody. So they bring the substance to patients. If the patients are going to be patient-administered, then they do a lot of educational work as to exactly how to store, how to keep things safe, how to prepare, what to expect, how to prepare themselves, and they are available to provide ongoing advice. Also, if it is a case of physician-administered, then they bring the substance to the physician, whoever the physician is.

Torrin Wilkins: How much and what kind of guidance exists for medical professionals and anyone involved in the process? And has any guidance or regulation, has any of stood out as particularly useful in the process?

Dr Paddy Glackin: I think it is probably an area where we could do better compared to some of the other states. Victoria went before us and they have tremendous information for patients and tremendous information for practitioners.

In terms of official publications, there is not much, to be honest. There is the official information, which is a statutory obligation. If a doctor receives a first request, even if they are a conscientious objector, they must provide the information to the patient. We have a lot of evidence that this is not happening and that patients are not getting the information that they need. But it is very complex, technical, correct, and legally sound. It is not really patient-friendly in terms of how it is written. And that is not the purpose. The purpose is to guide people very correctly through the process and explain the process to them.

So we have just had the three-year statutory review of the working of the Act because it has been three years since it was implemented. And one of the very strong recommendations was that there needs to be proper information. We need posters, we need leaflets, we need a publicity campaign.

We just had a state election. There has not been a change in government, but the new government has not been formed yet, as in the last few seasons of counting. So everything is frozen and slightly waiting for that. But we have been advised by the Chief Medical Officer that there will be a good quality educational campaign and a publicity campaign will be put forward. So hopefully we will start to get some better communication materials and educational materials.

But yeah, I would talk to colleagues probably in Victoria and Queensland, because from where we are, of course, we cannot really use their materials because there are subtle but important differences in the law. But they appear to have some really good material.

Torrin Wilkins: Is there anything that you think people could benefit from in terms of additional material on top of what you have got that would help people going through the process who might not say they understand it as much?

Dr Paddy Glackin: Yeah, I think it is. The Queensland University of Technology has just done a very good review of the workings of the Act, and there are some really powerful comments and quotes from patients. One of the things the patient said is that if you are getting palliative care, the vast majority of people who go through assisted dying because you have to be dying here are actively involved in palliative care. And so you are sitting in the waiting room waiting for your appointment, and there are leaflets about everything, and there are posters about everything except assisted dying. It is often quite a difficult subject to bring up, especially as a number of our consultants and palliative care colleagues are known to be quite vocally opposed. So I can put patients in a very difficult position.

So I think just posters and some simple information saying, look, here are the contact details for the statewide care navigator service. They can help you understand, help you with your decision, help you understand your eligibility, and help you understand what it is you need to do if you want to enter the process.

I mean, I think the numbers are really interesting here. So, in the most recent, 2023 to 2024 annual report, 1.6% of deaths in Western Australia were through VAD, which was higher than anybody anticipated. And given that roughly two-thirds of deaths are anticipated, it means that about 2.5% of anticipated deaths are VAD. We also know that roughly three people formally enter the system for every person who completes the VAD. It means about one in 12 people who have a terminal illness here at least begin the process of exploring VAD. So it is not a tiny minority. There is a substantial number of people who want to be able to look at this for themselves. So I think it is important that we have material to help with that.

Torrin Wilkins: Some organisations and charities are either very, very supportive or very, very opposed to assisted dying. The settings could include at home, in a hospital, in a hospice, speaking to a GP or just with family and friends. So, how do we ensure that people feel comfortable asking for or rejecting an assisted death?

Dr Paddy Glackin: Well, the first thing is here, you do not have to reject it. If you do not ask for it, it never happens.

But we are really fortunate. So I live in Albany in the great southern heart of Western Australia. We, for years now, have had articles in newspapers saying it is the best place to die in Western Australia. We have a super community hospice, which is community-run, so it is non-denominational. And I think we had the first VAD death in Western Australia there. And the hospice thought very long and hard about what the approach would be, knowing that again, some of the practitioners and people who are on tour or contractors, and what they decided was actually, since their mission is to help people die in the manner and place of their choosing, they would carry through on that. And it has been a tremendously positive experience.

We are very fortunate that the vast majority of our palliative care practitioners down here, whether that is doctors, nurses, all, at least, started as open to assisted dying. And I think their experience has led to pretty much everybody now being quite positive about it.

It was quite scary. I think initially, this is the thing that we did not have scripts for. When you have been in practice for a long time, when a patient asks a question, you have a script that you reach for, which will help guide you through the consultation. So this was new for a lot of us, but it has been very positive for us.

That is not, sadly, the case everywhere in Western Australia. We have some places where the public sector works in partnership with faith-based organisations. And several faith-based organisations have been very clear that it is not compatible with their beliefs.

We are talking to somebody from Queensland about this. They have some statutory provisions about how institutions that conscientiously object have to at least give some support, and have to be upfront about what they believe, so they have got people to understand what they will and what they will not do. And when patients do not have alternatives, they at least facilitate them in that situation. We do not have anything like that here in WA, and it was not in the recommendations for the review of the legislation, so we will not be getting it in the near future. So we just need to work around it.

I think probably the biggest thing we need to do is normalise the idea that assisted dying is part of end-of-life care, and it is a normal and valid part of end-of-life care. And people who wish to look at it, explore it, think about it, try it and possibly even go the whole way through it, that it is a perfectly valid thing for people to want to be able to do. But while we have got, especially in country areas where the faith-based organisations are the main providers of palliative care, that can be a real barrier and real problem.

I do not have an easy answer for that other than we just build bridges, do not fall out with people, and when we are setting up services, we recognise a proportion of patients will want to go this route, and therefore we have alternative pathways that they can follow.

Torrin Wilkins: Is there any way that you are Are you able to get rid of misconceptions around the system? I know that is something I have heard in previous interviews about the idea that there are lots of misconceptions about what the system is, especially when it is being implemented amongst groups who may be more opposed to it.

Dr Paddy Glackin: Look, I think a lot of people genuinely and in good faith are tremendously opposed. And I am certainly not going to seek to change what they think. However, we have got people who are in purely executive positions in the public sector who are invoking conscientious objection. We have got people who are administrative staff and clerical staff. And that can be very difficult, especially in smaller centres where you have not got many staff. But certainly, what we are seeing is that the more exposure people have to assisted dying, for those who do not have a deeply held objection, the more positive they feel it is. We have had VAD in pretty much all of our little country hospitals around here. And almost universally, people have found it to be a very positive experience for everybody involved.

Torrin Wilkins: So, how does Australia deal with liability for those within the process, particularly doctors, but also individuals who are practitioners?

Dr Paddy Glackin: Good question. Two other things that care navigators do are they also come to especially small hospitals and will support people in advance, help people get organised, and they also do counselling and debriefing for staff after the event, which I think is really important. So, yet another role for the very hard-worked and very under-resourced care navigators, because what has happened here also is that there is a lot more take-up than we anticipated, we probably have a resource on a statewide care navigator that is enough. But discussion for another day.

Another thing to say is, well, it is also protection in terms of coercion. If you help somebody die outside of the legislation, you commit a really serious criminal offence, and the full force of the criminal law still applies against you. So we have got a very tightly drawn piece of legislation.

There is an in-good-faith clause, which is that if you are trying to implement the legislation in good faith, then that is acknowledged. And you will not automatically be liable for action. Anybody who is a VAD practitioner is fully legally protected from criminal activity. We also have clauses, for example, bystanders are not compelled to carry out CPR. Ambulance staff and other people are not compelled to intervene, which they would be in any other situation where someone appears to be dying. Although it would be said that I think you have got a pretty clear case of advanced care planning, and somebody whose goals of care do not include being resuscitated.

Interestingly, I have just renewed my medical indemnity and many things they asked me: do I use artificial intelligence in my practice? Do I do any prescribing of hormones to persons under 18, and am I involved in gender reassignment? All things that potentially increase your medical legal risk as an insurer, not a single mention of assisted dying.

So I think it is very clear that for clinicians and practitioners who have to be accredited, there is a formal accreditation system. You are formally approved. You must at each point enter all your data into the system to be approved to go to the next point. I think it is clear you are working within a clearly defined, lawful framework.

Torrin Wilkins: So one concern is actually around rare diseases and rarer forms of cancer as well. And the concern seems to be that assisted dying may reduce the focus on these diseases or that it may reduce funding or research. So has this happened at all in Australia, and what is your experience, especially with patients who have rarer conditions?

Dr Paddy Glackin: I have to see if I can get that. I do not even understand intellectually where the question comes from. I mean, it is a complete kind of intellectual non-sequitur.

Australia has excellent research centres which do superb work on common and uncommon diseases and rare diseases. We have seen the genetic revolution that has happened recently. We are seeing MIBS, MABs, MUBS, all kinds of incredible and incredibly expensive and incredibly specific new medications. And I worked with a visiting, very late-career oncologist who got very grumpy when he was speaking to GPs. He said, I did not become an oncologist; I became an immunologist. Research in these areas is fascinating, exciting, and incredibly well-funded. And VAD is just part of end-of-life care.

Nobody suggests that having any other form of end-of-life care in any way or shape or form inhibits or reduces research. I think to be really clear, the vast majority of patients, other than patients who are very, very late. And we do get some of those because some people think about it for a long time and then begin to get a bit anxious as the end is near. But it is a bit late to be researching their diseases anyway. However, the vast majority of patients are still actively engaged in treatment. Whether that be active treatment of their condition, almost all are actively involved in palliative care. They want this as an option. And it is very much in “as well as” and not an “instead of”.

Torrin Wilkins: Another concern that has been raised, especially in the UK, is the impact of assisted dying on palliative care. And the idea is that assisted dying would be used as a result of a struggling palliative care system. So, has this happened in Australia, and what impact has assisted dying had on the system in Australia?

Dr Paddy Glackin: I think that was a concern that was raised here in Australia during the whole lead-up to the legalisation of assisted dying because we had patchy palliative care, especially in the country; patchy palliative care, poorly resourced, it was very much a Cinderella service.

And so the profession was very clear, patient groups were very clear, everybody was very clear that it would be absolutely unacceptable to be placed in the position where people were having to look at assisted dying because of a lack of access to palliative care.

So, what we got before assisted dying was a huge investment in palliative care. So we had a very small number of visiting services here. We now have three times as many visiting specialists as we had. We have now got palliative care, you call them GPs with special interest; we now have them in every small town. We never had any of those before. Now we used to just have a small palliative care team in the regional centre. We have a much bigger regional palliative care team, and we also have palliative care nurses in all of our smaller towns all across the region. We have now got, we are now trained in the diploma in palliative care, which we are the first place to do. We have got junior doctors working in it.

So we have had a step change in improvement in our palliative care. I am not saying it is because assisted dying happened, but I think it was very much seen as a necessary step to happen. And I think it is quite right too. And I think it probably helps focus all of our minds on the needs of patients at the end of life to have multiple options and to have access to the care that they need at this time.

Torrin Wilkins: Brilliant. Well, thank you so much for your time and for speaking to me today.

Dr Paddy Glackin: So you are very welcome.

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.