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The End-of-Life Choice Bill has now passed its third reading in the New Zealand Parliament, which takes the final decision on this divisive legislation into the public arena as the End of Life Choice Act (EoLCA).1 An individual’s choice to die should not be dismissed in terms of self-determination at this point in their life; however, concerns arise when families, healthcare practitioners and communities experience social consequences of actions taken.

The overriding discourse in countries where assisted dying (AD) is legal or under consideration concerns individual emancipation from the perspective of human suffering.2,3 Although the use of AD legislation may liberate individuals from perceived suffering, it is necessary to consider the impact embracing a new means of dying may have on families and the wider community.3 This case study interview of a self-identified individual who had experienced AD from a family perspective (in a country where it is legal) exposes a range of issues that require further debate that go beyond the rights of individuals to choose this option to relieve suffering. This paper focuses on three key concepts: that AD will become an expectation for others to pursue when unwell and potentially facing a life-threatening illness; stigma associated with using AD; and the potential for AD legislation to produce a contagion effect. The participant also raised problems with the process of AD, but this was outside the scope of this paper.

Background

The process of dying has become taboo for contemporary Western societies; it no longer naturally enters life’s discourse and has become feared as a form of human failure.4,5 This anxiety over death suggests that we have forgotten ‘the majesty of death’, in that lives that have been lived well should be rejoiced and celebrated.6 However, in contemporary Western cultures, death remains invisible, until frail, older, disabled or unwell people become a physical, social and financial burden on their communities.3,4,7 The next cohort to die includes the baby-boomer generation. It has been suggested that this will change the landscape of how death will occur, as this generation has experienced life through the lens of individualism and perceived freedom of choice and may therefore expect death to be similar.8

Despite the prevalence of right-to-die narratives that support those who are concerned about loss of dignity and quality of life, medicine (in collaboration with law) has maintained an unwavering stance that the right-to-die produces a ‘slippery slope’ effect, whereby some patients may be obligated to terminate their lives prematurely.9–11 This can be seen in the Netherlands, where one in 30 individuals died by euthanasia in 2012 compared with one in 90 in 2002.3 Such changes could suggest that right-to-die campaigns, despite the potential to alleviate individual suffering, have the potential to turn death into a duty for those of frail status, perhaps pressuring some individuals into ending their lives prematurely to fit with societal expectations that caring for our dying is burdensome and pointless.12

Another emerging issue is that there is a real possibility of stigma in some cases where AD has been used.13 More specifically, some family members found that disclosing use of AD as a mechanism for death was problematic, as they feared the reactions of other people and feeling judged.13 However, such stigmatisation is not solely the domain of family members but is also relevant for clinicians, who may not discuss participation in AD services for fear of professional stigmatisation and conflict with colleagues (although the latter is not discussed in this paper).14

Despite the potential for those using AD legislation to be judged or stigmatised, there is further concern that AD may produce a contagion effect.13–15 Jones and Paton observed that unlike some studies that perceived AD as providing a suicide-inhibiting effect, their results suggested that any inhibitory mechanisms were counteracted by “equal or larger opposite effects”.16–18

The potential for a contagion effect is also a concern in the New Zealand context, particularly if legislative boundaries slip thereby easing restrictions around eligibility. Research suggests that globally, similar bills have initially restricted eligibility to those with terminal illnesses to make AD more palatable, but the eligibility criteria subsequently became more flexible.19 Shariff suggested that a crucial aspect of such criteria is clear boundaries and limits that reflect the underlying justifications for assisted dying.19 Therefore, it is important to maintain “robust safeguards [that do not] become ritualised practices of verification”, and ensure compliance is not “reduced to ticking items off a checklist”.20An example of how quickly the contagion effect can occur is the 14-year-old girl (Valentina Maureira) from Chile who used YouTube to request assisted suicide, and subsequently admitted she got the idea after hearing about the assisted death of Brittany Maynard in Oregon in 2014.15 Therefore, the provision of positive role modelling of AD practices may normalise or even promote this means of death unless assisted deaths are protected by rigorous legislation that supports those involved. Such normative practices are evidenced in the Netherlands, where AD is now becoming the most prevalent mode of death for patients with cancer.3

Method

This study used the Yin case study approach to undertake a single semi-structured in-depth interview with a participant who self-identified as having first-hand experience of AD from a relative’s perspective (in a country where this is legal).21

The case

This study examined a specific case of an individual whose relative had accessed and used AD in a country where it is legal.21 The death occurred 12 months before the interview took place. The narrative depicted a situation where the individual concerned had a chronic and progressive illness, which had a mental health component. He was a highly educated scientist who was still relatively active and was able to mobilise around parks and reserves. Family members had noted some decline in his physical ability, but nothing unusual for the individual’s age (mid 70s). Some family members lived close to the individual while others were located overseas. The news of the individual choosing AD had not been discussed, except with the spouse, before the announcement of a date being set for the death, giving immediate family (spouse and siblings) only two weeks to prepare for the event. The interview participant was married to one of the siblings. The family of this individual, except for one child, all lived in the same country where AD is a legal option.

Data collection

The interview was conducted in a private setting to maintain confidentiality, and audio-recorded with the participant’s consent (questions in Appendix). The audio recording was transcribed verbatim by the primary investigator (RW). All names and references that had potential to identify the participant were changed. The interview transcript was member-checked and agreed as being accurate before dissemination to the research team for analysis.

Data analysis

Thematic analysis was used to interpret the narrative and identify trends and patterns emerging from the data.22 This was particularly pertinent given the conceptual nature of this study in an emerging field of research interest.23,24 The interview transcript was read by RW and RM, and coded separately. Thereafter, coding was discussed among RW and RM to determine themes emerging from the research, with the triangulation between the two reviewers improving the study rigour.25

Ethical considerations

Ethical approval was obtained from the Auckland University of Technology Ethics Committee (AUTEC), reference number 19/170. Written and verbal consent was obtained from the participant.

Findings

This paper discusses three key themes that emerged from the interview: AD becoming an expectation for others to pursue when unwell and potentially facing a life-threatening illness; the notion of stigma associated with using AD legislation; and the potential for such legislation to produce a contagion effect.

Life value and expectation to use AD

In considering the burden and expectations with regard to AD legislation, there appeared to be a shift in terms of where the burden sits. Life value was questioned, with the notion of being burdensome transferring to those still living, in that AD may become a future expectation for them. This was evident when the participant said:

“[AD] sets a precedent around suffering and even the value of living and life…and in a family that has some individuals who have chronic health issues…I’m thinking of what they’ll face years from now—they’ll have to make a decision about what their value is to society. What is that going to mean…when I become disabled to the point where I can’t do anything?…I think it means I’ll have to [use AD] and if it came through and they thought it was the right thing to do, I would do it.”

The participant had a chronic medical condition, and following the above comment, he was specifically asked “Do you feel like that’s something you would have to consider?” He responded, “I think it’s in my future, I can see it now”.

Stigma

Stigma can occur on both sides of AD legislation, with doctors and nurses being stigmatised whichever decision they make regarding service provision. The participant suggested that judgement exists even when the legislation is legal. He noted that despite a growing number of individuals using AD, they often fail to inform wider family and friend networks that they intend to use, or have used this legislation. For example,

“In terms of what it means for a family…is now…all this unspoken stuff happening. It’s hard…you know when they asked their kids [sic] not to tell their spouses. They just wanted him to have [appeared to have] died [naturally].”

In this instance, the person’s wife and siblings knew but were explicitly told to not tell anybody else, including partners, because

“…they were fearful of judgement…it might be legal but you know, so is marijuana now and there [is] plenty of society that thinks it’s shameful.”

The participant went on to note that two of his father’s friends had used AD legislation in the same 12-month period. Despite having had a life-long close relationship with one particular friend, that friend did not want to talk to his father about AD:

“He didn’t talk to my dad much, didn’t wanna [sic] tell my dad what was happening [AD]. [He said] ‘I don’t wanna [sic] talk to anybody, I don’t wanna [sic] talk to you. I can’t, I can’t talk to you about this [AD] right now, I can’t talk to you’. And hung up.”

AD as contagion

The participant hinted that there may be a contagion effect at play, as he had known three extended family members use the legislation over a short period of time.

“I don’t know if I told you this but two other extended family members have now gone through this [AD].”

He also noted that he was,

“…worried about my dad now, because he’s now had two people close to him make the decision [to die] and he’s like, I didn’t even know that people make those decisions—now he knows…I guess I worry it’s…I don’t think cancer is the right word…but I worry that its infectious.”

Discussion

In conducting this study, it was anticipated that social consequences of AD legislation may be present in terms of the slippery-slope discourse.10,11 However, it was unexpected to obtain data that painted a distinct picture of how the slippery-slope effect was unfolding in a country where AD was legal. While the right of individuals to choose assisted dying in some instances may be appropriate, evidence from this study must be factored into the New Zealand debate before the referendum on the End of Life Choice Act in 2020.

This study clearly showed how experiencing AD through a relative’s lens and by partial engagement with AD can impact broader family and friend networks, in a similar way to that observed by Gamondi.13 This was witnessed through the identification of the burden shifting from the physical and financial dimensions of care, towards AD becoming a future expectation for extended family members. This potential consequence of AD legislation reduces our future existence to being considered only through the practical lens relating to the cost of care and reduces our life to having a dollar value, as opposed to AD alleviating the fear of indignity, pain and suffering at end-of-life.

The results highlighted how AD remains contentious, irrespective of legality, which was demonstrated through the secrecy surrounding the participant’s relative’s death in terms of not including extended family members in decision-making, and not informing family friends of the cause of death.26 This family’s behaviour was similar to that reported by Gamondi, thereby offering further real-world clarification that using AD can have a stigmatising effect.13 However, despite such secrecy, the participant expressed concern that AD may be ‘infectious’. This was consistent with Kheriaty, who observed that exposure to the idea of AD can lead others to seek such assistance, thus the effects of legislation will require close and transparent monitoring to avoid this outcome.15

With these indicative social consequences comes the concern that the legalisation for AD in New Zealand has potential to fracture family and community structures, and the fracturing of such social networks may be difficult to repair in the aftermath of AD. For example, the participant suggested that:

“There are going to be fractured families, where someone is feeling like they’re a burden, they don’t have the support of their family, so their likelihood of making a decision…I believe [it] will be much easier for them to say ‘I’m alone anyhow, nobody cares…there are a lot of reasons to quit, a lot of reasons to go to sleep’.”

Such a notion was also depicted by Hendin and Foley, who considered lack of family support was a contributing factor to using AD.27 They described a case where ‘the eagerness’ of an older woman’s daughter and son-in-law was thought to have possibly influenced her decision to take ‘suicide pills’. Therefore, when considering such scenarios, we must also consider the potential of fracturing of our New Zealand communities and broader social settings. Even if we can ‘fix’ such fractures after AD is legislated and implemented, we may not be able to return them to their former status, thereby changing the supportive and intimate nature of the New Zealand social landscape. It is, therefore, imperative that should AD legislation be supported in the forthcoming referendum, it is introduced safely to support those who wish to access it, but simultaneously protects our vulnerable populations.

Conclusion

The introduction of AD legislation into New Zealand culture provides a potential hotspot for family, community and social discord that may not be easily remedied. There remains ongoing debate with regard to the slippery-slope effect of this legislation globally. However, this case study offers insight into some elements associated with slippage in terms of family members being expected to die when their care becomes too difficult or expensive. This study also suggests that as New Zealand moves forward with the EoLCA referendum in 2020, further study is required to investigate whether a contagion effect of AD is possible (or even probable), and how as a society, we negotiate what will be a conflicted pathway potentially complicated by prejudice, judgement and stigma for those who actively seek solace from indignity and suffering.

Although this is a singular case study, it exposes an individual’s experience of AD in a country where it is legal, and the issues faced at a grass roots level. It offers some evidence as to what occurs in the reality of AD legislation, and how it impacts beyond the immediacy of relieving individual suffering, and extends that suffering into realms that have not yet been adequately investigated.

Appendix

Interview questions/structure

1. The phase one case study will comprise of a loosely semi-structured interview to allow for free-flowing information regarding this under-researched field of interest.

2. Tell me about your story of assisted dying (this is a broad introductory question to get a feel for what happened)

3. Why did your family member choose assisted dying?

4. What are your experiences of involvement with the decision-making process for your family member?

5. Tell me about the process that occurred when your family member actually went to the clinic for the assisted dying.

6. What happened after their death?

7. How do you feel now about assisted suicide?

8. How do you feel about the possibility of a bill supporting assisted dying being passed in New Zealand? (If appropriate).

Summary

Abstract

Aim

To consider the possibility of consequences beyond the alleviation of perceived individual suffering, for families left behind, communities and society as a whole should the End of Life Choice Act gain public support in the September 2020 referendum in New Zealand.

Method

This study used the Yin case study approach to undertake a single semi-structured in-depth interview with a participant who self-identified as having first-hand experience of assisted dying from a relative’s perspective (in a country where this is legal). Thematic analysis was used to identify themes and trends from the interview transcript.

Results

Three key themes emerged from the interview: the potential for assisted dying becoming an expectation for others to pursue when unwell and possibly facing a life-threatening illness; the notion of stigma being associated with the individual using assisted dying legislation and the family left behind; and that there may be the potential for such legislation to produce a contagion effect.

Conclusion

The introduction of assisted dying legislation into New Zealand culture provides a potential hotspot for family, community and social discord that may not be easily remedied. Further study in New Zealand is required to investigate whether a contagion effect of assisted dying is possible, and how as a society, we negotiate what could become a conflicted pathway potentially complicated by prejudice, judgement and stigma.

Author Information

Rhona Winnington, Lecturer, Department of Nursing, School of Clinical Sciences, Auckland University of Technology, Auckland; Rod MacLeod, Clinical Adviser Hospice New Zealand and Honorary Professor, University of Sydney Medical School, Sydney.

Acknowledgements

Correspondence

Rhona Winnington, Lecturer, Department of Nursing, School of Clinical Sciences, Auckland University of Technology, Auckland; Rod MacLeod, Clinical Adviser Hospice New Zealand and Honorary Professor, University of Sydney Medical School, Sydney.

Correspondence Email

rhona.winnington@aut.ac.nz

Competing Interests

Dr MacLeod is Clinical Adviser to Hospice New Zealand.

1. End of Life Choice Bill. In: Parliament NZ, editor. 2019.

2. Karsoho H, Fishman JR, Wright DK, Macdonald ME. Suffering and medicalization at the end of life: The case of physician-assisted dying. 2016. p. 188–96.

3. Wardle LD. A Death in the Family: How Assisted Suicide Harms Families and Society. Ave Maria Law Review. 2016:43.

4. Philippe A. Invisible Death. The Wilson Quarterly (1976). 1981; 5(1):105.

5. Gawande A. Being mortal : aging, illness, medicine and what matters in the end: Profile Books; 2014.

6. Kevin F. Qualified to speak: Rush Rhees on the (vexed) subject of euthanasia. Philosophy. 2013; 88(346):575.

7. Buckinx F, Rolland Y, Reginster J-Y, Ricour C, Petermans J, Bruyère O. Burden of frailty in the elderly population: perspectives for a public health challenge. Archives Of Public Health = Archives Belges De Sante Publique. 2015; 73(1):19.

8. Schuklenk U. Is Assisted Dying the Baby Boomers' Last Frontier? Bioethics. 2016; 30(7):470.

9. Hendry M, Pasterfield D, Lewis R, Carter B, Hodgson D, Wilkinson C. Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying. Palliative Medicine. 2012; 27(1):13–26.

10. Pestinger M, Stiel S, Elsner F, Widdershoven G, Voltz R, Nauck F, et al. The desire to hasten death: Using Grounded Theory for a better understanding "When perception of time tends to be a slippery slope". 2015. p. 711–9.

11. Jackson E. Legalized Assisted Dying: Cross Purposes and Unintended Consequences. Dalhousie Law Journal. 2018(Issue 1):59.

12. Winnington R. Patient choice as illusion: Autonomy and choice in end-of-life care in the United Kingdom and New Zealand: University of Auckland; 2016.

13. Gamondi C, Pott M, Preston N, Payne S. Family Caregivers' Reflections on Experiences of Assisted Suicide in Switzerland: A Qualitative Interview Study. Journal of Pain & Symptom Management. 2018; 55(4):1085–94.

14. McDougall R, Hayes B, Sellars M, Pratt B, Hutchinson A, Tacey M, et al. ‘This is uncharted water for all of us’: challenges anticipated by hospital clinicians when voluntary assisted dying becomes legal in Victoria. Australian Health Review. 2019.

15. Kheriaty A. Social Contagion Effects of Physician-Assisted Suicide: Commentary on "How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?". Southern Medical Journal. 2015; 108(10):605–6.

16. Jones DA, Paton D. How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide? 2015. p. 599–604.

17. Posner RA. Aging and old age. Chicago: Chicago University Press; 1997.

18. Assisted Dying Bill. Sect. Columns 775, 905 (2015).

19. Shariff MJ. Assisted death and the slippery slope-finding clarity amid advocacy, convergence, and complexity. 2012. p. 143–54.

20. Halliday S. Comparative Reflections upon the Assisted Dying Bill 2013: A Plea for a More European Approach. Medical Law International. 2013(Issue 2–3):135.

21. Yin RK. Case study research : design and methods. 5 edition. ed: SAGE; 2014.

22. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006; 3(2):77–101.

23. Corbin JM, Strauss AL. Basics of qualitative research : techniques and procedures for developing grounded theory. Fourth edition. ed: SAGE; 2015.

24. Holloway I. Qualitative research in nursing and healthcare. Fourth edition. ed: Wiley Blackwell; 2017.

25. Denzin NK. Triangulation 2.0. Journal of Mixed Methods Research. 2012; 6(2):80–8.

26. Dyer O, White C, Rada Aser G. Assisted dying : law and practice around the world. BMJ: British Medical Journal. 2015; 351.

27. Hendin H, Foley K. Physician-Assisted Suicide in Oregon: A Medical Perspective. Michigan Law Review. 2007(Issue 8):1613.

Contact diana@nzma.org.nz
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The End-of-Life Choice Bill has now passed its third reading in the New Zealand Parliament, which takes the final decision on this divisive legislation into the public arena as the End of Life Choice Act (EoLCA).1 An individual’s choice to die should not be dismissed in terms of self-determination at this point in their life; however, concerns arise when families, healthcare practitioners and communities experience social consequences of actions taken.

The overriding discourse in countries where assisted dying (AD) is legal or under consideration concerns individual emancipation from the perspective of human suffering.2,3 Although the use of AD legislation may liberate individuals from perceived suffering, it is necessary to consider the impact embracing a new means of dying may have on families and the wider community.3 This case study interview of a self-identified individual who had experienced AD from a family perspective (in a country where it is legal) exposes a range of issues that require further debate that go beyond the rights of individuals to choose this option to relieve suffering. This paper focuses on three key concepts: that AD will become an expectation for others to pursue when unwell and potentially facing a life-threatening illness; stigma associated with using AD; and the potential for AD legislation to produce a contagion effect. The participant also raised problems with the process of AD, but this was outside the scope of this paper.

Background

The process of dying has become taboo for contemporary Western societies; it no longer naturally enters life’s discourse and has become feared as a form of human failure.4,5 This anxiety over death suggests that we have forgotten ‘the majesty of death’, in that lives that have been lived well should be rejoiced and celebrated.6 However, in contemporary Western cultures, death remains invisible, until frail, older, disabled or unwell people become a physical, social and financial burden on their communities.3,4,7 The next cohort to die includes the baby-boomer generation. It has been suggested that this will change the landscape of how death will occur, as this generation has experienced life through the lens of individualism and perceived freedom of choice and may therefore expect death to be similar.8

Despite the prevalence of right-to-die narratives that support those who are concerned about loss of dignity and quality of life, medicine (in collaboration with law) has maintained an unwavering stance that the right-to-die produces a ‘slippery slope’ effect, whereby some patients may be obligated to terminate their lives prematurely.9–11 This can be seen in the Netherlands, where one in 30 individuals died by euthanasia in 2012 compared with one in 90 in 2002.3 Such changes could suggest that right-to-die campaigns, despite the potential to alleviate individual suffering, have the potential to turn death into a duty for those of frail status, perhaps pressuring some individuals into ending their lives prematurely to fit with societal expectations that caring for our dying is burdensome and pointless.12

Another emerging issue is that there is a real possibility of stigma in some cases where AD has been used.13 More specifically, some family members found that disclosing use of AD as a mechanism for death was problematic, as they feared the reactions of other people and feeling judged.13 However, such stigmatisation is not solely the domain of family members but is also relevant for clinicians, who may not discuss participation in AD services for fear of professional stigmatisation and conflict with colleagues (although the latter is not discussed in this paper).14

Despite the potential for those using AD legislation to be judged or stigmatised, there is further concern that AD may produce a contagion effect.13–15 Jones and Paton observed that unlike some studies that perceived AD as providing a suicide-inhibiting effect, their results suggested that any inhibitory mechanisms were counteracted by “equal or larger opposite effects”.16–18

The potential for a contagion effect is also a concern in the New Zealand context, particularly if legislative boundaries slip thereby easing restrictions around eligibility. Research suggests that globally, similar bills have initially restricted eligibility to those with terminal illnesses to make AD more palatable, but the eligibility criteria subsequently became more flexible.19 Shariff suggested that a crucial aspect of such criteria is clear boundaries and limits that reflect the underlying justifications for assisted dying.19 Therefore, it is important to maintain “robust safeguards [that do not] become ritualised practices of verification”, and ensure compliance is not “reduced to ticking items off a checklist”.20An example of how quickly the contagion effect can occur is the 14-year-old girl (Valentina Maureira) from Chile who used YouTube to request assisted suicide, and subsequently admitted she got the idea after hearing about the assisted death of Brittany Maynard in Oregon in 2014.15 Therefore, the provision of positive role modelling of AD practices may normalise or even promote this means of death unless assisted deaths are protected by rigorous legislation that supports those involved. Such normative practices are evidenced in the Netherlands, where AD is now becoming the most prevalent mode of death for patients with cancer.3

Method

This study used the Yin case study approach to undertake a single semi-structured in-depth interview with a participant who self-identified as having first-hand experience of AD from a relative’s perspective (in a country where this is legal).21

The case

This study examined a specific case of an individual whose relative had accessed and used AD in a country where it is legal.21 The death occurred 12 months before the interview took place. The narrative depicted a situation where the individual concerned had a chronic and progressive illness, which had a mental health component. He was a highly educated scientist who was still relatively active and was able to mobilise around parks and reserves. Family members had noted some decline in his physical ability, but nothing unusual for the individual’s age (mid 70s). Some family members lived close to the individual while others were located overseas. The news of the individual choosing AD had not been discussed, except with the spouse, before the announcement of a date being set for the death, giving immediate family (spouse and siblings) only two weeks to prepare for the event. The interview participant was married to one of the siblings. The family of this individual, except for one child, all lived in the same country where AD is a legal option.

Data collection

The interview was conducted in a private setting to maintain confidentiality, and audio-recorded with the participant’s consent (questions in Appendix). The audio recording was transcribed verbatim by the primary investigator (RW). All names and references that had potential to identify the participant were changed. The interview transcript was member-checked and agreed as being accurate before dissemination to the research team for analysis.

Data analysis

Thematic analysis was used to interpret the narrative and identify trends and patterns emerging from the data.22 This was particularly pertinent given the conceptual nature of this study in an emerging field of research interest.23,24 The interview transcript was read by RW and RM, and coded separately. Thereafter, coding was discussed among RW and RM to determine themes emerging from the research, with the triangulation between the two reviewers improving the study rigour.25

Ethical considerations

Ethical approval was obtained from the Auckland University of Technology Ethics Committee (AUTEC), reference number 19/170. Written and verbal consent was obtained from the participant.

Findings

This paper discusses three key themes that emerged from the interview: AD becoming an expectation for others to pursue when unwell and potentially facing a life-threatening illness; the notion of stigma associated with using AD legislation; and the potential for such legislation to produce a contagion effect.

Life value and expectation to use AD

In considering the burden and expectations with regard to AD legislation, there appeared to be a shift in terms of where the burden sits. Life value was questioned, with the notion of being burdensome transferring to those still living, in that AD may become a future expectation for them. This was evident when the participant said:

“[AD] sets a precedent around suffering and even the value of living and life…and in a family that has some individuals who have chronic health issues…I’m thinking of what they’ll face years from now—they’ll have to make a decision about what their value is to society. What is that going to mean…when I become disabled to the point where I can’t do anything?…I think it means I’ll have to [use AD] and if it came through and they thought it was the right thing to do, I would do it.”

The participant had a chronic medical condition, and following the above comment, he was specifically asked “Do you feel like that’s something you would have to consider?” He responded, “I think it’s in my future, I can see it now”.

Stigma

Stigma can occur on both sides of AD legislation, with doctors and nurses being stigmatised whichever decision they make regarding service provision. The participant suggested that judgement exists even when the legislation is legal. He noted that despite a growing number of individuals using AD, they often fail to inform wider family and friend networks that they intend to use, or have used this legislation. For example,

“In terms of what it means for a family…is now…all this unspoken stuff happening. It’s hard…you know when they asked their kids [sic] not to tell their spouses. They just wanted him to have [appeared to have] died [naturally].”

In this instance, the person’s wife and siblings knew but were explicitly told to not tell anybody else, including partners, because

“…they were fearful of judgement…it might be legal but you know, so is marijuana now and there [is] plenty of society that thinks it’s shameful.”

The participant went on to note that two of his father’s friends had used AD legislation in the same 12-month period. Despite having had a life-long close relationship with one particular friend, that friend did not want to talk to his father about AD:

“He didn’t talk to my dad much, didn’t wanna [sic] tell my dad what was happening [AD]. [He said] ‘I don’t wanna [sic] talk to anybody, I don’t wanna [sic] talk to you. I can’t, I can’t talk to you about this [AD] right now, I can’t talk to you’. And hung up.”

AD as contagion

The participant hinted that there may be a contagion effect at play, as he had known three extended family members use the legislation over a short period of time.

“I don’t know if I told you this but two other extended family members have now gone through this [AD].”

He also noted that he was,

“…worried about my dad now, because he’s now had two people close to him make the decision [to die] and he’s like, I didn’t even know that people make those decisions—now he knows…I guess I worry it’s…I don’t think cancer is the right word…but I worry that its infectious.”

Discussion

In conducting this study, it was anticipated that social consequences of AD legislation may be present in terms of the slippery-slope discourse.10,11 However, it was unexpected to obtain data that painted a distinct picture of how the slippery-slope effect was unfolding in a country where AD was legal. While the right of individuals to choose assisted dying in some instances may be appropriate, evidence from this study must be factored into the New Zealand debate before the referendum on the End of Life Choice Act in 2020.

This study clearly showed how experiencing AD through a relative’s lens and by partial engagement with AD can impact broader family and friend networks, in a similar way to that observed by Gamondi.13 This was witnessed through the identification of the burden shifting from the physical and financial dimensions of care, towards AD becoming a future expectation for extended family members. This potential consequence of AD legislation reduces our future existence to being considered only through the practical lens relating to the cost of care and reduces our life to having a dollar value, as opposed to AD alleviating the fear of indignity, pain and suffering at end-of-life.

The results highlighted how AD remains contentious, irrespective of legality, which was demonstrated through the secrecy surrounding the participant’s relative’s death in terms of not including extended family members in decision-making, and not informing family friends of the cause of death.26 This family’s behaviour was similar to that reported by Gamondi, thereby offering further real-world clarification that using AD can have a stigmatising effect.13 However, despite such secrecy, the participant expressed concern that AD may be ‘infectious’. This was consistent with Kheriaty, who observed that exposure to the idea of AD can lead others to seek such assistance, thus the effects of legislation will require close and transparent monitoring to avoid this outcome.15

With these indicative social consequences comes the concern that the legalisation for AD in New Zealand has potential to fracture family and community structures, and the fracturing of such social networks may be difficult to repair in the aftermath of AD. For example, the participant suggested that:

“There are going to be fractured families, where someone is feeling like they’re a burden, they don’t have the support of their family, so their likelihood of making a decision…I believe [it] will be much easier for them to say ‘I’m alone anyhow, nobody cares…there are a lot of reasons to quit, a lot of reasons to go to sleep’.”

Such a notion was also depicted by Hendin and Foley, who considered lack of family support was a contributing factor to using AD.27 They described a case where ‘the eagerness’ of an older woman’s daughter and son-in-law was thought to have possibly influenced her decision to take ‘suicide pills’. Therefore, when considering such scenarios, we must also consider the potential of fracturing of our New Zealand communities and broader social settings. Even if we can ‘fix’ such fractures after AD is legislated and implemented, we may not be able to return them to their former status, thereby changing the supportive and intimate nature of the New Zealand social landscape. It is, therefore, imperative that should AD legislation be supported in the forthcoming referendum, it is introduced safely to support those who wish to access it, but simultaneously protects our vulnerable populations.

Conclusion

The introduction of AD legislation into New Zealand culture provides a potential hotspot for family, community and social discord that may not be easily remedied. There remains ongoing debate with regard to the slippery-slope effect of this legislation globally. However, this case study offers insight into some elements associated with slippage in terms of family members being expected to die when their care becomes too difficult or expensive. This study also suggests that as New Zealand moves forward with the EoLCA referendum in 2020, further study is required to investigate whether a contagion effect of AD is possible (or even probable), and how as a society, we negotiate what will be a conflicted pathway potentially complicated by prejudice, judgement and stigma for those who actively seek solace from indignity and suffering.

Although this is a singular case study, it exposes an individual’s experience of AD in a country where it is legal, and the issues faced at a grass roots level. It offers some evidence as to what occurs in the reality of AD legislation, and how it impacts beyond the immediacy of relieving individual suffering, and extends that suffering into realms that have not yet been adequately investigated.

Appendix

Interview questions/structure

1. The phase one case study will comprise of a loosely semi-structured interview to allow for free-flowing information regarding this under-researched field of interest.

2. Tell me about your story of assisted dying (this is a broad introductory question to get a feel for what happened)

3. Why did your family member choose assisted dying?

4. What are your experiences of involvement with the decision-making process for your family member?

5. Tell me about the process that occurred when your family member actually went to the clinic for the assisted dying.

6. What happened after their death?

7. How do you feel now about assisted suicide?

8. How do you feel about the possibility of a bill supporting assisted dying being passed in New Zealand? (If appropriate).

Summary

Abstract

Aim

To consider the possibility of consequences beyond the alleviation of perceived individual suffering, for families left behind, communities and society as a whole should the End of Life Choice Act gain public support in the September 2020 referendum in New Zealand.

Method

This study used the Yin case study approach to undertake a single semi-structured in-depth interview with a participant who self-identified as having first-hand experience of assisted dying from a relative’s perspective (in a country where this is legal). Thematic analysis was used to identify themes and trends from the interview transcript.

Results

Three key themes emerged from the interview: the potential for assisted dying becoming an expectation for others to pursue when unwell and possibly facing a life-threatening illness; the notion of stigma being associated with the individual using assisted dying legislation and the family left behind; and that there may be the potential for such legislation to produce a contagion effect.

Conclusion

The introduction of assisted dying legislation into New Zealand culture provides a potential hotspot for family, community and social discord that may not be easily remedied. Further study in New Zealand is required to investigate whether a contagion effect of assisted dying is possible, and how as a society, we negotiate what could become a conflicted pathway potentially complicated by prejudice, judgement and stigma.

Author Information

Rhona Winnington, Lecturer, Department of Nursing, School of Clinical Sciences, Auckland University of Technology, Auckland; Rod MacLeod, Clinical Adviser Hospice New Zealand and Honorary Professor, University of Sydney Medical School, Sydney.

Acknowledgements

Correspondence

Rhona Winnington, Lecturer, Department of Nursing, School of Clinical Sciences, Auckland University of Technology, Auckland; Rod MacLeod, Clinical Adviser Hospice New Zealand and Honorary Professor, University of Sydney Medical School, Sydney.

Correspondence Email

rhona.winnington@aut.ac.nz

Competing Interests

Dr MacLeod is Clinical Adviser to Hospice New Zealand.

1. End of Life Choice Bill. In: Parliament NZ, editor. 2019.

2. Karsoho H, Fishman JR, Wright DK, Macdonald ME. Suffering and medicalization at the end of life: The case of physician-assisted dying. 2016. p. 188–96.

3. Wardle LD. A Death in the Family: How Assisted Suicide Harms Families and Society. Ave Maria Law Review. 2016:43.

4. Philippe A. Invisible Death. The Wilson Quarterly (1976). 1981; 5(1):105.

5. Gawande A. Being mortal : aging, illness, medicine and what matters in the end: Profile Books; 2014.

6. Kevin F. Qualified to speak: Rush Rhees on the (vexed) subject of euthanasia. Philosophy. 2013; 88(346):575.

7. Buckinx F, Rolland Y, Reginster J-Y, Ricour C, Petermans J, Bruyère O. Burden of frailty in the elderly population: perspectives for a public health challenge. Archives Of Public Health = Archives Belges De Sante Publique. 2015; 73(1):19.

8. Schuklenk U. Is Assisted Dying the Baby Boomers' Last Frontier? Bioethics. 2016; 30(7):470.

9. Hendry M, Pasterfield D, Lewis R, Carter B, Hodgson D, Wilkinson C. Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying. Palliative Medicine. 2012; 27(1):13–26.

10. Pestinger M, Stiel S, Elsner F, Widdershoven G, Voltz R, Nauck F, et al. The desire to hasten death: Using Grounded Theory for a better understanding "When perception of time tends to be a slippery slope". 2015. p. 711–9.

11. Jackson E. Legalized Assisted Dying: Cross Purposes and Unintended Consequences. Dalhousie Law Journal. 2018(Issue 1):59.

12. Winnington R. Patient choice as illusion: Autonomy and choice in end-of-life care in the United Kingdom and New Zealand: University of Auckland; 2016.

13. Gamondi C, Pott M, Preston N, Payne S. Family Caregivers' Reflections on Experiences of Assisted Suicide in Switzerland: A Qualitative Interview Study. Journal of Pain & Symptom Management. 2018; 55(4):1085–94.

14. McDougall R, Hayes B, Sellars M, Pratt B, Hutchinson A, Tacey M, et al. ‘This is uncharted water for all of us’: challenges anticipated by hospital clinicians when voluntary assisted dying becomes legal in Victoria. Australian Health Review. 2019.

15. Kheriaty A. Social Contagion Effects of Physician-Assisted Suicide: Commentary on "How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?". Southern Medical Journal. 2015; 108(10):605–6.

16. Jones DA, Paton D. How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide? 2015. p. 599–604.

17. Posner RA. Aging and old age. Chicago: Chicago University Press; 1997.

18. Assisted Dying Bill. Sect. Columns 775, 905 (2015).

19. Shariff MJ. Assisted death and the slippery slope-finding clarity amid advocacy, convergence, and complexity. 2012. p. 143–54.

20. Halliday S. Comparative Reflections upon the Assisted Dying Bill 2013: A Plea for a More European Approach. Medical Law International. 2013(Issue 2–3):135.

21. Yin RK. Case study research : design and methods. 5 edition. ed: SAGE; 2014.

22. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006; 3(2):77–101.

23. Corbin JM, Strauss AL. Basics of qualitative research : techniques and procedures for developing grounded theory. Fourth edition. ed: SAGE; 2015.

24. Holloway I. Qualitative research in nursing and healthcare. Fourth edition. ed: Wiley Blackwell; 2017.

25. Denzin NK. Triangulation 2.0. Journal of Mixed Methods Research. 2012; 6(2):80–8.

26. Dyer O, White C, Rada Aser G. Assisted dying : law and practice around the world. BMJ: British Medical Journal. 2015; 351.

27. Hendin H, Foley K. Physician-Assisted Suicide in Oregon: A Medical Perspective. Michigan Law Review. 2007(Issue 8):1613.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

The End-of-Life Choice Bill has now passed its third reading in the New Zealand Parliament, which takes the final decision on this divisive legislation into the public arena as the End of Life Choice Act (EoLCA).1 An individual’s choice to die should not be dismissed in terms of self-determination at this point in their life; however, concerns arise when families, healthcare practitioners and communities experience social consequences of actions taken.

The overriding discourse in countries where assisted dying (AD) is legal or under consideration concerns individual emancipation from the perspective of human suffering.2,3 Although the use of AD legislation may liberate individuals from perceived suffering, it is necessary to consider the impact embracing a new means of dying may have on families and the wider community.3 This case study interview of a self-identified individual who had experienced AD from a family perspective (in a country where it is legal) exposes a range of issues that require further debate that go beyond the rights of individuals to choose this option to relieve suffering. This paper focuses on three key concepts: that AD will become an expectation for others to pursue when unwell and potentially facing a life-threatening illness; stigma associated with using AD; and the potential for AD legislation to produce a contagion effect. The participant also raised problems with the process of AD, but this was outside the scope of this paper.

Background

The process of dying has become taboo for contemporary Western societies; it no longer naturally enters life’s discourse and has become feared as a form of human failure.4,5 This anxiety over death suggests that we have forgotten ‘the majesty of death’, in that lives that have been lived well should be rejoiced and celebrated.6 However, in contemporary Western cultures, death remains invisible, until frail, older, disabled or unwell people become a physical, social and financial burden on their communities.3,4,7 The next cohort to die includes the baby-boomer generation. It has been suggested that this will change the landscape of how death will occur, as this generation has experienced life through the lens of individualism and perceived freedom of choice and may therefore expect death to be similar.8

Despite the prevalence of right-to-die narratives that support those who are concerned about loss of dignity and quality of life, medicine (in collaboration with law) has maintained an unwavering stance that the right-to-die produces a ‘slippery slope’ effect, whereby some patients may be obligated to terminate their lives prematurely.9–11 This can be seen in the Netherlands, where one in 30 individuals died by euthanasia in 2012 compared with one in 90 in 2002.3 Such changes could suggest that right-to-die campaigns, despite the potential to alleviate individual suffering, have the potential to turn death into a duty for those of frail status, perhaps pressuring some individuals into ending their lives prematurely to fit with societal expectations that caring for our dying is burdensome and pointless.12

Another emerging issue is that there is a real possibility of stigma in some cases where AD has been used.13 More specifically, some family members found that disclosing use of AD as a mechanism for death was problematic, as they feared the reactions of other people and feeling judged.13 However, such stigmatisation is not solely the domain of family members but is also relevant for clinicians, who may not discuss participation in AD services for fear of professional stigmatisation and conflict with colleagues (although the latter is not discussed in this paper).14

Despite the potential for those using AD legislation to be judged or stigmatised, there is further concern that AD may produce a contagion effect.13–15 Jones and Paton observed that unlike some studies that perceived AD as providing a suicide-inhibiting effect, their results suggested that any inhibitory mechanisms were counteracted by “equal or larger opposite effects”.16–18

The potential for a contagion effect is also a concern in the New Zealand context, particularly if legislative boundaries slip thereby easing restrictions around eligibility. Research suggests that globally, similar bills have initially restricted eligibility to those with terminal illnesses to make AD more palatable, but the eligibility criteria subsequently became more flexible.19 Shariff suggested that a crucial aspect of such criteria is clear boundaries and limits that reflect the underlying justifications for assisted dying.19 Therefore, it is important to maintain “robust safeguards [that do not] become ritualised practices of verification”, and ensure compliance is not “reduced to ticking items off a checklist”.20An example of how quickly the contagion effect can occur is the 14-year-old girl (Valentina Maureira) from Chile who used YouTube to request assisted suicide, and subsequently admitted she got the idea after hearing about the assisted death of Brittany Maynard in Oregon in 2014.15 Therefore, the provision of positive role modelling of AD practices may normalise or even promote this means of death unless assisted deaths are protected by rigorous legislation that supports those involved. Such normative practices are evidenced in the Netherlands, where AD is now becoming the most prevalent mode of death for patients with cancer.3

Method

This study used the Yin case study approach to undertake a single semi-structured in-depth interview with a participant who self-identified as having first-hand experience of AD from a relative’s perspective (in a country where this is legal).21

The case

This study examined a specific case of an individual whose relative had accessed and used AD in a country where it is legal.21 The death occurred 12 months before the interview took place. The narrative depicted a situation where the individual concerned had a chronic and progressive illness, which had a mental health component. He was a highly educated scientist who was still relatively active and was able to mobilise around parks and reserves. Family members had noted some decline in his physical ability, but nothing unusual for the individual’s age (mid 70s). Some family members lived close to the individual while others were located overseas. The news of the individual choosing AD had not been discussed, except with the spouse, before the announcement of a date being set for the death, giving immediate family (spouse and siblings) only two weeks to prepare for the event. The interview participant was married to one of the siblings. The family of this individual, except for one child, all lived in the same country where AD is a legal option.

Data collection

The interview was conducted in a private setting to maintain confidentiality, and audio-recorded with the participant’s consent (questions in Appendix). The audio recording was transcribed verbatim by the primary investigator (RW). All names and references that had potential to identify the participant were changed. The interview transcript was member-checked and agreed as being accurate before dissemination to the research team for analysis.

Data analysis

Thematic analysis was used to interpret the narrative and identify trends and patterns emerging from the data.22 This was particularly pertinent given the conceptual nature of this study in an emerging field of research interest.23,24 The interview transcript was read by RW and RM, and coded separately. Thereafter, coding was discussed among RW and RM to determine themes emerging from the research, with the triangulation between the two reviewers improving the study rigour.25

Ethical considerations

Ethical approval was obtained from the Auckland University of Technology Ethics Committee (AUTEC), reference number 19/170. Written and verbal consent was obtained from the participant.

Findings

This paper discusses three key themes that emerged from the interview: AD becoming an expectation for others to pursue when unwell and potentially facing a life-threatening illness; the notion of stigma associated with using AD legislation; and the potential for such legislation to produce a contagion effect.

Life value and expectation to use AD

In considering the burden and expectations with regard to AD legislation, there appeared to be a shift in terms of where the burden sits. Life value was questioned, with the notion of being burdensome transferring to those still living, in that AD may become a future expectation for them. This was evident when the participant said:

“[AD] sets a precedent around suffering and even the value of living and life…and in a family that has some individuals who have chronic health issues…I’m thinking of what they’ll face years from now—they’ll have to make a decision about what their value is to society. What is that going to mean…when I become disabled to the point where I can’t do anything?…I think it means I’ll have to [use AD] and if it came through and they thought it was the right thing to do, I would do it.”

The participant had a chronic medical condition, and following the above comment, he was specifically asked “Do you feel like that’s something you would have to consider?” He responded, “I think it’s in my future, I can see it now”.

Stigma

Stigma can occur on both sides of AD legislation, with doctors and nurses being stigmatised whichever decision they make regarding service provision. The participant suggested that judgement exists even when the legislation is legal. He noted that despite a growing number of individuals using AD, they often fail to inform wider family and friend networks that they intend to use, or have used this legislation. For example,

“In terms of what it means for a family…is now…all this unspoken stuff happening. It’s hard…you know when they asked their kids [sic] not to tell their spouses. They just wanted him to have [appeared to have] died [naturally].”

In this instance, the person’s wife and siblings knew but were explicitly told to not tell anybody else, including partners, because

“…they were fearful of judgement…it might be legal but you know, so is marijuana now and there [is] plenty of society that thinks it’s shameful.”

The participant went on to note that two of his father’s friends had used AD legislation in the same 12-month period. Despite having had a life-long close relationship with one particular friend, that friend did not want to talk to his father about AD:

“He didn’t talk to my dad much, didn’t wanna [sic] tell my dad what was happening [AD]. [He said] ‘I don’t wanna [sic] talk to anybody, I don’t wanna [sic] talk to you. I can’t, I can’t talk to you about this [AD] right now, I can’t talk to you’. And hung up.”

AD as contagion

The participant hinted that there may be a contagion effect at play, as he had known three extended family members use the legislation over a short period of time.

“I don’t know if I told you this but two other extended family members have now gone through this [AD].”

He also noted that he was,

“…worried about my dad now, because he’s now had two people close to him make the decision [to die] and he’s like, I didn’t even know that people make those decisions—now he knows…I guess I worry it’s…I don’t think cancer is the right word…but I worry that its infectious.”

Discussion

In conducting this study, it was anticipated that social consequences of AD legislation may be present in terms of the slippery-slope discourse.10,11 However, it was unexpected to obtain data that painted a distinct picture of how the slippery-slope effect was unfolding in a country where AD was legal. While the right of individuals to choose assisted dying in some instances may be appropriate, evidence from this study must be factored into the New Zealand debate before the referendum on the End of Life Choice Act in 2020.

This study clearly showed how experiencing AD through a relative’s lens and by partial engagement with AD can impact broader family and friend networks, in a similar way to that observed by Gamondi.13 This was witnessed through the identification of the burden shifting from the physical and financial dimensions of care, towards AD becoming a future expectation for extended family members. This potential consequence of AD legislation reduces our future existence to being considered only through the practical lens relating to the cost of care and reduces our life to having a dollar value, as opposed to AD alleviating the fear of indignity, pain and suffering at end-of-life.

The results highlighted how AD remains contentious, irrespective of legality, which was demonstrated through the secrecy surrounding the participant’s relative’s death in terms of not including extended family members in decision-making, and not informing family friends of the cause of death.26 This family’s behaviour was similar to that reported by Gamondi, thereby offering further real-world clarification that using AD can have a stigmatising effect.13 However, despite such secrecy, the participant expressed concern that AD may be ‘infectious’. This was consistent with Kheriaty, who observed that exposure to the idea of AD can lead others to seek such assistance, thus the effects of legislation will require close and transparent monitoring to avoid this outcome.15

With these indicative social consequences comes the concern that the legalisation for AD in New Zealand has potential to fracture family and community structures, and the fracturing of such social networks may be difficult to repair in the aftermath of AD. For example, the participant suggested that:

“There are going to be fractured families, where someone is feeling like they’re a burden, they don’t have the support of their family, so their likelihood of making a decision…I believe [it] will be much easier for them to say ‘I’m alone anyhow, nobody cares…there are a lot of reasons to quit, a lot of reasons to go to sleep’.”

Such a notion was also depicted by Hendin and Foley, who considered lack of family support was a contributing factor to using AD.27 They described a case where ‘the eagerness’ of an older woman’s daughter and son-in-law was thought to have possibly influenced her decision to take ‘suicide pills’. Therefore, when considering such scenarios, we must also consider the potential of fracturing of our New Zealand communities and broader social settings. Even if we can ‘fix’ such fractures after AD is legislated and implemented, we may not be able to return them to their former status, thereby changing the supportive and intimate nature of the New Zealand social landscape. It is, therefore, imperative that should AD legislation be supported in the forthcoming referendum, it is introduced safely to support those who wish to access it, but simultaneously protects our vulnerable populations.

Conclusion

The introduction of AD legislation into New Zealand culture provides a potential hotspot for family, community and social discord that may not be easily remedied. There remains ongoing debate with regard to the slippery-slope effect of this legislation globally. However, this case study offers insight into some elements associated with slippage in terms of family members being expected to die when their care becomes too difficult or expensive. This study also suggests that as New Zealand moves forward with the EoLCA referendum in 2020, further study is required to investigate whether a contagion effect of AD is possible (or even probable), and how as a society, we negotiate what will be a conflicted pathway potentially complicated by prejudice, judgement and stigma for those who actively seek solace from indignity and suffering.

Although this is a singular case study, it exposes an individual’s experience of AD in a country where it is legal, and the issues faced at a grass roots level. It offers some evidence as to what occurs in the reality of AD legislation, and how it impacts beyond the immediacy of relieving individual suffering, and extends that suffering into realms that have not yet been adequately investigated.

Appendix

Interview questions/structure

1. The phase one case study will comprise of a loosely semi-structured interview to allow for free-flowing information regarding this under-researched field of interest.

2. Tell me about your story of assisted dying (this is a broad introductory question to get a feel for what happened)

3. Why did your family member choose assisted dying?

4. What are your experiences of involvement with the decision-making process for your family member?

5. Tell me about the process that occurred when your family member actually went to the clinic for the assisted dying.

6. What happened after their death?

7. How do you feel now about assisted suicide?

8. How do you feel about the possibility of a bill supporting assisted dying being passed in New Zealand? (If appropriate).

Summary

Abstract

Aim

To consider the possibility of consequences beyond the alleviation of perceived individual suffering, for families left behind, communities and society as a whole should the End of Life Choice Act gain public support in the September 2020 referendum in New Zealand.

Method

This study used the Yin case study approach to undertake a single semi-structured in-depth interview with a participant who self-identified as having first-hand experience of assisted dying from a relative’s perspective (in a country where this is legal). Thematic analysis was used to identify themes and trends from the interview transcript.

Results

Three key themes emerged from the interview: the potential for assisted dying becoming an expectation for others to pursue when unwell and possibly facing a life-threatening illness; the notion of stigma being associated with the individual using assisted dying legislation and the family left behind; and that there may be the potential for such legislation to produce a contagion effect.

Conclusion

The introduction of assisted dying legislation into New Zealand culture provides a potential hotspot for family, community and social discord that may not be easily remedied. Further study in New Zealand is required to investigate whether a contagion effect of assisted dying is possible, and how as a society, we negotiate what could become a conflicted pathway potentially complicated by prejudice, judgement and stigma.

Author Information

Rhona Winnington, Lecturer, Department of Nursing, School of Clinical Sciences, Auckland University of Technology, Auckland; Rod MacLeod, Clinical Adviser Hospice New Zealand and Honorary Professor, University of Sydney Medical School, Sydney.

Acknowledgements

Correspondence

Rhona Winnington, Lecturer, Department of Nursing, School of Clinical Sciences, Auckland University of Technology, Auckland; Rod MacLeod, Clinical Adviser Hospice New Zealand and Honorary Professor, University of Sydney Medical School, Sydney.

Correspondence Email

rhona.winnington@aut.ac.nz

Competing Interests

Dr MacLeod is Clinical Adviser to Hospice New Zealand.

1. End of Life Choice Bill. In: Parliament NZ, editor. 2019.

2. Karsoho H, Fishman JR, Wright DK, Macdonald ME. Suffering and medicalization at the end of life: The case of physician-assisted dying. 2016. p. 188–96.

3. Wardle LD. A Death in the Family: How Assisted Suicide Harms Families and Society. Ave Maria Law Review. 2016:43.

4. Philippe A. Invisible Death. The Wilson Quarterly (1976). 1981; 5(1):105.

5. Gawande A. Being mortal : aging, illness, medicine and what matters in the end: Profile Books; 2014.

6. Kevin F. Qualified to speak: Rush Rhees on the (vexed) subject of euthanasia. Philosophy. 2013; 88(346):575.

7. Buckinx F, Rolland Y, Reginster J-Y, Ricour C, Petermans J, Bruyère O. Burden of frailty in the elderly population: perspectives for a public health challenge. Archives Of Public Health = Archives Belges De Sante Publique. 2015; 73(1):19.

8. Schuklenk U. Is Assisted Dying the Baby Boomers' Last Frontier? Bioethics. 2016; 30(7):470.

9. Hendry M, Pasterfield D, Lewis R, Carter B, Hodgson D, Wilkinson C. Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying. Palliative Medicine. 2012; 27(1):13–26.

10. Pestinger M, Stiel S, Elsner F, Widdershoven G, Voltz R, Nauck F, et al. The desire to hasten death: Using Grounded Theory for a better understanding "When perception of time tends to be a slippery slope". 2015. p. 711–9.

11. Jackson E. Legalized Assisted Dying: Cross Purposes and Unintended Consequences. Dalhousie Law Journal. 2018(Issue 1):59.

12. Winnington R. Patient choice as illusion: Autonomy and choice in end-of-life care in the United Kingdom and New Zealand: University of Auckland; 2016.

13. Gamondi C, Pott M, Preston N, Payne S. Family Caregivers' Reflections on Experiences of Assisted Suicide in Switzerland: A Qualitative Interview Study. Journal of Pain & Symptom Management. 2018; 55(4):1085–94.

14. McDougall R, Hayes B, Sellars M, Pratt B, Hutchinson A, Tacey M, et al. ‘This is uncharted water for all of us’: challenges anticipated by hospital clinicians when voluntary assisted dying becomes legal in Victoria. Australian Health Review. 2019.

15. Kheriaty A. Social Contagion Effects of Physician-Assisted Suicide: Commentary on "How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?". Southern Medical Journal. 2015; 108(10):605–6.

16. Jones DA, Paton D. How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide? 2015. p. 599–604.

17. Posner RA. Aging and old age. Chicago: Chicago University Press; 1997.

18. Assisted Dying Bill. Sect. Columns 775, 905 (2015).

19. Shariff MJ. Assisted death and the slippery slope-finding clarity amid advocacy, convergence, and complexity. 2012. p. 143–54.

20. Halliday S. Comparative Reflections upon the Assisted Dying Bill 2013: A Plea for a More European Approach. Medical Law International. 2013(Issue 2–3):135.

21. Yin RK. Case study research : design and methods. 5 edition. ed: SAGE; 2014.

22. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006; 3(2):77–101.

23. Corbin JM, Strauss AL. Basics of qualitative research : techniques and procedures for developing grounded theory. Fourth edition. ed: SAGE; 2015.

24. Holloway I. Qualitative research in nursing and healthcare. Fourth edition. ed: Wiley Blackwell; 2017.

25. Denzin NK. Triangulation 2.0. Journal of Mixed Methods Research. 2012; 6(2):80–8.

26. Dyer O, White C, Rada Aser G. Assisted dying : law and practice around the world. BMJ: British Medical Journal. 2015; 351.

27. Hendin H, Foley K. Physician-Assisted Suicide in Oregon: A Medical Perspective. Michigan Law Review. 2007(Issue 8):1613.

Contact diana@nzma.org.nz
for the PDF of this article

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