Voluntary Assisted Dying and Palliative Care — A personal reflection on faith, doctoring and a path forward

*The views expressed here are personal and do not reflect those of my employer and the organisations that I serve for in governance*

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I love running.

The open path ahead helps to bring focus to my often racing thoughts and the possibilities of what lies ahead always draws me forward (finishing!).

Where my eyes naturally focus tells me a great deal about my headspace, the burdens that I am carrying or the diatribes of self-doubt that I am trying to diffuse or a challenging question that I searching for answers to.

If my gaze is downcast, I usually know I suffering under the weight of decision but if it lifts to the horizon, I know that I am at peace within myself (and the run is usually easier!)

For me running is a spiritual experience. 

It is my time in solitude, connecting to the rhythms of my body, marvelling at our beautiful coastline and nature and most important of all, time alone conversing with my Creator in prayer.

As Phil Knight described in Shoe Dog, “if everyone were to run a couple of miles a day, the world would be a better place”. I certainly think so!

With my breath in sync and my heart rate steady, it has to be the oxygen flowing freely to my brain that brings me clarity of thought. I have found the resolution to many of my troubles and settled many displeasing thoughts with a good solid run.

Lately, however, there is one subject that occupies my mind more than others especially when I run, and that is about Voluntary Assisted Dying. This is because I know that my work in Palliative Care will be forever changed when this legislation becomes operational in July 2021 in Western Australia. 

Voluntary assisted dying has been at the front of my mind for at least the last six years ever since a well-meaning and well-intentioned previous patient of mine encountered legal trouble for importing Nembutal into Australia.

*Mr Ward and I talked in November 2020 and he granted me permission to write about our conversation and link to the news article*

In the safe space of my consult room, we discussed his views and his interesting life story long before this was ever news. I knew about his stance on Voluntary Assisted Dying, as we’d openly discussed his desire to end his life should he ever be diagnosed with a terminal illness and face a period of protracted and meaningless suffering. I understood his motives and had always found him to be an intelligent and engaging man and as his GP, I was more than happy to help him with his court woes with a character statement.

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One of the challenges that I have found about being a doctor is the skill of active listening. To truly listen is to be present (living in the moment and nowhere else and certainly not in the past feeling guilty or in the future, feeling worried). To truly listen is receive what another person is communicating, suspend your views and personal arguments and open your mind to understanding sometimes opposing and contrary views.

Over the last number of years of working as a doctor, I’ve learnt that some views and arguments may be extremely personal and intelligently constructed whilst others may be loosely held together and driven by the populist view of the day. But in all circumstances, I am learning to listen first and keep an open mind.

As I reflect, I like to think that I am the type of doctor who understands that my primary purpose is to help and serve my patients and that my personal views are held to one side. This has served me well especially when I have faced extremely challenging situations and dealt with complex interpersonal relationships.

The very essence of being a doctor is to provide high-quality medicine to anyone, regardless of who they are. In prisons, in homeless shelters, in the leafy beachside suburbs, in isolated indigenous communities, in detention centres, in war zones —doctors provide care to everyone, in any place at any time.

But there is one central and life-defining belief of mine that serves as the filter, the foundation and the very essence of my being and that is — my faith in Christ. 

This isn’t something that I can suspend or compartmentalise as it affects the way that I practice medicine. It is who I am, it is the foundation of my moral framework and my faith serves as the life-giving force that grounds me with wisdom, counsels and comforts me, softens my heart and leads the way for my short time here on earth.

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As I consider how I will professionally work in Palliative Care in Western Australia as Voluntary Assisted Dying laws become operational, my faith is central in helping to inform me. More specifically, it Jesus’s life that is my guide. 

Whilst the organisations that I work for and represent have decided upon their stance and are working towards their operational plan, this article reflects my personal view and how I will conduct myself professionally.

The foundation of my view is not purely based in academia nor is it an interpretation of legislation nor is it a thorough exposition of the etymology of Palliative Care, but it is formed first and founded on the centre of life — my faith in Jesus Christ before anything else.

My faith informs me 

It is plain to see that Jesus disliked religious people, zealots and those uncompromising in their strict strict application of the Jewish law. 

Jesus could see the weight that Jewish people were under. They wanted to do the right thing but their religious burden was heavy and exactingly scrutinised. For me, this is the definition of religion — rule-following, accumulation of good deeds to get favour and benefit from God, looking down on others and judging them but most important of all, living a life devoid of love and the saving grace that is represented by the cross.

This was not what Jesus taught or how he lived. Jesus always sought connection and relationship before anything else — he loved first (Grace is God’s characteristic attribute). Jesus was a friend and closest to those who were outcast from society and those who were struggling under the weight of religion. Jesus saw their eternal humanness first (that they were made in the image of God). He did not see their shortcomings or their lack of deeds as a barrier to his love. And if they wanted to follow him, it didn’t matter who they were and what they had done. They didn’t need deeds to follow him but rather faith in him as their Saviour and God.

Jesus saw their brokenness and he felt their suffering and he loved them for where they were in life. 

He met them at the bottom and did not judge their past but offered his hand of Grace.

Jesus lived his life as a reflection of his Father’s great love and his unlimited grace — and so should I.

Many of the patients who are referred to us are suffering and are deeply distressed. They do not need confrontation about their life choices or beliefs, they need care, connection and compassion first. Just as Jesus showed those who were burdened, diseased, outcasts and suffering.

To walk with someone who is suffering is to understand that we are standing in a sacred space — the very bottom of their existence. 

There is spiritual work happening here and if we are to truly help our patients, we must take off our shoes and shut up and listen. Judgement and piety are not welcome in the space of suffering. (Message Bible “Conversations” Job 11— Eugene Petersen)

“We must be quick to listen and slow to speak in the sacred space of suffering” 

Eugene Petersen — Conversations Job 11 (ref: James 1:19)

Our patients are longing for hope and in need of kindness. They need our love and they need our mercy. 

They need good quality Palliative care.

As a Christian doctor, my absolute purpose is to reflect the love of Jesus in EVERYTHING that I do. 

That is, when I enter a consult room, touch a patient to examine them, induce an anaesthetic or hold a family meeting, I bring the sweet aroma of Christ with me. I bring his love, his joy, his peace, his patience, his kindness, his goodness, his faithfulness, his gentleness and his self-control — wherever I go.

I am a human being in a relationship with Jesus Christ on this earth.

Because Christ lives in me, I bring his transcending peace, love and hope with me wherever I go.

Healing, wholeness and suffering

The end of life is an intensely spiritual journey for both the patient and the professional as they walk together towards healing. 

Now, how can a dying person be healed? 

Professor Mount Balfour defined healing as “a relational process that moves towards an experience of integrity and wholeness” that we as Palliative Care professionals can help to facilitate for our patients (Palliative Medicine 2003).

It is possible to die healed — not in the physical sense but within our spirit.

Spirituality does not necessarily mean religion. Spirituality is a connection to anything that helps us transcend “rise above or get through or find meaning” in the suffering that we are facing. 

Suffering being defined beautifully by Elisabeth Elliot as “having what you don’t want and wanting what don’t have”

Elisabeth Elliot (Suffering is never for nothing)

I believe that everyone has an innate spirituality that is unique and individual to them.

My Christian faith is the founding and absolute expression of my spirituality. And in the last days, weeks or months of a patient’s life, they may experience true healing by finding a transcendent connection in something that gives them hope and meaning and something that helps them find the strength to face their death. 

A farmer has an innate spirituality in his attachment to the land, his livestock, his crops, the beautiful landscape that he has spent all life working with. This is why many of our rural patients desire desperately to die at home, connected to their environment and landscape in their last days.

Our First Nation people are divinely connected to their land, to the spirits of their ancestors both past and present and to the healing power of being on country and using the earth and its bounty as medicine.

For others, their spirituality is expressed in connection with their family — finding forgiveness, experiencing closure, gathering around to share quality time and make memories before they die.

As a Christian, I believe firmly that true healing is found in accepting the saving grace and the salvation that comes from believing in Jesus’s birth, death and resurrection.

“I am the way, the truth and the life, no one comes to the Father except through union with me ” John 14:6 (TPT)

The one thing I know is this: 

If a patient of mine chooses Voluntary Assisted Dying, this will very likely be their way of finding healing — experiencing wholeness and integrity as they face declining health and their death and as they experience suffering that is unbearable to them.

This will be an expression of their spirituality — their beliefs, their connection, their hope in finding transcendence over their suffering and distress, that has led them here.

As a Christian Palliative Care doctor working in Palliative Care in Western Australia in 2021, I understand this. Whilst I may not agree with this position and expression of healing, it is not personal and it is not an attack on me or my faith and it isn’t even about me! 

And as I see this reflected in Jesus’s life. Even though he offered his hand of grace and pointed many towards eternal life, there were people that didn’t follow him. This is the nature of free-will given to us by God – to choose.

Suffering, meaning and the cross

The pointy end of voluntary assisted dying is relieving the experience of suffering and its threat to a person’s dignity, integrity and their sense of self.

The Victorian experience supports the view that the people who have chosen VAD did so because of a loss of autonomy and dignity and the inability to engage in meaningful activity anymore — the indispensable quality of suffering.

I love the simplicity of Elisabeth Elliot’s thoughts on suffering. Her story startles many as to how one woman can endure a life of repeated tragedy and unimaginable suffering, but continue on with a joy that wasn’t defined by her circumstances but by her faith in a wonderful God. She brought clarity to many about the meaning of suffering in work and life.

“Suffering is having what you don’t want and wanting what don’t have” 

Elisabeth Elliot (Suffering is never for nothing)

Suffering fascinates me because it has been the refining fire of my life and in the lives of many others, I know and have read about.

Nothing tests us or pushes us to think about who we really are and what we believe in when the comfort, plans, hopes and dreams of our lives are threatened and taken away.

The many religions of the world acknowledge suffering as a certain inevitability and to encourages believers to embrace suffering as a means of growing in faith and in oneself.

But without the framework of religion, an individual must look for meaning in their suffering in order for them to find hope and to transcend their circumstances. And in this, find healing and wholeness as they face the end of their life. 

I acknowledge that as I have thought deeply about Voluntary Assisted Dying, I understand that this may provide healing and wholeness for some as they face intractable suffering.

As a Christian, the centrality of my faith is inseparable from suffering. The cross represents Jesus’s suffering and his ultimate death. But it didn’t end there! 

His resurrection and life after his sacrifice on the cross represents his glory, his power and his victory over evil. And for me, my faith in Christ guarantees a personal and perfect relationship with God which allows me permanent access to God’s marvellous kindness, his unfailing love and his strength and peace in the midst of my suffering. This is the hope and certainty that grounds my faith and allows me to know that suffering is going to be part of my life here on earth but that suffering is never for nothing.

My Professional view on Voluntary assisted dying and Palliative Care

As a Palliative Care Doctor, it is my personal and professional view is that Voluntary Assisted Dying sits outside the definition and purpose of Palliative Care. Our purpose as a speciality is never to hasten or cause death but much more than that, my faith informs my practice.

Voluntary assisted dying is not Palliative Care

— Dr Jonathan Ramachenderan (February 2021)

As Christian Palliative Care Doctor, I believe that Palliative Care continues until the moment our patient’s lives are extinct and that INCLUDES those who choose Voluntary Assisted Dying.

As a Christian, I value life and understand that everything that happens for a reason. But most importantly, I believe that our life and times are in God’s hands as he numbers the days of our life.

For me and many other believers, there is meaning in suffering. There is meaning in the disappointments of life. There is meaning in a terminal diagnosis. And should I perish suddenly tomorrow or have an illness with protracted suffering — there is meaning and purpose to it beyond our human understanding.

So we are convinced that every detail of our lives is continually woven together to fit into God’s perfect plan of bringing good into our lives, for we are his lovers who have been called to fulfil his designed purpose — Romans 8:28

I believe and live confidently knowing that every challenging experience that I have faced in my past, had a meaning and purpose attached to it — if this how we choose to view it.

“Life is never made unbearable by circumstances, but only by lack of meaning and purpose” — Viktor Frankl

One thing that I have learned in my 40 years on earth is that I am an apologist. Through my writing and life, I uphold and celebrate my faith and in my professional life, I am a Palliative Care apologist as I uphold the value and benefit of Palliative Care.

In Western Australia, Voluntary Assisted Dying will become operational in July 2021. 

How do we defend our speciality? 

How do we preserve the value that we ascribe to in providing excellence in social-spiritual-psychological and physical care? 

More importantly, for those of us at the front line, how do we serve as Palliative Care professionals who are conscientious objectors to Voluntary Assisted Dying?

As I ran between Middleton Beach and Emu Point in COVID covered April 2020, three words came to divinely rest on my heart:

 Justice, Mercy and Humility.

I know that as Palliative Care professionals working with Voluntary Assisted Dying, we are ALL called to:

 “To act justly, love mercy and to walk humbly” — Micah 6:8

Act justly

Justice suggests to me that despite our personal view, to act justly is to recognise the law of our State. In Western Australia, legislators have passed Voluntary Assisted Dying as law and some of our patients will choose this. 

Their minds, their story and world view, will lead them to find healing and rest in having the freedom and peace to end their lives on their terms — and that is okay, this is now the law.

Justice is THEIR freedom to decide. It is nothing personal against Palliative Care or my faith — it is justice for them. Whilst I believe that Voluntary Assisted Dying does not sit within the practice of Palliative Care, the law now permits this to be part of end-of-life care.

Jesus knew that there would be some who would not follow him, that his words and truth would not find fertile ground to grow in their hearts. Even though he loved them deeply on this earth, he knew that he would not see them in eternity.

I choose to act justly, to give my patients who choose Voluntary Assisted Dying my very best, to bring my full attention and presence of mind to them and their plight — they are image-bearers of God who are suffering.

Love mercy 

To love mercy is to bring our attention to try and understand and assess our patient’s suffering and to offer kindness, compassion and our expertise.

Whilst we may not agree with what our patients have chosen, the essence of loving mercy is to see beyond that. To love mercy practically is to serve our patients who do choose Voluntary Assisted Dying, with good Palliative Care until the moment their heart stops beating. Whilst I will not participate in the assessment process, the prescribing or administering of medication that ends their life, I will provide them with good evidence-based Palliative Care and refer them to an excellent colleague who is a registered Voluntary Assisted Dying provider.

To love mercy is to walk with our patients towards healing —  to experiencing dignity in their last days, weeks and months. To finding wholeness in their human existence — a connection that helps them transcend their suffering, that they do not die broken, detached, raging in their spirit, but that they find peace. Whilst I may not participate in the process of their voluntary dying, Palliative Care is present to help them until that fateful day and their families after.

Walk humbly

To walk humbly is to set aside any overblown sense of importance, self-righteousness and the belief that our (my) view stands superiorly above — this is the essence of religion, not a relationship with God.

To walk humbly is to accept referrals for wonderful, beautiful and gorgeous patients who we will grow to love! Who will make us laugh till our sides hurt, who will cook us lunch and demand that we drink champagne with them at 11:00 am on a Wednesday but who will one day, end their lives sooner than we would have liked or expected — and that is okay, it was their choice to make. 

It isn’t personal or about us or the practice of Palliative Care — it was their choice.

While we personally will not be okay and while we may need to grieve, time to cry and need space to not have it together, to walk humbly is to understand that this is a normal outpouring of emotion. It will find us when we least expect and it will suck!

To walk humbly is to understand that our speciality of Palliative Medicine in Western Australia is about to change and that this will challenge us. It is going to cause unrest and it may cause us to unravel and experience deep sadness. 

To walk humbly is to gather a support network, make debriefing a regular part of our week, find a professional supervisor and create a sacred space for self-reflection and spiritual self-care.

Love

Love

Love is the basis and purpose of life.

In a dying person’s world, family and connection are all that matters — who they love and who loves them.

Love is not a feeling. 

Love is a practical word. That is because to truly love someone or something we make a “choice” to do so which is usually accompanied by action.

Love always “does” something. 

In this space, the Voluntary Assisted Dying space, I choose to love. 

Love chooses to act justly, to love mercy and to walk humbly.

The Palliative Care world I see in 2021

In 2021, I choose to serve my patients who choose Voluntary Assisted Dying by loving them by giving them my best. 

It isn’t a waste of my time or our resources and whilst I will not be participating in their death, when they are alive and dying I choose to act justly, love mercy and walk humbly with themby providing the best Palliative Care that I can.

This is my personal perspective on my professional life and it is about to change and that is okay with me. 

As a Christian, I am called to be an ambassador of Christ in this world — to be in this world but not of it. This means that whilst Voluntary Assisted Dying has been made available in Western Australia, it will certainly not be a clinical practice that I, Dr Jonathan Ramachenderan will participating in. 

I will provide Palliative Care for patients who choose Voluntary Assisted Dying in the organisation that I work and serve in governance over for and I will work closely with them as a conscientious objector to uphold the values of others that do not ascribe to Voluntary Assisted Dying.

“Work with” is defined for me as Palliative Care until the moment an injection is given/or tablet is taken to end a person’s life. It may happen when I am working within the facility that I am associated with but it will certainly not be a practice embedded into my practice of Palliative Medicine. Referrals to a Voluntary Assisted Dying provider and meaningful and respectful goodbyes will be my operational methods in this space.

What we are learning from our Victorian colleagues as we consult with them, is that to break the relationship with a patient and their family at the point of their voluntary death is shattering for both the patient and the staff who have grown to love, support and care for them. Voluntary Assisted Dying will never be Palliative Care core business for me and for others I suspect, but love does not push away those who need our comfort and care even though we respectfully disagree — Jesus’s life is my example here.

My faith is the cornerstone of my life and each day I move closer to coming home to be with my Father. God is not worried. God is not frazzled. He isn’t frantically thinking about how to manage this! He is God and everything is in his hands. All things work for our good and for his glory. 

And with that, I look forward to stepping into this new space. I choose to learn and keep getting better as a doctor. I choose to love and I choose relationship. I choose to keep killing it at life (pun not intended) and experiencing joy.

Thank you.

Live always with intention.
Love relentlessly and find meaning.
Enjoy your health.

Dr. Jonathan Ramachenderan
@thehealthygp
October 2020