South Australian Joint Committee on End of Life Choices Submission

This submission will provide content on each of the terms of reference of this inquiry.

We submit that it is not desirable to legalise assisted suicide in South Australia because it is opposed by medical professionals, in particular those involved in end-of-life care, it is bad public policy, it disproportionately affects the most vulnerable, and overseas experience demonstrates that once legalised, euthanasia and assisted suicide increasingly puts more people at risk.

Opposed by medical professionals

Opposition from medical associations

In 2016, the Australian Medical Association (AMA) affirmed its position on euthanasia and assisted suicide to be that ‘doctors should not be involved in interventions that have as their primary intention the ending of a person’s life.’[1]  

The World Medical Association (WMA) is also opposed to euthanasia and assisted suicide. Its position statement reads: “Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession.”[2] During the Victorian parliamentary debate for the introduction of euthanasia and assisted suicide in that state, the WMA directly petitioned the Victorian Legislative Council, asking it to reject the legislation.[3]

Across the world, 107 of the WMA’s 109 constituent National Medical Associations oppose euthanasia and assisted suicide.[4]  This number includes medical associations in jurisdictions where assisted suicide has been legalised.

Opposition from palliative care specialists

Those who work in end-of-life care in Australia are overwhelmingly opposed to euthanasia and assisted suicide. 

When Victoria and New South Wales were each considering legalising these practices, 101 Australian palliative care specialists signed an open letter[5], asking for the rejection of the legislation and petitioning for adequate resources to help them to care for those at the end-of life.  A joint statement from palliative care physicians was also submitted to the recent inquiry into end-of-life choices in Western Australia.[6]  Additionally, these specialists refuted the active and deliberate undermining of their work by euthanasia advocates in an effort to push these laws through.  The contents of this letter will be discussed later in this submission.

The Australian and New Zealand Society for Palliative Medicine also opposes euthanasia and assisted suicide.[7]

Opposition from geriatricians

President of the Australian New Zealand Society of Geriatric Medicine (ANZSGM) Queensland, Dr Chrys Pulle, told the parliamentary committee in Queensland considering end-of-life choices that ANZSGM, which has more than 1200 members, is “deeply concerned about the potential consequences of legalising voluntary assisted dying, as it portrays “a conflicting public health message that suicide is the preferred option in certain circumstances, placing pressure on frail older people who may feel they’re a burden on others.”

He also said that the introduction of euthanasia and assisted suicide would change the “concept of doctors being treaters, life savers and healers as espoused in the Hippocratic Oath to being providers of life-ending services,” noting it would “impact on the doctor-patient relationship, especially towards the end of life.”[8]

Opposition from medical professionals more broadly

At the time of making this submission, 670 medical professionals in Australia have put their name to a petition, affirming the position of the AMA and WMA on euthanasia and assisted suicide, and opposing its legalisation in Australia.[9]  The concerns raised by the petition, these medical professionals include:

  • assisting a person to suicide would “fundamentally weaken the doctor-patient relationship”;
  • the protection of the vulnerable “who can feel they have become a burden to others”;
  • the “strong evidence to the inherent lack of safety and proven abuses where physician assisted suicide and euthanasia laws exist”,

and declare instead that governments should focus instead on addressing “social, medical, palliative care and mental health service inequity in our society,” particularly in regional Australia.

Euthanasia and assisted suicide are bad public policy

A change in law affects the whole of society

Proponents of euthanasia and assisted suicide often ground their arguments in personal autonomy, that is that they should be free to do as they wish with their own bodies and lives, and that their personal decision affects no one else.  On deeper reflection however, it is clear that while death is personal, it is not private, and a decision to allow state-sanctioned suicide affects more than just the individual involved. 

The act of euthanasia or assisted suicide necessarily involves others, including the doctor prescribing or administering the lethal medication, legislators and bureaucrats, as well as family and friends of the person concerned.  It also has flow-on effects for other members of the community in terms of the quality of care available to them.

Effect on medical professionals

As stated in the Minority Report of the Legal and Social Issues Committee Inquiry into end of life choices - Final Report in Victoria:

“…in both euthanasia and assisted suicide, the ethical dimensions are inherently more complex since third parties are necessarily involved. It is not enough to assert a belief in the individual’s right to autonomy.  Any system of regulated euthanasia or assisted suicide must involve the active participation of members of the health profession and possibly also other regulatory arms of the state.”[10]

With respect to the medical professionals involved, a review of published research and testimony from medical professionals in jurisdictions where assisted suicide had been legalised found that “physician participation in assisted suicide or euthanasia can have a profound harmful effect on the involved physician,” including a “large psychological toll.”[11]  The same literature review also found that physicians reported feeling ‘intimidated and coerced by the family’ of a patient to participate in the assisted suicide.

These effects are demonstrated with the decline in doctor support of euthanasia from doctors following its legalisation.  A survey of Canadian doctors showed that, prior to the legalisation of assisted suicide in that country, 78 percent of doctors expressed a willingness to be involved in assisted suicide.  These numbers have now inverted, with 77 percent now claiming a conscientious objection to killing a patient.[12]

The impact is not only on doctors, but on others involved in medical care.  In an essay providing front-line observations of 14 years of euthanasia in Belgium, oncologist, Professor Benoit Beuselinck, noted that nurses and social workers in palliative care units have left the practice, as patients are increasingly referred to palliative care units for euthanasia.[13]

Effect on the choice of others

The exercise of one patient’s “personal autonomy” can affect the choices available to others.  In Oregon and California, where assisted suicide is legal, there have been reports of insurance companies denying cover for cancer treatment, but offering to cover the cost of assisted suicide instead.[14]  There have even been reports of insurance companies in California and Oregon refusing transfers to hospitals for treatments for non-terminal patients without which, the patients would become terminal, and then proposing assisted suicide to the referring physician.[15]

In a poignant example, Californian mother of four Stephanie Packer was diagnosed with a terminal form of scleroderma.  Ms Packer reported that her insurance company approved a chemotherapy drug, only to deny coverage once the assisted suicide law passed.  Ms Packer explained the effect on her own choice:

“You allowing those patients to make that choice affects me negatively and it affects my fight and my ability to stay here longer with my children.  I want to carry on.  I want to do everything I have to have one more second with my kids and as soon as this law was passed… patients fighting for a longer life end up getting denied treatment because this will always be the cheapest option. End-of-life care is the most expensive care everywhere.”[16]

Ms Packer’s experience is supported by the 7.3 per cent of Oregon assisted suicide patients who last year cited “financial implications of treatment” as a reason for requesting assisted suicide.[17]

The cost of end-of-life care and the potential savings of providing lethal drugs to patients in their final year of life has also been commented on in the academic sphere.

Researchers in Ontario found that the average health care cost in the last year of a person’s life was $53,361, and that the costs “rose sharply in the last 120 days prior to death.”[18]  These researchers went on to state that caring for people in their final year of life occupies 10 per cent of the annual health care budget, despite the relevant group comprising only 0.67 per cent of the population.

The cost-effectiveness of euthanasia and assisted suicide was confirmed by other Canadian researchers who, less than a year after these practices were legalised, published research that found that such a regime “could reduce annual health care spending across Canada by between $34.7 million and $138.8 million.”[19] 

Dr Chrys Pulle told the parliamentary committee in Queensland considering end-of-life choices that “adverse effects on the funding for palliative care services and research,” and “an increase in the justifications for voluntary assisted dying and potential for abuse, for example costs-savings to the health system” could be foreseen if euthanasia and assisted suicide laws were passed.  He went on to say that “the Australian New Zealand Society of Geriatric Medicine’s view is that policymakers and funders of health care can best help patients by [ensuring] adequate provision and funding of high-quality palliative care and geriatric medical services rather than providing legislation allowing voluntary assisted dying.”[20]

The stories from persons affected and the evidence of medical researchers and professionals challenge the idea that euthanasia and/or assisted suicide are matters of personal choice, affecting only those who decide to end their own lives, and demonstrate instead that providing the ‘choice’ of death to some limits the choices available to those who do not wish to die.

Abrogation of state’s duty

One of the fundamental duties and responsibilities of government is to govern for all its citizens, and particularly those who are especially vulnerable, due to youth, old age, disability, infirmity or other reasons.  This duty extends to protecting its citizens from injustice and oppression.  All citizens have the right to expect that society will care for them from the “cradle to the grave”; that a government will provide adequate health care for every stage of life, not least of which when people find themselves at the end of their lives and are particularly in need of care. 

In a society where the state does not sanction the killing of its vulnerable, there is no dilemma that presents itself for an elderly person who finds themselves ill or in need of long-term care.  There is instead a presumption that the community will care for them in need. 

Providing an option, sanctioned by the state, that taking your own life in certain circumstances is legally permissible, fundamentally alters this social contract.  It transforms the non-negotiable rule that ‘you must not kill’ to one that states that ‘you may kill some people in some circumstances’ and removes the responsibility of the state – and the community more broadly – to care for those in need.

Disproportionate effect on vulnerable groups

Those susceptible to feeling like a burden

When suicide or the administration of lethal injections becomes state-sanctioned, an unintended consequence is that those more susceptible to feeling like they are a burden on others can feel pressure to request euthanasia or assisted suicide in order to alleviate this burden. 

This burden is not merely physical, but financial as well.  As mentioned above, the cost of end-of-life care is high, and can become a factor in end-of-life choices when appropriate treatments are not covered by insurance and require significant contribution from the patient or their family.

A dilemma immediately presents itself for the vulnerable person: should they impose themselves on society and demand appropriate health care, or should they do the ‘unselfish’ thing and request euthanasia or assisted suicide?

Palliative Care Victoria has also argued that the legalisation of euthanasia may lead to further pressure on the elderly and vulnerable in our society:

“There is a real danger that legalising euthanasia and/or assisted suicide will lead to a growing sense of a duty to die. Matters of life and death involve difficult and at times tragic choices.  It is the responsibility of public policy and law to advance the public interest and to protect those who are most vulnerable.”[21]

This risk identified by Palliative Care Victoria and others is also borne out by experience in jurisdictions where assisted suicide has been legalised.  In Oregon, 63.6 per cent of those who used the assisted suicide laws last year listed “burden on family, friends/caregivers” as a reason for requesting lethal drugs.[22]  This is more than twice the number of people who cited ‘inadequate pain or concern about it’ as the reason for requesting assisted suicide.[23]

Presenting euthanasia and assisted suicide as options for those who feel like a burden on others risks transforming a right to die into a ‘duty to die,’ and there are no legislative safeguards that can reliably mitigate for this type of coercion.

Those at risk of coercion and/or elder abuse

Australia, like much of the western world, has an aging population, with 23 per cent of the population expected to be aged 65 or over by 2055.[24]  Into the mix of issues that the ageing population presages is a most worrying trend: elder abuse. This can and does include physical, financial and emotional abuse, often at the hand of a relative. The World Health Organisation has estimated that in high or middle-income countries the rate of elder abuse ranges between 2% and 14%.[25]  The estimated number of those suffering elder abuse in South Australia is twice this number. According to SA Health, “every year, approximately 5% of older people will experience some form of mistreatment, abuse, neglect, by someone known and trusted to them. For every reported case, another five cases remain hidden and unreported.”[26]  The difficulty with the data is the simple fact that elder abuse is known to be under reported precisely because it is often perpetrated by a relative.

If the majority of elder abuse is perpetrated at the hand of a relative, it follows that it becomes more difficult to detect, because those being abused are often reliant on their abuser for their needs.  For this reason, the abuse could also occur over many years, with the resilience of the vulnerable person slowly being broken down.  In a jurisdiction where assisted suicide and euthanasia is legal, this could mean that those who had been subjected to a sustained period of elder abuse could be convinced to requesting that their life be ended.

It is not hard to imagine that a relative who has been systematically abusing an elder emotionally and financially could see euthanasia as the final (and most profitable) card to play for personal gain.  It is not hard to imagine someone who has been emotionally abused over time succumbing to the suggestion that they “do the right thing” once their frailty and ailments reach a certain point.

The Aged Rights Advocacy Service in South Australia has listed risk factors for elder abuse, a number of which are relevant to those who would be eligible under an assisted suicide or euthanasia regime, including:

  • changing dynamics as the older person becomes frail;
  • a shift in the role of the older person within the family;
  • physical, psychological, emotional or financial dependence;
  • physical or emotional dependence, or reliance on the abuser for transport or social contact; and
  • social isolation due to physical disability or frailty[27].

The ability for a carer to influence a dependent to choose death was demonstrated in a Queensland court last year, when Graham Robert Morant was found guilty and sentenced to 10 years imprisonment for counselling his wife to commit suicide.  In that case, Justice Peter Davis found that Mr Morant took advantage of his wife’s poor physical and mental health in order to persuade her to kill herself, and that he did so for financial gain.[28] 

This type of coercion is difficult to detect, and consequently impossible to safeguard against.

A recent parliamentary report on elder abuse in New South Wales also referenced the failure of professionals to identify undue influence and so unwittingly facilitated elder abuse.[29]  Undue influence is increasingly being seen as a relevant factor in the financial abuse of elders.  Seniors Rights Victoria provides a useful summary of case law and best practice on undue influence in the financial abuse of elders.[30]

The Seniors Rights Victoria report notes that “Capacity Australia” observed that financial abuse is often fuelled by ignorance and family conflict, as well as ‘inheritance impatience’… It further noted that undue influence by one family member over another is commonly facilitated by legal professions because of their failure to detect when an older person is struggling to manage their financial affairs, that is, when they lack financial capacity.”[31]  The report cited research that found lawyers “sometimes have a very limited understanding of the interview skills required to determine an older person’s capacity to appoint a power of attorney or enduring guardian, and that they are doing so free of undue influence.”[32]

In financial matters, the courts can apply the remedy of rescission if undue influence is established. However, in the case of assisted suicide, a failure to identify undue influence before writing a prescription for a lethal dose will be incapable of remedy once the lethal dose is ingested.

Indigenous Australians

There is a particular vulnerability for Indigenous Australians when it comes to end of life care.  One reason for this is the lack of palliative care options available for those in remote or very remote regions, a significant proportion of whom are Indigenous. 

In Australia, there are only three specialist palliative medicine physicians who work in remote areas of the country, and none who work in very remote regions.  Additionally, only 15 palliative care nurses work in remote areas and only 3 in very remote areas of the country, comprising just 0.5 per cent of the total number of palliative care nurses in the country.[33]  There is no data on how many of these operate in South Australia.

The 2016 census has revealed that 5 per cent of Australia’s Aboriginal and Torres Strait Islander peoples live in South Australia, with 14.6 per cent of these living in remote or very remote regions,[34] demonstrating that a lack of access to palliative services in remote regions has a disproportionate effect on Indigenous Australians.

The lack of specialist palliative and other medicine in remote and very remote regions, coupled with the seeming indifference to rectify this problem from euthanasia advocates, places Indigenous Australians living in South Australia in a particularly vulnerable position, and any move to legalise euthanasia and assisted suicide would have a disproportionate effect on this group.

Those with disabilities

A recent report from the UN Special Rapporteur on the Rights of Persons with Disabilities on her visit to Canada included the following observation:

“I am extremely concerned about the implementation of the legislation on medical assistance in dying from a disability perspective. I have been informed that there is no protocol in place to demonstrate that persons with disabilities have been provided with viable alternatives when eligible for assistive dying. I have further received worrisome claims about persons with disabilities in institutions being pressured to seek medical assistance in dying, and practitioners not formally reporting cases involving persons with disabilities. I urge the federal government to investigate these complaints and put into place adequate safeguards to ensure that persons with disabilities do not request assistive dying simply because of the absence of community-based alternatives and palliative care.” [Emphasis added.]

The observations of the UN Special Rapporteur align with the experience of disability advocates, who have opposed the introduction of euthanasia and assisted suicide because of the specific threat it poses to those with disabilities.

Former chief executive of UK-based disability charity Scope, Richard Hawkes, described the reasons for the opposition to euthanasia and assisted suicide as follows:

“If you are disabled, you all too often face the view that it’s not worth being alive, and that you’re a burden.  The ban on assisted suicide sends a really powerful messaging countering this view.  It has provided crucial protection to any person who feels under pressure to end their life.  Many disabled people will be worried by any steps that undermine this.”[35]

Polling undertaken by Scope showed that 64 per cent of persons with disabilities would be concerned by the change in law[36].

Those suffering from mental illness

“Depression raises the question about how the depression interacts with decision making. What safeguards need to be in place to protect people from making decisions that might be affected in the short term by a depressive mood that might be manageable or treatable with additional support? Great care needs to be taken where a person is suffering from depression and is seeking either euthanasia or assisted dying.”[37]

Despite the complex interplay between depression and other forms of mental illness, there is a reluctance to make the existence of mental illness a disqualifying factor for euthanasia and assisted suicide.  Under Victorian legislation, the relevant test is not whether a person has a psychological or psychiatric condition, but whether this condition affects their decision-making capacity. 

The presents a particular vulnerability for people who are suffering from potentially treatable mental health conditions, because the legislative safeguards do not require that these conditions be addressed before considering a request for euthanasia or assisted suicide.  Mental illness is no barrier to obtaining lethal drugs, unless it is severe enough to render the patient incapable of making decisions.  Indeed, in Belgium, “untreatable depression” has been a reason for granting a euthanasia request.[38]

The only jurisdiction which has required a psychiatric assessment for each case of euthanasia was the Northern Territory.  However, even with such a ‘safeguard’ in place, this system failed to adequately identify mental health issues which may have been treatable in all four cases of persons killed under the Rights of the Terminally Ill Act 1995 (NT).[39]

But even limiting mental health assessments to decision-making capacity alone presents issues.

Only 6 per cent of psychiatrists in Oregon reported being very confident that they could adequately determine whether a psychiatric disorder was impairing the judgment of a patient requesting assisted suicide in a single evaluation.[40]  Another study found that “physicians are not reliably able to diagnose depression, let alone to determine whether depression is impairing judgment.”[41]

The difference in care a patient receives when psychological or psychiatric care is not mandatory can best be illustrated in individual stories.

In 2011, Dr Charles J. Bentz of the Division of General Medicine and Geriatrics at Oregon Health & Sciences University referred a 76-year-old patient to a cancer specialist for evaluation and therapy. The patient, a keen hiker who was suffering from depression partly because he could no longer engage in that activity, expressed a desire for assisted suicide to the cancer specialist, who promptly asked Dr Bentz to be the second concurring physician to the patient’s request. When Dr Bentz declined and proposed that instead the patient’s depression be addressed, the specialist found a more compliant doctor to sign off on the request. Two weeks later the patient was dead from a lethal overdose prescribed under the Oregon laws.[42]

There is no model from any jurisdiction that has legalised assisted suicide and/or euthanasia for adequately ensuring that no person who is assisted to commit suicide or killed directly by euthanasia is suffering from treatable clinical depression or other forms of mental illness that may affect the capacity to form a competent, settled, determination to die by assisted suicide or euthanasia.

Those at risk of suicide

Following on from a discussion of the risks to those suffering from mental illness, it is important to consider the particular impact on those experiencing suicidal ideations.

Legalising euthanasia is problematic in a jurisdiction which on the one hand, invests considerable resources into suicide prevention, and on the other encourages suicide nevertheless for some of its citizens. 

The issue is also challenging from the perspective of suicide contagion,[43] given that once a jurisdiction legalises assisted suicide, the message conveyed by the law is necessarily a positive one about suicide in some circumstances.  The implications of this for citizens with suicidal ideation must be taken into account as part of the discussion around the consequences of legalising euthanasia and assisted suicide.

In its report, the WA Joint Select Committee attempted to dismiss this risk by citing criticisms of a study[44] that found the legalisation of assisted suicide with an increased rate of total suicides, but neglected to comment upon – or even acknowledge – data from Oregon that shows an increase in suicide rates since it legalised assisted suicide.[45]  In 2014, Oregon’s suicide rate was 43.1 per cent higher than the national average. These figures do not include the number of deaths related to the Death with Dignity Act, as these are not classified as suicides under the law in Oregon.

As Professor Margaret Somerville has asserted, “state sanctioned assisted suicide endorses suicide as an appropriate response to suffering and suicide is contagious.”[46] 

Overseas experience

Expansion of categories of people eligible for euthanasia

Overseas evidence clearly demonstrates that once a jurisdiction legalises euthanasia, the categories of people who can apply for euthanasia and assisted suicide expand:

“In the Netherlands, euthanasia is no longer restricted to competent adults with unbearable suffering able to provide informed consent. It’s now available to children, new born babies with serious disabilities, and people with dementia and mental illness, such as depression, without physical illness. There are movements to legalise access to inflicted death for people ‘over 70 and tired of life’ or who feel they have a ‘completed life’.  Likewise, after just over a year of legalised euthanasia in Quebec, there are calls for it to be extended to euthanasia on demand, that is, that there should be no requirements for access by a competent person.”[47]

The examples from overseas jurisdictions are too numerous to list exhaustively.  The extensions that are now accepted in other jurisdictions where once the law was changed to deal with a small minority of cases of unacceptable pain and suffering include the following cases:

  • The Swiss Group ‘Exit’ has voted to extend assisted suicide to those who ‘feel old’.[48] Swiss law allows euthanasia providers to establish their own internal rules and the group added ‘suicide due to old age’ to its statutes by way of an annual general meeting, ‘allowing people suffering from psychological or physical problems associated with old age the choice to end their life.’[49]
  • The 2018 statistics from Belgium recorded that 57 people were euthanised because they were suffering from mental or behavioural disorders only, 83 people were experiencing psychological suffering only, 345 were not expected to die in the short term, and 22 were not conscious at the time they were euthanised.[50]
  • In Colombia, euthanasia has been expanded to children over the age of 6, and parental consent is not necessary for those aged 12 years or older.[51]
  • A 44-year-old transgender man was euthanized because he was devastated by the outcome of his sex change operation.[52]
  • Psychiatric patients in the Netherlands are euthanised.[53]
  • The Netherlands, Belgium and Luxemburg allow euthanasia and assisted suicide for dementia, alcohol and drug addiction, mental illness and disability, and Belgium and the Netherlands have reduced age restrictions to include minors.[54] In Belgium, data from 2015 shows that 15 percent of euthanasia cases (299 deaths) did not involve people who were terminally ill.[55] 

Professor Theo Boer, a former supporter of euthanasia, has warned against legalising euthanasia, saying other jurisdictions should learn from the Netherlands. He is reported as saying:

“I used to be a supporter of the Dutch law. But now, with 12 years of experience, I take a very different view. Whereas in the first years after 2002 hardly any patients with psychiatric illnesses or dementia appear in reports, these numbers are now sharply on the rise.  Cases have been reported in which a large part of the suffering of those given euthanasia or assisted suicide consisted in being aged, lonely or bereaved.  Some of these patients could have lived for years or decades. Pressure on doctors to conform to patients’ – or in some cases relatives’ – wishes can be intense. Pressure from relatives, in combination with a patient’s concern for their wellbeing, is in some cases an important factor behind a euthanasia request. Not even the review committees, despite hard and conscientious work, have been able to halt these developments.”[56]

The WA Joint Select Committee acknowledged the expansion of categories of eligible patients in certain jurisdictions, but found that because Oregon had not done this, the ‘slippery slope’ argument could not be supported.  By this flawed logic, unless every jurisdiction had changed its laws, the risk need not be considered.  Since the publication of the WA report, legislation to expand the categories of those eligible for assisted suicide has been put before Oregon’s  House of Representatives.  If passed, House Bill 2903 will no longer require death to be imminent or even foreseeable for a person to access lethal drugs.  This would expand the remit of the assisted suicide regime to any disease from which a patient might die at some point in the future, including degenerative diseases.

The breaching of safeguards

Evidence from overseas jurisdictions clearly demonstrates that safeguards are routinely breached in jurisdictions where euthanasia and assisted suicide have nevertheless been enacted with the promise of strict ‘safeguards’.[57]

For example, despite one of the criteria for euthanasia in the Netherlands being the consent of the patient, the government’s own statistics website outlines that in 2015, 431 people were euthanised in that country without their explicit consent.[58]

In Belgium, a study of the practice of euthanasia in that country has found the following reasons given for cases where a patient was euthanised without their consent:

  • The person making the decision to euthanise decided it was clearly in the patient’s best interests (17% of cases);
  • Killing the patient was the wish of the family (more than half the cases); and
  • It was an unbearable situation for the family (38 per cent of the cases).

In more than half the cases reported as part of that study, the patient had never expressed a desire for their life to be ended.[59]

Increase in number of people accessing euthanasia and assisted suicide

Evidence from overseas jurisdictions confirms that once euthanasia and/or assisted suicide are legalised, the number of deaths increases significantly from the time it is introduced.[60] 

The number of deaths from ingesting lethal substances prescribed under Oregon’s Death With Dignity Act reached 135 in 2015, up 28.57% from 2014, continuing a steady rise since 1988, the first year of the Act’s operation when 16 people died under its provisions.[61]

For example, Washington State’s Death with Dignity Act came into operation on 9 March 2009.  The legislation is based on Oregon’s assisted suicide regime.  The latest annual report with data from 2016 was published in September 2017. The latest data confirms that once assisted suicide was legalised, use of it increased from year to year.  In 2010, the first full calendar year of operation, some 87 prescriptions for lethal drugs were provided under the Act.  By 2016 this had nearly tripled to 248.  Prescriptions for lethal drugs increased by 15% from 2015 to 2016. Deaths from lethal drugs prescribed under the legislation have nearly quadrupled from 51 in 2010 to 192 in 2016, increasing by 13.6% from 2015 to 2016 alone.

The Guardian reports that the ‘taboo’ against killing has been removed in the Netherlands,[62] and that ‘concerns have been raised that assisted death is becoming normalised.’[63] There were approximately 7,000 people euthanised by doctors in 2017, an increase from 4,188 cases of euthanasia in 2013.[64]  Amongst these were 148 people suffering from dementia, 67 suffering from psychiatric disorders and 205 people suffering from “an accumulation of old age disorders.”[65]

Canada has also seen a dramatic uptake of euthanasia occurring, despite it being legal for only three years.  Data from Health Canada shows that at least 2614 people were killed by euthanasia in the ten months between 1 January and 31 October 2018, equating to about one person dying by lethal injection every three hours.[66]

Alarmingly, this does not include statistics for the whole country.  Three of the Canadian territories, (Yukon, Northwest Territories and Nunavut), did not share any data for the relevant reporting period due to, in part, “concerns for the privacy of the patients and the providers involved.”[67]

Additionally, Quebec did not provide any data for the period between 1 April 2018 and 31 October 2018.  The data would likely have seen a noticeable increase in the reported numbers, given that in the nine months prior to 1 April 2018, 845 people were euthanised in Quebec alone.  According to Health Canada, this lack of data “will result in an under-reporting of numbers at the national level.”[68]

Even with the numbers being so drastically underreported, the rapid uptake of euthanasia use should be a cause for concern. 

Alternatives to euthanasia and assisted suicide

Opposition to euthanasia and assisted suicide does not equate to a wish, or even an acceptance, that people must die with unbearable suffering.  Instead, governments should focus their resources in forms of end of life care that provide people with choices other than death.

Australian palliative care is world-class

One of the most prominent reasons given by advocates of euthanasia and assisted suicide is the wish to assist people who are suffering from ‘intolerable pain’, or serious or incurable conditions, and whose suffering is not able to be alleviated in a way that the patient considers tolerable.

However, in 2019, it is rare for patients to be in this situation.  Palliative care has developed significantly in the past 20 years to the point where most, if not all, pain can be alleviated through appropriate palliative care.[69]  Indeed, Australian palliative care services are currently rated the second best in the world[70] and its specialists reject attempts by euthanasia campaigners to undermine public confidence in their work in an attempt to gain support for legalised euthanasia.

An open letter written to Members of Parliament by Australian Palliative Care Professionals pointed out the misconceptions surrounding palliative care, and affirmed that palliative care, in all but extreme cases, relieves pain and suffering for those with terminal illnesses:

“Current Australian data indicates that no more than 2 in every 100 Palliative Care patients would be in moderate or severe pain at the end of life. In these unusual cases where when all other methods of palliation for pain and other symptoms is inadequate, and if the patient agrees, palliative sedation therapy is available to provide adequate relief of suffering.

This is not just a ‘pharmacological oblivion’ as some have claimed. It is the careful management of pain and other severe symptoms through individualised medication plans at therapeutically recognised doses, and with dignified personal care, delivered by experienced doctors, nurses and allied health workers. Family and carers are also supported with emphasis on a holistic approach.

No one is abandoned and everyone can be assisted or supported in some way.”[71]

Associate Professor Ian Haines, MBBS is a medical oncologist with 35 years’ full-time experience and palliative medicine specialist, wrote recently:

“I have seen palliative care reach the point where the terminally ill can die with equal or more dignity than euthanasia will provide.  It is now very effective and increasingly available for two of the three possible ways of dying, outside of sudden unexpected death, which are advanced cancer and chronic relapsing and remitting organ-specific disease such as heart or lung failure.

“Palliative care is also available for people with chronic progressive cognitive diseases such as dementia. This is the fourth way of dying and perhaps the most feared of all.

“Like Andrew Denton and others who have observed unbearable suffering in loved ones and the terrible failures of modern medicine in the past, I had once believed that euthanasia was the only humane solution.

“I no longer believe that.

“[Legalisation of assisted suicide] is not necessary, and … it will inevitably increase the pressure, both stated and perceived, for some chronically ill patients to move on and stop being a burden.

“I have received many euthanasia requests from patients and families over my 34 years in full-time oncology practice, some very passionate, but I have invariably found that they quickly disappear as reassurance and adequate medication doses provide the comfort that is desired and the newly exposed opportunities for patients and families to share deep and poignant moments of bonding and reflection, or nurse a new-born grandchild, or attend a wedding or a graduation.”[72]

Palliative Care Victoria has commented that “appropriately resourced palliative care will provide the best care possible to improve the quality of life of people with a life-limiting illness, to respond to their needs and preferences, and to support them to die with dignity and in comfort,” and outlines the following benefits of good palliative care:

  • “Improved management of pain and other symptoms
  • Increased likelihood of receiving care at their place of choice
  • Increased likelihood of dying at home, where this is their preference
  • Increased family support and satisfaction with the care provided
  • Greater emotional support
  • Improved communication with families
  • Significant improvements in quality of life and mood, and
  • Less aggressive care at the end of life but longer survival.”[73]

If it is interested in providing end-of-life choices for its citizens, the South Australian parliament must improve access to palliative care.

Palliative Care Australia has set a benchmark of 2.0 full-time equivalent (FTE) specialist palliative medicine physicians per 100,000 populations, to ensure that disparities in access to palliative care based on a patient’s condition and geographic location are addressed.[74]

Despite this, South Australia has just 1.0 FTE specialist palliative medicine physician per 100,000 population, which is half the recommended availability.  Additionally, South Australia has the second-lowest ratio of palliative care nurses per 100,000 patients in the country.[75] 

Increased use of Advance Care Directives

Only 14 per cent of Australians have an Advance Care Directive (ACD).

The WA Joint Select Committee report found that the reason for the low uptake of ACDs was because the both the medical profession and the general community has a poor understanding of ACDs, and that medical professionals are not prepared to talk about death and dying with their patients.  The report also found that the benefits of palliative care would be more readily available to patients “if difficult discussions about death and dying took place earlier.”

Studies have shown that advance care planning increases the use of palliative care, helping those with terminal illnesses die in the place of their choice, reducing the number and/or length of hospital admissions, and improve the bereavement experience of families, who report less stress, anxiety and depression after the death of their loved ones.

Conclusion

In the relatively short time that euthanasia and assisted suicide have been legalised in overseas jurisdictions, the empirical evidence (including peer reviewed studies and official government data) demonstrates that there are no safeguards that can prevent wrongful deaths or the coercion and steering of the vulnerable and elderly into seeking premature death under such regimes.

It is our particular concern that when governments seek to placate the claims of those who prioritise ‘personal autonomy’ above all other values, they inadvertently create environments that disproportionately affect the vulnerable in our communities, not least of all Indigenous Australians, as well as those experiencing mental illness and depression.

The priority of government should be to adequately fund and provide access to palliative care for all Australians regardless of their socio-economic status, and especially in our remote and rural regions. The inability of doctors to reliably diagnose depression or indeed determine whether depression is impairing judgment means that many people who would respond to appropriate treatment could find themselves at risk of wrongful death. How many wrongful deaths would the government deem acceptable under such a radical change to the law?

Doctors and palliative care specialists oppose euthanasia and assisted suicide.  A change to the law would reverse a long-standing and important prohibition in our legal system against doctors killing their patients. Such laws have been in place for hundreds of years to protect both doctors and patients, based on the inherent principle that human life is precious and must be protected and valued in all circumstances.  It would also represent a breach of one of the fundamental duties and responsibilities of government, which is to govern for all its citizens, and to ensure that those who are especially vulnerable are protected and cared for.

[1] Australian Medical Association (2016). Euthanasia and Assisted Suicide. Retrieved from https://ama.com.au/system/tdf/documents/AMA%20Position%20Statement%20on%20Euthanasia%20and%20Physician%20Assisted%20Suicide%202016.pdf?file=1&type=node&id=45402.

[2] World Medical Association (2013). WMA Resolution on Euthanasia.  Retrieved from https://www.wma.net/policies-post/wma-resolution-on-euthanasia/

[3] World Medical Association (2017). Statement by the World Medical Association (WMA)

on the Victorian Voluntary Assisted Dying Bill 2017. Retrieved from http://www.healthprofessionalssayno.info/uploads/1/0/9/2/109258189/statement_by_the_world_medical_association_final.pdf.

[4] Australian Medical Association. (2017). Euthanasia and Assisted Suicide. Retrieved from https://ama.com.au/media/euthanasia-and-physician-assisted-suicide

[5] Cigolini MC. (2017). Regarding: Voluntary Assisted Dying Bill 2017. [web log post]. Health Professionals Say No. Retrieved from http://www.healthprofessionalssayno.info/uploads/1/0/9/2/109258189/minister_roberts.pdf

[6] https://www.noeuthanasia.org.au/an_open_letter_from_wa_palliative_care_specialists

[7] Australian and New Zealand Society for Palliative Medicine. (2017). The Practice of Euthanasia and Physician Assisted Suicide. Retrieved from http://www.anzspm.org.au/c/anzspm?a=sendfile&ft=p&fid=1491523669&sid=

[8] The Legislative Assembly of Queensland. (2019) Health, Communities, Disability Services and Family Violence Prevention Committee. Public Hearing - Inquiry into aged care, end-of-life and palliative care and voluntary assisted dying. Retrieved from: http://tv.parliament.qld.gov.au/Committees?reference=C5149#parentVerticalTab5

[9] Kissane D. et al. (2019.) “Health Professionals Say No.” Retrieved from http://www.healthprofessionalssayno.info/

[10] Parliament of Victoria, Legislative Council, Legal and Social Issues Committee, Inquiry into end of life choices, Final Report, June 2016, Minority Report, beginning at p.343.

[11] Stevens, K.R. “Emotional and Psychological Effects of Physician-Assisted Suicide and Euthanasia On Participating Physicians,” The Linacre Quarterly, 2006, 73:3, 203-216.

[12] Opatrny L., Bouthillier M. “Décoder l'objection de conscience dans le cas de l'aide médicale à mourir,” Le Spécialiste, 2017, 19:4, 36-40.

[13] Jones D.A., Gastmans C., MacKellar C. *(eds). “Euthanasia and Assisted Suicide: Lessons from Belgium.”  Cambridge University Press. 2017. United Kingdom.

[14] Stephanie Packer in California was denied chemotherapy treatment by her health insurance company but offered to pay for assisted suicide. Refer Richardson, B. (2016). Assisted-suicide law prompts insurance company to deny coverage to terminally ill California woman. Retrieved from https://www.washingtontimes.com/news/2016/oct/20/assisted-suicide-law-prompts-insurance-company-den/.  See also case of Barbara Wagner in Oregon – denied health cover but offered assisted dying Donaldson James, S. (2008). Death Drugs Cause Uproar in Oregon. Retrieved from http://abcnews.go.com/Health/story?id=5517492&page=1

[15] Richardson B. (2017). Insurance companies denited treatment to patients, offered to pay for assisted suicide, doctor claims. Retrieved from: https://www.washingtontimes.com/news/2017/may/31/insurance-companies-denied-treatment-to-patients-o/

[16] Packer, S. (2016). Compassion and Choice DENIED [Full Film]. Retrieved from https://www.youtube.com/watch?v=S4z7GWP7EG8

[17]Oregon Health Authority, Public Health Division, Center for Health Statistics. (2019). Oregon Death with Dignity Act: 2018 Data Summary. Oregon: Oregon Health Authority.  Retrieved from https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year21.pdf

[18] Tanuseputro P, Wodchis WP, Fowler R, et al. The health care cost of dying: a population-based retrospective cohort study of the last year of life in Ontario, Canada. PLoS One. 2015;10(3):e0121759. Published 2015 Mar 26. doi:10.1371/journal.pone.0121759. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4374686/

[19] Trachtenberg AJ, Manns B. Cost analysis of medical assistance in dying in Canada. CMAJ. 2017;189(3):E101–E105. doi:10.1503/cmaj.160650.  Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5250515/

[20] The Legislative Assembly of Queensland. (2019) Health, Communities, Disability Services and Family Violence Prevention Committee. Public Hearing - Inquiry into aged care, end-of-life and palliative care and voluntary assisted dying. Retrieved from: http://tv.parliament.qld.gov.au/Committees?reference=C5149#parentVerticalTab5

[21] Palliative Care Victoria (2015.) “Submission to the Legal and Social Issues Committee, Inquiry into End of Life Choices.” Retrieved from https://www.parliament.vic.gov.au/images/stories/committees/lsic/Submissions/Submission_236_-_Palliative_Care_Victoria.pdf

[22] Oregon Health Authority, Public Health Division, Center for Health Statistics. (2019). Oregon Death with Dignity Act: 2018 Data Summary. Oregon: Oregon Health Authority.  Retrieved from https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year21.pdf

[23] Ibid.

[24] Australian Law Reform Commission (2017.) Elder Abuse – A National Legal Response: Final Report, ALRC Report 131. Retrieved from https://www.alrc.gov.au/sites/default/files/pdfs/publications/elder_abuse_131_final_report_31_may_2017.pdf, page 18.

[25] Ibid, p.17.

[26] SA Health. Government of South Australia. Stop Elder Abuse. Retrieved from: https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+topics/health+conditions+prevention+and+treatment/stop+elder+abuse

[27] Aged Care Advocacy Service. (2015) Fact Sheet 2.  Retrieved from: https://www.sa.agedrights.asn.au/files/608_fact_sheet_2.docx?v=849

[28] R v Morant [2018] QSC 251 at paragraph 105.

[29] NSW Legislative Council, General Purpose Standing Committee No. 2 (2016.) Elder Abuse in New South Wales. Retrieved from https://www.parliament.nsw.gov.au/committees/inquiries/Pages/inquiry-details.aspx?pk=2387#tab-reports

[30] Seniors Rights Victoria. Undue influence & unconscionable dealing. Retrieved from https://assetsforcare.seniorsrights.org.au/relationship-breaks-down/equity/undue-influence-unconscionable-dealing/

[31] NSW Legislative Council, General Purpose Standing Committee No. 2 (2016.) Elder Abuse in New South Wales. Retrieved from https://www.parliament.nsw.gov.au/committees/inquiries/Pages/inquiry-details.aspx?pk=2387#tab-reports, para 6.6.

[32] Ibid, p. 107, paras 7.8 and 7.11.

[33] Australian Institute of Health and Welfare, Palliative care workforce tables 2016, May 2018, np. Retrieved from https://www.aihw.gov.au/getmedia/097a44b2-fe7a-42ab-9d0f-ecaac2d2f090/Palliative-care-workforce-tables.xls.aspx

[34] Australian Bureau of Statistics. 2075.0 - Census of Population and Housing - Counts of Aboriginal and Torres Strait Islander Australians, 2016. (2018). Retrieved from http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/2075.0Main+Features202016?OpenDocument

[35] Scope (2018). Scope concerned by reported relaxation of assisted suicide guidance. Retrieved from: https://www.scope.org.uk/media/press-releases/scope-concerned-by-reported-relaxation-of-assisted-suicide-guidance/

[36] Ibid

[37] Parliament of Victoria, Legislative Council, Legal and Social Issues Committee, Inquiry into end of life choices, Final Report, June 2016, Minority Report, beginning at p.343, Chapter 3.

[38] Waterfield, B. (2015). Son challenges Belgian law after mother's 'mercy killing'. Retrieved from https://www.telegraph.co.uk/news/worldnews/europe/belgium/11382843/Son-challenges-Belgian-law-after-mothers-mercy-killing.html

[39] Kissane D.W.; Street, A.; Nitschke, P.; “Seven Deaths in Darwin: case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia”, The Lancet, Volume 352, October 3, 1998.

[40] Ganzini L. et al., “Attitudes of Oregon psychiatrists towards physician-assisted suicide”, American Journal of Psychiatry 1996: 153:1469-75. Retrieved: http://ajp.psychiatryonline.org/doi/abs/10.1176/ajp.153.11.1469

[41] Murphy G.E. George E. Murphy, The Physician’s Responsibility for Suicide. II. Errors of Omission, 82 Annals Internal Med. 305 (1975), cited in Herbert Hendin and Kathleen Foley, “Physician-Assisted Suicide in Oregon: A Medical Perspective” 106 Mich. L. Rev. 1613 (2008), at p.1623.

[42] Bentz C., “Oregon’s assisted suicide law isn’t working”, The Province, December 5 2011. Retrieved from  http://blogs.theprovince.com/2011/12/05/provinceletter-icbc-egypt-assisted-suicide-oregon-christmas-pre-marital-sex/

[43] Gould, M.S.; Lake, A.M., “The Contagion of Suicidal Behaviour” in Institute of Medicine and National Research Council, 2013, Contagion of Violence: Workshop Summary, Washington D.C: The National Academies Press.  Retrieved from https://www.suicideinfo.ca/resource/the-contagion-of-suicidal-behavior-2/

[44] Jones D. and Paton D., “How does Legalisation of Physician Assisted Suicide Affect Rates of Suicide?” 108 Southern Medical Journal (2015): 599-604 at p.599.

[45] Shen X. and Millet L., Suicides in Oregon: Trends and Associated Factors. 2003-2012 (Oregon Health Authority 2015). Retrieved from http://www.oregon.gov/oha/ph/DiseasesConditions/InjuryFatalityData/Documents/NVDRS/Suicide%20in%20Oregon%202015%20report.pdf

[46] Somerville M., “The Importance of Stories in the Euthanasia Debate” ABC Religion and Ethics, 28 February 2017. Retrieved from http://www.abc.net.au/religion/articles/2017/02/28/4627671.htm

[47] Somerville M., “Legalising assisted dying would be a failure of collective human memory and imagination” The Guardian. 20 September 2017. Retrieved from https://www.theguardian.com/commentisfree/2017/sep/20/legalising-assisted-dying-would-be-a-failure-of-collective-human-memory-and-imagination

[48] French, M. (2014). Swiss group to allow assisted dying for elderly who are not terminally ill. Retrieved from https://www.theguardian.com/society/2014/may/26/swiss-exit-assisted-suicide-elderly-not-terminally-ill

[49] Ibid.

[50] Federal Public Service. Public Health, Food Chain Security and Environment. Euthanasie – Chiffres de l’année 2018. (2019). Retrieved from https://organesdeconcertation.sante.belgique.be/fr/documents/euthanasie-chiffres-de-lannee-2018

[51] Triviño, M. (2018). Colombia has regulated euthanasia for children and adolescents – Latin American Post. Retrieved from https://latinamericanpost.com/20090-colombia-has-regulated-euthanasia-for-children-and-adolescents

[52] Aviv, R. “The Death Treatment”, June 22 2015, The New Yorker. Retrieved from https://www.newyorker.com/magazine/2015/06/22/the-death-treatment.

[53] Sharp rise in euthanasia for psychiatric patients - DutchNews.nl. (2015). Retrieved from http://www.dutchnews.nl/news/archives/2015/07/sharp-rise-in-euthanasia-for-psychiatric-patients/

[54] Bonython W. “From Oregon to Belgium to Victoria – the different ways suffering patients are allowed to die”, The Conversation, 6 December 2017. Retrieved from https://theconversation.com/from-oregon-to-belgium-to-victoria-the-different-ways-suffering-patients-are-allowed-to-die-88324

[55] Jones D.A., Gastmans C., MacKellar C. *(eds). “Euthanasia and Assisted Suicide: Lessons from Belgium.”  Cambridge University Press. 2017. United Kingdom.

[56] Doughty, S. (2014). Dutch who once backed euthanasia warns it leads to mass deaths. Retrieved from http://www.dailymail.co.uk/news/article-2686711/Dont-make-mistake-As-assisted-suicide-bill-goes-Lords-Dutch-regulator-backed-euthanasia-warns-Britain-leads-mass-killing.html

[57] Parliament of Victoria, Legislative Council, Legal and Social Issues Committee, Inquiry into end of life choices, Final Report, June 2016, Minority Report, Chapter 4.

[58] Centraal Bureau voor de Statistiek. (2017). “Deaths by medical end-of-life decision; age, cause of death.” Retrieved from https://opendata.cbs.nl/statline/#/CBS/en/dataset/81655ENG/table?ts=1525401083207

[59] Chambaere K, Bilson J, Cohen J, Onwuteake-Philpsen B, Mortier F, Deliens L. Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey. CMAJ. 2010 Jun 15;182(9):895–901. DOI: http://dx.doi.org/10.1503/cmaj.091876

[60] Parliament of Victoria, Legislative Council, Legal and Social Issues Committee, Inquiry into end of life choices, Final Report, June 2016, Minority Report, beginning at p.343, Chapter 2.

[61] Oregon Health Authority, Public Health Division, Center for Health Statistics. (2017). Oregon Death with Dignity Act: 2016 Data Summary. Oregon: Oregon Health Authority.  Retrieved from http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year19.pdf

[62] Boffey, D. (2017). 'Any taboo has gone': Netherlands sees rise in demand for euthanasia. Retrieved from https://www.theguardian.com/world/2017/nov/09/any-taboo-has-gone-netherlands-sees-rise-in-demand-for-euthanasia

[63] Ibid.

[64] Boffey, D. (2018). Dutch prosecutors to investigate euthanasia cases after sharp rise. Retrieved from https://www.theguardian.com/world/2018/mar/12/dutch-prosecutors-investigate-euthanasia-cases-sharp-rise-docter-assisted-deaths-netherlands

[65] Regional Euthanasia Review Committee. (2018). Annual Report. Retrieved from: https://www.euthanasiecommissie.nl/binaries/euthanasiecommissie/documenten/jaarverslagen/2018/april/11/jaarverslag-2018/RTEjv2018_DEF.pdf

[66] Health Canada. (2019). Fourth Interim Report on Medical Assistance in Dying in Canada. Retrieved from: https://www.canada.ca/content/dam/hc-sc/documents/services/publications/health-system-services/medical-assistance-dying-interim-report-april-2019/medical-assistance-dying-interim-report-april-2019-eng.pdf

[67] Ibid.

[68] Ibid.

[69] Palliative Care Victoria, “Submission to the Legal and Social Issues Committee, Inquiry into End of Life Choices,” July 2015 (Submission 236).

[70] Cigolini MC. (2017). Regarding: Voluntary Assisted Dying Bill 2017. [web log post]. Health Professionals Say No. Retrieved from http://www.healthprofessionalssayno.info/uploads/1/0/9/2/109258189/minister_roberts.pdf

[71] Ibid.

[72] Haines, I. (2016). 'I believed that euthanasia was the only humane solution. I no longer believe that.'. Sydney Morning Herald. Retrieved from https://www.smh.com.au/opinion/i-believed-that-euthanasia-was-the-only-humane-solution-i-no-longer-believe-that-20161118-gss921.html

[73] Palliative Care Victoria (2015.) “Submission to the Legal and Social Issues Committee, Inquiry into End of Life Choices.” Retrieved from https://www.parliament.vic.gov.au/images/stories/committees/lsic/Submissions/Submission_236_-_Palliative_Care_Victoria.pdf

[74] Palliative Care Australia. (2018). Palliative Care Service Development Guidelines. Retrieved from: http://palliativecare.org.au/wp-content/uploads/dlm_uploads/2018/02/PalliativeCare-Service-Delivery-2018_web.pdf

[75] Australian Institute of Health and Welfare, Palliative care workforce tables 2016, May 2018, np. Retrieved from https://www.aihw.gov.au/getmedia/097a44b2-fe7a-42ab-9d0f-ecaac2d2f090/Palliative-care-workforce-tables.xls.aspx

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