Ethical Principles in Palliative Care: Autonomy, Beneficence & VAD

Slide 1: Introduction:

Hello Everyone, hope you all are doing well. For today’s topic we will be discussing Voluntary Assisted Dying (VAD) in Australia, in the context of palliative care and the ethical consideration in patient care.  VAD has been legalized end-of-life option across all Australian states, including New South Wales (NSW). For brief history the Voluntary Assisted Dying Act 2022 commenced on 28 November 2023. The Australian Capital Territory (ACT) passed its VAD Act in June 2024, while it is to be implemented on 3 November 2025. The Northern Territory (NT) released a draft framework for VAD in 2024, which is being currently reviewed by government. These developments are made due to the considerable shift toward legislating to make the patient more autonomous during end-of-life care (Department of Health Victoria, 2021).

This brings the attention towards palliative care nurses, as VAD brings critical professional responsibilities and ethical complexities for the nurses. According to Molenaar et al. (2025), the palliative care nurses are frontline providers, who are responsible for supporting patients and their families through moral and emotional challenge and decision-making, while keeping themselves, patient and the care taker informed about evolving legal requirements and institutional protocols.

In this presentation we will be exploring two critical aspects including ethical debate around the VAD, which is being incorporated with the principles of autonomy, beneficence, non-maleficence, and justice. We will be also discussing the strategies to provide quality and safety of care for the patients who choose to go through this process by incorporating current research, legislation, and ethical frameworks. This discussion will highlight the significance of compassionate, evidence-based, and legally compliant nursing practices in the evolving healthcare setting where VAD is becoming part of advanced care planning more and more.

Slide 2: Overview of VAD Legislation in Australia

Braun (2024), state that the VAD legislation in Australia is a reflection of the country’s commitment to provide patient centered care for end of life services reinforced by strict legal safeguards.  On 28 November 2023, the Voluntary Assisted Dying Act 2022 was made into effect in New South Wales that provides the right to deserving adults the right to request assistance in dying under defined conditions (Parliament of NSW, 2022). While Australian Capital Territory (ACT) passed its VAD Act in June 2024, which will be implemented from November 2025, through this the region will become the first territory to legislate VAD. Similarly, the Northern Territory (NT) in 2024, released a report that proposed a legislative framework encompassing VAD, which is currently under governments’ review. The state and the territory laws ensure standard eligibility criteria and procedures that safeguards the patients’ well-being including multiple requests, independent assessments, and protections against coercion. With these evolving circumstances nurses must understand the jurisdictional specifics while complying to the national standards that prioritize ethical, safe, and compassionate VAD practices (Jeanneret & Prince, 2024).

Slide 3: Four Ethical Principles in Palliative Care

Autonomy, beneficence, non-maleficence, and justice are the principle that guide the palliative care nursing that enable ethical decision making during complicated end-of-life situations including Voluntary Assisted Dying (VAD) (Akdeniz et al., 2021).

Autonomy is patient right to make informed decisions regarding their healthcare treatment with VAD being a part of that right. Patients’ autonomy requires the healthcare providers to recognize each person’s individual values, cherished beliefs and informed preferences for care decisions despite opposing conventional medical standards. Beneficence, requires healthcare professionals to prioritize patients comfort, dignity, relief of suffering and overall working in patients’ interest. This is relevant to VAD as beneficence will require the healthcare professional to honor a patient’s decision to end their life when their suffering becomes unbearable (Alshawaf et al., 2024).

According to Attia, et al. (2025), non-maleficence is another principle that require the healthcare professional to avoid causing harm, which is relevant in the case of VAD as many view assisted dying harmful, while in contrast many see prolonged suffering as the greater harm. Lastly the principle of justice requires both fairness and equal opportunities for healthcare services. It requires all eligible patients to avail equal access to VAD and quality end-of-life support services in palliative settings without regard for geographic, cultural or economic background (Alshawaf et al., 2024).

If these principles are followed they will enable nurses in delivering compassionate, respectful, and ethically responsible care.

Slide 4: Ethical Arguments for Voluntary Assisted Dying (VAD)

Advocates of VAD present argument that it is in compliance of core ethical principles of healthcare including autonomy, beneficence, and justice. Autonomy is considered a key principle that enables the patient to take informed decisions regarding their own body and life, including the choice to die with dignity. In the cases of terminal illness, the patient often has to suffer from prolonged and intolerable suffering. Thus VAD allows the patient to decide and how they die can be viewed as a fundamental expression of personal autonomy (Matthys et al., 2023).

According to Gelegjamts et al. (2023) , beneficence, is another ethical obligation that requires to act in a patient’s best interest, reinforcing the argument that VAD prioritize the relief of suffering. It is argued that when palliative interventions no longer provide adequate comfort, VAD provides compassionate and humane option (White et al., 2022). Additionally, the principle of justice calls for equal access to end-of-life options, such that all eligible patient, no matter the geographic location, socioeconomic status, or background get equal access to quality VAD if they choose. Furthermore, the development of legal VAD frameworks with regulation allows populations to receive equitable end-of-life care and to respect their varying preferences. These ethical argument state that VAD represents both patient-centered and compassionate care in today's palliative environment.

Ethical Arguments Against VAD

The concept of Voluntary Assisted Dying (VAD), is a very controversial even though it is legally accepted. Multiple argument related to this are based in the principle of non-maleficence, which obliges the healthcare professional to not to harm.  The critics argue that the intentional ending of life raises question on the major responsibility of healthcare as a healing profession. Doing so does not sit right even at the patients request as assisting in patient’s death can be seen as a violation of the nurse’s ethical duty to preserve life and thus they should relieve suffering through non-lethal means (White et al., 2020).

Accoding to Kirchhoffer et al. (2023), another issue is the moral distress that comes with it. The critical concern arises when the nurses personal, cultural, or religious beliefs is in contradiction with concept of VAD. Although conscientious objection is protected by law, professionals still go through moral internal conflict, workplace tension, or emotional burden, even when they are indirectly involved in the VAD process.

Considering that ethical objection often leads to a slippery slope, critics warn that if VAD is normalized it will lead to broader implications. For instance, the vulnerable or marginalized population such as individuals with cognitive impairments, mental illness, or limited access to care can be co-erced into ending their lives prematurely. These concerns are valid hence call for rigorous steps to safeguard, ethical oversight, and constant ethical debate within healthcare (Boyle et al.,2024).

Nurse Perspectives & Challenges

The nurses in Palliative care go through profound ethical and emotional challenges after the legalization of Voluntary Assisted Dying (VAD). The moral distress being one of a primary concern, which arises when nurses have to take part in a process that conflicts with their deeply held personal, religious, or cultural values. Where legislation has allowed conscientious objection, the nurses still have to get involved indirectly leading to ethical tension, emotional fatigue, or even professional burnout (Kresin et al., 2021).

Furthermore, there is a significant impact on professional boundaries and emotional well-being. Often during the end of life care, nurses working with these patients develop close relationships. Thu the emotional response is magnified when patient chooses to pursue VAD. Hence navigating these emotions while maintaining professionalism requires strong emotional resilience and institutional support. Furthermore, another challenge is the role clarity, where nurses must be able to distinguish between their responsibilities in traditional palliative care and their legally permitted roles in the VAD process. Thus nurses may not administer VAD unlike physician, however they are crucial for to care coordination, advocacy, and psychosocial support. Principle may suggest that nurses should navigate personal values while respecting patient choices and legal boundaries. Thus nurses can only uphold their ethical integrity and professional responsibilities if crucial guidelines, education, and peer support are provided (Rutherford et al, 2021).

Ensuring Safety in VAD

Robust framework in accordance with legal safeguards, clinical accountability, and transparent processes must be ensured for the safety of patients who choose Voluntary Assisted Dying (VAD). The NSW Voluntary Assisted Dying Act 2022 mentions strict eligibility criteria, that requires the person to be an adult with decision-making capability, diagnosed with a terminal illness and expected to die within next six months or 12 months for neurodegenerative conditions, and must be going through intolerable suffering (NSW Government, 2022).

Additionally, the patient must make three separate request for VAD as per the legislation to avoid any possibility of coercion or impulsive decisions, and one of these decisions must be written and signed in front of an authorized witness. The law also mandates, two independent medical practitioners to conduct separate and comprehensive assessments to confirm eligibility, with objectivity and due diligence (NSW Health, 2023).

Furthermore, Hempton, (2019), state that clear documentation and mandatory reporting are crucial to ensure transparency and accountability. Every stage of the VAD process has to be accurately recorded and submitted to the Voluntary Assisted Dying Board regularly. This ensures compliance with legal and ethical standards enabling these multi-layered safety measures to protect patients, reassuring families, and supporting healthcare providers in delivering ethical and lawful VAD services.