End of Life Ethics, Human Tissue, and Child Protection

Lecture 2 covers end-of-life ethical and legal frameworks in Aotearoa New Zealand, including the End of Life Choice Act 2019, the Human Tissue Act 2008, and the clinician's obligations regarding child abuse.

END OF LIFE CHOICE ACT 2019 (NZ)

The End of Life Choice Act 2019 came into force in New Zealand on 7 November 2021, making NZ one of a small number of jurisdictions that permit assisted dying. Key provisions:

Eligibility criteria: (1) NZ citizen or permanent resident aged 18+; (2) Terminal illness likely to end their life within 6 months (or 12 months for a neurodegenerative condition); (3) Significant and ongoing reduction in physical capability, unable to be relieved in a manner acceptable to the person; (4) Experiencing unbearable suffering that cannot be relieved in a manner acceptable to the person; (5) Decision-making competence. Exclusion criteria: a person is NOT eligible solely on the basis of having a psychiatric illness, a disability, or being of advanced age.

Process: the patient initiates a request to their attending medical practitioner (AMP). The AMP assesses eligibility and must refer to an independent medical practitioner if they cannot determine eligibility. If the patient has a psychiatric illness, they must also be referred to a psychiatrist. Waiting periods apply (minimum 2 days between expressions of wish). The patient may rescind consent at any time. Conscientious objection: practitioners are not obliged to participate but must inform the patient that they may seek assistance from the Ministry of Health's support and consultation service.

Method: typically oral or IV administration of medication that causes death — in NZ, pentobarbital or phenobarbitone cocktail. The patient can administer it themselves or have the practitioner administer it.

DISTINCTION FROM EUTHANASIA/PALLIATIVE CARE: The Act uses the term "assisted dying." This encompasses both physician-assisted dying (practitioner prescribes, patient self-administers) and euthanasia (practitioner administers at the patient's request). Both are legal under the Act. Neither palliative sedation nor withdrawal of life-sustaining treatment requires the Act — these are already lawful as part of standard care.

HUMAN TISSUE ACT 2008 (NZ)

Governs the collection, storage, use, and disposal of human tissue (including blood, organs, and cadavers) in NZ. Key provisions: (1) Informed consent is required for collection and use of human tissue for educational, training, and research purposes. (2) Body donation: individuals may donate their bodies to medical schools for teaching anatomy (the University of Otago has a structured programme). Donation requires written consent; donors can specify restrictions (e.g., no photography). Families are given the opportunity to receive remains after use. (3) Post-mortem: requires either family consent (for hospital post-mortem) or coroner's order (for medicolegal post-mortem). The Act prohibits retention of tissue beyond what is consented to. Historical retention scandals (e.g., Bristol Royal Infirmary, Alder Hey) led to major legislative reform in the UK; NZ's Act reflects similar principles.

CHILD PROTECTION AND MANDATORY REPORTING

Child abuse recognition and the clinician's legal and ethical obligations are covered under the Oranga Tamariki Act 1989 (NZ) and the Children's Act 2014. Types of abuse: physical abuse, sexual abuse, emotional/psychological abuse, neglect (most common). Indicators in the ED: unexplained or inconsistent injuries, delay in presentation, injuries inconsistent with developmental stage, multiple fractures at different ages of healing (metaphyseal fractures — classic for non-accidental injury), retinal haemorrhages (shaken baby/abusive head trauma), burns with clear demarcation (immersion injury), disclosure by child or concerning statements.

Legal obligation: in NZ, any person who has reasonable grounds to suspect a child is being abused or at risk has a reporting obligation under the Oranga Tamariki Act. For health professionals, this is a professional and legal duty. Suspected abuse must be reported to Oranga Tamariki (the Ministry for Children) or police.

The clinician must: (1) ensure the child's immediate safety; (2) document findings carefully (photographs where appropriate); (3) consider involving a child protection specialist or paediatrician; (4) NOT confront the alleged perpetrator before securing the child's safety; (5) maintain confidentiality appropriately — the child's welfare overrides parental confidentiality.