Should Ireland legislate for assisted dying?

Dr Andrew Lyne: Yes. Most people who choose assisted dying don’t want a life without meaning

Nothing in the world is certain except for death and taxes. While most of the attention this week is on taxes, the Oireachtas Joint Committee on assisted dying continues its hearings. It is important to all of us as we will all face our mortality at some time, and most of us will know someone dying with a terminal illness.

We are a group of doctors in Ireland who are advocating for access to voluntary assisted dying for competent adults with a terminal illness, giving them the choice to end their lives and avoid unnecessary suffering. Over the last 30 years, our society has recognised the importance of individual autonomy in repeated referendums. We have empowered individuals to take control and responsibility over their lives. We should now extend that control to how we die.

Terminal illness and dying is an individual journey for each person. It is important that palliative care and social supports are adequately resourced to support people at the end of their lives. Thankfully in Ireland we have seen significant investment in palliative care over the past 20 years. It has brought great comfort to many people, but it is important to recognise its limitations.

Palliative care is unable to relieve all pain all the time. Some symptoms – including shortness of breath, nausea, vomiting, or unremitting itch – can be difficult to control. When the symptoms are overwhelming then terminal sedation, where the patient is rendered unconscious, may be used. Terminal sedation is very important to avoid patient distress and suffering but we should also recognise that it strips the patient of all autonomy. They are unconscious and unable to contribute to any decisions in their care.

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Palliative care is unable to relieve all pain all the time. Some symptoms - including shortness of breath, nausea, vomiting, or unremitting itch - can be difficult to control

When we look at the international experience, pain is not the most common motivation for people to request voluntary assisted dying. Loss of being able to live in a meaningful way and loss of ability to perform activities of daily living, such as being able to go to the toilet independently, underlie 80 per cent of requests. It is understandable that an individual might chose to voluntarily end their suffering before they lose their core abilities to function, when there is no prospect of improvement and when death is foreseeable.

Working as a GP for more than 20 years, I have had a number of patients whose terminal illness involved distressing symptoms and incapacity. I am certain many would never want voluntary assisted dying and it is good that their choice of palliative care was available. I have also had patients request assisted dying. Their requests were reasonable and understandable, but their choice has been not allowed by law.

In recent years more countries have legislated for voluntary assisted dying including New Zealand, several states in Australia, Canada and Spain. We can benefit and learn from their experiences.

The US state of Oregon introduced voluntary assisted dying 26 years ago and there has been no change in the legislation or practice of assisted dying since. If assisted dying is introduced in Ireland it would require further legislation and governmental debate before further changes could happen.

In many Australian states, voluntary assisted dying has been legislated for competent adults who have a terminal illness. They have implemented functional and appropriate safeguards, including requiring the assessment of two doctors and having a reflection period. Safeguards ensure that voluntary assisted dying is the genuine choice of the person and that their wish has been considered carefully and is their own. This experience demonstrates that assisted dying can be introduced in a safe and well-regulated manner.

Concern for vulnerable groups is often cited as a caution against voluntary assisted dying. Research has shown that vulnerable groups, including the poor, elderly and disabled, do not disproportionately choose it. Those who do are more likely to be younger, have a higher income, live at home and be married. Support for assisted dying is strong in jurisdictions where it has been introduced. Eighty three per cent of people in Victoria support their assisted dying laws, reflecting that it is valued as a compassionate choice.

I do not know what life will bring me. I do not know if I will want an assisted death. But I do believe that it should be my choice.

Dr Andrew Lyne is a Cork-based GP and a founder member of Irish Doctors supporting Medical Assistance in Dying

Prof Theo Boer: No. Wherever assisted dying is legal, the consequences are far reaching

A decision to legalise assisted dying – or euthanasia or assisted suicide – is one of the most consequential that a society can ever face. It is vital to look at the experiences of countries that have already taken this step. The image is clear and compelling: wherever it is made legal, the consequences are far reaching. In my own country, the Netherlands, euthanasia, from being a last resort, is becoming a default way to die; and from a way to prevent a terrible death (mostly in the context of terminal cancer) it is becoming a way to prevent a terrible life.

The logic is as simple as it is compelling: why euthanasia only for A and not for B? Why for A and B and not for C? In 2016, Canada legalised euthanasia in terminal illnesses; two years later the Superior Court of Quebec – I was an expert witness in the case – ruled that it is an injustice to deny chronic patients access to euthanasia. Once that access was secured, another court opened the door for euthanasia in psychiatric patients. Similarly in the Netherlands: from euthanasia in terminal physical illnesses, we now include chronic patients, patients with psychiatric illnesses, incompetent dementia patients with an advance directive, and euthanasia in infants and small children. We are now debating a proposal to grant assisted suicide to any citizen over 74 years old, regardless of illness. Within a decade I expect pleas to grant adult children of dementia patients the right to request euthanasia for their parents.

The reported numbers of people seeking euthanasia have expanded. After stabilising in the early 2000s (2,000 per year) the number has grown almost five-fold since 2006 and the increase is accelerating. When we started regulating euthanasia in the mid-1980s few foresaw these developments. Now that we are close to 10,000 deaths annually, some argue that 5.3 per cent of all deaths is “still relatively low”. However, this reflects a national average with some rural and more conservative districts well under 2per cent, whereas in more liberal districts the percentage comes closer to 20 per cent. In combination with exceptionally high numbers of palliative sedation (25 per cent of Dutch patients die under sedation with no food or fluid administered), in some neighbourhoods half of those dying die under the hands of doctors. Others argue that the numbers may be much higher than expected but if this is what patients choose, that simply means that we have a high degree of autonomy.

Euthanasia, from being a last resort, has become a default way to die

But this liberty for some comes at a price for others. The fact that ever more patients prefer death over old age, loneliness, care dependence and deteriorating health affects the resolve in others to deal with the frayed edges of life. When death is seen as a remedy to all kinds of serious and irremediable suffering, why would an individual lay claim to the ever more scarce medical resources of others? Not only our careers and our families, but also ageing and dying become projects to be managed.

[ Caregivers ‘obliged’ to care under most stress, palliative care study finds ]

[ Assisted dying: How has it worked in other countries? ]

Personally I am not opposed to assisted dying, just like I am not a pacifist. Killing may sometimes be necessary but only as a last resort. Given the excellent palliative care available and the dynamics that assisted dying has set in motion, I doubt whether the Netherlands should have legalised it. Let us rather avoid unwanted, unnecessary and harmful medical treatments to which many euthanasia requests are a response. Palliative care must be allowed, even if it may unintentionally shorten the patient’s life. While accepting an individual citizen’s tragic decision to put an end to their life, let us foster a shared resolve to deal with life’s many hardships. And let’s not burden our healthcare system with the heavy responsibility of offering death.

Theo Boer is a professor of healthcare ethics at the Protestant Theological University in Groningen. He was a member of a governmental euthanasia review committee from 2005 to 2014.