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Should assisted dying be legalised? Louise Campbell and Des O’Neill debate

An Oireachtas committee has recommended legislating for assisted dying in restricted circumstances for those with just six months to live – or 12 where they are suffering from a neurodegenerative condition

The debate about legalising assisted dying raises deeply uncomfortable questions. Photograph: Dean Mitchell
The debate about legalising assisted dying raises deeply uncomfortable questions. Photograph: Dean Mitchell
Louise Campbell
Desmond O'Neill
Tue Mar 26 2024 - 06:00

Dr Louise Campbell: Yes. Those for whom assisted death is a rational and freely-chosen alternative should not be denied access to it

The debate about legalising assisted dying raises deeply uncomfortable questions, not just about the kind of society we would like to have in the future but about the kind of society we have now.

In 2002, euthanasia and physician-assisted suicide were legalised in the Netherlands as a means of mitigating the suffering experienced by people living with advanced disease. Compassion was the explicit rationale for introducing assisted dying and it was seen as a last resort in situations in which there was no other means of relieving the person’s physical or psychological pain. To consider someone eligible for assisted dying, doctors must confirm that the patient is making a “voluntary and well-considered” request, has the capacity to make the decision and is suffering to a degree which he or she experiences as unbearable, with no prospect of relief. A range of procedural safeguards, such as second medical or psychiatric opinions, mandatory reporting requirements and review mechanisms, ensure these eligibility criteria are met.

Over the course of the past 35 years, the obligation to respect patient autonomy has become a definitive component of healthcare provision. Patients can request or refuse treatment – including life-sustaining treatment – based on their beliefs about what is important in life. This concept of autonomy has been used to reinforce arguments in favour of legalising assisted dying by drawing attention to a person’s right to determine for himself or herself what quality of life is acceptable to him or her and whether an earlier, controlled death is preferable to an unpredictable descent into pain, loss of independence and the potential obliteration of the person he or she is.

Philosophically, arguments resting on the perceived duty to relieve suffering and on the importance of autonomy have merit. Problems arise, however, when the clean world of theory collides with the messy realm of empirical practice. Permitting assisted dying in order to relieve unbearable suffering raises profound questions about what suffering is, what criteria are used to assess it and whether an objective evaluation of suffering is even possible. Numbers of assisted deaths are growing in all jurisdictions where it has been legalised, slowly in some (Oregon, Washington) and more rapidly in others (Flanders, Quebec). Some advocates of assisted dying worry that it is no longer seen as an option of last resort but has become normalised as one alternative in end-of-life care provision.

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If we legislate for assisted dying, rigorous scrutiny of what is happening in other countries should give us the opportunity to see what may otherwise have remained invisible

In a small number of countries which have legalised assisted dying, the eligibility criteria for accessing the intervention have subsequently been expanded. Before 2021, Canadian doctors were required to confirm that a person’s death was “reasonably foreseeable”, but this criterion was removed following a legal challenge, with the result that someone with a disability or progressive illness who is suffering intolerably is now eligible to request it. In the Netherlands, a person whose sole underlying condition is a mental illness may request euthanasia, provided that all other eligibility criteria are met. There is increasing concern that the practice has exceeded its intended limits in both jurisdictions, with Canadian media reports pointing to social isolation, poverty, inability to access services or lack of appropriate accommodation as factors compounding the suffering of those requesting assisted dying.

Disability rights activists argue that ableist assumptions undermine the value of lives lived with disability and obscure the failure of the state to provide the level of care needed by people with disabilities to live richer, more meaningful lives as valued members of society, resulting in an oblique pressure on them to see assisted dying as a real alternative to continued living.

If we legislate for assisted dying, rigorous scrutiny of what is happening in other countries should give us the opportunity to see what may otherwise have remained invisible: that in every jurisdiction in which mental healthcare, disability services and palliative care are inadequately funded, some members of society will see assisted death as an escape from the life they feel they have no choice but to live. This should not, however, mean that those for whom assisted death is a rational and freely-chosen alternative should be denied access to it.

Dr Louise Campbell is a clinical ethicist and a lecturer in medical ethics at the University of Galway

Prof Desmond O’Neill: No. Offering euthanasia says, directly or indirectly, that some lives are not worth living

Faced with societal challenges in Ireland, we often look to Nordic countries for solutions that balance effectively the rights and needs of individuals with the common good. Rarely flashy or populist, their sober and considered approaches don’t make controversial headlines but represent the hard graft of deep reflective thought that underlies authentic kindness to each other.

Little media attention was paid to the submission of the Danish Ethics Council to the joint committee considering euthanasia and assisted suicide. Delivered without showmanship, it displayed a highly professional and compassionate approach.

Tasked by the Danish government, a group of highly experienced ethicists, clinicians and other stakeholders concluded in 2023 that it was “in principle impossible to establish proper regulation of euthanasia”, recommending that the law in Denmark should not be changed. They insightfully acknowledged experience of jurisdictions with euthanasia: not a slippery slope but an open gate to inexorable widening of conditions eligible for euthanasia.

At a deeper level, they noted that the very existence of an offer of euthanasia would decisively change our ideas about old age, the coming of death, quality of life and what it means to take others into account: if euthanasia becomes an option, there is too great a risk that it will become an expectation aimed at special groups in society. Institutionalisation of euthanasia risks threatening the principle that we have the same claim to respect and dignity regardless of how much we suffer and how high the quality of life is assessed to be.

Offering euthanasia says, directly or indirectly, that some lives are not worth living. This in turn will amplify covert and overt prejudice against life with disability or conditions such as dementia. Adding this to the imperfections of any complex human system, such as modern healthcare, can be countered only by ensuring that the clinical gaze is directed towards positive therapeutic support and care, and not premature foreclosure of the possibilities of life with vulnerability. In the words of the Danes, assisted living rather than assisted dying.

‘Assisted dying’ is the preferred term of euthanasia advocates: this euphemism irons out the reality of asking doctors and nurses to engage with killing their patients, or assisting them to kill themselves

Bringing such profound and considered reflection to the Irish situation can be challenging, given the tenor of some of the debate at the joint committee. Discourse from some committee members echoed neoliberal, consumerist and populist perspectives whereby the wishes of the individual overshadowed consideration of the common good.

Also, for a country where we are often sensitive to the use of language – think Derry/Londonderry – there were unfortunate efforts to close down language reflecting what euthanasia and assisted suicide really entail. “Assisted dying” is the preferred term of euthanasia advocates: this euphemism irons out the reality of asking doctors and nurses to engage with killing their patients, or assisting them to kill themselves.

This short-circuits and undermines our professional impetus to care, comfort and support, damaging not only the framework of care but also our shared humanity. Current and future patients need to be reassured that the response of the healthcare professions to distress and pain is one of solidarity, compassion and care, addressing needs at a range of levels while respecting autonomy to the greatest extent possible.

Mindful of individual challenges, this is why the Royal College of Physicians of Ireland, representing more than 13,000 doctors in disciplines closest to care at the end of life, and the College of Psychiatrists of Ireland, representing specialists closest to suicide prevention, have advised against euthanasia and assisted suicide.

Present and future patients should be reassured by the evidence that death is widely experienced as occurring with dignity within current paradigms, as well as by existing and ongoing development of care paradigms, training and research to continuously enlarge the framework within which the final period of our lives is spent and where suffering is minimised to the greatest extent possible without undermining care and hope for vulnerable fellow citizens.

Prof Desmond O’Neill is a consultant geriatrician at Tallaght University Hospital and has been involved in research and teaching on clinical ethics at undergraduate and postgraduate levels