‘Assisted dying’ against best medical practice leading doctor tells committee

 

Doctors were before the Oireachtas Committee on ‘assisted dying’ last week, representing a group in favour, a group fully against, and a group mainly against. It’s important to note that while this gives the impression that doctors are more or less evenly divided on the matter, easily the biggest representative body in attendance, namely the Royal College of the Physicians of Ireland (RCPI), is totally opposed to euthanasia/assisted suicide.

Dr Feargal Twomey [pictured] spoke on behalf of the RCPI, and he told the committee that assisted suicide and euthanasia are contrary to best medical practice. The only true safeguard for seriously ill people is that the law does not change, he said.

The RPCI has more than 11,000 members and is the largest postgraduate medical training and professional body in the country.

He stated: “RPCI opposes the introduction of legislation for assisted suicide because, in our view, it is contrary to best medical practice. It is our view that the potential harms outweigh the arguments that can be made in favour of assisted suicide”.

He claimed that such legislation would undermine the efforts of doctors, nurses and healthcare professionals who deliver compassionate and expert care, “risking a shift away from funding, development and delivery of new and existing palliative care services”.

Dr Twomey reminded the committee that recent analysis of data from countries where so-called “assisted dying” is available shows a progressing broadening of the limits that were initially established by the law. In Canada, safeguards have been systemically eroded. In the Netherlands the extension of eligible groups now includes very sick new-born infants, while euthanasia is available in Belgium to children of any age.

Dr Twomey, who works in palliative care, said that the relaxation of restrictions in Canada and the erosion of safeguards have been frightening. Jurisdictions begin with what is presented as a conservative or moderate approach and then go down a slippery slope.

“My concern about the inability for safeguards to be maintained leads me to say the only way true safeguard is that the law does not change”, he commented.

Dr Gabrielle Colleran and Prof. Robert Landers, representing of the Irish Hospital Consultants Association (IHCA) also expressed concerns about legislative changes. “Ethical considerations must always be paramount in health. The ethical dilemma posed by intentionally ending the life of a patient challenges our fundamental commitment to preserving life and could potentially erode the trust that patients place in our care”, Prof. Landers said.

The IHCA has 3,500 members. Dr Colleran invited the committee to consider a report from the ethics committee of the Danish Parliament earlier this month that recommended against allowing euthanasia because, when it becomes an option, it also becomes an expectation aimed at special groups in society.

A small group called ‘Irish Doctors supporting Medical Assistance in Dying’ also addressed the committee. They claim to have about 100 members, out of 16,000 registered medical doctors in Ireland.

Presenting on their behalf, Dr Brendan O’Shea said that both euthanasia and assisted suicide should be available to adults who are within six months of death or have an incurable terminal condition causing progressive physical deterioration. This last criterion is potentially very broad and has no time limits. Would it include people with MS or Parkinson’s Disease who might be years away from death? Presumably it would. What about dementia patients? Ultimately, it is terminal also. In fact, Dr O’Shea specifically mentioned dementia in his presentation. He spoke about a dementia patient who applied for ‘assisted dying’ in Canada. He was approved. Dr O’Shea did not say he was opposed to this. “At the moment [our italics], we are not recommending that dementia be considered a primary qualifying condition on its own”, he said.

Dr O’Shea estimates that about 1,000 to 1,500 people would avail of ‘assisted dying’ over the next three to four years, if introduced in Ireland. This is guesswork, of course. It could be less, or it could be more. His figure would account for around 1pc to 1.5pc of all deaths in Ireland.

Commenting on the non-medical motivations that could lead to a request for assisted suicide, Dr O’Shea said that “for ourselves, we have to consider the legitimacy of not wishing to be a burden. It is certainly an imperative of a kind society that nobody should have to consider this, but, for me, it is a personal decision.”

This would seem to indicate ‘assisted dying’ should be available on very wide grounds indeed.

Oireachtas committee hears about Canada’s extreme euthanasia regime

 

Doctors and disability rights campaigners have presented the grim reality of the Canadian “Medical Assistance In Dying”(MAID) regime to the Oireachtas committee that is considering the introduction of such legislation in Ireland.

In Canada, euthanasia was introduced for the terminally ill only, which is the main proposal currently on offer here, but the ground expanded extremely quickly.

“Do not be Canada”, said Dr Heidi Janz of the Health Ethics Centre of the University of Alberta. Dr Janz is wheelchair bound. She told the committee that MAID was initially legalised in 2016 for people with ‘irremediable medical conditions’ but in 2021 the eligibility was expanded to people with disabilities, whose natural death is not reasonably foreseeable. From next year, those with mental illness as the sole underlying condition will qualify for MAID. All these changes were introduced on the basis that these are all forms of suffering and it would count as discrimination to offer euthanasia only to those who suffer physically or only to those who are dying soon.

“Canada is thus continuing its rapid descent down a slippery slope which many still claim does not exist. And so, I sit before this Committee today to implore you, for the sake of preserving true dignity and true choice for disabled, ill, old, and other structurally vulnerable people in Ireland, do not be Canada.”

Dr Leonie Herx, clinical professor of palliative medicine at the University of Calgary, explained that in more than 99.9pc of cases in Canada the lethal drugs are administered by a clinician. Assisted suicide, when the patient takes the drugs themselves, is extremely rare.

She claimed that MAID has had a profound effect on palliative care. “All healthcare facilities are expected to provide MAID, including hospices, whose core palliative care philosophy does not include hastening death. In Quebec, MAID legislation now requires all hospices and palliative care units to provide MAID. There are no euthanasia-free safe spaces”, she said.

Once legalised, it progressively becomes normal and is seen as a solution for virtually any form of suffering, she told the committee.

An increasing number of Canadians are receiving euthanasia “due to fear, loneliness and depression, social deprivation and isolation, lack of access to supports and adequate care needed for living, lack of access to parole for some prisoners, high cost of care and poor conditions at residential facilities.”

She quoted a former minister for disability inclusion who said that “in some places in our country, it’s easier to access MAID than it is to get a wheelchair”.

Prof. Trudo Lemmens, chair in Health Law and Policy at the University of Toronto, initially supported the first law but now he is troubled by having seen death being offered to patient with chronic illness or disability, often in a context of social disadvantage.

Canada is currently the country with the highest number of euthanasia deaths: more than 10,000 per year.

There are several reasons for this, according to Prof. Lemmens. The access criteria were vague in the legislation and have been interpreted excessively broadly by courts, leading to a constant expansion of those who qualify. Moreover, the fact that the lethal substances are administered by healthcare professionals, gives the false impression that it is part of medical care and makes it more acceptable. Regimes that allow only assisted suicide, such as Oregon, seem to have a lower uptake.

Also, Prof. Lemmens said, MAID is explicitly not treated as a last resort in Canadian law. “Healthcare providers do not need to agree that no other options remain. There is no obligation to make care or support available and try it first. Death has been transformed into first-line therapy for often only remotely disease-related suffering”, he said.

At the previous week’s hearings, pro-euthanasia TD, Gino Kenny (pictured), lambasted one of the witnesses about some of his claims about the Canadian regime. What was he thinking deep down this week after hearing the latest evidence?

A clash of worldview at the ‘assisted dying’ hearings

 

The Oireachtas committee on ‘assisted dying’ has met three times in the last two weeks. As usual, the hearings offered useful insights into the thinking of both sides of the divide. What follows are some highlights from the meetings.

Session One

The first session held on Tuesday 3rd October was dedicated to ethics.

Dr Thomas Finegan, assistant professor at Mary Immaculate College Limerick and member of the board of the Iona Institute, told committee members that euthanasia is a violation of the value of life. When introduced in the healthcare system, euthanasia goes against the primary healthcare norm which prohibits the intentional killing of a patient.

“Even if all such future choices were safeguarded from coercion, it would still be the case that the central purpose of healthcare is being overturned or at least severely qualified”, he said.

Euthanasia is often presented as a choice and defended in the name of personal autonomy but if we accept this principle, all attempts to draw a limit in terms of when or by whom it can be accessed will appear as unfair discrimination to someone who is excluded, he claimed.

“Consistency demands that if euthanasia were to be legalised, it would be available on virtually all medical grounds, including, for example, chronic illness, conditions closely associated with disability, experience of suffering – which is inherently subjective and not limited to physical suffering – and mental disorders, once capacity remains,” he said.

Dr. Annie McKeown O’Donovan, from University of Galway, believes that assisted suicide should be permitted but only when death is “imminent”, and the intent is to reduce harm. She also believes that no one apart from the patient should administer the lethal substance, and so she opposes direct euthanasia, which is when the substance is administered by a third party such as a doctor.

Dr Finegan replied that the logic of seeking to minimise harm means that assisted suicide should be offered even more to those who suffer chronic illness and therefore have more suffering ahead of them than those near death.

Dr Kevin Yuill, representing ‘Humanists Against Assisted Suicide and Euthanasia’, reminded the committee that “the inherent problem with any assisted dying legislation is that it is based on a subjective idea of suffering, what it means and who is suffering.” He mentioned the case of a Canadian man who sought ‘medically assisted dying’ because he was homeless.

This prompted a harsh reaction from Deputy Gino Kelly, who accused Dr Yuill and Dr Finegan of using “deeply distasteful and very selective language, to say the least.”

He also demanded evidence on the spot from Dr Yuill to back up his claim about the homeless person, and when Yuill said he could not do immediately, saying he would do so later, Deputy Kenny angrily accused him of not being credible.

But the case Dr Yuill was referring is well known. Mr Amir Farsoud, a disabled 54-year old, applied for ‘medically assisted death’ because was about to be made homeless and had no money. His request was approved by his GP although it needed a second doctor to approve it. It did not go ahead, but from next year in Canada, people suffering from mental suffering will be able to apply for ‘assisted dying’.

In this interview he clearly says: "I don't want to die. But I don't want to be homeless more than I don't want to die".  

https://toronto.citynews.ca/video/2022/10/13/choosing-death-over-homelessness/

Similar cases are emerging, here is another example: https://www.orilliamatters.com/local-news/homeless-hopeless-orillia-man-to-seek-medically-assisted-death-6415189 

A recent survey showed that 28pc of Canadians believe that homelessness should be a ground for access to assisted dying.

Also, a recent article in the New Atlantis revealed conversations between Canadian practitioners of euthanasia who believe the procedure should be made available for non-physical suffering.

Session Two

The second session of the hearings last week was devoted to the experience of the United States.

Dr Mark Komrad, a clinical psychiatrist at Johns Hopkins Hospital and a clinical assistant professor of psychiatry at the University of Maryland, told the committee that assisted suicide is not widespread in the US, and there have been 270 failed attempts to introduce such legislation in many states. Nine states have passed laws inoculating themselves against such legislation ever being introduced there in the future, he said.

Where legal, those practices can go terribly wrong. In Colorado, patients with anorexia were prescribed lethal drugs. In Oregon, at least nine patients survived after having taken such drugs.

The other two experts, Dr Tom Jeanne and Prof. Margaret Battin who both support assisted suicide, were a representative of the Oregon Health Authority and a professor of philosophy respectively.

Oregon has been presented as a good model by some who spoke to the committee in the past. Rates seems to be lower than countries such as Canada or the Netherlands, even if the numbers of those who died by assisted suicide have increased more than fourfold in the last five years.

The law allows only terminally ill patients to kill themselves through the self-administration of a lethal drug prescribed by a doctor. Most of them die at home. This seems to make a big difference to numbers because people are much more reluctant to self-administer a poison than to have a doctor do it for them.

Dr Komrad noted that the drugs are not monitored after they are provided to those who have requested them. In one case they were stored in a house for more than four years, with the risk that others might have taken them.

He commented: “The experience with assisted suicide in the US has demonstrated inadequate and mutating guidelines that eventually push beyond the limited scope of the original laws; flimsy safeguards; zealous physicians who do not follow the law … Leading medical organisations have declared this bad medical ethics, and the majority of American legislators have concluded that it is poor public policy. I hope Ireland can learn from our bad example”.

Senator Ronan Mullen mentioned a very recent study from the British Medical Journal which found that 46pc of those who opted for ‘assisted death’ were concerned about being a burden to others.

It also found that in Oregon, whereas in the past most (80pc) of those accessing assisted suicide were using private insurance to cover their expenses, now public insurance is mainly (80pc) covering costs. Assisted suicide in Oregon is covered by Medicaid, the government program that provides health insurance for those with limited income. This change from predominantly private to mostly public funding could explain the growth in number of cases of assisted suicide in Oregon, particularly among the less wealthy.

Session Three

This week, the Oireachtas heard from four witnesses from Ireland.

Elma Walsh (pictured), whose son teenage Donal became known in 2013 for his battle with cancer, told the Oireachtas committee of his good experience with palliative care, which allowed him to live the last months of his life as an inspiration for his peers. He visited schools and spoke against suicide, encouraging young people to value life.

Donal died with dignity, the mother said. She cautioned that by removing the present legal ban on euthanasia/assisted suicide the value of life will be significantly reduced.

The other three witnesses support assisted suicide and/or euthanasia to varying degrees.

John Wall, who was diagnosed with a terminal illness, believes that assisted suicide should be available when “it is blindingly obvious that the end is very nigh”.

Tom Curran, whose late partner Marie Fleming lost a Supreme Court case to access assisted suicide in 2013, favours the Swiss model, where a legal drug can be administered by non-medical professionals. He believes that anyone of a sound mind should have that choice, for any reason.

“It is not about aid or about end of life. It is about a choice as to when you feel that your life had ended”, he said.  In the past, he admitted that he had helped Irish people in Switzerland to access assisted suicide.

Garret Ahern, another witness, told the Committee about his late wife Vicky Jannsens who legally took her life in native Belgium, this April after having suffered from breast cancer for ten years. He lamented that it could not have happened here.

Mrs Walsh expressed fear that even a law for limited cases will be extended in the future. “Society must promote hope” she said, “assisted suicide is a statement of no hope. Palliative care allowed Donal to spread a message of hope and reduce the number of suicides. Telling young people that their life is valuable, no matter how uphill it may seem at the time, is important. As Donal said, “Everybody has their own mountain to climb.” Legalising assisted dying is to bring about a clash in society. Life is valuable no matter our age or circumstances. We can all help to fight against suicide by turning our back on assisted suicide.”

Committee hearings continue.

Insurance companies could easily offer euthanasia in the future

 

The Oireachtas Committee on ‘assisted dying’ continues to hear expert testimony on the matter. Last week it heard from a Dutch academic who was once a supporter but has now turned into a critic. He spoke of how insurance companies in his country are already funding the procedure for one provider, which is a chilling possible glimpse of the future.

The Dutch expert, Theo Boer, who is a professor of healthcare ethics, said the legalisation of euthanasia in the Netherlands has turned our view of suffering, ageing and taking care upside down. The numbers are speeding up and the biggest increase is now in illnesses that are not terminal.

He was initially supportive of euthanasia legislation and now, having reviewed 4,000 cases on behalf of the Dutch government, has become critical of it.

He told the committee that in 20 years the numbers availing of it in his country have quadrupled and, in some neighbourhoods, medically assisted euthanasia account for 15pc to 20pc of all deaths. These figures are underestimated, he said, as a governmental evaluation has found that between 10pc and 15pc of doctors do not report their participation in the programme.

He noted that there has been an expansion in the reasons for euthanasia — from those at the end of a terminal illness, to people today fearing loneliness, alienation and care dependency. Once euthanasia is introduced, why should it be provided only for terminally-ill patients, or for those suffering from physical illness and pain, he asked. Sometimes it is the absence of hope that provokes the suffering, he said.

“That is why we have now a law in parliament that legalises euthanasia for all people over 74 years, with or without an illness. Their age is the only reason they can have assisted dying. That in turn is why we now have a regulation that allows parents to request euthanasia for their young children aged from zero to 11 years old. I am convinced it is only a matter of time before we take the next hurdle, namely, allowing children of dementia patients to request euthanasia for their demented parents”, he told the committee.

The second expert who spoke was Silvan Luley, representing Dignitas, a group that facilitates assisted suicide in Switzerland, where it has been legal since 1942. Currently, about 1,700 per year avail of it. He claimed that Dignitas has almost 100 Irish members and 12 people from Ireland have been helped to kill themselves by his organisation.

Dignitas offers assisted suicide not only to those who are terminally ill but also to anyone who has an “endurable incapacitating disability” or suffers ‘unbearable pain’. Mr. Luley told the committee that fewer than 50pc of those who avail of their assistance are terminal. He explained that they offer a professional alternative to violent suicides.

“It is about having an emergency exit door that provides emotional relief and can prevent people from using rough, violent do-it-yourself suicide methods. The people in Ireland should have what everyone deserves: a legal way to exercise the human right of freedom of choice on all options of professional care to soothe suffering and end life at their home” he said.

Luley was challenged by Prof Boer who referred to new studies presented at a congress of 250 psychiatrists he attended recently. One study found that since the Netherlands allowed euthanasia for reasons of psychiatry, dementia and long-term chronic illnesses, the number of violent suicides has risen against expectations by 35pc, while it went down by 10pc in neighbouring Germany.

Moreover, another new study showed that “in places where there is more euthanasia, there is also a slightly higher suicide rate. … It cannot be proven that if one provides euthanasia, it will bring the suicide numbers down”, according to Prof Boer.

(Previous research from the Anscombe Bioethics Centre found similar results https://ionainstitute.ie/assisted-suicide-does-not-reduce-overall-suicide-rate-says-new-study/)

Prof Boer said that there is a general societal pressure that makes feel the patients a burden to their families and to their country.

He also pointed out that in the Netherlands, one organisation, funded by insurance companies, offers euthanasia. The cost is €3,300, of which the performing physician receives €2,000. “For some of these physicians it is kind of a profit thing. I have heard several of them say that they need this money for several reasons, even though most of them are retired. However, it is officially not for profit. … they only offer euthanasia. They do not offer any other help. They do not offer psychiatric or social help. They can only refer the patient back to where they came from.”

The Swiss group Dignitas, which is also not-for-profit, charges the equivalent of about €11,500, plus VAT, for the complete service, which includes funeral and administrative costs.

As the population ages, and healthcare costs mount, it is easy to envisage insurance companies offering to pat their customers for euthanasia. Think of all the money they would save.