This article examines An Bille um Bás Dínitiúil, 2020 to see what is being proposed for Ireland (and what was omitted) from a medical point of view.
This Bill legalizes Assisted Suicide and Voluntary Euthanasia [AS/VE] for terminal illnesses. Assisted Suicide is defined as the “…prescription of substance or substances which can be orally ingested by the person; (b) in the case of a person for whom it is impossible or inappropriate to ingest orally that substance or substances, by prescribing and providing means of self administration of that substance or substances.” [11.2.A/11.2.B] Assisted Suicide is the prime method to be used and Voluntary Euthanasia is allowed if “…it is not possible for the self-administer then the substance or substances may be administered.” [11.2.C]
In Canada AS and VE are both legal and optional. The vast majority of Canadian recipients choose the Voluntary Euthanasia and few withdraw once approved. Curiously, in Oregon—where AS is the only legal option—about 30% never fill the prescription or take the fatal medication. There may be differences between the groups, but it seems natural that humans prefer some other person to ‘do the deed’. Over time there will be a move to make Voluntary Euthanasia more available in Ireland.
Preamble
The initial sentence promotes the Bill and “…provision for assistance in achieving a dignified and peaceful end of life to qualifying persons and related matters.”
Dignity is a complex issue. Some might question whether taking one’s own life—or being killed by another person—can ever be ‘dignified’ especially if that action is precipitated by a lack of self-worth.
Palliative Care focuses on the dignified and peaceful end to life—without directly killing the patient.
Interpretation (Definitions)
Even in the ‘Interpretation’, Irish doctors, nurses and HC professionals are being conscripted to provide AS/VE, despite 2000 years of medical ethics to the contrary: “attending medical practitioner is the registered medical practitioner from whom a qualifying person has requested assistance to end their life…”
And,
“healthcare professional” means a member of any health or social care profession…”
If society mandates the provision of AS/VE, there should be a new, well-regulated provider. Doctors and nurses should remain the patient’s care-giver, advocate, counsellor and should be able to shield a patient against coercion and involuntary euthanasia.
Qualifying persons: Section 7
“…a resident on the island of Ireland and has been for not less than one year.”
Remarkably the definition of “Qualifying Persons” includes citizens of other countries. In particular it includes most adult British Citizens living in Northern Ireland (which will cause ‘Euthanasia Tourism’ to the Republic.)
Ireland is likely to have some interesting experiences dealing with countries like Russia, China and Iran when killing their citizens (even if the person themselves are willing.)
Terminally ill: Section 8
Most of the definition for the ‘terminally ill’ seems reasonable though the Bill does not specify a time-frame within which the Qualifying Person is expected to die. (In other countries, legislation frequently sets a time limit on the prognosis such as ‘death expected within 6 months.’) Irish providers might need to be circumspect if life expectancy is 12, 24 months or longer because reasonable people will then question whether AS/VE is for a “Terminal Illness” as most understand the term.
Declaration: Section 9
Like many countries this Bill allows for all of the assessments to be performed by just 2 doctors. Even though they act ‘independently,’ the doctors are most likely “like-minded” and in favour of AS/VE.
This Bill does not require any psychological testing before a doctor or nurse can become a provider. No psychological testing is required for those who provide AS/VE on an ongoing basis.
The 2 doctors must have: “separately examined the person and the person’s medical records” but there is no requirement to have known the patient prior to the request nor to communicate with the regular health-care provider or family, etc.
The two doctors must ensure that the: “person making it has been fully informed of the palliative, hospice and other care which is available to that person” but there is no requirement for the patient to have a palliative-care consultation, psychiatric assessment or review by a Social Worker, etc.
The Assisted Dying process can be revoked verbally: “A person who has made a declaration under this section may revoke it at any time and revocation need not be in writing.” The Bill is not clear whether the revocation then requires the process to start afresh if the patient changes their mind a second time and then wishes to continue the Assistance in Dying process.
The two doctors must ensure that the requesting person “has a clear and settled intention to end his or her own life which has been reached voluntarily, on an informed basis and without coercion or duress.” [9.3.C]
Coercion and duress are sometimes subtle and pervasive. A survey in Washington State showed that 56% reported they felt they were ‘being a burden.’ Even decisions by government to limit health care or social services can coerce people into accepting AS/VE. (Ask Roger Foley in Ontario, Canada what happens where there is a lack of home-care services.)
Brid Smith, TD—one of the sponsors of the Bill—verbalized a subtle form of coercion during the debate in the Dáil when she suggested that a person will choose Assisted Suicide/Euthanasia because “that choice is made out of love…for the life of those you are leaving behind.” The obvious corollary—which she did not verbalize—is that you do not love people if you choose to live with the terminal illness.
Assessment of capacity: Section 10
Of concern is that this Bill allows consent from a significantly demented patient: “The fact that a person is able to retain the information relevant to a decision for a short period only does not prevent him or her from being regarded as having the capacity to make the decision.”
Memory is an essential part of competence. We must be able to remember our previous decisions so we can amend them at a later date, if we so choose.
Assistance in Dying: Section 11
Waiting periods between the request for assistance and its provision are specified in the Bill. Over time this will be challenged by people who wish to proceed with their death immediately.
The process includes “The attending medical practitioner or assisting health care professional must remain with the person until the person has (a) self-administered the substance or substances or have it or them administered, (b) decided not to self-administer…or have it or them administered…is to be regarded as remaining with the person if the attending doctor or assisting healthcare professional is in close proximity to, but not necessarily in the same room as, the person.”
A particular concern is that the Bill does not require the attending medical practitioner (or their delegate) to witness the death of the Qualifying Person. Indeed, the attending medical practitioner does not even have to witness the ingestion of the poison (“not necessarily in the same room.”) This section does not specify what must occur in the event of the recipient having a complication at a time the attending medical practitioner is no longer available.
Conscientious objection: Section 13
The section on conscientious objection starts off well: “…nothing in this Act shall be construed as obliging any medical practitioner or assisting healthcare professional to participate in anything authorised by this Act to which he or she has a conscientious objection.”
Then the ‘BUT’: “A person who has a conscientious objection referred to in subsection (1) shall make such arrangements for the transfer of care of the qualifying person concerned as may be necessary to enable the qualifying person to avail of assistance in ending his or her life in accordance with this Act.”
Many doctors consider the making of “arrangements for the transfer of care…” to be actively participating in the provision of SA/VE. Many perceive this to be unethical or immoral.
In Canada a similar proviso was made by the Supreme Court of Canada (“In our view, nothing in the declaration of invalidity which we propose to issue would compel physicians to provide assistance in dying.”) Despite that statement and despite the Superior Court of Ontario acknowledging there was indeed religious discrimination, the SCO supported the requirement for physicians to provide an “effective referral.” (Alberta has an effective self-referral route for patients.)
Obligation to keep and provide records: Section 14
“Not later than seven days after the medical procedure has been carried out, the attending medical practitioner: shall make a declaration in the prescribed form and manner confirming that the procedure has been carried out in accordance with this Act; and shall forward, or cause to be forwarded, copies of the declaration to the Registrar of Births, Marriages and Deaths and to the Review Committee.”
This does not clarify whether the documentation to the Registrar includes the Medical Certificate of the Cause of Death. The Bill does not state whether deaths caused by AS/VE must be reported to the Coroner.
Assisted Dying Act Review Committee: Section 15
“The Minister shall, by order, appoint a day to be the establishment day for the purposes of this Act. On the establishment day there shall stand established a body to be known as the Assisted Dying Act Review Committee.
This is the total definition for the Assisted Dying Act Review Committee (other than they must receive documentation from the attending doctors on each AS/VE.) The Bill should provide clarity on the composition, powers, structure and governance of this Committee.
Other than if Ireland does not legalize Assisted Suicide/Voluntary Euthanasia, ante-mortem review of each case by the Review Committee (**while the Qualifying Person is still alive) is the appropriate way to minimize the risk of a citizen/resident being killed in error.
Dr. Kevin Hay
Kevin is a UCD grad & now a rural Family Physician in Alberta, Canada. He has been writing on Medical Assistance in Dying in Canada for the past 3 years. He has published Pro-Life/Whole Life articles in The Province (Vancouver) The Hamilton Spectator, Where Peter is (wherepeteris.com) and Catholic Arena (catholicarena.com) You can follow him on Twitter: @kevinhay77.