Assisted dying: Where does Irish medicine stand?

An Oireachtas committee on assisted dying will hear contributions from a range of parties, including doctors, in the coming months. Catherine Reilly reports on the positions of Irish medical organisations to date

The ICGP has recently conducted member focus groups on the matter of assisted dying. This engagement comes as a special Oireachtas committee prepares to reconvene in the coming weeks. The ICGP declined to comment on the specifics of the exercise when contacted by the Medical Independent (MI).

“The process of engagement with the College’s members is still ongoing and there is no comment at this time,” a spokesperson stated.

GPs who spoke to MI said the exercise gauged their views and concerns on  potential legalisation. This engagement did not involve polling activity, stated these GPs.

New committee

The first public meeting of the joint Oireachtas committee on assisted dying took place in June. The committee’s role is to consider and make recommendations for legislative and policy change relating to a statutory right to assist a person to end his or her life (assisted dying) and a statutory right to receive such assistance. This may also mean that no changes are recommended. Currently, the acts of euthanasia and assisted dying are unlawful in Ireland.

The new Oireachtas committee was formed after a recommendation by the joint committee on justice, which scrutinised the Dying with Dignity Bill 2020 tabled by Deputy Gino Kenny. This Bill proposed that it would be lawful for a doctor to “provide assistance to a qualifying person to end his or her own life” in accordance with its terms.

A qualifying person was an adult with progressive terminal illness. The person required the capacity to make a rational decision and a “clear and settled” intention to end their own life.

In July 2021, the justice committee determined that the Bill had serious technical issues and lacked sufficient safeguards to protect vulnerable people from undue pressure to access assisted death. It stated that the matter warranted a more thorough examination which could benefit from detailed consideration by a special Oireachtas committee. The Oireachtas committee on assisted dying was established earlier this year and has held five public meetings, with a particular focus on legal aspects to date. The committee, which has access to the submissions made to the justice committee, will report by mid-March 2024.

New Zealand

A relatively small, but growing number of jurisdictions have introduced assisted dying.  A recent example is New Zealand. It established an assisted death service in November 2021 following public support in a referendum held at the 2020 general election (65.2 per cent voted in favour). The processes are set out in the End of Life Choice Act 2019.

The service is open to adults experiencing “unbearable suffering from a terminal illness” and who are competent to make an informed decision. They must have a terminal illness likely to end their life within
six months.

The person must raise assisted dying with a member of their healthcare team (not vice versa). Healthcare practitioners may conscientiously object to providing/supporting the service, but they have certain legal responsibilities (eg, they must advise the person of their right to ask the statutory body for assisted dying for details of a doctor willing to participate).

A doctor and a second independent doctor must assess whether the person is eligible; if required, a psychiatrist will assess the person’s competency to make an informed decision. When the attending doctor informs the person of their eligibility, they may then discuss possible dates and times for the assisted death to take place.

The attending doctor or nurse practitioner can administer the medication by either an intravenous (IV) injection or orally (including by a feeding tube). The person can take the medication themselves by either triggering the IV or taking it orally (the attending doctor or nurse practitioner must be present to support the process).

There are different models and eligibility criteria internationally. Opponents often reference a ‘slippery slope’ whereby models may begin with restrictive criteria and expand over time, with examples from some jurisdictions. They also point to difficulties in identifying coercive control of people with vulnerabilities, evidence that a wish to die can be transient, and ambiguity around prognosis. The views of proponents largely focus on a right to personal autonomy, particularly in the context of suffering and progressive terminal illness.

Debate and discussion on this complex issue are occurring in several countries. In the UK, for instance, assisted dying is the subject of an inquiry by the parliamentary health and social care committee.

Postgraduate/professional body positions

In recent years, some of the UK medical professional bodies have polled members to inform their positions. The Royal College of Physicians (RCP), UK, and the Royal College of Surgeons of England, for example, have adopted ‘neutral’ positions following member surveys (in 2019 and 2023, respectively). This means they neither support nor oppose a change in the law to permit assisted death for patients with terminal illness under specific criteria (both colleges used definitions that referenced a doctor prescribing life-ending medication for patient self-administration in these circumstances). The Royal College of General Practitioners (RCGP) remains opposed to changing the law to permit assisted dying following a member survey in 2019.

The process of polling has prompted controversy due to low response rates and some disagreement about the positions taken. The RCP and RCGP faced potential legal challenges to their positions, but it is understood no such cases have proceeded.

Irish medical bodies – RCPI

The RCPI has formally stated its opposition to “any legislation supportive of assisted suicide because it is contrary to best medical practice”. The position paper, dated January 2021, stated: “Introduction of legislation on assisted suicide has the potential for immense harm and unintended consequences. These consequences are not theoretical; they are based on experience in jurisdictions where assisted suicide/euthanasia has been introduced.”

The consequences included expansion of the groups included under legislation; “inadequate” safeguards for vulnerable members of society; and a negative impact on the role of physicians/violation of medical ethics.

The RCPI position paper was first developed in 2017 by a working group of two palliative medicine consultants, three consultant geriatricians, and one consultant each from respiratory medicine, rehabilitation medicine, and liaison psychiatry. The group reviewed research literature and the positions of medical professional bodies in Ireland and worldwide and made a recommendation to the RCPI Council on the adoption of an RCPI position on “assisted suicide” in Ireland.

The paper was updated by the working group in late 2020 and submitted during the Dying with Dignity Bill consultation.

According to the paper, “dying with dignity is already present in our healthcare system.”

“Dying with dignity in our society is made possible by the delivery of compassionate and supportive and expert care by physicians, nurses, health and social care professionals, and others working in hospitals, hospices, GP practices, and other community settings across the country.

“These efforts are supported by specialist palliative care teams, by the efforts of families and friends, and by extension, the support of society. Legislating for assisted suicide threatens to undermine those efforts.”

The paper outlined a diverse range of concerns, including that “complications may occur in process of death by assisted suicide, which in themselves can cause great suffering”.

MI asked the RCPI about the specialty composition of the working group and whether there were plans to convene a broader group or hold a wider consultation process.

A spokesperson said the 2021 paper represents its current position. “[Consultant in Palliative Medicine] Dr Feargal Twomey, a member of the working group that developed this response, is the RCPI nominee to engage with the Oireachtas committee. The College will engage in future discussions with the membership on this issue as appropriate.”

College of Psychiatrists

The College of Psychiatrists of Ireland’s position paper, published in 2021, stated that introduction of “physician-assisted suicide and euthanasia” (PAS-E) would represent a “radical change in a long-standing tradition of medical practice, as exemplified in the prohibition of deliberate killing in the Irish Medical Council ethics guidelines”.

“We believe it will place vulnerable people at risk, and will lead to harmful consequences such as an increase in the numbers requesting euthanasia or assisted suicide.”

It advocated expansion of palliative care and hospice services; protection of the vulnerable patient and easing the care-giver burden; and enhanced psychiatric care for patients with terminal illness.

The document was prepared by the College’s human rights and ethics committee and approved by the College Council in September 2021.

A spokesperson said there are no plans to update the paper as it is relatively recent.

“While it was drafted as a response to the previous Dying with Dignity Bill 2020 and subsequent discussions on same, the paper represents our position on PAS-E relative to specific groups and patients that psychiatry supports.”

The spokesperson said all published position papers followed a process of
consultation conducted through its faculties, committees, management committee, and council.

“For this paper we undertook an additional step and process which involved our then President emailing all members for views, as well as through the faculties and committees (including the trainee committee).”

According to the spokesperson, the communication sought views in relation to PAS-E and did not constitute a poll.

There are avenues for individual members to voice differing views in addition to the outlined processes, they added.

RCSI

The RCSI’s submission on the Dying with Dignity Bill, dated January 2021, stated its support for the position paper published by the RCPI in 2017 and updated in 2020. This newspaper awaited comment on the process of formulating this position. 

Irish Doctors supporting MAiD

Irish Doctors supporting Medical Assistance in Dying (IDsMAiD) submitted a discussion paper on the Dying with Dignity Bill.

The paper, dated January 2021, was reviewed by the over 100 registered doctors who are members of IDsMAiD. It was also informed by people impacted by “lack of access” to assisted dying and a literature review.

According to the paper, the Bill appropriately restricted the “provision of MAiD” in that it only applied to competent adults; residents of Ireland; and only those with
a terminal illness that was “progressive
and incurable”.

IDsMAiD considered there were a number of “safeguards” to prevent the potential for misuse of the legislation and “to protect vulnerable people” such as a process of independent assessment. The group made recommendations to “enhance” the Bill, including a requirement for comprehensive data collection, audit, and monitoring.

In the context of people suffering with terminal illness, IDsMAiD members strongly believed in “individual patient autonomy” and supported choices for people at the end of their lives.

“While the medical profession has been traditionally opposed to MAiD, there is a growing acceptance within the medical community that MAiD is an ethical issue for society to determine,” according to the paper.

“This is an issue of individual conscience and as such professional medical organisations and colleges should adopt a neutral stance, respecting the differing opinions. Doctors who have a conscientious commitment to MAiD should be protected, if citizens have a legal right to access this medical service. Doctors who have conscientious objection to MAiD, should equally be respected and there should be no compulsion to participate in the provision of MAiD.”

The paper also recorded IDsMAiD’s support for “well-resourced palliative care services” including addressing regional inequalities.

Cork GP Dr Andrew Lyne of IDsMAiD told MI that this position paper remains its most recent. He said the issue comes down to patient autonomy at end-of-life.

“I think when it comes to the end of your life and you are suffering, that is a personal journey. I think the idea of saying that [someone’s] symptom control is sufficient, or that their pain is sufficiently controlled… is a bit paternalistic…. This is a true ethical and moral question as opposed to a purely medical one….”

He said data from Canada showed the most significant reasons for people requesting assisted dying were “an inability to live life in a meaningful way and the inability to perform activities of daily living…. It is not [principally] pain, it is the fact the illness has you confined to bed, you are unable to toilet yourself, unable to dress, unable to perform any activity because of your underlying cancer or neurodegenerative condition, and your only prospect is for this to get progressively worse, there is no prospect of this improving.”

Dr Lyne added that, rather than introducing a broad-sweeping right, he would favour “specific legislation that would have specific criteria and regulations”.

It would be important that the criteria and regulations are reviewed. “That doesn’t mean they are necessarily going to be more expansive; it may be that they tighten or change certain criteria.

“If assisted dying is introduced through legislation, any changes to the regulations and criteria requires further legislation, it is as simple as that. So any legislation changes will have to go through the scrutiny of the Dáil and have to be considered. It isn’t a slippery slope. It is like all elements of our society – will there be changes in 40 or 50 years, who knows, there may be. But those changes would have to be considered by the legislatures at that time.”

Irish Palliative Medicine Consultants Association

The Irish Palliative Medicine Consultants Association (IPMCA) is fundamentally opposed to any potential legalisation of assisted dying in any form. Its submission on the 2020 Bill echoed the issues raised in the RCPI and College of Psychiatrists’ papers.

Dr Regina McQuillan, Consultant in Palliative Medicine, told MI the IPMCA would welcome an opportunity to appear at the new Oireachtas committee sessions. Dr McQuillan said the IPMCA welcomed the fact that this “societal issue” will be the subject of detailed discussion and debate.

“We think it is a very important topic and it is really important that any potential change in legislation is very well considered and well debated.”

She said it is also vital that there is clarity about the role of palliative care and its absolute distinction from “assisted suicide” during the debates and discussions.

She said palliative care was established “in recognition of the struggles of people living with life-limiting illnesses” and to improve their quality-of-life.

In Ireland, she said, there needs to be more resourcing of palliative care services, better access to psychiatry and psychology services for patients, and more evidence-based non-pharmacological interventions for symptoms such as breathlessness and fatigue.

Dr McQuillan also acknowledged that the specialty needs to be more proactive about enhancing public understanding of its role.

“In relation to palliative care, I think there is probably not a good enough understanding among the wider public and wider healthcare services about the palliative care approach to illness, about the idea of treating people in a holistic manner, about trying to improve their quality-of-life alongside managing their symptoms and managing their underlying illness,” she noted.

MI asked Dr McQuillan about the argument by some proponents of assisted dying that prescription of certain medication regimens in palliative care can essentially hasten death at the end-of-life stage.

In response, Dr McQuillan firstly indicated that it would not be common to prescribe a dosing regimen that would have this type of effect. She underlined that the intent of any dosing regimen in palliative care, and other areas of medicine, would be to manage symptoms or disease and not to shorten lifespan. She described how a patient with extensive cancer may be treated with aggressive chemotherapy which has high risks of serious side-effects, including death. The treatment is only given if the potential benefit outweighs the potential harm, though the risk of harm is recognised.

An example in palliative care would be a patient with intractable delirium in the last days of life, who is agitated and frightened. A doctor may prescribe sedative medication with the aim of symptom control and relieving distress. She said doses are carefully managed to reduce the risks of harm such as shortening a patient’s life.

“If you are doing a medical intervention, all doctors are aware of potential harms and potential benefits,” according to Dr McQuillan.

“Your intention is not to sedate the patient and not to cause their death, but your intention is to treat the distressing symptoms of the delirium.”