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Palliative care experts oppose assisted suicide in new position paper

The Irish Association for Palliative Care (IAPC) has voiced opposition to the introduction of euthanasia and physician assisted suicide (PAS) in Ireland in its position paper submitted to the Joint Oireachtas Committee.

They said that outlawing Assisted Suicide “acts as a form of protection for vulnerable patients who may be basing their decision to die on confounding addressable factors, such as a sense of being burdensome” .

The medical experts argued that good palliative care already assisted patients to ‘die with dignity’ – though they meant ensuring that good care led to minimal pain or discomfort, rather than ending the patient’s life.

“Palliative care should not involve any action or treatment which is designed to cause a patient’s death. As such, the Irish Association for Palliative Care (IAPC) has put together this position paper, explaining why the use of euthanasia and physician assisted suicide is not compatible with the goals of providing palliative care,” the Association said.

IAPC was formed in 1993 as an all-Ireland body with the purpose of promoting palliative care nationally and and internationally.

The non-governmental organisation’s mission is to promote high-quality, evidenced-based palliative care in Ireland and internationally through research, education, networking, and publications and to use its expert voice to influence the development and implementation of national policy for palliative care, it states on its website.

The organisation shared its collective concerns on proposals to legalise assisted dying in a submission to the Joint Oireachtas Committee on Assisted Dying / Assisted Suicide made last week. The committee, which was formed in January, is currently in the process of considering legislative and policy change relating to the right to assist a person to end his or her life legally in Ireland.

Members of the IAPC Ethics Forum say a hearing with the Committee has been requested to discuss their concerns. The position paper was drawn up from the expertise of forum members together with up-to-date research in the area, IAPC said. In the paper, authors dealt with a comprehensive range of issues surrounding the topic, including coercion, dignity, personal autonomy, treatment of symptoms in illness, and a patient’s right to make decisions.

Opening the paper, IAPC stressed the importance and value of palliative care, writing that it should “not involve any action or treatment which is designed to cause a patient’s death”:

“Palliative care is a philosophy of care, focused on quality of life, and providing multidisciplinary holistic care to people with life-limiting conditions, and their families. Through the practice of palliative care, care can be provided not just at end of life but at any stage of a life-limiting illness.

‘FORM OF PROTECTION’

“Palliative care should not involve any action or treatment which is designed to cause a patient’s death. As such, the Irish Association for Palliative Care (IAPC) has put together this position paper, explaining why the use of euthanasia and physician assisted suicide is not compatible with the goals of providing palliative care,” the Association explained.

In its submission, it argues that: “The ban on healthcare professionals shortening a person’s life protects those who feel they ought to die.

“It acts as a form of protection for vulnerable patients who may be basing their decision to die on confounding addressable factors, such as a sense of being burdensome”.

IAPC said that while it acknowledged the suffering of those facing illness, solutions “lie in improving” both palliative care and social conditions. The organisation said it did not support any change to Ireland’s laws.

“The Irish Association for Palliative Care does not support any change in the law in order to legalise euthanasia / physician assisted suicide (PAS). We acknowledge the suffering of those diagnosed with serious medical illnesses.

“Solutions lie in improving palliative care and social conditions, and addressing the reasons for euthanasia / PAS requests rather than changing legal and medical practise to allow it,” the organisation said.

‘EROSION OF TRUST’

The organisation cited evidence which showed that the legalisation of euthanasia / PAS could lead to an “erosion of trust” between patients and doctors.

“Palliative care emphasises good communication between patients and healthcare professionals and the collaborative nature of care,” it stated.

“The importance of establishing trust between the patient and the healthcare team is vital so that patients know that their wishes will be respected, even when they are no longer able to voice them. Trust is a key element of any patient-doctor relationship.

“The legalisation of euthanasia / PAS could lead to the erosion of trust between patient and doctor.”

‘WE ACKNOWLEDGE THE SUFFERING’

It also tackled the issue of allowing patients to die with dignity, stating:

“Both the Irish Medical Council (Medical Council, 2019) and Nursing Midwifery Board of Ireland (NMBI) (Bord Altranais agus Cnáimhseachais na hÉireann, 2021) state in their guidelines that when death is imminent, it is the professionals’ responsibility to ensure that a patient dies with dignity.

“Basic principles of palliative care require that doctors offer patients appropriate medication to ensure that they are comfortable and pain free, which may include analgesia and sedative medication.”

“The IAPC endorses the importance of access to palliative care for all who need it,” it added.

“We acknowledge the suffering of those with serious medical illnesses. Our focus is on supporting people experiencing physical and existential distress, seeking to alleviate that suffering, rather than ending their lives. The IAPC does not support any change in the law to legalise euthanasia or physician assisted suicide”.

‘INDIVIDUAL AUTONOMY IS NOT ABSOLUTE’

The national organisation said that it is “the clear duty” of the doctor to ensure that a patient dies with dignity and “with as little suffering as possible”, stating:

“Treatment to relieve distress should not be withheld as long as a doctor acts in accordance with responsible medical practice, and seeks advice when necessary.

“Doctors and healthcare professionals should optimise treatment of physical, psychological, social and spiritual symptoms and they must avoid injury or harm to their patients”.

The comprehensive paper also delved into the issue of personal autonomy, a key feature of the debate around assisted suicide. Authors recognised that “requests for euthanasia or assisted suicide are often motivated by fears of loss of autonomy”.

However, IAPC said that healthcare professionals have a duty to provide care which “respects the values and wishes of patients, and which aims to enhance the patient’s personal autonomy and sense of self-worth”.

It said that while, for some, euthanasia / PAS may be considered an expression of this personal autonomy, “individual autonomy is not absolute, and needs to be balanced against the rights of others, and the needs of society as a whole”.

It said it was  particularly important to consider the “rights of those who are more vulnerable, whether that be due to health status, frailty or social status”.

“Regard for the autonomy of the individual cannot require health professionals to honour requests for euthanasia / PAS, given the harm which could ensue for the patient, for society and for healthcare professionals. The practice of euthanasia / PAS results in the death of a person.

“This is contrary to the principle of avoiding harm which is, in essence, the most fundamental principle governing the doctor-patient relationship. Our focus should be on supporting people experiencing physical and existential distress, rather than seeking to end their lives,” it said.

EXPERIENCE OF CANADA

The position paper also dealt with the issue of the dignity of those affected by disability, long term health conditions and lower socioeconomic status.

Authors used Canada as an example to demonstrate the impacts of introducing a right to die. It said that Canada, along with the Benelux countries where euthanasia and PAS are legalised, have shown the “potential impact of relaxing criteria for euthanasia and PAS in practice on people living in poverty”.

“In Canada, a cost analysis demonstrated the net reduction of healthcare costs that result from the introduction of MAID (Office of the Parliamentary Budget Officer, 2020). It is stressed that this report should in no way be interpreted as suggesting that MAID be used to reduce health care costs. We also stress that potential financial savings should not guide decision making about assisted dying at an individual level,” IAPC wrote.

“Quality of life is not measured simply in terms of physical well-being or productivity. It can be enriched at a profound level, even for those who are severely ill. We need to support and affirm the meaning in people’s lives, learn what is intolerable and respond to people’s needs,” it added.

COERCION

On the issue of coercion, IAPC said that assessing whether the choice to opt for euthanasia or PAS was  being made freely was a “key risk”.

“People respond to the wishes and feelings of others, most especially when we are dependent on them for care. Coercion, intended or implicitly experienced, may not be identified, by either healthcare professionals or others,” authors noted.

IAPC said that issues such as “depression, loss of hope and the fear of being burdensome are more clearly linked to a desire to hasten death for terminally ill patients than the severity of physical discomfort,” citing research from 2018.

“The ban on healthcare professionals shortening a person’s life protects those who feel they ought to die. It acts as a form of protection for vulnerable patients who may be basing their decision to die on confounding addressable factors, such as a sense of being burdensome or mental health conditions”.

PHYSICIAN ASSISTED SUICIDE FOR INFANTS AND CHILDREN

The body also said that it was clear that in places where assisted dying had been legalised, “safeguards have changed over time” – noting how PAS had even expanded to include children in Belgium, infants in the Netherlands, and people with disabilities, and those whose deaths are not foreseeable, in Canada.

“There is concern about the normalisation of euthanasia / PAS in societies where it has been introduced,” the organisation said.

“A focus should be placed on ensuring that patients have access to resources and discussions about end of life and dying. Healthcare professionals need to be upskilled and supported to feel able to engage in conversations about death and dying with their patient,” IAPC said.

It added that it felt “too few” people are aware of options for end of life care, which raises concerns that patients may request euthanasia or PAS because of “fears around physical suffering” which could be relieved.

The IAPC ended the paper by saying it endorsed the importance of access to palliative care for all who need it, rather than changing the law to allow for euthanasia or assisted suicide.

This piece was first published on Gript. 

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