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"Travesty" if assisted dying became "substitute for assistance in living" says top professor

An expert in treating mental health for cancer patients has told the Joint Committee on Assisted Dying/Assisted Suicide that “it would be a travesty if assisted dying became a substitute for assistance in living.”

Professor Anne Doherty, Consultant Liaison Psychiatrist and former chair of the Faculty of Liaison Psychiatry, told the Committee during an opening statement on Tuesday as the Committee met to discuss the topic of protecting autonomy and assessing decision making capacity.

The consultant psychiatrist spotlighted research from Oregon in the US and Switzerland, which reported a “significant increase in older women seeking assisted dying and dying by suicide” – something she described as “concerning” as she asked whether there could be a “gendered influence” at play.

The head of Psychiatry at University College Dublin shared her clinical experience of working with people who had expressed a wish to die – including people with incurable or life-limiting conditions.

She told politicians she was confident that everyone present “shares a vision for the highest standard of end-of-life care, which prioritises access to necessary treatment, and supports the avoidance of suffering, and the highest levels of dignity and autonomy.”

The consultant psychiatrist,  who works in the field of providing integrated care for patients with mental and physical health problems together, is the local Clinical Lead for Self-Harm and Suicide-related ideation, and also works as part of the Psycho-Oncology Service, providing mental health care to people with cancer.

Prof Doherty raised concerns with the Committee, chaired by Kerry Independent TD Michael Healy-Rae, that older women with treatable depression may be impacted by assisted suicide if the procedure is made legal here, due to ireland’s insufficient investment in mental health services.

She said that Ireland has had “notable success in reducing suicide rates” in the past ten years – saying that one likely factor for this was the Clincal Programme for Self-Harm and Suicide related ideation.

“The programme is based on the framework that no problem or set of circumstances is unsurmountable, and that, with good mental health care, suicide can be avoided,” Prof Doherty explained.

The academic spoke of her work in treating people with mental health challenges, including severe depression and people who want to die, as part of the Psycho-oncology Programme of the National Cancer Control Programme, to meet the mental health needs of those suffering from cancer.

“Not everyone who has thoughts of not wanting to be alive is necessarily suicidal, emotions such as helplessness, physical symptoms, mental health symptoms and deficits in social care provision can all contribute to a varying degree, and every individual’s experience is different,” she explained.

“Thoughts of not wanting to live can range from a passive death wish (where the person feels it might be good if they were to die in their sleep), to thoughts of suicide, to plans for suicide, to suicidal acts. The palliative care literature also describes the wish to hasten death, which has similarities to passive death wish.”

Prof Doherty told politicians how she has treated “countless patients” with cancer who have experienced suicidal thoughts – adding that this is “not unusual” according to scientific literature.

“In my experience, with a compassionate approach and the highest possible standard of mental health care we can treat these problems and restore quality of life. The scientific data notes that depression is very treatable in people receiving end of life care, with high recovery rates reported in the literature,” she said.

She pointed out how speakers addressing the Committee to date “have been clear” that those suffering from a mental illness would be “excluded” from assisted suicide legislation. However, she disputed that this may be the case – as she spotlighted the experiences of countries including Australia.

“However, the premise of these types of laws in other countries such as Queensland, Australia is founded on the basis that the person is experiencing intolerable suffering which cannot be relieved,” she said.

“Can mental distress be as severe as physical symptoms in terms of quality of life? Absolutely yes, and this is why in Canada a court challenge has resulted in a change in the law to allow people to access assisted suicide on grounds of mental illness alone,” Prof Doherty told the Committee.

She continued by highlighting findings from the Danish Council of Ethics, which last month warned against assisted suicide in the face of political support.

“This session is entitled Protecting autonomy and decision-making capacity. Is it possible to have robust safeguards which would prevent someone with a treatable depression from accessing assisted dying? The Danish Council of Ethics had doubts about the feasibility of this, stating in their recent report that it was “in principle impossible to establish proper regulation of euthanasia,” she said.

“People can have a significant depression, with symptoms which include low mood, hopelessness, negativity towards the future and a wish to die, without necessarily lacking capacity. However, in such a case the person’s low mood will certainly affect how they think and how they experience emotion. It’s hard to know how we would robustly ensure that a person in this situation would receive mental health treatment if they had an entitlement under the law to assisted dying,” the psychiatrist said.

She added that in addition to mental health conditions and cognitive conditions, there exist a range of psychological factors which could impact on a person’s decision-making, including coercion and elder abuse.

Prof Doherty continued by referencing a systematic review undertaken last year to examine the relationship between suicide and assisted dying – linked to the argument that assisted dying could reduce suicide rates. Prof Doherty said that “suicide rates did not significantly change” in countries where assisted suicide had been legalised.

She explained: “A systematic review is a rigorous research methodology, where, following a search for all relevant research in an area, the studies are evaluated for their quality.

“We found that in countries where any form of assisted dying was introduced, that there was no overall reduction in self-initiated deaths, and that overall, suicide rates did not significantly change.”

She also pointed to research from Oregon in the US and Switzerland, where the practise is legislated for, which reported a “significant increase in older women seeking assisted dying and dying by suicide.”

“This is concerning,” she said, “Because older women have high rates of depression. This trend raised the question of whether these deaths were being driven by potentially treatable depressive illnesses being left untreated, and whether there is a gendered impact influencing this.”

She said that while mental health awareness, along with access to supports, had improved in recent decades, a stigma remains towards mental health challenges in Irish society, with mental healthcare receiving poor funding – (6 per cent in our health budget, compared to 12-13 per cent in comparable countries.)

“We need to address this and ensure that we are providing the highest standard possible of health care both mental and physical and that people have full access to adequate palliative care and mental healthcare. It would be a travesty if assisted dying became a substitute for assistance in living,” the consultant psychiatrist said.

The Committee also heard from Janie Lazar and Justin McKenna from End of Life Ireland, and Dr Caroline Dalton: Director of Undergraduate Nursing and Midwifery Education at UCC and a member of the Healthcare Ethics. Professor Stephen Duckworth also addressed the committee, arguing for “choice and control” over the dying process.

Speaking as the meeting took place, Committee Cathaoirleach Deputy Michael Healy-Rae said that the question of whether safeguards “can be put in place to protect vulnerable people” had been a recurring one.

“The ratification of the UN Convention on the Rights of Persons with Disability and the enactment of the Assisted Decision-Making (Capacity) Act, 2015, has led to a focus on autonomy and decision-making capacity, from a societal, governmental and legislative perspective,” he said.

“Safeguards must be in place to ensure an individual’s right to autonomy is protected, to ensure people are not excluded from a range of decision-making opportunities relating to their end-of-life care but safeguards must also be available to support those who may be vulnerable to pressure or are at risk of having their autonomy undermined in relation to assisted dying.”

The Oireachtas committee has to make a recommendation for or against legalising for assisted suicide by March 2024.



This article was first published in Gript and is printed here with permission


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