Skip to main content
Normal View

Joint Committee on Assisted Dying debate -
Tuesday, 3 Oct 2023

Ethics of End-of-Life Care: Discussion

Parliamentary privilege is considered to apply to the utterances of members participating online during a committee meeting when their participation is from within the parliamentary precincts. There can be no assurances in relation to participation online from outside the parliamentary precincts, and members should be mindful of this when contributing. This committee discusses dying, including suicide. Support information can be found on the committee's web page.

Our business today is engagement on the topic of the ethics of end-of-life care. This is part of the module on ethics and professional issues. I warmly welcome: Dr. Annie McKeown O'Donovan, who received her doctorate in philosophy from the University of Galway in 2022 and who now works in the centre for transformative learning at the University of Limerick; Dr. Thomas Finegan, assistant professor with the department of theology and religious studies at Mary Immaculate College; and Dr. Kevin Yuill, CEO of Humanists Against Assisted Suicide and Euthanasia and associate professor of American history at the University of Sunderland.

We are grateful to them for sharing their knowledge with the committee. We will start first with the opening statements, which will be five minutes each. I call Dr. Annie McKeown O'Donovan first.

Dr. Annie McKeown O'Donovan

I thank the committee for the invitation to be here today and to contribute to this conversation. As the Cathaoirleach has already said, I completed my doctoral research, titled "Ethics and Assisted Dying in the Republic of Ireland", in 2021. My research provides a practical, achievable, philosophically defensible and, hopefully, socially acceptable position on this debate. It will in turn alleviate some fears about descending any slippery slope.

The term "assisted dying", as I use it, refers to the active assistance to die that is given to someone who is already dying. The dying person is the one who directly self-administers the life-ending substance. The necessary condition that a person is already dying and, indeed, will soon be dead anyway, is not necessarily present in the concepts of assisted suicide and euthanasia.

My research argued in favour of the moral and legal permissibility of assisted dying in Ireland within strict, ethically defensible parameters. The individual on whom I focused is imminently dying and has repeatedly and rationally requested assistance in dying. The one who is imminently dying is commonly suffering from a terminal disease that is an irremediable, incurable condition, which is expected to lead to death within a short period of time. I argued that this repeated and rationally made request for active assistance with death should be respected and fulfilled when it comes from someone who is imminently dying; who has exhausted all avenues of available respite; who finds their current and prospective quality of life unacceptable; who values death now more than an inevitably short period of life which is judged by them as intolerable, resulting in death anyway; and who values death now.

Ethical and professional issues are complex here. Public inquiries concerning assisted death hinge on this interaction between conceptual matters and their practical implementation. The prominent concepts addressed in such inquiries are often autonomy; the value of life; the doctrine of doing and allowing; the distinction between killing and letting die; the doctrine of double effect; and arguments about slippery slopes. I will briefly address some of these.

The word "autonomy" comes from the Greek word meaning "self-rule". Practically, this is the capacity and ability to decide what to do with one's own life, as well as when and how. This is always governed by one's bio-psychosocial temporal setting. An individual's decisions cannot be realised unless they have the support of others. We are socially situated beings and, as such, our autonomy and ability to be autonomous is inherently relational. Assistance in dying comes from someone else, arguably a healthcare professional. Their wish to provide this compassionate support in dying, or their refusal to take part in something they conscientiously object to, is also relational and needs to be recognised as such.

That human life is intrinsically valuable forms the basis of many arguments against assisted dying. I do not refute that human life has moral worth and value but rather assert that life has prima facie moral value that can be overridden in specific narrow contexts. Life's value can diminish in line with the perceptions of the individual whose life it is. In this context, when someone who is imminently dying wants to die now, rather than soon anyway, we only need to concern ourselves with the value of a very short period of time, a period of time in a life that is characterised by dying and the want to die. Of course, it is still morally valuable, but what needs to be meaningfully considered is whether prolonging this period of life, characterised by dying and the want to die, is morally preferable to assisting this dying person to die now, rather than soon anyway, if they want to. This latter choice could be seen as part of compassionate palliative care.

The doctrine of doing and allowing, or acts and omissions, proposes that actions that cause harm are morally worse than omissions of actions that allow harm to happen when the consequences of either doing or allowing are the same.

There are structural distinctions here which are often confused with moral distinctions. The move from structural to conceptual is complex, and I am happy to answer questions on this issue. When we apply this principle to assisted dying it can be interpreted as saying that actions that cause death are morally worse than omissions that cause death. In the context of an imminently dying individual who wants to die now rather than soon anyway, this moral application may be skewed and that is because the force of the distinction is much less in cases of late stage terminal illness. Omissions of action that allow death to occur, like the withholding of life-sustaining treatment, for example, can prolong the period of life that has been identified as harmful by and to this person who is dying. Acting to cause death now rather than merely allowing the person to die soon anyway can be seen as the more compassionate and morally preferable action. This helps to justify limiting assistance to these cases only. When this is articulated in the language of killing and letting die, we have the problem again. Instances of killing are frequently deemed morally worse than instances of letting die, and this simplifies the reality of experience because intention and context must play a role. When the intention is to relieve an individual who wants to die now of the short, harmful period of life at the end of his or her life that is characterised by the dying process and when other safeguards have been met, it can be morally better to act to cause death now rather than allow the patient to die soon anyway.

The slippery slope is usually defined as a form of argument where it is proposed that if P happens, then Q will happen and R will happen, resulting in S. We do not want S to happen; therefore, we should not permit P. This form of argument is often used against the introduction of assisted dying. It is compelling because it plays on our fears about what might happen in the future, fears regarding our uncertainty about the practical implementation of conceptual matters, and because it can be supported by empirical evidence. Laws have changed in some jurisdictions to widen the parameters of what is allowed and this is sometimes taken as proof that the slippery slope exists. However, descending down a slippery slope is not inevitable. Empirical evidence also demonstrates that we can safeguard against such a descent. The slippery slope argument makes a journey from a moral commitment to theoretical and value laden concepts to the practical application of these concepts in some hypothetical future. This move is neither always reasonable, straightforward nor a good basis for policy formation. Legalisation of assisted dying in Ireland will need the care of strict and considered safeguards, with the fine-tuned interpretation of ethical and professional issues and an examination of how conceptual concerns play out in practice.

I thank the committee for the opportunity to contribute to this process.

Thank you very much. Dr. Finegan is next.

Dr. Thomas Finegan

The main points I wish to make involve the moral logic underpinning the legalisation of assisted suicide and, or voluntary euthanasia. I use the term "euthanasia" to refer to both, and by that term I mean the deliberate medical co-operation in a competent person’s autonomous choice to end his or her own life. My remarks here are explained and defended in greater detail in my written submission.

The unique, distinguishing feature of euthanasia is the consensual, intentional killing of the patient. Introducing death as a legitimate healthcare intention would not be a mere expansion of healthcare. Rather, it could only be introduced by disavowing a primary healthcare norm, that of no intentional killing. The norm against intentional killing is a moral requirement necessary to protect equally the life of every person, which is of profound inherent worth, from being attacked. When the norm is sidelined to accommodate euthanasia it can no longer be maintained consistently that every human life is of intrinsic, equal, and inviolable worth. For the new law would now facilitate an individual to judge that his or her life has lost or is losing value such that death is preferable to life, and, on the basis of that judgment, to choose death and thus to treat his or her life as violable. Here, legal facilitation occurs precisely out of moral respect for both the individual’s judgment and his or her choice, the choice being contingent on the judgment. Euthanasia, then, is a violation of the intrinsic value of life. Since a person is inseparable from his or her life, euthanasia is also a violation of persons. It ends them through death, which itself is both a harm and a loss.

Against this, the central euthanasia rationale argues that choices for death are morally protected by the respect owed to individual autonomy in so far as expressions of autonomy concern the most important, self-regarding decisions one makes in relation to one’s life. It is a rationale which, once accepted, becomes the most important and directly relevant moral standard by which euthanasia restrictions and safeguards are to be judged. Acceptance of euthanasia’s autonomy rationale requires thinking very differently about killing and death. Outside the euthanasia framework, they are considered inherently bad.

Inside the framework, however, consensual death and killing are judged positively as morally protected expressions of autonomy. As such, acceptance of the autonomy rationale requires rejecting attempts to restrict euthanasia in order to limit consensual deaths. This poses a problem for proposals to legalise euthanasia insofar as such proposals advocate restrictions. When legalisation of euthanasia occurs per the autonomy rationale, there appears to be no consistent, non-arbitrary justification for limiting euthanasia access. Any line drawn between a legitimate euthanasia ground and an illegitimate one or between an acceptable annual number of cases and an unacceptable number thereof will appear as unfair discrimination against patients excluded from the right to access euthanasia. 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. Tellingly, pro-euthanasia contributions at the committee have, in general, avoided affirming euthanasia restriction.

It thus becomes clear that the real principled moral choice is not between no euthanasia and very limited euthanasia; rather, it is between no euthanasia and largely unrestricted euthanasia. As such, euthanasia becomes more obviously a rejection of a fundamentally important ethical norm, namely, no intentional killing. The fact that restrictive euthanasia provision is arbitrary helps to illustrate how principled, coherent and protective is the norm against intentional killing. A legislative decision to reject that norm would be much more ethically momentous than any subsequent decision to widen euthanasia grounds. It follows that a restrictive euthanasia model, such as the Oregon model, amounts to an ad hoc unstable compromise with an in-built orientation towards expansion of euthanasia grounds and increase in euthanasia cases. The orientation is demonstrated in the clear general trend towards expansion in countries that have had legalised euthanasia for five years or more. All of them have seen a substantial increase in annual euthanasia cases and, among those that legislate for grounds, all bar one have witnessed significant widening of grounds, whether occurring de facto or de jure or both. The movement is in one direction. If anything, it is accelerating. As my written submission explains, Oregon itself is subject to the trend of expansion and there is no reason to think New Zealand - which is based on the Oregon model - will prove any different. These trends support the claim that the idea of limited euthanasia is both morally incoherent and practically unstable.

A proposal to legalise euthanasia requires very careful thought about moral principles and moral consistency. Legislators should inhabit the central rationale of each of the two basic possible positions and think through whether a middle ground genuinely makes sense, or whether even a small step on a new path involves a radical reorientation away from key goods enshrined in the status quo, a reorientation which leads to a very different way of viewing healthcare, equality of human lives, killing and death, solidarity and the good.

As a matter of clear and coherent basic principle, our healthcare currently excludes choices to self-kill. Within the euthanasia framework, however, a consensual choice in favour of death becomes a principal part of good healthcare. There is no stable middle ground. The current law is the only credible safeguard on offer against the normalisation of consensual killing in healthcare.

Dr. Kevin Yuill

I thank the committee for inviting me to appear. I am emeritus professor of history at the University of Sunderland, chief executive officer of Humanists Against Assisted Suicide and Euthanasia and author of Assisted Suicide: The Liberal, Humanist Case Against Legalization. We are a group of individuals from various walks of life who are united by our lack of religious beliefs and our opposition to the legalisation of any form of assisted suicide or euthanasia. From here on, I will refer to it as assisted dying, though I have problems with the terminology.

A moral rule against killing is worth keeping even if we tolerate exceptions to the rule, which we should. Protecting life can only occur with a law against killing. Defining killing as medical treatment for suffering is inherently problematic and logically progresses to include anybody who suffers.

I will make four points. The first is that this issue is entirely different from abortion. Many of us, not least me, supported the repeal of the eighth amendment. Abortion is necessary for women to be equal to men. It is a real solution to a real problem. In contrast, the case for assisted dying is based on fear. The answer to fears about death, however, is better palliative care.

For those who are not, assisted dying is not the answer. In the Netherlands, where it has been legal for more than 20 years, between 28.5% and 42.8% of dying patients still experience pain and restlessness in their last hours, days and weeks. One can see that assisted dying is not the solution for that particular problem. We argue that abortion is a necessary event that must have legal and medical sanction. In contrast, the law needs to retain a reverence for human life, not just potential human life, and continue to treat death as a serious and solemn event rather than simply reducing it to a medical option.

The second point is that the case for legalised assisted dying is flawed. The case rests on two basic premises, and has done since it was first brought into being or proposed seriously in the modern form in 1870. Those premises are autonomy and compassion. True autonomy would mean that anyone with suicidal impulses should be allowed to have an assisted death. Compassion implies euthanasia and a judgment that death is in another individual’s best interests. As a historian, I can provide many examples of how that has become problematic and of how acting on compassion is not always a good thing.

Third, evidence shows that assisted dying has harmful effects where it is implemented. In every country where it has been legalised for a reasonable length of time, as the previous speaker said, cases have increased rapidly and the criteria for eligibility have expanded. I draw the committee's attention to Canada, the land of my birth, where assisted dying was legalised in 2016 and where many seek it for problems of homelessness, poverty and inadequate medical resources. Some 17.3% of those who opted for it in 2021 cited loneliness and-or social isolation as a reason. This is before mental illness becomes an eligibility criterion in March 2024. In the Netherlands, it has expanded. I will not go into it. Members can ask me if they like; I have it chapter and verse on that, as is said. We have seen a number of grotesque examples of unnecessary deaths outside of Canada, namely, in Belgium and in the Netherlands in particular, where it has been legalised for some time. For instance, we can see there have been at least eight cases in the Netherlands where the only illness was autism and the reason cited was intolerable disruptions to daily routines. There have been many more for mental illness. In Belgium, euthanasia for those suffering from dementia is increasingly routine. Even in the United States, where proponents pointedly do not campaign for extensions to criteria, it has expanded.

Fourth, we believe that it is wrong for the state to kill citizens, whether as punishment for a crime, as in capital punishment, or simply because peoples’ lives are wretched, either in their judgment or somebody else's. The problem is not the fate of the individual concerned but the fate of a society that agrees to kill them. Even when it involves best possible motives, institutional killing by the state is problematic. We have seen the grim evidence emerging from Canada, and we urge Ireland to think again about this issue and keep the law as it stands.

I thank Professor Yuill. Before we go to members, I remind everybody that we are going to be strict on time. Each person has six minutes, and that includes for the answer. I ask members to address an individual witness. If they are leaving it open to all of the witnesses to answer, I ask them to please state that. First is Deputy Higgins.

I thank the Chair. I also thank our esteemed witnesses for being with us today. As a committee, we have a very difficult job to do in a very short timeframe, so it is great to have their expertise to lean on.

I will start by saying that Professor Yuill and Dr. Finegan, to summarise their statements, have effectively taken issue with the idea of death as a medical treatment. Dr. Finegan said there is no stable middle ground here.

Dr. McKeown's testimony offered the counter perspective to both of those. My interpretation of her testimony is that medical treatment is about minimising harm and respecting the wishes of the patient and that strict and considered safeguards are a middle ground and could be done in a way that there is no slippery slope. Will Dr. McKeown O' Donovan tease that out a bit more for us given that she has now heard what Dr. Finegan and Professor Yuill have had to say with regard to those two specific points?

Dr. Annie McKeown O'Donovan

When we look at consensual life ending it is something that is compassionate and happens when life is ending anyway, we can reduce our concern about killing as a medical treatment because what we are doing, as the Deputy said, is minimising harm and suffering at the end of life. It can be something that is done within a palliative care setting. It can be done as something that is a choice and it can be done with care. It is not something that all healthcare professionals would be obliged to take part in. There is also the argument that this happens in end of life settings anyway. People's suffering at the end of life is reduced and death is sometimes hastened as a foreseen consequence as opposed to an intended consequence of careful and compassionate treatments

I know Dr. McKeown O' Donovan has done a lot of research in this area. I was quite struck by her summary of the research and how she says that it provides a practical, achievable philosophical, defensible and hopefully socially acceptable position in this debate. I thank Dr. McKeown O' Donovan for putting this perspective on the record with us. There has been a lot of discussion over the last couple of sessions on situations outside of imminent death. Will Dr. McKeown O' Donovan talk to us about that period of imminent death and why she feels that is what the committee should be concentrating on?

Dr. Annie McKeown O'Donovan

The concern that happens when death is not imminent is because of the possibility of life getting better. If someone wants to die with assistance due to chronic mental illness or for other reasons there is the possibility that life might get better for that person. When death is imminent, the period of life that we are concerned with is of a very short duration. Life is going to be over soon anyway. It is about making this short period of time as tolerable and as good for the person as possible and that helps us to narrow the parameters.

I will ask Dr. Finegan to comment on that point, when we are speaking about just that particular period of time when death is imminent and the person has decided for themselves that they are in intolerable pain or suffering. We have heard about Canada and the Netherlands where they are looking at very different stages in people's lives under very different circumstances. Does Dr. Finegan feel that is a stable middle ground?

Dr. Thomas Finegan

It is certainly not. One can test it for oneself by considering the rationale which is proposed for getting to that point. The rationale offered here is that first of all we respect rational choice, we then respect autonomy and we then seek to minimise harm. That triumvirate urges much wider euthanasia access beyond cases of terminal illness. There is nothing within any of those goods that would restrict the case for euthanasia to six months of terminal illness. In fact, if we are looking to minimise harm then the case for considering chronic illness within the parameters of acceptable euthanasia is stronger than when we consider terminal illness. Someone with a chronic condition could say that they have more harm ahead of them in their life. Someone with a terminal illness can say truthfully that their harm is coming to an end. The rationale is not at all stable. When scrutinised, it contains no reason for the restriction that it posits.

If this was introduced with very specific safeguards that people would then perhaps take a challenge because they did not feel that their situation was within the parameters of those safeguards and that things would naturally as a result expand? Is that the doctor's concern?

Dr. Thomas Finegan

As a matter of reason they would be orientated towards expansion, whether it be people taking challenges or the law overlooking what is happening or the judiciary interfering or legislators considering future amendments 12 or 18 months down the line.

The rationale has been directed on a path towards greater expansion such that those who try to limit it run up against the very reasons for introducing the law in the first place. They run into the questions of coherence and arbitrary discrimination and the problem of not having a stable, rational basis for excluding persons who wish to have euthanasia access. This is by no means a theoretical proposal on my part; it is very well backed up by the fact of how legislation has proceeded after its introduction. Even in Oregon, which has made a concerted effort at one level to be restrictive – through restricting to cases of terminal illness – we still see within the public data instances where chronic illness is passed as a justifiable ground for euthanasia. A concept that has been alluded to is that of someone thinking the value of his or her life is eroding or the idea of life's value diminishing according to the views of the person whose life is entailed. That could apply to anyone, whether terminally ill or not. There are four reasons offered that together justify euthanasia access, and individually and together they run counter to restricting euthanasia access to cases of six months' terminal illness or even to physical suffering.

I thank everyone for their contributions. I will ask all my questions now. I would like the delegates to note them rather answer each as it is asked.

The first question I have, for Dr. McKeown O'Donovan, is about value. She mentioned the value of a very short period of life, the life that is left. When considering the intrinsic value of life, can we somehow consider it to be different if death is imminent? Is the value of the portion of life left to live somehow different from that which has come before it? How is suffering categorised ethically? We talk a lot about ending someone's pain and we consider palliative care as an option allowing people to die peacefully, but we have to consider how suffering may go beyond actual physical pain. We must also consider whether someone is even coherent in the final days when they receive medication at a level that means they are not able to engage with family, talk or say proper goodbyes. They may be heavily medicated. How do we categorise that?

Having read Dr. Finegan's written submission, I respectfully refute the assertion that "Tellingly, pro-euthanasia contributions at Committee have generally avoided affirming euthanasia restrictions". That is unfair to the work of the committee because we have not affirmed anything; rather, we have tried to explore the boundaries and the lengths to which the conversation can go to best understand where the safeguards lie in terms of being able to fully examine an issue. It may be premature to state the committee has affirmed or not affirmed something in that sense.

Dr. Finegan mentioned the intrinsic value of life, something I keep pondering. I am wondering whether will, autonomy, agency and those other things we speak about also relate to the intrinsic value of life. How do we separate them? Is will of value in and of itself, or do we place a value on it only when we consider its consequences? I am referring to the will to live and the will to die. Do we oppose somebody's intrinsic values of autonomy and agency by separating them from the intrinsic value of life? It goes back to what I think Dr. McKeown O'Donovan said about not doing one thing because of the consequences of another. What is Dr. Finegan's position on the intrinsic value of will?

My other question is for Dr. Yuill. We were concerned when we read the comments on homelessness and unmet State needs.

However, I struggled to find a source for the observation in his opening statement that, "Canada is the most dramatic example [and we have heard many statements about Canada] where, having legalised in 2016, many seek euthanasia from problems of homelessness, poverty and inadequate medical resources." Looking at the application form, I see there is space for additional information. Is Dr. Yuill saying applicants have mentioned those things as part of the reason, or the only reason, they are seeking euthanasia? Is somebody who is homeless saying he or she would like to avail of euthanasia for that reason? There is also a part of the application form that looks for where somebody lives, whether they are incarcerated or perhaps live in a hostel. Is it their address that points out they are homeless or are they presenting with that information? I am wondering what is the source of that information. Has somebody availed of euthanasia because he or she is living in poverty and that is the only reason?

Loneliness has also been mentioned. I would want to know whether that is just one reason provided under the additional information section or is it the sole reason. Are we saying that is another matter that people consider when looking at their disability or illness if, for example, they have a cancer diagnosis? Such people might also mention that they are lonely. I want to ensure that the information we have is clear and accurate in that sense.

Dr. Kevin Yuill

The Senator has asked if applicants mention homelessness or if that is the sole reason for their application. What happens in Canada is that because the system is based on a charter of rights, people have the right, if they meet certain criteria, to an assisted death. The homelessness issue is a question of filling out forms correctly and-or doctor shopping, which people are able to do in Canada. The information about that is that people mention homelessness when they are asked about it or after they have been accepted. I can think of one particular case and I am sorry that I have forgotten the name of the gentleman involved. A 50-something-year-old homeless person filled out the form and had agreement from one doctor but not from two, which is necessary in Canada. He told the newspapers that his suffering was the result of homelessness. 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. Only the person who is suffering can define that. If somebody is suffering, his or her suffering is usually made up of many different things. It is not simply physical pain. There can be many different components. The Senator asked if people mention homelessness. They do, but they also meet the criteria for other reasons as well.

We share the aim of reducing suffering. The real question is whether by passing this legislation we are meeting the aim of reducing suffering without creating more harm. My argument is simply that more harm will be created by implementing this legislation.

I completely agree with the point that these safeguards will not be retained. Canada introduced the legislation with the idea that assisted dying would be restricted to those whose death is reasonably foreseen. Canada removed that because there is no moral distinction to be made between someone with six months to live or who will die imminently and somebody with longer suffering.

Dr. Thomas Finegan

When I said in my opening statement that, tellingly, no affirmations of restrictions had been made, I had in mind witnesses who have come before the committee and made a pro-euthanasia case.

The Senator raised the issue of will, autonomy or agency as a basis for life. I do not think any of those considerations can be the basis for the intrinsic value of human life, as understood by, for example, human rights documents because one could have a will and choose to think of oneself as not having value. That happens.

This is a very significant societal problem. Because that is so contingent, it cannot be the basis. Even if someone thinks that their life does not have value, they are tragically mistaken. They do have value. They have intrinsic, equal and inviolable value in their life and that is the basis of law for 2,000 years, and beyond.

If that is also the basis, the idea of them having will or agency means that those who, for example, are very young or have lost capacity, would be excluded from having human worth and having human rights protection.

From the point of view of healthcare protection, it makes no sense to focus so much on the idea of will and autonomy. Healthcare is about valuing body, health and life. It is a particularly pernicious idea to be incorporated into the healthcare system, aside from its general wrongness.

I thank Dr. Yuill and call Senator Ronan Mullen.

I thank the Cathaoirleach and welcome all of our guests and thank them for their contributions. What strikes me about the freshness of Dr. Yuill's contribution is that he is saying that very often the argument around euthanasia and assisted suicide is that at the root of the objection to it must be some kind of religious itch, whereas his presentation, perhaps would be quite challenging to many people in that he is addressing it through an exclusively social concern.

I was perhaps more struck by the contrast between the perspectives of Dr. Finegan and Dr. McKeown O'Donovan because what Dr. McKeown O'Donovan proposes as a "slippery slope" that we should not worry about is, however, where Dr. Finegan is suggesting that it is something more of a cliff, if I can put it that way. Is it fair to say that Dr. Finegan's ethical argument can be summarised in saying that if healthcare includes self killing; then self killing becomes normalised and ultimately turns healthcare on its head? Dr. McKeown O'Donovan is putting it to us, even in her use of the phrase "slippery slope"and that that thinking plays on people's fears. Is it not the case that the actual slippery slope thinking is very much an analysis that wherever euthanasia or assisted suicide is legalised, that things begin to move in respect of the wider expansion and the increase in numbers? Dr. McKeown O'Donovan said that there is empirical evidence that that does not happen but she did not give us any empirical evidence. Can she give that now, please, because Dr. Finegan seems to be offering empirical evidence even from Oregon that it does happen?

Dr. Annie McKeown O'Donovan

If one is characterising the "slippery slope" as something we are going to start by allowing a practice, and that in some future many other practices which we find objectionable are going to happen, then there is empirical evidence that that happens. We have not discussed why those practices which were initially found objectionable are not now found objectionable. What has happened in that intervening time? Have we expanded our understanding of choice at the end of life to recognise, as Dr. Finegan said, and include other qualities of people at the end of life into the first instance? I believe that the "slippery slope" is a very useful type of argument and it helps us to have these kinds of discussions which will help us to create strong and good safeguards. Using "slippery slopes" as a refutation against any kind of progress undermines our ability to, in fact, distinguish between cases which are impermissible and those which are permissible. It is useful to engage with that analogy.

With regard to the empirical evidence where it has not happened, the evidence which will come from New Zealand, perhaps, may offer this. It was said that it may follow the Oregonian path also, but that remains to be seen.

If one considers the idea of "intention" in law, where one presumes to intend the natural and probable consequences of one's actions, it strikes me that from what Dr. McKeown O'Donovan is saying is that she wishes that there might be empirical evidence to show that attitudes do not change. We heard from Professor Theo Boer last week who spoke about the social pressure which seems to have come on people because of euthanasia laws in his country. What one sees is a transformation of attitudes in society. It seems to me that what Dr. McKeown O'Donovan is actually saying is that there is a slippery slope in that people's attitudes change once one introduces this in some form. Is that not what we have to try to consider? People, for example, are more likely to feel a burden where they have severe illness or families may feel, really and truly, that there are better ways to deal with a long and lingering illness.

We must also consider the people who fund healthcare. We have heard of the case in Canada where a formerly elite Paralympian athlete sought a chairlift for her house and was offered euthanasia. Is this not what Dr. Finegan is talking about? Things change once you admit the principle that some people's lives can be ended and that the State is less interested in supporting some people in continuing to live. Is such a change of attitudes not the slippery slope?

Dr. Annie McKeown O'Donovan

Of course attitudes will change and evolve. That is human nature. Will the Senator repeat the last part of his contribution?

I give the example of older people being more likely not to value their lives or to feel they are a burden because the law allows them to legally have their lives ended. Is that a change of attitude Dr. McKeown O'Donovan would welcome in our society?

Dr. Annie McKeown O'Donovan

I suppose that could be reframed as an attitude supporting choice at end of life and supporting different choices. Such provision and increased care at the end of life are not mutually exclusive.

Where is the solidarity? If you make choice the supreme idea, how is the impact individuals' choices might have on other people's sense of worth, ability to cope with illness or sense of entitlement to State-funded healthcare considered? If all of those things are impacted negatively by somebody's individual choice, do you not have a social problem?

Dr. Annie McKeown O'Donovan

This is indeed an issue of social justice, if we want to frame it in that way. We want to make end-of-life care better so let us do that. It does not need to be a different issue.

Is it Dr. McKeown O'Donovan's philosophical view that euthanasia or assisted suicide should be legalised only in cases of terminal illness? Is she philosophically opposed to euthanasia or assisted suicide on wider grounds?

Dr. Annie McKeown O'Donovan

My research argued for the moral and legal justification of assisted dying within the parameters of an imminently dying individual. Somebody who feels like a burden at the end of life but who is not, in fact, suffering and deemed to be imminently dying would fall beyond the remit of the safeguards.

Dr. McKeown O'Donovan would not support euthanasia or assisted suicide on grounds other than those of terminal illness.

Dr. Annie McKeown O'Donovan

No because it is possible to provide care and support and to make life better for that person, as the Senator has said.

I apologise; I was at a meeting of the Joint Committee on Education, Further and Higher Education, Research, Innovation and Science prior to coming here. I thank the three witnesses for the opportunity to read their opening statements.

While I absolutely agree with Dr. Finegan that every human life is of equal intrinsic worth and while also agreeing with what has been said about trying to ensure that all supports, such as hospice care and so on, are available to those who need them, we are nevertheless tasked with a real examination of what we feel about the possibility of Ireland looking at assisted dying at the end of this process. Engaging with people of different views and looking at examples from other countries are very important to our learning process.

Following on from that, we heard very grim evidence from Canada, the Netherlands and Belgium at our last meeting last week. While I understand that the three witnesses are coming at this from a different base, do they feel that any country or jurisdiction has introduced assisted dying in a way that is compassionate and understanding while being as limited as possible to ensure we do not arrive at that slippery slope?

Notwithstanding what Dr. Finegan and Dr. Yuill have said, are there any circumstances whatsoever in which they feel assisted dying could or should be allowed?

Dr. McKeown O'Donovan spoke about assisted dying being morally acceptable within limited criteria and about maintaining those limits. Will she elaborate on the limits she believes should and could be set?

Dr. Thomas Finegan

On the circumstances the Senator asked about, in every case of consensual medical self-killing, there are circumstances where the patient's life is treated as a means to an end. The life is extinguished as a way of ending some sort of condition, suffering and so forth and that is always, necessarily, contrary to respecting that person and their life as valuable. My answer, therefore, is "No" on principle grounds, but that is distinct from the question of whether, within the idea that it is permissible, there is the germ of an orientation towards expansion, and I think that is clear when one tests it.

In principle, however, even in a limited case, it always involves treating that person's life as a means to an end. It always involves ultimately rejecting the idea that their life is of intrinsic, equal, inviolable worth. I think the compassionate, just and moral thing to do in that circumstance is to alleviate the person's suffering as best as one can without killing them.

Dr. Kevin Yuill

On whether there are any circumstances where it is acceptable, I would say "Yes". I am against a change in the law, not simply individual cases, and there are many individual cases where it might be appropriate. If you get to my age, you will probably have had near-deaths where there is suffering at the end of life, and if a doctor gives medication, for instance, that has the effect of alleviating pain but also of killing the patient as a side effect, I do not think I would have any objections. My objection is more to a change in the law and a change in the principle we are talking about, namely, where we value life. I think everybody in this room would want to reduce suffering at the end of life and elsewhere. It is a question of whether we go across what I would characterise as this moral precipice, rather than as a slippery slope, and identify death as some sort of healthcare.

On the issue of the slippery slope, I think that once we define killing as healthcare, it will be difficult to deny it to anyone who purports to need it. This is the real, practical problem we have when we are looking at this legislation. How can we deny healthcare of any variety to anyone, including children? If we define assisted dying as healthcare, that is the problem we will get.

Dr. Annie McKeown O'Donovan

The Senator asked how we should go about maintaining such limits. A limit we may all agree on, although I say that tentatively, is that the person must be an adult. In the case of people under the age of 18, we have to re-examine our conceptions of consent and the capacity to consent, so that would require a different study. A requirement to be a permanent citizen or resident of Ireland will mean we could be sure that a history of the person's healthcare has been well documented in settings and that the request that must be rational and enduring can also be verified. A requirement for the patient to be capable of administering the medication to himself or herself will make sure it is an instance of assisted dying as opposed to euthanasia. This will also help us maintain the limit of who will be able to avail of such care.

It also helps us to maintain the limit of who will be able to avail of such care. The requirement that the patient be suffering intolerably from an irremediable progressive chronic or terminal illness such that they are imminently dying involves a very narrow window. Of course, it is highly contentious because people live beyond such prognoses and die before them. As such, maintaining that limit is somewhat easier because it is such a narrow window.

I thank our witnesses. The key thing here is the requirement that the patient is in insufferable pain, the experience of suffering and how that is determined. One person's insufferable pain may not necessarily be the same as another's. I think everyone is agreed that it is inherently subjective. Dr. McKeown O'Donovan talked about autonomy and the ability to decide what to do with one's own life, when and how. If a person takes his or her own life through suicide, perhaps because he or she in insufferable pain and huge distress, he or she is acting autonomously. It is not something that we support. In fact, we have introduced measures to reduce suicide rates. We took a decision, and rightly so, to decriminalise the action of suicide back in the 1990s. A previous contributor to our debates here said that rather than legalise assisted dying or euthanasia, perhaps we should decriminalise it. I would be interested to hear Dr. McKeown O'Donovan's views on that.

She talked about the very limited criteria. In response to a question from a colleague she mentioned the criteria of terminal illness and imminent death, and said that is the way to avoid a slippery slope. There is evidence in countries where assisted dying has been introduced that even where there are really strict criteria initially, the criteria have been expanded over time. My fear is that if we introduce it with very limited criteria, people could actually make the case that they are discriminated against if they are excluded. One could foresee a case being taken before the European Court of Human Rights on the ground that we are introducing legislation that prioritises one person's suffering over another's. This morning on "Morning Ireland" we heard the CEO of ALONE talking about the pandemic of loneliness in Ireland. A person suffering from loneliness could describe living on his or her own as insufferable. I am concerned that if we were to introduce legislation along these lines, we would be normalising assisted dying and euthanasia. That could then be used as a mechanism to address the failings of the State, whether in tackling loneliness or abject poverty. I would welcome Dr. McKeown O'Donovan's views on that.

Finally, I believe Dr. Yuill stated that he could envisage assisted dying as being permissible to reduce suffering at the end of life. That already happens. Medics take the decision to administer morphine to a patient who is terminally ill. We all know, from inquiring about terminally ill patients, that medics will say that the morphine pump has been switched on. That is a clear sign that the end is near. The medics are administering medicine that will reduce pain and maybe hasten the end of life, but they are not intentionally taking the life away. That is palliative care as we know it.

Dr. Annie McKeown O'Donovan

The first thing the Deputy referenced was my definition of autonomy, namely, people being able to choose what to do, and when and how to do it. He said that people already die by suicide. This is characterised as distinct from assisted dying.

If we look at testimony from say, Marie Fleming or Debbie Purdy, or other people who have campaigned for the choice to die with assistance, we will see that they characterised their want as something different from suicidal ideation, so that is definitely something that needs more attention.

The Deputy asked about the distinction between decriminalisation and legalisation. As a philosopher I am not completely equipped to talk about the distinction between them with respect to our Constitution, but from a philosophical perspective, if we decriminalise something we do not automatically have a supportive right to do that the way we do when something is legalised. When something is legalised we can have support, safeguards and be very clear on what it is we have a right to do, but that is not present when something is decriminalised.

There was mention also of imminent death as a barrier to the slippery slope leading to the argument that people are being discriminated against by being excluded by the imminence criteria. That is a very real possibility, but what needs to be reiterated then is the question of life; when death is imminent, life is going to be over. The social justice issue comes in with those who are potentially going to be discriminated against because they fall outside that remit. We need to take better care of people who feel like assisted dying is the answer. The example of abject loneliness was used. I am not 100% clear on the link there. That ties into the question Senator Ruane posed to Dr. Yuill about whether that is the singular issue or one of the spectrum of problems someone is experiencing.

I thank all our witnesses. I will begin by saying that some of the language used here in the theses by Dr. Finegan and Dr. Yuill is deeply distasteful and very selective, to say the least. People should reflect on the language they are using in some of the critiques - I am thinking in particular of Dr. Yuill - because it does not stand up. If he is saying that in Canada somebody may avail of assisted dying because he or she is in a situation of homelessness, that is trivialising the whole debate and is deeply disrespectful to the issue. Again, I ask him to reflect on what he has said. We are conflating assisted dying with other societal issues, including that of deep inequality in society. It is not helpful to this debate. We are trying to have a civilised debate on something that is very complex and can be difficult regardless of what one's opinion on the situation is. I therefore ask people to reflect on their statements and so forth.

I read Dr. McKeown O'Donovan's thesis. It was extremely good. I hope we will see assisted dying available to those who want to avail of it in Ireland in the near future. That is very important. Public opinion points to the majority of people in Ireland supporting legislative change. It is has been borne out by a number of opinion polls. People are open to this debate and want to see legislative change.

The slippery slope argument is a bit of a red herring advanced by those opposed to assisted dying. It was suggested that if assisted dying were to be legislated for in this jurisdiction, it would lead to everybody wanting to avail of assisted dying. That is not the truth. It is not. If anybody wants to say different, I would like to hear it. The argument that anybody with an ailment wants to die is ridiculous. It is important to touch on that. Is there a framework that could be envisaged as working at the moment that could be a model for Ireland with regard to assisted dying?

Is there a framework that would fit into what the Irish public and legislators such as us could accept - we are the ones who will legislate for this - in terms of those who want to avail of assisted dying?

Dr. Kevin Yuill

I am sorry if there is deeply distasteful language. I am not certain which part of my language the Deputy found distasteful. There is a problem with language. When, as is the case in many jurisdictions, death by purposely ingesting deadly drugs is defined as something other than suicide, that is a corruption of the English language. This is the case in California, Oregon and Canada, where these kinds of deaths are defined as dying of the underlying disease. It is simply not true. They are dying by the particular deadly drugs given to these people. Will the Deputy state which distasteful language he is talking about?

Dr. Yuill said somebody availed of assisted dying because they were homeless. Can he give evidence of that?

Dr. Kevin Yuill

Yes, I can give evidence of that.

Will he tell us?

Dr. Kevin Yuill

Not right now because I do not have it right in front of me.

Come on. Dr. Yuill put in his statement that somebody in Canada availed of assisted dying because they were homeless. Will he give evidence of that?

Dr. Kevin Yuill

Yes.

Will Dr. Yuill give us the evidence then?

Dr. Kevin Yuill

I do not have the evidence in front of me.

He cannot go into very precise details of it.

It is extremely selective.

Dr. Kevin Yuill

I advise the Deputy to have a look at the case. I will happily send it to him after this meeting.

Why can he not say it here? He said in his statement-----

Dr. Kevin Yuill

I do not have it in front of me. I can give the Deputy the evidence and show-----

Dr. Yuill is not credible, unfortunately.

It is not easy to say in a public forum like this. There is no problem, Dr. Yuill can furnish it to us afterwards and it can be given to Deputy Kenny.

If it is in his statement, he should be able to explicitly state, in a public broadcast.

Witnesses cannot really go naming a person.

I do not want anybody to be named. I want the circumstances in which this happened to be named.

Dr. Kevin Yuill

I can tell the Deputy about that. The circumstance is that there was a gentleman who had a breathing disability and was signed off on assisted dying by one doctor and was seeking another. He then went to the newspapers and said he was seeking assisted dying because he was suffering because he did not have enough money or a home. The point I am trying to make is that you are able to do that in Canada so long as you meet the other criteria. Nobody can tell you that you cannot. That is in the charter of rights. That is why this is quite dangerous. The Deputy can find it as distasteful as he likes but those are the facts.

I think Dr. Yuill is being very selective.

It is a matter we will come back to. Witnesses do not have to give references in their opening statements. We must make that clear.

On a point of order, we can do better. We have all been in a situation where we were not in a position but could forward details later. I think we can do better than attacking our witnesses simply because we do not like something of what they propose.

No. That is not the case. No.

Is there not a courteous way to ask for further and better particulars at a later date?

That is not a point of order, Senator.

I find the professor's statement very distasteful. Some of the language he used-----

My job is to protect our witnesses in that they come here in good faith to give us information. My job is to make sure we treat them in a fair fashion.

I think that is the point.

We are way over time but I want to do the Deputy justice by allowing Dr. Finegan to respond also.

Dr. Thomas Finegan

Any of the language I used in my statement or submission is language reflected in court judgments and writings of bioethicists, including pro-euthanasia bioethicists. Various important issues were raised. Much of this comes down to the question of how to draw a line that allows euthanasia only in cases of terminal illness. I have challenged the idea that any such line is non-arbitrary and is coherent.

In response, Dr. McKeown O’Donovan justified the line by stating that outside of terminal illness, it is possible that life might improve. It is worth testing that justification against the four basic rationales offered for allowing any euthanasia at all. Those four basic rationales are: respect rational choice, autonomy, minimise harm and the idea that life’s value can diminish according to the views of the person whose life it is. None of those four rationales fits with the idea that we ought to restrict euthanasia just to cases of terminal illness. Each of those rationales individually, and more so collectively, justify-----

That is speculative.

Dr. Thomas Finegan

It is a matter of just reasoning it out. One can think through the case of when someone says-----

In legal terms, that is speculative.

Dr. Thomas Finegan

“Respect my rational choice. I am not terminally ill but respect my rational choice. I want euthanasia.”

That is speculating.

Dr. Thomas Finegan

It is thinking.

Dr. Finegan is speculating.

Dr. Thomas Finegan

I am not; I am thinking.

No, he is speculating.

Dr. Thomas Finegan

I am thinking it through. We also mentioned the issue that if euthanasia is restricted to cases of terminal illness, people will not be choosing it because they are a burden. However, the data from Oregon contradicts that. In more than 50% of cases in Oregon, people report feeling a burden as one of the reasons for choosing-----

Dr. Finegan is twisting the language. It is unfortunate he is doing that.

Dr. Thomas Finegan

I am reading the reports that are published and available online.

It is unfortunate he is doing that.

Dr. Thomas Finegan

They are available if the Deputy wants to look at them. I am thinking and reading data, which is different from speculating. That figure of more than 50% has risen from roughly 30% from when the law in Oregon was first introduced.

The last point I will mention before we move on is the issue of New Zealand and how it might be a restrictive model. The case numbers for the first year of euthanasia operation in New Zealand was 328, whereas in Oregon it was 16. That is an absolutely massive increase from where Oregon was initially. The population of Oregon is not too dissimilar from the population of New Zealand and New Zealand already has more euthanasia numbers than Oregon.

Thank you all. I call Deputy Lahart.

I thank the Chair.

(Interruptions).

We are over time.

My specific question went to Dr. McKeown O'Donovan.

She will bring it in before we finish, perhaps in the next round.

I thank the witnesses. I thank Dr. McKeown O'Donovan for taking up the doctoral research piece on this topic. It is not something everybody would be aiming for. Just as a matter of interest, what university department did that?

Dr. Annie McKeown O'Donovan

Philosophy in the University of Galway.

Someone may have asked Dr. McKeown O’Donovan this already, and it is on the record, so it is fine. She said the term “assisted dying” refers to “the active assistance to die given to someone who is already dying, and the dying person is the one who directly self-administers the life ending-substance”. The obvious question, as in the Marie Fleming case, is if someone not in a position to self-administer. Did Dr. McKeown O’Donovan deal with that?

Dr. Annie McKeown O'Donovan

In the case where someone is unable to self-administer, they will fall beyond the remit of the parameters, unfortunately.

So that would not be allowed under-----

Dr. Annie McKeown O'Donovan

Exactly.

Did Dr. McKeown O'Donovan cover this here already?

Dr. Annie McKeown O'Donovan

Not in great detail, no. It was briefly mentioned.

If a person did not have the capacity or ability to self-administer, Dr. McKeown O’Donovan is saying the existing position in Irish law is that if a person assisted, it is criminal, and that would remain a criminal offence.

Dr. Annie McKeown O'Donovan

Yes, because we then a move from assisted dying, where someone is given the help to carry out an act themselves, to euthanasia, where someone else carries out the act.

I will be switching back and forth. I refer to the theological perspective, which we had some of last week as well. Again, I thank the witnesses for their contributions. Dr. Finegan is coming from a religious or theological framework.

Dr. Thomas Finegan

My submission is purely philosophical, but I think there are extra theological reasons for being opposed to intentional killing.

I have no issue with that. I am completely neutral on it but I wish to interrogate it. I studied theology myself. I will repeat this and it is on the record. I think there is an input because people will potentially be making a decision in a referendum, if it came to that.

They may be believers in various forms of religion and will look to their religious leaders for advice, input or interpretations. We may not like that or agree with it, or we may agree and like both, and, as I said, I am kind of neutral for these purposes. Much of what Dr. Finegan says seems to assume a theological framework for decision making as opposed to just philosophical, in other words, that there is a God, there is a higher power, and Dr. Finegan talks about inviolable rights.

Dr. Thomas Finegan

Everything I have said has in principle been agreed with by Dr. Yuill, who is an atheist. No part of my argument has relied on theological premises. I think those theological premises are perfectly justifiable and admissible, but I am conscious that we are in the Parliament and we are dealing with the common good, not necessarily with the kingdom of heaven. The basic idea underpinning what I am saying is that every human life is equal, of intrinsic value and of inviolable worth. That is the basis of human rights documents and it does not rely on any theological premise. It is a cornerstone of just law and a just society, and it is something that can be demonstrated purely philosophically, considering the ways in which we differ from other animals, the significance of the natural capacities that we have, and how they involve a higher dignity and a higher value from ordinary sensate life.

They are important points to stress and to emphasise here. There is also in philosophy and theology a just war theory, where killing is, in very simple terms, morally permissible because of what you are fighting against. One of the things that sets us apart from the animal kingdom as human beings is our ability to think rationally and our freedom of thought, freedom of expression and freedom to make decisions. I am not trying to catch out or trap Dr. Finegan. However, if I, John Lahart, at some point in my life say that, after due consideration, considering the absolute context of my physical state, my impending demise, my quality of life or lack thereof, I have made a rational, considered, informed decision that I would like the opportunity and I am making a choice to end that sooner than might happen naturally, would Dr. Finegan deny me that right, notwithstanding that I have covered all of the bases that he is challenging in terms of freedom of decision, access to proper interventions and so on? After all of that, what if it is still my decision that I would like to do this?

Dr. Thomas Finegan

I am arguing that, morally speaking, there is no such right and that any such right is premised on the idea that your life has lost or is losing value such that death is preferable. It is one thing for you to think that; it is another thing entirely for a healthcare system to endorse it and facilitate it, even if only implicitly, because it has implications for the treatment of others well beyond your particular context. Personally, I would never do anything to kill you, if that is what you are asking.

You would never do what?

Dr. Thomas Finegan

I would never do anything to kill you, if you are asking me personally, but I am arguing for-----

This is an important point. I know you are talking about the common good. If I pleaded with you and said I had considered this, and said my life is completely meaningless and has lost its value for me, that I am in indescribable pain and have endured it for quite a long time, and it is not my inability to endure pain that is leading me to this decision; it is just the meaninglessness of it-----

Dr. Thomas Finegan

I would do anything I could to relieve you of pain.

What if you could not relieve me of pain?

Dr. Thomas Finegan

What I would not do is treat you on the basis that your life - and you are indissociable from your life - is worthless or is not equal to mine, or that you are violable as a person. I would not do that. I disagree with your particular self-judgment.

What if I am telling you my life is now simply devoid of quality?

Dr. Thomas Finegan

It may be devoid of quality, but it is not devoid of inherent worth and dignity. I would not kill you. I just would not do it.

Dr. Kevin Yuill

Can I comment?

No. I am sorry, I have to go to Deputy Farrell.

I thank Deputy Higgins for facilitating my earlier absence. I also thank our witnesses for coming before us.

My only outstanding question at this stage, and I apologise if I missed any of our witnesses' remarks, relates to limited criteria that might apply. Deputy Lahart has covered a lot of the territory I had questions about, including the complexity of life and illnesses and the rationale behind making such an informed decision if assisted dying were available and legal in this jurisdiction. My only question is, if such a scenario were to arise, what limitations would the witnesses apply? If they feel they have not covered the ground already, perhaps they will use the time left to answer that question. It relates to the point Deputy Lahart made quite well regarding that complex scenario where an individual's quality of life is so limited, and that person is in so much pain he or she has made an informed decision with his or her significant other, that he or she is not able to get out of bed and maybe cannot speak.

All sorts of different conditions are associated with being in a bed for a long period. I regret to say I have a very personal account of that with a beloved member of my family who is now deceased. I struggle with part of the entire debate we have been having for the past few months, namely, what do you do when an individual is living but not by any quality or measure anyone in this committee room would be willing to suffer for any length of time? That is the intrinsic question we must ask of ourselves. I would very much like to hear from all three witnesses if they have something to contribute in reply to my remarks.

Dr. Kevin Yuill

That is at the heart of the matter. It is very interesting. It is about suicide. Our question is that we prevent suicide because we assume that individuals' lives are of value. They may not have the right perception of the value of their lives. It is right that we prevent suicide and do so on the same basis that the law should remain against assisting somebody to die. For instance, there is no question but that there could be some suicides that are entirely justifiable. There are individual cases where somebody dying before they might die naturally is a good thing. I do not think any of us have any problems with that. It is the principle that is very important. The principle of assuming somebody's life is valuable and assigning value to that life means we do not take these lives. We continue with the idea that "Thou shalt not kill", which is, of course, in the Bible but which is something that is valuable for us atheists as well as Christians.

Dr. Annie McKeown O'Donovan

I do not think there is anything else. The criteria I have repeatedly spoken about concern somebody who is imminently dying, has exhausted all avenues of available respite, is at the point where his or her current and prospective quality of life are unacceptable and who values death now more than the inevitably short period of life judged by that person as intolerable, which will result in death soon anyway. The value-of-life argument ties back into the question I was asked, namely, whether this intrinsic value changes at this short period of life. No. Of course life is intrinsically valuable and of moral worth.

What happens is that it is outweighed. The want to die outweighs the want to continue living through something that is intolerable and is going to be over soon anyway. It can be overwritten. The other question is how this suffering is categorised ethically. As has been repeated and discussed, it is something that is subjective and should be a discussion between an individual and their healthcare provider.

Dr. Thomas Finegan

There was a lot raised there. On the quality of life argument, if we are going to proceed on the basis that a decrease in quality of life permits euthanasia access, then obviously that extends way beyond the case of terminal illness or even serious chronic illness because quality of life judgments ultimately come down to the individual. If the individual cannot-----

I am sorry to interrupt but I was specifically referring to terminal illness.

Dr. Thomas Finegan

I am just making the point that the very rationale or basis-----

Dr. Finegan might address the scenario I outlined with regard to terminal illnesses.

Dr. Thomas Finegan

I an simply making the point that if quality of life is the rationale, it cannot be restricted to only the case of terminal illness. This is something that-----

But it can. We are legislators. That is what we are in the business of doing, if we were to come to that. My question remains specific to cases of terminal illness.

Dr. Thomas Finegan

To clarify what I meant, it cannot be rationally, consistently or non-arbitrarily restricted to cases of terminal illness and cannot be restricted to physical suffering either because someone could judge their quality of life to be diminished purely on mental illness or psychological grounds. That is a key point. We might try to posit simply the parameters of terminal illness, but if quality of life is the way we get there, then quality of life will overshoot the runway by a long way, as will any other rationale, whether it is autonomy or rational choice. Dr. McKeown O'Donovan just mentioned in relation to quality of life that life always has intrinsic value, but this contradicts an earlier statement where she said that life's value can diminish in value according to the views of the person whose life it is. She used that point to justify her thesis. I put it to her that if we are thinking in quality of life terms, we cannot also affirm that everybody's life is of intrinsic, equal and inviolable worth. That is what is at stake. We might think we can think in terms of a very narrow little section or a little move from here to there and we can leave it at that, but we are dealing with principles and values that far extend the narrow confines or small moves by degree in either direction. This ruptures so much of what we take for granted and we will not be able to see this for generations but we will see it. Other countries are seeing it right now, including Canada.

We are now going to the second round. I call Senator Ruane.

I have a question for Dr. Yuill. I completely accept and understand the idea that when providing certain healthcare, there is an issue of how we then begin to discriminate within that healthcare in terms of who can and cannot access it. In an abstract way I think about that and what that means, but then in a practical way I think about all the policies and legislative frameworks we have to do that in many other areas of healthcare with regard to a person's needs, prognosis or diagnosis. Dr. Yuill said there is no comparison to, say, the repeal of the eighth amendment. I understand the distinction he is making but we as policymakers set those regulatory frameworks around when, how, who and what period. Looking at BreastCheck, there are many women in Ireland who get breast cancer diagnosis between the ages of 20 and 24 but yet the State policy is that we do not actually do breast screening until a certain age. There are already parameters in which legislators create frameworks around things. It is like there are philosophical and existential questions versus trying to take those questions and put them into implementable frameworks where we have to make moral choices. I do not think anybody wants to make dying or ending life early the most moral thing you can do or to say someone is a really moral person if they do that. Maybe the choice is not between deciding between what is moral and what is not. We are looking at what is practically acceptable for a person or an individual in a given time. Can Dr. Yuill see other situations or scenarios where the State already legislates parameters of healthcare?

That is something that exists in terms of how people access healthcare.

Dr. Kevin Yuill

The point is we already ration healthcare on a practical level. That is absolutely correct. However, we do it with individuals. The difference is that we are talking here about legislation that would make an entire category of people less equal than others. We therefore try to prevent suicide for those who are not imminently dying, but we say to others that their lives are not necessarily valuable enough for us to try to save and to try to prevent their death. The problem comes between individuals, where the Senator rightly says that a doctor with a 15-year-old and an 80-year-old on table may make that practical decision. If you can only save one, which one do you save? There is that sort of ethical dilemma where the doctor has to make a decision, whereas here we are talking about categories. It is worth remembering that the categories, which have expanded, generally include disabled people. This is one of the problems many of our members associated with Not Dead Yet have been raising. It makes their lives less valuable by saying we will not prevent their suicide but we will prevent the suicide of everybody else. Does that make sense?

I disagree with the last part of it, but I understand the response.

I understand that Dr. McKeown O'Donovan says she supports euthanasia, or assisted suicide specifically, in cases of terminal illness only. In that case only, among other things, there is no prospect that things will get better. I know many people might sympathise with a person's desire to express their autonomy in favour of ending their own life in those circumstances. My friend and colleague, Deputy Gino Kenny, frequently refers to opinion polls to bear out that point. However, what Dr. McKeown O'Donovan is struggling to overcome is the problem of collateral damage to others, even if one were to take that step. There is the question of whether the safeguards can ever stick, if there are any safeguards. There is the question of how it changes people's attitude to suffering, their attitude to each other, and the State's attitude to people. Dr. Finegan spoke, in that pretty memorable phrase, to the common good and not necessarily the kingdom of heaven, as he put it. Who are the people who will suffer if assisted suicide were introduced in the limited circumstances being posited here? Where is the downside, even if you were to concede the principle that, if there were to be no collateral damage, it would be allowed? Who loses it the law is changed?

Dr. Thomas Finegan

When we overturn something as fundamental as the principle against intentional killing, it brings choices for death and killing into legitimate healthcare. 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. That will change how people see themselves. It will change how different options are presented to people. It will change the sorts of options presented to people. An example of this would be in the case of someone approaching end of life or has a severe illness and is older. It would now be a live option for such people to access euthanasia. The law allowing that choice presents them almost with the responsibility to judge their life, as to whether they are a burden on others or their life is now worth living. That extra burdening on an individual to make those judgements about themselves is corrosive of their own sense of self worth and of others' appreciation of who they are, and it will play out negatively for solidarity between people, especially elderly people and sick and disabled people. That holds even if that person, after scrutinising his or her life for its burdensomeness or quality, freely chooses, uncoerced, to procure euthanasia.

Even though it is done freely, great harm has still occurred in terms of how we treat and that person and how they interact with others.

Increasingly, we see the practical implications of this working themselves out all across Europe and in Canada. Again, it is not merely abstract. One of the points I tried to make in my written submission is that when we talk about safeguards, for instance, a pro-euthanasia perspective refers to safeguards in terms of preventing coercion, that works both ways, which means that the idea of safeguards would seek to prevent people being influenced away from a choice of euthanasia. Euthanasia is then presented, in one sense, in a completely morally neutral fashion. That in itself contains a judgment that there is nothing wrong with or undesirable about euthanasia. That idea is now incorporated into healthcare and will work its way out in all sorts of ways to education, promotion, training, views, things that are said and left unsaid, etc. It is very difficult. No one here can predict all the ways it will work itself out. We see the effects of it in Canada, the Netherlands, Belgium and so on. We might not like it. We might consider it horrible but what we cannot say is that it is the limit, because what we are overturning is so fundamental. It is the idea now that death can become a part of medical treatment.

Dr. Annie McKeown O'Donovan

There was something said at the end, namely, that there is nothing good about euthanasia. The term "euthanasia" comes from the Greek words “eu”and “thanatos” and means a good death for the one who dies. It is understood as something that is valuable to someone's life, at the end of life. When the Senator spoke about the collateral damage-----

Dr. McKeown O'Donovan said she opposes euthanasia.

Dr. Annie McKeown O'Donovan

The concept itself means a good death.

Dr. McKeown O'Donovan said she opposes euthanasia.

Dr. Annie McKeown O'Donovan

I oppose the utilisation of it in this instance because-----

Dr. McKeown O'Donovan is now presenting it as something that is seen as good.

Dr. Annie McKeown O'Donovan

The concept is understood as something that is good for the one who dies.

Is that not part of the twisting of language where someone is told it is a good thing that their life no longer has value and that it is a good thing to choose to end their life? Is Dr. McKeown O'Donovan not making the point that language gets corrupted there?

Dr. Annie McKeown O'Donovan

Senator Mullen has added those pieces to the piece I just presented, which was that the word means a death that is good for the person who dies. The other contextual elements have changed in the different conceptions that have been presented.

Does it only refer to being good for the person who dies? Is it possible that the word, since it means a good death, is the problem that society comes to see death as a good. For example, if society does not want to pay for complex healthcare for people, what is actually bad is presented as being good. Is there a contradiction in Dr. McKeown O'Donovan's argument that if she says we should allow this where the State or some external party forms the view that things will not get better, and that in those circumstances, for example, where a terminal illness is involved, we give way to people's autonomy. Why would we not give way to people's autonomy where they form the view that things will not get better? This is the fear people have. How do we prevent suicide? In cases of suicide, there are people who feel things will not get better.

Very briefly now, Senator.

Is there not a contradiction in Dr. McKeown O'Donovan's view if she takes autonomy as the key value?

Dr. Annie McKeown O'Donovan

No, I think Senator Mullen has misunderstood. I have said repeatedly that it is the individual who deems whether or not their life is valuable.

And going to get better.

Dr. Annie McKeown O'Donovan

On going to get better, well, then we are back to the imminence criteria.

Supposing they determine that it is imminent and suddenly say that they will commit suicide if they are not allowed to access assisted dying.

Dr. Annie McKeown O'Donovan

That is a very important conversation that needs to happen between-----

Dr. McKeown O'Donovan is effectively saying-----

Dr. Annie McKeown O'Donovan

-----an individual and their healthcare provider.

Dr. McKeown O'Donovan is going beyond terminal illness then.

Okay, I have to move on.

Dr. Annie McKeown O'Donovan

No, I have not.

I have to move on to Deputy John Lahart.

I thank Dr. McKeown O'Donovan for what she said regarding the slippery slope argument because that is one of the things we have to consider as well. She said that using the slippery slope argument is "neither always reasonable, straightforward, nor a good basis for policy formation". It is important to note that.

Coming to Dr. Finnegan, and these are the things we grapple with, I refer to devaluing. He did not mention the Swiss model. Representatives from Dignitas came before the committee last week. The Swiss model seems to be a million miles from the Canadian one. I do not mean to call it a model; it is their way of doing things. It has been around for 40 years and does not seem to have suffered the consequences or the implications of the Dutch or Canadian models. It does not seem to have slipped down that slope.

It seems to have maintained itself within pretty strict parameters.

What has been said about the implications of doing this is not lost on me. They have been very well described and it has to be part of the committee's consideration that there are things we cannot perceive of now in terms of making decisions that will have consequences for how life might be viewed or valued.

The Dignitas model is not perfect by any manner or means. I can only speak for myself when I say that I do not want us to do a Canadian version of this. From what we were told last week, I certainly do not want to even consider a Dutch way of doing things, and I do not know whether that was the intention when setting out.

To Dr. McKeown O'Donovan, why discriminate against the person who cannot physically do this but who may be on an equal par with someone who can physically take their own life?

Dr. Finegan said that he would not make the decision to kill me. What if I said to him that I am not asking him to do that and, if we go back to the conversation we were having, that I am saying I have made the decision and I want the ability to be able to do it myself for the reasons I have outlined? I do take on board very strongly what he has said. What he is implying to me is that a conversation at some point along the line where he says, "You know, John, you are valued. You may not see it but there are people who care about you. It may not be visible to you right now but there are people for whom your loss would be quite devastating, even though that may never have been expressed or articulated", may have an impact on me who may feel like a burden, where I feel that if I hang around, it will have complications for those people around me. Those conversations could be game-changers, and I do not use that term lightly. I also think those are things we have to consider as a committee in terms of what leads a person to that conclusion.

I come back to a piece, and I thank the Cathaoirleach for sharing it, by Evan Davis in The Sunday Times, which is the story of his father who seemed to have made a very informed decision to end his own life, who certainly was conscious of the love he had for his family and was very conscious of the love his family had for him, and that this was not a reflection on anything but that life had come to a point. I am not certain and maybe Dr. Finegan can say a bit more about how the notion of the value of life and the right to help now might be altered irredeemably by a slight change in the law.

Dr. Thomas Finegan

To allow euthanasia access on the basis we are talking about, where the individual judges that his or her life has lost or is losing value or meaning such that death is preferable, which on one level is an individual judgment people can make and people, in a sense, are free to make since the decriminalisation of suicide, for example, under the 1993 Act, is quite different from giving legal endorsement and healthcare facilitation to that judgment, where it thereby becomes a right, based on a choice and judgment that life does not always have intrinsic, equal, inviolable worth. What was a private personal judgment - a mistaken one, I believe - now becomes publicly endorsed and something whose significance just simply cannot be restricted, either in logic or in practice, to that individual alone. It changes the public healthcare landscape of how life is judged and valued in ways that extend far beyond any cases, no matter how narrowly we may wish to construe them, and it works itself out logically through social practice and attitudes in an expansive manner.

The Deputy mentioned the Swiss model. If I understand it correctly, the Swiss model has not expanded as such because it was never restricted in the sense that it is just simple decriminalisation and there are no grounds that could be expanded. What has expanded is the number of cases annually that take place in Switzerland, so there is expansion.

The current law is at a disadvantage because we are familiar with it. We can see the hard cases that push up against our commitment to the equal and intrinsic value of all human lives and push up against respect for no intentional killing. What we cannot see as clearly is what happens when those two principles are abandoned. They are not abstract. They are instantiated in people and the value of their lives. What follows from that? That is where this idea of restricted euthanasia has an artificially protective affect, screening the fundamental euthanasia rationale from scrutiny. That is why it is so important to think in terms of what are the grounds on which we are basing this idea. What are the grounds for autonomy, rational choice, quality of life? They extend far outwards. Then we can see the hard cases the other side, in Canada, the Netherlands, Belgium and elsewhere.

I call Deputy Gino Kenny.

We have ascertained that there are variations around assisted dying in many countries where it has been legislated for. Probably more than 20 countries have legislated for assisted dying, in some format. In my personal opinion a person of advanced age or a person with a disability or mental health issues should not be able to avail of assisted dying. That is my opinion. Other people have opinions that differ from that. That is the framework. The framework I look towards is that of Oregon and New Zealand. New Zealand legislated a number of years ago. In circumstances where something was illegal and then becomes legal, people will avail of it. That can be applied to many things. It is understandable. Where there are variations, frameworks and safeguards, people should be able to avail of that choice. The witnesses will disagree with that. That is Dr. Finegan's and Dr.Yuill's prerogative. Deputy Lahart hit on it very well in regard to those who are in those circumstances. We have a paternalistic view that the doctor knows best or society knows best. However, in certain circumstances where a person is coming to the end of life, try to walk in his or her shoes. They should have a say. It is a fundamental right for any human being to say "I do not want to go through weeks, months or days of my life - and it is my life, not yours or anyone else's." A person should have a say, to refuse medical treatment, food or water. That is their prerogative. Why should they be stopped? If a person says "I do not want to go through a painful end to my life", it is a fundamental human right to have that choice. In order to change that narrative we have to change the law. The model to which I would look is New Zealand. Dr. McKeown O'Donovan’s thesis is good in regard to building a framework in Ireland. What are her opinions of the model in New Zealand? It is restrictive to those who have a terminal illness and six months or less to live. That is sometimes difficult to interpret but at least people now have a choice rather than not having a choice. We are talking about a human right. It is a fundamental human right for a person to have that choice. Hopefully people in Ireland can have that choice in the near future.

Dr. Annie McKeown O'Donovan

I agree with what the Deputy said about the wording of the law in New Zealand. Indeed we will have to see how matters progress, similar to the states in the USA where the law is similarly tight and refined and things have changed. As the Deputy said, when things become legal people choose to avail of them.

As the Deputy mentioned, when things become legal, people choose to avail of them. A question that needs to be considered in terms of policy formation is what number of people availing of such a choice is an okay number to accept. At what point do we say that the parameters have been pushed too far and too many people are availing of this? This is a different question that can come outside the implementation of such laws. The monitoring procedures around maintaining safeguards need to be tightly defined and fine-tuned in order to decide such empirical questions. I am sure that the argument will be made that any number is arbitrary, but once a choice is available to people, they will avail of it. This choice can also be part of good end-of-life care.

Dr. Kevin Yuill

I will make a couple of points. Unfortunately, once you have any kind of safeguard, you are patronising because you are saying that someone has suffered adequately for your purposes and, therefore, he or she will be able to avail of an assisted death while telling an entire category of other people that you have decided they are not suffering enough to avail themselves of an assisted death. This discrimination cannot be got rid of through any sort of legislation.

It is worth reminding ourselves that, in Oregon polls of those who avail themselves of assisted deaths, being a burden has always been a more important reason than physical pain in why people make that choice.

I will make a further observation. Anyone can bring himself or herself to become terminally ill by, for instance, refusing food and water. This means that safeguards cannot really prevent someone who is determined to get an assisted death from getting one.

I thank the witnesses-----

Dr. Finegan wishes to reply.

Dr. Thomas Finegan

I thank Deputy Kenny for his comments. He spoke articulately about the reasons for his particular proposal. He mentioned paternalism and the idea that, unless people can walk in someone’s shoes, people cannot see what he or she is going through. He also spoke about the ideas that euthanasia access was a fundamental right and that the life belongs to the person in question and no one else. All of these points count as the core of the rationale for euthanasia access, but each of them can be turned against the Deputy’s proposed restriction of euthanasia to cases of terminal illness. It fails to see that others have a fundamental right, that their lives are their own, that we have not walked in their shoes and that we are being paternalistic. When we see what the rationale means in principle and where it is oriented to go as a matter of reason, it becomes much less attractive than we might initially think and much more problematic in terms of respecting key goods that we take for granted in healthcare.

It was mentioned that Oregon was a good model. A good paper forthcoming in the BMJ Supportive and Palliative Care journal has analysed 25 years of the Oregon Death with Dignity Act. One of the matters it highlights is that all reporting from Oregon is self-reporting, which is an issue that the committee may wish to discuss during its session later. As I tried to make clear in my written submission, expansion is happening in Oregon beyond terminal illness into chronic illness and badly misprognosed cases. Importantly, the Oregon Health Authority has admitted – this is relevant to Dr. McKeown O’Donovan’s thesis – that someone with a non-terminal illness who refuses treatment for that illness, thereby translating that chronic illness into a terminal one, will not be refused access to Oregon’s assisted suicide provision. In other words, a law that tries to be structured around terminal illness cannot insist that the person go through treatment of a chronic or any other illness. This means that what was a non-terminal illness becomes terminal because of the refusal to treat it.

That is relevant to Oregon and is also relevant here because of the constitutional right here to refuse medical treatment. The restriction that one exhaust all avenues of respite, which Dr. McKeown O'Donovan advocates, is not present in any jurisdiction I am aware of in the world. I do not think it could be because it runs badly against a core rationale for euthanasia, which is autonomy.

On behalf of the members, the secretariat and myself, I thank Dr. McKeown O'Donovan, Dr. Finegan and Dr. Yuill for kindly coming here today and giving their time and opinions, which we respect very much. We really appreciated their engagement with the committee. The only way the committee will do its work properly and thoroughly is by listening to such witnesses with all the differing opinions and the different experience and knowledge they have. We appreciate that sincerely.

The joint committee adjourned at 12.56 p.m. until 7 p.m. on Tuesday, 3 October 2023.
The joint committee met for a second time on Tuesday, 3 October 2023 at 7 p.m.
Top
Share