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

Assisted Dying in the United States: Discussion

Apologies have been received from Deputy Alan Farrell and Senator Hoey.

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 respect of 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.

On our agenda is our engagement on the topic of assisted dying in the United States. This is part of the module on assisted dying in the international context. I welcome Professor Margaret Battin, distinguished professor in philosophy and adjunct professor of internal medicine in the University of Utah.

We are having an IT problem, so we will suspend for a moment.

Sitting suspended at 7.05 p.m. and resumed at 7.08 p.m.

We are back. I welcome Dr. Mark Komrad, a psychiatrist on the teaching faculty of the Johns Hopkins Hospital in Baltimore and a clinical assistant professor of psychiatry at the University of Maryland and Tulane University. I also welcome Dr. Tom Jeanne and Mr. Craig New of the public health division of the Oregon Health Authority. We are grateful to the witnesses for sharing their knowledge with the committee and we look forward to hearing their opening submissions. I thank them for having patience with us, the time delay and so forth. I also thank members and the secretariat for facilitating this evening meeting so that the time works for us all.

There will be a five-minute slot for each opening presentation. The witnesses may be able to see the clock here, so we will try to keep each presentation to that time. I invite Professor Battin first.

Professor Margaret Battin

I am happy to be here. There are two kinds of question that we need to consider. Since I know Dr. Komrad already, I think we will be disagreeing about various issues. The first kind of question is the matter of basic principles. What are the basic moral principles – my field is philosophy, hence my concern with this – that speak for or against medical aid in dying? There are two basic principles that should be honoured in any context.

The first of these is autonomy, where that is possible, and the second is the avoidance or relief of suffering. One should not make someone suffer, fail to relieve their suffering when that is possible or consign them to suffering when one could reasonably do otherwise.

The other kind of basic question that arises is about practical concerns. These are often concerns about the possibilities of abuse, the slippery slope, what the data show, what sorts of conclusions can be made, if there are abuses, if the safeguards are adequate, or if there are safeguards at all. I believe we will be hearing more about these issues from Dr. Komrad. Of course, we can discuss that.

I should point out that the original discussions about medical-aided dying, when it was still being called “physician-assisted suicide”, came from entities such as the American Medical Association, AMA, the British Medical Association, BMA, the Canadian Medical Association, CMA, and many others. They all expressed concerns and they based their opposition on the idea of the slippery slope. This is the fear that vulnerable groups would be encouraged, manoeuvred or somehow forced into ending their lives. The data we collected from Oregon and the Netherlands showed that this was in fact not true for ten groups of people in so-called vulnerable categories. In fact, just the opposite was the case. Who is getting medical aid and dying? These are quite affluent, well-educated, socially secure, non-disabled, non-minority people who are not in vulnerable categories, in all the usual senses. Therefore, that basis of objection has been largely overturned. It does not mean there are not any problems of equity, but it is people of privilege who have been getting this service, rather than the other way around.

The tensions here will be about prescriptions to patients. These are ongoing. The interest of the committee is regarding what is going on in the US. Prescriptions are made, patients receive them, take them home and use them when they want. This is compared with standard-of-practice developments, such as those that have been put forward by the new American Clinicians Academy on Medical Aid in Dying. It is a highly developed although quite medicalised set of considerations for practice.

Then there are problems with the requirements in the various statutes in the ten states in the US, as well as the District of Columbia, where this is legal. Does it have to be oral? Can it be gastrointestinal? What about self-administration? What about residency requirements and many other such things? That is just a small overview of what is at play here, although I think the central issues are regarding the positive aspects of medical aid and dying. Why should we regard this as honouring the basic principles of the position that I have just mentioned, such as autonomy, relief of suffering and, perhaps, other basic principles?

Dr. Mark Komrad

I appreciate the opportunity to discuss with the committee our laws and practices of physician-assisted suicide in the United States. I am a practising psychiatrist and medical ethicist. In my entire career, there has really been no issue that has been so singularly important to me as this. As such, I have been expressing my professional concerns worldwide that assisted suicide is neither good medical ethics nor good public policy. In fact, I might be the only one on this invited panel who will be expressing grave concerns about these practices in the US. The committee members might therefore see my hand being raised often today.

There are only 11 jurisdictions where assisted suicide is permitted in the US. Therefore, this is not widespread. The fact is that as of the last count, there have been 270 failed attempts to introduce legislation in many states, and some have failed up to 12 times in a single state. Nine states have actually passed laws inoculating themselves against such legislation ever being introduced there in the future.

Besides the ethical and public policy controversies, these practices can go terribly wrong, legal guardrails notwithstanding. For example, in Colorado last year, three patients with anorexia were prescribed lethal medications for suicide, despite the law there limiting eligibility to terminal illnesses only. This has emboldened some Colorado attorneys who represent anorexic clients in involuntary commitment hearings to argue that assisted suicide may actually be preferable as an alternative to involuntary hospitalisation. Hearing this, some of my own psychiatric patients are now eager to expand legal eligibility to include them, which they say is only fair and in the interest of mental health parity.

In Maryland, where assisted suicide is illegal, a physician helped six non-terminally ill people to commit suicide and several were mentally ill. He has never been prosecuted. Since lethal medications are not tracked once they are dispensed, they may sit around openly in people’s homes being unused for years, without safeguards. In fact, in Colorado recently, a man whose brother was prescribed lethal medications for assisted suicide tried to sample them. He was rushed to a hospital in a coma, and needed life support.

Physician-assisted suicide in the US is anathema to most physicians. In fact, even among those doctors who endorse these procedures, very few are actually willing to provide them. As the saying goes, people want the hamburger but nobody is willing to kill the cow. In fact, lethal prescribing tends to be done mostly by a very few extremely zealous physicians who write scores of lethal scripts for patients with whom they have had a relationship for as little as a few hours after a single consultation. Last year, one doctor in Oregon wrote 51 scripts.

Several leading medical organisations concluded, and continue to conclude, that these are not ethical practices of medicine. As the members of the committee have heard, these organisations include the AMA; the American College of Physicians, ACP; the American Psychiatric Association, APA; and the American Association of Hospice and Palliative Care, AAHP. In fact, after three detailed reviews, the AMA has recommended that the term “physician-assisted suicide” continue to be used in lieu of other euphemisms like “assisted dying”. That is why I continue to use the term today.

Over time, laws have mutated, sometimes dramatically. Initial guardrails have become moving goalposts with the passing years. For example, there are shortened waiting periods between evaluation and lethal prescribing. In Oregon, medications can now be prescribed on the same day as meeting and evaluating some patients. State residency requirements are being removed so that now anyone in the US can potentially get physician-assisted suicide by travelling to Vermont or Oregon. Despite initially forbidding euthanasia, there are now several strong efforts in some states to legalise it.

There are critical missing safeguards in our various laws. For example, there are no requirements to consult a psychiatrist prior to lethal prescribing in order to rule out treatable mental disorders. In the early years in Oregon and Washington, one in three cases was optionally referred for psychiatric evaluation before prescribing. In recent years, fewer than 1% have been referred. There are no requirements anywhere that palliative care alternatives be tried or discussed. Besides, there are too few adequately trained palliative care specialists in the US. Doctor shopping is allowed; second opinions can be received from a colleague in the same practice.

In short, the experience with assisted suicide in the US has demonstrated inadequate and mutating guidelines that eventually push beyond the limited scope of the original laws; flimsy safeguards; zealous physicians who do not follow the law; and the false assumption that we can distinguish those for whom suicide should be provided from those for whom it should be prevented. Leading medical organisations have declared this bad medical ethics, and the majority of American legislators have concluded that it is poor public policy. I hope Ireland can learn from our bad example.

I thank Dr. Komrad and I call Dr. Tom Jeanne.

Dr. Tom Jeanne

I thank the committee for the invitation to discuss Oregon’s experience with assisted dying. I am the deputy state health officer and epidemiologist at the public health division of the Oregon Health Authority in the United States.

Before I go further I will note that the Oregon Health Authority is neutral with regard to this matter, and we offer no opinion or legal interpretation about our law.

The Oregon Death with Dignity Act was a citizens' initiative passed by Oregon voters in November 1994. The law was the first of its kind in the world. Implementation was delayed by a legal injunction, and the law went into effect in October 1997. Since then, nine other US states and the District of Columbia have passed similar legislation. The Death with Dignity Act allows terminally ill patients to end their lives through voluntary self-administration of a lethal dose of medications prescribed by a physician for that purpose. The Act outlines specific patient requirements to participate. A patient must be 18 years of age or older, capable of making and communicating healthcare decisions to healthcare practitioners, and diagnosed with a terminal illness that will lead to death within six months. Two physicians must determine whether a patient meets these requirements and report that fact to the Oregon Health Authority at the time a prescription is written. The Death with Dignity Act is a permissive law that allows qualified patients to request a prescription and allows a physician to write the prescription. Determinations related to disease treatment and, if appropriate, end-of-life care options are made between the patient and the physician. The law does not include any medical oversight or regulation distinct from what is done for other medical care.

The Act requires the Oregon Health Authority, OHA, to collect information about the patients and physicians who participate in the Act and to publish an annual report. The OHA does not investigate whether patients met the Act’s criteria, nor how their diagnoses, prognoses, and treatment options were determined. The OHA does not have specific regulatory or enforcement responsibilities in the statute, other than the portion related to the reporting requirements. However, if an instance of non-compliance is found in the information received by the OHA, it is reported to the Oregon Medical Board for further investigation. The Act specifically prohibits euthanasia and states that ending one’s life in accordance with its provisions does not constitute suicide. The Act protects from criminal or civil liability or professional censure any person who in good faith compliance with the Act assists a patient to end his or her life. Since the Act was passed in 1997, a total of 3,712 people have received prescriptions under the Act and 2,454 people - approximately 66% - have died from ingesting the medications. Since 1997, the number of patients and physicians participating in the Act has increased but remains low, with fewer than 0.6% of Oregon decedents and approximately 1% of physicians participating in 2022.

Among all deaths under the Act through 2022, most patients were aged 65 years or older and white. The median age at death was 73 years. Patients’ most common underlying illness was cancer, followed by neurological disease and heart disease. Most patients died at home, and most were enrolled in hospice care. Excluding unknown cases all patients had some form of health insurance.

The three most frequently reported end-of-life concerns were decreasing ability to participate in activities that made life enjoyable, loss of autonomy and loss of dignity. Oregon’s experience indicates that concerns about whether participating patients are uneducated or have financial concerns have not been borne out by the data. Most participants had at least some college education, and financial implications of treatment were reported as a concern by only 5% of participants. Processes outlined in the Act are meant to safeguard patients from abuse. After making two verbal requests, separated by a 15 day waiting period, patients must make one written request in the presence of two witnesses, one of whom must not be related to the patient. The patient must be able to ingest the medication on their own. A physician or person other than the patient cannot directly administer the medication to end the patient’s life. Only the patient can do this. Coercion of a patient to participate is punishable as a class A felony. After 26 years of the Death with Dignity Act, there have been no cases of abuse or coercion, and no civil or criminal charges have been filed related to a participant in the Act.

I thank Dr. Jeanne. We will now go to our members, and start with Deputy Higgins.

I thank the witnesses for coming before the committee to share this international perspective on a difficult topic. At the moment in Ireland it is particularly complex and it is great that the witnesses can share their expertise with us. I compliment Dr. Jeanne on his fact-driven statement, which I found particularly useful. The facts and statistics presented dispel some of the myths, and I appreciate that. Dr. Komrad spoke about lethal medications in his statement, and said they are not tracked once dispensed. They may sit openly and unused for years in people's homes without safeguards. I am shocked by that. I know that the law provides that the patient must ingest the medication themselves. Does that mean there is no oversight of that? I do not like the idea of medications lying around. What could we learn from that if we were to legislate for this in Ireland?

It is great to hear statistics from Dr. Jeanne that 92% of people who have gone down this route were enrolled in hospice care. I hope that is of some comfort to Dr. Komrad who spoke about how hospice care should be offered to people. It is great that 92% of people were already in that situation. The OHA does not have regulatory or enforceable responsibilities. It only has reporting requirements. If we were to legislate for this in Ireland, is this something we should provide for? How many complaints went to the medical board for further investigation? I have a further question for my curiosity. If 66% of people died from ingesting medication, that leads me to believe that more than 30%, almost one third, of people did not. What happened in that situation? That is about 1,500 people.

Dr. Tom Jeanne

I will start with the last question. Dating back to 1998, 66% of people died from ingesting medications. The others died of natural causes, rather they all died of natural causes, but we have lost them to follow up.

I believe the Deputy also asked about compliance and non-compliance. There are currently 26 physicians whom we have reported to the medical board for non-compliance. In almost every case, that was simply due to paperwork not being filed or not being filed in a timely manner. There is one instance where the 15 day waiting period was not properly observed. However, I am not aware of any disciplinary action taken against any of those physicians.

Is it Dr. Jeanne's experience that there are a few zealous physicians only prescribing?

Dr. Tom Jeanne

I have some numbers. In Oregon, 78% of physicians writing prescriptions under our Act only wrote one or two. The majority write one or two. We have physicians writing up to 51, but those are the minority.

Is there any data on how many patients are seen by people on that end of the spectrum where there are 50?

Dr. Tom Jeanne

The extreme was 51 prescriptions for one physician, which was 51 patients that year.

Dr. Mark Komrad

I will respond. First, that statistic may be 51 prescriptions, but that year it represented 20% of all prescriptions. One out of every five prescriptions was written by a single doctor, and with short evaluation times. I will turn to the medications that are not tracked. This is true in every jurisdiction. These are boxes of lethal medications, typically barbiturates, and other items too. Once they are dispensed they get stored in the closet. In one case in Oregon, they were stored for 417 days, and in another case for more four years.

Is there a time limit?

Dr. Mark Komrad

They are stored in grandma's closet in the hope that the suicidal granddaughter does not find them.

With regard to reporting – which will be my final point and then I will yield – it is very important to note that a paper that is prepublication from the British Medical Journal states that financial worries occurred as a motivation in 50% of people, not 5%. The reporting shows that although there is a 15% rate of complications, including nine patients who actually woke up from the intended lethal experience and did not complete it, the recording is full of holes. The error rate of filling out the reports is as high as 70% or 80%, particularly when it comes to reporting complications.

I just have 20 seconds left so I wish to move on. Could Dr. Jeanne reply to that in terms of the data?

Dr. Tom Jeanne

Yes. Would the Deputy like me to reply about the prescriptions specifically? Regarding the concerns about unused medications, 90% of our patients have been on hospice care, and hospice will take care of those unused medications. In other cases where patients are dying at home, we do not have official guidance, but it would be like any other unused medication in that they should be returned to a pharmacy or other approved site for drug disposal. We have not had any reports of accidental ingestion of death with dignity lethal medications in Oregon.

I am sorry that I did not get to ask Professor Battin a question but I am sure many contributors will.

I will address Dr. Jeanne first. I refer to the idea that there is not any oversight or regulatory framework to oversee cases like there would be with other medical care. I am trying to find the line in his opening statement. He referred to “specific regulatory or enforcement responsibilities in the statute, other than the portion related to the reporting requirements”. Is he suggesting a good system should have that? It would then probably pick up some of the points my colleague made on unreturned medicines and so on. If there was a better system whereby physicians, chemists or families can report that particular regulations or criteria have been followed, would that be a safeguard for any system that is introduced?

On the statistics from Dr. Komrad, it is a difficult conversation to have. In Colorado last year, three patients with anorexia were prescribed lethal medications for suicide. It is a hard conversation to have because you do not want to look like you are supporting that in any shape or form, but I want to understand whether the patients received lethal medications for the reason of having anorexia or they were patients who had anorexia and were at a late stage of the dying process because of it. They are difficult questions to ask. At what point in time would a physician see it as a good thing to give this to somebody? Anorexia is already probably the number one killer of anything that is considered a psychiatric disorder. However, there is only a small proportion or percentage that would go on to need hospice care. Are there any sources for that information?

On the Maryland statistic of the doctor who gave prescriptions to 12 non-terminally ill people, is there a source for that? If there is, can Dr. Komrad send it to me? In my brief research, I could not find it. I found somebody who was struck off for giving six prescriptions to people who did not fit the criteria. Is this the same person? The research I found was from 2014. There are not any sources in respect of the doctor mentioned and I could not find any. I am wondering how that then ties in with safeguards. If we are saying that under the criteria a person has to be terminally ill and then a physician helped 12 non-terminally ill people, one would want to know what happened to that physician and how to safeguard against that in any particular case that may arise where somebody does not fit the criteria that a state puts down in regulation.

Dr. Mark Komrad

I corrected that. It was six, not 12.

Dr. Mark Komrad

In my verbal testimony, I changed that to six. I was incorrect in my written testimony.

The anorexic patients were given assisted suicide for anorexia. By the way, this is extraordinarily controversial, with very few people endorsing the notion of terminal anorexia. Most experts agree that does not exist and the problem with anorexia is inadequate access to the kind of specialty care that the patients require. That is important to note.

Professor Margaret Battin

I am happy to respond to many of the claims made before there are too many that are not answered.

I will first respond to the claim about the deaths in Maryland. Please remember that physician-assisted dying – medical aid in dying – is not legal in Maryland. That would be entirely out of the range of the legalisation statute that we are considering.

There is debate about anorexia. I am a member of the ethics committee of the American Clinicians Academy on Medical Aid in Dying, ACAMAID, which has discussed extensively cases of anorexia and whether or not there is such a thing as terminal anorexia. The point is that when one is so far along in this condition, it is very hard or impossible to turn it around because so much physical damage has happened, as I understand it.

On the frequency of physicians - this is not about Oregon, which Dr. Jeanne is clearly limiting his discussion to, as is understood - in California, there was one physician, namely, Lonny Shavelson, who, recognising that California had legalised medical aid in dying but physicians were hesitant about doing so, came out of retirement to found an organisation. When it became evident that other entities were relying on his, I think it was called the Bay Area Clinic for Medical Aid in Dying, and others were simply referring people there, he said “No more”. He stated that if they are committed to their patients and recognise the patients are making a legal request and meeting legal requirements, they should do it. He closed his practice to new patients and now the number of physicians has expanded.

I will also respond to the correct claim that of patients who are given prescriptions in Oregon, 30% do not take them. I think that it is about 30%. Is that right, Dr. Jeanne? There are many ways to read this fact. The most positive way to understand it is that it exhibits the fact that this is a voluntary process.

I thank Professor Battin. We have to move on to the next member and we will come back to this again. I call Senator Mullen.

Professor Margaret Battin

Let me also mention that medications are often stored in locked boxes so they are not vulnerable to the kinds of accidents mentioned.

Dr. Mark Komrad

There is no statutory mandate to do that.

I thank those presenting to us. I also thank Sinéad Fitzpatrick, our legal adviser, for her work in this area and her very helpful documentation.

Oregon, to a great degree, is presented as kind of the limited model that one might safely aim for. The background in the United States is that the Supreme Court ruled unanimously in two cases that there is no constitutional right to assisted dying and states can lawfully prohibit it. Dr. Komrad mentioned that although it is allowed in 11 jurisdictions, there have been 270 failed attempts to legislate for it and nine states passed inoculatory laws to prevent it being passed. Could Dr. Komrad briefly tell us why there is that overwhelming rejection of assisted suicide?

Dr. Mark Komrad

To put it in the simplest possible terms, the most prominent, thoughtful and deeply reflective leading professional medical organisations have felt this is not consistent with the ethical practice of medicine. Second is the fact that, as a public policy and philosophically, something we worry about in psychiatry and which legislators have been thoughtful about is making two tiers of suicide: the suicide you should provide and the suicide you should prevent. We do not have in professional psychiatry any clear ability to distinguish those two. There is a tremendous influence that derives from carving out a section of suicide that is not just allowable but in certain set cases desirable and even romanticised. It has a contagion affect on public health attempts to prevent suicide. We have data to support that.

The question of how this might impact our efforts at suicide prevention is a recurring theme here. I have seen a pre-published report on doctor-assisted deaths in Oregon. The report or study is shortly to be published in BMJ Supportive & Palliative Care. I am operating from an understanding that deaths from assisted suicide have increased tenfold since its introduction in Oregon and over fourfold in the past five years. The report is quite critical of Oregon. It says the proportion with private health insurance fell from 65% to 20% over the 25 years. Most of those having assisted suicide in 2022 had Government Medicare or Medicaid health insurance. That statistic causes me to wonder what it tells us about the demographic. Is there a demographic change in those availing of assisted suicide in Oregon?

The other big concern is, while people say it is limited to terminally ill cases, there seems to be some expansion. Of those terminally ill who opt for assisted death, 46% in 2022 were concerned about being a burden. That figure used to be only 30%. I put this to all three but will start with our expert from Oregon: does this not suggest a shift in attitudes or an increase in vulnerability among those who are terminally ill over time in Oregon?

Dr. Tom Jeanne

I thank the Senator for the questions. I am not sure I would agree with that. There are a lot of variables here. Regarding insurance, it is true the percentage of participants in our Act who are dying using these medications has gone down. The percentage with private insurance has gone down. That means the percentage with public insurance, including Medicare and Medicaid, has gone up. Part of that has to do with increasing coverage in Oregon. We have made great strides in reducing the number of people who are uninsured. Part of it may be that our median age of participants has gone up slightly so more are on Medicare, which is our insurance covering people over 65 in general.

Dr. Mark Komrad

Medicare does not pay for the assisted suicide; Medicaid does.

Dr. Tom Jeanne

Right, but these statistics are just what insurance they have at the time so that would include all of those.

Does that suggest any greater recourse among those who cannot afford private health insurance?

Dr. Tom Jeanne

I am not sure I could make a statement interpreting that. Many of the changes are mostly due to demographics. At the beginning of our experience in the late 1990s, there were very few people using this, and it has grown. On the trends over those 25-plus years, you have to be cautious in interpreting them when you go way back to the beginning.

What about the rise to almost half of those availing of assisted suicide reporting concern about feeling a burden? It is a significant rise over time. What is that telling us about the way those with terminal illness feel about themselves and how that has changed in the light of the assisted suicide regime?

Dr. Tom Jeanne

I will respond-----

Sorry, Dr. Jeanne, I have to stick to the clock. I will come to Professor Battin first after Deputy Lahart. The Senator will have another round but if I do not keep to the time I will be in trouble.

Professor Margaret Battin

I would like to have an equal share of time in this discussion. I understand but hope for some recognition further on.

I will be coming to Professor Battin soon.

Professor Margaret Battin

Thank you.

I call Deputy Lahart.

I thank the secretariat for organising these speakers and the witnesses for attending.

I hope I am considered reasonably objective. There is a clash of styles here. The witnesses will not have viewed our reactions to the past six or eight meetings we have had over a number of months. I find Dr. Komrad hard to take seriously as a witness. I hope he is not offended by that but the manner in which his presentation is written involves very dramatic language. I am not implying it is false or whatever but from an academic point of view, there are few citations in what he has given us.

Dr. Mark Komrad

I will be glad to provide all the citations the Deputy would like.

That would be useful. The language he uses is about zealots, extreme providers and doctors shopping patients. I find it shocking because it is not what I associate with this area and is not the kind of evidence we have been listening to or have heard from many-----

Dr. Mark Komrad

May I respond to that?

No. Deputy Lahart must finish. Then I will go to Dr. Battin and then to Dr. Komrad.

Dr. Mark Komrad

It was an ad hominem remark. I think I am entitled to respond to an ad hominem remark.

Out of courtesy to the witnesses, when something is personalised-----

I will come to him but have to let Deputy Lahart finish.

It is not personalised. It is my view of the statements we have been given. I have become accustomed to something much more academic and technical. I found it a casual presentation. I do not find it particularly pleasing to the eye. I have no issue with some of the facts presented. It is certainly not the model anybody here, although I can only speak for myself, would consider. There are some telling facts I want to address.

It is true, as someone stated in relation to the US Supreme Court, that there is no constitutional right to take one’s own life, but there was a majority Supreme Court judgment, referred to in our independent legal presentation on the matter, that could not define general standards of medical practice and stated these were matters for state law when it came to the prescribing of the drugs required for it. That is an important point in the evidence we have had before us.

Regarding Oregon, it seems that the regulatory environment is out of control and there is no follow-up. That seems to be a real weakness, and it is something I would have a clear issue with.

I am taken with the burden piece because it is a theme that keeps coming up and it has to be taken very seriously. If a strong contributing factor to someone making a decision or moving in the direction of ending their own life is the feeling of being a burden on their family, society or community, that is a cause for concern and ought to be a cause of concern for lawmakers.

On terminal anorexia, I admit my absolute innocence in that regard. It is the first time I have heard that term used, and I am not an innocent abroad in relation to the matter.

There is nothing personal meant in relation to Dr. Komrad's presentation. Our work is serious here and I found it dramatic and alarming in its presentation as opposed to considered and serious. As a result - it is a very personal view - I found it hard to take it very seriously and I would have liked to have heard and read a very serious and considered report. Dr. Komrad paints a picture of a system completely out of control - chaotic, actually - and I do not have a sense of that.

I thank the Deputy.

Dr. Mark Komrad

I do want to say I submitted-----

I am sorry, Dr. Komrad. I am going to Professor Battin first and then coming to you.

Professor Margaret Battin

I thank the Chair. I agree with Deputy Lahart about Dr. Komrad's presentation. He is a partisan in this discussion, as we all are, but he is a more ardent partisan and fails to see the positive aspects of this practice.

As for regulation, the committee is looking around the entire world at places where this is already in practice and noticing substantial difference. In the Netherlands, for instance, regulation occurs after the fact by review and regional committees, rather than the kind of before the fact regulation that goes on in the US. Switzerland has no oversight regulation. It is entirely dependent on the person providing what is there called euthanasia not having a personal interest or gain from this. Thus, a whole spectrum of kinds of regulation are possible. Is what goes on in Oregon and the US the best form? I imagine Ireland might follow the European model more than the US one, but that is of course entirely up to Ireland.

As far as there being no constitutional right to take one's own life, it is also true suicide is not a crime anywhere in the US and assisted suicide is one in all states, I believe. However, every statute in the US - Montana does not have a statute and all the other jurisdictions do - explicitly says this is not suicide and is not to count as suicide in any legal context, so when the rhetoric is this is suicide, that is not well founded. It is also the case the American Association of Suicidology issued a statement, which for full disclosure I was involved in, presenting the case that suicide in the conventional sense, that is, regarded as a tragedy and subject to the fullest prevention efforts, is simply not the same thing as participation in medical aid in dying. It listed 15 different focus points on which there are substantial differences, including differences in isolation versus interaction with physicians, family members and many different-----

I thank Professor Battin, but I must bring in Dr. Komrad now.

Professor Margaret Battin

Okay.

I have to give Dr. Komrad two minutes for a response, but that is it. I am going over the clock in the interests of fairness.

Dr. Mark Komrad

I thank the Chair. I appreciate that. To respond to this most immediate point, in March the American Association of Suicidology backed away from that position, decided there was actually not a sufficient evidence base for being able to discern the difference between the two and decided for the time being it was going to retire that position and come back to study it. I wanted to make that point.

With regard to my style, one of the things that perhaps might be different is I am a practising clinician. Professor Battin is a philosopher and Dr. Jeanne is an administrative physician. I deal with suicide every single day; it is my bread and butter. I am a psychiatrist. As such I encounter in the trenches the profound implications for what it means to be a physician, what it means to be a psychiatrist, how it is an inversion of a fundamental ethos of what I have embraced and the values I profess as a professional, as a physician but especially as a psychiatrist. This is, therefore, quite anathema to me so the passion the committee is hearing from me is born of my professional life and my professional experience. As I said at the start of my remarks, I am a hybrid of an academic medical ethicist and a physician who cares very deeply about my individual patients and about the issue in our public health of suicide prevention, which is a problem that is out of control in our society. Statistics show since the introduction of these laws in Oregon, the percentage increase in suicide is much greater than the percentage increase in suicides in the nation at large.

I thank Dr. Komrad.

Dr. Mark Komrad

It is like a suicide contagion. This is the origin of what I will certainly acknowledge as my passion. This is an extraordinarily serious matter to me in my daily professional life, not just in publications.

I thank Dr. Komrad. Senator O'Loughlin is next.

I thank the Cathaoirleach. I have a few things to ask about. I see very little reference to advanced care directives in the submissions, so I am interested in what our three witnesses have to say about that. Do any of the states allow for the use of advanced care directives?

I then have two specific sets of questions for Dr. Jeanne. He talked about the Act and said it requires the collection of information about the patients and physicians who participate in it and the publication of an annual report. That is always important in terms of what we can learn from that, but the fact the OHA does not investigate whether patients or indeed physicians met the Act's criteria or diagnosis, prognosis and treatment options is a concern, because it would seem then the Act as such is not being carried out. There is also the fact Dr. Jeanne said that since the law was passed in 1997, 66% of people who received prescriptions died from ingesting the medication, so I am assuming the other 34% did not. Will he clarify that please?

I also have two specific questions for Dr. Komrad. He said there have been 270 failed attempts to pass such laws in 18 states. I am interested in hearing a little more about that. I am very puzzled by what he said about nine states passing laws inoculating themselves to say they will never legalise such practices. I do not know how any state could say it could not happen either now or in the future. He mentioned doctor shopping, where one doctor refuses to approve and patients just keep moving. However, surely that depends on the legislation in the state? Those are my questions.

Dr. Tom Jeanne

I thank the Senator for the questions. The 33% are people who died of natural causes in general. They died before they had the opportunity to take the medication or decided not to take the medication at all and wait for a natural death. Part of our process is giving patients full control over this all along the way. They are the ones who submit the two verbal requests, the written request, they are the ones who must take the medication and they can rescind the request or not take it as they choose.

As an additional word about Oregon's experience and the laws, they are really focused on the patients and there are a lot of safeguards in place on the front end before they get the medication. On the medical decisions about terminal illness or competency or capability to make those decisions, that is entirely up to the two physicians who must agree and a psychiatric evaluation is required if either physician determines it necessary prior to the medication being prescribed. Consequently, there are a lot of safeguards in place and we really have not seen a lot of, or really any, major concerns in terms of patients' diversion or abuse.

Does Professor Battin wish to come in?

Professor Margaret Battin

About the failed attempts, legislatures are resistant to change.

As members know, this is a highly politicised issue. There are as many efforts in favour of legalisation. It has proceeded quite dramatically over time, given the difficulties of getting anything through a legislature. We should be aware of the greater acceptance of these practices and the ongoing efforts to legalise them. Ireland is an example of where this issue is now discussable and thinkable. Members will notice that in the US, unlike some other countries, things are highly partisan these days, for example, the undercutting of the national statute legal position on abortion and its return to the states. That has become vitriolic. I would not be surprised if we see the same thing with regard to medical aid and dying. That is more for political partisan reasons rather than actually thinking through what it is this practice gives to people in terms of the ability to be in control of their own dying. It has to be described as an effort for freedom of the person with respect to something that will happen to every single one of us and where some people, in this case comparatively few, do not wait to be erased or eclipsed by the underlying terminal illness. After all, approximately two thirds of us die of terminal illnesses with long courses, such as cancer, heart and other cardiovascular disease-----

I thank Professor Battin. I have to go to Dr. Komrad because I am over time again.

Professor Margaret Battin

Okay. That is the positive spin to this as well.

Dr. Mark Komrad

For the record, I understand the arguments that are supportive and see some of the positive aspects of this issue. I am trying to make a case for the fact that the problems with it vastly outweigh that. These are practical problems as well as the philosophical issues, including the profound changes in the course of a society and civilisation and, indeed, in the profession of medicine, in which a certain group of people, doctors of all people, are given the privilege of taking a life. They would not be getting out of the way of death, which is a standard of practice with palliative care in order to make people comfortable, but would be able to provide death.

I will also address the issue of psychiatric referrals. As I said, it started with one out of every three patients being referred to psychiatrists. It is optional in all states and has now dropped to one out of a hundred. On the ability to evaluate whether a patient has a psychiatric disorder and to evaluate capacity, a number of researchers have shown that most physicians miss psychiatric diagnoses. Capacity evaluation and competency evaluation is a very elaborate specialised skill set of a subspecialty of psychiatry, namely, forensic psychiatry. It is also called consultation liaison psychiatry in hospitals. As a general psychiatrist, I do not feel that I or my colleagues like me are competent in capacity evaluation and there are no standards for the evaluation of capacity in this particular context in order to make the irreversible decision to die.

I thank Dr. Komrad.

Dr. Mark Komrad

The American academy of forensic psychiatry has an 18-page template to evaluate this. Most states that have legalised this have four questions on capacity-----

I thank Dr. Komrad. I have to move onto Deputy Daly.

I am okay. If any of the witnesses feel they need to finish-----

No, that is fine. We will move on to Deputy Troy.

I thank our witnesses. We are dealing with what is an extremely emotive topic, when we are talking about life and death. There are times when we all might take offence at someone else's opinions but we have to respect everybody's opinions nevertheless and appreciate the good faith in which they are given. I am one who is coming to this debate totally undecided about what way I will ultimately go. I am trying to hold my decision until we conclude the hearings from international and national experts on how we square a circle, for want of a better description. I can see the positives but I also see huge risks. How do we assist people in a certain regard, while at the same time ensuring the right protections are in place?

I am struck by the paper we were given on the current state of play in Oregon. However, my colleague, Senator Mullen, seems to indicate through the paper he has in his hands that there has been an increase in the number of people availing of assisted dying over the past number of years. That is not evident from the paper we have. I ask all three witnesses the following questions. Even where strict limits have been imposed or introduced in the states where assisted dying is permissible, has there been a relaxation of the limits from when they were originally introduced? If there has been a relaxation of the limits or restrictions, has there been a corresponding increase in the number of people seeking assisted dying?

Dr. Tom Jeanne

It is important to understand that in Oregon we have had a couple of changes to the law over time. Several years back, there was a removal of the 15-day waiting period requirement only for those patients for whom it had been determined had less than that time to live. That is one thing that changed slightly. During this past year, we have also had the removal of the residency requirement. Initially, and for most of the law, patients had to be Oregon residents to use Oregon's law. After a lawsuit, that was found to be not right and has been removed from our requirements. It no longer has to be Oregon patients. However, it still has to be Oregon physicians who participate in this act.

On the general increase, we certainly had increasing awareness of this law and also perhaps normalisation of medical aid in dying in Oregon and other parts of the US. That is part of it. We also have an ageing population. There are more people with terminal illnesses who may want to use the law. I can only speculate that those are some of the reasons for the increase.

Professor Margaret Battin

I thank Dr. Jeanne. The increase can be understood in another way. The first thing to remember about this increase is that under US law in every single one of these jurisdictions, with the exception of Montana, which does not have a statute, all these patients must be identified as terminally ill. This is not a question of people simply electing suicide like ordinary suicides one might deal with in a psychiatric practice. These are people who are already dying and dying within an expected six months. That is a different kind of circumstance. The way we should see this is that what they are gaining is greater individual choice about how that death of theirs that is already coming shall go. This is to respect their choices and autonomous preferences to allow a death that can be determined in terms of time, setting, location, the people present, including family members and others such as religious advisers and spiritual companions, or anyone who might be important to somebody as they die.

It is to allow their death to be shaped the way they want, given that they cannot avoid dying but they can control the circumstances of dying. That is the main purpose.

It is important to understand that the US is the only jurisdiction of which I am aware that requires terminal illness. The European jurisdictions do not; they require intolerable or unbearable suffering. That would apply in the Netherlands, Belgium and elsewhere. Switzerland has no such requirements, as far as I am aware. Terminal illness is the major safeguard in the US.

Thank you. Dr. Komrad is next.

Dr. Mark Komrad

I would add Canada to that list of countries where terminal illness is not a requirement.

There are several considerations here in terms of why these things grow. First, in all of the living laboratories where this has occurred, in those countries that the committee has just heard about that have been at this for a while, as well as in Oregon, wherever one draws a line of eligibility based on contemporary ethical values, in addition to autonomy, fairness and justice, for example, people just on the other side of that limitation begin to make a case and ask "Why not us?". If the line is a six-month prognosis, they ask "Why not seven?" If it is a 12 month prognosis, they ask "Why not more?". If the line is assisted suicide drugs, they ask "Why not euthanasia, where doctors can start intravenous administration if we are not capable of doing it?" They will ask "Why not 17; why 18 only?" They will ask "Why only people with capacity; how about people with incapacity who have proxy consent?". There has always been, in every example, an expansion in the eligibility.

As someone who deals with suicide, both on an individual and a public health basis, the other point I would make is that there is a tremendous doubt as part of suicide prevention, not for stigma but for taboo. There is a difference and if someone wants to get into a discussion on that difference, we can do so. Removing the taboo on suicide by creating this zone of not only accepted suicide but suicide that can even have a romantic component, with stories, songs, newspaper articles, services and so forth, is very significant.

There is significant literature, which I will be glad to provide, on the trauma experienced by the families of people who have had assisted suicide and the physicians who were administering physician-assisted suicide. There is considerable literature emerging on the traumatic aspect of this. The committee should not take this as a beautiful, peaceful paean to dying.

Thank you. Deputy Gino Kenny is next.

I thank all of our witnesses for being here today. Obviously, we are debating and grappling with this subject. The debate on where we go from here has been ongoing for over a decade. It is good that we are debating the issues here and teasing out the international variations around assisted dying. My questions are for Dr. Jeanne and Professor Battin and relate to the situation in Oregon. Over the past 26 years, I have calculated that an average of 96 people per year have availed of assisted dying in that state. A total of 1,300 people did not avail of assisted dying even though they qualified and were given permission to do so. They chose not to, for all sorts of reasons. Sometimes there is comfort for people who are terminally ill when they know they have an exit strategy and one that is under their control rather than the control of anyone else. It is very important that those who find themselves in such circumstances have a say in all of this. It is a human rights issue.

As far as I can determine, the parameters that apply in Oregon have not changed in the past 26 years. What has the support within the medical community been like over the period? I presume there was a lot of opposition at the start and there is probably still some degree of opposition now. What has the narrative been from the perspective of the medical community over the past 26 years in terms of the evolution of the situation? Are the models that operate in other states in the US similar to the one pertaining in Oregon?

Dr. Tom Jeanne

I am not sure I can speak too much about the situation in other states but I will try to address some of the Deputy's other questions and perhaps the other witnesses can chime in. First, if the Deputy looks at page 5 of the report that I forwarded, he will see a graph showing the number of prescription recipients and the number of deaths over the past 26 years. There has been a more than linear increase, so it is really not an average of 96 people per year. There has been a real increase. One of the strengths of the laws to which the Deputy alludes is that when patients get terminal diagnoses, go through the process and receive the medication, it is entirely up to them what to do next. They can just set it aside and forget about it or, if it comes to it, they can decide that now is the time and they do not have to worry about processes or paperwork or that point; they can just take it. Empowering the patient in that way is one of the big strengths of our law.

I have forgotten the Deputy's other question.

I asked about the position of physicians in the state of Oregon.

Dr. Tom Jeanne

I am not sure I can make a generalisation here. There are lots of physicians who are not really involved and who probably do not have a strong opinion. There are physicians on both sides of the debate, on the right-to-life and anti-choice side and on the pro-choice side but the vast majority of physicians in Oregon are not participating in this act directly. They may be referring their patient to a physician specialist who would then go through the process with the patient. I do not have a sense that there is a unifying consensus from Oregon physicians as to whether this is a good or bad law. In one sense, that speaks to the fact that it is working as intended. Honestly, there is not a ton of dialogue in the public discourse or the in medical discourse about death or dignity. It has been running smoothly, or at least that is my impression.

Professor Margaret Battin

While I cannot give the Deputy an exact number, many organisations in this country, including medical associations, have switched their view from opposition to what can be called studied neutrality. Some of them have switched to support and some have remained opposed but a common position now is one of wait and see. They are neutral but continue to reflect on the circumstances. I believe that support among physicians has been growing but of course attitudes are tied to background experience, professional affiliations and religious beliefs.

In some states, including Washington for example, there is opposition that originates from religion and is a function of the fact that many of the hospitals in those states are owned by the Catholic Church, which prohibits this practice, as well as many reproductive practices, and so on. Physicians are not allowed to support this or to practise it, either in the Catholic facilities or off site. There are lots of political machinations.

Thank you. Senator Mullen is next.

I have a well-founded hope that this is the last session we will have where a guest is denigrated on grounds of style by one of the members and a fellow witness. We should allow people to have whatever style they have as long as they are backing up their statements with facts. I do not mind how trenchant they are as long as they are speaking in a bona fide manner. The last place we should have cancel culture or excessive sensitivity about people’s styles is in a national parliament. We need to allow people to tell the truth as they see it with the facts as they have them.

I wish to speak to the reality as I see it. We have had a tenfold increase in the number of assisted suicides in Oregon, no psychiatrist is required for an assessment despite the implications around suicidality and preventing suicide, and there is no requirement to discuss palliative care alternatives. We have broadly similar populations. If we were to have a situation like Oregon’s, there would be 350 deaths per year in Ireland.

I will start with Dr. Komrad. The number of people who qualify on grounds of terminal illness has risen dramatically to 46%. Does this not show that, even if we limit the grounds technically on which assisted suicide is made available, we will not necessarily limit the risks to the people involved?

Dr. Mark Komrad

That is true. The more people show up for it, the more people are vulnerable to the risks involved. The Senator spoke about terminal illness. Regarding the science of prognosis, even in areas we might expect it to be strong, such as oncology, it turns out that the ability to predict that someone is going to die from cancer – I can forward the study I am citing – is only 46% accurate. That is less than flipping a coin, which is 50%. The study demonstrated that no specialist was better than any other. For example, oncologists were no better than neurologists, general physicians or surgeons in predicting death. The more people show up, the more we will create a wrong case. How many cases of a doctor giving a patient the means to commit suicide and being wrong about it are acceptable? The idea that there has never been a mistake-----

I will clarify my question because I did not express it properly. The rise to 46% in 2022 was in the number of people qualifying on grounds of terminal illness for whom feeling like a burden was a factor. Behind the apparent limiting of grounds, there is still perhaps a change occurring in society and in how we see people who qualify under those grounds.

Dr. Mark Komrad

And also in the number of people who qualify. According to a Gallup poll in 2019, one out of four Americans did not seek healthcare simply because they could not afford it. The issue of being a financial burden is relevant to driving the increase in the number of people asking for this and in the thresholds, which are changing as those who prescribe grow more comfortable with doing so. Caution was illustrated at first by referring one out of every three people to a psychiatrist. Now, that number is one out of every 100 people. This is a barometer of how much more comfortable a doctor is, and how much easier it is for him or her, to think of eligibility for any particular patient.

Does Dr. Jeanne have any sense as to why the number of people who qualify in Oregon and feel like they are a burden has increased to 46%? What does this tell him about shifts in attitude or vulnerability among people who qualify?

If I am not mistaken, there are quite a few cases where people have actually outlived the six-month predicted period. We do not know exactly how many of those who availed of assisted suicide might have lived beyond six months. Are there issues in that respect?

Dr. Tom Jeanne

The burden issue is the fourth most common end-of-life concern cited. Please note that patients can choose more than one. Approximately 90% cite losing autonomy or being less able to enjoy life as their end-of-life concern. Some of those may also have selected being a burden as a concern. The figure for the top two concerns is 90% and the figure for being a burden is only 47% or 48%.

Dr. Tom Jeanne

It may be one of several reasons that people cite for their end-of-life concerns. I do not see that as particularly concerning. Only 5% cited financial implications as one of their concerns.

Regarding palliative care, physicians in Oregon certify that they have fully informed the patients of their diagnoses and prognoses, the risks of their medications and feasible alternatives, including palliative care. That is a requirement in Oregon.

A psychiatric evaluation is required if the physician determines that the patient may be suffering from a psychiatric or psychological disorder, including depression or anything else that might impair his or her judgment.

I thank Dr. Jeanne for the clarification on palliative care. I apologise for my mistake, but I understood that only 1%, or some other very low percentage, of cases involved psychiatry. I would have thought that, if people were serious about preventing suicide, the role of psychiatry would have been more central. I am also surprised that Dr. Jeanne does not see it as a problem that as many as 46% of those who qualify for assisted suicide include feeling like a burden as a reason. Many people in this country would be worried by that.

Dr. Mark Komrad

By the way, psychiatrists have particular expertise in addressing that problem, if given a chance.

Dr. Tom Jeanne

I will clarify my statement. I do not want to opine with my personal opinion too much but, among a handful of concerns that somebody with a terminal illness might cite at the end of his or her life, being a burden to his or her family would seem a reasonable one. I do not think that 46% of patients citing that means it was their one reason for choosing assisted dying.

But it is a rise from 30%, is it not? There is something happening.

Dr. Tom Jeanne

I would not put too much weight in the early years, given that so few patients were participating. From 1998 to 2020, the average over the period was 47.6%.

I thank Dr. Jeanne.

I will call Deputy Lahart, followed by Professor Battin.

For the record, I do not believe I was dismissive of or cancelled anyone. I have not finished my contribution. I could comment, but I do not want to drag the Senator down into the mire over his treatment of the Dignitas contributor last week.

I did not insult anyone.

Go back and look at the record, particularly at your last contribution on the matter, but I will leave it there.

I have a couple of follow-up questions-----

Yet again you have failed to produce evidence of any precise nature-----

It is on the record, actually.

-----except to express a feeling.

It was a witness whom I suspect was expressing himself in what was probably his third language as opposed to his first spoken language.

I said nothing to denigrate anyone.

I did not say “denigrate”.

I did not attack anyone’s style or the like.

If I read evidence to the committee claiming it is like asking a homicide perpetrator to turn himself or herself in, or people wanting a hamburger, but nobody's being willing to kill the cow, it sets a tone. We just did not have that kind of tone in terms of witnesses to the committee. However,-----

People talk in different ways.

Please, Deputy Lahart is speaking.

He was addressing me.

I made a point about the idea of being a burden because it had been a theme today. The witnesses might not be aware that this is our second multiple-hour session today. I am particularly struck by the theme of burden. It is not that this is a subjective piece, but it seems to play a big part in people’s consideration. I would like to see the committee explore it a little more. The point was made by all three witnesses, and I have listened respectfully to that.

In regard to the Oregon issue, we had a Supreme Court case, the Fleming case, but the Oregon model does not seem to deal with this situation because Marie Fleming's particular issue was that she was not in a physical position to self-administer because of her disability. Oregon would not have allowed Marie Fleming to end her own life because physically she was not in a position to do so. The other issue relates to the regulatory piece Dr. Jeanne presented, whereby the Oregon health authority does not investigate whether patients met the Act’s criteria nor how their diagnosis, prognosis and treatment options were determined. I find that alarming because some kind of oversight would have to be implemented there although I would have trust in medics and physicians.

Out of respect to Dr. Komrad who makes an important point, I would like him to furnish the committee with some background material on this. It is an area we will have to probe a little more ourselves. It is an important point when he says there are no validated standards for capacity to consent to irreversible death. That is a piece that troubles me. How do we know a person has the capacity when he or she is making the decision? He is saying that there is no way of measuring this. I would like us to probe that more.

Dr. Mark Komrad

Can I?

We will go to Professor Battin.

Professor Margaret Battin

The state of Washington I believe has an extensive document prepared by psychologists and psychiatrists on how to examine this. The claim that it is impossible to characterise capacity would be a problem for any medical procedure that involves significant risk. It is not only this issue. Also, keep in mind that this is not the difference between life and death, this is about a death that is by hypothesis and by requirement, already in the process of coming. It is very easy to forget that. In regard to self administration, the organisation I just mentioned, the American Clinicians Academy on Medical Aid in Dying, which includes several hundred physicians as well as others, has engaged and recently published an article on the dilemmas for people with neurological diseases, for example, amyotrophic lateral sclerosis, ALS, in which they do not retain sufficient physical strength to fully push a plunger or are no longer able to swallow medication or they cannot even engage a plunger to administer medications through a feeding tube or rectally. What this dilemma means is that somebody who is otherwise fully qualified but has endured their physically diminishing disease for so long that they lose the strength to do this, that is a serious ethical challenge which this committee is considering carefully. As I say, it has just published an article.

I call Dr. Komrad.

Dr. Mark Komrad

There are two concepts here that have a lot of overlap. One is informed consent and the other is capacity evaluation. The state-of-the-art of capacity evaluation has been developed for people who cannot consent to such things as surgery or competency to stand trial. These are extraordinarily different contexts. One of the things that one evaluates in capacity is the ability to understand informed consent, where you are told the benefits and the risks, what will happen if you engage in a procedure or do not engage in a procedure, and that is on the basis of our understanding about what the consequences are of going forward or not going forward with certain medical procedures. In fact, informed consent does not make any sense in this particular context because we do not know what the consequences are of dying, at least for the experience of the person. As a matter of fact, as part of those discussions, we also need to think about what are the consequences for the person's family and so forth.

In terms of one’s personal experience, we do not have that information so this really does not even fit into our established models of what informed consent means. In assessing informed consent through capacity, which as I pointed out is a highly specialised skill, there is no statutory requirement in any jurisdiction that the physicians who make these evaluations and decision get any training whatsoever. In regard to the experts Professor Battin notes in Oregon, this is a fait accompli. The state says “We are going to do this so you must provide for us guidelines” and so people prepare to do that. In Canada they tried to do the same in coming up with guidelines for psychiatric evaluation for the impending psychiatric euthanasia that is occurring there and ultimately-----

I thank Dr. Komrad. I have to go now to Deputy Gino Kenny.

My final questions are directed towards Professor Battin and Dr. Jeanne because I believe Dr. Komrad has made up his mind in relation to assisted dying as is his prerogative. Has there been a call for the expansion of the criteria around the Oregon model? Has there been support for expansion or even a drawback in regard to the criteria? Also, what lessons do they have for us as legislators and as people who represent people throughout Ireland, if we were to legislate in Ireland? What lessons have they learned over the past 26 years? Finally, in regard to the introduction of assisted dying, we hear those who oppose assisted dying say that if assisted dying was introduced, it would fundamentally change healthcare. I believe that is an exaggerated term. Doctors’ ethics state, “First, do no harm”. When looking at assisted dying as an issue that fundamentally determines and affects the individual, it is of fundamental importance to the individual, and that person should have a say in how his or her life ends. This is why I come back to this point all the time. Obviously, society says, “Assisted dying is a taboo issue and it cannot be introduced because there would be unintended consequences”. However, we have seen in other jurisdictions, in particular in Oregon, New Zealand and other places, that when assisted dying is introduced, the world does not fall apart. In fact, it gives people choice. To me, that is the most important issue.

I call Dr. Jeanne.

Dr. Tom Jeanne

I thank the Deputy for the questions. I believe when he asks about whether there have been calls for expansion of criteria, the Deputy is referring to within Oregon, to expand the criteria more broadly.

Dr. Tom Jeanne

It has mostly been focused around three issues, two of which have changed. I mentioned the waiting periods for which there are now exemptions for people who have a very short prognosis, a very short life expectancy. In those cases, people can be exempted from the 15-day waiting period from the verbal request, and in extreme cases exempted from the 48-hour waiting period between the written request, and the prescription being written. That has changed. The residency requirement has also been changed in the past year. The other call for expansion relates to other Bills in Oregon’s state legislature. There have been Bills to expand it, so that it is not just ingestion but other routes of administration. However, those have not passed to date, so it still requires ingestion. I do not believe it is specified in more detail beyond ingestion and self-administration.

It still requires ingestion and I do not believe it is specified in more detail beyond just ingestion and self-administration. As Dr. Battin mentioned, if a patient is not able to swallow and has a feeding tube, and if they are able to put it in their feeding tube that is certainly acceptable under our law. In terms of lessons for Ireland as this is being considered, I mentioned in my opening statement that Oregon has had, in my view, a pretty smooth experience with this and the limited nature of our process and the requirement for self-administration as opposed to a true euthanasia or active euthanasia where a provider could administer it avoids a lot of concerns. That would be our key takeaway.

Professor Margaret Battin

There are several things. I think these discussions are so interesting because we know the committee has talked to many other countries and we do not get to hear all of that. The experience around the world is remarkably interesting and different. One complaint about the discussion so far is the reference to informed consent. It seems that consent is absolutely irrelevant in this context. It is a request. There is no case in which the physician or any other party proposes this and then the patient consents or refuses to consent to it. That is just the wrong picture. This is a voluntary enterprise only.

About families, I am not aware of evidence in the US but in the Netherlands where this practice is widely accepted, evidence of which I am aware is that family members have lower levels of difficult breathing when the decedent elected what they call euthanasia. That is, this is easier for families partly because they do not have to see their loved ones die in a possibly difficult and prolonged way and they know this is the person's choice.

On euthanasia, another important thing to remember is that the meaning of the term is different in the US and in Europe, and also in Germany and Austria. In the Netherlands it is used in the Greek sense of Eu Thanatos, which means "good death" and is seen that way. In the US, we use the terms typically in a post-Nazi sense. This is true in Germany also. We associate it with killing that is in no way in the interests of the person who was killed and done entirely for political reasons. When we use the term "euthanasia", it has these two extremely different meanings.

Dr. Mark Komrad

I understand that the principle of autonomy is a core concept around which we have been orbiting here - self-determination and the right to decide how one dies. In these practices, it is really a kind of pseudo-autonomy or, heteronomy, as the term has been developed, because at the end of the day it really is up to the physician to decide what the prognosis is, whether there are other treatments, whether they accept the patient is suffering sufficiently, whether they think the patient has capacity and whether they think they should refer to a psychiatrist. The bottom line is that this still is the power of the physician. The idea that it is completely about self-determination is a simplification.

Also, let us remember that many kinds of coercions exist, not necessarily all of the explicit coercions but the implicit coercions of poverty, inadequate health access, the coercion of circumstance, and of despair. We are seeing an increasing number of deaths of despair in the United States. Autonomy is one of many values we have in our society. Another value is the common good and there are many challenges to the common good by giving individuals this particular privilege.

Speaking of privilege, a very important question for Ireland is whether Ireland wants to have this actually done in the house of medicine. What are the problems of outsourcing this and calling it a medical procedure, putting it in the hands of physicians and allowing physicians to make these decisions? There are very profound implications in the entire history of medical ethics of being able to now enter into the house of medicine where there is the opportunity to take a patient's life rather than coming away from it. That speaks to the common good.

On behalf of the members of the committee from the Houses of the Oireachtas, both the Deputies and the Senators, the secretariat and myself, I would like to thank Dr. Margaret Battin, Dr. Mark Komrad, and Dr. Tom Jeanne for giving their time, expertise and knowledge from so far away. It is wonderful we can do this using modern technology and that we can do this so efficiently and use our time effectively. I thank our three witnesses for their expertise and contributions. We really appreciate it and are very grateful and thankful to them. We have a very difficult task to do in Ireland but we believe that witnesses, such as these, will help us to decide in an informed way the best course of action to take in the future weeks and months.

The joint committee adjourned at 8.47 p.m. until 10.30 a.m. on Tuesday, 10 October 2023.
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