Joint Committee on Assisted Dying debate -
Tuesday, 23 Jan 2024

Healthcare Professionals and Assisted Dying: Discussion

An Cathaoirleach

Apologies have been received from Senator O'Loughlin who is away on official Oireachtas business. Parliamentary privilege is considered to apply to the utterances of members participating online in 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. 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.

The business today is an engagement on the topic of healthcare professionals and assisted dying as part of the module on the examination of potential consequences of assisted dying. I warmly welcome Dr. Suzanne Crowe, president of the Medical Council, Dr. Cameron McLaren, medical oncologist and palliative care provider and president of Voluntary Assisted Dying Australia and New Zealand, Dr. Laura Chapman and Dr. Peter Allcroft. I thank them for sharing their knowledge and experience with us today.

The format of the meeting is that members will ask questions after all the witnesses have given their opening statements. A member can ask a question of an individual or address a question to witnesses more generally. I ask that all witnesses keep their opening statements to the agreed five minutes. I invite Dr. Crowe to make her opening statement.

Dr. Suzanne Crowe

I warmly thank the committee for this opportunity to address it today. I am the president of the Medical Council, the statutory body responsible for the regulation of doctors in Ireland. The key objective of the council is to protect the interests of members of the general public in their interactions with registered medical practitioners while also supporting these doctors. The council protects the public by promoting and ensuring high standards of education, training, conduct and competence among doctors who are registered with the Medical Council. The Medical Council maintains the register of medical practitioners, that is, the register of all doctors who are legally permitted to undertake medical work in Ireland. The council also sets the standards for medical education and training in Ireland. It oversees lifelong learning and skills development throughout doctors' professional careers through its professional competence requirements. It is charged with promoting good medical practice. The Medical Council is also where the public may make a complaint against a doctor.

The Medical Council’s remit is set out in the Medical Practitioners Act 2007, as amended, and other relevant legislation. As part of its role, and to support doctors to meet these high standards, the Medical Council produces guidance on matters related to professional conduct, ethics and aspects of practice.

In November of last year, the Medical Council published the ninth edition of its Guide to Professional Conduct and Ethics for Registered Medical Practitioners.

The guide seeks to support doctors by providing principles–based guidance on how to best work in partnership with patients. It covers a wide range of topics and scenarios likely to arise over the course of their professional careers. The guide is also useful for patients as it clarifies the standards of care they should expect from their doctor.

This guide came into effect on 1 January, replacing the eighth edition. In preparation for the drafting of the ninth edition of the guide to professional conduct and ethics, a comprehensive public consultation took place, as well as a targeted round-table consultation with representative stakeholders. All feedback received was utilised to inform the drafting of sections and paragraphs in the ninth edition of the guide.

As with previous editions, and as mentioned, the guide seeks to support doctors by providing principles-based guidance on how to best work in partnership with patients. I hope many of the members have a copy of the guide in front of them. It includes some instructions on how it should be used. It is important that no one section is read in isolation but that the guide is read completely. As outlined in the introduction, the guide outlines general principles that we are expected to adhere to and observe as well as more specific guidance on identified aspects of practice. It is not, however, a legal code. It does not aim to address every clinical and non-clinical situation that arises in practice. However, understanding and applying these principles will assist doctors to safely navigate situations that arise in professional interactions.

The guide also outlines that doctors have a duty to comply with the laws and regulations pertaining to their practice. Their practice and conduct will also be informed by professional, clinical and organisational policies and guidelines. Furthermore, as stated in the guide, the guidance should be read in conjunction with all relevant policy and legal developments during its period of application.

When drafting the ninth edition, the committee considered existing and newly enacted legislation and how it applies to the protection of the public from medical regulatory and legal perspectives. It is important to point out at this juncture that the Medical Council does not have a position on the topic of assisted dying. It is the direct work of the committee to consider and make recommendations for legislative and policy change relating to a statutory right to assist a person to end his or her life, and a statutory right to receive such assistance. It may also be of benefit to the committee to address some recent commentary relating to one of the changes in the new edition of the guide. A number of paragraphs in the eighth edition were edited, merged or removed following the consultation and drafting. One such paragraph in the eighth edition does not appear in the ninth edition, namely, the phrase, "You must not take part in the deliberate killing of a patient". This removal has been misinterpreted by some. The guide states that the medical profession must comply with and operate within the law. As per legislation, it is illegal for all individuals, including doctors, to take part in the deliberate killing of a patient or to assist a person to end his or her life. The removal of this paragraph was not the Medical Council taking a stance or paving the way for any possible future change and should not be interpreted in this way. The removal of this sentence does not diminish the law.

In more broader terms relating to the guide, there is a detailed section on conscientious objection. Paragraph 42 details how a doctor may refuse to provide or to participate in a lawful procedure, treatment or form of care which conflicts with a doctor's moral values. I have provided the committee with the text of the conscientious objection and end-of-life care sections of the guide, in addition to a full copy of the guide.

In conclusion, I will paraphrase the guide by saying that doctors hold a privileged position of trust in society. To maintain this trust, they are expected to demonstrate professionalism through application of the required skills and knowledge and adherence to high standards of professional conduct and ethics.

The guide to professional conduct and ethics outlines the values and principles that underpin professionalism and good medical practice in the interests of patients and the broader population. It specifies how these values and principles apply in various aspects of a doctor's professional practice, for example, with patients, in practice settings, in the broader community and with colleagues.

Patients are individuals with diverse needs. The guide acknowledges their right to be treated with dignity and respect and to participate in decisions about their treatment and care. Given the constantly evolving healthcare environment, the council intends, over the next year and beyond, to issue additional guidance on a range of different areas. With the evolving nature of the practice of medicine and the delivery of healthcare in Ireland, the council will be regularly reviewing what additional support and guidance practitioners may require to supplement the guidance already available in the guide and to align with national health policy developments. I again thank the committee and Chair for the invitation to attend today.

An Cathaoirleach

I invite Dr. McLaren to give his opening statement.

Dr. Cameron McLaren

Voluntary Assisted Dying Australia and New Zealand is the peak body representing health practitioners involved in the provision of voluntary assisted dying, VAD, in Australia and New Zealand. We represent nearly 150 members involved in the provision of VAD care across all states in Australia, and in New Zealand. Although our members are entitled to advocate for voluntary assisted dying if they choose, the central goal of the organisation is to improve the quality and safety of VAD care provision.

I underwent training in voluntary assisted dying the night before the Act came into effect in the state of Victoria. I was not involved in voluntary assisted dying advocacy prior to this date. The reason I underwent the training was that I had been educated and trained in the paradigm of patient-centred and patient-led care. To me, involvement in voluntary assisted dying was a natural extension of that. I did not want to look after patients for months or years through their battle with cancer, only to refer them on to another provider if they chose to opt for an assisted death. Since beginning my work in this field, the main learning point it has provided me with is that patient-centred care is easy when the patient wants what you want, but it is no less important when the patient chooses a different path.

Overall, the experience of our providers has been that involvement in voluntary assisted dying is fulfilling and rewarding for them and empowering and comforting for the patients who elect to avail of this option. VAD is not seen, nor should it be seen, as an alternative to palliative care. It is seen, and discussed, as an option at the end of a palliative care journey.

Overall, VAD has been a positive change in the Australian and New Zealand healthcare landscapes, but it has not been without its challenges. If introduced in Ireland, I would encourage members to anticipate the need for evolution. This may be interpreted by some as advocating for a "slippery slope", but I firmly believe that the slope does not need to be slippery, simply patient-centred and allowed to evolve as all patient care does over time.

There have been unintended issues with access to voluntary assisted dying for the very people for whom the legislation was intended. Otherwise eligible people have been excluded from eligibility on mere formalities, due to the overbearing nature of some of the legislation in our states and the reluctance to leave many processes to the level of regulations. This has led to issues with access that cannot be resolved without legislative reform. I will now hand over to my colleagues, Dr. Chapman and Dr. Allcroft.

Dr. Laura Chapman

I have been a doctor for 25 years and an assisted dying provider for two years. I will start with words from a family I helped:

Dad was able to breathe a huge sigh of relief, and enjoy life as much as he could, looking forward to the day of his passing ... we went through some harrowing experiences with Dad's attempts to take his own life, and pleading for one of us to suffocate him. He desperately wanted to end his suffering. This was the best thing for Dad and our family.

I did not plan to be an assisted dying provider and I was deeply concerned that I would feel like a bad doctor after the first patient I helped to die. To my surprise, I felt like a good doctor, as I had worked with my patient to achieve the death he desired, peaceful and at home, surrounded by his family. I know I have helped some people to avoid deaths no doctor would want for anyone and that even great palliative care has limited ability to help, such as choking to death on a tumour growing daily in their mouth, or suddenly bleeding to death from a cancer eroding into a major blood vessel. In New Zealand, the option of assisted dying gives patients great comfort, and provides people who choose assisted dying with a good death. There are areas of the legislation which need revision but overall, New Zealand has made a safe and patient-focused start to the provision of assisted dying with strong provisions for conscientious objection and the right to not be involved for all clinical staff.

Dr. Peter Allcroft

I am talking from South Australia and the land of the Kaurna people, who I acknowledge are the traditional owners. I have been involved in caring for patients with palliative care needs for over 20 years. I co-founded the motor neurone disease clinic in South Australia in 2002 and have been involved with VADANZ as a member of the inaugural steering committee. I, like Dr. McLaren, have always advocated for person-centred care and when the legislation was passed in South Australia in June 2021, I became strongly involved to ensure the safe implementation and the planning that was required for such complex care for our patients but also for our healthcare professionals.

I have been involved with co-ordinating and consulting for patients requesting access to voluntary assisted dying since its commencement in January 2023 in South Australia. In those 12 months, I have been involved with 36 patients. These patients have lived in their own home, they have been in the acute care hospital setting, the local hospice where I work and, equally, they have been in our rural and remote regional towns.

I have always endeavoured to provide a holistic approach with a dual focus on their palliative care needs and the request for the consideration of voluntary assisted dying. Just this week, a patient who is in our hospice and is having palliative care has asked for assessment for voluntary assisted dying. After that assessment, he actually reported he had the best night's sleep he had had for several months, secure in the knowledge that there were other options available for him if it all becomes too overwhelming, with his loss of dignity, independence, enjoyment and his loss of ability to engage in activities that he previously enjoyed and was excellent at. He also fears symptoms of breathlessness progressing with his cancer.

I see voluntary assisted dying as a continuum of care, with the VAD process encompassing a small but important aspect of a patient's end-of-life journey. Most of the patients who I have dealt with have an underlying malignancy. Many have had motor neurone disease. A number have had advanced lung disease, airways disease or pulmonary fibrosis. All of them are equally deserving of consideration for combined palliative care and voluntary assisted dying if they so request.

I thank the committee for the invitation to participate in this session.

An Cathaoirleach

I thank all the witnesses for being here.

Senator Lynn Ruane

I thank everyone for their presentations. There is legislation coming up in the Seanad on a referendum Bill, so I will have to leave during the session and I want to apologise in advance.

Regarding the contributions, I am interested in chatting with Dr. Allcroft. Much conversation over the last while has been about how important and valuable palliative care is, but there seems to be some sort of competitive nature in the discussion when we talk about assisted dying, as if we are proposing or may propose that it is an alternative or better option, or that somehow they need to be taken as being in opposition to each other rather than being different types of end-of-life care. I am quite interested in that. Dr. Allcroft has had 20 years in palliative care and he has experience with assisted dying and motor neurone disease. I will ask all the questions, if Dr. Allcroft wants to note them, then I will let him respond to them all together.

Will Dr. Allcroft say a few more words on the statement that palliative care and assisted dying are not alternatives, where it must be one or the other, and discuss that from his own experience? He said he has been involved in co-ordinating and consulting for patients requesting access. What does co-ordination and consultation look like? It seems that all of the people involved in that consultation process are in different settings. Does he visit those settings? Are they all settings that are open to voluntary assisted dying happening? Obviously, if someone is at home, that is a different scenario compared with if someone is in a hospital bed or a care home. What does that look like in general?

Another question relates to motor neurone disease. Some dialogue in the committee over the last while is about how one begins to create the criteria. Will Dr. Allcroft give us a little insight on the criteria for the process where he is? How do those criteria for voluntary assisted dying work for somebody with motor neurone disease? Does somebody with motor neurone disease need more assistance at certain levels of the disease? How does that work when people require assisted dying and have a disease that will maybe hinder their ability to directly take the measures themselves? Will he give us insight on those patients and how that works? I think that is enough for now.

Dr. Peter Allcroft

I thank the Senator for those excellent questions. The palliative care society in Australia and New Zealand has varying opinions on voluntary assisted dying. What I have found personally in my service is that we have people who hold conscientious religious and faith-based objections and those like me, who have never campaigned for voluntary assisted dying. I have certainly campaigned for the safe introduction of patient-centred care and choice. It has involved some of the most respectful conversations and discussions with my colleagues about how we implement this safely in our service.

We have a reason that we provide both palliative care and assisted dying for those patients in our hospice and our acute care setting. I see the two working side by side, on parallel tracks if the Senator wishes to think of them as such. Sometimes they intersect then become parallel again. One may end up at an intersection and then may make a decision. Many of the patients who are approved for voluntary assisted dying never take their medicine for one reason or another. Often, it is their security blanket, which is there just in case. They do not actually need it and they have good palliative care running alongside, with the knowledge that the option is there if it all becomes too much, whatever the reason might be.

I see over time, as has happened in Canada, that it is never a day-to-day occurrence in our work. It is an extraordinary aspect of the care of the dying but it is part of the end-of-life care and not seen as diametrically opposed.

In 12 months, I have seen an evolution, a comfort and a confidence that it is okay. Some of the clinicians who were opposed to it have seen it in operation and said, "Actually I'm comfortable with what's happening" and have put their hand up to do the specialist training that is required by any of our practitioners anywhere in Australia to be a voluntary assisted dying clinician.

Regarding the co-ordination and consulting roles, in Australia, two doctors must assess the patients. Both of those doctors must hold a fellowship in a college. For myself, it is the college of physicians but it could be the college of anaesthetists or general practitioners or the college of surgeons. You must hold be a member of a fellowship or a registered vocational programme. One of those two doctors must have more than five years experience after the granting of the fellowship so very experienced doctors are undertaking these complex assessments.

The co-ordinating doctor is the doctor who accepts that first request from a patient. Where I work, the patient must raise it with me. I cannot raise it with patients. There are a few states in Australia such as Western Australia, New South Wales and Queensland where clinicians can raise it as an aspect of care but the patient must raise it and I can choose to accept that first request to his or her co-ordinating doctor. I would then refer him or her to a second doctor often using the voluntary assisted dying navigation service, which is a group of nurses, social workers and occupational therapists that helps co-ordinate and navigate this complex journey for patients and their families. I refer the patient to a consulting doctor who may be a doctor with specific experience and skills in the patient's disease but, again, is a doctor who has done the training for voluntary assisted dying, holds a fellowship and so has considerable experience. That consulting opinion is a one-off opinion. He or she assesses the patient, listens to his or her symptom burden and degree of suffering and assesses a prognosis. In South Australia, the patient's prognosis for cancer or chronic disease needs to be six months or less estimated by the clinicians or if it is a neuro-degenerative disease such as motor neurone disease, the prognosis needs to be 12 months or less.

The co-ordinating doctor takes the written request from the patient. That is then submitted to the Department for Health and Wellbeing where the chief executive officer of South Australia Health approves that permit based on the legislation that all dot points have been followed precisely. A permit is then issued and I request a script for the medication. That could be medication the patient takes at a time of his or her choosing or medication that I will obtain if it is physician-administered voluntary assisted dying. I see people in their homes, age care facilities, the acute care hospital setting or outpatient clinics. We are using telemedicine for assessing the patient's eligibility. That is the limit. We are allowed to use telemedicine digital platforms for assessment of the patient's eligibility and not for talking about the medicine or how it might work. The co-ordinating role probably takes somewhere between four to eight hours in total in a number of assessments of that patient, submitting paperwork and documentation and viewing Australian residency and citizenship.

Regarding motor neurone disease, the criteria were lengthened to a prognosis of less than 12 months.

Again, it is based on symptom burden and suffering. Many of the symptoms are existential such as loss of dignity, loss or independence, loss of autonomy and being totally dependent on someone for personal hygiene. For some, that loss of dignity is breathlessness because motor neurone patients predominantly die as a complication of respiratory failure because the breathing muscles just become too weak. Ultimately, even with non-invasive ventilation, life becomes intolerable for them.

An Cathaoirleach

I have to move on to the next member.

Senator Rónán Mullen

I welcome the witnesses and thank them for appearing before us. Like Senator Ruane, I may also have to leave before the end of this meeting to deal with the legislation in the Seanad so I offer my apologies in advance. I will focus on the Medical Council's submission. Please do not think me rude if I interrupt as I need to probe certain issues and time is always very limited here. In her opening statement, Dr. Crowe said that it is important to point out that the council does not have a position on the topic, which I get, nor does the council presume to prescribe what the law should be. I also get that.

The fact remains that the Medical Council has removed from its guidelines a very significant and important statement, namely, that doctors must not take part in the deliberate killing of a patient. Dr. Crowe told us how it came about in the context of merging paragraphs but she did not explain where the move to do that came from or why it happened. Who asked the council to make that change and remove that particular paragraph?

Dr. Suzanne Crowe

The project commenced about two and a half years ago so the work the committee is doing, which we very much welcome, was somewhat distant. The committee that was engaged in the drafting work and looking at the feedback and submissions that had been received decided to really incorporate and focus on the current legislation or the legislation that was coming very soon such as the Assisted Decision-Making (Capacity) Act and the Patient Safety (Notifiable Incidents and Open Disclosure) Act so at no time did the committee consider assisted dying. It is very important to say that-----

Senator Rónán Mullen

We are talking about the old council here?

Dr. Suzanne Crowe

Yes.

Senator Rónán Mullen

At what point was it proposed to excise those particular words and whose proposal was it?

Dr. Suzanne Crowe

I am not at liberty to attribute individual comments to individual committee members. It is important to state that.

Senator Rónán Mullen

This is important. When was it first mooted that this line be got rid of?

Dr. Suzanne Crowe

It was within the past 12 months while we were doing our-----

Senator Rónán Mullen

Under the old council?

Dr. Suzanne Crowe

Yes. The committee draws its membership from the old council, the new council and external members that represent both the-----

Senator Rónán Mullen

So the ethics committee is working on this. It is the ethics committee of the old council. Is that correct?

Dr. Suzanne Crowe

It is the ethics committee of the old council that began this project about two and a half years ago.

Senator Rónán Mullen

About 12 months ago, it was proposed to excise this particular line that doctors must not participate in the direct killing of a patient.

Dr. Suzanne Crowe

It was within the past 12 months.

Senator Rónán Mullen

Could Dr. Crowe be precise?

Dr. Suzanne Crowe

No, I cannot.

Senator Rónán Mullen

What I am trying to establish is whether it was definitely within the period of the old council.

Dr. Suzanne Crowe

Yes, it was.

Senator Rónán Mullen

So it would have been members of the old ethics committee that would have first considered this.

Dr. Suzanne Crowe

The ethics committee membership did not change over the period when the old council changed over to the new council. The existing ethics committee remained.

Senator Rónán Mullen

So it was the same personnel who were on the ethics committee of the new council.

Dr. Suzanne Crowe

It is the same membership of the committee that commenced the project two and a half years ago.

Senator Rónán Mullen

So even though there is a new council in place, the old membership of the ethics committee is working on this.

Dr. Suzanne Crowe

Yes, because all the committees do not change every time a council changes. The committees continue to do their work in the background. There might be some changes of membership but in general-----

Senator Rónán Mullen

Where did the impetus for getting rid of this line come from and what was the reason given for getting rid of this line?

Dr. Suzanne Crowe

The reason is that the council's job is to set standards for doctors.

Senator Rónán Mullen

I know that, but why is the line going? It is a big and important line and has been there for years.

Dr. Suzanne Crowe

Yes, it has been. It was felt that it was a little bit out of keeping with our principles-based guidance. We were very keen that it is not a legal code. It is principles-based guidance. In a sense, the committee could not understand why it was the only criminal statute that was referred to.

Senator Rónán Mullen

It is not a criminal statute. It is the Hippocratic oath. It is pretty ancient and has always been part of medical regulation. I do not understand why Dr. Crowe is saying it was somehow seen as out of keeping. One would have thought that it was medical ethics 101 that one would not participate in the direct killing of a patient.

Dr. Suzanne Crowe

It is the law of the land. Doctors-----

Senator Rónán Mullen

I know it is the law of the land. Medical ethics exist independently of the law of the land, or do they? Must medical ethics never disagree with what is considered permissible under the law of the land? Is it a separate journey that one makes? It was always the law of the land, yet all along it was clearly said. A medic who breaks the law of the land is of interest not just to the law of the land but also his or her medical standing. The council is setting basic standards for good conduct among doctors. It has always been the case that the council does not take part in the deliberate killing of the patient. Why was there a push to get rid of the oath?

Dr. Suzanne Crowe

If a doctor deliberately takes the life of the patient, they would face serious criminal sanctions.

Senator Rónán Mullen

I know that, but why-----

Dr. Suzanne Crowe

-----and also-----

Senator Rónán Mullen

Why is it no longer of interest to the Medical Council to make the statement that a doctor must not do that?

Dr. Suzanne Crowe

If a doctor did participate in the deliberate taking of a patient's life, they would also face serious regulatory sanctions that would likely-----

Senator Rónán Mullen

How? It is no longer a breach.

Dr. Suzanne Crowe

It is a criminal offence. If a doctor is convicted of a serious criminal offence, they will usually face serious regulatory proceedings as well that would likely result in the loss of their ability to practise.

Senator Rónán Mullen

How widely did the council consult with doctors about the omission of the specific section of the code? I think it is fair to say that it has raised eyebrows among a lot of people, including doctors. Was there any consultation with the generality of medical practitioners before the decision was taken to excise the section?

Dr. Suzanne Crowe

There was no specific consultation related to this issue. Instead, we went out to the public and profession. All of our stakeholders, on a wider consultation piece, to do with all of the aspects of care-----

Senator Rónán Mullen

The council did not ask doctors about this.

Dr. Suzanne Crowe

We did not.

Senator Rónán Mullen

That is surprising, given that this is a fairly fundamental change.

Dr. Suzanne Crowe

It does not change the principles-based guidance that we ask doctors to comply with, which is to be balanced and proportionate in how they look at their own ethical code but also the needs of the patient and the need of the patient to access lawful treatments.

Senator Rónán Mullen

It is fairly clear that we cannot draw any conclusions from what the council has done about what most medical professionals feel about euthanasia and assisted suicide since it did not consult them. It is only the view of the ethics committee that the paragraph be removed and the Medical Council ratified that. Dr. Crowe said that the removal of the paragraph was not the Medical Council taking a stance or paving the way for any future change and does not diminish the law. However, the removal diminishes the profession.

Dr. Suzanne Crowe

I do not feel it diminishes the profession. Our profession is very strong in meeting the needs of patients and putting their needs first.

Senator Rónán Mullen

Does the council think that students in medical schools should be required to study the administration of euthanasia and assisted suicide.

Dr. Suzanne Crowe

I think medical students should study a wide ethical code and principles-based practices.

Senator Rónán Mullen

They have to do more than study a code. They have to learn how to do things. Should they be required to study the administration and learn the practices of administering euthanasia and assisted suicide?

Dr. Suzanne Crowe

While that is not present in the law of this country, I do not think that would be relevant to medical practice in Ireland.

Senator Rónán Mullen

Clearly the Medical Council now has no problem with a change in the law.

Dr. Suzanne Crowe

The Medical Council has no position on the work that this committee is doing or the decision of the people.

Senator Rónán Mullen

It would be seen as convenient by those who would advocate the introduction of euthanasia and assisted suicide if the Medical Council would not need to change its guidelines were the law to change.

Dr. Suzanne Crowe

If there was a fundamental change brought in by the people of the country, the council would go out and engage in wide stakeholder engagement and consultation-----

Senator Rónán Mullen

Has the Medical Council not washed its hands of the rights and wrongs of this issue?

Dr. Suzanne Crowe

No, I would not accept that.

Senator Rónán Mullen

Okay. Thank you.

Deputy John Lahart

I thank the witnesses. I found their contributions very compelling. I have a number of questions. I had not intended to ask one question, but I want to follow it up following Senator Mullen's contribution. I ask for a brief answer from the contributors from Australia and New Zealand. Clearly, they must have come up against the Hippocratic oath in the law. How did they overcome that?

Dr. Laura Chapman

It is very challenging and I do not disregard that as a professional issue. The essence of my professional oath is to first do no harm. It is then about the definition of harm. New Zealand's law has been quite tightly written. There are six criteria that people have to meet in order to be allowed to go through with assisted dying, four of which are clinical. There is a tightly regulated system. I would like for it to be more tightly regulated in some respects.

From a moral point of view, as a doctor the Hippocratic oath is challenging. That is why I have chosen to speak publicly about it because I had no intention of being a participant. Doing no harm for the first patient I helped, and the many others I have helped in the past two years, meant enabling their death rather than anything else. I see that in the context of good palliative care. I saw a patient last week and have spent the time since building up a relationship with her general practitioner and ensuring she has palliative care so that I can decline her for assisted dying but not abandon her to a life that she does not currently want to lead.

I see it as part of the world of being a doctor. Part of that is enabling people not to live a life that they do not wish to live anymore when they are already dying. Our law is set up to enable people to choose the time and date of a death that is already coming in the next six months. Most people choose to shorten their life by a few days or weeks at most.

Deputy John Lahart

That is very useful. I am fascinated as to how Australia and New Zealand came to work together on the model. Towards the end of the meeting Dr. Chapman might have an opportunity to address that. It is a challenge to those who take the Hippocratic oath. There will be some who find it a challenge they cannot overcome and others, like Dr. Chapman, will see it as a natural progression of doing no harm.

Dr. Laura Chapman

It is very important for New Zealanders to know that the law was written as if conscientious objection was a binary choice. That is not how it has evolved in practice for the clinicians involved. That is an important thing to consider. It is much more about a spectrum of involvement. Some people choose to have absolutely no involvement. Some choose to be assisted dying providers, particularly within a care home or within a general practice, or a specialist who might contribute to my opinion or staff in a hospital where assisted dying is provided. There is a level of involvement. I do not think conscientious objection is simply a case of one being in or out. We need to consider the choices that people and staff bring to that across a spectrum.

Deputy John Lahart

Dr. Chapman made the point that initially she felt like a bad doctor approaching this. I thank her for her contribution. I will ask a number of questions and then allow the witnesses to come back in through the Chair.

An Cathaoirleach

We might direct something to Dr. McLaren too because he has not yet come in.

Deputy John Lahart

I can identify with what Dr. Chapman said because some representatives of general practitioners in Ireland came before the committee. Due to the fact that this is anathema to the culture in Ireland at the moment, it is interesting and refreshing to hear someone say that initially they felt like a bad doctor. I certainly have the feeling that there might be a public impression abroad that an assisted death might be a lesser death and it would be a conscientious issue for someone to overcome. Dr. Chapman might be able to comment on that.

Dr. Chapman mentioned something that is critical for me, namely end-of-life care at the very end of life. There is pain and there are conditions that are beyond palliative care. That seems to be very clear. I need "Yes" or "No" answers on that.

It is an important point. It is beyond the remit of palliative care.

Dr. Laura Chapman

Yes. There are things that palliative care cannot manage to a point of comfort but only manage through sedation. That is, therefore, why this is an option for those patients.

Deputy John Lahart

In regard to the arguments put forward I am taking another view on this. Reasons for supporting voluntary assisted dying would include loss of autonomy and independence, loss of dignity and loss of enjoyment of what was previously enjoyed, fearing systems and being personally really reliant on others for hygiene. People close to me experienced that and had what I would regard as a blessed period in their lives towards the end of life. It is valid for both cases. It is important to make that point. It jarred with me a little and I am struggling with it but that does not mean I will not overcome it. Maybe I will not but I resisted the naming of conditions because people are living with these conditions and they live as full lives as they can. I resisted naming them because I imagine that could be frightening for people who are watching this. However, it is a different perspective. Because we are dealing with the very end of the end of life, that possibly gives that a context. However, the naming of just one condition particularly jarred with me because I can think of other conditions and I certainly, as a member of the committee, did not want to focus exclusively on a condition as being a necessary prerequisite for interventions.

Dr. Cameron McLaren

I present on this topic a lot to medical students and the question about the Hippocratic Oath comes up quite often. I talk to them about which Hippocratic Oath we would really like to follow or talk about because if we talk about the original Hippocratic Oath, we are talking about a document that states:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant.

There are many outdated things in this document. It was updated most famously by Professor Lois N. Magner. The updated modern version of the Hippocratic Oath actually does not have an inclusion about not administering lethal medication. The oath itself was written in a time when medical providers or physicians were often called upon to act as government or political assassins as well and, therefore, part of the oath was to try to reduce or to self-regulate that practice. Many aspects of that oath are not applicable to current society and therefore to medical practice. I do not believe its relevance should be taken as gospel.

I hear also the point about the pain and the untreatable nature of some painful conditions. My perspective on that is if you talk to our patients who are going through assisted dying, that is not one of the most common reasons for applying for assisted dying. We did a pooled analysis of the reasons for applying for assisted dying of 344 applicants in the first 12 to 18 months of voluntary assisted dying. The most common was loss of dignity, the second was being less able to engage in activities that make life enjoyable and the third was losing autonomy. Importantly, only one patient out of the 344 reported uncontrollable pain, inadequate pain control or concern about it as the sole reason. Most of these people were reporting multifactorial reasons for applying. That goes back into the fact that what it really provides patients is that control. Often, these are people who have lost control since their diagnosis over the course of weeks, months or years. This is something they can do to bring that control back to themselves. Even if, as Dr. Allcroft said, they use medication, I believe approximately 30% of people who receive medication end up not taking it, it provides significant comfort to them to know that they have a trump card.

If their fears as to how their end-of-life care process is going actually materialise, they know they have a trump card. It provides them that comfort of being able to avoid their worst nightmare.

I agree with the point about the naming of conditions because there is a difficulty about making this too prescriptive. We have also seen that with people with certain conditions. I will take the Deputy's lead and not name the conditions. We have encountered conditions that are often very difficult to prognosticate even moreso than cancer, motor neurone disease or neurological diseases that were found ineligible because we are unable to prognosticate. That does not mean that people are not suffering. It does not mean they are ineligible under every other aspect of our eligibility criteria. However, we cannot progress their cases due to their not having a condition with a prognosis of less than six months. A line in the sand needs to be drawn at some point. A consideration for any jurisdiction considering this legislation is where that line is going to be. That is certainly a consideration for the committee.

Deputy Pa Daly

I have one or two brief questions. The first is for Dr. Crowe, in regard to what was she was asked earlier about the paragraph being removed. How many members of the ethics committee are there? Was there a vote on it? How did it go?

Dr. Suzanne Crowe

We work in a consensus style on drafting so we do not take votes on the work or on the material that we work on. We listen to each other's perspective and we come to a unified decision.

Deputy Pa Daly

For the attention of some of the New Zealand people, there is mention of a six-month timeframe. Previously, witnesses who came before the committee said that it was difficult to specify that. Why was the six-month period chosen? Why was it not three months? I have another question, perhaps for Dr. McLaren. He said he anticipates the need for evolution. How does he anticipate evolution will happen? What evolution does he see happening? He mentioned the overbearing nature of the legislation of some states. Will he give an example of what he means by overbearing? Finally, is psychotherapy obligatory before assisted dying is granted?

Dr. Cameron McLaren

I can probably talk to most of those points unless Dr. Chapman would like to talk about the six-month period.

Dr. Laura Chapman

I am happy to cover that first. I am not absolutely certain why New Zealand chose six months. Our Act was written by politicians and legislators. One of the complexities is that I do not believe there was enough clinical input into how to enact that. The clinical governance structures that I would have liked to see were not built in. However, our Act was written to be a slow, thoughtful and well regulated process. The outline is that it would take six to eight weeks. There is potential for patients to go through the process faster than that but if they only had a three-month prognosis, that would be a rush, which would lead to poor decision-making. I would not. therefore. want there to be a three-month prognosis as a barrier. I believe a six-month period is a reasonable point. Our legislation states that the patient has to be likely to die within six months, which has been defined as 51% or more. It is not a certainty. The six-month window gives us time to have considered decision-making, get to know somebody and ensure that no point of the process is rushed. That is really important.

In regard to the input of psychiatry, our Act states that if either of the two assessing doctors feels that capacity should be assessed by a psychiatrist, that is a compulsory step but it is not a compulsory step for other patients. It is a compulsory step if capacity is questioned.

Deputy Pa Daly

Psychotherapy does not relate to determining capacity then, rather in discussing the issue with the patient before the decision is taken.

Dr. Laura Chapman

There is no separate counselling. There are the two assessing doctors who in practice are both expected to counsel people about the process and why they want to engage with it and discuss whether they are under pressure.

That role is left to the assessing doctors. There is no separate psychotherapy or counselling process.

Deputy Pa Daly

Would that be a good idea?

Dr. Laura Chapman

It is within the skill set of a senior and experienced doctor to counsel patients about a huge number of difficult decisions, with personal, family, clinical, physical, mental, spiritual interactions. I think it is something to be considered but it is not necessary. It is important to recognise that doctors are used to counselling patients and that is an important part of the skill set of whichever doctor is allowed to participate in assisted dying.

Deputy Pa Daly

It is just that many palliative care doctors here refer for psychotherapy.

Dr. Laura Chapman

Yes. I do not know if that is a difference between Ireland and New Zealand. In New Zealand, we started from palliative care being very against assisted dying. One in 33 of our hospices allows assisted dying, that is the death, to occur on site but many more in the past two years have started to allow assessments. Assisted dying and palliative care are learning to work together. Palliative care is learning that assisted dying has no interest in doing anything other than support patients to receive great palliative care and assisted dying is just the very end point where some patients may choose to make different decisions. However, psychotherapy is not mandated under our law.

Deputy Pa Daly

Does somebody want to come in on the evolution and the overbearing nature of the state’s regulations?

Dr. Cameron McLaren

I practice within Victoria which was the first jurisdiction with legislation. I think the six-month requirement was also one of the points. I wrote them down so I will do them in that order. With our six-month requirement, I always talk to patients and say that the thing with people talking about this issues is that the majority of patients do not know they have six months to live until they have had a scan but then they have six weeks to live. It could be a case of one CT scan, where someone had been responding prior to it but the disease has suddenly progressed and we do not have any treatment options and we have to accelerate the palliative care pathway and journey. That transition is not smooth. It is more of a step type process. I think the six-month requirement is the most restrictive that I would recommend because on average, in Victoria, it takes between 25 to 30 days to get through the process. Someone in their last six months of life really will not enjoy spending a month of that through this process when they should be focussing that time on their family.

Interestingly, the committee may be aware that in Queensland has made it 12 months for all diagnoses. We are eagerly awaiting some feedback about how that goes and differences in that legislation. It has not been active for long enough to have a feel for that yet, however.

On the overbearing nature of legislation, it goes hand-in-hand with the evolution of the Victorian legislation, at the moment we are in our fifth year of activity in assisted dying. We are undergoing operational review of the legislation this year but I am not a legislator. There are many operational issues that cannot be resolved by legislative reform. It is a bit debated in many other states, as I think Dr. Allcroft mentioned before. Initiating the conversation about voluntary assisted dying is not allowed in Victoria or in South Australia. In some other jurisdictions it is allowed specifically in the context of a broader discussion about all treatment options. Those jurisdictions specify that it is not a health practitioner. It is a medical practitioner who is allowed to initiate those discussions. We have seen that be very beneficial for patients to be informed and to be aware of legislation and the options available. Patients are usually getting informed and educated about their healthcare options. Without the ability of being able to raise this as an option, one of my colleagues has said it is like being able to tell a patient, “You have a blocked artery in your heart and you can have tablets but I am not allowed to discuss surgery with you.” It does not lend itself to a fully informed nature of the care we are meant to be providing.

An Cathaoirleach

I thank Dr. McLaren. We will move on to Deputy Gino Kenny.

Deputy Gino Kenny

Good morning to Dr. Crowe and good evening to our doctors "down under" in New Zealand. This has been a very informative session. We have examined the template in Australia and New Zealand. The different compartments, so to speak, around assisted dying have been in evolution in the past four to five years. In the case of New Zealand, it has been by a popular vote, where the majority of people supported legislation on assisted dying. Obviously, we are having this debate in this country. The vanguard of the debate at the moment is in this committee and it will be coming to a conclusion relatively soon. We are drawing up parameters and possibilities around assisted dying, where it can be legislated for. I, for one, hope that assisted dying can be legislated for and that this committee supports legislation.

One of the templates we should consider is the New Zealand and Australia model, in terms of those who can avail of assisted dying and those who cannot. That is very important because there is a lot of scaremongering around this issue. General opinion in Britain and Ireland is that the majority of people support legislative change, when all the facts are put on the table.

If somebody wants to avail of voluntary assisted dying, could Dr. McLaren take us through the process? Do they contact their GP and then, via the GP, a process starts via the VAD specialists?

Dr. Cameron McLaren

This is a very important question because if people look this up on the Victoria department of health website, they will see a very over-simplified, flow diagram of a patient's journey but it is far more complex than that. I will touch on each step briefly. Initially a person becomes aware of this and that can be through general knowledge or a discussion with a family member or previous experiences, as we are seeing now with people who have had a brother-in-law or someone how has gone through voluntary assisted dying. Now they are facing the same situation themselves and the decision to chase that themselves. That is a huge part and we are not capturing that part of the journey because we capture them as soon as they make contact. Often at that stage they might make an inquiry with their GP and they will find our state-wide voluntary assisted dying care navigator. All GPs are not specifically trained in voluntary assisted dying and they are encouraged to refer to the voluntary assisted dying care navigator for the state which can help them through that process. The care navigator will find a doctor, who suits the person's needs. Many of these patients need a home visit because they cannot attend a clinic, as Dr. Allcroft mentioned. Most, if not all, of our assessments have to be done face to face. We need two doctors who can do home visits. In Victoria, we actually need one of those two doctors to be a specialist in the condition that the patient has. I would not recommend that as a model for Ireland to look at, otherwise there will be very busy oncologists trying to see all of these patients. Myself excluded, oncologists do not often do home visits.

Once the people see one doctor, they will be referred on. If they are found to be ineligible the process stops. If they are found to be eligible they will then be referred on to a consulting doctor who has to perform an independent assessment of their eligibility against a set of criteria. As part of the assessment, we promote that it is VAD care provision, so it is not just assessments of eligibility. We ensure that the patients are linked in with palliative care and we promote symptom control during those conversations as well. Those conversations have often been a gateway to actually get patients who have previously refused palliative care involvement to involve themselves while undergoing the process.

If they are eligible under those assessments, they will return to the first doctor, the co-ordinating medical practitioner, who then sits with them to do a written declaration of their wish to undergo voluntary assisted dying.

This is a written application which is pre-worded for them. Then a patient must verbally request, one more time, that they wish to proceed with voluntary assisted dying and then a contact person can be appointed. This contact person is responsible for the medication. If the patient receives it and does not use it - I always tell them that we cannot have that circulating in the community - the contact person becomes legally responsible for the return of the medication. Once that is all done, in Victoria we have to apply for a special permit to prescribe the individual medication to the individual each time and that can take a few days to turn around. Then we can prescribe the medication. Once that is with the single pharmacy in the state that does this, it is up to the patient and their contact person to contact the pharmacy and organise delivery and dispensing. This is a long process and is not just a drop off. It can take about two hours for the pharmacy to go through the steps. The pharmacy does its own capacity assessments. They look at all the medications that the patients are taking. They make sure that they can ingest 30 ml of liquid in three minutes, which is the recommendation. If at the end of that they are eligible to receive the medication, the pharmacy will then ask them if they would like the medication that day or on a different day. Some patients do not like the medication being stored in their house.

If the patient is unable to ingest or absorb the medication, we have to apply for a different permit which is called an intravenous permit. This is for situations where we might have a patient with a bowel obstruction or difficulty swallowing. One of the problems we have had is that those permits are separate. If someone receives oral medication and then loses their ability to swallow we have to return that medication, apply for a new permit, get the new prescription done and get the new medication kit delivered. Regarding some of the issues that we need to evolve in Victoria, these are some of the issues that patients are facing. If an end-stage cancer patient suddenly develops a bowel obstruction, they do not have that many days of not being able to eat or drink for us to get the medication process sorted and get the intravenous medication to them.

We finally get to the stage where they have either got the oral or intravenous medication and then it is completely up to the patient when they take it. It depends on who is available at the time. For oral administration, I offer to be present for all patients at their home or in the hospital when they choose to take the medication. I find that useful because I can talk the family through the process and explain to them what is going on at each step.

An Cathaoirleach

Thank you, Dr. McLaren.

Deputy Gino Kenny

Dr. Chapman just wants to come in briefly

An Cathaoirleach

Very briefly, please.

Dr. Laura Chapman

I just want to outline two differences between the New Zealand and the Australian processes. The first is to say that I think the New Zealand legislation focused very heavily, and rightly so, on a safe service, but it did not build in enough about delivering a quality service to patients.

The other key difference is that all of the medication in New Zealand is administered and carried by the doctor. The doctor is solely responsible and it would never be left in the patient's home. It is up to the doctor and the patient together to decide if oral or intravenous administration is better. More than 90% of our patients choose intravenous administration. The doctor takes the medicine to the house and administers the medicine to the patient. If the patient is swallowing it, the doctor waits until they have finished the medicine and waits in the house until they have passed, to support the patient and their family

An Cathaoirleach

Thank you, Dr. Chapman. I call Deputy Patrick Costello.

Deputy Patrick Costello

I thank the Chair and I welcome the witnesses. I have a couple of questions around the practicalities of the New Zealand and the Australian models. Can assessment be started before the six-month period that was referred to? Can a person start the assessment and make the application, so that they have their ducks in a row, so to speak, for when they reach the six-month threshold?

Regarding the people who did not take the medication - the witness mentioned polling - was it part of the polling? If not, why not? Can the witnesses speak to us around some of that, because I think it could provide an interesting and valuable insight.

What other information on polling could be relevant to the committee? It would be great if that could be shared with us, perhaps even offline if there is a report that could be emailed to the committee.

Several witnesses who have spoken to the committee have been concerned about this idea of the slippery slope and of the social impact of this, in that it sends a message that some people's lives inherently do not have dignity. I refer to the social impact of any legislative change. Having seen through that legislative change, could the witnesses speak to both of those issues?

I have a quick question for the Medical Council, which shared information around conscientious objection. It deals with complaints around doctors and doctors' practice. Are there complaints around conscientious objection, whether that is people complaining about a doctor who was objecting to treatment but outside of the standards and guidelines or whether it is a doctor trying to conscientiously object but not being allowed to do so? Does the Medical Council receive those kinds of complaints? Are they increasing or reducing? What is the pattern? In terms of rough percentages - I appreciate Dr. Crowe might not have the figures to hand - is it large? Is it a minority of complaints? If she wants to feed those exact figures back to us later, that would be fine.

Dr. Suzanne Crowe

I thank the Deputy for the question. Since we introduced our changes on conscientious objection in the amended eighth edition, which was in 2019, I cannot recall a single complaint where a doctor sought to step away for a particular treatment.

Dr. Peter Allcroft

With reference to six months, you cannot be initially diagnosed with an illness. You need to be within that six month period but you may not appreciate you are in a six month period until you are asked the question. We have had a number of patients who ask for assessment for voluntary assisted dying. They get that assessment but they are found not to be eligible because the likelihood of dying within that timeframe of six months is quite remote. That does not mean they are abandoned. There might be a referral back to their general practitioner or active ongoing engagement with the palliative care team. The patient can reapply at a later date, so it is not an abandonment just because they may not have that six months.

On why people do not take the medications, they just choose to change their mind. They may feel very comfortable that they have it as their trump card and they are comfortable with the care they are receiving and do not need the medication. That could be comfortable physically but also existentially and psychologically. They may die as a result of the disease. Things change so we may use alternative medications for sedation at that time. They may lose capacity, that is, if they have a delirium as part of their illness which we see a lot in end-of-life care. If they lose capacity, they cannot make that choice themselves and their family cannot administer.

It is important to know that if you look at the figures around the world with regard to the slippery slope, particularly with legislation that is tight, it is around 1% to 2% of all anticipated deaths. That has not grown exponentially across time. In Australia, it is roughly working out to be around 1% to 1.5% of all anticipated deaths, so we have not seen that as a slippery slope.

I do not think I, as an individual, can say that someone's dignity is better or worse than others. It is a personal choice as to how that person deals with what is important to them and what their goals are. I do not think it is our right to be able to imply someone's dignity is less important because it is their meaningfulness in life.

Those are important aspects for people. It is the individual's understanding and the importance of their dignity, their contribution to society and their losses. With medical illnesses, the losses are cumulative.

Deputy David Cullinane

I thank the witnesses for their evidence and their answers to the questions, which have been good. I will start with Dr. Crowe and her opening statement. I wish to be fair to her. She raised the change in the drafting of the ninth edition and what she called the misinterpretation of the removal of one paragraph. She has given a rationale for that removal. It is not unusual that, taking into account the previous seven editions, paragraphs would be deleted and additions and changes made. Is that part of the normal process of consultation, editing and reviewing those guides?

Dr. Suzanne Crowe

I thank the Deputy for the question. It is normal, and many other paragraphs were removed. I have been involved in several stages of this project and at each stage, some paragraphs have been removed. In this edition, we have removed all specific references to any particular treatments because we felt it wiser to step back and give principles-based guidance to guide the profession in future developments in care. Rather than being-----

Deputy David Cullinane

For the benefit of those listening and for our transcript, Dr. Crowe made it clear that from the perspective of the Irish Medical Council, that change had nothing to do with taking a stance or paving the way for a change to legislation in this area.

Dr. Suzanne Crowe

That is correct.

Deputy David Cullinane

That is the position.

Dr. Suzanne Crowe

We at no point considered assisted dying.

Deputy David Cullinane

I thank Dr. Crowe. I will come to Dr. Chapman, if I can. I ask that answers are as brief as possible although I appreciate that is difficult when we are dealing with a complex issue. I thank Dr. Chapman for her opening statement. She stated that in the context of the New Zealand legislation, "There are areas of the legislation which need revision." Would she outline to the committee what some of those areas are?

Dr. Laura Chapman

I certainly will. I have made a brief list because it is important to consider where we could improve as part of the committee's considerations. The first thing I think should be revised is that our legislation allows a postgraduate year 3 doctor to be the deliverer of assisted dying. That does not happen in most other places. I think a certain level of experience and qualification should be required. It should fall to people who are vocationally registered, which means they have completed specialist training, which would mean they would probably have at least eight years' experience, and more than likely more than ten years' experience. I do not think there is sufficient seniority and qualification in the level of providers within our legislation. I think most senior providers agree with me there.

As I said before, our legislation rightly focused on patient safety but not enough on excellent patient care and clinical governance. That should have been built into the legislation or the processing. We do not have a clinical lead as we have for most services. Our service is run nationally but there is no clinical lead, which is an omission. Clinical leads take clinical responsibility, govern their colleagues and enable things such as reviews of processes, reviews of patients who have declined and why, reviews of why patients are approved for the treatment but do not go through with it and reviews of patients who go through with it and what could have been done better. That is a normal part of clinical services that has been omitted and needs to be brought in.

I also think that there is not enough discussion. Our opinions are set up as two separate and independent opinions and although that brings good safeguarding, it is not normal medical practice and does not allow us to learn from each other. For instance, I have been a second doctor and turned down a patient that the first doctor has approved but I do not have permission to speak to that doctor to explain why I disagreed with him or her. I can speak to the patient, which is obviously the most important thing, but from the point of view of learning from a service, it is important that I can speak to the first doctor and explain why I disagreed. That is a more collegial and learning way to approach the issue. Those would be the first things I would like to revise.

Deputy David Cullinane

I will come to Dr. McLaren. His opening statement was interesting and I thank him for the evidence he has presented. He talked positively about the delivery of voluntary assisted dying, VAD, services in his country. That is his experience and I accept that.

It is important for us to hear that. He did say, however, that it is not without its challenges. He went on to talk about "the overbearing nature of some of the legislation in our states", and I get the points he is making. For us, as legislators, that is at the core of the dilemma when we make decisions. We ask how to get the balance right, how to legislate and at the same time deal with the unintended consequences and so on. Dr. McLaren also talked about the evolution of policy and so on in this area. What advice would he give to this committee or State if we were to legislate, looking back at what has happened in his country? What advice would he give us to ensure that on the one hand, we have safeguards, and on the other hand, that the legislation is not so onerous that it makes it difficult for patients to access?

Dr. Cameron McLaren

That is a very good question because at the time you are drafting and passing the legislation, you do not have control over the regulations and procedures that will then ensure the activity of the legislation. The individual forms that we have to fill out with patients are in our legislation. They are not in our regulations or policies. We found errors in those forms in terms of how the patients flow through the process such as, for example, with intravenous administration, we still have to appoint a contact person who is responsible for the medication. That medication is never in the possession of the patient or the contact person but is dispensed to the practitioner. There are certain things that are unexpected and were unforeseen. We try to explain to those who act as contact people for loved ones, which is a role many people feel is a burden. If it is not necessary, we should not burden that loved one any more. We would like that to be changed but we cannot change it until there is a proper legislative review. It would be important to consider how much one can trust the regulations to ensure a certain step is included at that stage and not necessarily in the legislation. The legislation needs to be very clear about for whom it is intended, the eligibility criteria and the overarching process but much of the nitty-gritty has been over-legislated in Victoria, in particular. That was a by-product of it being the first state to legislate and everyone wanting to ensure it was as safe as possible, which was admirable. However, parts of what was done could have been brought in at the next level.

Deputy Emer Higgins

I thank our guests for being with us today. We, as a committee, have a tough task and we benefit from the expertise that is shared with us. It is especially helpful for us to learn from international experience. They say that hindsight is 20:20 vision and we get to benefit from our guests' hindsight as we decide whether to recommend legislation in this area.

I thank Dr. Crowe for her attendance. I respect that the Irish Medical Council does not have a position on this issue. A number of the organisations that have been before us have positions but I have struggled to understand whether that is reflective of the people they represent, if people are polled and how those positions are arrived at. I appreciate Dr. Crowe being here with a neutral perspective to share her expertise and, as she has described it, principle-based guidance from the sector.

I will pick up on something Dr. Chapman said earlier. She said New Zealand has focused more on safety than on quality. In response to the previous speaker, she gave us an indication of what she means by quality. She said there could be clinical leads, better governance and improved communication between second-opinion doctors and first-opinion doctors. That is all really good and practical stuff for us to hear.

At this committee, what comes up repeatedly is safety and safeguards and I would be interested to hear our guests' view from a safety perspective. New Zealand has concentrated on safety. Could we hear advice as to what safety aspects could perhaps be used in another country, if we were to go down this route, to make sure safeguards were thorough? That is a huge concern for people working in this area and for society.

I have two other questions. I will run through them and hand over to our guests to respond, if that is okay. Dr. Allcroft mentioned in his remarks that he has assisted 36 patients and I am curious to understand how many patients came to him for advice overall on this topic. Apologies if this was asked earlier as I missed the start of the meeting. I am trying to understand how many came seeking help and how many got help. Also, if it is possible, although I understand Dr. Allcroft might not have the facts and figures, he might provide a breakdown as to the percentages of the settings it happened in, whether it was at home, in a hospice or in a hospital.

Perhaps I could ask the following question of our international representatives here today. We have heard from the palliative sector in Ireland. We heard the really strong concerns they raised and I am curious to hear what the response of the palliative care sector in Australia and New Zealand was and what the lived experience is now in a post-legislation world.

Dr. Laura Chapman

I thank the Deputy. That is a great question. There are two key features I would draw to attention that New Zealand does. The first is we have clear criteria for eligibility that are not disease based but are about the patient. You have to be over 18 years of age, you have to be a Kiwi citizen or resident, and then you have to have a disease that is going to cause you to die, likely within the next six months. You have to have unbearable suffering and physical decline in capacity. I have mixed feelings about physical decline but the fact you must be dying anyway and have death within six months and you must be suffering, and suffering is not necessarily physical but physical, mental, social or spiritual, and you have to have a capacity - those clear definitions - are important. We could have tightened up some of the wording. The word "illness" is not defined in the literature or law, but the fact that they are clear is helpful.

Then we have multiple checks in our process. We have a first assessment doctor and a second assessment doctor. Then there is a regulatory review to see if the application is compliant with the regulation and then you go through with it.

If you look at our applications, people are turned down at step one by the first doctor, they are turned down at step two by the second doctor and they are occasionally turned down at step three by the regulatory review process, so that is a very safety-focused process. Some people would say it was overly bureaucratic but I definitely think it has enabled us to have a safe process.

Obviously, the other unique feature about it in New Zealand is that we had a national referendum on this issue and we know that the country supported this in a vote. We are implementing this on behalf of the country and we need to implement it as safely as possible.

It is also important that provision is voluntary, so it is not mandated. It is not provided by our hospitals. It is voluntary and outside of the rest of our national health system. That means patients who have mixed feelings about it or who think it is a terrible to plan to have an assisted dying service know that the doctor in front of them, either the GP or at the hospital, does not have to provide and would not push it upon them. There is both psychological safety and clinical safety.

Dr. Peter Allcroft

With regard to the 36 patients, those are the 36 patients who I have registered on our digital platform as part of the voluntary assisted dying service. I have had a number of patients in my clinics with a variety of illnesses who have raised the topic. I knew they would not be eligible at that point in time from a prognosis perspective, but I did not dismiss that. I gently informed them that I am always willing to discuss it with them at a later date but that at this point in time they would not fit in with that legislation and that requirement of 12 months or six months.

Many patients bring it up in discussion in a clinical setting. Sometimes it is a general inquiry rather than a specific request for assistance with dying. There are general inquiries as part of overall general care. I could not say how many people raise it on a daily basis, but it is a lot. They are just making an inquiry, and they thank us for the information and say they will think about it.

A number of my patients come from the navigation service team because patients have rung the service which puts me in contact with them. About 65% to 70% of patients have utilised the medication at home. In the first 12 months of operation in South Australia, seven patients in my hospice have used the medication to end their lives. About 15 to 20 patients have had permits completed or have deteriorated so quickly that they have taken the first step but have not gone on to the second. There are some in acute hospital settings as well. The majority of patients in my state and nationally have had involvement with palliative care.

From a palliative care experience, some clinicians very much have a faith-based practice and hold a religious conscientious objection. There are a few that are perhaps card-carrying supporters for assisted dying. There are also those like myself who are there for the safe implementation and continuity of care for the patients I look after. There has been respectful dialogue and conversation. I have seen the spectrum narrowing across time. There is an understanding that there is no slippery slope or free-for-all. This is heavily regulated and legislated for and we adhere to national quality safety and standards.

Senator Annie Hoey

I thank the witnesses for their presentations. I have quite short questions. I will ask my questions and the witnesses can then answer them. I am struck by the case of patients with a bowel obstruction who need to change to a different system. Have the witnesses found that process is too onerous or bureaucratic? Have people missed the boat because there was an additional process that moved the step too far away and meant they could not avail of voluntary assisted dying facilities? Has the bureaucracy associated with the change piece caused trouble?

I refer to the evolution of policy. The witnesses spoke about legislation versus regulation or policy-making,d unexpected unforeseen circumstances and a review. Is there an appetite for a review? I find when difficult things are brought through the Legislature, there is no massive appetite to revisit them. The attitude is that this is what we went to the people with or said we were going to do, therefore we will stay away from this as much as possible. That may be more of a political issue in terms of a timed review. Is there an appetite for change?

In one state there was a public vote. While we have had some successes in Ireland with public votes, I am somewhat loath to repeatedly drag people out and ask them to sell their souls and sorrows in order to be able to access these things. I am a little iffy on that. I would be interested in hearing the thoughts on the witnesses on whether having a public vote strengthens the legislation. If there is a public vote and people are in support of it, there is support for it.

Do the witnesses feel that strengthens their hand in doing something like this? There have not been public votes across the world on this. Legislation has just been brought in. Do the witnesses think there is a preferable way to do it? I do not want to put my thoughts on referendums into the witnesses' mouths. Those are my questions.

An Cathaoirleach

Perhaps Dr. Chapman might answer.

Dr. Laura Chapman

I will try to answer briefly because I am sure Dr. McLaren and Dr. Allcroft will have other things to say.

In New Zealand, with the medication, the patient gets to choose. For a patient who chooses all medication, I would take a back-up intravenous option with me on the day of delivery. Our legislation allows us to do that. If I take intravenous medication, I would take a second set of intravenous drugs in case there is any difficulty. Our process has built-in back-up options for medication.

New Zealand's legislation very cleverly has a three-year review built into it. In November this year, our legislation will be reviewed because that was part of the original law. Is a referendum useful? I do not know the answer to that. Obviously, Ireland has experience with referendums. What is really important is that this is a major social change, as well as a clinical change, and the discussion that a referendum engenders is important. The most important thing is that people feel informed and supported and that it is not a threat to their existence and their relationship with doctors.

As a doctor, I know I hold a very privileged position of being trusted by people. They impart information to me and anything that threatens that is a major threat to our national healthcare system. Therefore, that is where I think the referendum for us has been beneficial. It is about taking the majority of people with us and, as both Dr. Allcroft and Dr. McLaren said, making sure the view of colleagues and the public who do not believe in the legislation is protected and enabled. That is why I got involved in the start. I was so concerned about my juniors - I do a lot of educational leadership - and about their role if they had a senior doctor who believed and how we would enable them to conscientiously object and step away from the person they are relying on for a reference. Therefore, the dynamic around it is really important both within the provider and healthcare staff and the public. That is the bit the referendum has definitely helped with, but there are other ways to address that.

An Cathaoirleach

I thank Dr. Chapman very much. Does Dr. McLaren want to come in next?

Dr. Cameron McLaren

I thank Senator Hoey. Yes, absolutely, we have had changes in permits and processes that then make patients practically not able to proceed with the treatment they wished. That has been regrettable. Some people would say that they are going to die soon anyway and we will make them comfortable, but we are still talking about not honouring their wish. That really is important, not only for that patient and for our role in advocating for that patient but also in the memory of that for the family and what they have left behind.

There is a lot of talk about coercion but we really do not have problems with that. What we see is advocacy for the patient from the family. They say their dad wanted this or this is the last thing that he wanted and I am going to get it for him. They come out and find the information and get all the documents we need. They work really hard and then it gets to the point and, unfortunately, that is no longer a possibility. That part of that process really made me recognise what some people would call the soft skill requirement for our profession and the art of what we do, and how to navigate that space in a way that is very sensitive to have a predictable outcome and understanding from that family in order that they accept that and we are still able to focus on the palliative care of that patient as they enter their terminal phase.

On the appetite for reform, I think it is difficult. It is very time dependent. The Senator will know better than I will how bloody the political floor can be sometimes and how often one has to pick one's battles. The appetite for reform is fluctuant based on whatever else is going on as well. My interaction with our Members of Parliament is that often, the appetite is there but they will say that they have three items of legislation or Bills that they have to debate first and they might have something to bring in around May. It is, therefore, difficult. I cannot speak to the referendum. Dr. Chapman has given that response. I will say that I think this legislation is for people who are dying and people who have terminal illnesses.

If it was possible to conduct a referendum solely of those people of that particular part of your population, that would be very informative. It makes it more complex when it is broader.

An Cathaoirleach

I thank Dr. McLaren. We are into the final round. I must advise everybody that this is a four-minute round. We could call it two minutes for the member and two minutes for the person to answer. I am sorry for being so down on the time, but I have to be. Senator Mullen has four minutes.

Senator Rónán Mullen

I thank everybody again for being very fluent and interesting today. I will ask for the Cathaoirleach's assistance on this since I have to go to the Seanad Chamber. I have a list of questions I would like to put that have been raised by today's discussion so far. I will go through them if that is all right and people might be kind enough to answer them. If they cannot do so in my time, which I suspect is going to run out very quickly, then maybe if there is time at the end of the proceedings the Cathaoirleach might give them an opportunity to return to these issues. If they are not answered today, I will be asking the secretariat to oblige us by getting answers as we move towards preparing a report. Is that all right?

An Cathaoirleach

That is no problem.

Senator Rónán Mullen

I will start with our Australian and New Zealand friends. Again, they should not take any of these questions personally. They are designed to elucidate information.

If I am correct in thinking there are 110,000 medics and doctors in Australia and another 17,000 in New Zealand, for how many active doctors and medics do the witnesses speak? If they have 1,000, that would be less than 1% of medics. The witnesses might tell us how many people they represent.

I am informed that for VAD training in Victoria, less than 5% of those trained are from palliative care backgrounds. Is that true? I understand why the witnesses are very much keen to present this in terms of an element of palliative care as opposed to something that undermines palliative care as, indeed, Irish and other experts have feared and who have expressed such fears.

I noticed that on at least two occasions, Dr. Allcroft seemed to confine conscientious objection to this or, indeed, objection to VAD, as being religious and faith based. Is that tactical? Would he accept that there are many people, because we certainly heard from them, who are not necessarily believers at all but who see this as unprofessional, unmedical and as undermining the relationship between doctors and patients and, ultimately, as being undermining of human dignity and causing people to feel a burden, as being incapable of expansion, which results in changed attitudes among the state and the planners and people who pay for medicine and so on? These are not just religious and faith-based concerns. Does Dr. Allcroft accept that among those who object to euthanasia or assisted suicide in his country are many who do not necessarily do so for religious and faith-based reasons but, indeed, other professional reasons?

I also noticed that in stressing palliative care, as the witnesses do, it has been suggested to me and from what I have seen that euthanasia, since it is a cheaper option, can actually disincentivise palliative care investment. The experiences of Belgium and New South Wales would appear to suggest that. Certainly, Canada, for example, had that situation where money was pulled back from palliative care. Is there not a clear dividing line between care that provides assistance in living and euthanasia and assisted suicide, which deliberately cause death?

We might look at the issue in Canada. Out of the 35 palliative clinics in Quebec in 2015, not one offered euthanasia on site. After threats of funding cuts, however, only four held out against medically-assisted dying. Then, the provincial government passed legislation to force them all to provide euthanasia. Is it not part of the dynamic here that palliative care does come under pressure in its funding, even though Dr. Allcroft seeks to portray euthanasia and assisted suicide as a dimension of palliative care at the end?

I mention the impact on doctors. The witnesses can tell me whether they agree with this or whether I am correct but again, it has been drawn to my attention that an Australian study in 2020 showed that up to one half of doctors who participated in assisted death experienced significant psychological and emotional distress. That is from an article by Kelly, Handley, Kissane and others in Palliative and Supportive Care of 2019, entitled, "'An indelible mark' the response to participation in euthanasia and physician-assisted suicide among doctors: A review of research findings".

Are the witnesses aware of that? Is my report on that correct in their view? What do they have to say to that? I notice also-----

An Cathaoirleach

I thank the Senator.

Senator Rónán Mullen

I have a few more questions if I may get them on the record.

An Cathaoirleach

I said I was going to stick to the four minutes. I am sorry. We will have to try to get them in some other way. I call Deputy Lahart. I am really up against the clock.

Deputy John Lahart

I will go through some points. These are directed towards our visitors. I ask them to tell us about some of those conditions that they have come across. They did not, in my hearing, mention burden. I thought it was interesting that none of the patients they have encountered mentioned being a burden as a reason for wanting to end their lives. We are clearly dealing with an Australia and a New Zealand system that envisages voluntary assisted dying at the very end of the very end of life. Are the vast majority of those who receive assisted dying in palliative care? I want to put it on the record again that I prefer to talk about symptoms as opposed to conditions.

I want to be sensitive about this. We have recently heard some interventions in the context of the death penalty in the USA, which have ended up horrendously. What guarantees are there if there are interventions at the very end of life that they do not end up in a more harrowing experience of death for the patient than if they proceeded to death under heavy sedation or naturally? Has there ever been a case, in the witnesses' experience, where a patient endured a more harrowing death as a result of VAD? It includes 1.5% of deaths in Australia and New Zealand and 3% or 3.5% in Canada. I am interested in those.

I have a question for the Medical Council. If the State decided, in whatever circumstances, with restrictions or whatever, to facilitate or legislate voluntary assisted dying, what paragraph would appear in the Medical Council's advice?

Dr. Suzanne Crowe

We would go back out to the profession, the public and our stakeholders and engage in consultation before drafting further guidance on the subject.

Dr. Peter Allcroft

There were many questions in two minutes. Many patients fear being a burden on their family and loved ones. That is considered quite strongly, supported, cared for and acknowledged within palliative care settings. About 80% of patients in Victoria and South Australia have had active involvement with palliative care services. In South Australia, we have a greater percentage of palliative care physicians involved with voluntary assisted dying. I think that is part of that evolution over time. I think it must be noted that the Kissane paper was written by people who hold strong conscientious objection to the legislation. I run the community of practice in South Australia for clinicians. My experience is that the doctors undertaking this role choose to be there. They are very experienced clinicians. They are comfortable with being uncomfortable. When I ask about their wellbeing, they all acknowledge that they are doing okay. I think we see burnout stress when any professional is placed in a position where they are out of control. My experience with all the clinicians I care for as a clinical lead in South Australia, where I run the community of practice, is that they feel their wellbeing is well looked after both professionally and personally. We talk about it quite openly.

Deputy John Lahart

I would like to get an answer to the question about any deaths being more harrowing as a result.

Dr. Peter Allcroft

I have no experience, whether personal, professional or anecdotal, that a voluntary assisted dying death has been more harrowing. They have been absolutely peaceful deaths where people go to sleep very quickly, within minutes of oral administration, and within 30 seconds of intravenous administration. They are deeply peacefully asleep and unaware of their surroundings. No, it is not harrowing.

Deputy Pa Daly

I have one question for Dr. McLaren.

Dr. Peter Allcroft

Sorry. Can I add that that is in Australia with our medications, safety and standards? I cannot comment on what happens in America.

An Cathaoirleach

Fair point.

Deputy Pa Daly

I have a question about what Dr. McLaren said about encouraging any jurisdiction to be clear on eligibility criteria to establish avenues of appeal or discretion. What does he mean by that?

Dr. Cameron McLaren

What we saw in the evolution of VAD legislation across Australia is that, in the last few iterations in New South Wales and Queensland, one of the issues that we have had is that in Victoria and the other states, we require people to be a resident of the state as well as a citizen of the country. That was very important when Victoria was first, so that we did not become a VAD tourism destination, for want of a better phrase. Now that all the states have it on board, it does not really have much of a role anymore. Queensland and New South Wales have also appreciated that they have border states, so they have introduced clauses in their legislation that say, "or at the discretion of the board". That tool could be utilised in other iterations or considerations in legislation. In some other cases, we have had patients who are Australian citizens or people holding a permanent residency visa who-----

Deputy Pa Daly

Is it just geographic eligibility criteria?

Dr. Cameron McLaren

I am sure it has been utilised but being able to do that has shown real strength. I think that could be extrapolated. If one has the concern of not having a prognosis but having severe suffering, maybe that is where the discretion of the board might be able to come in to provide individual access. That is for the committee and Ireland to consider. That would be something that could also protect against people who might not have that prognosis but who are in every other context suitable, eligible and deserving of legislation like this.

Deputy Pa Daly

Could Dr. McLaren explain that threshold of suffering?

Dr. Cameron McLaren

We continue to have diseases without prognoses but which cause severe suffering. We wish we had the ability to grant them their wish to engage in voluntary assisted dying but we have to talk to them and say that despite their severe suffering, there is no recourse.

Deputy Pa Daly

Would the discretion be Dr. McLaren's discretion or a doctor's discretion?

Dr. Cameron McLaren

I would not put it to the doctors to have the discretion. I would put it to the board or the overseeing body to say that a doctor may make an application for discretion to be considered by the board.

Deputy Pa Daly

So it would decide on criteria outside the regulations.

Dr. Cameron McLaren

I think that could be embedded in the regulations but it has to be considered in the legislation whether we want some way in which people can appeal that decision or be considered as a special case.

Deputy Pa Daly

Does Dr. McLaren think the appeal board would deal with different regulations to the initial application, including discretion?

Dr. Cameron McLaren

That would be the only place where the discretion would be able to be used. I cannot exercise any discretion. A patient is either an Australian citizen or not, or a Victorian resident or not. I do not have that discretion. I have a patient who has been living in Victoria for 20 years and has never taken up permanent residency or citizenship, so they are ineligible. It would be helpful to be able to have that recourse to be able to apply discretion.

Deputy Pa Daly

Would the board have different criteria from the original medical practitioner?

Dr. Cameron McLaren

I think it would be useful to have that ability to consider.

Deputy Gino Kenny

This has been a very informative session about assisted dying in other jurisdictions, in New Zealand and Australia in this case.

What has come across is that what is happening in New Zealand and Australia is highly regulated. There are some variations in each state in Australia and also in New Zealand. It is clear that assisted dying works. The vast majority of people even though they may be in circumstances where they could avail of assisted dying may never avail of assisted dying but it is about the choice. It is a fundamental human right. Hopefully, in Ireland, we will see that human right being legislated for in the coming years.

Regarding those who avail of assisted dying, a number of doctors said there are variations in those who will go through the process. Obviously the process takes time. In respect of those who take the ultimate decision to end their lives on their own terms, the witnesses said that in some cases, it is days, in some cases, it is weeks and in some cases, it is months. Is there a breakdown of time lapses regarding those who have the ability to avail of assisted dying in both jurisdictions?

Dr. Laura Chapman

There is no data on that in New Zealand. I think it would be very difficult to collect data on that because prognostication in the last few days and weeks of time is a notoriously difficult task until somebody reaches what we would call the terminal phase of life when he or she has two or three days left.

Deputy Gino Kenny

What about Australia?

Dr. Peter Allcroft

In South Australia, from first request through to the final request, at least nine days must have elapsed. If we think time is very short, we can apply to shorten that time period. I have done this for a few patients but my focus has been in providing intensive palliative to those patients rather than losing time with all the legislative dot points that must be adhered to to be eligible for the process. With those who are actively dying - within a week - I try to focus on palliative care. On average, for our patients, it is about 27 days from the first request through to the permit being provided to that patient. With some, it is little bit longer while with others, it is shorter but our mean in South Australia was 27 days in our first 12 months of operation. As our number of patient requests and providing clinicians grow, that will change. That is my personal practice. If somebody is actively dying, time is very short so I will concentrate on palliative care but we have it there as a back up if we need it.

Deputy Gino Kenny

Would Dr. Allcroft say that in certain circumstances, palliative care and assisted dying are complementary? Is this a good thing to say?

Dr. Peter Allcroft

I would agree that they can be complementary. Regarding palliative care spend in our state, by legislation, our health minister must report annually to the parliament the palliative care spend and no money can be taken from the palliative care budget to allocate to voluntary assisted dying. If an actuarial study was done, voluntary assisted dying per completed death may prove to be more expensive than palliative care because of the teams involved such as the navigation team, the pharmacy team, the health department team and the clinicians involved. If an actuarial study was done, it might prove assisted dying per completed death to be more expensive.

An Cathaoirleach

We are nearly finished but I wish to give the witnesses the courtesy of a very brief summary be that with regard to an individual's question or if there is any issue they wish to respond to.

Senator Rónán Mullen

On a point of order, I still have a few questions that I need to put on the record, so I am asking the Cathaoirleach for liberty to put those questions. I do not mind whether I get the answers today or at some future date but it is vital that I put some questions on the record.

An Cathaoirleach

Very briefly.

Senator Rónán Mullen

I will do my best but we have a big decision to make in this country. There is a report in The Daily Telegraph that the government of New South Wales slashed palliative care funding while directing some of that money to assisted suicide. This was AUS $150 million that was supposed to pay for items like palliative care, nurses, pain management, drugs and better end-of-life services and was put into the general New South Wales health budget, which includes AUS $97.4 million over four years to implement voluntary assisted dying laws. This is a report from last October. I do not understand why Dr. Allcroft questioned the Kissane study on the basis that Kissane has particular opinions. Very few people are without opinions but Dr. Allcroft has not questioned the quality of research or the findings and the statement that up to one half of doctors who participate in assisted deaths experience significant psychological and emotional distress. If Dr. Allcroft is letting that stand, I put it to him that this does not sound like normal medicine where doctors do their best. It sounds as if we are not talking medicine here if that is how so many doctors are reacting to their involvement.

On the question of pain, I think it was accepted here today that most of the time pain is not the issue, that palliative care generally deals with most symptoms and discomfort and that there is possibility of palliative sedation in extremis. It is about autonomy, choice and people's sense of control over their lives. I think this is coming across very strongly but I wonder why graphic descriptions of tumours causing bleeding and so on were used in an effort to persuade us. That is the human experience of suffering. Thankfully, so much can be done nowadays to address suffering. The question is whether there is an attempt to subvert our reasonable consideration of the issues by reference to the "yuck" factor.

Can the witnesses credibly talk about there not being a slippery slope considering that all this is very early days in Australia and New Zealand? We have seen how in Oregon, which is often cited as a conservative jurisdiction in this area, the percentage of people who feel a burden in the context of the reasons they have for wanting assisted suicide is growing year on year and is now at over 53%. Is it not the case that the witnesses cannot really give us any reassurance from Australia and New Zealand about whether people will feel a burden over time, whether medicine would be corrupted in the doctor-patient relationship and whether there will be implications for the funding of palliative care because they have only had this a wet week and the witnesses from these states are all involved so they are doing their best to put the best case for it?

My final question is for Dr. Crowe.

An Cathaoirleach

I am going to stop it now.

Senator Rónán Mullen

Can I ask two factual questions?

An Cathaoirleach

On a different subject, one thing I will not tolerate is people in the Public Gallery gesturing as if they are not happy with something. If somebody in the Public Gallery is unhappy with anything, I would very politely ask him or her to leave. People can remain here and listen to what is happening but I will not take direction from the Public Gallery about anything to do with the operation of this committee. I want to make that quite clear. I ask the Senator to finish up because I want to allow the witnesses to respond.

Senator Rónán Mullen

I am grateful to the Cathaoirleach for his latitude. I am galloping through these points and I think he would agree that they are all sincerely and credibly asked. Deputy Higgins was happy that the Medical Council was confining itself to principle-based guidelines. If the statement that a doctor must not take part in the deliberate killing of a patient is not a principle, what else is?

Can Dr. Crowe give an example of another specific prohibition or exhortation relating to treatment that was removed from the guidelines? It was suggested that this was one of many changes.

Dr. Crowe said the Irish Medical Council came to its decision by consensus. If one or two doctors or one or two other members of the Medical Council, of the ethics committee or of the full council, had opposed this momentous decision to excise the statement to which I have referred, would there have been a vote, and would Dr. Crowe have been in a position to give us the result of such a vote here today?

Finally, I am very disappointed that the Irish Pharmacy Union is not here today to deal with the issue of conscientious objection. There is a lot of concern that conscientious objection in this country is already very limited. There is a question as to whether, if there were a change in the law, institutions would have protection or whether, if, for example, a pharmacist, a doctor, a nurse or somebody just operating on the administration side believes that this is genuinely not proper medical procedure, or if it is against his or her professional and ethical instincts, whether religious or not, he or she can or should be able to avoid having any hand, act or part in the matter. As regards saying to somebody, "Okay, you need not provide the potion, but you must point to a colleague who will or tell the person he or she can get it at No. 10 across the road", is Dr. Crowe satisfied that that is adequate provision for conscientious objection?

An Cathaoirleach

I will make this very clear. Some other day, at some other time, if a member who may be of an opposing opinion wants latitude, he or she will be given the exact same latitude as was given today in this instance.

Dr. Suzanne Crowe

I am not sure I will remember all the Senator's questions but, to pick out one, he asked about other sections that have been removed. We did have a reference to participation around assisted reproduction and another section on doctors' role in the prescription and administration of ionising radiation. Those are two examples of very specific treatment episodes that were taken away from the current guide.

I have forgotten the Senator's other questions. I am very sorry.

Senator Rónán Mullen

I can assist-----

An Cathaoirleach

No. We will go to the other doctors now, to Dr. McLaren-----

Dr. Suzanne Crowe

I apologise.

An Cathaoirleach

You are fine.

Dr. Cameron McLaren

I thank the committee for the invitation to appear before it. I hope we have been helpful on some issues. I will pick up on a few points. First, as regards the New South Wales budget, I heard the same and had the same reaction. I do not know if it is a direct transfer. It is appalling if it is, and I would advocate strongly for the increase, not the decrease, of palliative care funding, unless it is voluntary assisted dying and can work together with palliative care. It is also important to recognise that the same paper was published in 2019. That was before there was any involvement in voluntary assisted dying in Australia, so that does not reflect the Australian experience.

As regards the point about being a burden, I will offer my reflection on patients' reports of that. I have experienced that there is a large difference between a patient saying he or she feels like a burden and a patient feeling as though his or her wife or husband thinks he or she is a burden. That should be treated, recorded and responded to very differently because a feeling that someone else thinks one is a burden means we need to focus on carer support. We should not, however, invalidate the experience of the individual who is not comfortable with having his or her personal care needs met by another individual. I would not be comfortable with that and I would not have someone challenge me on that.

Dr. Laura Chapman

I thank the committee for the opportunity to speak to members. This has been a very complicated, clinical and societal issue for New Zealand and Australia, so I am grateful to be able to share our experience to contribute to the committee's decision-making. As regards the key things I want to highlight, it is really important to consider the spectrum of conscientious objection to protect people who provide assisted dying, to protect people who choose not to do so and to recognise that there is quite a stressful spectrum in between. The three of us are not actually particular advocates for assisted dying. We have come to talk to the committee to try to inform its decision, but there are strong advocates and people who disagree strongly, and it can be quite a tense position to be somewhere in the middle with those people.

From a healthcare provider point of view, it is really important to look after junior staff and enable them to disagree with more senior staff.

Does assisted dying impose a burden on doctors? Providing clinical care for seriously unwell and dying people can create a burden on all doctors; we know that. My experience and the experience of the assisted dying providers in New Zealand is that assisted dying is not different from our normal clinical duties. We are a small country with a population of 5 million. We provide a national service.

I am very happy to come back, as I know Dr. McLaren and Dr. Allcroft would be, to discuss anything else that would be helpful or to make written responses to the committee. Our goal is to help members make an informed decision on what is right for Ireland, not tell another country what to do for itself.

An Cathaoirleach

I thank Dr. Chapman. That is very helpful.

Dr. Peter Allcroft

I wish all members well in their deliberations, debate and respectful discussions. This is such an important topic to get right in order to make sure patients have autonomy, choice, safety and safeguards, and are not abandoned. There are similarities between the Irish health system and the Australian and New Zealand health systems, which are very different from the American health system. The nationalised schemes that we all enjoy, with national support, really help patients. I refer to the disparity in America. I do not think we can compare how difficult it must be living in America at times due to the healthcare. I wish members well in their deliberations and share Dr. Chapman's sentiments. I am very happy to help with further information, if required, in the debate and decision-making.

An Cathaoirleach

On behalf of members and the secretariat, I thank very sincerely Dr. Suzanne Crowe, Dr. Cameron McLaren, Dr. Laura Chapman and Dr. Peter Allcroft for attending today's meeting. Their professionalism and experience are very important to us, as is hearing their views on this very important issue. I also thank members. The meeting went on perhaps a bit longer than anticipated but it was a very worthwhile experience.

The joint committee adjourned at 1.12 p.m. until 10.30 a.m. on Tuesday, 30 January 2024.