An existential issue for the medical profession

Following detailed scrutiny of the Dying with Dignity Bill 2020, the Joint Oireachtas Committee on Justice in July 2021 recommended that an Oireachtas Special Committee be established to undertake further examination on the controversial topic of assisted dying.¹

This Committee is expected to begin its deliberations in the new year. Last year, some ICGP members wrote to the College board requesting that it outline its plan to engage proactively with the membership on this sensitive issue.

In August 2022, the board of the ICGP set out its planned interaction with the College membership on the issue, while there were encouraging responses to ICGP medical director Dr Diarmuid Quinlan’s 2021 article² welcoming collaboration with members in exploring this issue in greater detail. This article provides that opportunity in accepting and responding to the board’s invitation.

As Dr Quinlan has stated,² the issue of assisted dying is indeed a sensitive and complex one for GPs, our patients and society.

Prof Des O’Neill³ has described assisted dying as a reaction to fear of current and foreseen suffering rather than adopting alternative therapeutic modalities for patients. In other words, doctors frequently witness the ability of patients to adapt to their present reality of illness and in doing so transcend their feared future scenarios.

In his March 2021 article,² Dr Quinlan acknowledged unsatisfactory experiences of death in Ireland in the context of the proposed Bill. This opinion is not, I would contend, universally shared. We can, for example, take encouragement from a study on cross-country comparison of expert assessments of the quality of death and dying in 2021,⁴ which rates the delivery of end-of-life care in Ireland to be among the top six out of 81 participating countries.

The language of the Bill

The College article¹ consciously uses the words ‘assisted dying’ to mirror the language used in the Dying with Dignity Bill; it references the Victoria Government in Australia’s report ⁵ regarding language use. David Albert Jones ⁶ says the term ‘assisted dying’ lacks clarity in the description of the deliberate ending of life involving a healthcare professional directly or indirectly; is indistinguishable from ‘care of the dying’ and he recommends the use of ‘euthanasia and/or assisted suicide’. 

To quote David Shaw et al: “Communication between physicians and patients can concern the description of some actions that may be perceived as morally problematic… Medicine is full of issues laden with moral tension such as abortion, euthanasia, organ donation and withdrawal or withholding of life-sustaining treatments… The wording used to describe such actions often conceals these moral tensions.”⁷

Shaw et al hypothesise: “this moral tension is not universally appreciated by society, healthcare professionals or institutions, and is not sufficiently discussed in medical school, postgraduate training or at an institutional level,” stating that “this lack of transparency may be used to influence the decision-making process, for example, when futility is being discussed”.

They propose that these moral tensions should be clearly explained to patients, more generally in society and at medical school and other medical institutions, thus leading to greater transparency and enabling transparent discussion, ensuring respect for patient autonomy and “decreasing any moral suffering endured by healthcare professionals because of such tensions”. 

The Oireachtas Justice Committee’s press release on the withdrawal of the Bill in July 2021 uses plain English to describe how the Bill “would give a medical practitioner the legal right to provide assistance to a qualifying person to end their life, according to the terms of this Act”.¹

Confusing terminology

College members could understandably be confused by the use of the term “assistance to end their life”. GPs already assist patients in their dying with a broad range of support and care, while not providing assistance that intentionally ends a person’s life. For example, palliative sedation in Ireland is used when a patient is starting to actively die and it is considered a therapy of last resort when the patient is suffering from terminal agitation and distress, refractory to all other treatments. Palliative care affirms life, but understands death and dying as inevitable and ordinarily there is no intention to either hasten or postpone death.

On the importance of language and terminology in this context, Dr Noreen O’Carroll,⁸ writing on the Dying with Dignity Bill, argues that language can shape attitudes to controversial issues.

Herx et al, writing on ‘normalisation’ of euthanasia in Canada,⁹ point to the conflation with palliative care and argue that use of the term ‘medical assistance in dying’ can perpetuate the myth that palliative care hastens death, possibly preventing patients from seeking timely palliative interventions.

Ethical principles

Dr O’Carroll argues that the use of the word ‘dignity’ in the Bill is problematic,⁸ as human dignity is an inherent quality as affirmed in the Universal Declaration of Human Rights, and this approach is shared by the Victoria Government of Australia report,⁵ which rejects the use of the term ‘dying with dignity’ for this reason.

Ole Hartling,¹⁰ in the BMJ, disputes whether self-determination is genuinely possible when choosing one’s own death.  Considering autonomy, Hartley raises several pertinent concepts, namely: a duty to die, internalised external pressure, the end of autonomy, the killing ban, the valuation of life and relieving suffering. He concludes that the choice regarding one’s own death is completely different from most other choices usually associated with the concept of autonomy.

In Principles of Biomedical Ethics,¹¹ the authors argue that construing respect for autonomy as a principle with priority over all other moral principles, rather than one principle in a framework of prima facie principles, gives it too much weight. The authors are also of the view that a patient’s right to autonomy should not be purchased at the price of the physician’s parallel right.

Prof O’Neill also argues that in misconstruing dignity and autonomy, proponents of assisted dying have not acknowledged that choice for the few diminishes the many.³ A further significant consequence is the implausible separation of two forms of suicide into one that is undesirable and another that is desirable. 

Concerns for GPs 

The Irish Hospice Foundation submission ¹² points out that in the Dying with Dignity Bill, it is unclear exactly who would be involved in implementing assisted dying. The Foundation felt that the views of all healthcare practitioners expected to be involved in implementing assisted dying were not known, including whether practitioners believe that the Bill is necessary or if they would want to be involved.  

Dr O’Carroll argues that the Bill has the capacity to corrode the ethos of healthcare.⁸ Similarly, Prof O’Neill warns that the supporters of change are unaware of the danger of upending the care ethos.³ If such legislation is eventually enacted by the Oireachtas, would the Medical Council be mandated to adopt its legislative provisions as ethical standards? A robust freedom of conscience clause or ethical guidelines protecting freedom of conscience, as declared a human right by the United Nations Office of the High Commissioner for Human Rights, would be required.¹³

As discussed by Herx et al, the formidable challenges faced by physicians and patients in the difficult Canadian experience should not lead to discouragement but should instead inspire a reaffirmation of the commitment to trusted person-centred medicine.⁹

They advise that suffering, pain, fear, loss of control or sense of burden are not solved by hastened death but by excellent care delivered in a community that honours and protects our most vulnerable citizens at the most difficult time in their lives, urging colleagues around the world to monitor developments in Canada carefully and wisely before making any changes to their own country’s legal framework. 

Of relevance in this context is the opposition to assisted dying legislation from the Irish Palliative Medicine Consultants Association,¹⁴ the RCPI,¹⁵ the College of Psychiatrists¹⁶ and the RCSI.¹⁷

Where does the ICGP stand on this existential question for our profession? To what extent will it need to support or advocate for members unable to countenance any involvement, including onward referral? 

Will the College consider a role in training in the provision of legalised dignity in dying or respectfully decline any request for involvement in such a role? Calls by the College to improve deficits in hospice, home care team, GP and palliative care consultant-led services across the country will benefit our communities, while the College maintains the core value as highlighted by Herx et al⁹ of seeking to reaffirm the vision of the physician’s role “to cure sometimes, to relieve often and to comfort always”.  

Conclusion 

The proposed legislation would allow lawful direct and intentional ending of adult life. This is a core issue of human rights. The protection of vulnerable groups is a core priority for the GP community.

The language used in the discussions around proposed legislation must be unambiguous. Freedom of conscience of GPs and other healthcare workers must be comprehensively protected. It is welcome that the Oireachtas will seek the views of the GP community and it is essential that it is comprehensively informed by GPs regarding the proposed wording of legislation. 

References

1. Oireachtas Joint Committee on Justice. “Joint Committee on Justice recommends Special Oireachtas Committee examines topic of assisted dying following scrutiny of Dying with Dignity Bill”. Press release, Jul 2021
2. Quinlan, Diarmuid. “A sensitive and  complex issue for GP’s our patients  and society”. ICGP eZine, Mar 2021
3. O’Neill, Desmond, “A fundament of human rights: Let’s talk of assisted living, not dying”. Irish Times, 28 Sep 2020
4. Finkelstein, Eric A. Et AL, “Cross Country Comparison of Expert Assessments of the Quality of Death and Dying”. Journal of Pain and Symptom Management, 21 Dec 2021
5. Victoria Government Australia “Ministerial Advisory panel  on Voluntary Assisted  Dying”, 31 July 2017
6. Defining the Terms of the Debate: Euthanasia and Euphemism. David Albert Jones. www.bioethics.org.uk.
7. Shaw D, Manara A, Dalle Ave AL .“The ethics of semantics in medicine” Journal of Medical Ethics Published Online First.: 26 August 2021
8. O’Carroll, Noreen. “Assisted Suicide, Euthanasia and the Dying with Dignity Bill 2020.” Studies: An Irish Quarterly Review, vol. 110 no. 438, 2021, p. 142-157. Project MUSE 
9. Herx Leonie, Cottle Margaret, Scott John.  “The  Normalization of Euthanasia in Canada . The  cautionary Tale continues”. World Medical Journal, April 2020  (Official Journal of The World Medical Association, Inc.)
10. Hartling O. “Euthanasia and assisted dying: the illusion of autonomy—an essay by Ole Hartling”. BMJ 2021;374:n2135
11. Beauchamp Tom L. and Childress James F. “Principles of Biomedical Ethics”. Oxford University Press 2019
12. IHF Submission to Justice Committee from Irish Hospice Foundation on the on the Dying with Dignity Bill 2020
13. United Nations Office of the High Commissioner for Human Rights. “Universal Declaration of Human Rights Module 1: Freedom of conscience”
14. The Irish Palliative Medical Consultants’ Association. “IPMCA Position Statement regarding Assisted Suicide”
15. 15. RCPI consultation submission on the Dying with Dignity Bill 2020. Submission to the Oireachtas Committee  on Justice, Jan 2021
16. 16. College of Psychiatrists. “Press Statement: Position Paper on Physician-Assisted Suicide and Euthanasia 2020”
17. 17. Royal College of Surgeons in Ireland. “Submission on the “Dying with Dignity Bill 2020”