Scotland and Assisted Dying….
A personal view
The intervention of the UK government in Scotland’s recent gender reform legislation has led to the Assisted Dying bill shortly going through the Scottish parliament being subjected to more legal scrutiny. Its LibDem proposer, MSP Liam McArthur is concerned about the possibility of medical professionals opting out of the legislation through a conscience clause. The General Medical Council rules on this type of issue, and the GMC is accountable to Westminster.
Under the proposals, two doctors would need to confirm that the patient was terminally ill, had mental capacity and was not being coerced. The patient would have to be aware of all the palliative care and hospice options available and would need to sign a declaration followed by a reflection period.
The patient would have to administer the life-ending drugs themselves and all assisted deaths would be recorded and reported. But the proposals have been criticised as there is no advice what a medic should do if a patient has a seizure, takes days to die, or fails to die, all of which have happened in Oregon since it legislated on this matter in 1997.
Scottish healthcare experts in the Our Duty of Care (ODOC) group nonetheless have concerns. They fear the Medical Advisory Group (MAG) set up to assist Mr McArthur in scrutinising the legislation did not try to present other viewpoints from the medical community, saying the measure may erode public trust in the medical profession.
In 2022 a survey of Scottish palliative care doctors found that most of them would refuse to participate in assisted dying and a large majority felt the legislation would adversely affect palliative care services and compromise access to care by vulnerable groups, that the proposed safeguards were not fit for purpose and would not stop vulnerable groups being subjected to coercion. Half said they would resign if their organisation undertook assisted dying.
Canada’s Assisted Dying Legislation
Canada is perhaps the most controversial country to have liberal assisted-dying laws. Over 10,000 Canadians used this law in 2021 (33% of all deaths, up 32.4% on the previous year. But many are not terminally ill. Canada’s Medical Assistance in Dying programme (MAiD) is extending its programme to the mentally ill and potentially to children and the Quebec College of Physicians is calling for it to be legal to kill severely ill or disabled newborns.
Canada, the tenth richest country in the world, is under attack from human rights campaigners and the United Nations, three of whose experts said the law violated the UN Universal Declaration of Human Rights.
The British Medical Association (BMA) is no longer opposed to euthanasia, defined as the act of ‘deliberately ending a person’s life to relieve suffering’. It may be referred to as physician-assisted or assisted dying, as distinct from assisted suicide, where someone actively assists someone to kill themselves, for example, by obtaining lethal drugs on their behalf.
Belgium and Assisted Dying
A physically healthy 23-year-old female was helped to take her own life due to being in a ‘medically futile condition of constant and unbearable physical or mental pain that cannot be alleviated’. Shanti De Corte suffered from post-traumatic stress disorder and depression after being involved in the Brussels Airport attack by Islamic State in 2016. Physically unharmed, she never got over the attack, attempting twice to take her own life. But this drastic end took all possible solutions away.
Views are still polarised in Canada
Professor Leonie Herx has testified to the ‘horrific effects’ of Canada’s Assisted Dying programme. As the remit covered has expanded, it is the vulnerable who are increasingly caught up in it. Extreme poverty, lack of suitable housing or money to access at-home services are drawing the vulnerable into its orbit, including a 93-year-old woman who could not bear another covid lockdown.
Professor Herx says people underestimate how good palliative care can be, going as far as to say that the Canadian laws are heading into the territory of ‘eugenics’. Disabled people have called it exactly that as the expanded legislation includes disability as a reason in and of itself to end your life. She also says that it is those ‘made vulnerable by poverty who [have] been put to wrongful and premature death’, and that they could have lived well if they had had the right support and funding. She claims the powerful Dying with Dignity lobby has had more meetings with Canadian politicians than anyone else has on this subject, and the media has been largely silent.
This is disputed by James Downar of the Division of Palliative Care in the Department of Medicine, Ottawa University, who claims a large study showed vulnerable people were less likely than the average to receive MAiD. He cites a federal report that over 98% of MAiD patients were in fact able to access the disability support and palliative care they need and that palliative services have expanded considerably since 2016.
But there are worrying cases. Paralympian army veteran Christine Gauthier asked for a stairlift but was instead offered assisted dying by a Veterans Affairs official, which also happened to another half dozen veterans. A male with epilepsy and diabetes whose benefits stopped on turning 65 and who fears being made homeless applied for MAiD, and got the first visit from a doctor to his home 11 days later to discuss assisted dying.
Another male suffering from a degenerative brain disorder secretly recorded staff in his Ontario hospital asking him, unprompted, if he had an interest in assisted dying while telling him how much it was costing to keep him alive. Amazingly, the unprompted suggestion from hospital staff was perfectly legal. Yet another Canadian male hospitalised as ‘suicidal’ was desperate to get out of hospital, but within a month had requested MAiD and was ‘euthanised’ despite his only health condition being hearing loss. His family and a nurse practitioner complained he did not meet the criteria as he lacked capacity and was not suffering unbearably.
One particularly disturbing case is a male who was hospitalised after a fall, but within a month he was euthanised for end-stage chronic obstructive pulmonary disease which it turned out he did not have, and a 37-year-old with a debilitating tissue disease had her life ended as she felt she had fallen through the cracks of getting treatment, saying it was easier to die than to keep going.
Canada’s Supreme Court dismissed fears of a ‘slippery slope into homicide’ when the law against euthanasia was overturned in 2015. Initially it was meant only for people suffering a terminal illness whose death was reasonably foreseeable, but within 5 years the slide had begun, and since 2021 there is no requirement of a terminal illness, merely ‘anyone suffering from an illness or disability that cannot be relieved under conditions that he or she considers acceptable, can, with the approval of two doctors or nurse practitioners, get MAiD free’.
An applicant is supposed to be competent and wait a minimum 90-day assessment period, but the patient need not have exhausted all other options first, unlike Belgium and the Netherlands.
Is cost a consideration?
A University of Calgary study in 2017 estimated that medically assisted dying could reduce Canadian national healthcare spending by $139 million a year (£83 million), finding that in some provinces, end of life care for the last six months of life took over 20% of healthcare costs. In 2021 96% of MAiD applications were approved.
The Future
Canada plans to extend the law to people with mental illnesses soon and even to ‘mature minors’ over the age of 12. One doctor who has euthanised 400 patients said poverty was definitely involved in some MAiD cases but ‘believes many would want to die’ whether they had money or not. Factors like loneliness or feeling like a burden may also be involved.
Professor Tim Stainton, director of Canada’s Institute for Inclusion and Citizenship at the University of British Columbia, thinks it is a huge threat to disabled people. Extending the right to the mentally ill is dangerous as it is impossible to tell if mental illness is incurable.
The ISP does not hold an official position but views it as a matter of individual conscience. Scotland needs to think about not only the benefits of assisted dying, but also about the message it sends to the vulnerable, elderly and ill. Safeguards must be robust to ensure this is not the start of something we may regret.
Julia Pannell
13/02/23