Professor Penney Lewis:

Palliative care is an area that is contested in the literature. I am sure, if one wanted, a person could be found who would tell the committee the opposite of what I am going to say. Having said that, what I am going to say is evidence-based. In fact, I will tell the committee about one recent Belgian study in a moment.

Generally, there is no evidence that palliative care suffers as a result of legalisation. That does not mean it is not theoretically possible. If a jurisdiction decides to disinvest in palliative care in favour of euthanasia or assisted suicide, then I suppose it could be possible but that is not what has happened in the jurisdictions that have legalised. One of the reasons the evidence in the Netherlands is contested is because it has a different model of providing palliative care to other jurisdictions. It is much more embedded in general practice. General practitioners tend to have long-term relationships with their patients. They tend to provide palliative care and they also are the most frequent providers of euthanasia. There may be less involvement with the hospice model but that does not mean that palliative care is not being provided. It is often being provided at home. Indeed, that is a model that is being rolled out in many jurisdictions. I am involved with the clinical ethics committee of St. Christopher's Hospice, the birthplace of the modern hospice movement. We do a lot of work providing palliative care to patients in their homes. That is a substantial part of St. Christopher's practice of palliative care. The Dutch evidence does not suggest that.

The Belgian evidence certainly does not suggest it. As I mentioned earlier, in Belgium, at the same time as euthanasia was legalised, a statute that created a right to access palliative care was also put in place. The evidence is that euthanasia is becoming embedded in palliative care. There is a recent study, published in the journal Palliative Medicinethis year, in which the authors looked at almost 7,000 deaths in Flanders. They found that those requesting euthanasia were more likely to have received palliative care - 70% of them had been in receipt of palliative care - than others who, according to the literature, were dying "non-suddenly", that is, those not dropping dead from heart attacks but who had conditions causing deterioration over a period. Euthanasia seems to have been embedded in palliative care in a way that it is another treatment possibility that one can access as part of one's so-called end-of-life care package.

The other question is whether lives would be at risk as a result of legalisation. The evidence does not bear this out. The reason I included the first comparison table is to show that termination of life without request is a small practice. Members will notice that the scale on that chart goes from 0% to 7%. Indeed, I had to increase the size in order that the committee would be able to see the detail. It is a practice that happens in permissive and prohibitive jurisdictions. Australia, for example, had a very high rate of termination of life without request. The Belgian rate has gone down following legalisation. The Dutch rate is also going down and is very low now. The evidence does not bear out that there is more termination of life without request in jurisdictions that legalise.

The evidence does not show that euthanasia is only practised in jurisdictions that have legalised it. This practice exists. The question is whether one wants to regulate it. The answer to that must be that it is certainly better to regulate it. That would be the way to avoid having people pressured or killed without valid requests.

If we do that, at least then we bring the practice into the open, we will know what is happening and if there are people behaving outside the legal regime, we can deal with them appropriately.