Dr. Louise Campbell:

It does not necessarily mean we will be finished after seven minutes. I might add a few more comments as we go along.

I will state my position at the outset. I am cautiously in favour of legalisation of medical assistance in dying. I empathise with many of Professor O'Neill's concerns about vulnerable people, the elderly, the disabled and people feeling coerced, perhaps, by family pressures and economic pressures. However, I would answer many of the questions that were asked earlier in a different way. I am a philosopher by trade and I have professional training in clinical ethics. That is my background.

Voluntary euthanasia is a deliberate act undertaken with the intention of ending the life of another person at his or her request. Assisted suicide is the act of intentionally providing another person with the knowledge or means to end his or her life at his or her request. The motivation for both is to end the suffering of the individual at his or her request. The term "assisted dying" is the term I will use. It is generally considered preferable because it avoids negative or stigmatising connotations associated with suicide. Assisted suicide, as such, is legal in the Netherlands, Luxembourg, Switzerland, Canada, the US states of Oregon, Washington, Vermont, California, Montana and Colorado, and Washington DC.

Euthanasia is legal in Belgium, the Netherlands, Colombia and Canada and a number of other jurisdictions are currently debating the permissibility of legalising medical aid in dying. Any legislature which concerns itself with this issue should consider the following seven points.

First, the capacity for autonomy or self-determination is a core value in the liberal political tradition and it is regarded as one of unenumerated constitutional rights of citizens in many jurisdictions, including Ireland. Contemporary clinical practice places increasing emphasis on a patient's right to make and execute decisions based on his or her values and beliefs, including decisions which go against the patient's medical best interests and which may result in death. Proponents of assisted dying argue that autonomous patients who are suffering intolerably and wish to control the manner and timing of their death should be supported in doing so. Some argue that the right to request a hastened death is a logical extension of the existing right to refuse life prolonging treatment. Autonomy should not be reduced to unfettered choice. Properly defined, autonomy refers to a person's interest in making and acting on choices of momentous significance in that person's life according to that person's most cherished values and beliefs. It is not just about having a range of choices and choosing between them. The idea of relational autonomy reinforces that.

Second, legalised assisted dying is premised on a perceived duty to help end the suffering of patients who are experiencing physical or psychological pain which is intolerable for them and which cannot be alleviated. Some jurisdictions restrict the right to request medical assistance in dying to patients who have a terminal illness or a prognosis of six months or less. Other jurisdictions take a broader view of the nature of suffering and allow patients with conditions which will not end their lives within a specific period of time to request a hastened death. This includes patients with serious mental illnesses who have decision making capacity.

Third, for many individual health care professionals and professional organisations deliberately ending a patient's life at that patient's request involves abandoning the core values of medicine - healing, compassion, empathy and preserving life. Opponents of assisting dying argue that incorporating the prescription or administration of lethal medication into the practice of medicine will irrevocably alter the culture of medicine and destroy public trust in the medical profession. Palliative care providers, in particular, maintain that timely, effective and accessible palliative care support can reduce or eliminate demand for assisted dying. There is a genuine concern among palliative care providers and organisations that legalisation of assisted dying has the potential to stunt the development of palliative care provision and undermine the culture of palliative care.

Fourth, against this advocates of assisted dying argue that the suffering of some patients cannot be relieved by even the most effective palliative measures. Even where high quality palliative services exist, it must be recognised, first, that not all physical suffering can be alleviated by pain medication and, second, that not all suffering can be reduced to physical pain. In fact, most people who request assistance in dying do not do so because they are motivated by pain. Existential suffering is distinct from physical pain and may incorporate elements of anxiety, hopelessness and depression as well as fear of what the future holds. In the 2,300 years since the hippocratic oath was written, the values of medicine have evolved and the relief of suffering is now central to the practice of medicine. This evolution is reflected in medical practices which generate ongoing controversy.

Doctors are permitted by law to withhold or withdraw non-beneficial life prolonging treatment, thereby allowing patients to die. Doctors are also permitted by law to administer medications as a last resort to alleviate refractory pain or distress even though the administration of certain medications may foreseeably render the patient unconscious until death occurs or, if inappropriately administered, may have the unintended effect of shortening the patient's life. These practices are very controversial. Advocates of assisted dying point to the difficulty of drawing a clear line between these practices, on the one hand, and the deliberate administration of medication to end a patient's life on the other. This position is vigorously opposed by providers of palliative care, who maintain that a clear line can be drawn. More clarity and transparency are needed around these practices in all jurisdictions and more guidelines are needed to inform practice.

Fifth, opponents of medical assistance in dying argue that while legalisation may benefit a relatively small number of patients who have the resources and the capacity to advocate for their rights, it poses a threat to those who are less autonomous and more dependent on others, such as the elderly, people living with dementia and mental illness and people with disabilities, among others. Almost all organisations that advocate for disability rights oppose the legalisation of assisted dying on the grounds that it would have a disproportionate effect on persons with disability and would reinforce existing prejudices about disability. We heard about this in the earlier presentation.

Sixth, data from the Netherlands, Belgium, Oregon and Washington, the jurisdictions in which there is a longer history of assisted dying, suggest that the practice of assisted dying operates within its intended limits and is not utilised disproportionately by vulnerable persons. However, critics of the practice raise questions about the adequacy of existing safeguards to protect patients with dementia or mental illness, particularly depression and mood disorders which may compromise capacity for making decisions to end their lives. Certainly, greater oversight is needed to ensure that the rights of these vulnerable patients are not violated. Any recourse to data is problematic, as I said in my main submission, because data is always approached from the perspective of the interpreter. Different people on opposing sides of the debate can look at the same data and choose to emphasise different aspects of it to support their views. Epistemologically, we cannot simply rely on data. This is a value laden debate and the values of those on both sides are central to how it evolves.

Finally, the most crucial aspect of this debate, in my view, is that it focuses attention on the need to improve care for people with disabilities, mental health issues and dementia, in particular, to ensure they do not request assistance in dying as a result of a lack of proper community and other supports in jurisdictions in which this process is legal. This applies to all jurisdictions.