Dr. Annie McKeown O'Donovan:

I thank the committee for the invitation to be here today and to contribute to this conversation. As the Cathaoirleach has already said, I completed my doctoral research, titled "Ethics and Assisted Dying in the Republic of Ireland", in 2021. My research provides a practical, achievable, philosophically defensible and, hopefully, socially acceptable position on this debate. It will in turn alleviate some fears about descending any slippery slope.

The term "assisted dying", as I use it, refers to the active assistance to die that is given to someone who is already dying. The dying person is the one who directly self-administers the life-ending substance. The necessary condition that a person is already dying and, indeed, will soon be dead anyway, is not necessarily present in the concepts of assisted suicide and euthanasia.

My research argued in favour of the moral and legal permissibility of assisted dying in Ireland within strict, ethically defensible parameters. The individual on whom I focused is imminently dying and has repeatedly and rationally requested assistance in dying. The one who is imminently dying is commonly suffering from a terminal disease that is an irremediable, incurable condition, which is expected to lead to death within a short period of time. I argued that this repeated and rationally made request for active assistance with death should be respected and fulfilled when it comes from someone who is imminently dying; who has exhausted all avenues of available respite; who finds their current and prospective quality of life unacceptable; who values death now more than an inevitably short period of life which is judged by them as intolerable, resulting in death anyway; and who values death now.

Ethical and professional issues are complex here. Public inquiries concerning assisted death hinge on this interaction between conceptual matters and their practical implementation. The prominent concepts addressed in such inquiries are often autonomy; the value of life; the doctrine of doing and allowing; the distinction between killing and letting die; the doctrine of double effect; and arguments about slippery slopes. I will briefly address some of these.

The word "autonomy" comes from the Greek word meaning "self-rule". Practically, this is the capacity and ability to decide what to do with one's own life, as well as when and how. This is always governed by one's bio-psychosocial temporal setting. An individual's decisions cannot be realised unless they have the support of others. We are socially situated beings and, as such, our autonomy and ability to be autonomous is inherently relational. Assistance in dying comes from someone else, arguably a healthcare professional. Their wish to provide this compassionate support in dying, or their refusal to take part in something they conscientiously object to, is also relational and needs to be recognised as such.

That human life is intrinsically valuable forms the basis of many arguments against assisted dying. I do not refute that human life has moral worth and value but rather assert that life has prima facie moral value that can be overridden in specific narrow contexts. Life's value can diminish in line with the perceptions of the individual whose life it is. In this context, when someone who is imminently dying wants to die now, rather than soon anyway, we only need to concern ourselves with the value of a very short period of time, a period of time in a life that is characterised by dying and the want to die. Of course, it is still morally valuable, but what needs to be meaningfully considered is whether prolonging this period of life, characterised by dying and the want to die, is morally preferable to assisting this dying person to die now, rather than soon anyway, if they want to. This latter choice could be seen as part of compassionate palliative care.

The doctrine of doing and allowing, or acts and omissions, proposes that actions that cause harm are morally worse than omissions of actions that allow harm to happen when the consequences of either doing or allowing are the same.

There are structural distinctions here which are often confused with moral distinctions. The move from structural to conceptual is complex, and I am happy to answer questions on this issue. When we apply this principle to assisted dying it can be interpreted as saying that actions that cause death are morally worse than omissions that cause death. In the context of an imminently dying individual who wants to die now rather than soon anyway, this moral application may be skewed and that is because the force of the distinction is much less in cases of late stage terminal illness. Omissions of action that allow death to occur, like the withholding of life-sustaining treatment, for example, can prolong the period of life that has been identified as harmful by and to this person who is dying. Acting to cause death now rather than merely allowing the person to die soon anyway can be seen as the more compassionate and morally preferable action. This helps to justify limiting assistance to these cases only. When this is articulated in the language of killing and letting die, we have the problem again. Instances of killing are frequently deemed morally worse than instances of letting die, and this simplifies the reality of experience because intention and context must play a role. When the intention is to relieve an individual who wants to die now of the short, harmful period of life at the end of his or her life that is characterised by the dying process and when other safeguards have been met, it can be morally better to act to cause death now rather than allow the patient to die soon anyway.

The slippery slope is usually defined as a form of argument where it is proposed that if P happens, then Q will happen and R will happen, resulting in S. We do not want S to happen; therefore, we should not permit P. This form of argument is often used against the introduction of assisted dying. It is compelling because it plays on our fears about what might happen in the future, fears regarding our uncertainty about the practical implementation of conceptual matters, and because it can be supported by empirical evidence. Laws have changed in some jurisdictions to widen the parameters of what is allowed and this is sometimes taken as proof that the slippery slope exists. However, descending down a slippery slope is not inevitable. Empirical evidence also demonstrates that we can safeguard against such a descent. The slippery slope argument makes a journey from a moral commitment to theoretical and value laden concepts to the practical application of these concepts in some hypothetical future. This move is neither always reasonable, straightforward nor a good basis for policy formation. Legalisation of assisted dying in Ireland will need the care of strict and considered safeguards, with the fine-tuned interpretation of ethical and professional issues and an examination of how conceptual concerns play out in practice.

I thank the committee for the opportunity to contribute to this process.