Dr. Siobh?n McHale:

I thank the Cathaoirleach and committee members for inviting us here today. I am a consultant liaison psychiatrist in Dublin. My colleague, Dr. Eric Kelleher, is a consultant liaison psychiatrist in Cork. My colleague, Dr. Anita Ambikapathy, is a consultant in intellectual disability in Dublin.

In addition, I am a special visitor appointed by the Decision Support Service, within the Assisted Decision-Making (Capacity) Act 2015. Dr. Kelleher, Dr. Ambikapathy and I are High Court appointed ward of court office medical visitors, with regard to specialist training and provision of capacity expertise in complex clinical cases or cases involving the courts. We are here representing the College of Psychiatrists of Ireland.

There are many challenges to consider, as have been thoughtfully presented to the committee over the time of its work. Our college paper, which members will all have, is clear in its outline and detail of our main concerns, and so we will focus in on some key areas which we hope will add to the discussion.

First, we are in agreement that thestatus quo, where we know that an important minority of patients are not receiving the optimal level of specialist palliative care and psychosocial support to allow them to die with dignity, cannot continue. The answer to this is not to end our patients' lives, but rather is to interrogate each and every incident of concern, to clarify relevant contributing factors, and to provide the appropriate evidence-based interventions ranging from improved pain control to family support. Where there is no access to the appropriate intervention, or there is a lack of evidence for these, then we must target our energies and resources in these areas.

In Ireland as internationally, we know there is an unequal distribution of palliative care services, a dearth of psychological and psychiatric supports available to people with challenging health journeys and insufficient research in end-of-life care, with most ethics proposals explicitly excluding patients at end of life from research. Addressing these deficiencies is the necessary next step, not to enable ending the lives of terminally ill people as a way to avoid these challenges. We can do better.

Second, as psychiatrists we believe it is not possible to clearly differentiate between suicidal patients and patients who request assisted dying. Suicidal people are human beings who cannot see any alternatives to ending their present or predicted future suffering other than by ending their lives. The work of the National Office for Suicide Prevention, NOSP, and Connecting for Life: Ireland’s National Strategy to Reduce Suicide are key, with people with chronic illness designated as a priority group requiring targeted approaches to reduce suicidal behaviour and improve mental health outcomes.

NOSP has referred to the potential for assisted dying to undermine the fundamental principles that suicide is preventable, and that interventions that are proven effective in suicide prevention should take precedence across our health system. As psychiatrists, this is at the core of our work. So, we engage with and support more than 12,000 people who present to our emergency departments each year with suicidal actions or thoughts. We then go to the ward to see inpatients with cancer or motor neurone disease who will often have additional challenges such as addiction or a history of trauma. We also engage and support these patients to find ways to alleviate their present suffering or fear of future suffering, including those patients who cannot see any alternative to ending their lives. This can only happen if patients and their families have access to good quality palliative care, mental health, social work and disability services. Far too often they do not. The view of our college is that we need to find a better way to substitute for these deficiencies than by offering assisted dying.

Third, we emphasise the impossibility of separating physical and mental disorders. Our long-standing splitting of illness into real, medically and socially validated physical conditions such as cancer or diabetes, and poor-moral-fibre, pull-your-socks-up mental health disorders has persisted, despite our advancing neuroscientific knowledge. We do not include the dynamic nature of trauma; external events, past, present and future; and social support, on how our brain functions as a central computer in managing our immune and hormonal systems, as well as our central nervous system. This is integral to an integrated physical and emotional response to illness and to response to treatment.

Fourth, autonomy and decisional capacity, and the cornerstone of any decision being voluntary and well considered are highly complex for people with autistic spectrum disorder or with intellectual disability and can be difficult to assess. Attempting to establish an absolute right to bodily autonomy by legalising assisted dying may undermine other individual and group rights, and by creating one class of people for whom life is expendable, that particular view may be extended by society to all groups possessing such attributes, such as permanently disabled people.

Finally, with regard to the question of whether one person’s choice of assisted dying will have an impact on another who does not so choose, we would say that the introduction of assisted dying legislation means that every person has to then choose it as a potential option or not for their end-of-life care. No person is an island.

In conclusion, we want to acknowledge the public service task that this committee, both collectively and as individuals, is faced with here in considering this radical change to our legal system and the direction of our society. It will take great wisdom and courage to find the balance for not just those who have clearly heard voices, but the unheard voices whispering from the future. Our college believes there is another way, and that Ireland can bring great leadership for others to follow.