Dr. Siobh?n N? Bhriain:

I thank the committee for the invitation to discuss the topic of examining a system for assisted dying. I am joined by my colleagues, Dr. Philip Crowley, HSE national director of strategy and research and a GP, and Dr. Feargal Twomey, HSE national clinical lead for palliative care and consultant in palliative medicine.

We would like to provide the committee with the view of the HSE senior clinical team, which is multidisciplinary and multi-specialty. The senior clinical leadership in the HSE is led by the chief clinical officer, CCO, who oversees a wide range of clinical domains. The CCO function ensures that there is multi-specialty and multidisciplinary input into the development of healthcare policy and strategy. The issues raised here cannot be said to represent the entire body of the HSE; rather, they are a representative example of those issues we believe need consideration in the matter of assisted dying. As there is no legislation in place for assisted dying, we cannot give definitive commentary on the exact requirements for implementation. However, we can provide the committee with some of the issues that we, as clinicians, consider and merit further thought. The CEO of the HSE has asked us to confirm that should draft legislation be forthcoming, the HSE will respond in more detail at the committee consultative stages, where invited to do so, and that the executive, as a statutory agency for health and social care services, will implement any legislation enacted in the future in accordance with its remit.

Ireland has a long history of providing palliative care through voluntary organisations and the public health service since the 1870s. Palliative care services provide active and often complex care and support to people with any advanced life-limiting illness, and at any stage of an illness, not just at end of life. Although palliative care services in Ireland are well developed, further work remains to be done to develop the service. My colleagues from the Department of Health will talk in more detail about that matter.

There are a variety of issues for those who may potentially wish to avail of assisted dying and those providing it that merit consideration. Some citizens are especially vulnerable and may be at particular risk of seeing themselves as a burden and of being subject to paternalism or coercion. These citizens may be particularly at risk of feeling undue pressure to consider assisted dying. While this is not an exhaustive list, we do consider that this does include older people, people with chronic conditions and those with physical or intellectual disabilities. These concerns have also been raised by others who have spoken to the committee.

We have also considered the potential impact on healthcare workers, HCWs. We discussed this aspect with representatives of the HSE employment assistance programme, which provides a counselling service for our staff. They have advised us of their experience of working with HCWs when they have been involved in experiences that may transgress their moral or ethical codes. This can negatively impact on the mental health of HCWs and can lead to feelings of self-blame and shame. The psychological impact of being witness to or making decisions relating to assisted dying or, indeed, involvement in the painful and prolonged death of a patient, have the potential to significantly transgress an individual HCW’s core values and their psychological and emotional well-being. That said, we as clinicians, believe we should be able to discuss death, dying and end-of-life care in a sensitive and non-judgmental way. Conscientious objection should be enabled as part of any legislation.

The committee will have heard from Dr. Anne Doherty in November 2023, who described treating people with cancer who have suicidal thoughts. She expressed concerns about how robustly such people would be investigated and treated for a potential mental illness if there was legislation on assisted dying, and these are concerns we share and would apply to other areas of clinical practice, including the diagnoses of other potentially life-limiting conditions such as certain neurological disorders, certain respiratory diseases and many others.

This, in turn, leads us to the issue of patient safety. There is a risk that a person may make a decision to seek assistance with dying, when, in fact, more robust investigation or time to consider the diagnosis, prognosis and treatment options may result in them opting for another or different approach to care.

Robust and commensurate safeguarding issues, drawing on citizen perspectives and research evidence, would need to be in place to support any person who is considering this route. International evidence in other jurisdictions does suggest that where legislation has been introduced, safeguards do change over time to include lower age thresholds, for example, in the Netherlands, and expansion of eligibility criteria.

We do believe that there is the potential for an intergenerational impact of assisted dying and that this warrants further consideration. We know from research that there is an intergenerational impact of suicide by increasing the likelihood of subsequent generations considering, and acting, on suicidal thoughts. There is a risk that assisted dying could have a similar impact. I have added some references, which are in my statement, that may help.

These are some of the issues that need to be considered when looking at the introduction of legislation to support assisted dying. The theme for today’s meeting is examining a system for assisted dying. It is the conclusion of the senior clinical group in the HSE that there are significant supports, both legal and medical, in Ireland to enable people to die in a dignified way.

The importance of will and preference is now enshrined in law. People do have a right to refuse life-sustaining treatment and there is access nationally to palliative care services. The draft palliative care policy will further enhance and embed palliative care across the spectrum of healthcare provision in Ireland. Also of note is the fact that there are legal protections in place in other areas of clinical care, such as the Mental Health Act.

This concludes our opening statement. My colleagues and I will endeavour to answer any of your questions. Go raibh míle maith agaibh.