Euthanasia & Assisted Suicide
The Care Alliance position regarding the legalisation of euthanasia and assisted suicide, agreed by all its member organisations (which includes all of the major providers of palliative care in New Zealand), is that they are unsafe, unwise and unnecessary.
The End of Life Choice Act 2019 lacks adequate safeguards against wrongful deaths.
The End of Life Choice Act is both broader in scope and less robust than laws in other jurisdictions that allow some form of assisted death.
The New Zealand End of Life Choice Act, which will only come into force if a majority of voters approve it, is less robust than laws in many of the other jurisdictions overseas that allow some form of assisted death. It is also broader in scope than many other laws because it allows both assisted suicide and euthanasia. By contrast, Victoria (Aus) – with a small exception – and States such as Oregon, Washington and California have narrower regimes, which only allow assisted suicide.
The End of Life Choice Act 2019 poses a significant risk of wrongful deaths. There are too many uncertainties involved, including the difficulties of accurately predicting how long someone is going to live, the possibility of a wrong medical diagnosis, and the difficulties of determining competence and mental health, especially depression.
Furthermore, there is a real risk that persons will be coerced – or pressured – both subtly and overtly, into ending their lives early. The wording in the Act, which states that the attending medical practitioner should “do their best to ensure that the person expresses their wish free from pressure from any other person”, suggests an acceptance that it is impossible to be sure that coercion is not present in all circumstances. This implies a lower standard of professionalism than is expected of health professionals in their other areas of work. The New Zealand Medical Association described the problem in their submission to the Justice Select Committee: “The provisions in the Bill will not ensure that a decision to seek assisted dying will always be made freely and without subtle coercion.”
Under the End of Life Choice Act 2019, terminally ill persons are not necessarily excluded if they are suffering from depression or an underlying mental illness. No mental health screening is required of a terminally ill person who asks for euthanasia. Depression is very difficult to detect, and even mild depression can seriously skew a person’s judgement about life and death.
There is no requirement that a person be competent at the point at which they make the final decision to end their life, unlike overseas jurisdictions such as Australia and Canada, which require that competence be assessed at the time of request and at the time of administration.
Incredibly, there is no mandatory cooling-off period before the administration of the lethal dose, such as the minimum of 15 days in Oregon (with a limited exception), 9 in Victoria or 10 in Canada. The only timeframe specified in the End of Life Choice Bill 2019 is a minimum of 48 hours between the writing of the prescription and the chosen time of death. That means the whole process from request to death could be completed in four days.
In 2019, a group of New Zealand academics, researchers and mental health practitioners wrote an open letter to MPs in which they highlighted that there is a real risk of the End of Life Choice Act leading to further increases in New Zealand’s already high suicide rates. The experts concluded: “Until it can be shown beyond reasonable doubt, based on robust evidence, that there is no causal link, and while suicides remain at epidemic levels in New Zealand, in particular for Māori, we maintain that it is too risky to legislate for euthanasia and/or assisted suicide in New Zealand.”
The End of Life Choice Act fails to give a corresponding right to New Zealanders to receive palliative care. In Canada, where the law is similar to the End of Life Choice Act, there is evidence of patients choosing to end their lives prematurely because they could not access quality palliative care. It is accepted that there is not yet uniform access to quality palliative care in New Zealand.
The End of Life Choice Act will fundamentally change our societal attitudes towards compassion for the worse.
Overseas evidence shows that once legalised, the criteria for euthanasia and assisted suicide inevitably expands to include many other forms of complex needs, resulting in the normalisation of death as a response to suffering.
The fundamental danger of passing the End of Life Choice Act 2019 is that we would cross a ‘Rubicon’ – a line of no-return – by creating a class of New Zealanders whose lives are deemed no longer worth living because of illness and disability. This would be a group of people for whom it is not just understandable, but logical, that they would want to end their lives prematurely.
In other words, the Act will, in practice, create two different categories of New Zealanders: those whose lives are deemed deserving of suicide prevention, and where our compassion and care take a life-affirming approach; and another group for whom the approach is to layout a pathway to death, – a path facilitated by the same healthcare system that would otherwise advocate for their well-being and resource their care.
Even if one wants to draw a line safely between those two groups, which is the purpose of the End of Life Choice Act, it ultimately becomes an impossible and incoherent thing to do. In a health environment in which resources are already scarce, making health professionals the gatekeepers for assisted death clearly introduces a conflict of interest that is both unethical and unwise.
Allowing the practice of assisted death to become part of the culture of end-of-life care will therefore change the way we think about people who are ill and disabled, all the more so in the context of a healthcare system that is operating under significant financial constraints.
Once assisted death becomes embedded in our practices of care, it follows that what starts as understandable and logical will become seen as desirable and to be encouraged, especially in a society which is already ageist and ableist – that is, biased towards the young, the strong, the healthy and the able.
In jurisdictions overseas where euthanasia is legal, including Belgium and the Netherlands, there is continual growth in the numbers of people being euthanised, which indicates that the practice is shifting from an act of last resort for terminal illness to becoming the default way to die. In certain Dutch cities, euthanasia now accounts for up to 15% of all deaths, and 30% of foreseen deaths.
Overseas, the reasons for wanting euthanasia continue to expand. Conditions include early dementia, age-related complaints, mental illness, and other cases such as blindness, autism, and grief. In the Netherlands “Hundreds of patients yearly receive euthanasia who could have lived for years or decades.”
While it is argued by some that providing people with euthanasia will prevent violent suicides, there is no evidence to support this. While it could be true for some, rates of suicide in the Netherlands have risen by 40% in the period 2007 – 2016 despite the wide availability and acceptability of euthanasia.
Euthanasia poses significant risks for vulnerable people, not simply because people might be pressured into it, but because such a law creates an increasing expectation that this is ‘the right thing to do’. The right to choose will become a ‘duty to die’, and it creates an additional burden on those who do not actually want to die early, to ‘justify’ their decision not to die, particularly if their care is perceived as expensive, and/or hard work for those around them – whether family or the health system. Physician assisted suicide and euthanasia are unethical, and go against the fundamental tenets of medical practice. They are not in the interests of patient-centred care.
Legalising physician-assisted suicide or euthanasia under any conditions may also compromise the effective delivery of Palliative Care, and places at risk the frailest and most vulnerable patients that the medical profession has the privilege to care for.
The rising rates of suicide in countries such as the Netherlands, where euthanasia is easily available, points to a ‘cultural shift’ in which death is increasingly seen as an acceptable solution to any form of suffering.
We can address end-of-life suffering without using lethal doses of drugs. There is hope, not for cure, but for relief.
We must focus, instead, on providing high quality end-of-life care – physical, emotional, social, spiritual and cultural – for each individual and their family.
Much of the public debate around end-of-life issues, including assisted death, actually emerges from inadequacies in our current healthcare system. If we legalise the End of Life Choice Act 2019 without first thoroughly addressing the problems with our healthcare system, we risk a scenario where people will decide to end their lives without first having had access to other quality end-of-life care choices. This is already happening in Canada, which has a similar law to the one being proposed in New Zealand.
The intention of the End of Life Choice Act 2019 is to prevent needless suffering. There are better ways in which this can be done without resorting to using lethal drugs to deliberately end the life of any person. Instead of focussing on the elimination of suffering through death, we need to improve the delivery of, and access to, high quality end of life care in New Zealand.
Such care is provided through Palliative Care. This medical specialty exists to improve the quality of life of patients with life-limiting illnesses and their families. Palliative care is holistic, encompassing not only the physical, but also the emotional, social, spiritual and cultural needs of the individual and their whanau.
A Dutch study looking at the impact of euthanasia on Primary Care Practitioners concludes that GP’s often feel forced by patients to offer euthanasia because of the hopeless circumstances in which patients find themselves. The lack of choices for quality end-of-life care in New Zealand is a reason to improve access to such care, not a reason to legalise assisted suicide and euthanasia.
Expert evidence from those in favour of legalising euthanasia, and also those opposed, is clear that in the worst-case scenario, palliative sedation (which is temporary and fully reversible) is available to address intractable physical pain.
Our current laws, which provide essential protection for all citizens and residents of New Zealand, are not broken.