Dr Jack Havill, past president of End-Of-Life Choice, outlines the stance of the Society in relation to different issues and population groups.
Click on each heading to find the answers.
Would the elderly be vulnerable if Physician Assisted Dying (PAD) was legalised?
Opponents of Physician Assisted Dying (PAD) are extremely vocal in saying that the elderly would be very vulnerable if legalisation occurred. They point to the elder abuse that is not that uncommon in our NZ population. The Voluntary Euthanasia Society NZ say that there is no evidence for elder abuse associated with PAD, and it is virtually impossible.
- Elder abuse is clandestine at the moment and is usually only dealt with when it emerges before professional health personnel and bodies such as Age Concern.
- The safeguards intended under the Maryan Street EOLC Bill include
a) they have to meet the criteria of a terminal disease and/or irreversible unbearable condition
b) they have to be mentally competent
c) they have to ask for PAD in writing twice with a separation period of 7 days
d) two doctors are involved in looking at the criteria and looking for coercion etc
e) each decision is reviewed by an expert committee
f) the process is reviewed by parliament annually
These criteria and the formal, above the radar, process makes it virtually impossible for family and others to use PAD as part of an abusive pattern. The Supreme Court of Canada (Feb 2015) agrees with this assertion and says that medical practitioners are capable of discerning abuse and coercion.
3. The elderly may sometimes feel a burden to others or feel that they are lonely or have had enough of life. This is a legitimate feeling and is common. However PAD is not possible for them unless they meet the strict criteria as above. Just because they feel that way does not mean they qualify for PAD
4. The experience in legalised jurisdictions has not shown any elder abuse associated with PAD – in fact the only study done on various vulnerable groups has confirmed lack of abuse. The onus is on bodies such as Care Alliance to show evidence for their claims.
Dr Jack Havill
on behalf of the Voluntary Euthanasia Society NZ (End-of-Life Choice)
Would the legalisation of Physician Assisted Dying (PAD) encourage suicide in the NZ population?
Opponents of Physician Assisted Dying (PAD) are vocal in saying that the introduction of PAD into NZ would increase suicide. The Voluntary Euthanasia Society NZ says that there is no evidence that this would happen or has happened. In fact there is some evidence that the absence of PAD leads some individuals with relentless disease to take their lives prematurely while they are still physically able to do that.
Suicide rates in legalised jurisdictions
If what opponents of PAD say about ‘encouragement of suicide’ is true, one might expect that in countries where legalisation of PAD has occurred, the suicide figures would confirm a link. However, from data available, there is no evidence of a causative link in countries where PAD is legalised.
- Suicide rates in both Luxembourg (9/100,000) and Switzerland (12/100,000) are decreasing (2010 figures are significantly lower than in 2007).
- Oregon: the ‘Death with Dignity Act’ in Oregon was passed in late 1997. They have always had a high suicide rate compared with the average for the USA (although they are lower than some States). In 1986 there was a peak at 17/ 100,000, and while lower in the intervening years (14-15), they have returned to 17/100,000, with sharp upward spikes in 2009 and 2010. This increase mirrors an increase in the average for the rest of the USA.
- Netherlands: the Netherlands legalised PAD in 2002. At 10/100,000 of the population (after rises over the previous 6 years), the rate of suicide in 2011 is back to the level which was present in the early 1990s. However, the suicide rate is still less than NZ figures, which have hovered between 10 and 15/100,000 between 1985 and 2011. It is noteworthy that the average European Country rate is 12/100,000, and out of 25 countries, 17 are higher than the Netherlands.
- Belgium has traditionally had high rates of suicide e.g. 15/100,000 (1965), 22.1 (1980), 23.1 (1985) and 19.4 (1995). In 2013 the rate was 15.7/100,000 which is lower than all previous rates since 1970. Legalisation of PAD in Belgium occurred in 2002.
Summary of Suicide Statistics above:
The above figures show there is no correlation between the legalisation of PAD and increased suicide rates. Luxembourg, Switzerland and Belgium have decreased rates. Oregon is the same as more than 10 years prior to legalisation. The Netherlands rate is the same as 10 years prior to legalisation, and is lower than most of the other European countries and NZ.
Power of Words
Even though there is no statistical correlation between suicide rates and legalisation of PAD, the possibility that change in the concepts around the word ‘suicide’ still exists. All we have shown above is that those who claim that legalising PAD encourages suicide, have not demonstrated a correlation between PAD and increased suicide rates. It is possible that among the many factors affecting suicide, some may be drowned out by others e.g. cultural and environmental effects.
However since spontaneous irrational suicide is completely different to PAD, we consider it best not to use the term ‘suicide’ in the context of PAD, because there is no need. There are various alternatives including ‘physician assisted dying’ and ‘aid in dying’.
‘SUICIDE’ - irrational suicide is impulsive, often violent, and causes extreme distress to family and friends. Almost always the mental condition which leads to the act is treatable and hence reversible. It usually makes grieving difficult.
‘PAD’ – there is a type of PAD where at the request of the patient, the physician prescribes the drug, and the patient takes it to end their life. This is often called ‘physician assisted suicide’. This type of PAD is beneficial to the patient, prevents suffering, is a compassionate act from the doctor, can be regarded as an extension of treatment at End-of-Life, is respectful of the patient’s autonomy, and allows the relatives and friends to say goodbye before the ravages of disease and intense sedation make this impossible. It also allows some ceremony and spiritual and religious involvement.
Premature Death by Suicide because PAD is not available
There is abundant evidence now that individuals will often commit suicide rather than endure the ravages of their disease, because PAD is not available to them.
- Professor John Weaver did a major study on suicide deaths in NZ between 1900 and 2000. In the last 50 years of that period, he found that 5-8% of all suicides were what he termed ‘euthanasia deaths’ to prevent them having to die slowly from their disease. They were well characterised, often had letters explaining the situation, and were frequently very violent and undignified deaths.
- The Voluntary Euthanasia Society NZ regularly sees and hears of such cases, some known to members personally, some accounts of which reach the media, and some of whom are already under hospice care. We also receive requests for help to die, but under the present law we cannot help. We have to advise that they have legal options of suicide, such as starving themselves to death, but cannot receive help to die from their doctor. There is an alternative organisation in NZ called ‘Exit’ which discusses ways a person might end their own life in a less violent way than the usual methods of slashed wrists, hanging, and gunshot etc. The Voluntary Euthanasia Society NZ does not give such advice.
- Knowing that the option of PAD is available to a patient should they need it, clearly allows peace of mind to individuals, and in some cases prolongs life. The issue was acknowledged by the Canadian Supreme Court February 2015 and they agreed with this.
Prepared by Dr Jack Havill
President of Voluntary Euthanasia Society NZ (End-of-life Choice)
130 Mahoe St Hamilton 3206
Would the legalisation of Physician Assisted Dying (PAD) be a major threat to disabled people?
Many disabled individuals and disabled people-led organisations oppose the legalisation of assisted dying, as they fear the consequences that it may have for people with disabilities. They argue that it will make people with disabilities feel obliged to end their own lives so as not to be a burden on family, friends, and society. Some go as far as to liken physician assisted dying to eugenics movements of the past.
The Voluntary Euthanasia Society NZ (VESNZ) does not share these views on assisted dying. They amount to saying that members of the disabled community have such a low sense of self worth that the availability of assisted dying would make them feel obliged to end their lives in order to avoid being a burden on others. There is no justification for projecting that view onto an entire category of society.
Disabled people have the same rights to dignity and autonomy as non-disabled people. Disabled people can also suffer from terminal illnesses and conditions with irreversible and unbearable hopeless suffering.
Legalising assisted dying generally is unlikely to exacerbate disenfranchisement of disabled people. To the contrary, the process of legalisation would have great benefits. This is because it would bring society's attitudes of discrimination towards disabled people into the public consciousness through debate in parliament and the media.
Disabled people are currently more at risk from suicide-related harm than if assisted dying were legal.
Conflating the issues of disability discrimination and assisted dying is not useful for either disabled people, or for competent people (disabled or otherwise) who are suffering from a terminal illness or a condition with irreversible and unbearable hopeless suffering, and are seeking the right to choose assistance to die.
Many disabled people value equally their right to live and right to choose to end life in the case of acute suffering. In a position where suffering was intolerable, and assisted dying was available, certain disabled people would want the same right to choose to end suffering as anyone else.
A society should not deny one right by promoting another.
The above document was written by Phillip Patston, Managing Director of Diversity New Zealand Ltd for VESNZ
Dr Jack Havill
President of the Voluntary Euthanasia Society NZ (End-of-life Choice)
130 Mahoe St Hamilton 3206
Frequently Asked Questions about euthanasia
What is meant by euthanasia, assisted suicide, and physician assisted dying?
Involuntary euthanasia is the practice of ending another’s life, without their consent and perhaps without their knowledge. End-of-Life Choice (EOLC) does not condone involuntary euthanasia, but advocates voluntary euthanasia, which is the practice used in countries such as the Netherlands and Belgium. In New Zealand we also use the terms End-of-Life Choice and Physician Assisted Dying.
Assisted suicide is a term we don’t use in New Zealand, preferring the term ‘physician assisted dying’. It covers the process of assistance whether or not the person is able to take the medication themselves or needs someone else to help them. Suicide is currently legal in New Zealand, but assisting in a suicide is a criminal offence.
Assisted dying, as proposed by the ‘End of Life Options Bill’ is for those who have a terminal diagnosis or suffering that cannot be alleviated. People in that category do not have a choice in how they live, but with the ‘EOL Options Bill’ they would have a choice in how they can achieve a peaceful death, surrounded by their family, and supported by the medical community.
Isn’t the End-of-Life Options Bill a path toward a slippery slope?
The Slippery Slope argument has been raised by opponents of end-of-life rights whenever and wherever the issue of assisted dying is raised. The argument states that permitting limited physician assisted dying will then lead to broadening of the acceptability of the practice and then make an opportunity for broadening the parameters of the laws to make more and more people eligible for the process. The argument claims that normalising assisted dying will legitimise involuntary euthanasia, and then lead to the unwanted deaths of the most vulnerable among us.
In jurisdictions where assisted dying is legal, such as in the U.S. states of Oregon and Washington, and in the Netherlands and Belgium, the statistics do not bear out that argument. After 15 years in Oregon and nearly 12 years in Belgium, for example, the number of patients who request assisted dying remains very low. The Dutch number is less than three percent of all deaths associated with assisted dying. In Oregon and Washington State, it is less than one-half of one percent. There is not much sliding happening in this field.
Won’t those who are vulnerable, have a disability, or are a burden to the family be encouraged to use assisted dying?
This is a common and completely false claim. New Zealanders will not support a loosely written, open-ended law. The law's multiple safeguards specifically require and guarantee direct patient involvement. In direct contrast, euthanasia is an ambiguous concept that often implies a person's involuntary death. Oregon and Washington State have two carefully written and regulated Death with Dignity laws. There have been no efforts to expand either law beyond their strict guidelines.
What is meant by 'Safeguards'?
Safeguards are points in the Bill that protect not only the patient, but also family members, friends, and the medical community. For instance, a written request for medication, signed by witnesses who will not benefit from the death, ensures that patients are not being coerced. Legalising a process and protocol for medications protects the medical community from feeling like they need to participate in illegal activities to alleviate the suffering of some patients. And setting strict parameters and rules for who qualifies for using the law takes the guess-work away from medical care providers and family members. Although assisting in a suicide is now illegal, assisting with a planned death, under the EOLOptions Bill, would not be. Patients could achieve death with family at their bedside, rather than alone. The safeguards written into the EOLOptions Bill include three points of protection:
- The law respect and upholds the integrity of the relationships between medical practitioners and their patients.
- The law requires that either the patient self-administer the prescribed medication, or that the patient’s medical practitioner inject the prescribed medication to hasten death, under strict medical protocols.
- The law ensures the patient is the driving force, the ultimate and conscious decision maker in the process.
In addition, the Bill requires the formation of an interdisciplinary review panel: a collective of experts in end-of-life care, who track usage of the law to ensure it is working as it should.
Can't people just use hospice and palliative care?
Anyone with a terminal illness can--and should--access the best hospice and palliative care available to them. In Oregon, 95% of those who use the Death with Dignity Act are enrolled in hospice care, and benefit from pain and symptom management. However, about 5-10% of hospice patients around the world do not benefit from modern pain management protocols, because the drugs don’t work for them, they are allergic to the drugs, or they cannot be prescribed doses large enough to alleviate pain without leading to an unintended death. There is also the issue of intrinsic pain that can’t be addressed with drugs, such as loss of dignity, loss of control, and loss of ability to enjoy life. For the patients who fall into these categories, the death experience is tedious and painful.
Are medical practitioners required to assist their patients in this process if it conflicts with their beliefs?
Medical practitioners are allowed to opt-out of the process for any reason, or for no reason. The language of the Bill states that they must refer a patient to another medical practitioner who chooses to assist. Such requirements are currently the norm in New Zealand.
How does one qualify for using the proposed EOL Options Bill to hasten death?
- Must be a New Zealand Resident.
- Must be at least 18 years old , with a terminal diagnosis, or medical condition that makes life unbearable.
- Two medical practitioners must agree on the diagnosis, and that the patient is within 6 months of death, or has enduring unbearable suffering.
- Must submit two written requests for the medication.
Can people simply stop eating and drinking to hasten death?
Yes, stopping eating and drinking will hasten a death, eventually. This is the option many New Zealanders use now. However, it is less than optimal, can take days or weeks, and often requires palliative sedation to relieve negative symptoms of the fasting process.
Answers to eight assertions about legal euthanasia
“Euthanasia-Free NZ” has produced a pamphlet called ‘8 Dangers of Legal Euthanasia’ which is handed out at various meetings they run. We responded to each assertion. If they agree with the first certifying medical practitioner, the procedure may take place. This independent second medical practitioner will be drawn from a panel of experienced participating medical practitioners set up by the Health Ministry.
1. Legal safeguards cannot protect the vulnerable from euthanasia abuses
Answer: the above is simply untrue. In fact, there are good international studies to confirm that the vulnerable are not targeted and are safe. Rates of assisted dying showed no evidence of heightened risk to the vulnerable compared with background populations.
P. Battin, A. van der Heide and L. Ganzini et al., “Legal Physician-Assisted Dying in Oregon and the Netherlands: Evidence Concerning the Impact on Patients in ‘Vulnerable’ Groups.” J Med Ethics 33 (2007): 591–97.
Assemblée Nationale Québec, Select Committee “Dying with Dignity Report,” March 2012.
2. Euthanasia and assisted suicide are the ultimate tools for elder abuse
Answer: there is absolutely no evidence to support this statement. In fact about 75% of the patients who have doctor assisted dying are less than 75 years of age. Patients have to be competent (understand what they are doing) when initially requesting assistance and they have to be assessed for that at that time. They also have to have terminal disease or unbearable irreversible suffering. They are also encouraged to seek usual treatments such as hospice and palliative care. In jurisdictions where voluntary euthanasia is allowed, the reporting is compulsory.
3. It sends a hypocritical message about suicide
Answer: the difference between medically assisting someone to die who is already dying, and suicide for irrational reasons, does not seem to be understood. A person who is depressed can almost always be treated and therefore does not qualify. If they are very depressed with disordered thinking they are not competent and therefore do not qualify. Loneliness is not a criterion for voluntary euthanasia.
4. The killing escalates over time
Answer: it is accepted that there will be some increase in Voluntary Euthanasia as it becomes more accepted as a way of managing dying, just as for all new treatments. However, it is remarkable how low the numbers are. For instance, in the Netherlands the numbers are relatively steady and have never been above 3% of all deaths.
B. D. Onwuteaka-Philepsen, A. Brinkman-Stoppelenburg, C. Penning et al., “Trends in End-of-Life Practices Before and After the Enactment of the Euthanasia Law in the Netherlands from 1990–2010: a Repeated Cross-Sectional Survey,” The Lancet 380, no.9845 (2012): 908–15.
5. Mistaken diagnosis of terminal illness is not uncommon
Answer: mistaken diagnosis at the stage where a person might request assistance to end their life is very rare. Almost always the action occurs in the last few weeks before death is likely and its approach is self-evident.
6. A dignified death is not guaranteed
Answer: with properly trained doctors and nurses the likelihood of complications can be reduced enormously. If the patient is helped by an injection, vomiting or fitting are both rare. When an intravenous injection is used, the drugs used are identical to those used in anaesthesia – we don’t stop anaesthesia because the occasional patient vomits during their use.
7. It compromises the hospice movement
Answer: this has been shown to be untrue and opponents of Voluntary Euthanasia now agree that palliative care and hospice care has increased and improved in jurisdictions where assistance to die is legal. It is important to realise that Voluntary Euthanasia should be seen as merely one ‘treatment’ in a complex journey through palliative and hospice care.
8. Trust in doctors & nurses falls
Answer: this is not true. Probably the opposite is true. In the Netherlands, for instance, 85% of the population support Voluntary Euthanasia. In 2008 a report showed that 88% of respondents in Belgium and 91% in the Netherlands trust their doctors – one of the highest rankings in Europe.
It is the view of those supporting Voluntary Euthanasia that patients are more likely to trust their doctors because they remain with, and work with them, to achieve a peaceful death instead of walking away and saying ‘I can’t help you’.
‘No more will die but fewer will suffer’
Frequently Asked Questions about Euthanasia
What is 'euthanasia'?
Answer: the term used in NZ is Voluntary Euthanasia (competent patients request help), which under the EOLC Bill would be available to patients with terminal illness, and also some patients who have irreversible illness causing unbearable suffering. If the disabled have one of those conditions they would qualify, but unless they have those criteria, the disabled would not qualify. In other words, to be disabled is no different than being fully able. The seriously ill would also have to meet the criteria.
What is physician-assisted suicide (PAS)?
Answer: we believe it is best to use other words than ‘suicide’. The term ‘medically assisted dying’ is more accurate. ‘Suicide’ in its normal sense and ‘medically assisted dying’ are quite different. One is irrational and hurtful to loved ones etc; the other is compassionate help on request under strict criteria and medical supervision in a person who is already dying or undergoing irreversible, unbearable suffering.
Isn't euthanasia already occurring in New Zealand hospitals?
Answer: this opens up very grey ethical and practical areas. Terminal or palliative sedation is where the symptoms of the dying patient are so bad that they have to be drugged to the point of unconsciousness. Usually, at this stage, fluids and food are stopped. Whether the doctor intends to hasten death or not, the result is the same – death is hastened. There is also the possibility of doctors and nurses and relatives giving extra drug to secretly hasten death because they want to help the patient out of their suffering. This is shown in a 2004 study where doctors and nurses in NZ admitted that they hastened death from time to time.
Also in intensive care situations many patients who are dependent on life support, have that removed when the treatment is considered futile and harmful, with a resulting predictable immediate death. If that had not happened, they would have survived longer – this is a form of euthanasia, usually not voluntary.
K. Mitchell and G. Owens, “End of Life Decision-Making in New Zealand General Practitioners: a National Survey,” NZMJ 117, no. 1196 (2004)
Should not the person have the right to request euthanasia if their life is unbearable?
Answer: Yes. During their life an individual has the option of undergoing treatments to prolong life and also has the legal right to refuse treatments, yet they cannot under NZ Law request medical assistance to die. The law produces the apparently irrational result that people can choose to die lingering deaths by refusing to eat, by refusing treatment to keep them alive, or by being disconnected from respirators and suffocating, but they cannot choose a quick, painless death that their doctors could easily provide.
Surely people should be able to control when and how they should die? It's a private matter after all.
Answer: we agree that no one can have complete autonomy and nor is it an absolute right e.g. driving on the correct side of the road. However, in the case of VE, the statement that hundreds of thousands of others lives are put at risk is untrue. The main risk is that without VE, many would have to endure meaningless suffering at the end of their life because of an ideology held by a minority of the population.
Pro-euthanasia advocates recommend euthanasia as the way to ensure one dies with dignity. What's wrong with that?
Answer: some argue that dignity is not guaranteed. However, at the end of their life when dying from a terminal illness, currently many patients have fits, vomiting, hallucinations, pain, breathlessness, psychological suffering, extreme indignities, and some spend their last days in and out of drug induced coma. They are very happy to risk a small complication of the medical assistance process. Waking up after oral administration is extremely rare but can occur. Waking up after an injection is almost unheard of. Loved ones uniformly attest to the dignity around assisted deaths.
DID YOU KNOW?
1. Voluntary Euthanasia (VE) has been legalised in the Netherlands, Belgium, Switzerland, Luxembourg, Quebec, USA States (Oregon, Washington State, Vermont). Britain, Australia, and other European States are very active in efforts to legalise VE.
2. The Horizon Poll conducted independently in NZ (2012) showed 63% and above for legalisation of Voluntary Euthanasia as described in the End-of-Life Choice Bill (Maryan Street Members Bill 2012). Only 12% were opposed.
3. Recent polls of people with religious affiliations in both Britain and Australia have shown over 70% support of legalisation of Voluntary Euthanasia. This includes Catholic adherents.
‘No more will die but fewer will suffer’