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Source: Jersey Evening Post
Even when doctors have just been surveyed on the subject, it still feels awkward to ask a GP about ending the life of a patient.
Dr Nigel Minihane, Saturday interview on assisted dying. Picture: JON GUEGAN. (25973012)
Despite the way that the results of a recent survey, answered by around a third of local doctors, have been used by those on both sides of the debate, they do not provide conclusive assistance. Was the notable thing the majority who thought it, sometimes or always, acceptable in given circumstances to assist someone with an incurable condition to end their life? Or was it the minority – a significant proportion, nonetheless – who thought it never acceptable in any circumstances?
Dr Nigel Minihane, chairman of the Jersey Primary Care Body, accepts that views within the profession are as polarised as those held by the public. Yet he detects a shift in the centre ground of public opinion to which the profession is starting to respond at national level.
‘We have to listen to our patients and it would appear that the public at large actually feels that a patient’s autonomy is something that has largely been ignored by the medical profession. Something like 80%-plus of the public are saying that we should be considering assisted dying and it would perhaps be rather arrogant of the profession not to listen’, he said.
Certainly, the signs nationally are that the official opposition to assisted dying may be being replaced by a more nuanced position. The Royal College of Physicians decided in March this year that it would take a ‘neutral’ position on the question, while the Royal College of GPs, which is currently opposed, is due to ballot its 53,000 members again shortly.
One of the things that makes the assisted dying debate so difficult is that the often distressing circumstances envisaged by the desire to escape life come into conflict with safeguarding the interests of the potentially vulnerable. But to talk about those circumstances with a doctor concentrates the mind.
‘In some situations, it is not so much the pain but the mode of death that might be severe. For example, there are rare conditions where a tumour might erode into an artery and there’s nothing you can do. It is going to burst and people are literally going to bleed to death.
‘It’s one of those circumstances where it’s ethically acceptable now to give terminal sedation [a substantial dose of morphine beyond that required for pain relief], but at the moment that’s only acceptable when that situation actually occurs. If someone knows that is the mode of death, would you look at it differently?’ Dr Minihane asks.
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Such dilemmas appear to transcend the normal boundaries of palliative – or supportive, as it is now known – care where the doctor ensures that the patient has access to appropriate symptom control throughout their illness. ‘Some of that is curative but some of it is about making sure life is bearable,’ Dr Minhane said.
Central to the debate is the patient’s right to choose. Whereas in the past you might have visited a doctor expecting to be told what do to, the assumption today is that, equipped with the relevant information – what Dr Minihane calls the doctor’s ‘braindump’ on a particular condition – a patient will make his or her own informed decision about their best interests.
Yet problems arise with patient autonomy when supportive care simply does not work and the patient’s pain cannot be controlled by the prescribed drugs, or when they do not want to endure their illness and the palliative treatment.
‘If they know they are on a trajectory to death or unbearable suffering what about their decision then? It is, after all, their body.’
For Dr Minihane the patient-doctor dialogue which takes place in relation to a minor complaint – whether, for example, to take antibiotics for the condition – should also take place in relation to serious illness.
‘At the cancer end of life the same should apply. We tell a patient: this is what we can do. We can’t cure you but this is how we can make life better for you. But perhaps the autonomy which we have made the central pillar of what we do isn’t being addressed in the same way at the end of life as it might be,’ he said.
The present position is clear legally. Both assisted dying, where patients are given a cocktail of drugs to take that will end their life, or euthanasia when their death is brought about by a third party are not paths available here.
‘In these situations we have to point out that it is illegal and we point out all the alternatives. What we are trying to ensure is that people have their symptoms controlled so that we can give them the best quality of life for as long as possible.
‘For me that’s no different from what we do everyday as a doctor so, whether someone comes into the surgery with a cold or cancer, I often say to them my job is to make life as good as I can for you for as long as I can. There may be other circumstances that prevent me from doing so but that’s my job.’
However, it is precisely those ‘other circumstances’ which lie at the heart of the current debate, situations when the suffering of the patient or the patient’s attitude to their situation mean that they cannot exercise their own control in the way they might wish.
‘I remember seeing one gentleman years ago with a cancer of the lower bowel which had eroded through the bowel and went into part of his spinal cord and the peripheral nerves, and he died in severe pain. His mother came to me afterwards and her words echo in my head, “My son died in pain” and I had to agree that he did.’
Central to the debate about assisted dying is the question of safeguards. How to ensure, if the law were changed, that only those in agreed circumstances, governed by their medical condition and its prognosis, and free from coercion would be able to obtain help to die.
The difficulty was brought into sharp focus during one of this year’s BBC Reith Lectures given by former Supreme Court – and former Jersey Court of Appeal – judge Lord Jonathan Sumption who was challenged by a member of the audience to say whether he would support changing the law to permit assisted dying.
The lady who posed the question had been investigated by the police, having returned from Switzerland where she had taken her terminally ill husband to die. She was understandably distressed by the experience.
But Lord Sumption told her that the law should continue to make helping someone die a criminal offence, even if there was also acceptance that, in certain circumstances, it was right for people to break that law.
For Dr Minihane, the exchange has to be understood in the wider context of the lecture’s theme: the need for the courts not to intrude into affairs which are properly the territory of political decision-making. It is for the legislature rather than the judiciary to decide whether assisted dying is legal and, if it is, the circumstances in which it should be permitted.
What he calls those ‘specific delineated safeguards’ might include the patient’s terminal prognosis, their view that it was in their own best interests and the fact that they had capacity to make the decision.
Yet the recent local survey of doctors’ opinions highlights a further issue if the law were to be changed – the freedom of the doctor to opt out if they entertained honest objections.
‘If the law were changed I think one would have to look at it in a similar way to the abortion debate where there are “conscientious objectors” among the medical profession who will not deal with abortion because of their religious convictions and it’s entirely appropriate that that remains’.
Dr Minihane sees an interesting distinction between the abortion debate which is about the mother’s choice in relation to an unborn child – within limits set out by the law – and the debate about assisted dying which involves dealing with a person who has the capacity to make a decision about themselves with appropriate safeguards.
So what about the view of Dr Nigel Minihane, not as a spokesperson for the Primary Care Body but as a general practitioner himself?
‘I think I would say that the important aspect is autonomy. I have changed my practice over the years and it’s all about the patient, the person in front of you and what they want.
‘If things are within the law and it’s something which in all conscience I can do then it’s something that I would consider. However, until the law is passed and the safeguards are established I couldn’t give a full opinion,’ he said.
The End of Life Choice Bill has moved through another phase of its committee stage in Parliament and opponents' efforts to change the bill have again been voted down.
David Seymour Photo: RNZ / Ana Tovey
National MPs put forward around 20 amendments to ACT leader David Seymour's bill last night - but unlike the last session, where MPs stayed voting until 1am, the voting wrapped up at 10.30pm.
Mr Seymour's chief opponent Maggie Barry, who apologised for yelling at Labour's assistant speaker Ruth Dyson during the last debate was not in the House last night.
However, her proposed amendment still got a lot of air time through her colleagues.
Ms Barry wanted the death certificate of someone who dies from assisted dying, for the purposes of any life insurance contract, to state that the person died as a result of the administration of medication.
National MP Melissa Lee told the House legislation shouldn't compel someone to misreport or misrepresent a cause of death.
"We should not try and hoodwink the actual reason why someone had in fact died ... this bill of David Seymour's is trying to actually say they did not in fact die from a lethal dose of a poison.
"That to me is actually a lie and I do not think that legislation should facilitate the falsehood," Ms Lee said.
But Mr Seymour said there's no deceit or deception going on.
"Under the requirements of this legislation, the death certificate says that the person died of the illness that qualified them to be eligible for assisted dying, also the fact that they died from assisted dying.
"So anybody reading that certificate I think can figure out that this was done under the law.
"There's no subterfuge, it's very easy for anybody to read and understand what that's saying", Mr Seymour said.
The amendment was voted down 38 votes to 81.
Alfred Ngaro Photo: RNZ / Dom Thomas
National's Māori, Pasifika, and ethnic MPs also tried to push for cultural considerations and the Treaty of Waitangi to be properly addressed by the bill.
MPs Harete Hipango and Alfred Ngaro put forward amendments that Deputy Speaker Anne Tolley ruled out of order because they related to other parts of the legislation that were debated weeks ago.
But Ms Hipango submitted another amendment during the debate and put forward her case.
"It is well known that the legislation of this land requires that commitment [to the Treaty] which has been mandated.
"I implore members of this House, I implore members of the public, that we have a duty of care and responsibility to our most vulnerable. This bill that's proposed has no lens, no optics whatsoever in terms of addressing that," she said.
Mr Ngaro accused Mr Seymour of being dismissive of the importance of cultural considerations.
"The question that has to go to the member of the Bill who talks about the importance of choice, what about the importance of ensuring that people know what choices they are making?
"Many times when we think about it in different cases with different cultures people may be asked a question, and if I talk about the Pasifika community, people will nod and say yes do you understand.
"The truth and the reality is they do not understand the technical implications in this regard," Mr Ngaro said.
But Mr Seymour said putting in a specific requirement around cultural considerations would be problematic.
"Of course we expect all medical professionals in New Zealand to be respectful of who their patients are, it would be quite extraordinary if that wasn't the case.
"And I think it would be a terrible signal for Parliament to send that in specific instances they're required to carry out those kinds of duties because the implication might be that they weren't expected to carry out duties of cultural competency in other settings," Mr Seymour said.
The End of Life Choice Bill will be up in the House again late next month when New Zealand First's proposal that the bill be put to the public in a referendum is expected to be debated.
Wednesday, 18 September 2019, 3:02 pm
Press Release: ACT New Zealand
ACT Party Leader David Seymour has welcomed New Zealand First’s release of the question to be put to the public at a referendum on the End of Life Choice Bill.
“The wording of the question put forward by New Zealand First today will allow MPs to vote for a referendum knowing exactly what two options the public will be given to choose from at the election booths next year.
“SOP [Supplementary Order Paper] 361 in the name of Jenny Marcroft will give certainty to MPs that the wording of the question put before the public on the End of Life Choice Bill will be decided collectively by all of Parliament during debate on the Bill in Committee of the Whole House, rather than at a later stage by Cabinet.
“I support this SOP put forward by New Zealand First.
“I am confident that this question proposed by New Zealand First will ensure the fairest outcome at a referendum for both those for and against the Bill and ask all MPs to support its passage in the House.
The SOP can be found here »
Act Party leader David Seymour's voluntary euthanasia bill has cleared another stage in Parliament.
MPs voted 70 to 50 in favour of the End of Life Choice being given a third and final reading. But that was only after Mr Seymour introduced several amendments, including a requirement that doctors will not be able to suggest to patients they consider ending their lives.
David Seymour joined RNZ's Wellington studio to discuss the bill.
Source: NZ Herald
Euthanasia legislation has inched closer to a final vote in Parliament as opponents criticised the speed of the debate.
Act leader David Seymour's End of Life Choice Bill, which would allow terminally ill adults to request assisted dying, returned to the House on Wednesday night for the third of what will be five lengthy debates over last-minute changes.
The legislation passed its second reading by 70 votes to 50 in June and Seymour has promised a swathe of amendments to secure much-needed votes ahead of the third-and-final reading.
He scored another victory on Wednesday night as his latest tranche of changes was voted through 68 votes to 52 as the Committee of the Whole House debated a section of the bill that sets up the organisations that would oversee and monitor assisted dying.
It lays out requirements such as reviewing the legislation after three years and for a "Review Committee" that will have to look at reports about every death to see if there's any non-compliance.
Seymour's changes for this section were largely technical.
But those opposed to the bill put forward 35 of their own amendments this week, many trying to tighten the rules for who could be appointed to the oversight bodies.
"They must be beyond reproach," National's Melissa Lee told the House as she asked for backing for her amendment that would ban anyone who had ever faced a professional complaint from one of the panels to be set up.
Several of the amendments had yet to be voted on, but all 15 considered ahead of Seymour's were rejected.
It's part of the push and pull between the Act leader and the bill's critics that has characterised the debates.
Those against have largely dominated the time in the House, calling for as many speeches as the chair of the debate will allow, and making clause-by-clause attacks in an effort to show the bill as not safe enough given the seriousness of its implications.
National MP Chris Penk described his interrogation of the bill on Wednesday as a "fine examination".
While every amendment from opponents has so far been voted down, the individual vote called for each proposal has seen sessions in Parliament run long into the night and across days.
Seymour, meanwhile, on Wednesday went as far as to complain during the votes that the teller for the "noes" (the person counting their votes), Maggie Barry, was taking too long to count and criticising her for taking to Twitter in the middle of one vote.
In Barry's tweet, she argued the debate had been shut down for a vote too early in the night without all amendments being given proper time, describing it as a "terrible injustice".
The person chairing the committee - on this occasion Assistant Speaker and Labour MP Ruth Dyson - effectively gets to end the debate when they think there's been enough argument, as long as the majority of MPs agree.
What's already been changed?
The previous two debates saw a raft of major changes introduced by the Act leader, including:
• Limiting the bill to only apply to those with six months to live, whereas it previously covered people with "grievous and irremediable" conditions
• Prohibiting a health practitioner from initiating any discussion about assisted dying
• Giving employment protections for any doctor, nurse, or psychiatrist who objects to taking part in the process on any ground
• Explicitly stating that if any pressure is suspected on a person applying for assisted dying, doctors and nurses must stop the process
What happens next?
The bill will return to the House on September 25 for a fourth debate. But it's the fifth that will be the most contentious.
During that final session, MPs will have to consider whether to put the legislation to a referendum.
New Zealand First has demanded a plebiscite as a condition of its support and vowed to vote "no" if it doesn't get it.
Without NZ First's nine votes, Seymour could not afford to lose another single vote from the second reading - a difficult ask.
That's why he's promised to support the referendum. But with plenty of MPs taking a wait-and-see approach, it's not yet clear whether there's enough support in the House for him to get one.
Source: Letters, Herald Scotland
THE topic of assisted dying has been back on the discussion agenda recently, but I wonder if the subject is too polarised, and whether a more nuanced approach is necessary.
A relative of mine recently died in hospital, having existed, for several days, in excruciating pain on which the legal maximum palliative relief had no effect, while his wife and family had to sit by his bedside and watch as he kept pleading for release from the torture. Since this level of suffering is such as we would not allow an animal to endure, I cannot understand how it can be considered acceptable to inflict it on a human being, and I can only imagine the nightmare for the family at the bedside, let alone the trauma they will now have to live with for the rest of their days.
I once heard an Australian doctor suggest that this was not a matter of obeying the Hippocratic oath to prolong life but was simply prolonging death. Some say it is allowing nature to take its course, not deliberately ending a life, but if letting nature take its course is the correct approach, why treat other life-threatening illnesses and diseases? Is the reason in these other instances not to end suffering? Granted that the end result is hopefully to restore a viable life, does that mean that suffering should continue, no matter how unbearable, simply because death is the inevitable end?
I believe that relieving suffering is a duty under the Hippocractic oath that takes precedence over preserving life. For that reason, if at the end a patient is suffering ongoing excruciating pain, the prime consideration should be to alleviate that, even if the treatment may possibly, or even certainly, hasten the inevitable death. At least then there can be a dignified, peaceful and pain-free end to life. Where is the dignity or peace in a long-drawn-out death in agony?
Can we not stop regarding this as a question of “assisted dying” and instead regard it as a humanitarian process of alleviating suffering? Should we not allow whatever level of palliative treatment the degree of suffering requires, and regard the possible hastening of death as a compassionate side-effect? At the very least, we should allow people to put their wish for this in writing and guarantee to honour that wish. At the very least, can we not accept that concession?
This is exactly what I would wish for myself.
P Davidson, Falkirk.
Source: Letters, Herald Scotland
WHAT a sad set of circumstances that have led to Richard Selley ending his life, yes, in the way he would have wished but not at the time nor in the place that he would have preferred ("‘The end was dignified and calm... he had taken control’", The Herald, September 7).
Any pet owner has the right to end the suffering of a well-loved cat, dog or other animal.
It defies logic that under similar circumstances, with appropriate safeguards, a sentient human cannot terminate his or her own life, at the appropriate time and in a dignified manner.
Condolences to his family and friends and may this brave man rest in peace.
David Chadwick, Carluke.
GORDON MacDonald concludes his article against voluntary assisted suicide for the terminally suffering by quoting Leo Alexander, Chief Prosecutor at the Nuremberg trials: “It started with the acceptance by doctors of the idea, basic in the euthanasia movement, that there is such a thing as a life not worthy to be lived” ("Change to law would send a message some lives are worth less than others", The Herald, September 8).
Since what the Nazis were doing was killing people who very much wanted to live and since the present campaign is for terminally ill people in great distress to be able to choose to have their death hastened, the comparison is misleading in the extreme and comes very close to a smear. Opponents of assisted suicide often play down or ignore the fact that it would be entirely voluntary, with safeguards in place to ensure that the dying patient is making a considered choice and is not under the influence of a passing mood. Instead, such opponents spread a false impression that it would mean jackbooted doctors inflicting death on those who very much want to live. Dr MacDonald here shows himself to be of that number.
Paul Brownsey, Bearsden.
The experiences shared in this report are as harrowing as anything I have encountered as a Member of Parliament. I have had two bouts of cancer and am no stranger to the nastiness of the disease and its treatments, but nothing prepared me for the horror of what is described here.
In 2019 British people are being forced to endure unbelievable suffering at the end of life. Some will retch at the stench of their own body rotting. Some will vomit their own faeces. Some will suffocate, slowly, inexorably, over several days, their last moments of life disfigured by terror. Any one of us might suffer such a fate.
[This is also happening in New Zealand.]
Read more here »
This is a film about a film. Fatal Fraud is a case study about techniques used by opponents against evidence-based public policy initiatives. In this film, Andrew Denton explains with the help of leading experts how emotional manipulation, fear, framing and omission are deployed to sow Fear, Uncertainty and Doubt in the minds of legislators and the public.
Watch the film here »
by Maryan Street
On 21 August, the House debated Part 2 of the EOLC bill. This was the very substantial part of the bill which dealt with processes and procedures. It was a protracted debate, with supporting MPs deliberately sitting quietly and not taking calls in order not to prolong the debate, while the opposition exhausted their arguments, the Speaker's patience and the whole House in the end. By agreement between the parties, while it did get to voting before 10pm, the House suspended voting part way through in order to avoid another late night marathon as had occurred in the previous debate.
That means that the next Member's Day on 11 September will BEGIN with the EOLC bill and the interrupted voting straight after the General Debate at about 4pm. There are no other bills ahead of it currently. There are 15 SOPs left to be voted on which pertain to Part 2, but an educated guess says that at least 5 of those will be ruled out of order by the Associate Speaker because they contradict David's amendments to the Part which have already been passed. So that leaves 10 SOPs to be voted on. I imagine that will take until about 5pm or shortly after. Then the House will move on to Part 3 which should not take very long because it is more technical in nature and should be disposed of by 10pm. That leaves Part 4 and the Schedules to be debated on the next day (25 September), and then Clauses 1 and 2 remain.
Clause 1 is the title of the bill, and there are some SOPs in to change that ("Assisted Suicide Bill" etc.) and Clause 2 is the Date of Commencement. It is in Clause 2 where NZFirst's SOP about a referendum will be debated, obviously because it will alter the date of enactment. That will be the last debate at the Committee stage. Thereafter, it moves on to its third and final reading which is a time-limited debate and will only take two hours (or a little more if the Business Committee decides to be generous and extend the time a little, as it did before). This will occur in October, all going well.
So there is not much longer to go!
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