Assisted Dying: Important Issues and Considerations

This is an article published by the British Islamic Medical Association’s report called: Euthanasia and Assisted Dying: An Islamic Perspective. B5-InFocus-Euthanasia-AD_24.10.24_Low_Res (2)

Legal and Constitutional challenges

The European Court of Human Rights recently determined, in the case of
Karsai vs ECHR in June 2024, that the Hungarian lawyer with motor neurone
disease had a Right to Life (article 2). He also has a right to refuse treatment,
but there is no right to have his life deliberately ended by, or with assistance
from, another person. In their ruling, they determined that articles 8 and 14
have not been violated by their judgement.

International Models

“Assisted Dying” is a broad euphemism, covering both assisted suicide and
euthanasia. In assisted suicide, a person is prescribed lethal drugs to take
themselves at a time of their choosing, as in Oregon and a small number
of other US states. Belgium legalised only euthanasia, not assisted suicide.
Other countries such as the Netherlands and Canada legalised both, but
euthanasia is the vastly predominant mechanism for ending life. Where
euthanasia occurs, the death rates are about tenfold the rates where only
assisted suicide is permitted.

Notably, in every jurisdiction that has legalised “assisted dying” the criteria
have widened either through interpretation of eligibility or through legislative
change or both. However, there are vigorous campaigns to further widen
eligibility criteria, as seen in all countries considering this.

Ethical considerations

Autonomy and choice are promoted as key reasons to support legalisation
of “assisted dying”. As Onora O’Neill has pointed out, we are interrelated
and interdependent. The actions of one affect another. We are not able to
exercise “mere sheer choice”. People who are seriously ill need real choices
in care, not driven to seek death through fear of what may lie ahead,
particularly in areas where services to meet their needs are less available.

Safeguards

So-called safeguards are in reality only eligibility criteria, which cannot be
verified with legal certainty. Terminal illness is difficult to define, ranging
from rapid short-term illness to illnesses of many years’ duration. Prognosis
is impossible to state with accuracy and many patients are alive weeks,
months or years longer than their perceived prognosis. Even when expected
to die within 72 hours, around 3 percent of patients outlive this. Diagnostic
errors are found at post-mortem, where about 1 in 5 patients die as a result
of a condition different to the condition stated on their death certificate.

Psychiatric evaluation

Mental Capacity assessments are complex and mental capacity fluctuates in
illness. Few doctors are adequately experienced in assessing mental capacity
for major decisions. Expert evaluation should be part of any assessment
process for eligibility to lethal drugs.

Conscientiousness objections

Moral injury is described by many healthcare workers involved in the
“assisted dying” processes. Participation must be through opt in mechanisms.
Conscientious objection clauses have been found to fail several individual
practitioners.

Lethal Drugs

None of the lethal drugs mixtures have been approved anywhere in the
world by the relevant licensing authorities for their use in doses and
combinations to end life. The complication rate associated with such
drugs is also significant. Oregon’s official reports note that 9 patients have
reawakened after taking lethal drugs.

Detecting Coercion

Doctors are poor at detecting coercion. Hourglass data shows that around 1
in 6 people over the age of 65 have been affected by abuse. Domestic abuse
across all age groups is unfortunately rife in our societies and remains
severely under-detected. Coercion through feelings of being a burden to
family, friends and care-givers is an end-of-life concern reported by 47%
of Oregonians who died through assisted suicide. This is higher than those
citing pain or fear of uncontrolled pain (29%) as a concern.

Even the strongest people become vulnerable when faced with serious
illness. Ontario’s review published this week (Reports attached) shows
how easily “medical aid in dying” can become used for social problems in
vulnerable groups in society.

Palliative Care

Maintaining a clear distinction between palliative care and “assisted dying”
services is an extremely important distinction. In countries where this
distinction has not been made, the quality of palliative care provision has
fallen.

Suicide

Unassisted suicide rates do not fall when “assisted dying” is legalised but
suicide tend to become normalised across society.

In Summary

The Danish Ethics Council’s report on Assisted Dying concluded that neither
the Oregon nor the Dutch model are “sufficiently clear in their delineations,
fair in their justifications for access, or sound in terms of control mechanisms”.
They also stated “the members consider euthanasia to be in conflict with
palliative care and are therefore against the legalisation of euthanasia as
long as we as a society have not exhausted the possibilities for relief.”