Opinion: what approach should our society take to the end of life and should this involve aid in dying?
Society is always changing, and sometimes even those in the midst of dramatic changes don't register them. Almost unthinkable a generation ago, the question of the right to die is being posed increasingly concretely across the globe. In one form or another, aid in dying is now accessible in many countries for those with irreversible and terminal illness, those experiencing great distress arising from severe and irreversible loss of function, and those suffering severely from psychological conditions.
In France, a Citizens' Convention has been convened to discuss the matter, while the Portuguese parliament has passed a bill to legalise assisted dying. Here in Ireland, a Special Oireachtas Committee is to be established on foot of the PBP-Solidarity’s proposed Dying With Dignity bill.
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From RTÉ Radio 1's Late Debate, discussion on plans for a new Oireachtas committee on medically assisted dying
These developments are arising because of sharp demographic changes. Put simply, people are living longer. In 2015, the life expectancy in the UK was 79.3 years for men and 82.9 for women; in 1915, this was 48.4 and 54 respectively. This is testament to advances in medicine, public health, nutrition, work and living standards in that period. Causes of death have also changed. A century ago, the predominant causes of death were infectious diseases, but death today is overwhelmingly attributable to illnesses related to lifestyle such as heart attack, stroke, cancer etc.
These changes bring their own issues. As people live longer, more of us spend our final years with reduced abilities, compromised independence, and resulting distress. Many of the illnesses we see in old age can cause physical discomfort and pain. Dementia is another consideration and age is a confirmed risk factor here, with one-fifth of 80-85 year-olds affected.
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From RTÉ Radio 1's Drivetime in 2020, The Irish Times' Fintan O'Toole discusses the Dying with Dignity Bill
It is understandable that some might prefer to bypass such loss, discomfort and dependence in favour of a more positive experience of death. Above all, the right to autonomy is central to arguments that people should be allowed to make the crucial choices in their own lives.
But arguments against assisted dying are also manifold, and feature in much research on attitudes of healthcare professionals. A 2012 review in the UK found physicians were largely opposed, citing religion, the belief that end-of-life care was adequate, and concerns about safeguards. In the US, a similar review in 2005 highlighted a more positive attitude among physicians, although again there was a reluctance to actively perform aid in dying.
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From RTÉ Radio 1's Drivetime in 2020, health reporter Priscilla Lynch on how the issue of assisted dying has been addressed across the EU
We conducted a related review in 2021 and found conflicts between healthcare professionals doing what they felt might be best for the patient, but also having a professional stance of maintaining life. Lack of resources and guidelines were also raised as concerns, as were religiosity, personal values and fears regarding safeguarding. In Ireland, several specialists in palliative care have expressed opposition to the Dying With Dignity Bill, citing among other factors the effectiveness of pain treatment.
We all know that we are aging; and this is embraced, but we also all know this increasing age brings the challenges described above. Acknowledging this, we need to discuss what approach we wish to take as a society to the end of life. In my view, here are some things we need to consider
(i) Do we believe that people have the right to choose when to end their lives? Do we believe that people have the right to assistance in doing so? If we are in favour, what profession(s) should be involved?
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From RTÉ Radio 1's News At One in 2020, RTÉ Social Affairs Correspondent Ailbhe Conneely reports that Christian churches have expressed concern over the Dying with Dignity Bill
(ii) If we support assisted dying, do we promote an active approach (professionals intentionally bringing about death at patients' request) or a passive approach (patients being provided with the means to end their own lives)?
(iii) How do we approach safeguarding? An obvious concern is the risk of coercion. We are all aware of the phenomenon of elder abuse, but the subtype of financial elder abuse is maybe less well known. This refers to exploitation, or plain theft, of the resources of older people - often by family - and was estimated to affect 1.3% of older Irish people in 2010.
Is it unimaginable that unscrupulous people would exert pressure on elderly relatives to choose death, so as to inherit their worth? If older people find themselves in that position, what supports and alternative care options should our society provide? This may sound extreme, but recent evidence from Canada suggests that some older people are choosing assisted dying because they cannot access suitable supports or housing. The same issue can of course arise with physical or emotional abuse - what supports and alternatives do we provide? What should we provide?
Are we against facilitating dying rather than in favour of facilitating living?
(iv) If a key argument against aid in dying is the effectiveness of pain relief, how do we respond to the fact that there are long waiting lists for outpatient pain relief? Because pain can be controlled, does that mean we must behave as though it is? If not, then what must be done?
(v) If we oppose aid in dying, what steps do we take to add life to years as well as years to life – to promote independence and dignity? Or, bluntly, are we against facilitating dying rather than in favour of facilitating living?
The views expressed here are those of the author and do not represent or reflect the views of RTÉ. If you have been affected by issues raised in this article, support information is available online
