1. Why 18 years of age?
- Maryan Street, President of VES, is on record as stating that “Application for children with terminal illness was a bridge too far in my view at this time. That might be something that may happen in the future, but not now.” The only basis for her holding this view is to make a law change more palatable to the public, because it cannot be defended ethically, legally or medically.
- Euthanasia became legal in the Netherlands in 2002. It allows euthanasia for those aged at least 12 years of age. Children aged from 12 – 15 years require parental consent. More recently, some Dutch doctors are urging lawmakers to extend the euthanasia law to include children aged 1 to 12.
- Belgium, which introduced euthanasia for those at least 18 years of age in 2002, voted to extend the practice to children in 2014.
- For any society “which tolerates euthanasia in certain defined circumstances already, to deny children with capacity the same opportunities to end their suffering humanely, to the same extent as their older contemporaries, must surely be as unjust as it is discriminatory.”
Jo Samanta. See Diversity & Equality in Health and Care (2015)
Conclusion: It is discriminatory to limit access to a particular group on the basis of age. The age limit of 18 years is arbitrary. The choice of 18 years as a limit is for political reasons only and not for ethical, legal or medical reasons.
2. Are people with mental illness in or out?
- David Seymour’s Bill states that a person is eligible for euthanasia and assisted suicide who suffers from “a grievous and irremediable illness”. This will include people with a mental illness.
- Euthanasia in the Netherlands, which also requires that a “patient’s suffering is lasting and unbearable”, now includes those suffering from psychiatric disorders. In 2016, 60 cases of euthanasia were for psychiatric disorders and 141 cases of dementia (see p. 12).
- “Rarely in those societies with liberalised assisted dying laws are psychiatrists involved in the decision-making for individuals requesting early death. This role is fulfilled by non-specialists.” (Macleod, Sandy. “Assisted dying in liberalised jurisdictions and the role of psychiatry: A clinician’s view.” Australian & New Zealand Journal of Psychiatry 46.10 (2012): 936-945).
- Legalising either euthanasia or assisted suicide in the current New Zealand context where it is readily acknowledged that specialist mental health and addiction services “are experiencing increasing pressure” (p. 3) places a significantly large number of vulnerable people (162,222 in 2015) in an extremely risky situation
Conclusion: Persons with mental health conditions would be eligible under the David Seymour Bill.
3. Why involve doctors? Why not lawyers?
- The New Zealand Medical Association Position Statement on Euthanasia states: “Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s request or at the request of close relatives, is unethical. Doctor-assisted suicide, like euthanasia, is unethical … This NZMA position is not dependent on euthanasia and doctor-assisted suicide remaining unlawful. Even if they were to become legal, or decriminalised, the NZMA would continue to regard them as unethical.” The World Medical Association Resolution on Euthanasia “strongly encourages all National Medical Associations and physicians to refrain from participating in euthanasia, even if national law allows it or decriminalizes it under certain conditions”.
- The Australia and New Zealand Society of Palliative Medicine (ANZSPM) Position Statement on Euthanasia (2017) states: “In accordance with best practice guidelines internationally, the discipline of Palliative Medicine does not include the practices of euthanasia or physician assisted suicide.”
- The Scotland Report on Assisted Suicide reports that both supporters and opponents of the Assisted Suicide Bill acknowledge that “the involvement of healthcare professionals in assisted suicide, even if it were legal, would not amount to ‘medical treatment'” (n. 207). Similarly, Boudreau and Somerville note “… healing and euthanizing are simply not miscible [able to be combined] and euthanasia can never be considered ‘medical treatment’” (p. 63).
- The most common recent argument for Assisted Suicide/Euthanasia, “that patients have a right to control when and how they die – in fact points to the involvement not of doctors but of legal agencies as decision makers, plus technicians as agents” (p. 323).
- In Oregon, the most common reasons for requesting assisted suicide are social/existential rather than medical; 90% are concerned about losing autonomy; 90% are concerned about being unable to engage in enjoyable activities; 65% are concerned about loss of dignity; and 49% fear being a burden on family and/or friends/caregivers. Only 35% cite inadequate pain control or concerns about inadequate pain control as one of their reasons.
Conclusion: Euthanasia and assisted suicide are not medical treatment. “Doctors are not necessary in the regulation or practice of assisted suicide. They are included only to provide a cloak of medical legitimacy”.
4. How many deaths per year from this Bill?
- The Netherlands requirements concerning eligibility for euthanasia are very similar to those in David Seymour’s Bill. We would therefore expect that based on current Netherlands statistics, there would be around 1,200 deaths per year in NZ under this Bill.
- In the Netherlands (and 2016), Belgium and Oregon, the numbers of cases of euthanasia/assisted suicide have increased consistently since the practice was legalised. We should expect the same pattern to occur in New Zealand were we to legalise either of these practices.
- When a country legalises euthanasia and assisted suicide, the grounds for eligibility become broadened over time which further increases the number of deaths. In the Netherlands, for example, 87 per cent of deaths in 2004 were of people who had cancer. By 2016 that proportion had fallen to 68 per cent. The conditions that are on the increase include cardiovascular disease, disorders of the nervous system, lung disease, age-related illnesses, dementia and mental health conditions.
Conclusion: Current figures from the Netherlands indicate we can expect about 1,200 deaths per year in New Zealand from euthanasia and assisted suicide under David Seymour’s Bill.
Overseas experience indicates that arguments supporting euthanasia and assisted suicide are initially based on relief of suffering for a small number of ‘extreme’ cases. Once the practice becomes legal, however, the arguments have shifted toward ‘rights’ and ‘choice’ and the categories have broadened. This has meant that the numbers of deaths continue to rise significantly.
5. What is the error rate of medical diagnosis?
- “The diagnosis is wrong 10–15% of the time.” A diverse range of research into this issue over the past several decades suggests that this range is very much on target (p.1).
- Winters, Bradford et al (2012, p. 894) note, in a paper published in the British Medical Journal, that 28% of autopsies report at least one misdiagnosis. An autopsy-confirmed study of 500 cases between 1959 and 1999/2000 (2012, p. 159) showed that in spite of the progress in diagnostic technology, the rate of false-positive diagnoses (people falsely diagnosed as having a particular condition) increased between 1959 and 1999/2000 from 7% to 15%.
- A study of doctors’ prognoses (the medical prediction of the course of a disease over time) for terminally Ill patients found that only 20% of predictions were accurate – that is, within 33% of actual survival time.
- To qualify for assisted suicide under Oregon’s “Death With Dignity Act” a doctor needs to determine that a person will die within six months, the same provision found in David Seymour’s Bill. In Oregon, the range of days between request and death over the period 1998-2015 is 14 to 1009 days (p.11). This means that at least one person judged eligible for assisted suicide on the basis they would die within six months survived for 2 years and 9 months.
Conclusion: Medical diagnosis is widely accepted as being wrong in at least 10-15% of cases and medical prognoses are inaccurate up to 80% of the time. Under the Bill that David Seymour has drafted, significant numbers of patients could decide to end their lives in error because of a misdiagnosis, and doctors would be asked to make claims about a patient’s prognosis which they cannot possibly substantiate with a high degree of accuracy.
6. How do you prevent subtle coercion of older people?
- In a 2015 New Zealand study published by the Office for Senior Citizens, 10.1% of those aged over 65 years report “coercion” and 6.9% report “not trusting most people in their family” (p.15). The same study shows (p. 16) that women and men over 65 years experienced feelings of vulnerability (11.3% and 7.5%), dependence (12.4% and 10.4%), dejection (18.2% and 17.6%) and coercion (8.7% and 11.3%) respectively.
- Age Concern in New Zealand reports that it receives more than 2000 cases of elder abuse or neglect each year of which “about three quarters are confirmed to involve elder abuse or neglect” (about 1500 in total). Over 75% of cases involve psychological abuse. One third of abused older people live alone and three quarters of alleged abusers are family members, of which almost half are adult children. It has been estimated that only about 16% of actual elder abuse cases come to the attention of service agencies (p. 11) such as Age Concern. This means that the likely number of our elders being abused or neglected in New Zealand is in excess of 9,000 every year.
- Research published in 2005 by the NZ Ministry of Health has shown that those making serious suicide attempts are likely to be characterised by high rates of social isolation, feelings of loneliness, poor social support and lack of a close, confiding relationship (pp. 20, 30). Several studies have established that loneliness is a significant problem for the elderly in New Zealand: an Auckland Council commissioned study found that 44.5 percent of Auckland residents aged over 50 consider themselves to be moderately lonely and nine percent consider themselves “severely” or “very severely” lonely (p. 11); the New Zealand Longitudinal Study of Aging (see page 19) described 41.2 percent as ‘moderately lonely’, 7 percent as ‘severely lonely’ and 3 percent as ‘very severely lonely’.
- We live in an increasingly ageist society that devalues being elderly and fosters negative attitudes towards the elderly. The struggle of older workers seeking employment is a particular symptom of this. As a 2011 NZ Institute of Policy Studies Working Paper notes: “The number of older people experiencing or vulnerable to FEA [Financial Elder Abuse] appears to be increasing, and this may not be solely due to population ageing … The economic pressures on families and the demands of paid work are growing, contributing to the allure of assets in the hands of older relatives” (p. 22 – 23).
- A proponent of euthanasia, British neurosurgeon Henry Marsh, responded to the defeat of the Assisted Dying Bill in the UK in 2015 with the comment: “They argue that grannies will be made to commit suicide … Even if a few grannies get bullied into it [suicide], isn’t that the price worth paying for all the people who could die with dignity?“
Conclusion: It will not be possible to prevent or even detect subtle coercion of older people. Large numbers (in the Auckland area more than 50%) of our elders in New Zealand are already lonely, itself a form of systemic coercion, while significant and growing numbers report being coerced by, or not trusting, family members.
7. How much money will this save in healthcare spending?
- The ‘unthinkable’ idea that older people cost too much to be cared for, and that this is a sufficient reason for legalising euthanasia or assisted suicide, is taking hold in New Zealand as evidenced in numerous public submissions to the recent Health Select Committee Investigation into Ending One’s Life in NZ, mostly from older people. The following excerpts from submissions to the Health Select Committee are illustrative of this thinking:
- “This drive to keep people alive at all costs soaks up a huge amount of resources – human
as well as financial – which could be better invested in vulnerable children at the
beginning of their lives.”
- “The cost of both Nursing Homes and Palliative care is enormous and we believe that the
money spent on this could be used for medical research or for patients that can get long
- “Many people who would opt for medically assisted dying (MAD) depend heavily on the Health Services. When they would
make use of MAD the Health Services would save much money, They can use that for people
urgently needing the Health Services. Wait ing lists could be reduced and subsequently the
suffering of patients.”
- “This drive to keep people alive at all costs soaks up a huge amount of resources – human
- It has been estimated that euthanasia and assisted suicide will reduce annual health care spending in Canada by between $34.7 million and $138.8 million. The very existence of this report highlights the frightening prospect that money and markets are likely to influence the scope and reach of euthanasia and assisted suicide in the event that it was ever legalised in New Zealand.
- There is evidence from physicians that “insurance companies in states where assisted suicide is legal have refused to cover expensive, life-saving treatments for [their] patients but have offered to help them end their lives instead … The patients were not terminal, but ‘would have become terminal without the procedures. It was estimated that their chance for cure — cure, not just adding time — [was] about 50 percent in one case and 70 percent in the other case.’” In 2008, two patients from Oregon who were on Medicaid – ‘the state’s health insurance plan for the poor’ – were denied state-sponsored treatment but told the state would pay for assisted suicide.
- The language used to refer to our elders all too frequently draws on pejorative descriptors (such as ‘tsunami’ – see here p. 181 and here) when commenting on the growing numbers of elders. In a context where there is increasing pressure on healthcare resources, it is telling that media reports routinely focus on the future financial ‘cost’ and ‘burden’ of caring for older people – for example dementia. In a regime where euthanasia and assisted suicide were legal, this could, in the future, play into the hands of health administrators and politicians wanting to find “easy” savings in the health budget and be seen as ‘not unreasonable’ by a public who have gradually bought into the same negative ideas about the burdens (personal, familial and societal) of ageing.
- Studies show that there is a strong link between cost-cutting pressure on physicians and their willingness to prescribe lethal drugs to patients in the event these drugs could be legally prescribed (p. 18).
- In the context of a healthcare system that is stretched and in which some people have better access to quality palliative care than others, it is foreseeable that the introduction of euthanasia and assisted suicide would have a potentially greater negative impact on those with fewer resources to navigate the health system. As Hirini Kaa has written: “The problem is, what is ‘choice’? For the middle class advocates who have been pushing this issue, ‘choice’ is a wonderful thing … But what I also know will happen is that those on the margins will have less ‘choice’. When their whanau can’t afford the petrol to come and visit them in hospital, when they don’t like the nurses and doctors, when the power bill is due at home, when you are whakama (ashamed) of your situation – you name it, the problems mount up for poor sick people far beyond the medical … Then, the ‘choice’ becomes much clearer.” In other words, euthanasia and assisted suicide, if legalised, will be practiced through the same prisms of social inequality, prejudice and discrimination that currently characterises the delivery of other state-funded services (such as education and health) in our society and which lead to poorer outcomes for certain (less advantaged) groupings.
Conclusion: There will be ongoing and increasing pressure on future governments to control healthcare spending. When taxpayer money is involved, moral, social and public policy issues will arise beyond those presently recognised and intended by advocates of euthanasia and assisted suicide.
A law change allowing euthanasia or assisted suicide will be permanent but health policies and health services will be subject to the vagaries of insurance companies, future parliaments and economic climates. The scope of a euthanasia and assisted suicide policy that is implemented in a society increasingly shaped by negative perceptions of the elderly as a ‘burden’ will be influenced by discussions related to the affordability of end-of-life care.
Even if politicians reassure us now that cost savings are not part of the motivation for euthanasia and assisted suicide, this could easily change in the event such deaths become more and more the norm. In this context, economic considerations would contribute to a strong climate of coercion for a premature death for many people.
8. How does this not undermine suicide prevention efforts?
- Since euthanasia was legalised in the Netherlands in 2002 the rate of completed suicides (excluding premature death by euthanasia) has risen from 9.6 to 11.1 per 100,000 population (1,500 people in 2003 to 1,871 people in 2015).
- Legalising assisted suicide in Oregon and Washington states “has been associated with an increased rate of total suicides relative to other states and no decrease in non-assisted suicides.” (Jones and Paton, 2015)
- Being exposed to suicide increases the risk of suicide by family and friends:
- “Familial transmission of suicidal ideation and suicide attempts: evidence from a general population sample.” (Goodwin, Renee D., Annette L. Beautrais, and David M. Fergusson, 2004).
- “Exposure to the suicidal behaviour of family members has been well-established as a risk factor for youth suicidal behaviour in the professional literature” (M. Franci Crepeau‐Hobson, and Nancy L. Leech)
- “Risk of suicidal behaviours among those exposed to the suicide is significantly higher than those unexposed” (Maple, Myfanwy, et al. 2016)
- Last year, 579 Kiwis took their own lives. Chief Coroner Judge Deborah Marshall observed at the time that New Zealand has a long way to go in turning this “unacceptably high” total around. New Zealand rates of suicide for 15-24 year olds between 2009 and 2012 was the highest for 34 OECD countries in 2016.
- New Zealand suicide rates increase for people over 70, and for males over 85 years the suicide rate of 40.9 per 100,000 is the highest for any age group. If euthanasia or assisted suicide is legalised, many ‘legal’ and so-called ‘voluntary’ requests by elders would disguise an underlying depression that is directly related to abuse or neglect, social isolation or the limitations of ageing – a depression that can and should be treated.
Conclusion: Providing suicide assistance for some undermines suicide prevention for everyone. There is no bright line between so-called ‘rational’ and ‘irrational’ suicide because all the same social, economic and health factors are involved.
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9. Why is assisted suicide seen as a compassionate act for young disabled people when suicide is seen as a tragedy for other young people?
- Not Dead Yet Aotearoa argue that part of the unease disabled people feel about euthanasia and assisted suicide “relates to evidence that lives of disabled people are valued less than those of others. There is a history of euthanasia and eugenics, which have gone hand in hand for disabled people … They were labelled ‘useless eaters’. Many disabled people today still feel the residual power of that label as they struggle with cuts to services, parsimonious supports and subtle pressures to find work.”
- Disabled people routinely face prejudice from able-bodied people who think people with their conditions are ‘better off dead’. Carol Gill has found that “health professionals significantly underestimate the quality of life of persons with disabilities compared with the actual assessments made by people with disabilities themselves” (page 530). In one study only 18% of physicians, nurses and technicians imagined they would be glad to be alive with a severe spinal cord injury – while 92% of a group of 128 persons with high-level spinal cord injuries said they were glad to be alive.
- Baroness Campbell of Surbiton, former Commissioner of the Equality and Human Rights Commission and of the Disability Rights Commission, who has spinal muscular dystrophy has argued in the UK House of Lords: “ … imagine that it is already law and that I ask for assistance to die. Do your Lordships think that I would be refused? No; you can be sure that there would be doctors and lawyers willing to support my right to die. Sadly, many would put their energies into that rather than improving my situation or helping me to change my mind. The Bill offers no comfort to me. It frightens me because, in periods of greatest difficulty, I know that I might be tempted to use it. It only adds to the burdens and challenges which life holds for me”.
- A 2009 study found that people with physical disabilities were significantly more likely to seriously contemplate committing suicide, and the risk was even greater among younger people. These findings highlight the risks of euthanasia and assisted suicide for young disabled people in particular.
- “Assisted suicide laws create [a] discriminatory double standard for who gets suicide prevention and who gets suicide assistance.” John Fox notes: “We already know as disabled people that we have to fight to have a job, fight to be born, fight structural prejudice, patronising assumptions, and cultural realities which call us less than, and worth less. Those challenges are likely not equal for you and me, and the impact of David Seymour’s bill would not be equal either.”
Conclusion: Euthanasia and suicide, if legalised in New Zealand, will be practiced through the same prisms of social inequality, prejudice and discrimination that currently characterise the delivery of services (such as education and health) in all segments of society and which lead to poorer outcomes for less advantaged groups including disabled people. If euthanasia and assisted suicide are legalised, the risk of premature death would significantly increase for disabled people in a society which is ambivalent about disabled people who are pitied and/or perceived as having little or nothing to contribute while consuming large amounts of health resource.
“Encouraging the self-destructive urges of persons with disabilities who despair is not merciful or compassionate. It is dangerous for those individuals, for all disabled people as a devalued group, and ultimately for a society founded on equality”(Carol Gill).
10. Would a person with chronic arthritis be eligible?
- Those eligible for euthanasia under the David Seymour Bill include people who are not terminally ill. A person is eligible for euthanasia if he or she is “in an advanced state of irreversible decline in capability” and experiencing “intolerable suffering that cannot be relieved in a manner that her or she considers tolerable”.
- David Seymour’s Bill defines eligibility using the terms: “grievous and irremediable”, “irreversible decline” and “unbearable”, making the extent of coverage both subjective and wide-ranging.
- These conditions for eligibility are very similar to those that apply in the Netherlands, which now provides euthanasia to people with disabilities, with psychiatric disorders and with dementia. Cases there have included a person with “aging-related conditions, including arthrosis of the knee, pain from vertebral compression fractures caused by osteoporosis, headaches, poor kidney function, incontinence, impaired vision, atrial fibrillation and hemiparesis following a CVA” and “the feeling that life was no longer meaningful” because of functional decline and dependence on others (Annual Report 2014, p. 23).
Conclusion: Someone with chronic arthritis would be eligible for euthanasia under David Seymour’s Bill. The Bill is based on widely-drawn parameters that would include many persons suffering from incurable, but relatively common, conditions.