Anscombe Centre Submission to Isle of Man Consultation on Private Member’s Bill for Euthanasia and Assisted Suicide (EAS)

From 01 December 2022 to 26 January 2023, a Consultation was held on a Private Member’s Bill introduced into the House of Keys proposing to introduce euthanasia and assisted suicide (EAS) into Manx law and medical practice.

The Consultation took place via a series of set questions, with multiple choice answers and space to give explanations of the answer. The below is the submission on behalf of the Anscombe Centre (beginning administrative questions on person / institution submitting are omitted) composed by our Director, Professor David Albert Jones.

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8. In principle, do you agree or disagree that assisted dying should be permitted for terminally ill adults on the Isle of Man?

Agree / Disagree / Not Sure

Please explain the reasons for your response

By ‘assisted dying’ is generally meant either physician-assisted suicide or euthanasia or both; see our briefing paper on definitions. The Parliamentary Office of Science and Technology, in Westminster, has completed a briefing paper which may be of use to the Tynwald. It defines ‘assisted dying’ as an umbrella term covering both physician-assisted suicide and euthanasia.

Physician-assisted suicide and euthanasia involve intentional ending of life by, or with the assistance of, a doctor. This is fundamentally different from ordinary medical care and from palliative care. It represents a radical departure from the traditional ethic of medicine which allows the taking of risks and acceptance of side effects, and allows treatment to be withdrawn when it is no longer effective or is doing more harm than good, but never allows doctors to aim to kill their patients. Killing is controversial even in warfare and in policing, and while it may be permitted against enemy combatants or violent criminals it is never permitted against the innocent. The World Medical Association, which represents 116 medical associations world-wide including the British Medical Association, has strongly urged that:

“No physician should be forced to participate in euthanasia or assisted suicide, nor should any physician be obliged to make referral decisions to this end”.

If doctors are permitted to end the lives of their patients, or to give patients the means to commit suicide rather than seeking to prevent suicide, then further harms will follow inevitably. Those countries that have legalised physician assisted suicide or euthanasia have seen large increases in assisted deaths. Between 2010 and 2019 officially reported assisted deaths increased in the Netherlands by 103%, in Belgium by 167%, in Oregon by 189% and in Switzerland by 427%.  Canada, which only legalised euthanasia in 2016 now has more than 10,000 deaths a year.  For sources of these data see the Centre’s Evidence Guide

https://www.bioethics.org.uk/research/all-research-papers/euthanasia-and-assisted-suicide-a-guide-to-the-evidence/

The most commonly reason cited for seeking assisted death is not fear of pain or other physical symptoms but loss of the ability to engage in enjoyable activities. In Oregon, a majority (54% in 2021), cite fear of becoming a ‘burden on family, friends/caregivers’ as a reason for seeking death.  In Canada this reason is cited by more than a third and one-in-six cite ‘isolation or loneliness’.

There have been four studies published in 2022 on the impact of physician-assisted suicide or euthanasia on rates of self-initiated death and on suicide rates. All show large increases in self-initiated death. Unassisted suicide also increases. Legalisation of euthanasia or assisted suicide is a threat to suicide prevention.

https://www.bioethics.org.uk/research/euthanasia-assisted-suicide-papers/suicide-prevention-does-legalising-assisted-suicide-make-things-better-or-worse-professor-david-albert-jones/

There is also clear evidence that killing without request or consent is widespread in the Netherlands and Belgium with hundreds of such deaths a year. The Irish case of Fleming v. Ireland [2013] (para 104) raised the concern that the number of assisted deaths without explicit request remains ‘strikingly high’ in the Low Countries. This was cited in as a reason to keep the present law. Since 2013 there has been more evidence of intentional ending of life by doctors even without the consent of the patient. In Belgium, for example, this is increasingly done by ‘terminal sedation’.  For these and other dangers  see

https://www.bioethics.org.uk/research/euthanasia-assisted-suicide-papers/voluntary-euthanasia-physician-assisted-suicide-the-two-slippery-slope-arguments-prof-john-keown/

In summary there is ample evidence that changing the law of assisted suicide and/or on homicide with consent leads to real world harms. The rationale of the practice creates a pressure that pushes towards further expansion: first to those with non-terminal conditions; then to those with mental health conditions; and finally to those who have not asked for death. More people come to seek death because they feel they are a burden to others and more end their lives whether by assisted or unassisted suicide. If such laws are passed then some people will have their lives ended reluctantly or even without their consent and some will die by unassisted suicide who might have lived.

9. Do you think that there should be a limit on their life expectancy?

6 months / 12 months / Longer / Not Sure

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10. Do you support the provision of assisted dying for someone who has a condition which causes unbearable suffering that cannot be alleviated by other means but which may not give a terminal diagnosis?

Yes / No / Not Sure

11. If they are unable to take oral medication should a health care professionally be permitted to administer medication intravenously to achieve death?

Yes / No / Not Sure

12. Do you agree that assisted dying should be available only to people over the age of 18 Years?

Yes / No / Not Sure

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13. Should they have to be permanent residents of the Isle of Man?

Yes / No / Not Sure

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14. If you agree they should be permanent residents please state for how long.

For over 1 year / For over 5 years / Other

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15. Do you agree with the proposal that two different doctors should meet with the person independently and establish they are mentally competent to make an informed decision without pressure or coercion?

Yes / No / Not Sure

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16. Should any health professional be able to conscientiously object to being part of an assisted dying programme?

Yes / No / Not Sure

17. Do you agree that if either doctor is unsure about the person’s capacity to request an assisted death, the person should be referred to a psychiatrist for a further capacity assessment?

Yes / No / Not Sure

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18. Do you agree that the two doctors should ensure that the person has been fully informed of palliative, hospice and other treatment and care options?

Yes / No / Not Sure

19. Do you support the proposal that the person signs a written declaration of their request, which is witnessed and signed by both doctors?

Yes / No / Not Sure

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20. Do you agree that there should be a waiting period of 14 days from this time to the provision of life-ending medication to allow the person to reconsider their decision?

Yes / No / Not Sure

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21. Do you feel that this period should be shortened to 7 days if the person is expected to die within 30 days?

Yes / No / Not Sure

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22. Should the person themselves or a relative be able to collect the relevant medication from a designated pharmacist?

Yes / No / Not Sure

23. Should this be able to be stored securely in the person’s home until they decide whether they want to take it or not?

Yes / No / Not Sure

24. If they change their mind should the medication be returned to the pharmacy immediately?

Yes / No / Not Sure

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25. Should a health care professional be required to be with the patient once they have taken the medication until they are certified to have died?

Yes / No / Not Sure

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26. Should an annual report be produced regarding the number of people who have taken advantage of assisted dying, and be published?

Yes / No / Not Sure

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27. Should it be possible to include the provision of assisted dying in a “living will” or advanced directive?

Yes / No / Not Sure

28. Do you have any comments on the process to provide Assisted Dying which will be included in the draft Bill?

Any other comments __________

While the Centre is based in Oxford, and the director is resident in England the Centre covers the British Isles, including England, Wales, Scotland, Northern Ireland, the Republic of Ireland, and the Isle of Man.

Many of the ‘Yes / No’ questions in this consultation have been skipped. This is not because the questions have not been considered but because those questions seem to presuppose that there would be a law, whereas this submission argues that such a law should not be enacted as it would be harmful.

It should not be assumed, however, that the skipping of these questions implies approval for the most dangerous options, for example, for physician-assisted suicide and / or euthanasia for minors (question 12) or for those who might lack of capacity (question 17) or approval for the Isle of Man becoming a centre for suicide tourism (question 13).

If, despite these dangers, legislation moves forward in the House of Keys then Members should seek to limit the danger by restrictions such as age, residence and the nature of the person’s condition. However, the idea that these restrictions constitute ‘safeguards’ is naïve. It first of all ignores the fact that in all jurisdictions with such laws the practice expands beyond the law and doctors are rarely if ever prosecuted. It also ignores the reality that in most if not all jurisdictions with such laws, the laws have already been extended, either by court cases or by tabling amendments. For example Canada was at first restricted to the terminally ill but this was extended to those with chronic illness, and Oregon was at first restricted to residents but this has been extended to non-residents and in Belgium euthanasia was restricted to adults but now it has been extended to children (without any lower age limit).

Once the major barrier to intentional ending of life is removed, then the minor restrictions put in place are much easier to amend. These restrictions are not based on a long history or a deep and clear principle but are recent provisions based on pragmatic arguments. The proposed restrictions will not prevent future expansion and future abuse. The key question is thus the principle of the legislation and the principle should be judged as though the law had no ‘safeguards’ because the experience of other jurisdictions is that, as soon as they are found to be inconvenient, these restrictions are removed. If euthanasia or physician-assisted dying is legalised then there will be no stopping its expansion. If you blow up the dam, then the waters will not be held in place by a few sand bags further down stream.