ࡱ>    bjbj bwj  $ $O1(w1 333%3%3%38]3t3|%3-^M4^4(4455==4>]]]]]]]aǻ]3<^<|JCJC]112l4(5H]&IIIJCp242R5]IJC]IIZ2"X]407%3F\,]]<-^\tdHdXX]d3X]H#>?&I@Ay#>#>#>]]tI#>#>#>-^JCJCJCJCd#>#>#>#>#>#>#>#>#> $ 0:  The debate on assisted suicide A briefing paper for unions commissioned by the TUC Disability Committee  The debate on assisted suicide A resolution carried at the 2010 TUC Disability Conference called for the publication of a legal opinion on the position regarding assisted suicide in the UK, compared with other countries, and for a presentation of the opposing views in the debate on this subject. It was recognised that the topic, which has been the subject of attempts to change the law, is highly controversial and raises many wider questions. The TUC Disability Committee decided to commission a legal opinion from a leading disability rights lawyer, and to invite two campaign bodies representing the alternative viewpoints in the debate, Not Dead Yet and Dignity in Dying, to present their arguments. The purpose of so doing is to provide the basic information to enable trade unions to inform their members of the issues involved and to provide background material for debate. Neither the TUC, nor the Disability Committee, has adopted a position, recognising both the strongly held opinions on whether or not assisted suicide should be legalised, and the wider context that applies, particularly from the viewpoint of disabled people. This briefing contains the papers as commissioned. IN THE MATTER OF ASSISTED SUICIDE _______________________ A D V I C E _______________________ I am asked to advise the TUC on the legal position of those assisting a suicide, in detail for the UK and by way of an overview for countries outside the UK. The legislation relating to suicide for England and Wales is contained in the Suicide Act of 1961. This Act decriminalised suicide (section 1). The sections relevant to the assisting of suicide are as follows: 2 Criminal liability for complicity in another's suicide [(1) A person (D) commits an offence if (a) D does an act capable of encouraging or assisting the suicide or attempted suicide of another person, and (b) D's act was intended to encourage or assist suicide or an attempt at suicide. (1A) The person referred to in subsection (1)(a) need not be a specific person (or class of persons) known to, or identified by, D. (1B) D may commit an offence under this section whether or not a suicide, or an attempt at suicide, occurs. (1C) An offence under this section is triable on indictment and a person convicted of such an offence is liable to imprisonment for a term not exceeding 14 years.] (2) If on the trial of an indictment for murder or manslaughter [of a person it is proved that the deceased person committed suicide, and the accused committed an offence under subsection (1) in relation to that suicide, the jury may find the accused guilty of the offence under subsection (1)]. (3) The enactments mentioned in the first column of the First Schedule to this Act shall have effect subject to the amendments provided for in the second column (which preserve in relation to offences under this section the previous operation of those enactments in relation to murder or manslaughter). (4) ... no proceedings shall be instituted for an offence under this section except by or with the consent of the Director of Public Prosecutions. [2A Acts capable of encouraging or assisting] [(1) If D arranges for a person (D2) to do an act that is capable of encouraging or assisting the suicide or attempted suicide of another person and D2 does that act, D is also to be treated for the purposes of this Act as having done it. (2) Where the facts are such that an act is not capable of encouraging or assisting suicide or attempted suicide, for the purposes of this Act it is to be treated as so capable if the act would have been so capable had the facts been as D believed them to be at the time of the act or had subsequent events happened in the manner D believed they would happen (or both). (3) A reference in this Act to a person (P) doing an act that is capable of encouraging the suicide or attempted suicide of another person includes a reference to P doing so by threatening another person or otherwise putting pressure on another person to commit or attempt suicide.] [2B Course of conduct] [A reference in this Act to an act includes a reference to a course of conduct, and a reference to doing an act is to be read accordingly.] Thus a criminal offence is committed if anyone does an act capable of encouraging or assisting the suicide or attempted suicide of another person and the act was intended to encourage or assist a suicide or attempted suicide. These provisions, however, require the consent of the DPP before they are invoked. Relatively recently, arguments based on the European Convention on Human Rights (which was subsequently explicitly incorporated into our domestic legal system by means of the Human Rights Act 1998) have been used by those wishing to have assistance in committing suicide as a result of a debilitating condition. Pretty v UK (Application No. 2346/02) was a case brought by Dianne Pretty, who had motor neurone disease. She was paralysed from the neck down, her life expectancy was short, she was fed by a tube and she had almost no decipherable speech. However, her intellect and capacity to make decisions were unimpaired. As s.2(1) Suicide Act 1961 provides that it is offence in English law to help somebody else to commit suicide, in July 2001 Ms Pretty wrote to the Director of Public Prosecutions ('DPP') asking him to undertake not to prosecute her husband ('B') if he helped her to commit suicide in accordance with her wishes. The DPP refused to make such an undertaking. Ms Pretty applied for judicial review of the decision. She complained of a violation of Art.2 European Convention on Human Rights on the grounds that the right to life provided a corresponding right to die and that there was a positive obligation on the State to protect this right. She also complained of violations of Art.3, Art.8, Art.9 and Art.8 taken together with Art.14 of the Convention. Article 3 is the right not to suffer torture, punishment or inhuman and degrading treatment; Article 8 concerns the right to respect for home, family and environment; Article 9 is the right to freedom of thought conscience and religion, whilst Article 14 is the right not to be discriminated against in relation to any of the rights under the Convention. She sought: (i) an order quashing the DPP's decision; (ii) a declaration that the DPP's decision was unlawful or that the DPP would not be acting unlawfully if he undertook not to prosecute B; and (iii) either a mandatory order requiring the DPP to give the undertaking or a declaration that s.2 of the Act was incompatible with Art.2, Art.3, Art.8, Art.9 and Art.14 of the Convention. In October 2001 the Divisional Court held that the DPP could not give the undertaking and that s.2(1) of the Act was not incompatible with the Convention. Ms Prettys appeal to the House of Lords was dismissed in R v Director of Public Prosecutions (Respondent), ex parte Dianne Pretty (Appellant) & Secretary of State for the Home Department (Interested Party) (2001). Having exhausted all legal avenues in the UK, Ms Pretty then submitted her case to the European Court of Human Rights, where third party interventions were made by the Voluntary Euthanasia Society and the Catholic Bishops' Conference of England and Wales. The European Court of Human Rights held that Ms Prettys complaint raised questions of law that were sufficiently serious to warrant an examination of the merits and that it was therefore admissible. The court went on to say that Art.2 was one of the most fundamental provisions of the Convention and imposed a positive obligation on the State to protect life as well as to refrain from taking life. Whilst it was accepted that in some instances a right to do something also protected a right not to do something, (see  HYPERLINK "http://www.lawtel.com/HR/Document.aspx?AG1000056" \t "_self" (1) Young (2) James (3) Webster v United Kingdom (1981) in which it was held that Art.11 encompassed the right not to join a trade union), a right to die could not be read into the right to life protected by Art.2. There had been no violation of Art.2. Of Art.3, the court said that it imposed on States a positive obligation to prevent inhuman or degrading treatment. It was clear that the UK was not responsible for inflicting ill-treatment on Ms Pretty and that she was not being refused medical care. The Court was sympathetic to the fact that she faced a distressing death and was unable to commit suicide without assistance but the State's obligation to prevent ill-treatment could not be considered to include permitting actions designed to cause death. The State was not required to undertake not to prosecute B if he helped Ms Pretty to commit suicide. Nor was the State required to provide a means of lawfully committing assisted suicide. There had been no violation of Art.3. The court went on to say that the right to refuse medical treatment was within the ambit of Art.8; and that Ms Pretty's inability to end her life constituted an interference with her private life. In those circumstances, the Court had to go on to consider whether the interference was justified (Art 8(2)) i.e. that it was in accordance with the law and necessary in a democratic society; that it was in the interests of national security, public safety or the economic well-being of the country; or for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others). The Court said that it was clear that the interference was prescribed by law and pursued a legitimate aim. With respect to the question of proportionality, it was not considered that a blanket prohibition on assisted suicide was disproportionate or that the principle of proportionality was jeopardised by the DPP's refusal to give the undertaking. The interference complained of was "necessary in a democratic society" and there had been no violation of Art.8. The Court held that Art.9 did not protect all convictions or beliefs. Whilst Ms. Prettys beliefs were strongly held, her beliefs about assisted suicide did not fall within the meaning of Art.9 and there had been no violation of that Article. The UK was held to have had an objective and reasonable justification for not distinguishing in law between individuals who were and were not capable of committing suicide and thus there had been no violation of Art.8 taken together with Art.14 of the Convention. Thus the European Convention on Human Rights was not going to provide individuals with the right to have someone assist them in committing suicide. The issue of assisted suicide was returned to, though, in the case of R. (Purdy) v Director of Public Prosecutions [2010] 1 A.C. 345. Ms Purdy challenged the refusal of the DPP to publish details of his policy on prosecutions under the Suicide Act for assisting suicide. Ms Purdy, who has a debilitating illness, had declared her wish to travel to a country where assisted suicide was lawful in order to end her life when it became utterly unbearable. She sought information in order to make an informed decision about whether to ask for her husband's assistance in doing so. The DPP had declined to say what factors, other than the general factors contained in the Code for Crown Prosecutors, he would take into consideration in deciding whether, under  HYPERLINK "http://login.westlaw.co.uk/maf/wluk/app/document?src=doc&linktype=ref&&context=24&crumb-action=replace&docguid=I8B9E3330E44811DA8D70A0E70A78ED65" s.2(4) of the Act, it was in the public interest to prosecute those who assisted people to end their lives in countries where assisted suicide was lawful. Ms. Purdy argued that (1) the prohibition in s.2(1) constituted an interference with her right to respect for her private life under art.8(1); (2) such interference was not "in accordance with the law" as required by art.8(2) because there was no offence-specific policy by the DPP which set out the factors that would be taken into account by him and the Crown Prosecutors acting on his behalf in deciding under s.2(4) whether it was in the public interest to bring a prosecution under that section. The High Court (  HYPERLINK "http://login.westlaw.co.uk/maf/wluk/app/document?src=doc&linktype=ref&&context=24&crumb-action=replace&docguid=I05C12A30FF1E11DDBB748945C50BBA89" R. (on the application of Purdy) v DPP [2009] EWCA Civ 92, [2009] 1 Cr. App. R. 32 ) held that the absence of a crime-specific policy did not make the operation and effect of the  HYPERLINK "http://login.westlaw.co.uk/maf/wluk/app/document?src=doc&linktype=ref&&context=24&crumb-action=replace&docguid=I8B9E3330E44811DA8D70A0E70A78ED65" Suicide Act 1961 s.2(1) unlawful. The court also held that it did not mean that it was not in accordance with law for the purposes of the European Convention on Human Rights 1950 art. 8. The House of Lords reached a different conclusion though. It held that that the right to decide when or how to die was not excluded from art.8(1) (this was based on the European Court of Human Rights decision in  HYPERLINK "http://login.westlaw.co.uk/maf/wluk/app/document?src=doc&linktype=ref&&context=24&crumb-action=replace&docguid=I28B77F30E42811DA8FC2A0F0355337E9" Pretty v United Kingdom above) . Article 8(1) was engaged in the instant case. The Court said that the Code would normally provide sufficient guidance to Crown Prosecutors and to the public as to how decisions should, or were likely to be taken as to whether, in a given case, it would be in the public interest to prosecute. That could not be said of cases where the offence was aiding or abetting the suicide of a person who was terminally ill or severely and incurably disabled, who wished to be helped to travel to a country where assisted suicide was lawful and who, having the capacity to take such a decision, did so freely and with full understanding of the consequences. The Code was therefore insufficient to satisfy the art.8(2) requirements of accessibility and foreseeability in assessing how prosecutorial discretion was likely to be exercised in s.2(1) cases. That was underlined by the decision letter in the case of Daniel James , in which the DPP, when considering the discretion under s.2(4), had found that many of the factors listed in the Code were irrelevant and that other unlisted factors had to be considered in such difficult cases. The DPP was required to promulgate an offence-specific policy identifying the facts and circumstances that he would take into account in deciding whether to consent to a prosecution under s.2(1). Following the successful appeal, and after a consultation, the DPP published its policy on prosecuting in cases of assisted suicide (February 2010). The Code makes clear the following: Prosecutors must apply the Full Code Test as set out in the Code for Crown Prosecutors in cases of encouraging or assisting suicide. The Full Code Test has two stages: (i) the evidential stage; and (ii) the public interest stage. The evidential stage must be considered before the public interest stage. A case which does not pass the evidential stage must not proceed, no matter how serious or sensitive it may be. Where there is sufficient evidence to justify a prosecution, prosecutors must go on to consider whether a prosecution is required in the public interest. The DPP will only consent to a prosecution for an offence of encouraging or assisting suicide in a case where the Full Code Test is met. The Code says of the evidential test as follows: In these cases, for the evidential stage of the Full Code Test to be satisfied, the prosecution must prove that: the suspect did an act capable of encouraging or assisting the suicide or attempted suicide of another person; and the suspect's act was intended to encourage or assist suicide or an attempt at suicide. The Code goes on to set out the sixteen public interest factors in favour of prosecution which are: The victim was under 18 years of age. The victim did not have the capacity (as defined by the Mental Capacity Act 2005) to reach an informed decision to commit suicide. The victim had not reached a voluntary, clear, settled and informed decision to commit suicide. The victim had not clearly and unequivocally communicated his or her decision to commit suicide to the suspect. The victim did not seek the encouragement or assistance of the suspect personally or on his or her own initiative. The suspect was not wholly motivated by compassion; for example, the suspect was motivated by the prospect that he or she or a person closely connected to him or her stood to gain in some way from the death of the victim. The suspect pressured the victim to commit suicide. The suspect did not take reasonable steps to ensure that any other person had not pressured the victim to commit suicide. The suspect had a history of violence or abuse against the victim. The victim was physically able to undertake the act that constituted the assistance himself or herself. The suspect was unknown to the victim and encouraged or assisted the victim to commit or attempt to commit suicide by providing specific information via, for example, a website or publication. The suspect gave encouragement or assistance to more than one victim who were not known to each other. The suspect was paid by the victim or those close to the victim for his or her encouragement or assistance. The suspect was acting in his or her capacity as a medical doctor, nurse, other healthcare professional, a professional carer (whether for payment or not), or as a person in authority, such as a prison officer, and the victim was in his or her care. The suspect was aware that the victim intended to commit suicide in a public place where it was reasonable to think that members of the public may be present. The suspect was acting in his or her capacity as a person involved in the management or as an employee (whether for payment or not) of an organisation or group, a purpose of which is to provide a physical environment (whether for payment or not) in which to allow another to commit suicide. The six public interest factors against prosecution are: The victim had reached a voluntary, clear, settled and informed decision to commit suicide. The suspect was wholly motivated by compassion. The actions of the suspect, although sufficient to come within the definition of the crime, were of only minor encouragement or assistance. The suspect had sought to dissuade the victim from taking the course of action which resulted in his or her suicide. The actions of the suspect may be characterised as reluctant encouragement or assistance in the face of a determined wish on the part of the victim to commit suicide. The suspect reported the victim's suicide to the police and fully assisted them in their enquiries into the circumstances of the suicide or the attempt and his or her part in providing encouragement or assistance. Scotland The Suicide Act 1961 does not apply to Scotland. In Scotland, it would appear that attempting suicide was a crime at common law, at least until the 18th century. By the twentieth century, this crime had become entirely obsolete; neither committing nor attempting to commit suicide are in themselves punishable in Scots law. It has been suggested, however, that attempting suicide may be prosecuted as breach of the peace, even where the act is carried out in a discreet and private setting. The position with regard to assisting a suicide is not quite so clear. Whether any prosecution will be deemed to be in the public interest depends entirely on the opinion of the Lord Advocate - Scotlands chief prosecutor - as does the precise nature of the charge. In theory, the assistant could be charged with murder. It is more likely, however, that the charge would be one of culpable homicide (this is where the accused has caused loss of life through wrongful conduct, but where there was no intention to kill or 'wicked recklessness' it is roughly equivalent to manslaughter in England and Wales) . Following the decision of the House of Lords in Purdy, The Lord Advocate, Elish Angiolini, stated that legal guidelines on assisted suicide would not be prepared in Scotland. Ms Angiolini said it would be inappropriate for her to publish detailed guidance in light of a separate decision covering England and Wales. It is important to recognise the different legal landscape in Scotland, where involvement in a suicide might amount to homicide, as well as a different system of public prosecution," she wrote in response to a letter from Liberal Democrat MSP, Jeremy Purvis (see http://news.stv.tv/scotland/125194-no-legal-change-for-assisted-suicide-in-scotland/). Other Countries In the United States, Oregon and Washington have laws permitting assisted suicide in certain situations. In Montana, the Montana Supreme Court ruled that nothing in state law prevents patients from seeking physician-assisted suicide, paving the way for the procedure (though some argue that it is still possible for a physician in these circumstances to be charged with homicide). Other states criminalise assisting a suicide in a variety of circumstances. In Canada, it is a crime to assist a suicide, as it is also in New Zealand. There is no provision for assisted suicide in the Northern Territory of Australia, though a bill permitting this is currently proceeding in relation to Southern Australia and Tasmania. In Mexico, passive euthanasia is lawful this allows the disconnection of life support equipment but not, for example, to administer poison. In Sweden, Norway, Denmark, Finland, France and Italy, assisting a suicide is either a specific criminal offence or there is a possibility of an assister being charged under other legislation. Belgium, Switzerland, the Netherlands and Luxembourg all have provision for assisted dying of terminal patients at their request. In Belgium and the Netherlands a doctor must be involved, as well as a psychologist if there are doubts about the patients competency. There is no specific requirement for this involvement in Switzerland, but right to die societies insist on medical certification of a patients being terminal before they will assist a death. All these countries bar Switzerland require an individual to be a resident in order for the assisted suicide to be lawful. Belgium and the Netherlands permit voluntary euthanasia. In Japan, medical voluntary euthanasia was approved by a High Court in 1962 but it is rarely invoked. If there is anything further that I can assist with, or if further clarification is required of the above, please do not hesitate to contact me. CATHERINE CASSERLEY 12th April 2011 Cloisters Temple LONDON EC4Y 7AA ------------------- Not Dead Yet UK: why legalising euthanasia threatens the lives of disabled people Current debates about legalising voluntary euthanasia are concerning in their own right. Those changes in law, if brought about, will have a wider impact and one possible consequence would be in creating conditions in which more liberal responses to involuntary euthanasia are made possible, and practiced. Would legalising physician-assisted suicide threaten the lives of disabled people? The short answer is: Yes. Patient safety is at the heart of good clinical governance. Medical interventions already bring with them an element of risk: reliance on a ventilator brings risk of pneumonia; cross-infection in hospitals may lead to the transmission of e.g. MRSA; operations are inherently dangerous these are just some examples in which patients can suffer unintended harm whilst in medical care which many practitioners are working hard to reduce Just like all patients, disabled people need to feel safe when receiving healthcare: not having confidence in, the capacity to seek or equality of access to safe healthcare reduces opportunities to seek medical intervention early for some unexplained symptoms, for example. This already poses a threat to the lives of disabled patients (cf DRC:2006). So, existing health inequalities and the practices that give rise to them may already erode a sense of safety in medical care. Legalising euthanasia, it can be argued, will create a further erosion of confidence in healthcare and thereby constitutes a greater threat to well-being, continuing care and management, and life itself. A more direct and immediate threat to life in medical care, directly associated with impairment, also already exists. One patient, born with spinal muscular atrophy, being treated for her life-threatening pneumonia, was told by two doctors they presumed that if she experienced respiratory failure, she wouldnt want to be resuscitated with a ventilator You wouldnt want to live on a ventilator. No ventilation, no resuscitation meant she would die. Very scared, she stayed awake in hospital for more than 48 hours. DNR (Do not resuscitate) notices have been a cause for concern for some time, especially when put in a patients notes without permission or even discussion. Crucially, the doctors judgment in cases like this and in terminating pregnancies where severe (or even sometimes mild) impairments are detected, is based on the idea of a life not worth living. This is a moral judgement. It is precisely not a judgement of facts (medical or otherwise). It comes to: I wouldnt, couldnt live like that, a judgement of the value of another, disabled persons life. But it is not a judgement doctors are generally entitled to make. A law permitting euthanasia would reinforce this belief, and further clear the ground to take away lives based on a moral judgement rather than medical fact. The threat will extend to the lives of older, disabled people too. Lord McColl, a surgeon, said: When a Dutch doctor was asked what his first case of euthanasia was like he said, it was dreadful. We agonised all day. But the second case was much easier and the third case was a piece of cake. Many elderly people in Holland are so fearful of euthanasia that they carry cards around with them saying that they do not want it. (McColl:2005) This is not a slippery slope argument: these are existing practices which reveal a reality, and dangers in other countries which would be replicated in the UK. At the heart of the matter is the fact that some suffering deemed to be intolerable. The judgement that it must end, by ending the life of the sufferer, is seen as the lesser of two evils, a relief from suffering, and is sometimes described in the media as mercy killing. But there is no safe measurement tool here, which determines categorically when suffering becomes intolerable. It is a problem when such tools as there are, rely on subjective reporting, especially when it becomes clear that people who are experiencing severe symptoms and interventions (e.g. major surgery) are more likely to categorise that experience as intolerable, in line with their other feelings about life. Further, what one person describes as intolerable is not necessarily intolerable to another. Imagine a situation when medical technology can measure on instruments all the level of neurological activity taking place in the body, including pain signals: it is logically possible that two people, registering the same levels would have different experiences, one writhing in agony whilst the other is calmer and managing their pain experience. This is one way in which modern medical science speaks about different people having different pain thresholds. Another important question here is: why should any suffering left to be intolerable? That appears to be, at least in part, due to an absence of service provision. But if palliative care is as good as it can be and as widely available as necessary, if the fear of (future) suffering could be removed, is there still a need to change the law? Pain management can also be, to an extent, taught and is bound up with a persons view of themselves and their situation, which is why undergoing operations can increase some peoples experience of pain. Of course, pain is not the only factor in intolerable suffering and account needs to be taken of emotional responses such as feeling oneself to be a burden on others. Some disabled people also say: I dont want to live like this. We make no judgement of that position, consciously making no appeal to the expressed pain and suffering of individuals. This is not to ignore it; rather it is precisely because that appeal to individual cases is flawed that no appeal is made to them. (Nor does it mean that those who fear what a change in law will bring, lack compassion. Thats a distracting ad hominem - it is entirely consistent with deep compassion for the suffering of another, to still think clearly and want to resist the threats inherent in legalising intentional, medicalised killing.) It must be recognised that there is not one isolated, central question here, and current debates cover a wide range of aspects surrounding this complex, difficult and emotive subject. There are questions in law. For example, lawyer Charles Foster (2011) wonders why we need an assisted dying law when the one we have works so well. It may be that a law is needed to redress the balance after the legal position was weakened in the Crown Prosecution Services 2010 response to Purdy. It is an odd position when our laws reflect little or no shame in failing a person who commits suicide, and yet expresses what can only be described as outrage at times for keeping people alive. There are, naturally and obviously, questions in medicine and for medical practitioners. In the first instance, proposals to bring forward law to permit assisted suicide placed responsibility for the decision to end life and for the act of doing so on doctors. Perhaps inevitably, some doctors and nurses support such a change in law, whilst many others do not, fearing prosecution under the current legislative framework in the UK, or for moral reasons. Although less likely to be prosecuted, there are also questions about the non-medical person who makes the choice to assist, and their motivations for doing so. Motivations are notoriously difficult to lay bare in their entirety: often an individual may not even be completely aware of all of their own motivations. Indeed it may be impossible to ever have a pure motivation of any kind, is isolation. Questions then naturally arise as to whether it could ever be determined with absolute clarity, morally or in law, who exactly can be deemed to be a fit or proper person to assist another in dying. Indeed, questions also arise about who should or should not be allowed to be assisted in their dying. Suffering, compassion and individual autonomy are most often cited as compelling reasons why someone should be allowed assistance to die, but whether these are sufficient reasons is another question. On the face of it, suffering can be unbearable and what is accountably a human reaction to that suffering is the wish to end it. So a loved who wishes to die might be helped by their spouse, other family member, friend, or sympathetic doctor, who wishes to help them to die out of compassion. But this gives rise to questions about those who wish to die who are not, for example, terminally ill; about what is unendurable/intolerable suffering and who decides (should it be the person themselves, or in cases where the person does not have the capacity to decide - a newly born baby for example - should a doctor have the power to make the decision to end life?). How far should this go? Should someone who is broken-hearted but has no other illness, or is deemed to be depressed, have the same consideration of their wish to die? Personal autonomy, sometimes couched as the right to choose, is another one of the apparently sufficient reasons to allow assisted dying, i.e. that each person has the right to choose and to act on their choice. Onora ONeill (2010) argues that a few safeguards in legislation cannot offer enough protection from involuntary euthanasia and that current debates rely on two important assumptions which render the debates about assisted suicide wholly inadequate. The first relies on the tendency to think of the situations of certain individuals that are so miserable that we are tempted to feel that anything must be an improvement (her emphasis). But, as she points out, individual cases cannot be the basis for a legal framework for all, and therefore there must be some distinction between the most difficult cases and others. In logic, this is the fallacy of moving from the particular to the general case, which is what a law legalising euthanasia would have to do this persons situation demands this reaction, therefore all people in this or similar situations demand this reaction: that is simply not a legitimate conclusion from the premise. The second assumption she believes mars these debates is the idea alluded to above in discussing pure motivations, that there is no such thing as a wholly compassionate person, when even the most loving of families may be stretched by the burden of caring for a very ill person or indeed, be suffering serious financial problems as a result of doing so. Compassion, she says quite rightly, may be mixed with frustration, perhaps anger, and even the hope that someone might die. (An overwhelming sense of powerlessness might be added to this list.) ONeill concludes: In a world of idealised wholly autonomous patients, and of wholly selfless and compassionate families and professionals, legislation providing for assisted dying might, if ethically acceptable, not be risky. But we do not live in that world, and I doubt whether we can draft legislation that is safe for human beings with their full variety of situations and dependence on one another. The philosopher Bernard Williams was, I think, right to suggest that we should not put too much weight on the fragile structure of the voluntary. (ONeill: 2010) So there are also questions of practicality about whether a law could be formulated which covered all situations in which assisted suicide was considered; or whether such a person as a wholly autonomous patient or a wholly compassionate assistant even could exist. This is by no means an exhaustive list of the range of complex discussions that surround the so-called right to die. Another fatal flaw in the argument is that there is nothing clear about what could possibly constitute such a right. There is a difference here which bears examination, between the value of death and the value of life the fact of death is not chosen, it is inevitable for everyone (even if its manner and timing might be chosen). But with death, choice and reason come to and end. This will be important in trying to make sense (or not) of the notion of a right to die. Since suicide was decriminalised (1961), we might be said to have a right to end our own lives, but more recent arguments have transformed into the nonsensical idea that we have a right to die. Death is inevitable and is not an event in life: it is the end of our experience of living in the world, including holding rights. It makes no sense to speak of a right to die. What is usually being claimed here is a right to have assistance to end ones own life, a right to a premature death, which is not inevitable. This claim just is controversial. Arguments for voluntary euthanasia are variously based on other fatal flaws the internal problem in ever finding wholly autonomous patients and wholly compassionate assisters, and why framing with a few safeguards just cannot suffice, indeed why it is impossible to draft a law to cover all cases,  and apart from the fact that the move from the particular to the general case is fallacious (this person wants it and should have it, so all people in their situation want/should have it). The argument is also based in the morally bankrupt philosophy that is Utilitarianism, purporting to measure human happiness as a way of determining moral behaviour. This feeds the equally spurious notion that quality of life can be measured too (in QALYs or even DALYs). The phrase we own (sic) our own bodies is entirely empty. And so on. It is impossible to cover all these confused matters here. But they are lined up to threaten the lives of disabled people, whether that is anyones intention or not. But all the while these discussions are complex, they fundamentally involve deep moral questions that cannot and must not be treated as though they were merely matters of fact with clear and obvious answers which everyone must share, as though logic dictated it. The lives of many disabled people depend on resisting attempts to introduce a law legalising the intentional act of killing which is euthanasia. Dignity in Dying, February 2011 Dignity in Dying On behalf of our 25,000 supporters, Dignity in Dyings aim is to reduce suffering at the end of life. Alongside universal access to good quality end-of-life care, we advocate safeguarded assisted dying this gives terminally ill, mentally competent adults the choice to control the time and manner of their own death with self-administered life-ending medication. We do not advocate assisted suicide for non-terminally ill people and we do not advocate euthanasia which allows doctors to directly end patients' lives (this can be with or without their consent). We campaign to allow assisted dying only for dying adults in the terminal phase of a terminal illness. We do not campaign for people who are disabled, elderly or incurably ill but not dying to have assistance to end their lives. The ethical case to permit assisted dying is that when a dying person is suffering unbearably, everything possible must be done to alleviate their suffering. Even with more or better palliative care, there are some people whose suffering, and consequent desire for an assisted death, cannot be alleviated. When someone is in the terminal phase of a terminal illness and they have assistance to die, they control the manner and timing of a death that would otherwise be unbearable to them. This is not suicide - they are substituting a bad death with a good death. Extent of public support for assisted dying The British Social Attitudes Survey consistently finds that 80% of the population of the UK support assisted dying for terminally ill adults. Support for assisted suicide for disabled or incurably ill adults is consistently found to be lower at around 40%. Support for assisted dying is spread throughout society. Groups generally portrayed as opposed, are largely supportive of assisted dying for terminally ill people, e.g. 75% disabled people, and 71% of religious people. There is very little research on terminally ill peoples views on assisted dying. However, in 2006 a qualitative study to examine the views of those who were close to death found overall support in favour of a change in the law. Another study found 9.8% of patients expressed a request for the end of their life to be hastened, and in the majority of cases (74%) the request stayed consistent. Regulation is preferable to dangerous, underground practice The lack of choice for dying people drives some to attempt suicide alone, ask a loved one to help them die, or travel overseas for assistance to die. Over 135 British citizens have been helped to end their lives in Switzerland. At least another 700 are members of Dignitas. Organisations providing assistance to die overseas (and self-deliverance information here in the UK) do so with considerably less safeguards than those offered by the type of legislation we propose. Without regulation, people continue to make these decisions without legal safeguards or the support of health and social care professionals who would be best placed to identify whether the persons wish to die is actually due to unmet social, mental or physical needs, or external pressure. At present, doctors decisions are also largely closed to scrutiny. In the UK in 2007/08 0.21% of deaths attended by a medical practitioner were as a result of voluntary euthanasia and 0.3% of deaths were as a result of non-voluntary euthanasia. These are illegal acts. We need regulation to better protect patients. This would ensure those making requests have access to palliative, medical and social support, and that they have the chance to discuss their feelings openly with doctors and loved ones. Current law and practice The Director of Public Prosecutions Prosecuting policy on cases of assisting or encouraging suicide, published in February 2010, is the result of the Law Lords ruling in the Debbie Purdy case of 2009. Lord Browns judgment on the case set out the need for a policy indicating the various factors for and against prosecution, to distinguish between those situations in which, however tempted to assist, the prospective aider and abettor should refrain from doing so, and those situations in which he or she may fairly hope to be,forgivenfor giving assistance. The prosecuting policy gives individuals a much clearer indication of how they are likely to be treated by police and prosecutors and formal recognition that in certain circumstances, people should not be prosecuted for helping someone to die. However, the policy states It may sometimes be the case that the only source of information about the circumstances of the suicide and the state of mind of the victim is the suspect. This is the inherent difficulty of afterthe-event investigations. A safeguarded assisted dying law would mean cases would be considered when someone asks for help to die, rather than after they have died. This would allow dying adults to make informed decisions after discussions with loved ones and doctors, and would offer better protection against abuse than the current law and prosecuting policy. The inadequacies of after-the-event investigation are particularly pertinent in light of the concern that potentially vulnerable people (for example, disabled people or older people) may consider assisted suicide because of fears of being a burden, outside pressure or influence, or because they are not receiving adequate support to live their life. At present these people can be assisted to end their lives in Switzerland, or in secret at home, without any UK based safeguards. Whilst Dignity in Dying is only campaigning for assisted dying for terminally ill adults, a clear, open process for requesting an assisted death would at least ensure that requests made by vulnerable people could be properly addressed and any support needs met. Positive benefits of assisted dying and experience overseas Introducing assisted dying legislation gives dying people choice, which improves their quality of life, and provides greater protection to patients than the current law. In Oregon 525 people have had an assisted death since the Oregon Death With Dignity Act was enacted in 1997. But many more have benefited from having the choice - having the option brings great comfort to many people with many seeing the option as an emotional insurance, there only if needed. Legal assisted dying enables open conversations, improving doctor-patient relationships (is there another reference for this?). A seven-country study found trust in doctors was highest in the Netherlands. Evidence demonstrates that assisted dying legislation compliments palliative care, encourages wider discussions around end-of-life care, increases investment in end-of-life-care, and increases the uptake of palliative care training by health care professionals . In Oregon, for example, the quality of palliative care is considered excellent and the rate of use of assisted dying legislation has been described as very low by researchers, who suggest that the reason for this may be the high quality of care provided by Oregons hospices . Investment in palliative care has increased in Belgium and the Netherlands since legislation . Concerns surrounding assisted dying in relation to disability Several common concerns are raised in relation to the subject of disabled people and assisted dying. It is crucial to take an evidence-based approach when addressing fears about any future societal change. Although case studies of people travelling abroad to die, for example, often grab the media spotlight, we do not feel individual cases or anecdotes alone should promote, or challenge, the case for assisted dying. Here we try to address some of the arguments raised by groups such as Not Dead Yet UK and Care Not Killing, using research from the UK and other jurisdictions that have assisted dying legislation in place. The slippery slope argument - will legislation be extended to include disabled people? Dignity in Dying is committed to achieving a change in the law on assisted dying only for mentally competent adults in the terminal phase of a terminal illness. We do not support legislation that would allow assistance to die to either someone who is disabled, but not dying, or to someone who lacks mental competence. We would share the concerns of disability groups such as Radar, Scope and Not Dead Yet UK that legislation offering assistance to die to disabled people who are not dying, could present a very negative image of disability. We have consistently stated our opposition to this in public consultations that have addressed this issue. Evidence from overseas shows that assisted dying can be practiced without calls for assisted suicide or euthanasia to be legalised. In Oregon (on whose legislation our proposals are based), safeguarded assisted dying for terminally ill, mentally competent adults was voted for in 1994 and came into effect in 1997. Since then, there have been no calls to allow assisted suicide, either for people who are not terminally ill, or for people who do not have mental competency. Assisted dying legislation with the same criteria as Oregon has also been introduced in Washington State, again with no calls for the introduction of assisted suicide for non-terminally ill, or non-mentally competent adults, or for those who cannot self-administer life-ending medication. One commonly asserted misconception is that assisted dying legislation in the Netherlands was once limited to terminally ill people and has since been extended. In fact, the Termination of Life on Request and Assisted Suicide (Review Procedures) Act (2002) was drafted to cover those who make a voluntary, well-considered request for assistance to die, who face lasting and unbearable suffering, who understand their situation and the alternatives to voluntary euthanasia, and who believe that there is not another reasonable alternative for them. There has been no extension of the law in the Netherlands the law there started from a much broader position than just terminal illness. Finally, the most important protection from descent down the so called slippery slope comes from public attitudes. Several opinion polls show that support for legislation significantly drops when it is suggested that it might be extended beyond terminally ill, mentally competent adults to include disabled people who are not dying or people who lack mental capacity. The most significant and reliable of such polls is the 2007 British Social Attitudes survey which found that while 80% agreed that a person with a terminal and painful illness from which they will die should be allowed an assisted death, only 43% agreed that a person who is not in much danger of death, but becomes dependant on relatives for all their needs should be allowed assistance in dying. It therefore seems unlikely that legislation would be extended in the future with such little public support. Does assisted dying represent a shift in societys view of disabled and terminally people that some lives are not worth living? Some people fear that assisted dying represents a cultural shift whereby others will take life and death decisions on behalf of vulnerable patients based on their personal perception of the patients quality of life. In reality, assisted dying allows greater patient autonomy by giving terminally ill people freedom to exercise control over the timing and manner of their death. It is not about an objective valuation of the life of a terminally ill person. There is absolutely no evidence to suggest that societal valuations of terminally ill or disabled peoples quality of life are affected in jurisdictions where assisted dying is legal. Research tells us that when assisted dying is legalised and regulated, rates of non-voluntary euthanasia (where a third party ends the life of a patient without their consent) have fallen significantly - non-voluntary euthanasia has fallen by half in the Netherlands since legislation (from 0.8% of deaths in 1990 to 0.4% in 2005). This is strong evidence to suggest that assisted dying, far from devaluing the lives of disabled and dying people, sees a shift in the power to make major decisions about an individuals life into that persons own hands and away from health and social care professionals. Addressing this imbalance would empower patients at the end of life and ensure that, where possible, patients determine their own options. The potential threat of coercion or abuse The most comprehensive research carried out on the impact of assisted dying on vulnerable groups was conducted in 2007 and looked at the experience in the Netherlands and Oregon. Within the study, vulnerable patients included adults aged 85 or older, disabled people, people of lower socio-economic status and those with mental health problems. Researchers found that vulnerable groups had not been adversely affected by legislation, and in fact those groups were under-represented in the numbers of assisted deaths. The typical person who seeks an assisted death in Oregon tends to be aged between 55 and 84, white, has a good education, has cancer as the underlying illness and has medical insurance12. Studies from Oregon have also examined the reasons terminally ill adults seek assisted dying. Reasons for choosing an assisted death are focused on the patients wish to gain control and their poor quality of life rather than pain, being a burden or the financial implications of treatment. Loss of autonomy (97%), being less able to engage in enjoyable activities (86%) and loss of dignity (92%) are the main reasons for patients choosing an assisted death. Inadequate pain control (10.2%), burden (25%) and financial implications of the treatment (2%) are less frequently given as reasons. Where burden is mentioned, this is strongly related to patients concerns about losing autonomy. Legislation in Oregon also includes the safeguards that people who apply for assisted dying must be informed of all their options (including palliative care and pain relief), must have the capacity to make this decision, and that the request for assisted dying must be voluntary and well-informed. Issues around coercion, burden and outside influences apply in existing legal end-of-life medical practices (for example the right of a mentally competent patient to refuse life-saving medical treatment). In contrast, a safeguarded assisted dying law would provide a regulatory framework that would enable health professionals to screen for abuse and coercion. Closing remarks Dignity in Dying continues to work to design a process of assisted dying legislation that not only affords terminally ill, mentally competent adults choice and control over the final moments of life, but that also addresses concerns raised by interested parties and crucially, gives greater protection to vulnerable people than the current system of post-death investigations.  Disability Rights Commission (DRC): 2006 Equal treatment: Closing the gap The overall research findings showed health inequalities for the two studied groups of disabled people, people with learning disabilities and those with mental health issues. The research showed a higher incidence of major health problems, and a completely new finding for people being treated for schizophrenia, who were twice as likely to develop bowel cancer.  Professor the Lord McColl, speech in the House of Lords, 10 October 2005  ONeill, Onora. 2010: Autonomy and assisted suicide: we should not put too much weight on autonomy Symposium on ethics of assisted suicide, Royal Society of Medicine, London 30 June 2010  Wittgenstein, L 1921: Tractatus Logico-philosophicus 6.4311 (Eng trans: 1961: Routledge & Kegan Paul)  op cit  Quality-adjusted life years or disability-adjusted life years      Assisted suicide PAGE 2 DMSC/123 TUC debate on assisted dying  PAGE 1  Select Committee: Assisted Dying for the Terminally Ill Bill (2005) HL Paper-86, Volume 1 Report, and BMA, Medical Ethics Today: The BMAs handbook of ethics and law, 2nd Ed., BMA Publishing Group, and Macmillan, (2004); and Macmillan Cancer Relief, End of life issues position statement, (2003)  Clery E, McLean S, Phillips M (2007) Quickening death: the euthanasia debate, in Parks A, Curtice J, Thomson K, Phillips M and Johnson M (eds.) British Social Attitudes: the 23rd report perspectives on a changing society London, Sage: 35-54  Ibid  Clery E, McLean S, Phillips M (2007) Quickening death: the euthanasia debate, in Parks A, Curtice J, Thomson K, Phillips M and Johnson M (eds.) British Social Attitudes: the 23rd report perspectives on a changing society London, Sage: 35-54. Additional analysis of survey results supplied by Clery E, in correspondence with Dignity in Dying, March 2010  McAndrew S (2010) Religious faith and contemporary attitudes, in Park A, Curtice J, Thomson K, Phillips A, Clery E, Butt S (eds) British Social Attitudes: 2009-2010. The 26th Report London, Sage: 87-113  Chapple, A Ziebland, S McPherson, A Herxheimer A (2006) What people close to death say about euthanasia and assisted suicide: a qualitative study Journal of Medical Ethics 32;706-710  Seale C (2009) Hastening death in end-of-life care: A survey of doctors Social Science & Medicine 69(11): 1659-66  Goodchild S (2010) Dignitas promises pleasant final stay at its suicide hotel, Evening Standard  Seale C (2009) End-of-life decisions in the UK involving medical practitioners Palliative Medicine 23: 198-204  R (on the application of Purdy) v DPP, [2008] EWHC 2565; [2009] EWCA Civ 92; [2009] UKHL 44  Crown Prosecution Service (2010) Policy for Prosecutors in respect of Cases of Encouraging or Assisting Suicide  Summary of Oregons Death with Dignity Act 1999-2010 (2011) Oregon Department of Human Services  Norwooda F, Kimsma G. Battin M (2009) Vulnerability and the slippery slope at the end-of-life: a qualitative study of euthanasia, general practice and home death in The Netherlands Family Practice 14: 1-9  Kmietovicz Z (2002) R.E.S.P.E.C.T. - why doctors are still getting enough of it British Medical Journal 324 (7328): 11-14  Brinkman A (2009) NPTN: palliative care comes under the spotlight in the Netherlands European Journal of Palliative Care 16(3): 151-153  van Beek K, Menten J (2010) The Organisation of Palliative Care in Belgium 117-136 & Woitha K, Engels Y, Hasselaar J, Vissers K (2010) The Organisation of Palliative care in the Netherlands 181-195, both in Ahmedzai S, Gomez-Batiste X, Engels Y et al (eds.) (2010) Assessing Organisations to Improve Palliative Care in Europe (2010) Vantilt Publishers, Netherlands  Ganzini L et al (2002) Experiences of Oregon nurses and social workers who requested assistance with suicide New England Journal of Medicine 347(8): 582-8  Centeno et al (2007) Facts and indicators on palliative care development in 52 countries of the WHO European region: results of an EAPC task force Palliative Medicine 21: 463-471  Lien Foundation (2010) The Quality of death: Ranking end-of-life care across the world. A report from the Economist Intelligence Unit Economist Intelligence Unit  HYPERLINK "http://www.dignityindying.org.uk/includes/spaw2/uploads/files/Dignity%20in%20Dying%20response%20to%20Scotland%20Bill.pdf" http://www.dignityindying.org.uk/includes/spaw2/uploads/files/Dignity%20in%20Dying%20response%20to%20Scotland%20Bill.pdf  Clery E, McLean S, Phillips M (2007) Quickening death: the euthanasia debate, in Parks A, Curtice J, Thomson K, Phillips M and Johnson M (eds.) British Social Attitudes: The 23rd Report perspectives on a changing society London, Sage: 35-54  Van der Heide et al (2007) End-of-life practices in the Netherlands under the Euthanasia Act New England Journal of Medicine 356(19): 1957-1965  Battin MP, van der Heide A, Ganzini L, van der Wal G and Onwuteaka Philipsen BD (2007) Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in vulnerable groups Journal of Medical Ethics 33: 591-97  2010 Summary of Oregons Death with Dignity Act (2011)  Oregon Death with Dignity Act, 1997  HYPERLINK "http://www.oregon.gov/DHS/ph/pas/ors.shtml" http://www.oregon.gov/DHS/ph/pas/ors.shtml briefing !"=>jklmw x z +   )   " E ûٷ٬zlhYph &5>*OJQJhi#bCJaJh &h1U$CJaJh &hi#b6CJaJh &CJaJh &h &CJaJh &hi#bCJaJhi#bjh1U$Uhh1U$CJaJhhi#bCJaJh1U$jh1U$UhmHnHu%jh1U$CJUhmHnHsH u'">k+       ! 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