The shape of the Nathaniel Centre 's submission (below) was defined by the questions the Ministry formulated.

Access to assisted dying

Do you think changes are needed to the eligibility requirements for a person to receive assisted dying?

i. An assisted death must remain a voluntary choice.

There are those who seek to broaden the parameters of eligibility to include persons who will not be competent at the time of administration, for example those with dementia. This would represent a major shift and a challenge to public perceptions of the safety provisions of the current Act.

ii. We do not wish to see removal of the current requirement that death must be within six months.

Removing this requirement so that, for example, only ‘grievous and irremediable suffering' was required, would lead to a significant expansion in the numbers eligible for assisted death, as has happened in other jurisdictions.

While there are ‘hard cases' currently not eligible, doing away with this requirement would put at risk much larger numbers of sick, disabled, and dying people whose lives may be seen as ‘not worth living' or, even more worryingly, who may come to see themselves as a burden to family and society. This is particularly risky in the current ‘ableist' environment that defines our society.

Safeguards

Do you think the Act provides sufficient safeguards to ensure that people only receive assisted dying if they are eligible, actively seek and consent to it, are competent to consent and provide their consent free from pressure from others?

i. We are concerned that no more than one percent of all applications for an assisted death are referred for a psychological or psychiatric assessment. An independent assessment by a suitably qualified person should be a requirement for every person who applies for an assisted death.

ii. There is currently no requirement for a ‘cooling off' period to ensure that the decision for an assisted death is not hasty or impulsive. Overseas jurisdictions do allow for this, e.g. 15 days in Oregon, 9 in Victoria, or 10 in Canada.

iii. There is currently no requirement in the Act for the person's competence to be assessed at the time of the administration of medication.

iv. There is currently no requirement for medical practitioners to undertake a formal assessment for coercion. (Refers to Clause 11 of the Act). Coercion can be informal, subtle, and difficult to detect.

Those requesting euthanasia/assisted death may be frail, powerless and vulnerable.

There needs to be a system of formal assessment of the possibility that the person seeking the end of life may be responding to pressures from family, or to notions about the ‘burden' they may think they place on others by continuing to live.

v. There is no requirement for independent witnesses to be present at any stage of the process. Other jurisdictions include the need for independent witnesses to be present when the request is made (Victoria), and at the signing or the written request (Oregon, Victoria and Canada).

Process to receive assisted dying

Do you think any changes are needed to the process to apply for and receive assisted dying?

The Act does not require applicants to be screened for depression or other mental health issues. The opinion of a psychiatrist is required only if the attending or independent medical practitioners consider the applicant is not eligible.

Depression and mental health issues can be difficult to recognise and diagnose, something that is well understood in the justice system when a psychiatric examination may be demanded.

Practitioners providing assisted dying

Do you think changes should be made to the requirements for medical practitioners and nurse practitioners to provide parts of the assisted dying process?

i. Doctors must not be able to suggest the option of assisted death to their patients.

At a time of significant personal upheaval, fear, and vulnerability, for a doctor to raise the ‘option' of assisted dying creates a risk that it will be interpreted by their patient as a ‘suggestion' that it is the most desirable way forward - ‘Why else would the doctor talk about it?'

ii. the right to conscientious objection for Health Practitioners must not be weakened.

Under the current Act, an attending medical practitioner who has a conscientious objection must tell the patient and inform them that they have the ‘right to ask the SCENZ Group for the name and contact details of a replacement medical practitioner'. There should be no change to this requirement.

iii. Some practitioners may not object in principle to assisted dying but may be concerned that the Act is unworkable (e.g. when it says they must give a definite prognosis or try to ensure the patient's request is not affected by pressure from others) and therefore may want to exercise their conscience
right to opt out of involvement in assisted dying on professional grounds.

Any expansion of the current eligibility criteria may also create new conscience issues for doctors who don't currently object.

iv. The current ability for Institutions to exercise conscience must be protected.

While the EOLC Act is silent on institutions, it has been ruled ‘that organisations like hospice services, aged care facilities, or GP practices can object to assisted dying, as set out in the End of Life Choice Act, taking place on their premises or with the assistance of their staff', under the right to freedom of conscience under the New Zealand Bill of Rights Act 1990.

Access to assisted death has been described as ‘working well'; there is no need to force institutions such as hospices or hospitals or rest homes to provide assisted death on their premises; such a change could bring about a significant impact on the atmosphere of these places and on the ability of the staff there to work in ways that support their approach to healthcare.

Oversight of assisted dying

Do you think changes are required to the roles and responsibilities of the entities established under the Act to oversee assisted dying?

i. Reporting and data are inadequate in New Zealand. The recording and reporting required by the Act is minimal.

The Review Committee is given only very basic information about things like the place, date and time of death, the method used (e.g. ingestion or injection), and any problems that occurred in the administration of the medication and how they were dealt with.

Other jurisdictions, for example, the Netherlands and Oregon, collect much more detailed data.

Oregon records and reports patients' reasons for requesting assisted suicide, the time between ingestion of the medication and death, the types of complications observed and their frequency, and the length of the relationship between the patient and the doctor who prescribed the medication.

ii. To fully understand the application of the EOLC in New Zealand, to ensure it is applied correctly, and, in particular, to ensure that all the appropriate restrictions are observed, it is essential that more extensive data, such as that collected in Oregon and other jurisdictions, is collected and made publicly available.

In particular, there must be detailed reporting on the reasons people are applying for an assisted death.

iii. We also have serious concerns about the robust operation of the Review Committee, including long periods with key vacancies and insufficient data to be able to review the safe operating of the Act.

Alignment with the wider health system

Do you think the assisted dying process aligns with other parts of the health system?

Providing an assisted death is not part of healthcare. It is, in fact, the antithesis of ‘healthcare' since it means the end of healthcare.

It is not a medical procedure, and doctors should play no role in its practice. If we wish to continue to provide assisted dying as a legally permissible activity, it should be set up outside of medicine.

Many Medical Associations around the world hold that physician assisted suicide and euthanasia are unethical, even if they are made legal.

Is there anything that could be improved?

While, as argued above, assisted dying is distinguishable from the provision of healthcare (and should not be described as an act of medical care), its safe operation within Aotearoa must be evaluated from a systems perspective - it does not operate in isolation from, or without being influenced by, the broader healthcare environment that currently exists. This means:

i. The Aotearoa New Zealand health and care systems are widely described as ‘in crisis' at present.

Expanding access to assisted death to those who may suffer from dementia, disability, or who have difficult or long-term health care needs, in the current crisis situation, is unsafe.

This represents a strong reason NOT to broaden eligibility.

ii. Palliative Care needs to be properly funded. An assisted death is fully funded while quality palliative is neither fully funded nor equitably available throughout Aotearoa New Zealand.

True autonomy requires the ability to have a choice among options.

Currently many people in this country are unable to access quality palliative care.

It is of deep concern that the June 2024 Annual Report from the Registrar shows one in four applicants (22.4 percent) for assisted dying were not receiving palliative care, without detailing why this is the case. There needs to be more transparency around what lies behind this disturbing statistic.

Other feedback

Do you have any other feedback related to the Act?

Use of honest, clear language: We note the frequent use of the term "assisted death" in the Review document - a total of 38 times.

This is a more honest reflection of what takes place than the legal term employed in the Act - "assisted dying".

We regard the term assisted dying as (i) a euphemism and (ii) as confusing the intentional premature death of people with what all good health-carers, especially palliative care staff, have done for centuries and continue to do - looking after people and assisting them to have a pain-free dignified death without intentionally hastening their death.

• The Nathaniel Centre - the New Zealand Catholic Bioethics Centre - is an agency of the New Zealand Catholic Bishops' Conference. It seeks to bring the light of the Gospel and the moral tradition of the Catholic Church to issues in bioethics.

His comments come as the Ministry of Health is conducting a mandated review of the End of Life Choice Act within three years of its implementation to assess its effectiveness and determine whether amendments are needed.

The current review will be finished by November.

Kleinsman was speaking on 1 News.

Changes needed

Kleinsman say the current legislation needs changing as it lacks:

• a formal assessment for coercion
• a requirement for an independent witness during the assessment phase
• adequate screening for depression and other mental health issues
• no cooling-off period after a request is made

He recognises that the case for assisted death is motivated by a desire to show mercy to those suffering.

While individual cases may appear justified without immediate harm, concerns arise about the cumulative impact of cases and shifting public perceptions, he says.

Kleinsman warns that the growth of habits and attitudes of mind gradually reshapes public perceptions of what is happening and what assisted dying means.

He points to several international examples that cause concern.

Countries like the Netherlands, Belgium, Luxembourg and Spain now permit assisted dying for mental illness, with several other countries also allowing it for minors, infants and individuals with dementia.

Then, in a related development, a 2023 Canadian poll revealed that 28 percent of respondents supported assisted dying for individuals experiencing homelessness, while 27 percent were in favour of those living in poverty.

The findings have fuelled further controversy as stories emerge in Canada of patients opting for assisted dying due to inadequate social support and healthcare rather than an autonomous choice driven by their medical condition.

"This shows us a glimpse into our own future if we loosen our eligibility criteria - the price could involve "severe unintended consequences" Kleinsman said.

He adds that we must continue to protect the integrity of palliative care and have AD-free spaces. Many people want this, and it's essential for upholding real choice.

He says that to replace the requirement for a terminally ill patient's life expectancy to be under six months with a clause like "grievous and irremediable suffering" would be wrong.

Forbidding doctors to raise the option of assisted dying with a patient must not change, he says.

Pro assisted dying changes

Social Justice NZ CEO Jackie Foster says she voted "no" at the referendum but has changed her mind.

Foster said, after losing her mother to cancer and having a close friend aged 51 die from a degenerative disease, it is often difficult for doctors to determine if people will die within six months, so she wants the removal of that time restriction.

She wants two changes to the legislation -

• the removal of the words "within 6 months" from section 5(1)(c)
• inserting a new sub-section 5(1)(g) into the Act that says "suffers from a degenerative disease that will ultimately end their life"

Foster believes that the first three years of this legislation have brought the country closer on the issue.

In 2020, 65 percent of voters said "yes" to the legislation but she believes that number would be higher today.

Source

• 1News

Ministry of Health officials have highlighted "complex and sensitive elements" to the End of Life Choice Act and incoming assisted dying regime in a briefing paper to Health Minister Andrew Little.

The paper had been given to Director-General of Health Dr Ashley Bloomfield in January, highlighting numerous unresolved questions and risks surrounding assisted dying services.

Among the "elements" include "uncertainty" over how many people will seek assisted death, terminally ill patients having to travel for services when the law comes into effect, competing pressures in the health system, and a possible need to rewrite parts of the law to resolve "legislative issues".

A statutory body, Support and Consultation for End of Life in New Zealand (SCENZ), will include up of 11 medical experts who will manage the incoming assisted dying regime.

SCENZ will develop and oversee the standards for terminally ill patients should receive when they seek an assisted death.

Although the ministry says work to implement the new Act is "well underway", legal action over assisted dying services is considered "almost certain", due to the "strong views from sections of the public in favour and against assisted dying".

Dr John Kleinsman, the director of The Nathaniel Centre for Bioethics sees "a tragic irony in the fact that the Ministry of Health is able to put so many resources into enabling assisted death, and fully funding it in our country, when palliative care is not equitably available and also not fully funded.

"Advocates of the law change campaigned for change on the basis of choice, but for too many people they won't have the choice to access quality end of life care.

"I am not surprised by the prospect of further legal action. On the one hand, the Act is a terribly weak piece of legislation and I and many others, including lawyers and health practitioners, pointed out its many problems when the Bill was being considered.

"Too many MP's chose not to listen."

"Many proponents of the new law made it abundantly clear at the time it was passed that they thought it too restrictive! So they will be pushing hard for the law to be expanded. It is what has happened in every other jurisdiction and it will happen here."

Although Little has been approached by media about the Act in recent weeks. he has not been available.

The three "key risk factors" health officials identified in the briefing paper given to Little and Bloomfield are that: parts of the health sector are refusing to be involved in assisted dying; competing resources and pressures in the health system; and inadequate or insufficient engagement with "stakeholders" within the short timeframe to enact the law.

A "key question" is whether assisted dying should be fully government funded, or a "mixed-model". How a mixed-model could work was not detailed.

The legislation, which was a members' bill, may need to be rewritten "to ensure that the Act functions as intended", the paper said.

Source

• Stuff
• Supplied: The Nathanial Centre for Bioethics
• Image: Stuff