Examination of Witnesses (Questions 28
- 39)
TUESDAY 14 SEPTEMBER 2004
PROFESSOR JONATHAN
GLOVER, PROFESSOR
IRENE HIGGINSON
and MS PENNEY
LEWIS
Q28 Chairman: Good afternoon, we
would like to extend a welcome to our witnesses for today. Professor
Glover, you will be in charge of the distribution as it were,
and we have about an hour and a half to devote to the hearing
of the evidence you would like to put before us. The evidence
is taken down and you will get an opportunity of considering whether
any typographical corrections and so on are required. We would
invite you to arrange for a short statement, either from one or
from each of you, as you see fit, and then the Committee would
wish to ask you some questions. It is possible that during the
time we are hearing evidence there may be a call for a division
in the House; in which case you will understand if we suspend
the sitting for a time sufficiently long to enable to members
who wish to do so to vote and to return. Would you like to make
your introductions?
Professor Glover: Thank you. I am Jonathan Glover,
I teach ethics at the Centre of Medical Law and Ethics at King's
College. My background is in philosophy, in particular moral philosophy.
This is Irene Higginson, who is a physician who specialises in
epidemiology and especially palliative care, who has worked in
St Joseph's Hospice in Hackney and is now Professor of Palliative
Care and Policy at King's College. This is Penney Lewis, who teaches
medical law at the Centre of Medical Law and Ethics at King's
College. She has done a wide range of research in a number of
areas of medical law, but one of her particular specialities is
end-of-life issues, and she has spent some time in France looking
at the legal position there. I am going to start by saying that
the Centre of Medical Law and Ethics as such has no view. You
have heard from, no doubt, Pro-Life groups, the Voluntary Euthanasia
Society and so on; we as a Centre have no view, but that is not
to say that as individuals we do not have views, but we are not
here representing a particular viewpoint. Our aim is to try to
contribute to clarifying the underlying moral issues, but also
some of the practical issues that arise in this debate. We are
going to present in three parts: I am going to talk a bit about
some of the underlying moral questions that are at stake on both
sides of the debate, and some of the practical issues that arise
in their implementation. Irene is going to link my abstract principles
with the real world of medical practice—she is going to
be discussing such issues as what we do and do not know about
the stability of the preferences of people who maybe come within
the scope of this Bill, and she is also going to discuss something
about how widely available palliative care actually is. After
that, Penney is going to look at different jurisdictions and what
lessons we can learn from different approaches taken elsewhere
to these matters, but also she is going to raise the question
of how adequate the safeguards in the Bill are and make some comments
on that, safeguards against some of the possible abuses. I will
start, if I may, with, some of the fundamental principles. I want
to suggest that the debate on this Bill, and the debate on assisted
suicide and voluntary euthanasia generally, always seems to me
to take place at two rather different levels. At the one level
there are really quite deep clashes—the fundamental world
view, fundamental moral principles, which really people deeply
disagree about, sometimes because of differences of religion,
sometimes for other reasons. Then there are also practical debates
about how can we really know what a person wants, how can we be
sure that it is a deeply-rooted preference: Is there not a danger
of a slippery slope towards things which we would not like to
see? There are questions about whether there are dangers of family
pressures being put on people to ask for assisted dying, and what
we can do about that? I want to start by talking about some of
the underlying moral principles at a deep level of the debate.
As I understand it, the arguments for the Bill really centre around
two types of claim: one is the claim about the value of autonomy—the
value that was brought out very clearly in that play and film
Whose Life is it Anyway? Should the person in question
have autonomy over decisions about life and death? And, second,
the appeal to what one might call the humanitarian principle,
the principle that when other things are equal it is desirable
to prevent avoidable suffering if you can. The central argument
against the Bill at the level of moral principle does seem to
me to be the sanctity of life, sometimes defended on religious
grounds but also sometimes supported for quite secular reasons.
Then there is another principle that comes into the debate which,
interestingly, is appealed to by both sides, and that is respect
for the individual, respect for the individual's dignity. I will
not say much about that, I will simply say here, as an aside,
that I think it is fairly clear that there are two rather different
perceptions of dignity which are in play in the debate. On the
one hand, there are the people who use dignity as an argument
for the Bill and have in mind the indignities of incontinence
and other forms of loss of control, and say that it is desirable
that, if people want to be spared those indignities, they should
be so spared. On the other hand, the principle of people's dignity
is also sometimes invoked on the other side, where people say
that you cannot have the proper amount of respect for human dignity
unless you have absolute respect for the principle of the sanctity
of the individual human person's life. I am going to talk a little
bit about autonomy and a little bit about the humanitarian principle,
and then talk a bit about the principle of the sanctity of life.
The argument from autonomy in favour of passing this Bill, or
one like it, is really a concern related to the fact that in the
1961 Suicide Act we removed the legal prohibition against committing
suicide. That was done for a number of reasons, but one of them
was the idea that, whether we think suicide is morally somebody's
right or whether we think it is morally unacceptable, people ought
to be able to decide that sort of thing for themselves. Supporters
of the Bill very often appeal to the idea that the Bill is an
extension of that, giving people the right to decide for themselves
about their own death, and as an extension of that to people who
are not able in practice to kill themselves. This raises a number
of issues. One is that there is a question of what respect for
someone's autonomy requires. People who favour the Bill say that
it requires assisted suicide if the person requests it and is
not able to carry out suicide himself or herself. But other people
say that respecting someone's autonomy does not necessarily have
to involve providing positive help. For instance, I may respect
other people's religious autonomy, and that simply means that
I do not obstruct them, I do not harass them, I do not try and
interfere or prevent them practising their freedom of worship;
I am not obliged to build churches, mosques or synagogues in order
to respect their autonomy. So there is a difference between respecting
autonomy requiring not interfering with what someone does and
providing positive assistance. That is one part of the debate.
There is also an absolutely key practical issue about interpreting
autonomy, and that is that there is obviously a question about
the genuineness of the request. This raises a number of issues:
one is how do we decide whether or not a person is making a competent
decision—something Penney will talk a bit about later; another
is whether there is freedom from external pressures by other family
members. It is not clear at all if someone's request to die counts
as an autonomous request if they are doing so under that kind
of pressure. Then there is the issue that we all know people's
moods change enormously— people get depressed and think
quite differently about their lives from how they think at other
times. How do we know that this is a stable request, because respecting
autonomy seems to require not just acting on any whim that someone
may have at any moment, but being sure that this reflects what
they most deeply think when they are reflective. And that is something
which Irene will be talking about— how we can know about
the stability or otherwise of their desires, how we do know about
that. I now turn to the second principle used in favour of the
Bill, the humanitarian principle that we should prevent avoidable
suffering where we are able to do so. I have a couple of points
to make about this. One is that suffering, of course, does not
have to be just physical pain, but clearly psychological distress,
for instance of suffering indignity or not having your autonomy
respected. One issue is— are there less drastic alternatives?
We all know that there are great disputes of fact at stake here
about whether, for instance, palliative care is sufficiently adequately
available, whether it is always possible to eliminate pain. Sometimes
people on one side of the case say euthanasia is never necessary
because good medical practice will always eliminate pain. That
is a disputed claim and one which I as a philosopher have rather
little, I am afraid, to say about, but Irene is going to talk
a bit about that. As I see it, the main issue at stake here is
that the two principles I have mentioned, autonomy and respect
for autonomy and the humanitarian principle, the prevention of
avoidable suffering, may well come into conflict with the principle
of the sanctity of life, so it is to that that I now turn, the
central principle on the other side of the debate. Firstly, there
is a question of interpretation. I interpret the sanctity of human
life, as I think most people who believe in it do, as suggesting
that there is an absolute prohibition on the intentional killing
of innocent human beings. I have worded that rather carefully
because it is not just a prohibition on killing; the word "innocent"
for instance allows the possibility of defending the killing of
people in a just war, because people who are part of a threat
in a war no longer count as innocent. They may be morally innocent,
it may not be their fault they are fighting on the wrong side,
but innocent is used in a slightly technical sense here. Then,
again, intentional killing is the thrust if we are allowing someone
to die, and the cases which come under the moral theology principle
known as the "doctrine of double effect" being those
cases where death can be the foreseen but unintended outcome of,
for instance, stepping up doses of medicine intended to relieve
pain. Some issues about the sanctity of life principle. One issue
is that the phrase "sanctity of life" suggests a religious
prohibition and one criticism has been that it is hard to see
how something which is purely a religious prohibition could be
an adequate justification for law in a pluralist society, where
people have many different religions and some have none. I do
not believe that only religious people support the doctrine of
sanctity of life: I think there is a secular version too. Another
set of criticisms are of the moral relevance of the distinction
between killing and letting die and of the distinction between
unintended and foreseen consequences. The second one is sometimes
described by its opponents as a distinction without a difference.
I would just mention some of the risks and dangers, and in doing
so, of course, one has to compare risks and dangers on both sides.
There may be risks and dangers in passing the Bill, there may
also be risks and dangers in the status quo. I will start with
the risks and dangers of the status quo and then go on to the
risks and dangers of allowing assisted dying. One of the risks
and dangers of the status quo is that the law may get out of touch
with public opinion. When there is a particularly distressing
case which might reinforce it, there may be a wave of sympathy
for the person and a widespread sense of indignation that the
law does not allow the person to exercise his or her desire to
die. Then, again, there is a danger that doctors may secretly
be assisting suicide behind the scenes, without it being legalised,
and there may be all sorts of dangers in that; danger and risks
to the people concerned because there may not be adequate safeguards,
and there may also be the risk of bringing the law into dispute;
I cannot also think that it is necessarily in the interests of
the medical profession to have to act furtively in that sort of
manner. Then, again, there may be people who go abroad—a
recent case comes to mind—for assisted suicide, not available
here. One wonders whether that could really be a rational defence
of the state of affairs. I think the biggest risk of danger, looking
at it on the side of the status quo, is that people in favour
of the Bill say that it is more than a risk, it is an actuality—
that people have their autonomy overridden and sometimes die in
indignity and distress which could have been avoided if the Bill
had been passed. On the other hand, the risks and dangers of allowing
assisted dying. One question is—are there adequate conscience
safeguards to prevent the medical profession from being pressured
into acting against their conscience? And are there adequate safeguards
to prevent requests resulting from family pressure? I have to
say that in my reading of the Bill I got the impression that the
Bill was rather stronger on protecting the medical profession
from doctors having to act against their conscience than it was
on the family thing. But I am not the expert on that: the other
two speakers on my either side you should listen to rather than
me about that. Another issue is the slippery slope argument. Any
debate on euthanasia has to be a little bit at least in the shadow
of the terrible fact that the Nazis murdered 70,000 psychiatric
patients in the name of what they called euthanasia. But, of course,
what they were practising was not voluntary euthanasia: they were
not motivated by compassion for the individual people concerned,
they were not motivated by a desire to respect the autonomy of
individual people, they were trying to tidy up the gene pool in
a way that most of us would find revolting. There is the question,
if we allow this Bill— is there a slippery slope that might
lead us in that direction? My belief is that it is very difficult
to evaluate slippery-slope arguments. We all know that there are
some slippery slopes that, as individuals, we do fall down and
others we do not— it is possible to have a glass of wine
without going all the way down the slope to being an alcoholic.
It seems to be a very difficult empirical question where one needs
evidence before one too readily says either there is or is not
a serious danger of going down a slippery slope. I think I have
talked too long; I will stop there and hand over to Irene.
Professor Higginson: Good afternoon. My evidence
takes a somewhat different tack in that I am looking at some of
the evidence in terms of research and in terms of what we know
in two fields, really: the first is understanding the trajectory
of desire for death or wish for euthanasia or, conversely, the
will to live; the second area of evidence I want to look at is
that of access to palliative care services. Our understanding
of what people want towards the end of life, or the wishes of
those who are suffering a terminal illness, from reasonable research
studies or from any kind of systematic selection of data is extremely
poor indeed in most countries, and it seems that it would be important
to recognise that the views of people who are actually at the
end of life may be different to the views of people at earlier
stages of their illness. We know from the Disability debate that
it is not possible to project views; so I, as a healthy , now
might say what I want when I reach a terminal illness, but by
the time I reach a terminal illness my view may actually be quite
different. That change in perception— which is known as
a Response Shift, when people recalibrate and reframe what is
important to them— is not well understood, but it seems
to me that we should be looking where we can at the evidence from
people who are actually reaching the end of life in trying to
make those decisions. In Canada Chochinov and a group of colleagues
have done some work interviewing people with advanced illness
about their will to live and also about desire for death and euthanasia.
In particular, in one study, by Tarbalan and Chochinov, they interviewed
168 patients with cancer who were admitted to a terminal care
unit, and they asked about will to live measured using a simple
self-report scale, which they measured every day. During the period
of time in the palliative care unit in Canada, just over half
the patients, that is 58 per cent, displayed a high will to live
over the time of care, including during their illness progression.
A further 11 per cent sustained a fairly unchanged moderate will
to live. However, for just over a quarter of people (28 per cent)
the will to live fluctuated over time, it was not stable, and
it increased for some and reduced for others. A minority of patients
(around 3 per cent) sustained fairly constantly a low will to
live. While it is not clear from this study to what extent a moderate
or low will to live translated into a wish for assisted dying
under the terms of this Bill, the study does certainly suggest
that a wish to die or a lack of will to live, and therefore any
request to do so, is likely to fluctuate over time in most people
who may make such a request. Understanding what influences this
wish to die is also quite complicated. Studies, primarily from
the States and from some other countries, suggest that will to
live or, conversely, the move towards life-terminating measures,
is influenced by a whole host of factors. But ones that have been
highlighted in particular include depression, pain, feeling a
burden to others, loss of a sense of purpose, loss of meaning
or hope, and loss of dignity. Some of these concepts are really
quite poorly understood, although in some countries—in particular,
the work of Chochinov—people are trying to develop interventions
to improve, for example, a feeling of hope or ways to improve
feelings of dignity. Similarly, the concept referred to in this
Bill as "unbearable suffering" has not yet been clearly
defined in the literature. It is not something that is easy to
measure and it is really open to quite wide and varied interpretation.
It too, like will to live, may be prone to fluctuations over time.
However, the studies that I have quoted you are small in number.
The Chochinov work is from a single unit in Winnipeg in Canada
which includes fairly highly selected people who were entering
the palliative care service at the time of the study and therefore
were fully aware of their diagnosis and may also have been well
aware of their prognosis and so would be a selected group of people.
We do not know what would be found if a study of this kind were
replicated in this country. Indeed, research in the UK into ways
to understand patients' wishes about, or to find ways to improve,
care at the end of life has been relatively neglected. Analysis
by the National Cancer Research Institute, which has recently
been established in this country, shows that in the UK, of all
the research money spent on cancer research by the main research
organisations—which would include Cancer Research UK, Macmillan
Cancer Relief, Marie Curie Cancer Care, the Medical Research Council,
the Department of Health and a number of other smaller charities—0.18
per cent of it was spent on end-of-life and palliative care issues.
So a very significant minority of work that goes on in research
in the medical field is not directed towards the field of palliative
care. One of the issues is that this dearth of knowledge and the
absence of support for research into understanding what people
want towards the end of life, how this changes and ways to improve
care, need to be addressed. The second area I wanted to highlight
is the variation in access to care. There is a fairly wide variation
in the UK in the dissemination and availability of and access
to palliative care services. There are certain under-privileged
communities which have lower access to palliative care services,
and in particular these include those who are living in rural
areas, those from ethnic minorities and those in the older age
group, who all have a lower chance of receiving expert palliative
care and pain relief. Work that we have done in the south London
area has shown a mixed experience in advanced cancer, for example,
among the local black Caribbean community; and reports from family
and friends of people from the black Caribbean community revealed
quite a mixed experience, but fairly significant unmet need, with
poorer access to specialist palliative care services, a trend
towards a greater number of unmet needs and also reports of less
satisfactory care across a range of different measures when their
reports were compared to a local white UK-born population. The
second point to consider is that much of the palliative care available,
particularly that in in-patient hospices, is concentrated on patients
who have cancer. Although a few patients with Motor Neurone Disease
and far-advanced AIDS have received hospice care, in general few
patients with non-malignant conditions receive in-patient hospice
and in some instances home palliative care. For example, analysis
in the UK has shown that less than 5 per cent of new referrals
to many in-patient and community palliative care services have
conditions other than cancer. It is slightly different for some
hospital palliative care services, but then that only addresses
care whilst patients are in hospital. I have provided to the Clerk
to the Committee some figures which demonstrate the disparity
in services and systems experienced within the London region.
Ms Lewis: Good afternoon. Given the time, I
am just going to briefly outline some areas in which the experience
of other jurisdictions which have already legalised either euthanasia
and assisted suicide or assisted dying might be of assistance,
and then I think I will leave it to members of the Committee to
pick me up on those areas later. There are two ways in which we
derive assistance from the experience of other jurisdictions.
The jurisdictions that I am most familiar with are The Netherlands—which,
I am sure you will know, has recently codified the existing legal
situation, so there has not been a really dramatic change in the
law as a result of their legislation (there were many years of
case law and prosecutorial practices which had effectively legalised
euthanasia for some time); Belgium, which I think can be contrasted
with The Netherlands because they have recently legalised euthanasia
without having any kind of experience of effective legalisation
through judicial decisions; and finally Oregon, which has an even
more unusual experience, I suppose, in the sense that they legalised
assisted suicide through a referendum seven years ago. There are
two ways in which we can use this experience. One is to look at
ways in which euthanasia and assisted suicide are regulated in
those jurisdictions and how those regulatory frameworks develop,
and then we can maybe look at the regulatory framework proposed
in the Bill and see if we can learn anything from other such frameworks
and how they developed. The second way is to look at the evidence
that exists in those jurisdictions, and possibly other jurisdictions,
about the effectiveness of the regulation that is in place, in
particular in The Netherlands (because they have the most data,
but there is also quite a lot of data from Oregon as well), in
terms of how effective their regulation has been and who, for
example, is using the provisions of their statute. There are four
aspects which might warrant the scrutiny of this Committee. The
first is the kind of criteria that one might choose for accessing
assistance with dying. Generally one thinks of criteria—and
these are the criteria that appear in the Bill—relating
to suffering and to possibly some kind of terminal disease. Interestingly,
we might compare the position in Oregon and the position in the
Bill—which both require there to be a terminal disease—with
the situation in The Netherlands and Belgium, neither of which
require there to be a terminal disease. So these criteria are
not necessarily the only ones one might contemplate. The second
aspect relates to regulation of the request for assistance, so
issues around the competence of the patient, the voluntariness
of the request, what kind of information is being provided to
the patient before the request is acted upon, etc. The third aspect
is one which Jonathan already referred to, which is in relation
to the safeguards that might be put in place. I think in particular
what I would really like to highlight—and I am happy to
talk about this later—is something which is very important
when considering The Netherland's experience, which is the nature
of the physician/patient relationship. I think there is a danger
in thinking about The Netherlands without realising that the nature
of the physician/patient relationship in The Netherlands is very
different, for example, from that in Oregon. Most acts of euthanasia
in The Netherlands are carried out by general practitioners who
have known their patients for many, many years, and the reason
why this is significant is because issues like competence and
voluntariness are very difficult to assess on the basis of one
meeting. If there is an existing and long-standing relationship
between the patient and the doctor, I think that that does change
the dynamic of evaluating whether or not this is a competent and/or
voluntary request. If you look at the data from Oregon you will
see that often there is a very, very short-term relationship between
physician and patient. Other safeguards which I think are worth
considering and maybe learning from how other jurisdictions have
regulated them are: consultation with another physician, psychiatric
consultation and psychiatric referral and when that should take
place—should it be mandatory in all cases? Or should it
just be triggered in certain cases? And, if so, what should be
the triggering circumstances? Also what should the psychiatric
referral be doing? What should it be looking for? Is it a competence
assessment or is it looking for something more? Is it trying to
diagnosis depression etc? What role should the next of kin have?
The Bill adopts the Oregon model of saying that the doctor should
recommend to the patient that the next of kin be told. The Netherlands
and Belgium have adopted a model where the doctor is obliged,
if the patient wants, to discuss with the next of kin the situation.
Also, what role should the nursing staff have and also other healthcare
professionals who may be involved, particularly in terms of multidisciplinary
palliative care teams? The final safeguard that, I think, is worth
looking at is that of a waiting period: how long should it be?
What are the advantages and disadvantages of having a longer waiting
period or a shorter waiting period? Or, indeed, as in The Netherlands,
no waiting period at all? Finally, and this goes back to something
Jonathan alluded to as well, what does the evidence from other
jurisdictions tell us about how malleable these criteria are and
how effective these kind of safeguards are? In particular, I think
it is worth looking at the debate around the evidence which relates
to the slippery slope. How is the evidence in The Netherlands
interpreted? How does it compare with evidence from other jurisdictions,
both jurisdictions which have legalised euthanasia and jurisdictions
which have not? What kind of comparisons can we make? What kind
of evidence is there of a causal link between evidence of non-voluntary
euthanasia and legalisation, for example? Those are the four aspects
which I think might warrant scrutiny, and I am happy to deal with
them.
Chairman: Thank you very much. It is
now open to members of the Committee. Lord Turnberg, would you
begin?
Q29 Lord Turnberg: Thank you very
much, I found that extremely valuable and helpful. I was very
interested in Professor Higginson's report of the Canadian study
of patients who were in this end-of-life state who were suffering
from cancer, the vast majority of whom were not particularly interested
in assisted suicide, but there were some who might have been if
that had been on offer. It is important to have the views of patients
who are likely to be in this position, and you pointed to large
groups of individuals. But in Oregon and in The Netherlands they
have had a lot of experience. Have there been any studies of this
type?
Professor Higginson: Not that I am aware of.
I have looked in Oregon and The Netherlands and we do see evidence
of people who take up the request, obviously, for euthanasia and
then do or do not use it, but how that relates to whether people
have thought about it or the will to live or depression or changes
in views over time, I am not aware of studies that have looked
at that.
Q30 Lord Patel: Can I pursue that
study a bit further? I accept what you say about it being a small
study of 168, but did I understand you correctly to say that,
of those 168, 3 per cent had shown a consistent will not to live?
Professor Higginson: Yes, that is correct. Of
that group, which was a group of people entering the hospice,
3 per cent had a consistent view, which really did not fluctuate
very much, of a will not to live. As I said, that was reported
as a low will to live on the scale that they used, but that is
as much as you can take from that. You do not know whether that
would have translated or not into a wish for euthanasia, but that
group reported a low will to live.
Q31 Lord Patel: Then there were 25
per cent?
Professor Higginson: 28 per cent of people fluctuated;
some increased and became more interested in living and some people
reduced and some people moved back and to.
Q32 Lord Patel: Was there further
stratification or further information on these two groups as to
whether they were different kinds of patients in any way?
Professor Higginson: If you read the papers,
they did attempt to look at factors which made people more or
less likely to change their mind, in the fluctuating group in
particular. And factors which Chochinov developed from that that
seemed to make people change their mind or fluctuate were related
to elements such as depression, feeling a burden or not to others,
feeling that their life was uninteresting or hopeless or not and,
to some extent, pain, although pain was not a huge feature in
his study. When Chochinov has talked informally about his work
in presentations and so on, which is not written in papers and
is hypothesised, is whether some of the issues in the small percentage
who remained unchanged are not so much related to external views
but issues of a wish to feel in control. He has put forward that
hypothesis, but it is only a hypothesis and it was not measured
as far as I can see.
Q33 Lord Patel: It was not that with
these patients the palliative care, the symptom relief care, was
failing?
Professor Higginson: It is difficult to judge
from the data he has presented. There certainly was some fluctuation
in relation to depression and in relation to feeling a burden
on others. He did not have a measure of failing, so I am not sure
whether your question could be answered.
Q34 Lord Patel: I pursue this, because
one of the things that comes out in several of the submissions
of evidence that we have had is the need to have good quality
palliative care and that, if we had, then the number of people
seeking such recourse to voluntary euthanasia would diminish.
Professor Higginson: There is evidence of that
from the Oregon experience, and the experience in Oregon of the
legalised position of assisted suicide shows that nearly half
the people requesting it changed their mind after substantive
palliative care interventions had been provided. That you can
see in papers from the Oregon experience.
Q35 Lord Patel: Half did not change
their mind?
Professor Higginson: Half did and half did not,
so there is some change, yes. There is evidence in other literature
that there is some change.
Q36 Lord Joffe: You mentioned this
research in Canada and you, of , are familiar with the research
in Oregon and, presumably, with Professor Ganzini's , which suggests
that people who continue with the wish for assistance to die tend
to be powerful people, people who are used to controlling their
lives, and once they make up their mind they continue with that
course; and they are different perhaps from the rest of the population
who express a mild wish to die but they do not actually carry
on with the request.
Professor Higginson: There is not really comparable
work of that kind in this country, and the study you are quoting
is not one I have before me. But it would be consistent with the
findings from the Chochinov work. Studies of that kind are not
available in this country, are they?
Q37 Lord Joffe: You mean in relation
to this population?
Professor Higginson: Yes.
Q38 Lord Joffe: In all the authorities
and all the papers I have seen on both sides there is extensive
reference to what happens in other parts of the world, in Oregon
and in The Netherlands, and presumably that is so because it is
thought to be relevant to what will be the likely position over
here, although obviously there can be differences of culture.
Would you agree with that?
Professor Higginson: I never like to agree with
a really long sentence.
Q39 Lord Joffe: I will pose it more
simply. Would you agree that the evidence of what happens with
assisted dying in Oregon and The Netherlands is relevant to this
Bill?
Professor Higginson: I think evidence anywhere
across the world is relevant to this Bill, and I point to the
fact that there is a lack of evidence in many countries. Translating
from the United States to the UK brings with it some challenges:
the organisation of healthcare is different, the population in
Oregon is different from the UK population in terms of its educational
level, its knowledge and so on, from what I understand. So there
are issues and dangers always when you extrapolate from one healthcare
system or one country to another, which was exactly the reason
why I placed some caution on quoting from the Chochinov study,
and I would place the same caution on quoting the work of Oregon
and The Netherlands or wherever.
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