Select Committee on Assisted Dying for the Terminally Ill Bill Minutes of Evidence

Examination of Witnesses (Questions 2420 - 2439)



  Q2420  Baroness Hayman: Have there been very difficult cases with tetraplegics or people with advanced ALS where you have not been able to help them despite their express wish because they did not have the physical capacity to take the last act?

Dr Zucco: In my experience I never had any case like that. I cannot speak for other people. I never heard that we had such a case, maybe because we try to clarify the whole process from the very beginning.

  Q2421  Chairman: So the prosecutor is quite happy with a large degree of assistance, if I can put it that way, in terms of getting the infusion ready and everything else, as long as there is a discernible last act that is the patient's?

Dr Zucco: There was some concern some time ago concerning this infusion and the reason was that the prosecutor of Zu­rich thought that an infusion required more preparation so that the patient might be impressed by these preparations and might decide that now he has to die because everything has got so far. Now it has been accepted because what we do is keep asking until the last second, "Do you really want it?". We try to make it easy for the patient to say no.

  Q2422  Chairman: If there was a big assembly of preparation required would that be thought possibly to put pressure on the patient, "Having gone this far I cannot return", as it were, so that until the very last minute when the patient's action of some kind is required, you keep telling them, "You need not do this"?

Dr Zucco: Yes.

  Q2423  Baroness Hayman: In terms of your concern with the monitoring and the keeping to the rules and the conditions, how do you verify that each of the people who works as an accompanist is abiding by these rules and how does the state do that? Is their view only retrospective, after the event, or do they have any knowledge of your procedures or checks or random checks and procedures?

Dr Zucco: We have very frequent and strong supervision where cases, especially difficult cases, are discussed and we from the team are supposed to follow certain courses for improving our capabilities and for making sure that we abide by the law. I must say that during all these years, and EXIT was founded 23 years ago, there have been very few cases where there were problems with justice, for instance. It was mainly related to a company assisting people who had psychiatric problems. This is several years back. The possibility for the authorities to verify what has happened later on is almost impossible. The only way is to have an autopsy of the corpse, but this can only establish if the barbiturate was used, not much more than that. Also, the clearness of the will cannot be established post mortem.

  Q2424  Chairman: Do you normally have a writing from the patient at the beginning if the patient is able to authenticate a document? Do you get that at the initial stage when they see your official in the first instance?

Dr Zucco: This is not required but we are very glad if we get something like this. There are patients who like to keep a sort of diary on the disease so if we get copies of this, especially if it is handwritten, we are very glad.

  Q2425  Chairman: The authentication afterwards that the law has been fulfilled depends, I suppose, on seeing what sort of equipment there was there and whether there was one of these things and then on the integrity of the relatives, if they are there, and of your representative who is there?

Dr Zucco: Right.

  Q2426  Chairman: It is normally just one person from EXIT, is it?

Dr Zucco: Yes. Dr Hotz mentioned that in special cases there would be a second person. Generally speaking the second person who is always there is not from EXIT. It is generally speaking a relative or a friend or whoever. He or she has the function of a witness.

  Q2427  Bishop of St Albans: I think I may have missed something, which is the place where all this happens. Is it usually in the patient's home? Where do most of the assisted suicides happen?

Dr Zucco: In most cases by far the patient dies at home. There are cases where the patient does not have a home any more because they are in a public institution. Zu­rich is different from the rest of Switzerland because in old people's homes in Switzerland it is possible for EXIT to become active, but for all the rest of Switzerland this is generally speaking not allowed. In these cases it is difficult because the person has no home. Actually, the old people's home is his home. If he or she wants to die with EXIT he will have to leave this home and then the only alternative is that EXIT has a room in Zu­rich and one in Berne where these people can come to die.

  Q2428  Bishop of St Albans: Can I follow up on a different subject which is about the exercise of power by those who control the barbiturate? You were saying earlier that personal autonomy is the key and yet, if I am 70 years of age and I wish to exercise personal autonomy that you think I should not, I cannot, so there appears to be a kind of exercise of power by someone other than the patient over their own autonomy. Have I misunderstood that?

Dr Zucco: There are two aspects. One is EXIT and the other one is the doctors who are supposed to write the prescription. There may be cases where EXIT agrees to assist somebody but where no doctor is prepared to make the prescription. Because we only use this barbiturate then in these cases we have to stop. There is no way that we can assist somebody. This is why other organisations have been looking for different ways of assisting people who want to commit suicide which would not require a prescription. There was one such organisation in Switzerland, very small, and they had problems with justice, so at present they cannot continue to practise. As far as EXIT is concerned there has been some time ago a change of philosophy because in the beginning EXIT was only prepared to assist people who were terminally ill or had very strong pains or were disabled, for instance, they had to spend their life in bed, and recently it has been decided that we would also assist elderly people who simply decide that they do not see any meaning in their life any more. They have different problems, for instance, they do not see well any more or they cannot leave their room or whatever, but they would not die of this. These people we are now prepared to assist. There is no opposition, let us say, from the authorities.

  Q2429  Bishop of St Albans: Suppose it was a 17-year old young person who was suffering from depression or just wanted to die. Would you think that was an acceptable thing for them to do?

Dr Zucco: You say depression?

  Q2430  Bishop of St Albans: Or whatever.

Dr Zucco: For depression this makes a difference because this is what you can consider a psychiatric disturbance and because this is a very controversial subject EXIT decided about five years ago to stop assisting such people even if, according to the law, this would have been completely possible. Very recently there has been again a decision in the other direction, that in selected cases where people who have a psychiatric disturbance are very clear in their will they can again be assisted.

  Q2431  Bishop of St Albans: Could you say on what moral grounds as opposed to legal grounds you make these distinctions?

Dr Rippe: There are two principles. It is not only the principle that follows autonomy but also on the other hand we have the principle of care or of benevolence and to make a responsible choice of the person there has to be some evidence that it is their autonomous will. For example, for the 17-year old person who has depression we have to believe that he has tried all possible therapies. There is a long dialogue with the person to make it clear that it is his autonomous will, that he has considered all the facts and all the options of his life and if his decision is well considered with all necessary information and so on. Therefore we have always two principles—care and autonomy.

  Q2432  Chairman: In such a case you would still need to get a doctor's prescription?

Dr Rippe: In all cases there will be a doctor's prescription.

  Q2433  Chairman: So the doctor's guidelines will apply and in the 17-year old person's case the doctor might take a different view of whether it was advisable and whether in conscience he could decide to assist by granting a prescription?

Dr Rippe: I think for a 17-year old boy or young lady with depression no doctor will do it because they can be cured.

Professor Schwarzenegger: That is a legal question also and you can find in the documentation that our medical legislation also prohibits doctors from prescribing barbiturates in such cases. There must be an analysis of the case and it must be well documented and only under these circumstances is a doctor allowed to hand out a prescription. That is like a third filter in the system which is a control mechanism beyond the reach of autonomy. It is the medical legislation field which could lead to punishment against the doctor and also to disciplinary measures like revoking his licence. That is why this does not happen.

  Q2434  Chairman: It would be useful to get a little bit more detail. This is medical legislation that controls the barbiturate prescription?

Professor Schwarzenegger: That is right.

  Q2435  Chairman: We have not actually been referred to that unless it is in this document.

Professor Schwarzenegger: It is in this document. We have translated the provisions from the law on pharmaceutical products where this is contained and because it is a narcotic it also falls under the narcotics law. This, in combination with the health law of the cantons, prohibits doctors from issuing a prescription in such cases as you mentioned before. This is like the third filter level after one has controlled the legal capacity of the person and the second problem area is whether the person is committing suicide and taking the last action by himself or herself. This is a second important filter in our system and the third one is the control over the narcotics. You will find the details in the document.

  Q2436  Chairman: I have just been looking at them. On pharmaceutical products it says, "Prescribing and dispensing of pharmaceutical products must be carried out in accordance with the acknowledged rules of medical and pharmaceutical science". Is it your view that in the case that the Bishop has mentioned, of a 17-year old person suffering from depression, the acknowledged rules of medical and pharmaceutical science would not permit the prescribing of barbiturates in that situation?

Professor Schwarzenegger: That is right. They would indicate to treat the depression.

  Q2437  Chairman: And you have given us the narcotics law you immediately underneath and again it is the acknowledged rules, this time of medical science, pharmaceutical being missed out?

Professor Schwarzenegger: That is right.

  Q2438  Baroness Hayman: Would there also be an issue under Article 16 about legal capacity?

Professor Schwarzenegger: That is the first filter. That is what EXIT is taking a lot of attention to filter out right from the start, that this is done in the first contact.

  Q2439  Baroness Hayman: The depression could be a reason for saying that someone did not have capacity and therefore did not get over the first hurdle?

Professor Schwarzenegger: That is absolutely right.

Dr Rippe: In the case of depression no people from EXIT will prove that they have the capacity to act autonomously, so there is a fourth filter for these persons.

Dr Zucco: If there is a case where depression is involved or psychosis or whatever, then we request a certificate from a psychiatrist that this person, in spite of that, is capable of deciding whether to live or to die, and if the psychiatrist does not issue this document we have to refuse the case.

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