Analysis

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Margaret Somerville's latest and repeated misinformation deserves censure.

If there’s one thing you have to admire about Margo Somerville, Catholic Professor of Bioethics at the University of Notre Dame Australia, it’s her persistence in the face of being called out for misrepresenting facts about assisted dying. She’s at it again.

Today in the Sydney Morning Herald, Somerville was quoted spruiking her credentials via a recent publication in the peer-reviewed Journal of Palliative Care.1 Since I study the professional literature, I’m aware of said article, which was published several weeks ago. It's a shocker.

The authority bias

Somerville shows herself to again to not care much for the full facts. She seems more comfortable with calling on the ‘authority bias’: advancing her credentials as a “Professor of Bioethics” along with nine “international counterparts” in the authorship of said paper.

I’ll spare you a blow-by-blow analysis of how the JPC article skilfully employs reassuringly professional tones to stake a wholly one-sided and shockingly ill-informed stance against assisted dying law reform.

A very telling example of misinformation

Let’s look at just one very telling example: the statistics that the authors quote about non-voluntary euthanasia (NVE) rates in Belgium and the Netherlands. NVE is a doctor’s act of hastening a patient’s death without a current request from the patient. The authors say that:

“Administration of lethal drugs without patient request occurred in 1.7% of all deaths in the Flanders region of Belgium alone and 0.2% of all deaths in the Netherlands.”

Are these figures correct? Yes indeed they are... as at the date of the cited sources. However, they are just cherry-picked tidbits from a larger and very different smorgasboard of evidence.

A throbbing great falsehood with warts

Do the figures mean what the authors say they mean? In no uncertain terms, absolutely and incontrovertibly not.

The authors don’t just coyly suggest, imply or impute that those NVE rates are caused by the legalisation of assisted dying, they directly claim it. Right in front the statistics, they state categorically that:

“Allowing voluntary euthanasia has led to non-voluntary euthanasia.”

Let’s put this the politest way we can: that’s a throbbing great falsehood with warts on it. The authors would have known this if they’d paid attention to published research facts beyond their own opinions.

Comprehensively ignoring peer-reviewed facts

Had the paper’s authors (and the supposed peer reviewers) actually known much about the subject matter, they wouldn’t have referred to those figures, because they’re massively unhelpful to the case the authors attempt to prosecute. Here are three central published facts about the case:

Fact 1: Before the Netherlands’ euthanasia Act came into effect, the NVE rate was 0.7%. Then in the next research round with the Act in place it had dropped to 0.5%, and the round after that, to 0.2%. The last is the figure the authors quote as evidence that “VE leads to NVE”, despite the fact that the rate had massively dropped, not risen.

Fact 2: Before Belgium’s euthanasia Act came into effect, the NVE rate was 3.2% [typo 3.5% corrected]. Then in the next research round with the Act in place it had dropped to 1.7%, the figure the authors quote. Again, the rate had massively dropped, not risen.

Fact 3: The rate of NVE in the United Kingdom was researched around the same time as the later Dutch figures, and found to be 0.3%.2 The UK has never had an assisted dying law, so the 0.3% NVE rate, which is higher than the Dutch 0.2% rate the authors quote, can't have been caused by one.

So, these three key published facts — known to most of us with an interest in lawful assisted dying — squarely contradict the authors' VE-causing-NVE claim. It's at the very least astonishing and inexcusable that all the numerous authors and peer reviewers of this “scholarly” article either didn’t know, or “overlooked”, them.

Indeed, despite holding one of the world’s largest scholarly libraries on published assisted dying research, I know of no study that establishes a VE-to-NVE link. All the evidence is contrary.

Not the first time

We could perhaps be a little forgiving if the authors just got a statistic wrong. After all, we're all human. But there are ten authors, plus peer reviewers. And there’s the egregious offence the authors committed in making an unequivocal but false claim about the data. Did none of them know what they were talking about or bother to check?

In this case I’m wholly unforgiving. That's because I’ve called Somerville out multiple times before for misrepresenting data, including for misrepresenting Belgian and Dutch NVE data precisely as she does again in this JPC article. We’ve even publicly exchanged words about it via the ABC’s Religion and Ethics portal. It’s not like she simply didn’t know.

I’ve also called Somerville out for wrongly claiming that Dutch Minister of Health Dr Els Borst regretted the euthanasia law; and wrongly claiming the Dutch elderly go to German hospitals and nursing homes for healthcare for fear of being euthanased in the Netherlands, including that NVE actually does occur in German nursing homes, despite, as Somerville notes, “their strict prohibition on euthanasia”.

This rubbish deserves censure and ridicule

While I argue strongly that different views about assisted dying law reform are welcome in a robust democracy, repeatedly spreading such egregious misinformation about assisted dying is an embarrassment to and unworthy of scholarly attribution to professorship. Such rubbish deserves to be rejected, censured and ridiculed.

 

References

  1. Sprung, CL, Somerville, MA, Radbruch, L, Collet, NS, Duttge, G, Piva, JP, Antonelli, M, Sulmasy, DP, Lemmens, W & Ely, EW 2018, 'Physician-assisted suicide and euthanasia: Emerging issues from a global perspective', Journal of Palliative Care.
  2. Seale, C 2009, 'End-of-life decisions in the UK involving medical practitioners', Palliat Med, 23(3), pp. 198-204.

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DyingForChoice has translated the entire 2016-2017 report into English

Belgium's Federal Commission of Control and Evaluation of Euthanasia this week published its full 2016–2017 biennial report. The report is published only in French and Dutch, which places English-speaking jurisdictions at something of a disadvantage.

DyingForChoice has translated the entire report, as well as a copy of the Belgian Euthanasia Act (2002) as it currently stands with amenedments, so that English-speaking audiences can read and understand it.

A summary of key points, the full report in English, and a full copy of the Euthanasia Act, can be found in this Fact File.


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DyingForChoice has translated the Belgian 2016-2017 report into English

The Belgian Federal Commission of Control and Evaluation of Euthanasia has released its full 2016–2017 report. Its reports are published only in Belgium's two national langauges: French and Dutch. So that English-speaking countries can read the report in full, DyingForChoice.com has translated the entire 70 page report into English.

Major takeouts of the 2016–2017 report include:

  • There is ample evidence that doctors take diligent care by often consulting more widely than the Act requires.
  • Assisted dying by advance directive remains very uncommon (1.3% of 2016/17 cases): almost all cases are by current request.
  • There has been a significant increase in the ‘poly-morbidities’ category, in part because of a change in the classification system, but also because more folks fall into this category as the population ages.
  • Cancer is still the major reason that patients choose assisted dying (64% in 2016/17), though its proportion of contributing illnesses is falling.
  • The number of assisted dying cases in relation to psychiatric illness went down, not up, compared to previous years.
  • Since changing the law in 2014 to permit assisted dying choice for minors, there have been just three cases: two in 2016 and one in 2017, all of severe and intractable illness. Extensive consultation occurred in each of the three cases, including assessment of decision-making capacity by at least one specialist child psychiatrist or psychologist.
  • The typical age profile of euthanasia cases has in recent years increased a decile, as the population ages. Our own analysis of Belgian official death stats (not the Commission’s) shows that the elderly are not an ‘at risk’ group: the age distribution profile of assisted deaths is still younger on average than total deaths.
  • The Commission notes that cancer diagnoses are increasing, so the counts of assisted deaths are expected to continue to rise in coming years.
  • The Commission discusses several cases that required extended review, but no cases were referred to the public prosecutor in 2016/17.

 

The full (unofficial) English report can be downloaded here: PDF 1.4Mb.

A full (unofficial) English translation of the current version of the Belgium Euthanasia Act can be downloaded here: PDF 0.3Mb.

The authoritative original versions of the Belgian 2016-2017 report can be accessed in French and Dutch.

 

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The Parliament of Western Australia is investigating end-of-life choices including VAD. Photo: WA Parliament

DyingForChoice.com's major submission to the Parliament of Western Australia on end-of-life choices, including assisted dying, has now been published and is available online. It contains recent updates to research data about assisted dying.

Download a full copy of the submission PDF.

Table of Contents

Terms of reference. p5

Definitions. 6

Statement of Barbara Roberts, former Governor of Orergon. 7

Part A: Introduction. 8
  A critical principle. 8
  Decision-making biases to be avoided. 8
  Potential bias 1: Strong emotional language diminishes critical faculties. 8
  Potential bias 2: Repetition doesn’t make a falsehood true. 8
  Potential bias 3: Use of ‘authorities’ as undeserved ‘evidence’ cues. 8
  Assisted dying law reform is necessary. 9
  Consequences of denying lawful assisted dying choice. 10
  Overmedicalisation and institutionalisation of death. 12
  Choice to die can be rational 13
  Regulation of existing underground practice. 14

Part B: Overwhelming support. 16
  Australian voter attitudes by demographic. 16
  Assisted dying a major issue for voters. 20
  More supporters than opponents think reform important. 20
  Voters will punish opposing MPs more. 20
  Not just a silver-hair issue. 21
  Summary of Australian public attitudes. 22
  Australian health professional opinion.. 23
  AMA opposed stance indefensible. 23
  RACGP supportive stance. 23
  Nurses & Midwives’ Federation supportive stance. 23
  Australian Psychological Society supportive stance. 24

Part C: Opposing arguments critiqued. 25
  Time to name up filibustering for what it is. 25
  Hippocratic Oath fictions. 25
  ‘First do no harm’ fails in the real world. 26
  Assisted dying is not about ‘saving money’. 27
  Assisted dying is consistent with the right to life. 28
  Palliative care availability improves. 28
  Trust in doctors remains high. 28
  Ample evidence against ‘slippery slope’ theories. 30
  Failure 1: Rhetorical sham. 30
  Failure 2: Unsupported by overseas evidence. 32
  Failure 3: Unsupported by domestic evidence. 33
  Opposing world views can be concurrently accommodated. 35

Part D: Correcting misinformation about lawful jurisdictions. 37
  Dr Els Borst remains proud of euthanasia law reform. 37
  Dutch elderly happy with nursing homes. 38
  Non-voluntary euthanasia rates fall, not rise. 39
  No suicide contagion. 42
  Not in Oregon. 42
  Not in Switzerland. 45
  Not in the Netherlands. 46
  Not in Belgium. 48
  Belgian nurses are like anywhere else. 49
  Dutch happy to go to hospital 51
  Groningen Protocol a wise policy. 52
  Theo Boer always an assisted dying law sceptic. 52
  Women are not vulnerable to voluntary euthanasia laws. 53
  Victorian MP publishes extensive misinformation..\ 54
  Opponents admit no slippery slope ‘cause and effect’. 54

Part E: Potential models of assisted dying law reform. 56
  Oregon/Washington model. 56
  Benelux model. 56
  Swiss model. 57
  Options for Western Australia. 58

Conclusion. 59

Statement of Ginny Burdick, Acting Senate President, Parliament of Oregon. 60

Summary of recommendations. 61

References. 62

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The deeply-flawed Jones & Paton, and Kheriaty articles purporting to show suicide contagion.

In the ongoing political campaign against assisted dying law reform, opponents have spread one piece of egregious misinformation after another. One of the most common is supposed “suicide contagion” from assisted dying laws to general suicide, a theory popularised by Catholic Prof. Margaret Somerville. Despite the nonsense of her claim being comprehensively exposed, she still believes that her opinion “will prove to be correct.” Two journal papers published in 2015 purported to, but didn't, establish suicide contagion in Oregon and Washington states.

Note: the report is now published here.

Assisted dying law reform opponents are still relying on a 2015 paper by Catholics David Jones and David Paton, bolstered by a glowing editorial of it written by Catholic psychiatrist Aaron Kheriaty, published in the Southern Medical Journal, as continued ‘proof’ of suicide contagion theory, at least in respect of USA states Oregon and Washington (since data from other lawful jurisdictions contradicts the theory).

Jones & Paton’s article reported the use of econometric modelling to test for ‘suicide contagion’ from Oregon and Washington’s Death With Dignity Act (DWDA) laws. But, in an exposé to be published this week, no fewer than ten ‘deadly sins’ of the study are peeled back to reveal the rot within.

The very deep flaws and biases of the original articles include:

  • Cherry-picking information from cited sources to argue their case, while omitting information from the same sources that contradicted their case;
  • Including test and control subjects whose consequence was likely to maximise the likelihood of finding a positive association;
  • Demonstrating a poor understanding of suicide and its risk and protective factors and failing to control for most confounding effects in their econometric model ‘pudding’;
  • Overegging the “causative suicide contagion” interpretation when no correlation between assisted dying and general suicide rates was found; and
  • Failing to use direct, robust and readily-available evidence that showed their study couldn’t possibly have hoped to return scientifically valid “contagion” proof.

 
The USA’s National Violent Death Reporting System (NVDRS), of which Oregon is a founding member, shows that even if “assisted dying suicide contagion theory” were true, fewer than 2 of 855 Oregon “total suicides” in 2014 could have been attributed to “contagion” from DWDAs.

Further, both Oregon and Washington state rankings for suicide rates have improved, not deteriorated, since their DWDAs came into effect, while the suicide ranking for a relevant control state — Oklahoma — has deteriorated substantially over the same time.

Ultimately, through numerous and deep methodological flaws, the Jones, Paton and Kheriaty articles reveal a bias to promote “assisted dying suicide contagion theory” while ignoring the robust evidence from multiple lawful jurisdictions, including in their own ‘study,’ that contradict it.

The exposé, titled “The ten deadly sins of Jones, Paton and Kheriaty on ‘suicide contagion’,” will be published by DyingForChoice.com later in the week.

Note: the report is now published here.


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With a handful of exceptions, the Coalition has demonstrated itself to be 'unrepresentative swill' on assisted dying law reform.

It was with tongue in cheek that I recently quoted former Prime Minister Paul Keating to wonder if politicians voting on assisted dying Bills were ‘unrepresentative swill.’ The now-obvious answer to this question has become more than just humorous, with the publication yesterday of the Hansard record of Victoria’s Legislative Assembly vote on the Voluntary Assisted Dying Bill 2017.

How ironic it was that the very day after I quoted Keating’s slight against his then-hostile Senate, Keating himself, a conservative Catholic, would come out against voluntary assisted dying (VAD) reform.

Hansard record makes compelling reading

But, more importantly, the Hansard record of votes on the Victorian Bill in the lower house make for compelling reading.

Figure 1 shows Victorian voter support for VAD (from ANU Australian Election Study 2016 data) by political preference, and MP votes in support of the Victorian Bill (lower house, 2017).

Chart: Victorian electorate support and MP vote support for VAD (lower house, 2017)Figure 1: Victorian electorate support and MP vote support for VAD (lower house, 2017)
Sources: AES 2016; Hansard

It’s quite obvious that Greens MPs (100% v 91%) , Labor MPs (86% v 84%) and minor/independent MPs (67% v 76%) approximately represented the proportion of voter support. (It’s unsurprising that all Greens MPs vote in favour of VAD Bills: it’s Greens policy; while it’s a ‘conscience’ matter for other parties.)

The yawning Coalition chasm

But the yawning chasm of Coalition MPs not representing their own voters (14% v 73%) is even more stark. That’s a gap of nearly sixty percentage points. Surely that would be enough to raise the eyebrow of any conservative voter?

Aside from a handful of Coalition MPs who voted in support of the VAD Bill, it’s clear that there’s generally no real ‘conscience’ vote across the Coalition benches.

The corridors have been buzzing with stories of threats to Coalition promotions and preselections, and threats to preference deals for the state election next year, though of course there’s nothing public and on the record. Just the serene statement that “our members have a conscience vote.” The discrepancy amongst Australian Coalition ranks has been formally uncovered before in university research.

It’s a national story

However, it’s not like this is confined to Victoria. Here’s the same chart (Figure 2) for all state VAD bills across Australia since 2000 which have had a division on the vote — so we know who voted which way.

Chart: Australian electorate support and state MP vote support for VAD (all state Bills since 2000)Figure 2: Australian electorate support and state MP vote support for VAD (all state Bills since 2000)
Sources: AES 2106; Hansards

Again, the largest and most striking gap between voter desire for reform and MPs opposing their voters’ wishes is amongst the Coalition ranks, at a full sixty percentage points short of proper representation.

It’s a similar picture to that published by university researchers in 2008, who found just 17% Coalition voting support in favour of VAD in the federal parliament, too.

As I’ve explained before, the Party leader’s public statements can be ‘persuasive,’ and Mr Matthew Guy, leader of the Victorian Parliamentary Coalition, has made his entrenched opposition to this reform loud and clear.

Inform your own voting

As debate in Victoria’s upper house commences tomorrow, we’ll be watching who’s in favour and who’s against. And we’ll report the voting record to help inform how you cast your own vote at Victoria’s state election in November next year.

In the meantime, here’s the full record of the Victorian Legislative Assembly votes.

Full voting record – Victorian Legislative Assembly 2017 VAD Bill

Ayes

47

  

Noes

37

Allan, Jacinta

Labor

 

Angus, Neil

Liberal

Andrews, Daniel

Labor

 

Battin, Brad

Liberal

Britnell, Roma

Liberal

 

Blackwood, Gary

Liberal

Bull, Josh

Labor

 

Blandthorn, Lizzie

Labor

Carroll, Ben

Labor

 

Bull, Tim

Nationals

Couzens, Chris

Labor

 

Burgess, Neale

Liberal

D'Ambrosio, Lily

Labor

 

Carbines, Anthony

Labor

Dimopoulos, Steve

Labor

 

Clark, Robert

Liberal

Donnellan, Luke

Labor

 

Crisp, Peter

Nationals

Edbrooke, Paul

Labor

 

Dixon, Martin

Liberal

Edwards, Maree

Labor

 

Fyffe, Christine

Liberal

Eren, John

Labor

 

Gidley, Michael

Liberal

Foley, Foley

Labor

 

Guy, Matthew

Liberal

Garrett, Jane

Labor

 

Hodgett, David

Liberal

Graley, Judith

Labor

 

Kairouz, Marlene

Labor

Green, Danielle

Labor

 

Katos, Andrew

Liberal

Halfpenny, Bronwyn

Labor

 

McCurdy, Tim

Nationals

Hennessy, Jill

Labor

 

McLeish, Cindy

Liberal

Hibbins, Sam

Greens

 

Merlino, James

Labor

Howard, Geoff

Labor

 

Northe, Russell

Ind.

Hutchins, Natalie

Labor

 

O'Brien, Danny

Nationals

Kealy, Emma

Nationals

 

O'Brien, Michael

Liberal

Kilkenny, Sonya

Labor

 

Pesutto, John

Liberal

Knight, Sharon

Labor

 

Richardson, Tim

Labor

Languiller, Telmo

Labor

 

Riordan, Richard

Liberal

Lim, Hong

Labor

 

Ryall, Dee

Liberal

McGuire, Frank

Labor

 

Ryan, Steph

Nationals

Morris, David

Liberal

 

Smith, Ryan

LIberal

Nardella, Don

Ind.

 

Smith, Tim

Liberal

Neville, Lisa

Labor

 

Southwick, David

Liberal

Noonan, Wade

Labor

 

Suleyman, Natalie

Labor

Pakula, Martin

Labor

 

Thompson, Murray

Liberal

Pallas, Tim

Labor

 

Tilley, Bill

Liberal

Paynter, Brian

Liberal

 

Wakeling, Nick

Liberal

Pearson, Danny

Labor

 

Walsh, Peter

Nationals

Perera, Jude

Labor

 

Watt, Graham

Liberal

Sandell, Ellen

Greens

 

Wells, Kim

Liberal

Scott, Robin

Labor

     

Sheed, Suzanna

Ind.

     

Spence, Ros

Labor

     

Staikos, Nick

Labor

     

Staley, Louise

Liberal

     

Thomas, Mary-Anne

Labor

     

Thomson, Marsha

Labor

     

Ward, Vicki

Labor

     

Williams, Gabrielle

Labor

     

Wynne, Richard

Labor

     

 

 

 

 

 

 TOTAL AYES

 

 

 TOTAL NOES

 

Labor

38

 

Labor

6

Greens

2

 

Greens

0

Liberal

4

 

Liberal

24

National

1

 

National

6

Other

2

 

Other

1

TOTAL

47

 

TOTAL

37

         

Abstained

2

     

Asher, Louise

Liberal

     

Victoria, Heidi

Liberal

     
         

Did not vote

1

     

Brooks, Colin

(Speaker, Labor)

 

Note: The vote represents 87 of 88 seats. The seat of Northcote was vacant owing to the untimely death of its representative, Fiona Richardson, from cancer.


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The Victorian parliament is debating the Government's Voluntary Assisted Dying Bill

Former Australian Prime Minister Paul Keating once famously branded the Senate “unrepresentative swill” for obstructing his legislative agenda. Today, the question of how representative our political masters are remains moot.

Major community support for VAD

Take voluntary assisted dying (VAD) for example. Poll after poll demonstrates that the overwhelming majority of Australians want this additional choice for people in extremis at the end of life. The impeccable Australian Election Survey (AES) conducted by Australian National University scholars last year confirmed that 77% of Australians want VAD reform, with 13% undecided and just 10% opposed.

Strong support (43%) is ten times greater than strong opposition (4%), and support is high across the political spectrum: amongst minor/independent (69%), Coalition (77%), Labor (80%) and Greens (87%) voters. Public support has been in the majority for more than four decades.

Political support missing in action

But since the Northern Territory Rights of the Terminally Ill Act in 1996, none of the many VAD Bills before various state parliaments has passed. And the Northern Territory’s Act was torn down by the federal parliament just eight months after coming into effect.

A 2008 university study of federal MP voting opportunities found 100% of Greens, 55% of Labor, and a paltry 17% of Coalition MPs voting in favour of VAD.

New analysis

Now, a new analysis of the ten state VAD Bills since 2000 where final divisions were called, offers further insights. It found 100% of Greens MP voting opportunities were in favour, along with 51% of Labor, 29% of minor party and independent, and a similarly paltry 17% of Coalition MPs. Excluding South Australia, whose parliament has debated the greatest number of VAD Bills, the Coalition support rate was just 9%.

Overall, while state Labor MP votes fell 29% short of Labor voter attitudes, Coalition MP votes fell an astonishing 60% short of Coalition voter attitudes. At the state level, Coalition MPs had the most voting opportunities — nearly half (48%). No wonder passing VAD Bills is challenging.

It begs the question, how is it that our legislative representatives fail to reflect clear public majority views on matters of conscience for so long?

Hidden reasons behind MP opposition

Obviously, lobbying on both sides of the conversation in part informs MPs’ views, but there are several more persuasive factors.

For a start, there’s a “truism” held by many MPs that their vote in favour of a VAD Bill would lose them more votes at a general election than would a vote against the Bill. However, the opposite has been demonstrated in multiple studies.

Further, I’ve shown before that opposition to VAD is largely religious.  A university study has also found that those who are more religious and who are politically engaged tend to hold very conservative views. So while there are religious MPs on both sides of politics, Coalition MPs are naturally more inclined to hold much more conservative views.

But that doesn’t fully explain the massive 60% representation gap on the Coalition side, either.

In good conscience?

A key factor lies in the seemingly reassuring principle of the “conscience vote.” The major parties have announced that their members are accorded a conscience vote (also known as a “free vote”) on the VAD Bill. That simply means that there’s no official published party policy on the matter and party members may vote freely on the basis of their own conscience.

There are two significant issues with this state of affairs.

The first is that the member may refer exclusively to their own conscience. But what if the MP’s conscience is at odds with the electorate’s? For my home state of Victoria, the 2016 AES study found 79% of the community in favour of VAD. There are 88 members of the Victorian parliament lower house, and just 40 members in the upper house. Therefore, it’s possible for as few as just 20 Victorian MPs to vote “no” in order to extinguish the will of 3.2 million Victorians (79% of 4.05 million Victorian voters).

If that weren’t enough, the second issue is that the right to ‘conscience’ is granted only in respect of the Bill itself, not on procedural matters about the Bill. It can make a huge difference.

How the parry works

Here’s what happened in 2008 when Victorian Greens MP Colleen Hartland’s VAD Bill was before the Legislative Council. MPs were afforded a conscience vote, and many of them had said they were supportive of VAD in general, but couldn’t support Hartland’s Bill in its current form. (That’s also a common ruse of MPs who in reality oppose the reform in principle but wish to appear ‘open minded’.)

When the final vote on Hartland’s Bill was lost, then Greens MP Greg Barber immediately moved a motion to refer the Bill to a parliamentary committee so that it could be improved to MPs’ satisfaction. Neither Labor nor Coalition parties afforded their members a conscience vote on this procedural matter, instead directing MPs to vote against such motions. The referral, which may have resulted in Victorians having wider end-of-life choices years ago, was cynically buried.

Most voters remain unaware of the shenanigans played in the corridors of power to achieve such results.

Australia’s special political conservatism

They’re not the only shenanigans, though. Another university study comparing federal MP conscience voting patterns in the UK, New Zealand and Australia found Australia to be different, accounting for why the UK and NZ have legalised marriage equality, while Australia hasn’t.

Firstly, the centre-left in Australia has a larger proportion of Catholic members than in the UK and NZ, accounting for some of the shortfall in Labor representation of progressive views.

Secondly, those amongst Coalition ranks, but with more liberal social consciences, had been lashed by Coalition party whips to vote against progressive reform. So while there was a public display of fairness and neutrality, the reality was quite different.

Borne out in state parliaments

These findings are replicated in Australian state parliament votes too, with Coalition MPs rarely if ever voting in favour of progressive social reform. Coalition MP votes on VAD including and since Hartland’s legislative attempt in 2008 are telling: in Victoria 2008 10:5 against, in Tasmania 2009 6:0 against; in Western Australia 2010 19:1 against; in NSW 2013 10:0 against; in South Australia 2016 14:7 against and in Tasmania 2017 13:1 against.

Rather than reflect 77% Coalition voter support for VAD, Coalition MP voting patterns reflect the highly negative stance of party leaders, whipped through the parliamentary party membership. For example, then WA Premier Mr Colin Barnett made it clear he thought assisted dying was “government-sanctioned killing”. Tasmanian coalition leader Mr Will Hodgman said that “protection for [vulnerable] people cannot be guaranteed.” Then-NSW Premier Mr Barry O’Farrell declared himself “strongly opposed”.

Back to Victoria’s Bill under debate

The situation in Victoria is looking somewhat more positive, with Premier Mr Daniel Andrews and many in his Cabinet publicly supporting reform. A lengthy, detailed, professional and well-resourced process has informed the crafting of the Bill.

However, opposition leader and would-be Premier Mr Matthew Guy has stated his resolute opposition to it and that he intends to vote “no”. That would mean he is quite comfortable for his own personal view to extinguish the contrary views also held in good conscience by 34,626 of the 43,831 voters in his own electorate of Bulleen, and 3.20 million of Victoria’s 4.05 million voters. (Electorate numbers as at 10 October 2017.)

An obvious solution

There’s an obvious solution for MPs whose own consciences disallow them from reflecting the overwhelming majority conscience of the electorate.

They could consider abstaining — simply absenting themselves from the chamber during the division. That would keep their own consciences intact while allowing the electorate’s conscience to be reflected.

I’m a constituent of Mr Guy’s. Over a period of months I made six robust attempts to meet with him to discuss these matters, especially the covert whip arrangements and the consideration of abstention. I can be persuasive in obtaining appointments, but my best efforts proved wholly unfruitful.

As I said to Mr Guy’s private assistant after the last failed attempt, voters could be forgiven for believing he’s more interested in meeting allegedly shady characters in fancy Brighton restaurants, than meeting with his own constituents.

Victorians are watching the parliamentary VAD debate. We’re taking notes that will inform our votes at the state election late next year.

Indications are at present there’s a good chance that Victorian MPs won’t be “unrepresentative swill”.


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Those actively opposing assisted dying laws are Australia's most religious. Photo: Donaldytong

A claim was recently made on ABC’s QandA that at least 70% of Catholics and Anglicans support assisted dying. The claim was challenged and a FactCheck prepared and vetted by scholars. They concluded that some but not all polls supported the statement. I show unambiguously that relevant polls do. I show further, as I have in the past, that opposition is largely associated with Australia's most religious.

Get the full, detailed report here.

Known polls

In 2007, a Newspoll survey found that 74% of Catholics and 81% of Anglicans support assisted dying. The 2016 Australian Election Study (AES), run by scholars at Australian National University, found almost identical rates: 74% of Catholics and 79% of Anglicans. Although a majority of all religious denomination groups support assisted dying, opposition is highest among minor Christian denominations (Figure 1).

adattitudesreligdenomination.gifFigure 1: Attitudes toward assisted dying by major religious denominations
Source: AES 2016. Note: Chr. = Christian

A significant majority of support for assisted dying was also found across all age groups, education levels, income levels, states, and major political party affiliations and religious denominations, with support amongst Australians overall at 77%.

Casting doubt

However, another poll cited in the FactCheck found far less support: the 2011 National Church Life Survey (NCLS). It found just 28% of Catholics and 25% of Anglicans supported assisted dying.

The problem with the NCLS poll is that it didn’t take a valid sample of Australian Catholics and Anglicans. It sampled mostly or only those who frequently attend religious services.

Views vary widely by attendance frequency

Figure 2 shows the level of support amongst the Australian public, by frequency of attending religious services. While just 2.4% of those who never attend religious services oppose assisted dying, 46.1% of those attending at least once a week oppose it.

adattitudesreligiosity.gifFigure 2: Attitudes toward assisted dying by frequency of attending religious services
Source: AES 2016

NCLS poll cannot answer the question

The NCLS results were even more negative than the AES ‘at least once a week’ results. That’s explained by the NCLS methodology. Firstly, occasional attenders were underrepresented, and non-attenders were excluded altogether. Secondly, more church employees (the most deeply committed and aligned with church policies) than others would have participated. Thirdly, responders may have felt pressured to toe the church line because the survey forms were collected by the churches themselves. And fourthly, those who disagreed with the church line would be less likely to participate.

ABC QandA question answered

So we can discount the NCLS poll because it was not suited to answer the question about all Australian Catholics and Anglicans.

On that basis, it is not only reasonable to say that “up to 70% of Catholics and Anglicans support assisted dying,” but to say that “at least 70% of Catholics and Anglicans support assisted dying.”

Religious connections of opposers

But, back to the opposition of assisted dying. AES data shows that 92% of those opposing and 94% of those strongly opposing assisted dying have a religious affiliation (self-identify with a religious denomination) or attend religious services. So, while a tiny minority of opposers had no religious affiliation nor attended religious services, almost all those opposing have a religious connection.

Frequent service attendance entrenches opposition

If we focus in on those who identify with a religious denomination and who disagree with assisted dying, we find that there’s a massive difference in opposition to assisted dying between the ‘at least once a week’ attenders and everyone else (Figure 3).

adattitudesreligiosityopposers.gifFigure 3: Frequency of attending religious services amongst those with a religious affiliation and who disagree with assisted dying
Source: AES 2016

Not only are the majority of opposers weekly religious service attenders, but weekly attenders are more likely to be strongly opposed. This highlights the strong alignment with and commitment to religious teachings, which (with rare exceptions) oppose assisted dying.

If we define the most religious Australians as those who attend religious services monthly or more often and who self-identify with a religious denomination (“Regulars” in Figure 4), and who make up just 15.7% of the population, their attitudes are remarkably more opposed to assisted dying than all other Australians — by a factor of more than eleven to one.

adattitudesregularssum.gifFigure 4: Attitudes by religious service attendance plus denomination affiliation (“Regulars”)
Source: AES 2016

Amongst the 84.3% of Australians who are not “Regulars”, almost all of them (85.7%) agree with assisted dying, and almost none of them (3.6%) disagree.

Demographic differences explained by religiosity

The variation in attitudes toward assisted dying by general demographics is largely explained by religiosity — defined here as ‘the frequency of attending religious services’.

For example, the increased opposition amongst older Australians is explained by their increased religiosity. The same applies to religious denomination affiliation (e.g. Catholics attend services more often than Anglicans), education, urban versus rural residence, and political party first preference.

Religiosity was the only variable that independently explained variations in opposition to assisted dying.

The double whammy — affiliation and attendance

Also informative is the comparison of those with or without a religious affiliation versus those who do and don’t attend religious services. (Australians fall into all four categories.)

Amongst those with no religious affiliation, people who do attend religious services are only slightly less likely (than those who don’t attend) to support assisted dying (-7%), and their difference in attitude is mostly to neutrality.

However, of those with a religious affiliation, people who do attend religious services are significantly less likely to support assisted dying (-27%), and the majority of their difference in attitude is opposition rather than neutrality.

Thus, those more deeply aligned with their religious denomination through service attendance are significantly more likely to oppose assisted dying.

Moderated by personal experience

The 2007 Newspoll study asked respondents if they had personal experience of someone close who was hopelessly ill and had wanted voluntary euthanasia.

Amongst those with no religious affiliation, this personal experience increased support for assisted dying by just 3.7%, because support was already very high: from 90.9% to 94.6%.

However, amongst those with a religious affiliation, personal experience increased support for assisted dying markedly by 15.2%: from 72.4% to 87.6%.

Thus, those attending religious services, yet with close, personal experience of hopeless illness with a desire for assisted dying, were significantly less likely to align with opposed religious doctrine.

The most religious are a small minority

With so much opposition amongst Australia’s most religious, why is overall support for assisted dying so high? It’s because Australia’s most religious are a small minority of the population.

Nearly half (48%) of Australians never attend religious services, two thirds (65%) attend less than once a year or never, and three quarters (75%) attend once a year or less, including never.

Those who attend religious services frequently (weekly or more often) comprise just 12% of the population, while those who attend regularly (monthly or more often which includes the weeklies) comprise 16%.

Religion in Australia has been declining for decades, and the fall is likely to continue (see Appendix A of the full report, here), meaning that support for assisted dying is likely to increase in the future.

Conclusions

I’ve previously demonstrated how all the signatories to a major anti-assisted dying advertisement were deeply connected with religion. The AES and other studies further our understanding of wider public attitudes toward assisted dying in Australia. They show that while a substantial majority of Australians support assisted dying, almost all the opposition to it is connected with religion, particularly amongst the most religious who are a small minority of the population.

Despite the religious connection of those opposed, there is ample, robust evidence that a great majority of Catholic and Anglican Australians support assisted dying, backing the claim made on national television.

Clergy opposing assisted dying are not representing the broader views of their flocks. Perhaps they may not see that as their role, and perhaps this misalignment of attitudes and beliefs is an example of why religion in Australia is declining.

However, reflecting the views of the great majority of the constituency is the role of politicians, who would do well to take note of this robust evidence of a significant majority of support for assisted dying.

Get the full, detailed report here.

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Oregon (left) and Washington legalised assisted dying by ballot in 1997 and 2008 respectively. Photos: Oregon Department of Transportation; Cacophony.

A scientific study just published in the New England Journal of Medicine reveals that residents of both Oregon and Washington states, which legalised assisted dying in 1997 and 2008 respectively—as well as establishing formal advance directive programs—are far more likely to experience the kind of death they prefer, and with better access to palliative care, than is the average USA resident.1

It's well-established that most westerners would prefer to die peacefully at home rather than in a medicalised or other institutional setting. Yet it is recognised by doctors and families alike that there is a kind of medical ‘conveyer belt’ to acute care at the end of life that tends to shunt the dying individual through to ICU—a place where more and more burdensome medical interventions are administered with less and less likelihood that they’ll actually provide any benefit. These kinds of deaths, with vigorous and invasive procedures performed on a frail person approaching a natural death, can lead to longer and more complex bereavement recovery for surviving loved ones.

It’s also claimed by opponents of assisted dying law reform that assisted dying is a ‘competitor’ of palliative and hospice care, and that legalisation of assisted dying would result in the deterioration or at least stunting of palliative care services.

This latest study, including longitudinal data, provides further evidence that such claims are not only false, but that the legalisation of assisted dying improves the focus on all end of life decision making, whatever those decisions are.

Avoiding burdensome and questionable invasive care

ICU was used in the last 30 days Figure 1: ICU was used in the last 30 days of life
Percent of fee-for-service Medicare service beneficiary patients

Figure 1 shows that the ‘shunting’ of dying patients to ICU in the last 30 days of life is significantly lower in Oregon, which legalised assisted dying in 1997. Oregon also established a statutory comprehensive advance care directive (Physician Orders for Life Sustaining Treatment, or “POLST”) program earlier than other states, in 1993. Washington, which piloted a POLST program in 2000 and formally endorsed it in 2005 — and legalised assisted dying by ballot in 2008 — was already trending down from the national average (close to it in 2000), as public discussion of end of life decisions ratcheted up in the lead-up to reform. Since the POLST endorsement and ballot reform, Washington has continued to trend well below the national average.

Facilitating a non-institutionalised death

Patient was discharged from hospital in the last 30 days of life Figure 2: Patient was discharged from hospital in the last 30 days of life

Figure 2 shows that both Oregon and Washington have continued to trend above the national average for facilitating patient wishes to die at home after a stay in acute care in the last 30 days of life.

Hospice care received at home

Dying patient received hospice care at home  Figure 3: Dying patient received hospice care at home

Figure 3 shows that by 2000, Oregon was already providing home hospice services at 2.1 times the national average, but that as the national average plateaued from 2005, the rate in Oregon continued to rise significantly, reaching 2.5 times the national average in 2013. To qualify for an assisted death, Oregon and Washington residents must be certifed by their doctor as expected to die within six months—which qualifies the patient for free hospice care.

Washington was close to the national average on the delivery of home hospice care prior to assisted dying law reform, beginning to deviate as conversations were held about permitting assisted dying and its POLST program was endorsed in 2005, increasing to 1.8 times the national average in 2013.

Death preferred at home

The individual died at home Figure 4: The individual died at home

Figure 4 shows that both Oregon and Washington states continue to facilitate a private home-based death, according to patient and family wishes, at a rate considerably higher than the national average.

Conclusion

The results of this USA study mirror the kinds of findings from Dutch and Belgian research, which I have previously published,2 and another USA report from the Journal of Palliative Medicine which placed both Oregon and Washington amongst the top eight states for palliative care access in hospital settings.3 This study furthers these insights by showing that access to palliative care services in home settings is also significantly higher than the national average in Oregon and Washington.

Assisted dying opponents’ claims that legalising assisted dying would result in a deterioration or stunting of end of life decisions and in particular access to palliative care are contradicted by the data from lawful jurisdictions.

 

References

  1. Tolle, SW & Teno, JM 2017, 'Lessons from Oregon in embracing complexity in end-of-life care', New England Journal of Medicine, 376(11), pp. 1078-1082.
  2. Francis, N 2016, Assisted dying practice in Benelux: Whitepaper 1, DyingForChoice.com, viewed 13 Nov 2016, http://www.dyingforchoice.com/resources/fact-files/assisted-dying-benelux-whitepaper-1.
  3. Morrison, RS, Augustin, R, Souvanna, P & Meier, DE 2011, 'America's care of serious illness: A State-by-State report card on access to palliative care in our nation's hospitals', Journal of Palliative Medicine, 14(10), pp. 1094-1096.

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Lead author Professor Ezekiel Emanuel discusses the findings of the JAMA study.

Several of the world's foremost researchers in medical end-of-life matters have released a detailed and comprehensive review of the practice of assisted dying in lawful jurisdictions around the world. Published in the Journal of the American Medical Association, it does not support slippery slope hypotheses.

Professors from universities in the USA, the Netherlands and Belgium studied data from government and statutory authority reports, primary scientific studies and other sources to examine how assisted dying has been practiced in different jurisdictions around the world where it is lawful in one form or another: self-administered medication (physician-assisted dying) or physician-administered medication (active voluntary euthanasia).1

Their primary conclusion is that:

"Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices."

Key findings

Key findings include:

  • Public opinion favouring assisted dying in developed countries has been increasing, or remained stable at high levels of approval.
  • The trends seem to correlate with decreasing religiosity in Western countries.
  • The only place where assisted dying approval appears to be decreasing is in eastern Europe, where religiosity has been increasing.
  • Approval amongst physicians seems to be consistently lower than amongst the public.
  • Assisted dying occurs everywhere, including juridictions where it is unlawful (as I have previously reported).
  • Most individuals who choose assisted dying have advanced cancer (as I have previously reported).
  • Supposedly 'vulnerable' groups are not represented in assisted dying figures at rates any higher than their presence in the overall population.
  • Numbers of assisted deaths in lawful jurisdictions continue to increase, but represent a tiny minority of deaths.
    • In jurisdictions where only self-administration is permitted, assisted deaths represent around 0.3% of all deaths.
    • In jurisdictions where physicians may administer, assisted deaths represent around 3–5% of all deaths.
  • Assisted deaths for minors and those with dementia are a very small minority of cases (as I have previously reported).
  • The dominant reasons for requesting assisted death include loss of autonomy and dignity and the inability to enjoy life and regular activities; not physical pain.
  • Doctors still report that honouring a request for assisted death is emotionally burdensome; not a routine or welcomed option.
     

"In no jurisdiction was there evidence that vulnerable patients have been receiving euthanasia or physician-assisted suicide at rates higher than those in the general population."

Complication rates

One aspect of the study is worthy of special mention: the small rate of assisted dying procedure complications. The available data suggests that complications may occur more often for self-administered medication than for physician administration:

  • For self-administration—
    • Difficulty in swallowing in 9.6% of cases
    • Vomiting or seizures in 8.8% of cases
    • Awakening from coma in 12.3% of cases
  • For physician administration—
    • Technical problems such as difficulty in finding a suitable vein in 4.5% of cases
    • Vomiting or seizures in 3.7% of cases
    • Awakening from coma in 0.9% of cases
       

This data is however of Dutch practice in the 1990s, before assisted dying was codified in statute—at a time when practice was poorly defined and a range of drugs, including opioids, were widely used. Now, practice is well-defined with almost universal use of barbiturates. The researchers expressly note that these complication rates may well have reduced.

Further, the authors refer to more recent data from Oregon and Washington which indicate very much lower complication rates (in those jurisdictions for self-administration only):

  • In Oregon, the complication rates are around 2.4% for regurgitation and 0.7% for awakening from coma.
  • In Washington, the complication rates are around 1.4% for regurgitation, plus a single case of seizure.
     

The importance of context

It is worth comparing the complication rates of assisted dying procedures with rates for other medical interventions to provide an appropriate context so that they may be realistically interpreted.

For example, a study of common over-the-counter analgesics for short-term pain management2 found that significant adverse effects occurred amongst 13.7% of ibuprofen users, 14.5% of paracetamol useres and 18.7% of aspirin users.

In another example, an anlaysis of primary research about surgical outcomes found that 14.4% had adverse events, almost half of which (47.5%) were moderate to fatal in severity.3

Conclusion

The study is a solid synthesis of research data and indicates that assisted dying is accessed sparingly and in accordance with the intentions of each legislature.

The adverse event rate for assisted dying appears to be substantially lower than the rate of adverse events in the use of common over-the-counter analgesics and in surgery.

 

References

  1. Emanuel, EJ, Onwuteaka-Philipsen, BD, Urwin, JW & Cohen, J 2016, 'Attitudes and practices of euthanasia and physician-assisted suicide in the united states, canada, and europe', JAMA, 316(1), pp. 79-90.
  2. Moore, N, Ganse, EV, Parc, J-ML, Wall, R, Schneid, H, Farhan, M, Verrière, F & Pelen, F 1999, 'The PAIN Study: Paracetamol, Aspirin and Ibuprofen new tolerability study', Clinical Drug Investigation, 18(2), pp. 89-98.
  3. Anderson, O, Davis, R, Hanna, GB & Vincent, CA 2013, 'Surgical adverse events: a systematic review', Am J Surg, 206(2), pp. 253-62.
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