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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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Jones, Paton and Kheriaty's articles demonstrate poor science and multiple, egregious instances of bias.

In 2015, Dr David Jones and Prof. David Paton published an article titled “How does legalization of physician-assisted suicide affect rates of suicide?” in the Southern Medical Journal. The article purported to establish suicide contagion from Oregon and Washington Death With Dignity Act (DWDA) deaths to “total suicides.”  It also purported to establish no decrease in general suicide rates, which Jones & Paton argued should occur by substitution of assisted death for some general suicides. (Notice how these two ‘expected’ results — an anticipated rise and an anticipated fall in suicide rates — are at odds in principle.)

In my thorough and empirically-backed response, I expose the disgraceful playbook of these authors as they shambolically commit no fewer than ten deadly sins against science in the pursuit of their opposition to lawful assisted dying.

Get the full report here

Executive Summary

In 2015, Dr David Jones & Prof. David Paton published an article in the Southern Medical Journal titled “How does legalization of physician-assisted suicide affect rates of suicide?” This study examines the article, as well as an enthusiastic editorial of it by Dr Aaron Kheriaty in the same journal issue, both of which portray “suicide contagion” from Oregon and Washington’s death with dignity acts (DWDA).

However, while contagion from general suicides is a well-established phenomenon, there are multiple sound reasons to reject contagion theory in relation to assisted deaths, including:

  • Most healthcare professionals readily acknowledge key differences in the characteristics of assisted deaths: for example, a fully informed, tested and rational decision with shared decision-making.
  • Those using Oregon and Washington’s DWDAs are, by qualifying for it, already actively dying. Thus, they are choosing between two ways of dying rather than between living and dying.
  • Most of those using the DWDA discuss it with their families (expected, peaceful death), whereas most general suicides occur in isolation and without discussion (unexpected, often violent death).
  • Multiple studies show that while families of general suicide experience complicated bereavement, families of assisted dying cope at least as well as, and in some cases better than, the general population or those who considered but did not pursue assisted death.

 
Even if “suicide contagion from assisted dying” theory were sound, direct evidence from official government sources shows that the number of potential suicides in Oregon in 2014 would have been fewer than 2 in 855 cases: undetectable by general modelling methods.

Jones & Paton’s article title conveys an air of skilled and scientific neutrality. However, close examination of the article, and Kheriaty’s editorialisation of it, reveals least ten serious flaws or ‘scientific sins.’

The authors demonstrated little understanding of the complex issues surrounding suicide, willingness to unjustifiably equate assisted dying with general suicide, contentment with failing to search for, consider or include contrary evidence including from sources they cite to argue their case, unreasonable trust in a model that couldn’t hope to legitimately resolve their premises, satisfaction with executing their model amateurishly, a disposition to overstate confidence of causation in the absence of meaningful statistical correlations, and an inclination for emphasising results in accordance with their theories while de-emphasising or ignoring others.

Any of these flaws was serious enough to invalidate Jones & Paton’s article and Kheriaty’s conclusions of it, yet there is not one deadly flaw: there are at least ten.

Their claim of a supposed 6.3% suicide contagion rate from assisted dying in Oregon and Washington is a conceptual and mathematical farce.

The Southern Medical Journal is a peer-reviewed journal. However, it is difficult to reconcile the rigorous standards and sound reputation that peer review is intended to maintain, with the numerous, egregious flaws in this study and its dissemination.

Rather than inform the ongoing conversation about lawful assisted dying, the Jones & Paton and Kheriaty articles misinform and inflame it.

Given the numerous egregious flaws, both articles ought to be retracted.

 

Get the full report here

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Update: Margaret Somerville is now Professor of Ethics at the Catholic University of Notre Dame Australia.

In the previous video a claim by Catholic Professor of Ethics Margaret Somerville was rebutted: that the Dutch and Belgians seek health care in Germany because they fear being killed by their own doctors and without being asked. In this video, she furthers her bizarre claim by referring to Dutch and Belgian non-voluntary euthanasia rates as 'proof' of her border-crossing healthcare thesis.

However, her cherry-picked statistic establishes nothing, whereas her claim is contradicted by robust research, which I discuss in this video.

It's unclear why Professor Somerville seems to be unaware of or ignores readily-available yet contradictory evidence of central importance to her claim.

This 'non-voluntary slippery slope' claim is another one that's popular amongst campaigners against assisted dying.

 

Transcript

Neil Francis: In the last video, we established as false, Professor Margaret Somerville’s absurd claim of the Dutch going to Germany for health care because they feared being killed by their doctors. But she goes on.

Margaret Somerville: In actual fact they’ve got good reason to fear that, uh, there’s a minimum of, a minimum of 500 cases a year, of doctors who administer euthanasia to people in the Netherlands, where it’s legal, and the patient does not know they’re being given euthanasia, and has not consented to it. Some reports put the figure as high as 2000 cases a year.

Neil Francis: And she makes a similar case for Belgium. So let’s look at the empirical evidence.

Neil Francis: What she’s referring to is non-voluntary euthanasia, or NVE. It occurs in every jurisdiction around the world. A study published in 2003 found these rates. You’ll notice that Italy had the lowest and Belgium the highest NVE rates. And at the time of this study, which countries had legalised assisted dying?

Neil Francis: Switzerland had since 1942, and the Netherlands since 1982. But none of the others had. So the Swiss and Dutch NVE rates, with assisted dying laws, were lower than Denmark’s, without one. And the higher Belgian rate wasn’t caused by an assisted dying law, because none existed at the time.

Neil Francis: But did the Belgian and Dutch NVE rates go up when each country legalised assisted dying by statute in 2002? Here’s what happened in Belgium: the rate didn’t go up — it went down, and the drop is highly statistically significant.

Neil Francis: And in the time since Professor Somerville made her misleading claim, it’s remained lower.

Neil Francis: And here’s what happened in the Netherlands. This rate before the Act is around 1,000 cases a year, and this one after the Act is around 500, the rate that Professor Somerville refers to in her claim as “the minimum”. What she failed to mention is that since statutory legalisation of assisted dying, the Dutch NVE rate dropped, not risen, and to a similar level as the UK, the world’s gold standard for palliative care, and which has never had an assisted dying law.

Neil Francis: And since Professor Somerville made her misleading claim, it’s dropped even further.

Neil Francis: If Professor believes that she has verifiable empirical evidence to back up her claims, let her produce it for examination. Until then, her non-voluntary euthanasia “slippery slope ”is nothing more than fear-mongering innuendo.

Visit the YouTube page.

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Professor Margaret Somerville makes an indefensible 'suicide contagion' claim.

Catholic ethicist Professor Margaret Somerville claims that every assisted suicide jurisdiction shows 'contagion' to the general suicide rate. The empirical evidence contradicts her claim.

Get the full report here.

Professor Margaret Somerville, currently Professor of Ethics in the School of Medicine at the Catholic University of Notre Dame Australia,[1] has enjoyed ongoing publication of her opinions, with few challenges published to date.

Back in 2007, Somerville, then a Professor of Ethics at McGill University in Montreal, Canada, appeared as an expert witness in an Iowa District Court case. The court comprehensively rejected her testimony, determining that she:

“…specifically eschews empirical research and methods of logical reasoning in favour of ‘moral intuition.’ She has no training in empirical research…”

Professor Somerville, I argue, has again fallen short on empirical research and logical reasoning. To illustrate, I will analyse her claim, published in an opinion piece in ABC Religion and Ethics that:

“…the general suicide rate has increased in every jurisdiction that has legalized assisted suicide.

While her claim may be her own personal opinion, she has presented it expressly stating that she is a Professor of Ethics at her current university of employment, lending the claim perceived authority.

This report demonstrates how her claim and her defence of it are contradicted by multiple sources of empirical government and other primary research evidence. It also demonstrates that she failed to engage appropriate scholarly standards that require the active search for, acquisition and analysis of all reasonably available relevant data in an attempt to answer a particular question.

In making her claim, Prof. Somerville:

  • Cites ‘supportive’ data from lawful jurisdictions while overlooking other data, sometimes even in the same data set, that are inconsistent with her claim;
  • Cites as supporting evidence an econometric modelling study that did not find a statistically-significant relationship between assisted dying law and the general (non-assisted) suicide rate;
  • Fails to consider data from all jurisdictions with assisted suicide laws while making a claim about them all — overlooking Switzerland, whose empirical data is clearly at odds with her claim;
  • Repeatedly cites non-academic anti-euthanasia lobbyist Mr Alex Schadenberg (who also cites her) as a source of evidence for her claim and who in turn quotes a television source and another lobbyist’s opinion to underpin his own beliefs about ‘suicide contagion’; and
  • Conflates voluntary euthanasia (physician-administration) with assisted suicide (patient self-administration) such that her argument, at least in the context of Belgium and the Netherlands, is substantially about the novel concept of ‘euthanasia contagion’ rather than the more familiar ‘suicide contagion’ expression she uses.
     

These findings are consistent with the Iowa court’s ruling that Prof. Somerville sometimes relies on ‘moral intuition’ rather than sound empirical research and logical reasoning.

My report also draws a number of connections between those advancing misinformation on assisted dying ‘suicide contagion,’ and Catholic identity. Catholic identity is not a reason to reject arguments, but it does help identify the source of a majority of ‘suicide contagion’ misinformation.

Finally, I argue that the appropriate course of action for Prof. Somerville is to retract her ‘suicide contagion in every jurisdiction’ claim.

 

Get the full report here.


[1]   Not to be confused with another Professor Margaret Somerville, who is Director of the Centre for Educational Research at Western Sydney University.

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Assisted dying rates in Dutch-speaking cultures (orange bars) are much higher than elsewhere.

In this whitepaper, Benelux (Belgium, Netherlands and Luxembourg) primary empirical data on assisted dying is analysed — including with new and advanced approaches — to provide fresh insights into contemporary practices. Investigation reveals that the assisted dying rate in Dutch-speaking cultures appears to be uniquely higher than in other cultures irrespective of the permissiveness of the legislative framework, yet is still practiced conservatively.

Download a full copy of the Whitepaper here: PDF (648Kb).

Summary

This new compilation and unique analysis of primary research data from statutory authorities and the peer-reviewed literature provides fresh insights into assisted dying practice in Benelux, including:

  1. Rates of assisted dying in the Netherlands and Belgium have followed an expected sigmoid curve, now beginning to level out.
  2. Several factors have contributed to the higher increase in the Netherlands rate, including recovery from a suppression of cases immediately following statutory reform, a rise in cancer diagnoses, and an increase in granting of assisted dying through new visiting teams launched in 2012.
  3. Both Netherlands and Belgium doctors demonstrate caution if not conservatism when assessing assisted dying requests.
  4. Despite most assisted dying occurring in cases of cancer, fewer than one in ten cancer deaths in the Netherlands and one in twenty in Belgium is an assisted death.
  5. Other conditions such as degenerative neurological, pulmonary and circulatory illnesses each account for a very small proportion of the increase in cases since legalisation in Benelux.
  6. The assisted dying rate in dementia and other mental illness is very low despite controversy around—and a tiny rise in granting of—such cases.
  7. The hypothesis that females or the elderly would be ‘vulnerable’ to assisted dying law is contradicted by the data.
  8. The rate of non-voluntary euthanasia has decreased significantly in both the Netherlands and Belgium since assisted dying was permitted by statute.
  9. Assisted dying rates in Dutch-speaking cultures are significantly higher than in non-Dutch cultures, seemingly unrelated to the permissiveness of the jurisdiction’s legal framework.

 

beneluxratessmall.gif
Benelux country reported assisted dying rates (as a percentage of all deaths)
as at 2014. The three countries have similar assisted dying laws.
 

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Dr Megan Best and the AMA profoundly misrepresent what this research says.

In my report about Dr Megan Best misreporting research findings about assisted dying practice in Belgium, I said that I would ask the Australian Medical Association (AMA) to publish a correction statement. I did just that, posting a courteous notice explaining the misinformation and requesting the correction, as a comment to their online article. What happened next was supremely revealing about how the conservative medical establishment opposes your right to choose assisted dying. I expose six reprehensible aspects of Dr Megan Best’s ‘expert’ opinion and MJA InSight’s response to my report.

 

Response 1—Try to bury the correction request

How did the AMA respond? Well, first of all, they simply deleted my post from the Medical Journal of Australia article (in MJA InSight).1

Subsequently, AMA member Dr Rosemary Jones posted my advice and request for correction. They dared not delete the post of a member, because Dr Jones’ post remains and MJA InSight have now responded… in a fashion.

Response 2—Plead it’s not the AMA

First up, Cate Swannell, editor of MJA InSight as well as “MJA news and online,” wrote that MJA InSight is:

“…editorially independent from the AMA and the AMA does not influence our content and editorial decisions in any way, shape or form … Thanks.” — Cate Swannell

It would be fair to take Ms Swannell’s word for it that the AMA doesn’t make a habit of sticking its nose into individual items at the Medical Journal of Australia (MJA). But consider this: MJA, of which MJA InSight is a part, is published by a wholly owned subsidiary of the AMA. That is, even in the absence of direct influence, one might reasonably expect that the AMA has broader, long-term influence over “content and editorial decisions.” After all, a core purpose of establishing a wholly-owned subsidiary is to help promote owner’s interests (which at present are officially and trenchantly opposed to the legalisation of assisted dying).

Those interests are further intertwined at DoctorPortal which is co-owned and operated by the AMA and its entity that publishes MJA. The portal includes the ‘MJA Bookshop’ where doctors must log in using their AMA credentials to obtain discounts.

MJA InSight is in real and practical terms a publication of the AMA.

Refresher: The original allegations

Before we cover the further AMA responses, let’s remind ourselves of the ‘expert opinion’ the AMA obtained from Dr Megan Best about Belgian assisted dying practice as published in MJA InSight:

“I am concerned by the reduction in referral to palliative care doctors and specialists in the euthanasia approval process, as GPs are less likely to know whether or not the suffering can be alleviated – the keystone of the act,” she said.

“This is a weakening of the due process of the act and suggests that the ‘safeguards’ are seen more as a barrier to be overcome than an opportunity to improve life to the extent that euthanasia is no longer necessary.” — Dr Megan Best

Response 3—Confirm the ‘cherry-picking’ misrepresentation

Here’s how Sarah Colyer, author of the article in which Dr Best’s nonsense was quoted, responded to Dr Rosemary Jones’ objections:

“…there are two findings related to the involvement of palliative care doctors in the study. First, the study found palliative care physicians were less likely to be the legally-required ‘second doctor’ to sign off on the decision for euthanasia, as more GPs took on the role.” — Sarah Colyer

What a profound fudge. The paper does not say that. There is a notional mathematical decrease in palliative care (PC) ‘sign-offs,’ but with a p value of 0.3 it is not in the slightest bit statistically significant. In other words, it is not possible to validly assert that it became “less likely.” And this is the reason that the researchers correctly didn’t draw such an inference in their discussion and conclusions.

This is extraordinary. In its defence, this AMA publication confirms and defends that Dr Best had cherry-picked a supposed trend with no statistical significance and which seems to (but doesn’t) support opposition to assisted dying law reform, while utterly failing to mention a highly significant trend (p = 0.001) in the opposite direction, present in the very same table of data (Table 3 of the cited research paper).2

While the original MJA article reported on both data series, it failed to identify that one was in no way statistically significant while the other was highly so.

Response 4—Execute an impressive flip-flop

“Second, and as Sarah Edelman is quoted saying, 39% of patients had contact with palliative care teams in the lead up to euthanasia (but these doctors were not necessarily involved in sign-off).” — Sarah Colyer

Both Dr Megan Best, and Sarah Collyer in defence, express concern about what they see as the insufficient ‘signing off’ or approval of assisted dying by Belgian PC specialists. Yet Palliative Care Australia explicitly states that:

“The practice of palliative care does not include euthanasia or physician assisted suicide. Palliative care does not intend to hasten or postpone death.” — Palliative Care Australia3

So on the one hand Australia's national PC body demands that PC have nothing whatever to do with assisted dying, while an Australian PC specialist (who is opposed to assisted dying) demands that it must: not just ‘incidental’ involvement to ensure the patient is well-informed as to what PC may offer, but to directly insert itself in the assisted dying approval process.

What an impressive ‘must not, yet must’ flip-flop.

Response 5—Confirm bias about consultations

Sarah Colyer goes on to say:

“Although this latter figure is an increase from 33%, the article makes clear that this is more about palliative care doctors being ‘notified’ than necessarily having any professional input into the decision-making process.” — Sarah Collyer

If my point 3 above exposed a ‘profound’ fudge, this is a spectacular one. Indeed it’s utter fiction. Nowhere in the cited research report do the data or authors suggest in any way that PC teams were merely ‘notified.’ They were consulted. The word is used explicitly in no fewer than seventeen times specifically in relation to PC. What is a professional ‘consultation’?: “a meeting or discussion to obtain advice.”

To suggest that these are mere ‘notifications’ is absurd: why would a physician even bother to formally ‘notify’ other relevant carers if he or she had no intention of the notification having any meaningful consequence?

The only outcome of this ‘notification’ fiction is to make Belgian physicians seem careless or disinterested—a shabby and biased approach to describing overseas colleagues who engage in lawful conduct of which the commentators (at least, Dr Best) personally disapprove.

Response 6—Demonstrate fundamental ignorance about research

Remember that Dr Best complained about her perception of a low assisted dying PC consult rate as obstructing the “opportunity to improve life to the extent that euthanasia is no longer necessary”. Sarah Colyer defends and amplifies the ‘low consult rate’ message of the Belgian research:

“Although Dr Edelman and the study authors said this [increase in palliative care consults] was a positive development, Dr Best and another respected palliative care doctor who provided background for the article said it was still overall a very low rate of palliative care involvement.” — Sarah Colyer

These remarks reveal a deep ignorance about research evidence. The reported data the 'experts' criticised was only in respect of PC involvement after a request for assisted dying. It did not include any PC consults that occurred in the patient’s care trajectory prior to the assisted dying request. (Indeed, the assisted dying request may in some cases have developed as a consequence of palliative futility.) The research authors are even explicit about this:

“The reporting form does not record whether patients have previously received palliative care.” — Dierickx, Deliens, Cohen et al2

Contrary to Best and Colyer’s indefensible assumption, empirical research evidence indicates that around 74% of assisted dying cases in 2013 at least in Flanders, the Dutch-speaking larger half of Belgium, involved specialist PC services.4 The Dierckx et al2 data is also in respect only of PC-primary-specialist consults. Many Belgian physicians, especially but not only many oncologists, themselves hold PC sub-specialty endorsements, yet only their primary organ or disease specialty is recorded on the report forms.

The 74% PC consult figure of course by definition excludes those who made a request but who subsequently rescinded it (i.e. not captured in the data because there was no assisted death). The patient may have rescinded their request as a consequence of PC consultation. Other published scientific research indicates that in 2013 around 18% of Belgian assisted dying requesters revoked their request.5

Indeed, more than half (59%) of Belgian patients making a request in 2013 died before the consulting team had reached a decision, and 7.5% of requests were denied by physicians because the patient wasn’t terminally ill even though that is not a requirement of the law.5 The wider evidence suggests that Belgian doctors remain conservative and cautious rather than pursuing poor practice as Dr Best and Ms Colyer invalidly attempt to conclude.

What is “very low”?

Just for good measure, let’s compare a Belgian assisted dying 74% PC consult rate with the general PC rate in Australia (where assisted dying is illegal). There’s precious little data around and Palliative Care Australia didn’t respond to two requests. [Addendum 5th Oct: Palliative Care Australia responded but advised that to the best of their knowledge the specific statistics were not available.] The closest relevant official data I could find with hours of intensive research, reports that in 2011-12, 39.5% of hospital inpatients who died received PC consults.6 Of course, PC consults can only be relevant in respect of non-sudden deaths because there’s no opportunity to make such decisions in a relatively sudden death. About two thirds of all deaths are not ‘sudden,’ so let’s adjust up the original figure to reflect that, resulting in a hospital non-sudden-death PC consult rate of around 60%.

Half (50%) of all deaths in Australia occur in hospitals, 38% in residential and community (i.e. other institutionalised) care, and just 12% elsewhere (mostly at home).6 Let’s say for the sake of argument (and lack of data) that the PC consult rate for other institutions is similar to hospitals. Let’s also assume that of (two thirds non-sudden) deaths at home, all of them received palliative care consults. That raises the Australian PC consult rate to around 68% of all non-sudden deaths. Maybe the real figure is somewhat higher or lower.

But it is wholly incorrect to conclude, given Belgium’s Flemish PC consult rate for assisted dying at 74%, that the Belgian palliative care consult rate is “very low” as the two ‘expert’ PC commentators wrongly assert and Sarah Colyer reports on the basis of data about a different measure.

Conclusion

The AMA widely promotes evidence-based decision making, but it has comprehensively offended its standard in regard to this issue. The AMA’s response to this further critique will give the Australian public a strong indication as to its intent, ethics and credibility. Of course, I'll let you know how they respond.

As for Dr Megan Best offering such ill-considered and evidence-defying nonsense as ‘expert opinion,’ I would hope that she permanently retires from offering commentary.

Now at least you can see the kinds of rubbish arguments that the conservative medical establishment uses to justify opposing your right to consider an assisted death.

 

Inexpert opinion via the AMA’s MJA

Through its MJA InSight article and response, the AMA has published and defended misinformation against assisted dying, a choice that the overwhelming majority of Australians want on the table, but which the AMA explicitly opposes.

  1. First up, the AMA tried to bury my critique of its incoherent and incorrect ‘expert opinion’ by deleting the critique.
  2. Then it tried to argue that its published misinformation was nothing to do with the AMA.
  3. It confirmed that it had reported a cherry-picked non-significant ‘trend’ from a research paper’s data that was, coincidentally, consistent with AMA opposition to assisted dying, while omitting to mention a highly statistically significant trend—in the same table of data—that contradicted the AMA and commentators’ stance.
  4. Its article and critique response argued that PC must be involved in approving assisted dying requests at the same time that Palliative Care Australia insists that assisted dying is nothing to do with PC.
  5. It fictionally asserted that the Belgian research paper suggested PC specialists were merely ‘notified,’ while the research paper said no such thing and referred repeatedly to ‘consultation.’
  6. It ignorantly claimed that the Belgian PC consult rate was “very low” (when it isn’t) on the basis of what happened only after an assisted dying request, ignoring that PC consults can and do occur before an assisted dying request.

 

References

  1. Colyer, S 2016, Belgian euthanasia model splits Aussie experts, MJA InSight, viewed 26 Sep 2016, https://www.doctorportal.com.au/mjainsight/2016/37/belgian-euthanasia-model-splits-aussie-experts/.
  2. Dierickx, S, Deliens, L, Cohen, J & Chambaere, K 2016, 'Euthanasia in Belgium: Trends in reported cases between 2003 and 2013', CMAJ, September 12, 2016.
  3. Palliative Care Australia 2016, Euthanasia and physician assisted suicide: Position statement, viewed 1 Sep 2016, https://palliativecare.org.au/download/2448.
  4. Chambaere, K, Vander Stichele, R, Mortier, F, Cohen, J & Deliens, L 2015, 'Recent trends in euthanasia and other end-of-life practices in Belgium', N Engl J Med, 372(12), pp. 1179-1181.
  5. Dierickx, S, Deliens, L, Cohen, J & Chambaere, K 2015, 'Comparison of the expression and granting of requests for euthanasia in Belgium in 2007 vs 2013', JAMA Internal Medicine, 175(10), pp. 1703-1706.
  6. Swerissen, H & Duckett, S 2014, Dying well, Grattan Institute, Carlton, Victoria, pp. 37.

 

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Dr Megan Best at 'The Palliative Care Bridge'

The Australian Medical Association (AMA) has just published an article about the Belgian assisted dying law experience, which it says “splits Aussie experts.” But the AMA report indicates that at least one, Dr Megan Best, gets her facts fundamentally wrong.

AMA writer Sarah Colyer reports on Belgian assisted dying practice in the latest edition of MJA InSight, “Belgian euthanasia model splits Aussie experts.”

In the article, Colyer writes (and let’s assume she’s quoting Dr Best accurately and fairly):

Dr Megan Best, a bioethicist and palliative care practitioner at Greenwich Hospital in Sydney, told MJA InSight:
 

“I am concerned by the reduction in referral to palliative care doctors and specialists in the euthanasia approval process, as GPs are less likely to know whether or not the suffering can be alleviated – the keystone of the act,” she said.
 

“This is a weakening of the due process of the act and suggests that the ‘safeguards’ are seen more as a barrier to be overcome than an opportunity to improve life to the extent that euthanasia is no longer necessary.”

Colyer was reporting, and Best was providing commentary on a study of assisted dying practice in Belgium recently published in the Canadian Medical Association Journal.

Dr Best selects one factoid (the increase in second-opinions from GPs)—and claims there’s been a reduction in palliative care referrals—to argue a case that Belgium’s is a risky model.

And she’s absolutely wrong.

In the detail of the report (where you have to look to find the mention of GP second-opinions which she reports correctly), is also the clear statement that:

“…the proportion of cases in which at least one palliative care team was consulted about the request increased [with high statistical significance].”

But you don’t even have to read the whole report from cover to cover to find that out, even assuming that you had access to the full report—it’s behind a subscription paywall. Right there on ‘the cover of the tin’ (the publicly-available Abstract), it says in plain English that:

“Palliative care teams were increasingly often consulted about euthanasia requests, beyond the legal requirements to do so [with high statistical significance]” and “palliative care teams were increasingly consulted about the euthanasia request” [at least in respect of Flemish cases]

So, while Dr Best claims the study reported a “reduction in referral to palliative care doctors” the study itself says the exact opposite in multiple places: “palliative care teams were increasingly often consulted.” While Dr Best claims “a weakening of the due process of the Act”, the evidence in regard to palliative consults demonstrates the opposite: “a strengthening of the due process of the Act.”

Is this another example of the religiously opposed noticing ‘evidence’ that apparently supports their stance while failing to notice solid evidence (and in this case in a sentence immediately adjacent to the selected one) that contradicts that stance?

I have no doubt that Dr Best is an excellent palliative care practitioner, but in this matter she is utterly and evidentially wrong—and the evidence was anything but 'buried' in the report on which she chose to provide 'expert' commentary.

I ask the AMA to add an addendum to the article on their website, correcting the erroneous statement that there was a "reduction in referral to palliative care doctors."


Who is Dr Megan Best?

Dr Megan Best is an experienced palliative care physician and Chief Medical Officer for Community Palliative Care at Greenwich Hospital in NSW. The hospital is a Christian charity which believes all people are made in the image of God, and which operates according to the Gospel of Jesus Christ. Dr Best is a Fellow of the Centre for Public Christianity in Sydney, a media company offering “high-quality and well-researched” material to the public via the mainstream media, and is its spokesperson for palliative care.

She is author of Fearfully and Wonderfully Made, a “biblically-based ethical handbook” which holds “the Christian Bible as authoritative” and in which she concludes “may the God of all comfort hold you in the palm of his hand.” She is also author of A Life Already Started, giving advice to women faced with unwanted pregnancy that “God has not left you to manage on your own.” She is also a regular contributing writer to the Centre for Christian Apologetics, Scholarship and Education.

Dr Best completed her Master of Arts in Applied Ethics in Health Care at the Australian Catholic University in 2001.

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Back in 2013 the High Court of Ireland rejected a legal bid by multiple sclerosis sufferer Marie Fleming to achieve a lawfully-assisted peaceful death.

The Court naturally relied on expert testimony in reaching its judgement, yet its conclusions included a statement containing significant errors of fact.

The erroneous statement

In its judgement,1 the Court made the following statement:

Above all, the fact that the number of LAWER (“legally assisted deaths without explicit request”) cases remains strikingly high in jurisdictions which have liberalised their law on assisted suicide (Switzerland, Netherlands and Belgium) — ranging from 0.4% to over 1% of all deaths in these jurisdictions according to the latest figures — without any obvious official response speaks for itself as to the risks involved.” [My emphases in bold]

In fact, the Court's judgement is wrong on not one, not two, but three significant matters. But that hasn't stopped opponents of assisted dying law reform from quoting the judgement as though it were factual and persuasive, when it isn't: relying on it because it was made by a High Court—the 'authority bias.'

Consequences

Here are just a few examples of the Court's statement being wielded by assisted dying opponents as though it were conclusive evidence against law reform:

 
These examples illustrate the frequency of quoting the misinformation and how it feeds into and wrongly shapes public policy formation.

Three strikes

So what are the three counts on which the Court's judgement was seriously wrong?

Strike 1: Wrong concept

First, let’s get the concepts right. LAWER is not “legally assisted deaths without explicit request.”

Such nomenclature is an oxymoron. To ‘assist’ is to accommodate, serve or help someone accomplish something. But if there has been no request then one cannot be helping. You can’t ‘assist’ a little old lady across the road if she has expressed no interest in going there: you’d be forcing her across the road. Equally, you can’t ‘assist’ a death if there’s no proper ‘request.’

LAWER in fact stands for “Life-ending Acts Without Explicit Request” (of a competent patient).5 And with the exception of the possible ‘lawfulness’ of the doctrine of double effect, such acts are illegal.

Further, if such acts were legal as the Court’s statement posits, then there would be no need for an “obvious official response” as the Court then concludes. The statement lacks fundamental coherence.

Strike 2: Not ‘strikingly high’

The Court's judgement states unequivocally that LAWER (otherwise known as Non-Voluntary Euthanasia or NVE) rates in Switzerland, the Netherlands and Belgium are ‘strikingly high’, though no comparative yardstick is recorded in the judgement by which one might draw or justify that subjective judgement. Similar 'strikingly high' statements also appear in sections 102 and 104 of the judgement.

There is in fact a scientific study, published in The Lancet in 2003, that provides sound empirical evidence that could have properly informed the Court (Figure 1).6

Non-voluntary euthanasia in seven European countriesFigure 1: The non-voluntary euthanasia (NVE) rates of seven European countries in late 2001/early 2002

As revealed by this study, the NVE rates in Switzerland and the Netherlands were in fact lower than in Denmark, a country which has never had an assisted dying law.

The only country which did appear to have an NVE rate notably higher than the others was Belgium. The research study collected the data for analysis between June 2001 and February 2002. However, Belgium’s Euthanasia Act was not passed by its Parliament until 28th May 2002, well after data collection was complete. Thus, even in describing Belgium’s NVE rate as ‘strikingly high’ compared to a number of other European countries, it cannot be attributed to an assisted dying law because none existed at the time.

In fact, the NVE rate in Belgium had been found to be high back in 1998,7 well before the Bill for the country's Euthanasia Act was even tabled in Parliament.

Further, if assisted dying laws had such effects, it might be expected that the NVE rate would increase the longer that assisted dying laws were in place. In that case the NVE rates in Switzerland (statute since 1942) and the Netherlands (regulation since the early 1980s) would have NVE rates much higher than Belgium’s (statute since 2002). But the exact opposite is true.

Indeed, Rietjens and colleagues8 further concluded in their review of NVE in the Netherlands, Belgium, Denmark and Switzerland that “the use of drugs with the intention to hasten death without an explicit request of the patient is part of medical end-of-life practice in the studied countries, regardless of their legal framework, and it occurs in similar fashion.” The study, published in 2007, would also have been important evidence before the Court.

Strike 3: Not ‘remaining’ high

The Court's judgement states unequivocally that the LAWER (NVE) rate of the three countries ‘remains’ strikingly high. No specific evidence was supplied in the judgement to support this statement. Indeed, the judgement notes:

  • In section 28 that Dutch NVE had been “consistently declining.”
  • In section 91 that “the number of LAWER deaths has significantly declined in both [Dutch and Belgian] jurisdictions.”
  • In section 94 that “the trend in [Dutch] LAWER cases are declining in numbers (from 1,000 in 1990 to 550 in 2005)” and that in Belgium “the number of LAWER cases has declined since legalisation of assisted death.”
  • In section 101 that the NVE rates of both the Netherlands and Belgium had dropped.

 
Despite this clear and repeated evidence, the Court summarises in section 96 that the evidence cannot be “regarded as encouraging or satisfactory.”

But what does empirical research tell us about the NVE trends? In both the Netherlands and Belgium, since assisted dying was enshrined in statute and became effective in 2002, the rate of NVE has decreased significantly (Figure 2).7,9-11 In fact, the rate in the Netherlands is now similar to that in the UK, a country which has never had an assisted dying law and which provides the world’s gold standard in palliative care practice.

Non-voluntary euthanasia rates have decreased in the Netherlands and BelgiumFigure 2: Empirical trends in NVE rates before and after legalisation of assisted dying

These are critical yardsticks by which to judge practice in jurisdictions that have assisted dying laws with jurisdictions that don't. The UK study was published in 2009 and was readily available prior to the High Court’s hearings, yet appears not to have been presented in evidence.

The final (2010) Dutch NVE statistic in Figure 2 may or may not have been available to the Court: it was published in 2012 around the time the Court was taking evidence. The final (2013) Belgian statistic would not have been available to the Court as it was published in 2015.

Conclusion

While the High Court worked diligently within the scope of evidence brought before it:

  • The Court’s definition of LAWER is incorrect and incoherent;
  • Its statement that the NVE rates of the Netherlands and Switzerland are ‘strikingly high’ are evidentially wrong when compared with other countries without assisted dying laws;
  • Its implication that the higher NVE rate in Belgium was caused by assisted dying law reform is evidentially wrong; and
  • Its statement that the rates remain high is evidentially wrong.

 
The High Court's judgement does not provide defensible evidence or argument against assisted dying law reform.

Many lobbyists have repeated these incorrect statements, significantly misleading media, policy makers and legislators.

Now that the facts are readily available it’s appropriate to avoid repeating evidentially wrong statements, regardless of the apparent 'authority' of their source.
 

Summary of facts

  1. LAWER stands for "Life-ending Acts Without Explicit Request". Its practice is similar in countries with and without assisted dying laws.
  2. The NVE rates in the Netherlands and Switzerland are lower than the rate in Denmark, a country which has never had an assisted dying law.
  3. The NVE rate in Belgium appears higher, but was so long before assisted dying law reform and so cannot have been caused by such a law.
  4. The NVE rates of the Netherlands and Belgium have both decreased significantly since their assisted dying statutes came into effect in 2002.

References

  1. High Court of Ireland 2013, Fleming v Ireland & Ors - Determination, [2013] IEHC 2, Dublin.
  2. Boudreau, JD, Somerville, MA & Biller-Andorno, N 2013, 'Physician-assisted suicide: should not be permitted/should be permitted', New England Journal of Medicine, 368(15), pp. 1450-1452.
  3. Somerville, M 2016, 'Killing as kindness: The problem of dealing with suffering and death in a secular society', The Newman Rambler, 12(1), pp. 1-26.
  4. Keown, J 2014, 'A right to voluntary euthanasia? Confusion in Canada in Carter', Notre Dame Journal of Law, Ethics & Public Policy, 28(1), pp. 1-45.
  5. Pijnenborg, L, van der Maas, PJ, van Delden, JJM & Looman, CW 1993, 'Life-terminating acts without explicit request of patient', Lancet, 341(8854), pp. 1196-1199.
  6. van der Heide, A, Deliens, L, Faisst, K, Nilstun, T, Norup, M, Paci, E, van der Wal, G & van der Maas, PJ 2003, 'End-of-life decision-making in six European countries: descriptive study', The Lancet, 362(9381), pp. 345-350.
  7. Bilsen, J, Cohen, J, Chambaere, K, Pousset, G, Onwuteaka-Philipsen, BD, Mortier, F & Deliens, L 2009, 'Medical end-of-life practices under the euthanasia law in Belgium', New England Journal of Medicine, 361(11), pp. 1119-1121.
  8. Rietjens, JA, Bilsen, J, Fischer, S, Van Der Heide, A, Van Der Maas, PJ, Miccinessi, G, Norup, M, Onwuteaka-Philipsen, BD, Vrakking, AM & Van Der Wal, G 2007, 'Using drugs to end life without an explicit request of the patient', Death Studies, 31(3), Mar, pp. 205-21.
  9. Seale, C 2009, 'End-of-life decisions in the UK involving medical practitioners', Palliat Med, 23(3), pp. 198-204.
  10. Onwuteaka-Philipsen, BD, Brinkman-Stoppelenburg, A, Penning, C, de Jong-Krul, GJF, van Delden, JJM & van der Heide, A 2012, 'Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey', The Lancet, 380(9845), pp. 908-915.
  11. Chambaere, K, Vander Stichele, R, Mortier, F, Cohen, J & Deliens, L 2015, 'Recent trends in euthanasia and other end-of-life practices in Belgium', N Engl J Med, 372(12), pp. 1179-1181.
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