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An article in 'Anasthesia' did NOT find high rates of regaining consciousness in contemporary VAD practice.

A recent article by Sinmyee et al, "Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying", published in the journal Anasthesia1 was an attempt to identify a professional standard for inducing and maintaining unconsciousness prior to voluntary assisted dying (VAD) death, a laudable aim.

However, the authors’ underlying premise of contemporary VAD practice failing to reliably maintain unconsciousness — potentially leading to 'inhumane deaths' — is not established by their cited sources. They cite exactly three sources to establish their claim: their citations 31, 32 and 33.

Citation 31 — Iserson et al 1992

This is a qualitative article by Ken Iserson and colleagues.2 Published in 1992, it outlines a single case of assisted suicide, forming the backdrop for several Californian ethics committees to comment.

Not only was this a single case rather tha a sample of dozens or hundreds of cases, but assisted dying was illegal right across the USA in 1992 and earlier. Therefore, the article is wholly uninformative to contemporary practice under assisted dying laws.

Citation 32 — Groenewoud et al 2000

This is a study by Johanna Groenewoud and colleagues.3 Published in 2000, it analyses Dutch data collected between 1990 to 1996 — long before the Netherlands’ 2001 euthanasia Act, which came into effect in 2002.

In 1997 the Dutch medical association (KNMG) formed the Support and Consultation on Euthanasia in Amsterdam (SCEA) network to assist doctors implement the practice more reliably. The successful program was made national (…in the Netherlands, SCEN) in 1999, with a four-year implementation resulting in strong consultation and positive outcomes.4

In addition, the KNMG and Dutch pharmacy association (KNMP) have improved their guidelines for euthanasia practice since 1996: in 1998, 2007 and most recently in 2012.5 Independent studies show that use of opioids (inappropriate method) was high in the Netherlands in 1995-96,6 but replaced entirely with (appropriate) barbiturates and neuromuscular relaxants in reported VAD cases in 2010.7

The most recent published report of the Dutch Euthanasia Commission, which assesses every reported case of VAD, did not note any failures of the VAD procedures.8

Citation 33 — Lalmohamed & Horikx 2010

This is a study by Arief Lalmohamed and Annamieke Horikx, published in 2010, of doctor responses to a survey the KNMP conducted between 2007 and 2009.9 The study reported on issues with the storage, preparation and administration of VAD drugs. It noted that the recommended dose of Thiopental was increased from 1500mg to 2000mg so that patient-dependent dosages need not be calculated.

The study noted one negative experience for some patients: pain on injection of Thiopental. Recommendations were made for preparation and administration of the drug to avoid this problem. No other negative patient outcomes were reported.

The upshot

Thus, of the three sources the authors employed to make the case of a significant and systematic problem in the conduct of contemporary VAD cases, none did so: the first was a single case outside the law in the early 1990s, the second a study from the early to mid 1990s from whence contemporary practice has greatly improved, and the third a 2010 pharmacological investigation that found some patients experiencing pain on injection and recommending improvements to avoid it. Nevertheless, Sinmyee et al concluded that:

“For all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and reawakening from coma (up to 4%), constituting failure of unconsciousness.”

These assertions are highly misleading in regard to contemporary VAD practice.

The most recent Oregon Death With Dignity Act annual report, covering all cases from 1997 to early 2019 reports that just eight of 1,467 deaths where lethal medication was consumed, resulted in the patient regaining consciousness.10 That’s an efficacy rate of 99.5%, a high standard for a medical procedure.

There have been no cases of regaining consciousness in Washington state under their Death With Dignity Act.11

In comparison, regaining consciousness under professional surgical anaesthesia is a problem12 with an incidence rate of around 0.13% in the USA13 though the rate appears to be much lower in the UK.14 Even over-the-counter analgesics like paracetamol, ibuprofen and aspirin have significant adverse effects rates of 14.5%, 13.7% and 18.7% (respectively).15

From unsubstantiated to polemical

While Sinmyee and colleagues were attempting, via their article in Anasthesia, to argue the case for improved VAD practice, it was inevitable that ginger groups opposing the legalisation of VAD would commandeer cherry-picked extracts from the article to further their cause, painting a picture of disaster and mayhem.

Sure enough, the Catholic-backed Euthanasia Prevention Coalition’s Alex Schadenberg ran with it, cherry picking the “190 times higher” rate the authors claim for “failure of unconsciousness” using their invalid citations. Schadenberg conspiratorially concluded that “the laws are designed to cover-up [sic] problems with the law”.16

Also, predictably, Catholic-backed HOPE’s Branka van der Linden followed suit, plucking quotes like “…failure rates of assisted dying by these other methods seems extraordinarily high” without similar context.17

It’s disappointing that the original article with its misleading statistics based on figures plucked from a single historical article and in the absence of considering significant intervening improvements, passed peer review. Its misinformation led to more nonsense being energetically pedalled by anti-VAD campaigners.

 

References

  1. Sinmyee, S, Pandit, VJ, Pascual, JM, Dahan, A, Heidegger, T, Kreienbühl, G, Lubarsky, DA & Pandit, JJ 2019, 'Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying', Anaesthesia, 74(5), pp. 630-637.
  2. Iserson, KV, Rasinski Gregory, D, Christensen, K & Ofstein, MR 1992, 'Willful death and painful decisions: A failed assisted suicide', Cambridge Quarterly of Healthcare Ethics, 1(2), pp. 147-158.
  3. Groenewoud, JH, van der Heide, A, Onwuteaka-Philipsen, B, Willems, DL, van der Maas, PJ & van der Wal, G 2000, 'Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands', New England Journal of Medicine, 342(8), pp. 551-556.
  4. Jansen-Van Der Weide, MC, Onwuteaka-Philipsen, BD & Van Der Wal, G 2004, 'Implementation of the project 'Support and Consultation on Euthanasia in the Netherlands' (SCEN)', Health Policy, 69(3), pp. 365-373.
  5. KNMG/KNMP 2012, Guidelines for the practice of euthanasia and physician-assisted suicide, Utrecht, pp. 56.
  6. van der Maas, PJ, van der Wal, G, Haverkate, I, de Graaff, CL, Kester, JG, Onwuteaka-Philipsen, BD, van der Heide, A, Bosma, JM & Willems, DL 1996, 'Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995', N Engl J Med, 335(22), pp. 1699-705.
  7. 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.
  8. Regional Euthanasia Review Committees (Netherlands) 2018, Annual report 2017, Arnhem, pp. 66.
  9. Lalmohamed, A & Horikx, A 2010, '[Experience with euthanasia since 2007: Analysis of problems with execution] Ervaringen met euthanastica sinds 2007: Onderzoek naar problemen in de uitvoering', Ned Tijdschr Geneeskd, 154(A1983), pp. 1-6.
  10. Oregon Health Authority 2019, Oregon Death With Dignity Act: 2018 data summary, Department of Human Services, Portland, pp. 16.
  11. Washington State Department of Health 2018, Washington State Department of Health 2017 Death with Dignity Act Report, Olympia, WA, pp. 15.
  12. Cook, TM, Andrade, J, Bogod, DG, Hitchman, JM, Jonker, WR, Lucas, N, Mackay, JH, Nimmo, AF, O'Connor, K, O'Sullivan, EP, Paul, RG, Palmer, JH, Plaat, F, Radcliffe, JJ, Sury, MR, Torevell, HE, Wang, M, Hainsworth, J, Pandit, JJ, Royal College of, A, the Association of Anaesthetists of Great, B & Ireland 2014, 'The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues', Anaesthesia, 69(10), pp. 1102-16.
  13. Sebel, PS, Bowdle, TA, Ghoneim, MM, Rampil, IJ, Padilla, RE, Gan, TJ & Domino, KB 2004, 'The incidence of awareness during anesthesia: A multicenter United States study', Anesthesia & Analgesia, 99(3), pp. 833-839.
  14. Thomas, G & Cook, TM 2016, 'The United Kingdom National Audit Projects: a narrative review', Southern African Journal of Anaesthesia and Analgesia, 22(2), pp. 38-45.
  15. 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.
  16. Schadenberg, A 2019, Assisted dying can cause inhumane deaths, Euthanasia Prevention Coalition, viewed 25 Feb 2019, http://alexschadenberg.blogspot.com/2019/02/assisted-dying-can-cause-inhumane-deaths.html.
  17. van der Linden, B 2019, The "myth" of a pain-free euthanasia death, HOPE, viewed 22 Mar 2019, https://www.noeuthanasia.org.au/the_myth_of_a_pain_free_euthanasia_death.
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'HOPE' is pedalling assisted dying misinformation to politicians again.

The Catholic-backed anti-assisted-dying ginger group, HOPE, was represented for years by Paul Russell. He's retired and Branka van der Linden is now at the helm. But its penchant for pedaling egregious misinformation hasn't changed. Van der Linden recently sent an email to all WA members of parliament, containing three points.

Van der Linden's email reads:

 

Dear [MP salutation],

Did you know that the WA majority report that recommended assisted suicide for WA either dismissed or failed to report on the following statistics?

  • In the Netherlands in 2015, 431 people were euthanised without their explicit consent.
  • In Belgium, 8 per cent of all deaths were without explicit consent from the patient.
  • In Oregon in 2017, the ingestion status of 44 (out of 218) patients was ‘unknown’, making it impossible to ascertain if these 44 patients ended their lives voluntarily and without coercion.

Yours faithfully,

Branka van der Linden

Director, HOPE

 

The trouble is, all three claims by van der Linden are either directly false or egregiously misleading. Here are the actual facts:

FACT: Peer-reviewed scientific research shows that the non-voluntary euthanasia rate of both the Netherlands and Belgium has dropped significantly since their assisted dying Acts came into effect in 2002, consistent with more careful end-of-life decision making across the board.

Fiction 1: van der Linden improperly cherry-picked a single year’s statistic for each country (and, incoherently, a raw count for one but a percentage for the other), implying that lawful voluntary euthanasia increases non-voluntary euthanasia, when the opposite is true.

Fiction 2: van der Linden claimed Belgium’s non-voluntary euthanasia rate is 8%. It has never been anywhere near that figure: the most recent figure is 1.7% and it was 3.2% before Belgium’s euthanasia law.

FACT: Oregon’s health department actively matches death certificates with prescriptions issued for assisted dying. At any time some prescriptions have not been taken and the person may still be alive, and for the deceased, death certificates are still being processed. This naturally means that some prescription/death statuses will temporarily be ‘unknown’ to authorities, even though they will be later determined.

Fiction 3: van der Linden comically implies that this proper process is sinister.

It's curious how 'HOPE' likes to repeatedly demonstrate how HOPElessly uninformed it is about the actual facts and that its methods include cherry-picking data which it thinks supports its anti-assisted dying case, but which don't.

Western Australians deserve better than HOPE's silly propaganda campaign.


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A forensic analysis exposes Theo Boer's smoke and mirrors on 'suicide contagion'

In my most recent article in the Journal of Assisted Dying, I forensically analyse Dutch ethicist Professor Theo Boer’s 2017 paper purporting to find suicide contagion from assisted dying in the Netherlands. It doesn’t go well for Professor Boer, to put it mildly. You can find the full article here.

I also find an astonishing coincidence that occurred in 2014, the year Boer went feral against the Dutch euthanasia law.

Multiple fatal flaws

In the ‘analysis’ outlined in his article, Boer commits a number of fatal scientific no-noes, including failing to analyse the variable he actually surmised might cause suicide contagion, cherry-picking data that supported his conclusion while ignoring or offhandedly dismissing data at odds with his conclusion, and wrongly forming a causative conclusion from a simple correlation while failing to control for any confounding variables of which there are many.

A litany of scientific offences

In addition to the fatal flaws, Boer’s article contains numerous other scientific and academic offences. My forensic analysis concludes:

“In summary, Boer’s article contains a litany of scientific and scholarly failures. Its speculations are ill-informed, poorly-assembled, incoherent in places and mostly uncited, the data cherry-picked and invalidly interpreted, and the laissez faire methodology incapable of validly supporting its conclusion.
 

Boer conjures up mere smoke and mirrors to argue suicide contagion from VAD in the Netherlands. The article should be retracted.”

The article also reflects badly on the journal that published this smoke and mirrors: the Journal of Ethics in Mental Health. Neither peer review nor editorial effort identified or attempted to correct any of the nonsense in the article.

What was he thinking?

Professor Boer is an expert in Reformist Protestant theology. As a religious ethicist, it’s astonishing that he considered himself suited to conducting and publishing a ‘causative’ scientific study.

In his article, Boer proposed VAD as the only factor to contribute to changes in the Netherlands’ general suicide rate (and dismissed the Belgian data which contradicted his theory).

In reality, numerous risk and protective factors affect the suicide rate, and in the Netherlands as I’ve established using their official government data, just one factor — unemployment — explains 80% of the variance in the Dutch suicide rate since 1960. Boer casually dismisses this without providing the faintest fume of an empirical analysis himself.

Boer’s article did little but amply demonstrate his underlying anchoring and confirmation bias on the subject, his unfamiliarity with the complexity of suicide, and ignorance of proper scientific principles.

For good measure, he casually threw in a comment about “suicide contagion” or copycat suicides, without understanding that in suicide, copying is the method of causing death. But by definition, general suiciders don’t follow the provisions of the euthanasia Act.

His endeavour made as little sense as me writing a conclusive article about Reformist Protestant theology, about which I know very little.

A copycat analysis?

Coincidentally, the structure of the storyline, the litany of scientific offences committed, and the conclusions reached in Boer’s article were surprisingly similar to those in an ‘analysis’ of Oregon’s suicide rate in another paper by Jones and Paton. Like Boer, Jones and Paton start out by surmising that assisted dying ought to lower the general suicide rate, and conclude the opposite.

Boer approvingly cites the Jones and Paton article, even though a forensic analysis found no fewer than ten major scientific flaws in it and provided multiple sources of empirical evidence at odds with the article’s conclusions.

But Boer manages to cock even the citation up, referring to the article’s authors as Holmes and Paton.

Will the real Theo Boer please stand up?

Boer notes that he’s always been a euthanasia sceptic. Nevertheless, as a Reformist Protestant, he had long accepted assisted dying in “emergency” situations, of which intolerable and otherwise unrelievable suffering is a ‘qualifying’ criterion, and which is the substance of the Dutch euthanasia law (it’s regarded in legal circles as a law of “necessity”). He also opined that the Dutch model was a decent one that other jurisdictions could emulate.

Boer served as the ethicist member of one of the five Dutch euthanasia review commissions, examining every case reported to it between 2005 and 2014.

In 2014 he publicly quit his post on the review committee, slamming the Dutch assisted dying system. He’s been badmouthing it to anyone who will listen, since.

In preparation for this analysis, I asked Boer if his vocal opposition to the Dutch assisted dying model was now based on an in-principle opposition to assisted dying, or only in regard to more recent practice under the Dutch euthanasia Act. Despite a couple of iterations, I didn’t get a specific answer.

The law hasn’t changed

Here’s the point. While Boer repeatedly opines that things changed radically in the Netherlands around 2007, the country’s euthanasia Act hasn’t changed since it was passed in 2001 (and came into effect in 2002). Not. One. Word.

In addition, the Dutch Supreme Court determined in 1994 that individuals with mental (in the absence of concomitant physical) illness could qualify under the then regulatory euthanasia framework, and it was found that cases occurred every year.

And the 2001 Act formalised in statute the regulatory framework that had existed since at least 1984, when the Dutch medical association first published guidelines for euthanasia.

Thus, the Act reflects very long-standing practice, and it hasn’t changed since it was enacted, in contrast to Boer’s claim that things have radically changed.

Flimsy and incoherent ‘ethics’ part 1

This brings us to the first fatal incoherence of Boer’s “ethics”: that he now opposes the law because people with psychiatric illness and other conditions are, in slightly increasing numbers, availing themselves of the euthanasia law. It is these cases against which Boer rails, despite having previously said the Dutch model is a good example for the world, and having actively participated in the system.

Boer’s flip flop is to argue that a law that permits assisted dying under a range of medical conditions (and has done so for decades) is a good law, provided some of those who might qualify (like psychiatric cases) never use it.

Try and explain the ethics behind that position.

Flimsy and incoherent ‘ethics’ part 2

The second fatal incoherence of Boer’s ‘ethics’ is his repeated complaint that until around 2007, the numbers of euthanasia cases was “somewhat steady”, but increased after that. Never mind that the majority of the increase was still in relation to terminal cancer: Boer simply railed at the increased numbers as a major problem.

But, try and explain using ethical principles, why it is appropriate for 2,000 people a year to avail themselves of the euthanasia law, but inappropriate for 4,000 (who all qualify)?

Indeed, the Dutch euthanasia Act makes no mention of numbers: there is no legislated limit on the count of people who might choose to use the law. Rather, it is based on due care criteria, outlining the circumstances of who may qualify, and the process by which they may.

The legislature’s intent remains unchanged and is still being adhered to, though more people, the majority of whom have terminal cancer, are using the law.

It’s astonishing that a Professor of Ethics fails to reflect on the fatal incoherence of his own ‘ethical’ arguments.

What happened?

Boer, who had supported and promoted the Dutch euthanasia model suddenly and incoherently changed his position to vocally opposed in 2014. What happened?

One factor might shed some light. In 2014, Boer was appointed to the endowed professorship of Lindeboom Chair in Ethics in Healthcare at Kampen Theological University.

While Kampen Theological University is a Dutch Reformist Protestant institution and therefore may support assisted dying in “emergency” cases, the Lindeboom Institute, which endows Boer’s eponymous professorship, is less understanding.

The Lindeboom Institute was co-founded by several orthodox Christian institutions and cooperates with the Netherlands Evangelical University which studies science from an creationist Biblical perspective.

The Institute demands “biblically sound medical ethics” along with “Christian norms and values”. You’d be left wondering what that actually means, until you find on its website that the Board’s role is “the protection of people at all stages of life”.

In addition, participating organisations that fund the Lindeboom endowment, like the Dutch Patients Association, Pro Life Health Insurance and the Foundation for Christian Philosophy, are strongly opposed to assisted dying in any form.

It turns out that the authors of that other ‘analysis’ that commits numerous similar scientific offences which generate smoke and mirrors, Jones and Paton, are devout conservative Catholics.

Gosh. What a coincidence.


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Netherlands 'suicide contagion' from assisted dying: Theo Boer's smoke and mirrors


Author(s)

Neil Francis

Journal

Journal of Assisted Dying, vol. 4, no. 1, pp. 1–11.

Abstract

Background: Concerns had been raised about the scientific quality of a 2017 article by ethicist Theo Boer in which he theorised that lawful voluntary assisted dying (VAD) would potentially ‘dampen’ suicide rates, but drew the opposite conclusion: the suggestion that VAD cases have caused higher suicide rates.
Methods: A structured, forensic examination of the article was conducted.
Results: Numerous serious shortcomings were found, including (a) profound unfamiliarity with the complexity of suicide; (b) lack of a clear and specific pre-hoc methodology; (c) numerous unsupported speculations; (d) cherry-picked data and casual dismissal of data at odds with the conclusion; (e) a simple correlation interpreted as causation while failing to control for any confounding factors; (f) incoherent, contradictory and misleading statements; and (g) multiple editorial errors.
Conclusions: Boer’s article is poorly conceived and carelessly assembled, revealing unfamiliarity with both the subject matter and with scientific principles. The conclusions drawn are not supported by the article’s methodology or data. The article offers mere smoke and mirrors to conclude that VAD may increase suicide rates, at odds with wider evidence.

Article keywords

voluntary assisted dying, euthanasia, suicide contagion, Werther effect, Netherlands, methodology

Full PDF

Download the full PDF: Download the full article (5.4Mb)

Citation

Francis, N 2019, 'Netherlands "suicide contagion" from assisted dying: Theo Boer's smoke and mirrors', Journal of Assisted Dying, vol. 4, no. 1, pp. 1-11.

Download the citation in RIS format: RIS.gif


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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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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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More Dutch evidence contradicts Margaret Somerville's 'suicide contagion' theory

I’ve previously published an extensive analysis of how Professor Margaret Somerville, of the Catholic Notre Dame University of Australia, cherry-picked her way through select data that seemed to be (but wasn’t) consistent with her ‘contagion’ theory from assisted dying to the general suicide rate. I provided ample evidence from lawful jurisdictions that comprehensively contradicts her claim. I also published the summary in ABC Religion & Ethics.

Yet Somerville still says despite extensive real-world experience to the contrary, that “I believe that my [suicide contagion] statement will prove to be correct.”

She and her Catholic colleagues still hold onto several tenuous threads of information that might — just might — appear consistent with her theory, despite the truckloads of evidence to the contrary.

One of those tenuous threads is that the general suicide rate in the Netherlands has increased from 2008, around the same time that use of the Dutch euthanasia law also increased. (The general suicide rate previously fell as assisted dying rates increased.)

I reported official Dutch government statistics and expert financial reports to show that the unemployment rate explains most (80%) of the variation in the Dutch general suicide rate since 1960, and that the Netherlands was particularly hard-hit by the global financial crisis from 2008 — whereas neighbouring Belgium wasn’t and its suicide rate dropped as assisted dying numbers increased. Unemployment in hard times is a known significant risk factor for suicide.

Now, a detailed and peer-reviewed analysis of Dutch data recently published in the Netherlands Journal of Medicine throws more mud in the face of Somerville’s theory.1

The research looked at the Dutch assisted death and general suicide rates from 2002 through 2014, separately for each of the five Euthanasia Commission reporting regions.

Headline results of the averages for 2002–14 are shown in Figure 1.

netherlandsfiveregionmap.jpgFigure 1: The average assisted death rate (and suicide rate) as a percent of all deaths by region, 2002-14
Source: Koopman & Putter 2016

As you can see, Region 3, which includes Amsterdam, had by far the greatest assisted death rate (3.4%), compared with the other four regions (1.7% – 2.0%). Yet Region 3’s suicide rate at 1.2% was the same as Region 5 which had only half the assisted death rate of Region 3 (1.7% vs 3.4%). (The authors, unusually, expressed suicides as a percentage of all deaths rather than per 100k population.)

The results are the opposite of Somerville’s theory which says that Region 3’s general suicide rate should be much higher than (not the same as) Region 5’s.

Those figures are the average for 2002–14. It’s possible that the picture is a little different for the more recent years in which the assisted dying rate is higher.

To answer that question, I’ve retrieved official Dutch Government data and calculated the assisted dying rates and general suicide rates for 2014 alone, the most recent year for which all the data is available. I’ve also calculated the general suicide rate per 100,000 population, the more usual way of reporting and comparing suicide statistics. The results are shown in Figure 2.

dutchregionsveandsuicide2014.gifFigure 2: The Dutch assisted death rate and general suicide rate by region for 2014
Sources: Euthanasia Commission annual reports, Dutch Government statistics

While region 1 (the far north) has the lowest assisted death rate (3.2% of all deaths), it has by far the highest general suicide rate (13.6 per 100k population).

The latest Dutch regional data shows the opposite of Margaret Somerville’s ‘suicide contagion’ theory, adding to the already extensive evidence against it.Conversely, region 3 (which includes Amsterdam) has by a very large factor the highest assisted dying rate (6.0% of all deaths), yet it has the second-lowest general suicide rate (10.3 per 100k population).

This latest empirical evidence is consistent with other extensive evidence I’ve published showing an inverse — or no — relationship between assisted dying rates and general suicide rates.

The question is whether Margaret Somerville and her Catholic friends will pay the slightest attention, or continue to rely on invalid, cherry-picked morsels of data that they think support their theory, but don’t.

 

References

  1. Koopman, JJE & Putter, H 2016, 'Regional variation in the practice of euthanasia and physician-assisted suicide in the Netherlands', Netherlands Journal of Medicine, 74(9), pp. 387-394.

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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.

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

Catholic Professor of Ethics Margaret Somerville claimed in a University address that elderly Dutch people are fearful of being euthanased in nursing homes and hospitals and instead travel to Germany for health care.

She provided no sources or evidence for her claim.

Dr Els Borst, the Minister resonsible for the Netherlands' euthanasia law, reveals these claims about 'fear of being killed' in nursing homes as 'absolute lies.' Dutch Senator Heleen Dupuis confirms that it is untrue.

The claim is popular amongst opponents of assisted dying law reform. It raises questions about how a Professor of Ethics came to state is as authoriative fact.

Transcript

Neil Francis: Former Dutch Minister for Health, Dr Els Borst, shared an experience her Government had with the Vatican about assisted dying

Els Borst: Their journal, the Osservatore Romano, was writing, was publishing articles saying that in the Netherlands, people who went to a nursing home or an old people's home, didn't dare to do that any more because they were so afraid they would be killed by their doctor after a week or so.

Els Borst: And we were so angry about this, absolute lies, that we went together, to the Vatican, and we told them that if they didn't stop that sort of lies in their journal, that we would stop diplomatic relations with Vatican City.

Els Borst: We had an ambassador there, and my colleague the Minister for Foreign Affairs said, "I'll withdraw that ambassador and he'll never return."

Else Borst: And then it stopped.

Neil Francis: Well perhaps the Vatican did, but here's Catholic Professor of Ethics, Margaret Somerville.

Margaret Somerville: Old Dutch citizens are seeking admission to nursing homes and hospitals in Germany, which has a strict prohibition against euthanasia because of its Nazi past, and they're too frightened to go into nursing homes or hospitals in the Netherlands.

Neil Francis: I asked Dutch Senator, Professor Heleen Dupuis, about the claim.

Heleen Dupuis: OK, stupid. It is simply not true.

Neil Francis: It's time to stop spreading such fearmongering scuttlebutt.

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