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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.)

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

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

Note: the report is now published here.

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

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

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

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

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

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

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

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

Note: the report is now published here.


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

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

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

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

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

Avoiding burdensome and questionable invasive care

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

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

Facilitating a non-institutionalised death

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

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

Hospice care received at home

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

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

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

Death preferred at home

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

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

Conclusion

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

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

 

References

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

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Alex Schadenberg's latest shrill and misleading article

Catholic Canadian anti-assisted-dying blogger Alex Schadenberg is at it again. This time he’s parading his ignorance and spreading bull about a potential change in Oregon’s assisted dying legislation.

The Bill

Mr Schadenberg correctly reproduced Section 3 of Oregon Senate Bill 893, which states:

SECTION 3. An expressly identified agent may collect medications dispensed under ORS 127.815 (1)(L)(B)(ii) and administer the medications to the patient in the manner prescribed by the attending physician if:

(1) The patient lawfully executed an advance directive in the manner provided by ORS127.505 to 127.660;

(2) The patient’s advance directive designates the expressly identified agent as the person who is authorized to perform the actions described in this section;

(3) The patient’s advance directive includes an instruction that, if the patient ceases to be capable after medication has been prescribed pursuant to ORS 127.800 to 127.897, the expressly identified agent is authorized to collect and to administer to the patient the prescribed medication;

(4) The medication was prescribed pursuant to ORS 127.800 to 127.897; and

(5) The patient ceases to be capable.

Mr Schadenberg fails to mention Section 2, which states:

SECTION 2. Section 3 of this 2017 Act is added to and made a part of ORS 127.800 to 127.897.

What is the ORS range?

And what precisely isORS 127.800 to 127.897’ (ORS = Oregon Revised Statutes)? Why, it’s the entirety of Oregon’s existing Death With Dignity Act!

In other words, a patient still has to be terminally ill, fully informed, made a formal request, the request assessed as genuine and free, waited the required cooling off period, made another formal request, been assessed as qualifying all the requirements by multiple doctors, has legally appointed an agent expressly for the purpose of administering lethal medication pursuant to the Death With Dignity Act, have their medication prescribed (immediately before which the attending physician must again verify that the patient is making an informed decision) and then the patient ceases to be capable, before the agent may then administer.

Mr Schadenberg exposes that at best he fundamentally doesn’t understand the Bill, nor took much if any effort to do so.

That’s hardly the free-for-all Mr Schadenberg posits in his shrill blog implying that ‘assisted suicide and euthanasia’ was being extended to ‘incompetent people’ without further qualification; falsely insinuating that any incompetent person could then obtain assistance for suicide or euthanasia.

No ‘defence’

If Mr Schadenberg were to claim that he really meant ‘only within the scope of the current Death With Dignity Act,’ and that he’s been taken out of context, that simply won’t wash. Bill 893 makes a provision only for someone else to administer the lethal dose (that is, what Mr Schadenberg refers to as ‘euthanasia’) if the patient ceases to be capable after already qualifying under the existing Act. The Bill does not permit patient self-administration: that is, using Mr Schadenberg’s own language, ‘assisted suicide’—which he expressly refers to in his article.

Parading a non-existent extension of ‘assisted suicide’ clearly exposes that at best he fundamentally doesn’t understand the Bill, nor took much if any effort to do so.

Wrong again…

He also got it completely wrong as to who may administer when the patient ceases to be capable:

“The bill enables the doctor to administer…” — Alex Schadenberg

However, if you read Section 3 of the Bill (above) that Mr Schadenberg himself reproduces, you’ll see clearly that the patient must expressly identify a particular person ('agent') to administer lethal medication should the patient cease to be capable. The patient may appoint his or her doctor, but can appoint in their Advance Care Directive anyone to be the agent; including a trusted and loved family member. The only particular requirement for the agent’s administration is that he or she must “administer in the manner prescribed by the attending physician.”

Conclusion

But let’s not the facts get in the way of a gratuitous reaction trumpeting shrill hyperbole and headline, shall we Mr Schadenberg?

And as usual, Catholic Australian anti-assisted-dying blogger Paul Russel has dutifully reproduced Mr Schadenberg’s farce.


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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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St Patrick's Cathedral, Melbourne, Australia. Photo: Donaldytong

Against current moves to legalise assisted dying, Australian Catholic Father John George invokes Nazi Germany, resorts to ad hominem attacks to dismiss those who disagree with him, and demands that the Pope’s edicts are binding on everyone regardless of their own faith or world view.

On 24th September 2016, Journalists Greg Brown and Rick Morton published an article in The Australian, Victorian coroner credited with turning tide on euthanasia, summarising recent Australian moves to legalise assisted dying choice.

Catholic Father John George commented on the article online, quoting four sections of the Catholic Church’s catechism that prohibit assisted dying (sections 2276–9).

Pushback

Other readers of The Australian remarked that they respected his view for himself but they had no interest in the Pope’s views given the readers were not Catholic. In fact, repeated polls in Australia have shown that even the great majority of Catholics (three out of four) do not agree with the Vatican on the matter of assisted dying, a matter which Fr George dismisses merely as ‘fickle votes and polls.’

I would remind Fr George that these are not fickle: Australian public opinion in favour of assisted dying choice has been consistently in the majority for now more than four decades.

Fr George further quoted Catholic sources, for example the LJ Goody Bioethics Centre in Perth, Australia, which he failed to mention is, literally, an agency of the Catholic Archdiocese of Perth. He also selectively quoted Palliative Care Australia, failing to mention that they have acknowledged that not all pain and suffering can be eliminated at the end of life, even with the best palliative care.

Ad hominem attack

In response to a rising tide of objections to his musings, including from Mr Ian Wood, a fellow Christian and co-founder of Christians for Voluntary Euthanasia Choice, Fr George resorted to the ad hominem attack: to attack the person (or persons) rather than the arguments. He said:

“The pro euthanasia claque here make professional Nazi propaganda expert Goebbels look like a 5th rate amateur.” — Father John George.

For anyone in the dark, a claque is a group of sycophants hired to applaud a performer or public speaker. How rude. Fr George seems to have neglected to reflect that it is he who is hired to promote the performance of the Vatican. I applaud his right to do so, and I do not compare him to a treacherous propagandist in a murderous wartime regime in order to dismiss his arguments: I address the arguments themselves.

Nazi Germany

Fr George makes repeated mentions of Nazi Germany as a core reason to deny assisted dying choice.

In contrast, several years ago I was chatting at a conference with the pleasant and engaging Peter McArdle, then Research Director of the Australian Catholic Bishop’s Conference. He volunteered that he very much disliked the “Nazi Germany” argument so often used in religious circles, and wished it would stop because in so doing it meant they’d already lost the debate.

I agree. It’s a lazy and indefensible argument: that rational people in a functioning democracy must be denied choice for themselves on the basis of what some murderous regime did against others at the point of a gun.

Indeed, to rely on such a standard would be to equally argue against the right to religious practice, because the Catholic Church, through its inquisition practices (medieval C12th, papal C13th, Spanish C15th, Roman and Portuguese C16th) relied on torture and resulted in confiscation of property and at least tens (if not hundreds) of thousands of executions for witchcraft and heresy.

Ultimate hubris

But the real crux is that Fr George then unequivocally demands that:

“Principles elaborated by the pope are universally applicable.” — Father John George.

This ultimate hubris reveals a profound lack of self-reflection, both personally and organisationally. Even entertaining for a moment the premise that one individual (or even organisation) can tell everyone on the planet how they must live their lives, how would we choose that person or organisation? Why is it less valid for the head of any other branch of Christianity, of Judaism, Islam, Hinduism, Buddhism (or any other religion) or an agnostic (which I am) or an atheist, to set such rules for everyone, overriding other deeply-held beliefs and values?

A keener example of ‘blinded by faith’ would be hard to find.

Conclusion

I argue that Fr John George displays some of the gravest hubris of some members of the Catholic church. I respect and applaud his world views for himself and those who wish to subscribe. But using canonincal arguments (that is, religious arguments demanded as universally true by virtue of the supposed authority that dispensed them) is probably a major contributor to the current flight of people away from organised religion.

More happily, such an attitude is also contributing to accelerating the legalisation of assisted dying choice because folks can see these arguments for what they are. For that I doff my hat to Fr George.


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

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

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

Their primary conclusion is that:

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

Key findings

Key findings include:

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

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

Complication rates

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

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

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

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

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

The importance of context

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

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

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

Conclusion

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

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

 

References

  1. Emanuel, EJ, Onwuteaka-Philipsen, BD, Urwin, JW & Cohen, J 2016, 'Attitudes and practices of euthanasia and physician-assisted suicide in the united states, canada, and europe', JAMA, 316(1), pp. 79-90.
  2. Moore, N, Ganse, EV, Parc, J-ML, Wall, R, Schneid, H, Farhan, M, Verrière, F & Pelen, F 1999, 'The PAIN Study: Paracetamol, Aspirin and Ibuprofen new tolerability study', Clinical Drug Investigation, 18(2), pp. 89-98.
  3. Anderson, O, Davis, R, Hanna, GB & Vincent, CA 2013, 'Surgical adverse events: a systematic review', Am J Surg, 206(2), pp. 253-62.
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The more anti-euthanasia campaigner Mr Wesley Smith publishes, the more I think he’s missed his true vocation as a comedian. His latest comical gig against assisted dying is a gem.

Mr Smith starts with the case of two Californian doctors found guilty of Medicare fraud: billing fake hospice care for patients who weren't terminally ill. He artfully turns the story into a series of anti-assisted-dying gags.

Who’s on first, What’s on second?

Mr Smith directly connects the money-grabbing fraud case with the Obama administration, ribbing us that the President and federal authorities won’t hold doctors accountable for breaking assisted suicide law. Mr Smith, an attorney, is holding his breath to see if his audience figures out this little joke: oh, the confused jurisdiction names… right!

The Death With Dignity laws are State laws. If the law is broken it is State responsibility to pursue and prosecute offenders. The Feds have no jurisdiction. If, however, Medicare has been defrauded then it’s a Federal matter (FBI): and the Feds did indeed investigate and prosecute.

It’s a bit like the Laurel and Hardy confused “Who’s on first, What’s on second” name sketch, isn’t it? But only if you get it. Grin.

I say, I say, I say: what’s worse—being evil or being dead?

Mr Smith then refers to the case of Michael Freeland, an Oregonian dying of lung cancer who considered using the Death With Dignity Act. Citing himself and referring to the physician who prescribed lethal medication, Mr Smith compares Dr Peter Reagan with the Medicare fraudsters, saying that Dr Reagan “regularly takes on patients solely for the purpose of facilitating their suicides.”

Defamation is always good for a cackle. It’s so droll, like saying that Mr Smith “opposes assisted dying solely because of the great value of redemptive suffering whether others agree or not.” Which, of course, your dear writer is not saying (because Mr Smith has already stated on the record that he doesn't think suffering is redemptive). I’m just saying, you know, for laughs.


PeterReaganEvilAndDead.gif

Wesley Smith jokes that Dr Peter Reagan is both evil and dead.


To add even greater mirth, Mr Smith describes Dr Reagan as “now late”. OMG, I've met Dr Reagan and he’s a top fellow. He’s died!? No, he hasn't. Fortunately, like Mark Twain, Dr Reagan happily reports that news of his death has been greatly exaggerated.

Phew, comic relief—what a hoot.

The Clause you have when you’re not having a Clause

Mr Smith then tells the one about how doctors ordinarily have to comply with an accepted medical “standard of care,” but that “death doctors” (love those stereotypes, chuckle!) only have to act in “good faith,” which, Mr Smith razzes us, is quite hard to assess. Oh. Awkward audience silence; a cricket chirps. Um, punchline please?

You have to supply your own punchline for this quip I’m afraid, because Mr Smith rather absent-mindedly forgets to. The Oregon Death With Dignity Act 1997 says explicitly in Clause 126.885 §4.01(7), “No provision [of this Act] shall be construed to allow a lower standard of care…”

Ah, more comic relief: the old 'pull-the-wool-over-your-eyes' caper, chortle.

The flip-flop routine 

But the most comical gag is the one I reckon Mr Smith doesn’t even realise he’s told: the joke that we’re all going to die from lethal prescriptions, artfully developed by featuring someone he carefully points out didn’t take the lethal prescription. We just love a good flip-flop. LOL.

Oh, that and teasing us that the Medicare fraud case in which the purpose was to get more money is a great story against assisted dying whose purpose, he banters, is to get less (save) money. Double flip-flop: Ta-ching!

Loud guffaws and applause all round.


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Dr William Toffler (left) acknowledges no slippery slope cause-and-effect evidence, with Drs Bentz and Stevens

A new scholarly journal focused on end-of-life ethics, decision-making and practice has just been launched: the Journal of Assisted Dying. In the first article, claims by Oregon lobby group Physicians for Compassionate Care (PCC), including Doctors Bill (William) Toffler and Ken Stevens (and others) are assessed against empirical evidence and found to be completely wrong, or highly misleading as a result of selective use of data.

The new scholarly journal, the Journal of Assisted Dying, is dedicated to careful and holistic analysis of evidence in regard to the various forms of assisted dying that are lawful in a number of jurisdictions around the world... and to practices in jurisdictions where assisted dying remains illegal.

In the first article of a series on Oregon, I examine claims and speculations made by various doctors (and others who quote them), that Oregon has the second-highest suicide rate in the USA (or is always in the top 10), that Oregon's Death With Dignity Act has resulted a massive increase in the state's general suicide rate, and other astonishing statements.

Of course, the empirical evidence from the Oregon Health Authority and from the USA Centers for Disease Control and Prevention does not support these statements and interpretations, and I analyse and critique the evidence.

Some of the claims are just plain factually and hugely wrong. Others are the result of failing to read their sources more carefully, misunderstanding what the data actually represents. Still further claims are made on the basis of selectively-chosen statements from government reports, while omitting statements that are contrary to, or provide alternative and well-researched explanations for Oregon's recently rising general suicide rate.

Drs Toffler and Stevens have even published some of their claims and speculations in the British Medical Journal.1 It goes to show that even good journals sometimes publish bunkum:  their article was a letter to the editor rather than peer-reviewed research. Great care is required to sort real evidence from hype and opinion.

Ultimately, Dr Bill Toffler of PCC has acknowledged on video that there is no cause-and-effect evidence between Oregon's Death With Dignity Act and Oregon's suicide rate, an acknowledgement that went unchallenged by his two PCC colleagues present at the time, Dr Ken Stevens and Dr Chuck (Charles) Bentz. You can see Dr Toffler's statement here (at 10'50").

The Journal of Assisted Dying is an open-access journal, and you can read the full article here.

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1. Toffler, WL & Stevens, K 2015, 'Re: Assisted dying: law and practice around the world', BMJ, vol. 351, 19 Aug, p. h4481.


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