Rhetoric: Slippery slope

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The terminally ill are not choosing between life and death, but between two ways of dying, according to their own beliefs and conscience. Photo: Andrew Drummond/AAP

In Monday’s Herald Sun, Victorian Archbishops Philip Freier and Denis Hart, and Bishops Ezekiel, Suriel, Lester Briebbenow, Bosco Puthur and Peter Stasiuk published a half-page advertisement admonishing the Victorian government for its initiative to legalise assisted dying for the terminally ill, an ad similar to the one published by religious figures in 2008.

I have no quarrel with individuals of faith regarding their own private beliefs. However, the bishops’ attempt at public “leadership” through the advertisement is deserving of redress for its multiple fallacies.

The ‘abandonment’ fallacy

The bishops claimed that assisted dying “represents the abandonment of those who are in greatest need of our care and support”. On the contrary: to ignore the deeply-held beliefs and rigorously-tested wishes of people at the end of life is to abandon their values and critical faculties in favour of the bishops’ own religious dogma.

The ‘competition’ fallacy

The bishops demand there should be more funding for healthcare rather than assisted dying, fallaciously pitting one option against the other. The Victorian government is indeed increasing funding for palliative care. It’s also aiming to provide lawful assisted dying for when even the best palliative care can’t help – which Palliative Care Australia has acknowledged – giving lie to the faux competition.

The evidential fallacy

Contrary to the bishops’ false presumption that legalised assisted dying will decrease trust in “the treatment and quality of care” from doctors, scientific studies into attitude change show that more people trust doctors when assisted dying is legal. Patients can then talk openly about options, even if they decide against assisted death. The bishops have abandoned facts in favour of religious assumptions.

The equivalence fallacy

The bishops refer to assisted dying as “government endorsed suicide”. They fallaciously equate a reasoned, tested and accompanied decision for a peaceful assisted death in the face of a terminal illness, with the impulsive, violent, isolated and regrettable suicide of individuals (many of whom have mental health and substance abuse issues) who are failing to cope with problems that can be addressed.

However, while the latter are choosing between life and death, the terminally ill are choosing not between life and death, but between two different ways of dying, according to their own beliefs and conscience. Rigorous 2016 research from Australian National University shows that the vast majority (79%) of Victorians support assisted dying choice for the terminally ill (with just 8% opposed), clearly distinguishing it from general suicide.

Shame on the bishops for disrespectfully equating the two.

The inconsistency fallacy

They also argue that assisted dying ought to remain prohibited because within healthcare, “mistakes happen and the vulnerable are exploited,” and “that in spite of our best efforts, our justice system could never guarantee” no one would die by mistake or false evidence. However, as I’ve pointed out before, an identical hypothetical problem exists under the refusal of life-saving medical treatment, a statutory right that Victorians have enjoyed for nearly 30 years. The statute has only three “safeguard” requirements, yet even those only apply if the refusal is formally documented, but not if it’s verbal.

Further, the United States Conference of Catholic Bishops directs that patients may refuse treatment if it imposes “excessive expense on the family or community,” yet makes no mention of the hypothetical “vulnerability” of the patient to be persuaded so, nor directs any requirements to assess the veracity of the refusal.

In stark contrast, the Victorian proposal for assisted dying legislation contains more than 60 safeguards and oversights.

The bishops are at risk of ridicule for such a gargantuan flip-flop: supporting the refusal of life-saving treatment with little or no oversight, while vocally opposing assisted dying legislation that mandates an armada of protections.

The not-so-hidden agenda

The bishops’ methods are rather unsubtle – hoping that these arguments, erroneous but carefully crafted to avoid any religious connotations, will be accepted as non-religious. Yet religion is writ large across their plea: as signatories to the letter they are all clerics employed directly and centrally in the promotion of their religions.

The authority fallacy

They might also rely on their religious status to convey gravity and authority to their pleas. Yet as people paid to do a job, like anyone else, their titles grant them no special privileges in lecturing Victorians about how they should die in the face of a terminal illness.

According to the 2016 census, just 23% of Victorians identified as Catholic, 9% as Anglican, 0.5% as Lutheran, and the other bishops’ signatory denominations so small as to not appear separately in the government’s statistics. Combined, the bishops’ faiths represent around 33% of the Victorian population, while 32% of Victorians identify with no faith at all. Surely the bishops are not arguing that they’re speaking for these other Victorians, too?

But the bishops don’t represent the views of their own flocks, either. According to the 2016 ANU study, 89% of non-religious Victorians support assisted dying law reform, as do 78% of Victorian Catholics and Anglicans. Indeed, opposition to assisted dying exists mostly among those who attend religious services once a week or more often – that is, those who are frequently exposed institutional religious messages of opposition – yet who comprise just 12% of Australians and 11% of Victorians.

Minding their own flocks

Australians are abandoning religion in droves. For example, when Freier ascended to the top job of Anglican Primate of Australia in 2006, some 19% of Australians identified as Anglican (2006 census). A decade later under his leadership, the 2016 census showed a drop of about a third to just 13%, and in Victoria, his home territory, to just 9%.

Hart’s Catholic church has experienced a drop in affiliation too, and it’s likely to continue and accelerate as Australians react with shock and disgust to the extent of child sexual abuse that the royal commission has exposed from under his organisation’s “pastoral umbrella”.

In conclusion, rather than bishops lecturing the government and Victorians with fallacious and faintly desperate arguments about the choices they shouldn’t have at the end of life, attending to their own flocks may be more useful Christian leadership.

May their God go with them in that endeavour.

 

This article was originally published in The Guardian.


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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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Yet more research contradicts Prof. Margaret Somerville's Dutch NVE claim

I’ve criticised Catholic ethicist Professor Margaret Somerville in the past for promoting misinformation about assisted dying. One of her favourite stories is about supposed non-voluntary euthanasia (NVE) ‘contagion’ from voluntary euthanasia laws.

NVE is where a doctor deliberately hastens the death of a patient without a current explicit request from the patient.

Somerville claims that elderly Dutch citizens fear NVE — a slippery slope claim previously promoted by the Vatican. She stated that:

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.”

She made the claim with certainty and without qualification.

She also stated it under the credentials of Professor, yet has offered not a shred of sound, verifiable evidence. That's unscholarly.

Her claim is premised on two false beliefs, that:

  1. The Dutch assisted dying law causes NVE —extrapolated to mean that elderly Dutch are therefore fearful of NVE in the Netherlands; and
  2. Because assisted dying is illegal in Germany, NVE doesn’t happen there — extrapolated to mean that elderly Dutch are confident in German healthcare and seek it in preference to their own.

Belief 1 is soundly contradicted by the evidence. Researchers have found small but significant rates of NVE in every country they’ve studied (though that to date hasn’t included Germany). They’ve also found that the rates of NVE in the Netherlands and Belgium have dropped (not risen) significantly since their assisted dying laws came into effect in 2002.

Now, new research comprehensively knocks Belief 2 off its perch, too.

In a pilot study just published in the German Medical Weekly, a team led by Professor Karl Beine of Witten/Herdecke University in Germany found that around 3.1% of doctors and nurses surveyed were aware of deliberately hastened deaths (which is illegal in Germany) in the past twelve months, and that 2.4% of them administered it themselves.

A new study has found that of German nurses and doctors who had intentionally administered life-ending drugs to patients (which is against the law), 40% of them had not been asked to do so by the patient: non-voluntary euthanasia. Further, of those who administered it themselves, 40% hadn’t been asked for it by the patient. That's NVE.

While previous evidence strongly suggested that NVE would occur in Germany as everywhere else, this study now factually establishes that it does.

The study authors concluded that “illegal intentional life-ending acts were administered by physicians and nurses in all healthcare areas [hospitals and nursing homes] under investigation.”

So much for Somerville’s second premise.

Now both premises of her misinformed NVE story are soundly contradicted by empirical research evidence.


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Patricia Flowers calls Margaret Somerville's arugments 'bullshit' on national television. Photo: ABC

Last week, Mr Xavier Symons published a defence of Professor Margaret Somerville, whose arguments against assisted dying were called ‘bullshit’ by Patricia Flowers on the ABC’s Q&A program. Symons and Somerville are colleagues at the Institute for Ethics and Society at the Catholic Notre Dame University of Australia.

Mr Symons made an important point: that a law about restricted self-choice for assisted dying is in no way comparable to the Nazi Germany euthanasia (or more correctly, eugenics) programme. While Prof. Somerville agrees that such comparisons are invalid, she nevertheless often mentions Nazi Germany as a ‘question’ when debating assisted dying. That’s a bit of a fudge.

And Mr Symons, in his defence of Prof. Somerville, offers some fudges of his own. While Dr Iain Brassington has offered a cool philosophical examination of Mr Symons’ opinion piece in a Journal of Medical Ethics blog, I’ll provide more of an evidential analysis.

Wrong on Dutch law and practice

Mr Symons said that euthanasia was legalised in the Netherlands in 2002. While technically that may be true, it's misleading. Assisted dying was actually made lawful in the Netherlands in 1982, after considerable debate and a number of court cases, when the Board of Procurators-General (the highest prosecutorial authority) formalised a set of conditions under which doctors would not be prosecuted for helping a patient die.

In practice, wider physician participation commenced in 1984 when the Royal Dutch Medical Association (KNMG) issued its own guidelines for clinical practice, based on the Procurators-General ruling, and grew to more than a thousand cases a year by the late 1990s.

It was in 2002 — when the Termination of Life on Request and Assisted Suicide (Review Procedures) Act came into effect — that the Dutch law on assisted dying changed from regulatory to statutory.

Mr Symons also claimed that since 2002, the “Dutch legislation [has] changed several times.” That’s not true: in fact, not one word of the Act has changed since it came into effect.

Nor has there been a “steady rate of increase” in the Dutch assisted death rate since 2002 “even when there was no legislative change” as he claimed. There has been an increase, but far from ‘steady.’ Rather, it’s a sigmoid (stretched-S) curve with very little initial increase, then increasing, and then levelling out again. It’s a pattern typical of human behaviour adoption, and has occurred in both Belgium and the Netherlands.

Selective Euro-evidence

Mr Symons also claimed “significant evidence from Belgium, Netherlands, Luxembourg” for his argued slippery slope. Yet he quotes percentages for only the Netherlands, correctly noting that assisted deaths increased from 1.3% of all deaths in 2002 to 3.7% in 2015.

Mr Symons doesn’t mention that:

  • the Dutch assisted dying rate was lower for a number of years after 2002 than before — as physicians and the public were still getting to grips with the new Act;
  • the Netherlands’ assisted dying rate dropped between 2014 and 2015;
  • the rate in Belgium (1.8% in 2015) is half the Netherlands’;
  • the rate in the Flanders (Dutch) north of Belgium (2.5% in 2015) is higher than in the Wallonia (French) south (0.87%), suggesting that higher rates may be a characteristic of Dutch culture;
  • the rate in Luxembourg, with very similar legislation, is a tiny one twentieth of the Dutch rate — 0.18% in 2014 (the most recent year of available data); or that
  • there is no evidence to date of the rate increasing in Luxembourg.
     

Selective North American evidence

While Mr Symons reports the Dutch rate as a percentage of all deaths, he reports his only other figures (for Oregon) as raw counts: rising from 16 in 1998 (before which assisted dying was entirely illegal) to 132 in 2015. (Actually, the final figure for 2015 was 135 cases.) What he fails to mention is that the Oregon rate in 2015 was 0.38% of all deaths, just one tenth of the Dutch rate. That is, the percentage is far less ‘impressive’ to his thesis and raises questions about ‘inevitable slippery slopes.’

The increase is hardly surprising given that when conduct is made newly lawful, only a few people might pursue it in its first year, with more people pursuing it seventeen years later. Even then, one hundred and thirty-five cases out of nearly thirty-six thousand deaths is hardly a “normalisation,” as Mr Symons argues.

He also argues that Quebec’s initial figures are “alarming,” without reporting the rate as a percentage of all deaths. Data from the first year (2015–16) indicates a rate of 0.74%, slightly lower than French-speaking Wallonia in 2015 (0.87%). (Half-way through the 2015–16 period, Canada’s Federal Parliament also passed an assisted dying law.)

The latest comparative data

The latest data on assisted death rates in Benelux and North America is shown in Figure 1. As I explain in one of the most detailed comparative analyses of lawful assisted dying practice conducted to date, it is likely that the higher rates are associated with Dutch culture.

adrates7jurisdictions.gifFigure 1: Assisted dying in Benelux and North America as a percentage of all deaths

Notes: Dutch cultures appear in orange. Flanders is the northern Dutch, and Wallonia the southern French, ‘half’ of Belgium.
Sources: Government statistics offices and assisted dying authority reports; Quebec, CBC News

The case of Vermont

In the USA state of Vermont (with an Oregon-like Act since 2013), a small number of people (38) have been prescribed lethal medication in the first three years. (Data is not available by year.) Assuming for the sake of argument that all of them took the medication (while Oregon and Washington data indicates that a third or more don’t), that would equate to an assisted dying rate of around 0.27% of all deaths as an annual average for 2013­–15.

Don’t mention Switzerland

Switzerland is perhaps the most ‘inconvenient’ case for slippery slope hypotheses, which might explain why assisted dying opponents usually avoid mentioning it. It has the world’s oldest assisted suicide law, in effect since 1942. It is also the least prescriptive: the only specific statutory requirement is that any assistance rendered must not be for reasons of self-interest. That’s it.

Surely a law in effect for 73 years and devoid of all the complex requirements of others would be the foundation for an out-of-control assisted dying rate, much higher than the Netherlands at 3.7%?

It isn’t. In 2015, the rate for Swiss-resident assisted deaths was 1.4%. The rate including foreigners — in other words, with a global population of potential ‘slippery slope candidates’ — was 1.7%. That’s less than half the Dutch rate.

Conclusion

To summarise, the lawful assisted dying rate varies widely between cultures, currently by a factor of twenty. Yet there’s one thing consistent amongst them all: the most common reason for pursuing an assisted death is advanced cancer.

Ultimately, the only thing Mr Symons’ argument establishes is that he prefers to negatively describe any use of a law of which he disapproves as “normalisation,” regardless of its usage rate. If this were not true it would be incumbent on him to nominate a non-zero assisted dying rate that he thinks acceptable, but not “normalised.”

To be sure, I agree with Mr Symons that it’s important to “review the hard facts” around assisted dying.

And yet, when he promised the reader that his “valid slippery slope” argument would be based on “compelling empirical” evidence, he made incorrect or misleading statements, provided cherry-picked morsels of data, and wrapped it all up in a loaded assumption. I think that Patricia Flowers would call that ‘bullshit.’


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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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Dr Michael Gannon announces the AMA's policy review to AMA members in 2015

In 2016, the Australian Medical Association (AMA) reviewed its policy on ‘euthanasia and physician assisted suicide.’ Despite ample evidence to the contrary, the AMA executive set its policy as opposed to assisted dying, when the only position that would have acknowledged and respected the views of most of its membership was a position of neutrality.

amauncoveredinfographicmar2017.jpg Infographic summary of 'AMA uncovered'

 

Get the PDFs: Infographic | 'Sixteen questions' | Full report

 

AMA policy review

The Australian Medical Association (AMA) has been historically opposed to legislative reform that would permit doctor-assisted dying for patients in unremitting and untreatable extremis. Its hostile position had been expressed through a Position Statement (PS) in effect for at least a decade, although its Code of Ethics has been completely silent on the matter.

The AMA’s opposition to doctor-assisted dying has been one of the factors leading to the failure of a number of attempts at assisted dying law reform.

In 2015 the AMA announced a review of its ‘policy’ on ‘euthanasia and doctor assisted suicide,’ managed through its Federal Council. The review was conducted from late 2015 and throughout 2016. It included an online survey of more than 3,700 Australian doctors.

Deeply flawed survey — against assisted dying

The survey methodology contained, however unconsciously, multiple serious design flaws biased against assisted dying: flaws which were brought to the attention of the AMA executive separately by two survey design experts. The executive dismissed the criticisms, incoherently arguing that while the AMA’s reviews are “fully-informed decisions based on well-researched, comprehensive information,” the survey was “not formal ‘research’ as such” and merely a “means to engage our members.”

The AMA relied on selected statistics from the survey to publicly explain the outcome of its review. It also provided its own members a private, detailed report of the review, of which more than half was a comprehensive statistical analysis of the survey.

The ‘Survey Limitations’ section of the report mentioned several minor issues, but not the significant biases brought to the attention of the executive by experts.

Yet supportive doctor responses

Despite these significant biases against assisted dying, the survey found:

  • 68% of doctors said that even with optimal care, complete relief of suffering is not always possible.
  • 60% of doctors said that if lawful, euthanasia should be provided by doctors, and more than half of them (total 32%) said that they would indeed practice it.
  • 52% of doctors said that euthanasia can form a legitimate part of medical care.
  • 50% of doctors expressly disagreed with the AMA’s statement that “doctors should not provide euthanasia under any circumstances.”
  • 38% of doctors expressly disagreed with the AMA’s policy opposed to assisted dying (only half expressly agreed), and 35% of doctors said that euthanasia should be lawful.
     

Some doctors oppose legalisation, not euthanasia itself

In relation to the last point, other scholarly research has found that an additional 25% of Australian doctors are opposed to law reform not because they are opposed to assisted dying itself, but because they would rather practice it in private without regulatory ‘interference.’ This confirms that more than half of Australian doctors believe assisted dying can be a legitimate and practical part of medical care.

AMA not representative of Australian doctors

Only AMA members were invited and permitted to participate in the survey, and more than 70% of Australian doctors are not AMA members, despite the AMA expressly advancing itself as representing all Australian doctors. Non-members are likely to be more supportive of assisted dying — snubbing AMA membership due to the AMA’s ‘officially’ hostile stance.

Hostile tweets by President during review

During the review process, AMA President Dr Michael Gannon made repeated public statements hostile towards assisted dying, including a statement that doctor assisted dying would offend the Declaration of Geneva. The Declaration has nothing specific to say about assisted dying, and any general Declaration statements Dr Gannon relied upon would be equal arguments against abortion. Yet the AMA accepts abortion practice by doctors.

Indefensible conclusion by AMA Executive

Finally, in the face of ample evidence (despite the methodological biases) that at least half of the AMA’s own members favour doctor involvement in lawful assisted dying and deem it legitimate medical care, and 38% of its own members expressly disagreeing with its opposed policy, the AMA executive decided to maintain ‘official’ organisational opposition in the revised PS.

The PS, which was previously named broadly as about ‘end of life care’, is now exclusively named as about ‘euthanasia and physician assisted suicide,’ even though it continues its broad coverage. This suggests that, however unconsciously, the executive’s attitudes against assisted dying have become more entrenched.

The PS continues to unequivocally state as before that “The AMA believes that doctors should not be involved in interventions that have as their primary intention the ending of a person’s life.” In announcing the conclusions of its review the AMA has promoted this statement widely and as though it applies to all Australian doctors, most of whom are not AMA members.

Neither AMA 'policy' nor its Code of Ethics is binding

Despite the confidence and certainty of the statement, the AMA advises that neither Australian doctors in general nor even its own members are bound by its PSs. Thus, statements in AMA PSs are more ‘suggestions’ or ‘thought bubbles’ rather than authoritative statements.

More recently, the AMA’s Code of Ethics has been updated, yet remains entirely silent on doctor-assisted dying, in curious contradiction of the ‘certainty’ of its PS. The Code of Ethics is not binding on doctors (even AMA members), either.

Incoherent demands for policy consultation

The AMA executive continues to demand deep involvement in the development of a legal framework for assisted dying (despite saying that doctors should not be involved in the practice), yet it has developed no specific frameworks for three other related, already-lawful medical practices: refusal of life-preserving medical treatment, continuous deep sedation until death, and the voluntary refusal of food and fluids.

These discrepancies collectively raise the question as to whether the AMA’s ‘official’ opposition to assisted dying law reform is political rather than medical.

Conclusison

The evidence is clear that the only “justifiable” position the AMA executive could have taken was to declare the AMA neutral towards lawful assisted dying — a matter of individual conscience for its member doctors.

Australian doctors may well question the AMA executive as to how such a flawed process arrived at the outcome it did, and a collection of questions are posed for the AMA to answer. Sixteen questions are posed below.

 

Get the PDFs: Infographic | 'Sixteen questions' | Full report

 

Sixteen questions for the AMA

  1. Why does the AMA, through its Tasmanian representative, think it appropriate to state on national television that dying patients in extremis and without relief can suicide by themselves, even if the AMA doesn’t “encourage” it?
  2. Why did the AMA repeatedly delete corrections to its negative MJA misinformation about assisted dying practice in Belgium?
  3. Why did the AMA decide to review its “policy on euthanasia and physician assisted suicide” when it didn’t specifically have one? It had a policy on the role of doctors in end of life care.
  4. Why did the AMA review comprehensively ignore the substantial secondary data that already exists about the attitudes and practices of doctors and patients in end of life decisions?
  5. Why did the AMA not proactively obtain professional advice and assistance with the design and conduct of its doctor survey, and prefer to use such an amateurish one?
  6. If the AMA really represents all Australian doctors, why did it expressly exclude more than two thirds of them from its survey?
  7. Why did the AMA persistently use inappropriate language and inadequate definitions about assisted dying?
  8. Why did the AMA not make any serious attempt to understand patient perspectives beyond superficial statements that ‘opinions are divided’?
  9. Why did the AMA not report the multiple significant biases in its survey, which it knew about, in the ‘limitations’ section of its final report?
  10. Why did the AMA President consider it appropriate to make multiple statements hostile towards assisted dying while the review was underway?
  11. Why did the AMA executive decide to continue to demand doctors not participate in assisted dying, when more than half of its own members said it could be appropriate clinical practice provided by doctors, nearly four in ten expressly disagreed with the policy, and a third said they’d participate if assisted dying were legalised?
  12. Why does the AMA consider it appropriate to make repeated categorical, public statements that doctors should not be involved in assisted dying, when its Position Statement is not binding on its own members, let alone all Australian doctors?[1]
  13. How can the AMA justify the incoherence of having an expressly opposed stance to assisted dying in its revised Position Statement while it remains totally silent on the matter in its Code of Ethics, revised at the same time?
  14. How can the AMA legitimately demand to be centrally involved in developing an assisted dying framework — in which it says doctors should not be involved — for law reform, when it has no frameworks at all for the similar contexts of refusal of life-preserving medical treatment, continuous deep sedation until death, and the voluntary refusal of food and fluids (all currently lawful and practiced)? When will it develop and publish those?
  15. Why does the AMA continue to present itself to the media and the public as representing all Australian doctors, when more than two thirds of them are not members?
  16. Will the AMA include a formal analysis and critique of this deeply flawed policy review as part of its modernisation efforts in order to rebuild its brand value and stem the falling tide of its membership? That is, is the AMA prepared to learn from its mistakes?

[1]   The AMA’s Code of Ethics is not binding even on its own members, either. So when the Code states “don’t engage in sexual, exploitative or other inappropriate relationships with your patients,” that’s merely a ‘suggestion’ or ‘recommendation’ rather than an ‘obligation’ as a member of the AMA.

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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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The AMA announces an 'update' of its "euthanasia and physician assisted suicide" policy.

The Australian Medical Association (AMA) executive (policy group) recently concluded a major review of its official policy on assisted dying. The last major review was in 2007. Through a deeply flawed process the AMA executive continues to expressly disrespect the diversity of views amongst Australian doctors — a diversity confirmed by its own review — and hasn’t altered its opposition to assisted dying in any meaningful way.

Unrepresentative of Australian doctors

The AMA promotes itself as “leading Australia’s doctors,” yet more than two thirds of Australian doctors (70.5%) are not members. Its executive might like to think it’s leading, but most Australian doctors aren’t following. Claimed representation is particularly important when it comes to professional medical practice policies, because the AMA behaves as though its policies apply to all Australian doctors.

So who did the AMA consult in conducting its major review of policy on assisted dying? Only its own members. In other words, the AMA claims to represent all Australian doctors, but in reality consulted less than a third of them in the setting of its assisted dying policy. As AMA member Dr Rosemary Jones pointed out, some doctors eschew the AMA because of its opposed stance towards assisted dying. That creates a sampling bias in the AMA’s study… against assisted dying.

Further, the response rate to its survey of members was around 13%, meaning that only the most engaged AMA members (thus around 4% of all Australian doctors) offered a voice.

Biased survey

There are numerous flaws in the AMA’s survey. Here’s just one. In the preamble to the questionnaire, the AMA expressly told responding doctors (who, remember, are AMA members and probably don’t want to tick off their association) what its positions on certain end-of-life practices were. Then, in the first questions, it asked the doctor whether they agreed with the positions: strategies certain to result in substantial confirmation and acquiescence biases.

This just isn’t on. As a professional social and market researcher, I sent a detailed critique of the many problems with the survey to AMA President Dr Michael Gannon. I received a courteous but dismissive response from administration. A highly-respected Fellow of the Australian Market & Social Research Society sent a similar critique, also receiving a non-committal reply.

Survey results

While the AMA hasn’t published the survey results in detail yet, key headline statistics have been reported. What did the AMA discover on the basis of a methodology swayed against assisted dying?

  • Around four out of ten doctors believe that doctors should be involved in assisted dying cases, while around five out of ten thought they shouldn’t. One out of ten had no view either way.
  • If assisted dying were legalised, a majority said that doctors should be the ones to do this work.

That’s a clear message that a substantial proportion of doctors think assisted dying can not only be legitimate practice, but is the business of the medical profession — at least for those who wish to participate.

Executive’s ‘interpretation’

And what did the AMA executive make of these important insights after deliberating on them for months? Here are the AMA’s previous and ‘revised’ core policy statements:

Previous (2007) statement

‘Revised’ (2016) statement

The AMA believes that medical practitioners should not be involved in interventions that have as their primary intention the ending of a person's life. This does not include the discontinuation of futile treatment.”

The AMA believes that doctors should not be involved in interventions that have as their primary intention the ending of a person’s life. This does not include the discontinuation of treatments that are of no medical benefit to a dying patient.”
 

Despite the gratuitous change of a few words after a year of ‘research,’ the statement remains the same.

Doctors and the public have a right to ask of the AMA, “what part of the evidence that there is a genuine diversity of respectable views, did you miss?”

Failure to respect diversity

The executive might argue that it did listen. Here are its statements about diversity:

Previous (2007) statement

‘Revised’ (2016) statement

The AMA recognises that there are divergent views regarding euthanasia and physician-assisted suicide.”

The AMA recognises there are divergent views within the medical profession and the broader community in relation to euthanasia and physician assisted suicide.”

 
Despite another increase in wordiness, this statement too remains the same.

The AMA executive says it recognises that there are divergent views, but by continuing to insist that no doctor should be involved in assisted dying, it reveals that it doesn’t respect some views. How does it justify this hubris?

Failure to respect the patient

The revised policy also says in part:

“Doctors should … endeavour to uphold the patient’s values, preferences and goals of care.”

The sting in the policy tail is, given the AMA executive’s wholly opposed stance toward assisted dying, that the doctor should only uphold patient values, preferences and goals of care if the AMA executive approves of them (and assuming to do so is legal).

Was it a foregone conclusion?

The AMA executive’s continued opposition to assisted dying was unsurprising. The signals were clear. While the policy review was in play, AMA President Dr Michael Gannon made a series of tweets and media comments, all unsupportive of or directly opposed to assisted dying. Here’s a few.

In response to an article in The Australian “Catholic stance allows eased exit”, he tweeted a faux ‘competition’ between palliative care and assisted dying:

@amapresident 13 Aug 2016: Different views society on assisted dying. Hope all agree improved PalliativeCare access a priority @westaustralian

He also tweeted in support of the ‘doctrine of double effect’, a controversial policy (which the AMA promotes as uncontroversial) that contends it’s quite OK for a doctor to hasten a patient’s death after all… provided they don’t really mean to: hardly a robust or verifiable standard.

@amapresident 24 Aug 2016: Doctors should be careful, must obey the law and understand their code of #ethics. Double effect is not #Euthanasia

In an article in The Australian on 15th September, Dr Gannon argued against assisted dying on the basis of it being ‘extremely complex.’ If complexity were a reason to oppose anything, the AMA would be opposed to the entire healthcare system: it’s incredibly complex. His argument collapses at the slightest inspection.

@amapresident 18 Sep 2016: Hippocratic medicine older than some of the world’s great religions, every political ideology, trend #ethics @medwma

Dr Gannon then invoked the Hippocratic Oath, which bans assisted dying. That’s cherry-picking at its best. Doctors do not take the Hippocratic Oath: it swears allegiance to ancient Greek gods, forbids women from entering the profession and outlaws surgery, amongst other things.

@amapresident 19 Sep 2016: Agree @DrSallyCockburn admire #euthanasia work done by @CMA_Docs. Equally careful, compassionate, intelligent approach from @TheBMA #ethics

He commends the British Medical Association’s “intelligent approach” against assisted dying: an approach I have comprehensively exposed as superficial and ill-informed fear-mongering, fiction, flip-flop and hubris.

@amapresident 1 Oct 2016: It is inevitable that if #Euthanasia laws are passed, they will over time be expanded to include children, mentally ill, vulnerable #ethic

Dr Gannon demonstrated ignorance of basic facts with this ‘slippery slope’ claim. In Oregon, which has the world’s oldest specific assisted dying framework (in effect since 1997), there have been no changes in who may qualify. He also ignores peer-reviewed research showing no ‘slippery slope’ for the supposed ‘vulnerable’. Canadian Professor Harvey Chochinov, Chair of his government’s expert panel which investigated legislative options for assisted dying, confirmed the evidential absence of the ‘slippery slope’ in a keynote address at Swinburne University in Melbourne last week.

@amapresident 11 Nov 2016: Doctors maintain this Trust with everyday care for patients, by upholding #DeclarationOfGeneva @medwma @juliamedew @Rania_Spooner #ethics

Dr Gannon also claimed that assisted dying would erode patient trust in doctors, at odds with the fact that people’s trust in doctors is high amongst OECD countries with assisted dying laws. Indeed, trust in doctors amongst Dutch, Belgian and Swiss citizens is significantly higher than Australians’ trust in our own doctors.

During the review period, Dr Gannon also repeatedly promoted the (medical) Declaration of Geneva (e.g. see previous tweet), which states that doctors must not participate in assisted dying. If the Declaration’s canonical opposition was indeed the authoritative stance on assisted dying, then it would be irrelevant for the AMA to conduct a review process of its policy.

Doctors and the public might ask a legitimate question: “Why did the AMA President think it appropriate to publicly and repeatedly indicate what review conclusion he favoured, while the review was in progress?”

Declining to correct misinformation

In September, the Medical Journal of Australia (MJA: a wholly-owned subsidiary of the AMA), published a news report containing significant misinformation that painted a hostile picture about assisted dying in Belgium. I published a critique of why the opinion was wrong, and commented on the online MJA article with a link to my correction. The MJA promptly deleted my comment.

AMA member Dr Rosemary Jones then put up the same objection which, by dint of her membership, they wouldn’t delete. The MJA then responded, but only to dig in its heels to defend the misinformation and reveal even more serious flaws in its arguments.

I wrote a further research-backed analysis of why its defensive arguments were even more wrong than the original and posted a note and link on the original MJA article page (Figure 1).

MJA inSight has deleted my post correcting its misinformation.Figure 1: The second post on MJA inSight which was subsequently deleted.

Once again, my post has been deleted. The result of this is that erroneous information about Belgium remains published on the MJA website as though it is correct, while failing to mention or acknowledge that it has been soundly refuted.

It’s disappointing that the AMA and its President continue to make such uninformed remarks given that Dr Gannon claims to be a stickler for scientific evidence:

@amapresident 18 Aug 2016: Being a doctor is a huge privilege. Also carries responsibility to provide accurate scientific info, act ethically.

Spotlight on the AMA

Legitimate questions serve to shine a spotlight on the AMA. Firstly, given the circumstances, what was the likelihood of a real change to the AMA’s entrenched opposition toward doctor participation in assisted dying?

Secondly, given the AMA’s entrenched opposition, how can it expect its demands that it be consulted about any potential law reform to be treated seriously? If assisted dying is nothing to do with doctors, why is what doctors think relevant?

Utterly resistant to modernisation?

At its 2016 AGM, AMA member Dr Harry Hemley noted that the AMA largely represented its more hard-core, long-term older members and warned of the AMA’s increasing irrelevance and impotence (Figure 2). He moved an urgency motion to commission a review and report with “recommendations for a plan, vision and determination that will lead to re-invigorating and sustaining the AMA.”

ama_less_relevant2.jpgFigure 2: Dr Harry Hemley speaks to the urgency motion to investigate organisational reform

The motion wasn’t in relation to an actual or particular reform: merely to investigate the potential for reform and to provide recommendations for consideration. We can only hope that the AMA will drag itself into the 21st century at some stage.

Conclusion

The AMA is deeply out of touch with Australians on the issue of assisted dying. It represents fewer than a third of Australian doctors and has failed to respect the very range of perspectives it obtained by consulting its members. It further strains its credibility by insisting that doctors mustn’t be involved in assisted dying, yet demanding to be consulted on any law reform to permit it.

If the AMA is to become relevant to contemporary society it must move on from the ‘old boy’ approach to medicine and adopt a stance of neutrality toward assisted dying. Only neutrality demonstrates appropriate respect for the true range of views held in good conscience by Australian doctors.

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This article has been published in OnlineOpinion.


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BMA House in Tavistock Square, London, home to the British Medical Association since 1925.

The British Medical Association (BMA), in the latest incarnation of its policy on assisted dying (AD), insists that AD must not be legalised in the UK. I argue that its indefensible stance reveals ignorance, incoherence and hubris. It fails to respect the true range of views amongst UK doctors. I expose the comprehensive rot.

The BMA categorically states in its July 2016 policy update on assisted dying:

“The BMA policy … insists that voluntary euthanasia [and] physician-assisted suicide should not be made legal in the UK.” — British Medical Association1

BMA comprehensively out of touch

The BMA claims to represent UK doctors—though fewer than half are members. What is the empirical evidence for UK doctor attitudes toward assisted dying?

In a 2009 survey,2 35% said that AD should definitely or probably be legalised. The same study also found that 35% of UK doctors said AD should definitely not be lawful even in cases of terminal illness. That is, the stance of just 35% of UK doctors was identical to the BMA’s—insisting that it not be lawful, while an equal proportion thought AD could be legalised. “Greater religiosity” was the strongest correlative factor with opposition to lawful AD.

Indeed, numerous studies have found a substantial minority of UK doctors in favour of lawful AD, including results approaching equality with opponents.3 Even a survey commissioned by the UK Catholic Medical Association in 2003 found around 25% of UK doctors in favour of AD and who would practice it if legalised.4

UK doctor support for AD, then, is substantial and hardly restricted to a mere handful of fringe-dwelling medical crackpots.

Ignorant and disrespectful BMA stance

It is untenable that the BMA unilaterally ‘respects’ the views of 35% of UK doctors at the same time as expressly disrespecting the views of another significant cohort. Perhaps as in general politics, its power base is more heavily populated with religious souls: those who have a deeper interest in shaping what options others do and don’t have?

Appalling and trivialised ‘rationale’

Let’s take a look at the five moribund reasons the BMA offers in defense of its institutional opposition to AD and see how they use flapdoodle, fudge, fiction, fear-mongering, flip-flop and hubris to ‘advance’ their position.

“Current BMA policy firmly opposes assisted dying for the following [five] key reasons:”

1. Permitting assisted dying for some could put vulnerable people at risk of harm.

Flapdoodle. Firstly, as I have explained before, the “vulnerable at risk” argument is a rhetorical sham. People ‘at risk’ are by definition ‘vulnerable,’ and would still be so if we wore yellow socks on Wednesdays or outlawed pizza. It has nothing to do with AD being legalised or not.

Fudge. Secondly, the BMA ignores repeated reviews published in the professional literature indicating that supposed harms have not eventuated in jurisdictions with lawful assisted dying. Indeed, the quality of medical practice has improved.

Flip-flop. And thirdly, if ‘risk of harm’ was a sufficient condition to deny patients a particular option, we must equally ban the right to refuse life-saving medical treatment (no matter how unwanted or burdensome) because greedy relatives eyeing off the estate might convince the dying patient to refuse. It’s incoherent to oppose assisted dying, but to support refusal of treatment (as the BMA does), in the face of this identical possibility.

2. Such a change would be contrary to the ethics of clinical practice, as the principal purpose of medicine is to improve patients’ quality of life, not to foreshorten it.

Fudge. Medicine has a number of primary purposes. Relief of suffering is one.5 That may come into conflict with another purpose, “the avoidance of premature death and the pursuit of a peaceful death” (which itself has internal conflicts). A dying individual may herself believe that an AD would not be premature, and whose peaceful nature is vastly preferable to continued intolerable and unrelievable suffering.

3. Legalising assisted dying could weaken society's prohibition on killing and undermine the safeguards against non-voluntary euthanasia. Society could embark on a 'slippery slope' with undesirable consequences.

Fear-mongering. Non-voluntary euthanasia (NVE) is currently illegal. It remains illegal even when AD is legalised. The BMA therefore incoherently conjectures that NVE doesn’t occur while it’s illegal (before AD legalisation), but might occur while it is still illegal (after AD legalisation).

Fiction. There are no current ‘safeguards’ against NVE as the BMA statement implies. It is practiced in secret. There are no statutory requirements or reporting standards as there are for AD (where legal). Research clearly demonstrates that NVE occurs everywhere, including the UK. Further, the rate of NVE has significantly decreased in the Netherlands and Belgium since their AD statutes came into effect.

4. For most patients, effective and high quality palliative care can effectively alleviate distressing symptoms associated with the dying process and allay patients' fears.

Flapdoodle. The BMA says “effective … palliative care can effectively alleviate…”: another circular, self-‘proving’ argument.

Hubris. The BMA acknowledges here—as unarguably established in the professional literature—that palliative care can’t help everyone. And that’s precisely what assisted dying law reform is about: for people that palliative care can’t help. But the BMA brushes them under the carpet.

5. Only a minority of people want to end their lives. The rules for the majority should not be changed to accommodate a small group.

Flip-flop. In ‘reasons’ 1 and 3 above, the BMA speculates that too many people will die if AD is legalised. Here is it arguing that too few will. Which is it? Too many or too few? The argument also ignores the international evidence that dying individuals (and their loved ones) experience profound relief merely from knowing that AD is available, even if they don’t pursue it. That itself is good palliative care.

Hubris. And if “not changing the majority's rules to accommodate a small group” were a gold standard as the BMA argues, then there would be no leglisation to (a) ensure facilities access to people with a disability, (b) outlaw discrimination on the basis of race or religion, or (c) allow same-sex marriage: all enshrined in law in the UK.

Hubris argues for ignoring the BMA itself

If, as the BMA argues, we should override the wishes of a group on the basis of its small size, it’s pertinent to consider the size of the UK doctor population: around 0.4% of the total. By comparison, in jurisdictions where AD is legal, around 0.3% (Oregon) to 3.8% (Netherlands) ultimately choose an assisted death.

If we are to ignore 0.3%–3.8% of the population because it’s ‘too small,’ we must equally ignore 0.4% of it. This, by the BMA’s own argument, would be reason to force it to support AD because that’s what the majority (UK population) favour. After all, “the rules for the majority should not be changed to accommodate a small group [of doctors].”

Of course most of us recognise, unlike the BMA, that this is not a ‘popularity contest.’ A stance of neutrality would demonstrate respect for deeply-held views across the spectrum.

Conclusion

The British Medical Association demonstrates profound ignorance about the available evidence, and about UK doctor attitudes. It resorts to fear-mongering speculation, fudge, fiction, flapdoodle, flip-flop and hubris to maintain its indefensible opposition to assisted dying.

The BMA’s stance does a great disservice to the British people. It’s an embarrassment to professional doctors regardless of their stance on assisted dying. The policy deserves to be entirely scrapped, and one of neutrality adopted in its place.

 

References

  1. British Medical Association 2016, Physician-assisted dying: BMA policy, viewed 26 Sep 2016, https://www.bma.org.uk/advice/employment/ethics/ethics-a-to-z/physician-assisted-dying.
  2. Seale, C 2009, 'Legalisation of euthanasia or physician-assisted suicide: survey of doctors' attitudes', Palliative Medicine, 23(3), Apr, pp. 205-212.
  3. McCormack, R, Clifford, M & Conroy, M 2011, 'Attitudes of UK doctors towards euthanasia and physician-assisted suicide: a systematic literature review', Palliative Medicine, 26(1), pp. 23-33.
  4. Catholic Medical Quarterly 2003, 'Euthanasia and assisted suicide: Results of survey of doctors attitudes', Catholic Medical Quarterly, May, pp. 1-3.
  5. Hastings Center Report 1996, 'The goals of medicine. Setting new priorities', The Hastings Center Report, 26(6), pp. S1-27.
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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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