Fiction

A thing that is untrue, or invented or feigned by imaginatoin with no sound or verifiable evidence.

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Victorian MP Daniel Mulino's minority report contains multiple serious errors and misinformation.

Last year, the Victorian Parliament's Legal and Social Issues Committee concluded an extensive investigation into end of life choices, publishing a report of over 400 pages recommending improvements to palliative care and for assisted dying. Catholic-backed Shop, Distributive and Allied Employees' Association (‘shoppies’ union) Labor member of the Victorian Parliament Mr Daniel Mulino furnished his own minority report, opposing the majority recommendation for assisted dying law reform. That’s entirely his right. However, his report contains multiple, serious cases of misinformation. He must withdraw his report.

Daniel Mulino, Labor parliamentary member for the Victorian Region of Eastern Victoria,1 and a member of the Catholic-backed ‘shoppies’ union,2 was a member of the Legal and Social Issues Committee that thoroughly investigated end of life decision making and produced a 400+ page report in 2016 making recommendations for law reform and regulation.

Mr Mulino furnished a “minority report” as an addendum to the main report in order to oppose the Committee’s recommendation that assisted dying be legalised.3

Promoted by Catholics to Catholics

Mr Paul Russell, South Australian publisher of the Catholic anti-euthanasia website ‘HOPE,’§ says this of Mr Mulino’s minority report in the Catholic lawyer association’s blog:4

Daniel Mulino MLC's analysis should be read first, before the Majority Report. It forms not only a sound academic and rigorous approach but also, by implication, is damning of the narrow, outcome focus of the Majority Report.”

How sweet of Mr Russell to so generously plug Mr Mulino’s report. But, in gushing about the ‘sound academic and rigorous approach’ he claims to be in it, shows that he doesn't understand what constitutes proper and sound evidence, and that he's easily impressed by charts and lots of ‘literature’ citations.

Numerous fundamental faults

The reality is very different.

Rather than bore you with a mind-numbing blow-by-blow dissertation on the numerous fundamental faults in Mr Mulino’s report, I’ll demonstrate how the report cherry-picks, misquotes and misunderstands its way through the evidence, via four revealing examples.

Example 1. Cherry-picking ‘helpful’ data

Mr Mulino’s minority report illustrates the rise in number of assisted deaths in the Netherlands and Belgium, and produces some statistics (Figures 1 & 2 are directly from his minority report).

mulinocharts1and2.gif Figures 1 and 2 (of Mr Mulino’s minority report): Assisted deaths in Belgium and the Netherlands

Note that Belgian data is for the years 2003–15, but the Netherlands only for the years 2008–15. That’s odd, because the euthanasia Acts for both countries came into effect in 2002, and so 2003 was the first full year for both.

Mr Mulino doesn’t point out that his report treats the two countries differentially, and provides no explanation as to why. We might notice, however, that the dicrepancy has the consequence of making his claims look 'better.'

Using Mr Mulino’s presentation style, Figure 3 illustrates all the relevant data for the Netherlands.

netherlandsfullfig2.gif Figure 3: The full Netherlands data
Source: Official Euthanasia Commission reports

As you can see, there is a virtual flatline between 2003 and 2007. Indeed, there is even a tiny drop in numbers between 2005–06. This is an inconvenient truth to Mr Mulino’s thesis that there has been a consistent massive rise in numbers. It also substantially reduces the compound annual growth rate he wrongly quotes for just 2008–15.

He’s also cherry-picked only raw data. In fact, the only valid way to compare year to year, and jurisdiction to jurisdiction, is to use the rate for each year: that is, the number of assisted deaths as a proportion of total deaths in the same year and jurisdiction, so that you’re comparing apples with apples. It's necessary because the total deaths count goes down and (mostly) up a bit each year. The official government statistics for total deaths by year for both countries are readily available online, so there’s no excuse for not using them.

When you calculate the rates, you get validly-comparable results, as I illustrate in Figure 4.

dutchbelgianratesto2015.gifFigure 4: Rate of assisted dying as a percent off all deaths in the Netherlands and Belgium 2003–2015
Sources: Official government statistics; Euthanasia Commission reports

As I explain in my detailed research whitepaper on Benelux assisted dying,5 these are sigmoid (stretched-S) shaped curves which are typical of human behaviour change. And there is a drop in the rate in both countries in 2015, which Mr Mulino doesn’t report.

My Benelux whitepaper also reports the data from Luxembourg (Figure 5), which Mr Mulino fails to mention, even though it has legislation, since 2009, almost identical to the Netherlands and Belgium, and the Luxembourg government's data is freely available online.

dutchbelgianluxratesto2015.gifFigure 5: Rate of assisted dying in the three lawful Benelux countries
Sources: Official government statistics; Euthanasia Commission reports

Luxembourg’s data (yellow in Figure 5; no data available yet for 2015), is also an inconvenient truth to the case Mr Mulino attempts to prosecute. There’s no substantial rise.

Example 2. Comparing apples with oranges: mis-matching data

Mr Mulino again fails to compare apples with apples. Take, for example, his vocal claim that the annual total death counts for the Netherlands decreased at the same time as the total counts for assisted dying increased.

When you look at the data he’s used (the citation for the negative total deaths trend he quotes in his Table 2), you find that he’s used total death data for 2000­–10, which is falling, while his assisted dying data is for 2008­–15, which is rising.

This just isn’t on: it’s completely invalid to compare data like this from one period with data from another period to claim or imply a causal relationship. Of what possible relevance is the total death data for 2000–02, while his total deaths data for 2011–15 is missing? I illustrate the full story in Figure 6.

 

mulinomismatcheddata.gifFigure 6: Netherlands total and assisted deaths for different periods
Sources: Official government statistics; Euthanasia Commission reports

The solid blue and orange lines are data Mr Mulino used and reported, and their dotted ends are data that he omitted. It’s easy to see that the total deaths data his report inappropriately relies upon has a negative (downwards) slope (left-hand blue dashes), while the matching total deaths data he should have used has a positive (upwards) slope (right-hand blue dashes). Valid comparison gives lie to his claim.

Example 3. White is the new black: Misquoting the opposite

Mr Mulino’s report also argues that there’s ample evidence that a significant proportion of people with depression are gaining access to assisted dying:

“Ganzini et al, in a broad ranging review of instances of assisted dying in Oregon, found that twenty percent of the patients had symptoms of depression.” [Italics mine]

This assertion is nonchalantly plucked from the review6 without reading it properly, seemingly to support his thesis. In fact, the source does the exact opposite. Figure 7 is an image of the Abstract, where it says in large print, right up front:

Twenty percent of the patients had symptoms of depression; none of these patients received a prescription for a lethal medication.” [Emphasis is mine]

ganziniabstract2000.gifFigure 7: The paper Abstract articulates exactly the opposite of Mr Mulino’s claim
Source: Ganzini et al 20006

Had Mr Mulino bothered to read either the abstract or the methodology of this study properly, he would have realised that the doctor sample was of those eligible to prescribe under Oregon’s Death With Dignity Act, not just those who had, and that none of the study's patients who were assessed with possible depression had accessed an assisted death.

It's not like the information was hard to find — his report cites literally half a sentence to support his claim, when the full sentence says the opposite.

Example 4. Any port in a storm: Cherry-picking, misunderstanding and misrepresenting out-of-date data

In attempting to establish a 'slippery slope' from voluntary, to non-voluntary euthanasia (NVE) — a practice where doctors may hasten death (e.g. by administering increasing doses of opioids) when the patient hasn’t explicitly requested it — Mr Mulino states in his minority report:

“Two countries with the highest rates of this type of end-of-life (Belgium at 1.5% and the Netherlands at 0.60%) allowed the practice of euthanasia and assisted dying.”

Oh dear, Mr Mulino's report cherry-picks again. Just look at his source.7 The study, published in 2003, contains Table 2, with the relevant data in it (Figure 8).

vanderheide2003table2.gifFigure 8: Table 2 from the 2003 study Mr Mulino cites
Source: van der Heide et al 20037

There are no fewer than five major offences Mr Mulino commits here.

Firstly, look at the table. I’ve highlighted the line in yellow from which Mr Mulino draws his figures of 1.5% for Belgium and 0.60% for the Netherlands. You can immediately and easily see that Denmark’s rate of 0.67% is higher than the Netherlands' of 0.60%.

So, Mr Mulino’s statement mentioning only Belgium and the Netherlands with “highest NVE rates” is misleading. He failed to either report or explain why Denmark’s rate is higher than the Netherlands, while Denmark doesn’t have an assisted dying law; the opposite of his thesis.

Secondly, he also fails to mention Switzerland’s NVE rate of 0.42%, or to explain that it’s lower than the Netherlands and Belgium. That’s highly relevant, because Switzerland has the world’s oldest assisted dying law — in effect since 1942 — and its statute contains none of the safeguards in the Belgian and Dutch Acts. This too is at odds with Mr Mulino’s thesis.

Thirdly, if Mr Mulino had read the study properly instead of just cherry-picking convenient figures from it, he would have noticed in the methodology section that the fieldwork (doctors filling in questionnaires) was completed in 2001 and early 2002, that is, before either the Netherlands or Belgian Acts came into effect later in 2002 (the Netherlands in April and Belgium in September).

Thus, the Dutch and Belgian data points Mr Mulino advances as ‘evidence’ of an NVE ‘slippery slope’ from legislated assisted dying have nothing whatever to do with assisted deaths under their Euthanasia Acts, because neither Act existed at the time the study was conducted.

Fourthly, he is resorting here to a single point-in-time study, which has little to no scientific power to establish ‘causation’. To really establish causation, as a minimum you have to assess longitudinal data, which I show in Figure 9. It demonstrates the precise opposite of Mr Mulino's ‘slippery slope’ thesis that voluntary euthanasia causes NVE, which if true would lead to a significant increase in the NVE rate in both countries after statutory legalisation.

dutchbelgianuknverates.gifFigure 9: Longitudinal NVE rates in the Netherlands, Belgium and the UK
Sources: Netherlands8; Belgium9; UK10

Both the Dutch and Belgian NVE rates have dropped with high statistical significance since their euthanasia Acts came into effect. Indeed, the NVE rate in the Netherlands is now similar to the rate in the UK, which is acknowledged as the world’s gold standard in palliative care and which has never had an assisted dying law. This is consistent with assisted dying law reform shining a bright light on all end of life practices.

It’s not like he simply didn’t know

Fifthly, it’s particularly disappointing that Mr Mulino’s report only cherry-picked outdated data in an attempt to ‘prove’ his case when I had already directly furnished the current relevant evidence to his Committee as a properly-researched formal submission: Figure 9 above is Figure 19 in my submission, and I provided the peer-reviewed research citations for the data.11

Not only that, but the official transcript of my appearance as an expert witness before the parliamentary Committee confirms that Mr Mulino specifically quizzed me on that Figure 19 and I pointed out the sources of its data:12

Mr MULINO — Figure 19, for example.

Mr FRANCIS — The reference should be in the text. The last sentence on the previous page gives you the citations for that data.

Mr MULINO — Okay.”

Even further, when fellow-Committee-member and Catholic assisted dying opponent Mrs Inga Peulich asked about the same thing (with Mr Mulino present) — “1,000 of those who have been accidentally euthanased in the Netherlands” — I literally put the chart up on the projection screen and explained it in full to the Committee until they had no more questions. The “1000” figure is the approximate rate prior to the Dutch Euthanasia Act, while the rate has dropped significantly since.

The evidence is irrefutable: it’s not like Mr Mulino was merely blissfully unaware of the relevant data contradicting his NVE ‘slippery slope’ claim. His minority report expressly overlooks this robust evidence and instead refers inapproriately to selective and outdated data that seemed to, but didn’t, support his argument.

Five major offences in a single citation: surely Mr Mulino’s report — far from ‘academic and rigorous’ — sets a new record?

A common religious thread?

The NVE ‘slippery slope’ claim is also popular amongst and spread by the Catholic Archdioceses of Melbourne,13 Sydney14 and Brisbane,15 as well as by other Catholic anti-assisted dying lobbyists such as Alex Schadenberg,16 Paul Russell,17 and Professor of Ethics at the Catholic University of Notre Dame Australia, Margaret Somerville.18

Indeed, Mr Mulino’s minority report appears amongst 11 Catholic responses against assisted dying law reform published by the Catholic Archdiocese of Melbourne (Figure 10).

cam-mulino-report.jpg Figure 10: Daniel Mulino’s minority report appears amongst Catholic responses on the Catholic Archdiocese of Melbourne’s website19

Indeed, Mr Mulino’s linked document doesn’t seem to emanate from his parliamentary office or from wider parliamentary services: the PDF file's metadata reveals that it was authored, electronically at least, by “mmacdonald”.

Calls to both Mr Mulino's electorate office and to the Parliament of Victoria confirm there is no "M Macdonald" at either. I did, however, find online one Matthew Macdonald, researcher and Executive Officer of the Catholic Archdiocese of Melbourne’s (CAM) Office for Life, Marriage and Family — in other words, the same organisation that published the list in Figure 10 containing the link to Mr Mulino’s minority report.

Mr Macdonald is also listed as the CAM's official contact person in its submission (#705) opposing assisted dying to the Victorian Parliament's inquiry into end of life choices.20 Both the CAM and Mulino reports also refer to a journal paper by Catholic doctor José Pereira,21 and neither report mentions the subsequent evidential rebuttal outlining why Pereira's claims were merely "smoke and mirrors".22 Even more curiously, the Pereira paper is included in Mr Merlino's minority report bibliography, though his report doesn't actually cite it as the CAM submission does.

The CAM parliamentary submission was authorised and signed by Episcopal Vicars Anthony Ireland and Anthony Kerin, who also appeared as witnesses before the parliamentary Committee, during which they told, as I've explained, a whopping great falsehood about Oregon.23

Conclusion

Contrary to Paul Russell’s enthusiastic claim that Daniel Mulino’s minority report provides a ‘rigorous’ case against assisted dying law reform, the report merely serves as further evidence of how those implacably opposed to assisted dying can cherry-pick, misunderstand and rather desperately clutch their way through their ‘evidence.’

Mr Russell is not an academic expert and one can understand his limited capacity to judge whether work is ‘scholarly.’ However, Mr Mulino holds a PhD in economics from Yale,* so it’s quite astonishing that he published a ‘researched’ report containing multiple major flaws, including outdated and cherry-picked data contrary to more recent, direct and relevant evidence of which he was specifically aware, actively inquired into and had explained and cited to him in full.

These anomolies beg the question: did Matthew McDonald or someone else at the Catholic Archdiocese of Melbourne write Mr Mulino’s report for him? Mr Mulino needs to explain himself, since regardless of who authoried it, he signed it off in his own name and is therefore ultimately responsible for it.

Given the multiple fundamental errors, the honourable course for Mr Mulino to pursue is to withdraw his minority report.

The question is: will he rise to the occasion?

 

Addendum: A missed opportunity for primary research

Mr Mulino — as well as Mrs Peulich who also wrote a minority report against assisted dying — declined to join other members of the parliamentary Committee on an official overseas fact-finding tour to jurisdictions where assisted dying is lawful. This was a critical opportunity for Committee members to directly quiz proponents, opponents, researchers, regulators, legislators and others with direct experience. It would have given them invaluable opportunities to directly examine and test  assumptions, hypotheses and performance. How curious then that these two non-participataing Committee members each furnished a minority report opposing the majority recommendation to legalise assisted dying in Victoria.

 

---------------

§    The HOPE website is an initiative of the Australian Family Association (AFA), a faith-based organisation founded by Australia’s most famous Catholic, B. A. Santamaria. Mr Russell is a former Vice President of the AFA, and a former Senior Officer for Family and Life at the Catholic Archdiocese of Adelaide.

*    While Mr Mulino holds a PhD and would be entitled to be addressed as “Dr”, his Parliamentary title is “Mr”.

References

  1. Parliament of Victoria 2017, Daniel Mulino, viewed 20 Mar 2017, http://www.parliament.vic.gov.au/members/details/1764-daniel-mulino.
  2. Tomazin, F 2016, Explainer: The push towards a dying-with-dignity policy in Victoria, Fairfax Media, viewed 3 Dec 2016, http://www.theage.com.au/victoria/explainer-the-push-towards-a-dyingwithdignity-policy-in-victoria-20161203-gt3bso.html.
  3. Legal and Social Issues Committee 2016, Inquiry into end of life choices. Final report, Parliament of Victoria, Melbourne, pp. 444.
  4. Russell, P 2016, End-of-life choices report: A sugar coated poison pill for Victoria, Melbourne Catholic Lawyers Association, viewed 14 Jun 2016, http://www.catholiclawyers.com.au/latest-news/853-end-of-life-choices-report-a-sugar-coated-poison-pill-for-victoria.
  5. 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.
  6. Ganzini, L, Nelson, HD, Schmidt, TA, Kraemer, DF, Delorit, MA & Lee, MA 2000, 'Physicians' experiences with the Oregon Death with Dignity Act', New England Journal of Medicine, 342(8), pp. 557-563.
  7. van der Heide, A, Deliens, L, Faisst, K, Nilstun, T, Norup, M, Paci, E, van der Wal, G & van der Maas, PJ 2003, 'End-of-life decision-making in six European countries: descriptive study', The Lancet, 362(9381), pp. 345-350.
  8. Onwuteaka-Philipsen, BD, Brinkman-Stoppelenburg, A, Penning, C, de Jong-Krul, GJF, van Delden, JJM & van der Heide, A 2012, 'Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey', The Lancet, 380(9845), pp. 908-915.
  9. Bilsen, J, Cohen, J, Chambaere, K, Pousset, G, Onwuteaka-Philipsen, BD, Mortier, F & Deliens, L 2009, 'Medical end-of-life practices under the euthanasia law in Belgium', New England Journal of Medicine, 361(11), pp. 1119-1121.
  10. Seale, C 2009, 'End-of-life decisions in the UK involving medical practitioners', Palliat Med, 23(3), pp. 198-204.
  11. Francis, N 2015, Submission to the Parliament of Victoria Standing Committee on Legal and Social Issues on the Inquiry into End of Life Choices, DyingForChoice.com, Melbourne, pp. 51.
  12. Parliament of Victoria 2015, Standing Committee on Legal and Social Issues inquiry into end-of-life choices: Witness-Mr Neil Francis, DyingForChoice.com, Melbourne, pp. 10.
  13. The Catholic Leader 2010, No to euthanasia – Yes to genuine care, Catholic Archdiocese of Brisbane, viewed 15 Dec 2010, http://catholicleader.com.au/analysis/no-to-euthanasia-yes-to-genuine-care_70380.
  14. Catholic Archdiocese of Sydney 2017, Experts warn against following overseas experience with euthanasia, viewed 12 Mar 2017, http://www.sydneycatholic.org/news/latest_news/2017/2017120_1449.shtml.
  15. Catholic Archdiocese of Brisbane 2010, No to euthanasia - yes to genuine care, The Catholic Leader, viewed 25 Feb 2012, http://catholicleader.com.au/analysis/no-to-euthanasia-yes-to-genuine-care_70380.
  16. Schadenberg, A 2013, Exposing vulnerable people to euthanasia and assisted suicide, Ross Lattner, London ON.
  17. Russell, P 2015, Submission 926: Submission to the Victorian Legal and Social Issues Committee inquiry into end of life choices, HOPE, Melbourne, pp. 56.
  18. Francis, N 2017, Margaret Somerville misleading claim - 'Non-voluntary euthanasia slippery slope', DyingForChoice.com, viewed 19 Apr 2017, http://www.dyingforchoice.com/resources/videos/margaret-somerville-misleading-claim-non-voluntary-euthanasia-slippery-slope.
  19. Catholic Archdiocese of Melbourne 2017, Why now in Victoria?, viewed 3 Aug 2017, https://www.cam.org.au/euthanasia/Be-Informed/Why-now-in-Victoria.
  20. Catholic Archdiocese of Melbourne 2015, Submission to the Legal & Social Issues Committee: Inquiry into end of life choices, Submission 705, Melbourne, pp. 16.
  21. Pereira, J 2011, 'Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls', Current Oncology, vol. 18, no. 2, pp. e38-48.
  22. Downie, J, Chambaere, K & Bernheim, JL 2012, 'Pereira's attack on legalizing euthanasia or assisted suicide: smoke and mirrors', Current Oncology, vol. 19, no. 3, Jun, pp. 133-8.
  23. Francis, N 2015, Catholic Church misinforms Parliamentary inquiry, DyingForChoice.com, viewed 25 Nov 2015, http://www.dyingforchoice.com/blogs/catholic-church-misinforms-parliamentary-inquiry.

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

She provided no sources or evidence for her claim.

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

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

Transcript

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

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

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

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

Else Borst: And then it stopped.

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

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

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

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

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

Visit the YouTube page.

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Catholic Professor of Ethics Margaret Somerville claimed in a University address that the Minister who brought in the Netherlands' euthanasia Act (that's Dr Els Borst), said that doing so had been "a serious mistake."

In an offence against scholalry standards, Prof. Somerville did not check her facts with the primary source before making the claim. I know, because I did. I interviewed Dr Borst in Utrecht: Prof. Somerville had not contacted Dr Borst, and Dr Borst stated clearly and without hestitation that she still thought it a good law.

Prof. Somerville instead chose to repeat scuttlebut circulating amongst assisted dying law reform opponents.

Transcript

Neil Francis: Before her death, I visited Dr Els Borst in Utrecht, to seek her current views about the Netherlands' euthanasia Act, which she introduced into the Dutch parliament, and which had been in effect for many years.

Voice of Neil Francis (interview): What are your feellings about the law?

Els Borst: I'm still very happy with it. I think we did the right thing there, also in the way we formulated it.

Neil Francis: But despite the clarity of Dr Borst's continued support for the law, Professor Somerville claimed the opposite in an address at the University of Tasmania.

Margaret Somerville: The Minister who was responsible for shepherding through the legislation that legalised euthanasia in the Netherlands admitted publicly that doing so had been a serious mistake."

Neil Francis: Oh dear. I showed Dr Borst the video of Professor Somerville's claim, and here's her response.

Els Borst: I know that story. I'd like to meet this Margaret S... what's her name?

Vice of Neil Francis: Margaret Somerville

Els Borst: ... well maybe she wouldn't listen anyway.

Neil Francis: The public have a right to ask why Professor Somerville chose to spread scuttlebut, instead of checking her sources in a proper, scholarly fashion.

Visit the YouTube page.

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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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Wesley Smith and 'intelligent design' at the Discovery Institute

The Discovery Institute's Wesley Smith is at it again. In his latest anti-assisted-dying tirade published by LifeNews.com, he promote lies about the Dutch Groningen Protocol, despite my published detailed analysis — of how that regulation actually works in practice — providing ample evidence to disprove Mr Smith's polemic theories.

Creationism…with lipstick

Wesley Smith is a Senior Fellow at the Discovery Institute (DI). That's the organisation that promotes ‘human exceptionalism’ (the concept that humans are theologically pre-eminent in the universe), opposes the foundations of evolution, and controversially attempted to have ‘intelligent design’ taught as science in Pennsylvania public schools. The Pennsylvania District Court tossed out DI's ‘intelligent-design-as-science’ argument on the basis that:

“Teaching intelligent design in public school biology classes violates the Establishment Clause of the First Amendment to the Constitution of the United States (and Article I, Section 3, of the Pennsylvania State Constitution) because intelligent design is not science and ‘cannot uncouple itself from its creationist, and thus religious, antecedents.’” — Middle District Court of Pennsylvania

Intelligent design is, after all, merely creationism…with lipstick.

Mr Smith is also the fellow I've previously busted for promoting the false ‘suicide contagion’ theory about Oregon, and cherry-picking his way through other ‘evidence’ to fuel another of his polemics.

More nonsense — this time the Groningen Protocol

And now he's at it again. In his latest anti-assisted-dying tirade, he says this:

“Although technically illegal, infanticide happens regularly in Netherlands without legal consequence, and a bureaucratic checklist was published that determines which babies can be killed. Showing the direction of the current, the Groningen Protocol§ (as it is known) was published with all due respect and without criticism, in the New England Journal of Medicine.” — Wesley Smith

Mr Smith does nothing but parade astonishing ignorance and bias with this statement.

The facts

From my extensive and detailed research about the Groningen Protocol published in the Journal of Assisted Dying, Mr Smith ought to know that:

  • Neonatal euthanasia occurs around the world whether it is regulated or not. It occurs, for example, in France, where there is no protocol and no adult assisted dying law, at a rate far higher than the Netherlands.
  • The Groningen Protocol is lawful in the Netherlands and has recently been overhauled and further strengthened.
  • Its provisions are considerably more strict than are those of the Dutch euthanasia Act for decisionally-competent minors and adults.
  • In the nine years since the Protocol came into effect, there have been just two cases of neonatal euthanasia, both for cases of Herlitz type epidermolysis bullosa, a fatal and untreatable illness characterised by extreme internal and external blistering.
  • That compares with twenty two cases, mostly in relation to spina bifida, in the nine years prior to the Protocol coming into effect.
  • The Protocol was subject to considerable criticism from opponents when it was first published in the New England Journal of Medicine (NEJM).

 
Highly relevant too is that the Royal College of Obstetricians and Gynaecology also argued in 2006 (not long after the original Groningen Protocol was published in NEJM) for neonatal euthanasia to be possible in extreme cases in the UK.

Not the only criticism of Mr Smith

Mr Smith has been criticised before by others for selectively using evidence and being:

"prepared to bend the truth to make a point, turn a stomach, and potentially radicalize a reader." — Matthew K. Wynia and Arthur Derse, Medscape

Perhaps Mr Smith doesn't care for the facts getting in the way of a good polemic? While he's entitled to his opinions, by repeatedly bending the truth and making statements contrary to the readily-available evidence, I argue that Mr Smith directly undermines any apparent 'authority' he claims for his musings.

Conclusion

The recurring pattern of resorting to misinformation reveals a lack of any real argument. I challenge Mr Smith to lift his game or retire his quill.

-----
§ Mr Smith links ‘Groningen Protocol’ to a blog published by the Euthanasia Prevention Coalition which is run by Canadian Catholic Alex Schadenberg. That blog is in turn based on a blog published by the Catholic online blog Mercatornet. The Mercatornet blog is itself a reproduction of an article by Dr Felipe Vizcarrondo who was a Clinical Bioethicist at Georgetown University (a Catholic and Jesuit institution), and  which was originally published in Linacre Quarterly, the journal of the USA Catholic Medical Association.


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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 and the AMA profoundly misrepresent what this research says.

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

 

Response 1—Try to bury the correction request

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

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

Response 2—Plead it’s not the AMA

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

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

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

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

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

Refresher: The original allegations

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

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

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

Response 3—Confirm the ‘cherry-picking’ misrepresentation

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

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

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

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

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

Response 4—Execute an impressive flip-flop

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

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

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

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

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

Response 5—Confirm bias about consultations

Sarah Colyer goes on to say:

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

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

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

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

Response 6—Demonstrate fundamental ignorance about research

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

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

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

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

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

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

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

What is “very low”?

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

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

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

Conclusion

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

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

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

 

Inexpert opinion via the AMA’s MJA

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

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

 

References

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

 

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