Flapdoodle

An argument that superficially seems intuitively attractive, true or real, but is in fact meaningless or nonsensical.
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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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Brad Mattes' blog containing misleading and evidentially false statements.

The latest misinformation employed by assisted dying opponents is to imply that Belgium’s general suicide rate is high as a consequence of its assisted dying law: i.e. to argue the discredited 'suicide contagion' line which has in the past been peddled about the USA state of Oregon. I have demonstrated that it was false in Oregon, and I equally demonstrate here that it's false in Belgium.

Mr Brad Mattes recently published emotional anti-assisted-dying nonsense in LifeSiteNews. (LifeSiteNews is a Canadian blog site that was established by the conservative Christian Campaign for Life Coalition and which has a primary principle of promoting “traditional Judeo-Christian principles”. Mr Mattes is radio host for Ohio’s Life Issues Institute, an anti-abortion lobby group established by conservative American John C. Willke who claimed that women’s bodies were resistant to pregnancy as a result of rape.)

Putting on the misinformation running shoes

In his blog Mr Mattes quickly establishes a practice of communicating misinformation by first claiming that assisted dying laws have “devastating effects” around the world including Japan and Albania—which don’t have such laws.

He then sprints onwards to the ‘650 babies euthanized in the Netherlands’ claim—which I have already comprehensively exposed as fake in the Journal of Assisted Dying—and then onto the bogus claim that the Netherlands has descended into a mire of ‘killing’ without the patient’s ‘consent,’ contrary to empirical evidence I've published that such actions occur around the world regardless of assisted dying laws, and which have decreased significantly in the Netherlands and Belgium since their assisted dying statutes came into effect in 2002.

Let’s add fries to that

Having served up a lot of fat and salt that might appeal to those on a fast-food anti-assisted-dying diet, he then offers the unqualified statement:

By the way, Belgium has the second-highest suicide rate (nonrelated to euthanasia) in Western Europe.” — Brad Mattes

The ‘informational’ consequence is unequivocal: by Mr Mattes failing to contextualise this ‘incidental factoid’ in any way, the reader is destined to deduce that it is Belgium’s euthanasia law that causes Belgium’s suicide rate to be the second-highest in Western Europe. In other words, Mr Mattes is another poorly-informed commentator using the 'suicide contagion' line.

But what are the facts?

Depending on the source and year of data, one can certainly argue that Belgium’s general suicide rate is the second-highest in Western Europe. Setting aside for now the serious question of why it is valid to exclude all of the world’s other countries from the comparison, WorldLifeExpectancy.com reports figures that were published in 2014 (Table 1).

Table 1

Country

Suicides*

Finland

15.11

Belgium

14.64

Iceland

14.06

France

12.84

Austria

11.87

Sweden

11.43

Ireland

11.06

Germany

9.59

Switzerland

9.56

Norway

9.28

Denmark

9.19

Luxembourg

9.14

Netherlands

8.54

Portugal

8.49

Turkey

7.92

UK

6.28

Malta

5.75

Spain

5.23

Italy

4.76

Greece

3.86

* Suicides per 100k population, age-adjusted

The table includes all the countries in the wider definition of “Western Europe”, bar four: no suicide statistics are published for Liechtenstein, Monaco, Andorra or San Marino.

As you can see, Belgium is indeed the second-highest. But this begs the question:

If the reason Belgium is the second-highest is due to its assisted dying law, how come Finland, which Mr Mattes doesn't mention by name and which has no such law, is higher?

It also begs the question:

If assisted dying law were the fundamental cause of a high general suicide rate, how come Switzerland (statute since 1942), Luxembourg (statute since 2009) and the Netherlands (practice since the early 1980s and statute since 2002) have rates that are much lower, all key facts that Mr Mattes also fails to mention?

These are of course indications that the factoid has been included as a cherry-picked morsel of 'proof' because it sounds so compelling as a throw-away sentence amongst the other (false) statements.

But wait, there’s more

We can go further than merely wondering about the country comparisons, by comparing Belgium’s general suicide rate before and after assisted dying law reform. A critical step in establishing causation is to first establish correlation. If there is no correlation, there can be no causation.

Published OECD data shows that in 2013 (the most recent available data), Belgium’s general suicide rate was 16.7 per 100,000 population. What was it before their 2002 law reform? Well in 2000 it was 20.5, in 1990 it was 19.2, … you get the idea.

Has Belgium’s general suicide rate soared (or even increased modestly) since their 2002 assisted dying law came into effect? No. It’s dropped. Indeed, the slight downward trend apparent before the statute came into effect in 2002 has accelerated downward since (Figure 1).

Belgium's suicide rate since 1987Figure 1: The Belgium general suicide rate before and after assisted dying law reform

Even the headline is misleading

Mr Mattes fails to point out in his blog that assisted dying statutes in Benelux countries (Belgium, the Netherlands and Luxembourg) never restricted access to only the 'terminally ill,' that is, those imminently dying. He also fails to point out that USA states whose laws do restrict assisted dying to the terminally ill—most notably Oregon and Washington—have not changed their statutes in this regard since they came into effect.

Therefore, his headling implying that lawful jurisdictions have broadened their laws from 'only the terminally ill' is also wrong.

Conclusion

Mr Mattes makes multiple false and misleading claims and it’s easy to see his opinion for what it is: an emotional dump that fails to engage with and indeed flies in the face of actual evidence. The latest 'suicide contagion' implication, that assisted dying law causes Belgium’s general suicide rate to be the “second-highest in Western Europe” is evidentially false.

I call on LifeSiteNews to withdraw Mr Mattes' article because it breaches their primary principle:

“1. Accuracy in content is given high priority. News and information tips from readers are encouraged and validated. Valid corrections are always welcome. Writing and research is of a professional calibre.” — LifeSiteNews

 

Summary of facts

Belgium's general suicide rate is one of the higher ones in Western Europe. However:

  1. At least one country without an assisted dying law has a higher suicide rate, inconsistent with 'suicide contagion' theory.
  2. Other Western Europe countries with assisted dying laws have suicide rates much lower than Belgium's, also at odds with 'suicide contagion' theory.
  3. But the clincher is that the suicide rate in Belgium has dropped, not risen, since their 2002 assisted dying law came into effect.

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Schadenberg and Russell falsely call the Oregon Medical Association the "assisted suicide lobby" in contradiction of the facts.

Last week, Alex Schadenberg wrote—and Paul Russell republished—another nonsense article, this time about medical associations going neutral on assisted dying. They opine that there is no such thing as neutrality. And start out by getting their facts wrong... again.

Got the facts wrong yet again, lads

Messers Schadenberg and Russell claim that the Oregon Medical association is an "assisted suicide lobby" group. Had they bothered to check the rudimentary facts before sounding off, they would have known that the Oregon Medical Association remains neutral toward assisted dying. It reconfirmed its neutral stance as recently as early this month. It does not hold a 'supportive' stance.

How did Schadenberg and Russell come to their conclusion?

American Medical Association AGM

They refer to a motion that the Oregon Medical Association put to the recent annual general meeting of the American Medical Association. The motion sought to establish a process by which the American Medical Association would consult in order to re-evaluate its opposed stance to assisted dying, given that assisted dying is legal in a number of USA States and there are already many doctors who in good conscience provide assistance to die to qualifying patients.

Heavy-handed partisanship

In their usual style of heavy-handed partisanship, Schadenberg and Russell describe the Oregon motion as the "assisted suicide lobby" applying "pressure" to the American Medical Association.

They fail to level the same criticism at another group, the Louisiana Medical Society who put another motion to the meeting. The Louisiana motion sought to expressly confirm and entrench the American Medical Association's currently opposed stance. Schadenberg and Russell fail to criticize the Louisiana motion as "pressure," despite the fact that Oregon's motion was for open consultation, while Louisiana's was for a closed position.

Good sense prevails

In fact, they don't mention the Louisiana motion at all. Why? Because wiser heads prevailed at the national conference. The Louisiana motion was defeated and the Oregon motion was passed as I reported last week.

Desperate hyperbole

Schadenberg and Russell then desperately argue that you can only support or oppose assisted dying. There is no neutral, they say.

In the language of 'influence' we call this rhetoric "the sucker's choice." You put up just two options and demand folks pick one or the other.

"You're either for us or agin us!"

No other options, no nuances, no consideration of different options for different folks. Hardly the kind of stuff that would pass even a junior high school debate.

Back to the real world

Of course it's possible to be neutral.

Individually, a doctor may be personally opposed to assisted dying, but appreciate that another doctor, having equally examined their conscience, may support choice. Thus, the first doctor opposes for themselves but remains neutral to the position of other doctors. Indeed, an individual doctor may neither support nor oppose choice.

Collectively, it makes sense for a professional medical body to hold a neutral stance. How can it justify respecting the deeply-held beliefs and values of some of its members at the same time as explicitly disrespecting other members' views that are as closely examined and deeply held?

Conclusion

The best that opponents running the global charge against assisted dying can do is to first get their facts wrong (again), develop their false assumptions into shrill hyperbole, and then try to press the false dichotomy of a "suckers choice" into doing some heavy lifting: an exercise that falls flat on its face.

The evidence is crystal clear: they provide no real argument at all.


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The more anti-euthanasia campaigner Mr Wesley Smith publishes, the more I think he’s missed his true vocation as a comedian. His latest comical gig against assisted dying is a gem.

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

Who’s on first, What’s on second?

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

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

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

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

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

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


PeterReaganEvilAndDead.gif

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


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

Phew, comic relief—what a hoot.

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

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

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

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

The flip-flop routine 

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

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

Loud guffaws and applause all round.


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Wesley Smith never seems to tire of spreading opinion. In another piece of published nonsense, he's proposed that USA's rise in national suicide rate is in significant part a consequence of assisted dying law in those few states that permit it (up until the most recent general suicide data that's Oregon, Washington state, Vermont and Montana). His claim flies in the face of actual evidence.

Wesley Smith is a Senior Fellow at the Discovery Institute. Remember that? It's the organisation that a USA Federal court ruled pursues "demonstrably religious, cultural, and legal missions," and which comprehensively lost a test case in which it tried to have 'intelligent design' (that's creationism with lipstick) taught as a 'scientific' alternative to evolution.

In a piece recently published by conservative blog NationalReview and reprinted in pro-life LifeSiteNews, Mr Smith has asserted that assisted suicide has a significant part to play in the rising USA national suicide rate. "Color me decidedly not surprised. We are becoming a pro-suicide culture," he asserts.

"I am convinced that the correlation [between assisted suicide advocacy and the general suicide rate] could also be at least a partial causation."

On the matter of rhetoric, notice how Mr Smith cleverly mixes certainty ('convinced') with uncertainty ('could') in order to hedge his literal argumentative bets while giving the impression of valid authority. Ultimately, however, being certain about uncertainty can only be... uncertain.

Mr Smith argues from a USA Centers for Disease Control (CDC) report that the national suicide rate increased more after 2006, "the very time when the assisted suicide movement has become the most vigorous and made its most dramatic advances [emphasis is Smith's]." He offers not one shred of quantitative empirical evidence to support his contention that the assisted dying movement's 'vigor' changed suddenly and substantially from 2006.

So, what does analysis of relevant and readily-available data show? I've reproduced the USA national general suicide rates obtained from the USA government's CDC online database, plus unemployment rates obtained from the USA government Bureau of Labor Statistics online database in Figure 1. (The suicide data does not include deaths under state Death With Dignity Acts because under these Acts such deaths are not suicides.)
 

USA national suicide and unemployment rates

Figure 1: USA national suicide and unemployment rates

 

The national annual suicide rates are shown in red, and the unemployment rates are shown in blue with linear regression lines for before and after 2006. It's easy to see that prior to 2006 the unemployment rate peaked at around 6%, while after 2006—and clearly in response to the global financial crisis (GFC)—the rate peaks much higher at nearly 10%.

Suicide is indeed a complex phenomenon, with a wide range of both risk factors (e.g. unemployment, mental illness, substance abuse) and protective factors (e.g. mental illness mitigation programs, unemployment benefits), and it would be glib to assert only one or a few factors. Nevertheless, Figure 1 demonstrates a clear correlation between trends in unemployment and the overall suicide rate.

Correlation is of course not causation: though I will in a future report show how extensively common this correlation is around the world and over time. Nevertheless, the data, had Mr Smith bothered looking for it, offers a vastly more rational and compelling explanation of the rise in suicide rate than does some hokey theory about how just 325 rational adults in two states (Oregon and Washington state Death With Dignity Act deaths in 2014) who were already dying and quietly and privately chose to go a little early in response to intolerable suffering, caused the suicide rate amongst 319 million inhabitants (2014) across a nation of fifty states, to rise by a "huge and alarming" amount.

Mr Smith backhandedly acknowledges that there are multiple causes of suicide. "There is no question that assisted suicide advocacy is not the only factor causing this alarming increase in suicides," he says, presumptively positioning his hypothetical reason as definitely one of them.

Mr Smith does refer to a recent journal article by David Jones and David Paton that purports to show a weak link between assisted dying and the total suicide rate (with the weak link appearing only if assisted deaths are counted as suicides). I have analysed that paper in detail and shall deal with it in due course. How it passed peer review (if it was indeed peer reviewed) remains a mystery. The study is of an unacceptably poor standard on a range of facets as I will demonstrate.

In conclusion, did the CDC report that Mr Smith cites suggest that 'assisted suicide contagion' was a possible cause of the increase? Nope.

It's really time that Mr Smith and colleagues gave the misinformation campaign a rest.


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The Sydney Morning Herald opinion piece by Dr Andrew McGee

Dr Andrew McGee, Senior Lecturer in law at Queensland University of Technology, published an opinion piece, "Why Bob Hawke is wrong about euthanasia," opposing assisted dying law reform in the Sydney Morning Herald on the 19th April. He invokes straw-man arguments and conflates different issues. 

His ‘they might choose to die too early’ argument overlooks both the current tragedy of the terminally ill suiciding by violent means, as well as that in currently lawful jurisdictions like Oregon and Washington, a third of people who qualify for their medication never take it: it provides strong psychological relief that there is another option available whether they take it or not.

His argument that any boundary in regard to who may qualify would be arbitrary is to overlook the intrinsic boundary-ness of law. A minor (under 18) cannot lawfully buy alcohol. A person may not lawfully participate in ‘sophisticated’ investments unless they earn more than $250k a year. We accept legal boundaries as normal and necessary even if some feel a particular boundary is arbitrary. Necessarily, some will be excluded.

Further, arguing against assisted dying law reform on the principle that it’s ‘complicated’ is to argue against law in any case of alleged complexity. Marriage and divorce are complicated. Should we outlaw those?

Dr McGee’s arguments lack coherence and consistency and comprehensively fail to mount a persuasive case against the legalisation of assisted dying.


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He was red in the face and the veins on his neck were standing out. He involuntarily spat as he shouted while furiously jabbing a scientific journal paper high into the air. “This paper proves that palliative sedation doesn’t hasten death!,” he bellowed from the audience.

The recipient of the Catholic priest’s[§] ire was Dr Rodney Syme, who had just delivered a paper at a Catholic bioethics conference in Melbourne, Australia.

The presentation didn't win over an already skeptical audience given that his address was to argue, by referring to the scientific literature, that palliative care can’t always help alleviate refractory end-of-life symptoms and that continuous deep sedation (CDS) may hasten a patient’s death.

By the end of the address the audience was bristling with hostility and our priest bolted to his feet to commence the attack.

I hadn’t seen the journal paper the priest was brandishing, so immediately after the conference I retrieved a copy and studied it.1 You can obtain your own copy here.

But first, a little background on the doctrine of double effect.

 

Doctrine of double effect

There has been ongoing debate—both scholarly and otherwise—about whether CDS (particularly the administration of higher doses of opioids) for dying patients may hasten their death. CDS may be administered where the dying patient is suffering from intolerable and otherwise unrelievable symptoms, for the purpose of relief from those symptoms through the cessation of consciousness, even if it might hasten the patient's death.

To some, this is an uncontroversial medical intervention supported by the doctrine of double effect. The doctrine is widely attributed to thirteenth century Catholic Saint Thomas Aquinas, though he probably developed it from ancient Roman principles.

The doctrine says that it is acceptable to take this kind of action if it is proportionate to the suffering of the patient, that there are no other

 

less problematic alternatives, and that the doctor's intention is to relieve the suffering and not to hasten the patient’s death.

Skeptics of the doctrine point out that it can’t be reliably determined what the doctor was actually intending when they administered CDS prior to death. They also identify that the notion that it’s OK for a doctor to kill their patient (hasten her death) as long as the doctor “doesn’t really mean to,” is ethically questionable.

So, on the one hand the doctrine of double effect is relied upon to defend doctor actions, and on the other, it is claimed that CDS doesn’t hasten death in any case.

That’s having your cake and eating it too. If CDS didn’t hasten death, doctors wouldn’t need the doctrine of double effect as a defense.

Poor methodology

Back to the brandished paper. Having read it, I don’t understand how this paper passed peer review, assuming it was indeed peer reviewed. It’s a fact of life that on occasion, even prestigious journals like Lancet and the Journal of the American Medical Association publish manuscripts that shouldn’t see the light of day. I argue that this article (from Annals of Oncology) is one of them.

The research suffers from multiple, serious methodological problems.

The research suffers from multiple, serious methodological problems. Sure, the researchers attempted to match test patients (who received CDS) with control patients (who didn’t receive CDS), by age, class, gender, reason for admission and for functional status. But there the good work ends.

Here are some of the serious methodological flaws in the study.

  1. Primary measure invalid. The authors report that they measured patient survival time from admission to hospice until death from any cause. This alone invalidates the entire study. If you say you are measuring the effects of CDS, then you have to measure from the commencement of CDS, not from some other event that is not the substance of your test.
  2. Insufficient inclusion control. There is so much variability amongst the test and control subjects that the possibility of sufficient sensitivity to detect differences is highly unlikely. For example, around half of patients (53%) were admitted for uncontrolled symptoms of many and varied kinds but were not imminently dying, while a large minority (41%) were imminently dying. There was a wide range of cancer types from slow to aggressive, and of metastatic sites. The sheer breadth of patient contexts gave rise to a survival standard deviation (68% of observed variance, 6 days) that was 50% larger than the mean survival period (4 days). Translating that into 95% confidence (two standard deviations), the variance was three times larger (12 days) than the mean (4 days). Put another way, at 95% confidence, patients survived from minus 8 days to plus 16 days (from admission, not administration of CDS). Hardly the stuff to drive assertive conclusions.
  3. Insufficient intervention assessment. The researchers considered only the administration of sedatives, not of any other medical or palliative interventions in their assessment of patient survival. What other interventions were administered, when and in what amount, and how successful were they? The authors also assumed that any necessary nutrition and hydration was given to patients (whether natural or by tube) equally across hospice units because “the best palliative care should be provided.” There was no mention of whether the various units had identical (or any) written palliative care practice standards or whether those standards were known and actually practiced by attending physicians and nurses in patient cases for this study.
  4. Insufficient intervention control. A wide range of sedative types (not just opioids) were administered in a wide range of doses for widely ranging periods of time; from sudden, light and intermittent, to heavy and continuous. Around half the patients receiving sedation received multiple different sedatives.

It is hardly surprising then, given this sorry state of affairs, that the study failed to find a significant difference in ‘survival’ between test and control groups: the design was certain to result in insufficient sensitivity. (Curiously, the CDS patients survived on average longer (12 days) than the control patients (9 days), though the difference was not statistically significant.)

Unscientific conclusion

In scientific studies—particularly those which have yet to be successfully replicated by other researchers—best practice dictates that the minimum ‘significance’ is cautiously attributed to the results. The minimum significance in this case would be that “our study did not find evidence to support the contention that administration of sedation hastens patient death”.

The conclusion asserted by the researchers
is not established by the study.

The next level of attribution is still cautious, but a little more assertive: “the results suggest that the administration of sedation doesn’t hasten patient death”. It is my belief, especially given the poor design and conduct of the study, that this level of attribution would be too high.

But the authors went all out. They categorically concluded that “PST [palliative sedation therapy] does not shorten life” and trumpeted it in the article’s title: “Palliative sedation therapy does not hasten death.” On the basis of this unjustifiable interpretation they further categorically concluded that the doctrine of double effect is therefore unnecessary.

The authors in my view committed a serious scientific blunder in translating an exploratory and poorly-designed study into unqualified and assertive, unsupported conclusions. How this passed peer and editorial review is a mystery.

The upshot

The upshot of this is that our priest, perhaps with an understandable deficit of expertise in scientific endeavour, grabbed a paper that supported his hypothesis and fervently believed it to provide unarguable evidence, given its unequivocal title and conclusion.

In reality, each and every paper published in scientific journals has to be read and judged on its own merits. It is not appropriate to simply accept a study’s conclusions merely by virtue of its publication in a journal, even a prestigious one.

In reality, each and every paper published in scientific journals has to be read and
judged on its own merits.

Critical appraisal (including cross-checking other sources) is the scientific standard of practice I employ as I follow trains of research and commentary on various facets of end-of-life decisions and assisted dying, across my literature collection now well in excess of five thousand journal articles, theses, books, professional policy papers and other sources.

It is a standard I commend to everyone in order to hone in on the truth and to avoid dissemination of flapdoodle, fudge and fiction.

References

1    Maltoni, M, Pittureri, C, Scarpi, E, Piccinini, L, Martini, F, Turci, P, Montanari, L, Nanni, O & Amadori, D 2009, 'Palliative sedation therapy does not hasten death: results from a prospective multicenter study', Ann Oncol, 20(7), pp. 1163-9.


[§] The meeting was conducted under Chatham House rules, so what was said can be reported, but who said it cannot.

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Bulldust is often advanced by opponents of assisted dying law reform—a reform which most citizens want—to scare or bamboozle us against the reform.

Why is there so much misinformation about? The answer is straightforward: because so far it's worked.

More than academic niceties

This isn't just an academic argument about getting the facts right. It's a fundamental battle between different world views, where misinformation against assisted dying law reform has often held sway. Here are just two real examples:

Examples of real impacts of misinformation

  1. In Australia, in every Parliamentary debate over an assisted dying Bill before them, numbers of opposed politicians have quoted the rhetorical sham "the vulnerable will be at risk" (see why it's a sham here). With the exception of the Northern Territory's Rights of the Terminally Ill Act in 1996, every Bill before Australian Parliaments has been lost or filibustered until the end of the Parliamentary term on this fearmongering. And the Rights of the Terminally Ill Act was annulled by the Federal Parliament in 1997 on the same grounds.
     
  2. In Ireland, the High Court made a determination as to whether Marie Fleming, with advanced multiple sclerosis, was constitutionally allowed to receive assisted dying (Fleming v. Ireland and Ors 2012 10589 P). The court rejected Fleming's claim, saying that the "strikingly high" rates of non-voluntary euthanasia in Switzerland, Netherlands and Belgium "speaks for itself as to the risks involved". But sound research shows that the rates in these countries are similar to rates in other countries without assisted dying laws: evidence of the high degree of 'evidential' bull that was served up to their Honours.

It's time to stop the bull in its tracks

DyingForChoice.com believes it's time for the bull, the misinformation, to stop. It is unacceptable for rational citizens to be denied freedoms on the basis of scaremongering and erroneous information. This is the purpose of the F files. It provides citizens, politicians, policy advisors, healthcare workers, media professionals, researchers and others the evidence, arguments and resources to be properly informed and to avoid misinformation.

 

The F Files

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“The vulnerable will be at risk if we legalise assisted dying.”

This silly, nonsensical statement (flapdoodle) is promoted frequently and persistently in opposition to assisted dying law reform. Various forms are advanced not only by lobbyists, commentators, journalists and politicians, but even by judges and professional medical bodies (see the Appendix).

But why is this statement, and ones like it, just so much flapdoodle? The reason is because it’s false and self-serving rhetoric dressed up as a profound or self-evidential truth. Here’s the Full Monty on how this simple deception works.

What’s the argument?

The argument is structured in such a way that an original group (in this case ‘the vulnerable’) is claimed to morph into a new, different group (those ‘at risk’) on the basis of some approved or disapproved action introduced as a change statement (‘legalise assisted dying’). It takes the form of a supposedly consequentialist argument as shown in Figure 1.

vulnerableatriskfig01.jpgFigure 1: A supposedly consequentialist argument.

But the argument's a complete sham.  Why?

What's the sham?

A quick check of the definition of ‘vulnerable’ reveals the real answer. The Oxford dictionary says "at risk". Dictionary.com offers “susceptible”, and Merriam-Webster defines it as “open to harm”. So, the two groups are in fact one and the same cohort as shown in Figure 2.

vulnerableatriskfig02.jpgFigure 2: The ‘original’ and ‘new’ groups are in fact identical.

It is a circular sham—a tautology or rhetorical pretence—to claim that a group defined as at risk, susceptible or open to harm will become at risk, susceptible or open to harm, as a consequence of some argued change statement. The same thing applies to ‘the weak’, who by context are ‘the vulnerable’ or ‘those at risk’.

Through its self-truth, the circular group claim wrongly lends the change statement’s claim a halo of validity, rendering it intuitively (even seductively) but falsely attractive, as shown in Figure 3.

vulnerableatriskfig03.jpgFigure 3: The circular group claim wrongly casts a halo of ‘validity’ on the change statement’s claim.

Principle and examples of the sham

So, in principle, this rhetorical sleight of hand takes the form:

Group A becomes same Group B if dis/approved change.

[            The circular sham            ]     Change statement

The claim about assisted dying can be seen for what it is, a proposal basking in ‘self-proving’ rhetoric:

The vulnerable will be at risk if we legalise assisted dying.”

Let’s make the principle absolutely clear with some further examples:

  1. You want people to reject democracy.

The self-interested will promote their own agenda if we hold so-called ‘democratic’ elections.”

Analysis: the ‘self-interested’ are one and the same people who vigorously ‘promote their own agenda’ and so it proves nothing about democratic elections despite the attractiveness of wanting to minimise self-interest—which is presented here as only possibly negative. Note also the pejorative expression ‘so-called’ and placing ‘democratic’ in quote marks so as to also tarnish the reputation of free and fair elections.

  1. You are making a case to go to war.

Our brave soldiers will be denied valour if we oppose this just war.”

Analysis: ‘bravery’ and ‘valour’ are the same thing, and something we esteem highly, regardless of whether this particular war is waged or not. Note that presenting the war as ‘just’ (i.e. ‘righteous’) compounds the ‘offence’ of denying brave soldiers the chance of valour.

  1. You want to compel people to attend church.

If we allow people to skip church, the damned will be condemned to eternal hell.”

Analysis: by definition, the damned are condemned to eternal hell (assuming hell exists) regardless of whether people attend church or not. Might private prayer or a life of service to others—not just church attendance—help avoid eternal hell?

  1. You want ‘men’s entertainment galleries’ to be banned.

Sexual predators will continue to abuse their prey unless we ban table-top dance bars.”

Analysis: Sexual predators by definition abuse prey whether table-top dance bars exist or not.

How does the sham fool us so easily?

How is it that the ‘proof’ of the circular group reference so easily transfers a halo of validity to the change statement?

It does so by the close and intuitive relationship of the group topic to the change statement topic—in the main case, death, and in the further examples: political system; war; religion; sex. When the group and change statement topics are closely related, the nature of the change statement doesn’t trigger critical examination and we are likely to automatically accept the effect of the change statement as intrinsically true and meaningful, when it’s not.

How do I spot the sham easily?

To test a statement for the circular sham, simply replace the topic-related change statement with an unrelated one, for example:

Sexual predators will continue to abuse their prey unless we put a price on carbon.

Heavens! In order to protect people from sex crimes we must put a price on carbon!

The vulnerable will be at risk if we wear yellow socks on Wednesdays.”

vulnerableatriskfig04.jpgFigure 4: To protect the vulnerable from being at risk, we must outlaw the wearing of yellow socks on Wednesdays.

It becomes immediately obvious, by replacing a related change statement topic with an unrelated one, just how invalid the halo effect is. The jarring topic difference triggers our critical faculties and we easily see through the sham.

What to do when you find the sham

Authentic and healthy community debate about weighty matters deserves better than misleading rhetoric.

If you encounter the flapdoodle of this circular sham, ask those making it to correct their error and advise them that:

“No proof is found by just going round.”

If you get no satisfaction, report the flapdoodle to us and we'll add it to our examples.

 

-----

Appendix: Real-world examples of assisted dying ‘vulnerable at risk’ flapdoodle

1.   Medical journal headline

Dr Bill Noble (2013). ‘Legalising assisted dying puts vulnerable patients at risk and doctors must speak up.’ British Medical Journal 346: f4062.

2.   Medical association television statement

Dr Gerard McGushin (for the Australian Medical Association) (2013), Channel 10 TV ‘The Project’, 16-Oct — ”Anyone who’s weak and vulnerable in our society will be at risk [from legalised assisted dying].”

3.   Published book statement

Prof. Margaret Somerville (2014), ‘Death Talk: The case against euthanasia and physician-assisted suicide’, 2nd Ed., McGill-Queens University Press, Montreal — “… the community, especially its vulnerable memberslegalized euthanasia …  could place even their continued existence at risk” (Preface, p. 6 of 38, Kobo edition).

4.   Supreme Court (Canada) determination

Rodriguez v. British Columbia (Attorney General), [1993] 3 SCR 519, “… persons who may be vulnerable to the influence of othersmay find themselves at risk at the hand of others[in the intentional termination of life]”, p. 558.

5.   Magazine article

Bill Muehlenberg (2008), Quadrant Online, 3-Sep, http://quadrant.org.au/opinion/bill-muehlenberg/2008/09/some-objections-to-legalised-euthanasia/ (viewed 28-May-2014), “The most vulnerable will be at riskwith legalised euthanasia”.

6.   Legislator’s speech in Parliament

Rev. Hon. Dr Gordon Moyes (2003), Speech by the Rev. Hon. Dr Gordon Moyes AC, MLC in the NSW Legislative Council Chamber on The Voluntary Euthanasia Trial (Referendum) Bill 2003, “The most vulnerable will be at risk[from] voluntary euthanasia”.

7.   British Medical Association Policy Statement on Assisted Dying

British Medical Association (2014), What is current BMA policy on assisted dying?, https://www.bma.org.uk:443/advice/employment/ethics/ethics-a-to-z/physician-assisted-dying  (viewed 28-May-2014), “Permitting assisted dying for some could put vulnerable people at risk”.

8.   Newspaper quotes cleric

Rev. Dr Brendan McCarthy (2012), Assisted suicide comment: euthanasia puts the vulnerable at risk, http://www.telegraph.co.uk/news/uknews/law-and-order/9478399/Assisted-suicide-comment-euthanasia-puts-the-vulnerable-at-risk.html (viewed 28-May-2014).

9.   Anti-euthanasia campaign website

Alex Schadenberg (2013), Assisted dying law would bring risks for the vulnerable, http://alexschadenberg.blogspot.com.au/2013/11/assisted-dying-law-would-bring-risks.html (viewed 28-May-2014).

10. Anti-euthanasia blog

Paul Russell (2012), Euthanasia: Vigilance needed to protect the vulnerable, Newsweekly, http://newsweekly.com.au/article.php?id=5226 (viewed 28-May-2014) — “…the whole question of vulnerable patients at risk…”. [only the affirmative is argued]

11. Anti-euthanasia campaign website

Euthanasia Prevention Coalition [now the Patients Rights Council] (2007), ‘Turning the Tide’ DVD has sold more than 1000 copies, Newsletter October 2007 — “…the question of whether euthanasia puts vulnerable patients at risk…”. [only the affirmative is argued]

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"The vulnerable will be at risk if we legalise assisted dying."

This silly, nonsensical argument (flapdoodle) is promoted frequently and persistently in opposition to assisted dying law reform. Various forms are advanced not only by lobbyists, commentators, journalists and politicians, but even by judges and professional medical bodies (see examples).

But the statements are flapdoodle because they use circular rhetoric dressed up as a profound or self-evidential truth to fabricate a case for or against change.

The fabrication is to present ‘the vulnerable’ and people ‘at risk’ as different groups. They aren’t. The Oxford English dictionary defines ‘the vulnerable’ as “at risk”, and Merriam-Webster agrees: “open to harm”.

Therefore it’s a circular sham to argue that a group becomes itself on the basis of some arbitrary change. We could equally say:

“The vulnerable will be at risk if we wear yellow socks on Wednesdays.

Indeed, if you come across an example of this circular sham, ask the author to correct it because:

“No case is made when a circle is laid.

If they don't, let us know!

 

Examples

  1. Magazine article: Bill Muehlenberg (2008), Quadrant Online, 3-Sep, http://quadrant.org.au/opinion/bill-muehlenberg/2008/09/some-objections-to-legalised-euthanasia/ (viewed 28-May-2014), “The most vulnerable will be at risk … with legalised euthanasia”.
     
  2. Anti-euthanasia campaign website: Alex Schadenberg (2013), Assisted dying law would bring risks for the vulnerable, http://alexschadenberg.blogspot.com.au/2013/11/assisted-dying-law-would-bring-risks.html (viewed 28-May-2014).
     
  3. Legislator’s speech in Parliament: Rev. Hon. Dr Gordon Moyes (2003), Speech by the Rev. Hon. Dr Gordon Moyes AC, MLC in the NSW Legislative Council Chamber on The Voluntary Euthanasia Trial (Referendum) Bill 2003, “The most vulnerable will be at risk … [from] voluntary euthanasia”.
     
  4. Professional medical body statement: British Medical Association (2014), What is current BMA policy on assisted dying?, https://www.bma.org.uk:443/advice/employment/ethics/ethics-a-to-z/physician-assisted-dying  (viewed 28-May-2014), “Permitting assisted dying for some could put vulnerable people at risk”.
     
  5. Supreme Court (Canada) determination: Rodriguez v. British Columbia (Attorney General), [1993] 3 SCR 519, “… persons who may be vulnerable to the influence of others … may find themselves at risk at the hand of others … [in the intentional termination of life]”, p. 558.

 

Want a forensic analysis of the circular sham and how it so easily works to fool us? Check out the Full Monty here...

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