Australia

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Palliative Care Australia's position statement on assisted dying.

I’ve written previously about palliative care specialists trying to filibuster assisted dying law reform. In this F file, I reveal how Australia’s peak body for palliative care (PC), Palliative Care Australia (PCA), segues from a state of ignorance to its own filibuster that would stall assisted dying choice.

First up, let me say that I hold deep admiration for the generally excellent services PC specialists provide at the bedside. I believe that PC deserves strong support and good funding. The peak body’s leadership in regard to its stance on assisted dying, however, is of a dramatically lower calibre.

Revised policy statement

In PCA’s latest incarnation of its Position Statement on ‘Euthanasia and physician assisted suicide’,1 the organisation says that:

“Public discussion and policy development on issues related to euthanasia and physician assisted suicide should be informed by research. There is insufficient research into euthanasia and physician assisted suicide.” — Palliative Care Australia, Position Statement

One can only agree wholeheartedly with the first sentence. Of course public discussion and policy development should be informed by research wherever possible.

The filibuster

And there follows the filibuster rub — PCA unequivocally claims that there is insufficient research. The logical consequence of PCA's juxtaposition is that we ought to muzzle public discussion and policy development because, PCA alleges, there is insufficient research to inform it.

Certainly in terms of Australia there are only a handful of published studies into attitudes and practices. But assisted dying is illegal in Australia. There are very substantial ethical and legal issues when it comes to conducting research.

Who is PCA to claim "insufficient research"?

PCA is the peak body for PC, a specific discipline within medicine that represents (well-paid) doctors. It runs a staffed office in Fyshwick ACT, and is overseen by a Board and Executive. It has a key purpose of lobbying in the halls of power in the Federal Parliament, and, presumably on the basis of the statement above, has a goal of ensuring that government PC policy (and funding) is informed by research. You'd think it might have some resources and connections to go looking for some research evidence.

A revealing comparison

In comparison, I conduct my assisted dying law reform work on a completely pro-bono basis, as a single individual, in my spare time. I have a formal literature collection on end-of-life decision making, including assisted dying, of currently over six thousand articles. I’m not talking about mere opinion published in the media: I’m talking about articles published in professional journals and in official government and agency reports.

I just ran a quick check across my database, looking for items specifically in respect of assisted dying (not medical or palliative care in general) in the Netherlands, Belgium and Oregon, where assisted dying has been legal for some time. Here’s what I found.

In respect of assisted dying the Netherlands I hold 366 journal articles and 25 official reports. For Belgium, I hold 152 journal articles and 11 official reports. And for Oregon I hold 144 journal articles and 32 official reports.

That’s a total of 662 journal articles and 68 official reports in respect of three lawful assisted dying jurisdictions. And that doesn’t count any holdings of book chapters, conference papers and the like. The journal article count will be somewhat overstated because a minority of journal papers are about more than one lawful jurisdiction (e.g. the Netherlands and Belgium). So let’s estimate that downwards to, say, a mere 400 journal articles.

That’s an abundance of evidence from and review about jurisdictions where assisted dying is legal. Could we always know more about assisted dying? Sure.

Double standards when it comes to evidence

We could also know a lot more about PC. I recently asked PCA for a simple but critical headline statistic — one you’d think was necessary to inform policy about PC resources and funding: “what proportion of Australians who experience a non-sudden death (i.e. deaths where PC might be relevant) actually receive PC?”

PCA kindly responded, but the answer in a nutshell was “we don’t know.”

But I wouldn't suggest for a moment that we muzzle “public discussion and policy development on issues related to PC” because the peak body hasn't done enough research to calculate (or even estimate) a fundamental policy-informing statistic.

Conclusion

The Australian community would be better served if PCA acquainted itself with the extensive available literature on assisted dying in lawful jurisdictions (as well as headline PC statistics), and dropped its inappropriate filibuster.

 

References

  1. Palliative Care Australia 2016, Euthanasia and physician assisted suicide: Position statement, viewed 1 Sep 2016, <http://palliativecare.org.au/download/2448/>.
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Dr Megan Best at 'The Palliative Care Bridge'

The Australian Medical Association (AMA) has just published an article about the Belgian assisted dying law experience, which it says “splits Aussie experts.” But the AMA report indicates that at least one, Dr Megan Best, gets her facts fundamentally wrong.

AMA writer Sarah Colyer reports on Belgian assisted dying practice in the latest edition of MJA InSight, “Belgian euthanasia model splits Aussie experts.”

In the article, Colyer writes (and let’s assume she’s quoting Dr Best accurately and fairly):

Dr Megan Best, a bioethicist and palliative care practitioner at Greenwich Hospital in Sydney, told MJA InSight:
 

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

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

Colyer was reporting, and Best was providing commentary on a study of assisted dying practice in Belgium recently published in the Canadian Medical Association Journal.

Dr Best selects one factoid (the increase in second-opinions from GPs)—and claims there’s been a reduction in palliative care referrals—to argue a case that Belgium’s is a risky model.

And she’s absolutely wrong.

In the detail of the report (where you have to look to find the mention of GP second-opinions which she reports correctly), is also the clear statement that:

“…the proportion of cases in which at least one palliative care team was consulted about the request increased [with high statistical significance].”

But you don’t even have to read the whole report from cover to cover to find that out, even assuming that you had access to the full report—it’s behind a subscription paywall. Right there on ‘the cover of the tin’ (the publicly-available Abstract), it says in plain English that:

“Palliative care teams were increasingly often consulted about euthanasia requests, beyond the legal requirements to do so [with high statistical significance]” and “palliative care teams were increasingly consulted about the euthanasia request” [at least in respect of Flemish cases]

So, while Dr Best claims the study reported a “reduction in referral to palliative care doctors” the study itself says the exact opposite in multiple places: “palliative care teams were increasingly often consulted.” While Dr Best claims “a weakening of the due process of the Act”, the evidence in regard to palliative consults demonstrates the opposite: “a strengthening of the due process of the Act.”

Is this another example of the religiously opposed noticing ‘evidence’ that apparently supports their stance while failing to notice solid evidence (and in this case in a sentence immediately adjacent to the selected one) that contradicts that stance?

I have no doubt that Dr Best is an excellent palliative care practitioner, but in this matter she is utterly and evidentially wrong—and the evidence was anything but 'buried' in the report on which she chose to provide 'expert' commentary.

I ask the AMA to add an addendum to the article on their website, correcting the erroneous statement that there was a "reduction in referral to palliative care doctors."


Who is Dr Megan Best?

Dr Megan Best is an experienced palliative care physician and Chief Medical Officer for Community Palliative Care at Greenwich Hospital in NSW. The hospital is a Christian charity which believes all people are made in the image of God, and which operates according to the Gospel of Jesus Christ. Dr Best is a Fellow of the Centre for Public Christianity in Sydney, a media company offering “high-quality and well-researched” material to the public via the mainstream media, and is its spokesperson for palliative care.

She is author of Fearfully and Wonderfully Made, a “biblically-based ethical handbook” which holds “the Christian Bible as authoritative” and in which she concludes “may the God of all comfort hold you in the palm of his hand.” She is also author of A Life Already Started, giving advice to women faced with unwanted pregnancy that “God has not left you to manage on your own.” She is also a regular contributing writer to the Centre for Christian Apologetics, Scholarship and Education.

Dr Best completed her Master of Arts in Applied Ethics in Health Care at the Australian Catholic University in 2001.

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

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

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

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

Pushback

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

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

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

Ad hominem attack

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

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

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

Nazi Germany

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

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

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

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

Ultimate hubris

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

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

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

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

Conclusion

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

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


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Back in 2013 the High Court of Ireland rejected a legal bid by multiple sclerosis sufferer Marie Fleming to achieve a lawfully-assisted peaceful death.

The Court naturally relied on expert testimony in reaching its judgement, yet its conclusions included a statement containing significant errors of fact.

The erroneous statement

In its judgement,1 the Court made the following statement:

Above all, the fact that the number of LAWER (“legally assisted deaths without explicit request”) cases remains strikingly high in jurisdictions which have liberalised their law on assisted suicide (Switzerland, Netherlands and Belgium) — ranging from 0.4% to over 1% of all deaths in these jurisdictions according to the latest figures — without any obvious official response speaks for itself as to the risks involved.” [My emphases in bold]

In fact, the Court's judgement is wrong on not one, not two, but three significant matters. But that hasn't stopped opponents of assisted dying law reform from quoting the judgement as though it were factual and persuasive, when it isn't: relying on it because it was made by a High Court—the 'authority bias.'

Consequences

Here are just a few examples of the Court's statement being wielded by assisted dying opponents as though it were conclusive evidence against law reform:

 
These examples illustrate the frequency of quoting the misinformation and how it feeds into and wrongly shapes public policy formation.

Three strikes

So what are the three counts on which the Court's judgement was seriously wrong?

Strike 1: Wrong concept

First, let’s get the concepts right. LAWER is not “legally assisted deaths without explicit request.”

Such nomenclature is an oxymoron. To ‘assist’ is to accommodate, serve or help someone accomplish something. But if there has been no request then one cannot be helping. You can’t ‘assist’ a little old lady across the road if she has expressed no interest in going there: you’d be forcing her across the road. Equally, you can’t ‘assist’ a death if there’s no proper ‘request.’

LAWER in fact stands for “Life-ending Acts Without Explicit Request” (of a competent patient).5 And with the exception of the possible ‘lawfulness’ of the doctrine of double effect, such acts are illegal.

Further, if such acts were legal as the Court’s statement posits, then there would be no need for an “obvious official response” as the Court then concludes. The statement lacks fundamental coherence.

Strike 2: Not ‘strikingly high’

The Court's judgement states unequivocally that LAWER (otherwise known as Non-Voluntary Euthanasia or NVE) rates in Switzerland, the Netherlands and Belgium are ‘strikingly high’, though no comparative yardstick is recorded in the judgement by which one might draw or justify that subjective judgement. Similar 'strikingly high' statements also appear in sections 102 and 104 of the judgement.

There is in fact a scientific study, published in The Lancet in 2003, that provides sound empirical evidence that could have properly informed the Court (Figure 1).6

Non-voluntary euthanasia in seven European countriesFigure 1: The non-voluntary euthanasia (NVE) rates of seven European countries in late 2001/early 2002

As revealed by this study, the NVE rates in Switzerland and the Netherlands were in fact lower than in Denmark, a country which has never had an assisted dying law.

The only country which did appear to have an NVE rate notably higher than the others was Belgium. The research study collected the data for analysis between June 2001 and February 2002. However, Belgium’s Euthanasia Act was not passed by its Parliament until 28th May 2002, well after data collection was complete. Thus, even in describing Belgium’s NVE rate as ‘strikingly high’ compared to a number of other European countries, it cannot be attributed to an assisted dying law because none existed at the time.

In fact, the NVE rate in Belgium had been found to be high back in 1998,7 well before the Bill for the country's Euthanasia Act was even tabled in Parliament.

Further, if assisted dying laws had such effects, it might be expected that the NVE rate would increase the longer that assisted dying laws were in place. In that case the NVE rates in Switzerland (statute since 1942) and the Netherlands (regulation since the early 1980s) would have NVE rates much higher than Belgium’s (statute since 2002). But the exact opposite is true.

Indeed, Rietjens and colleagues8 further concluded in their review of NVE in the Netherlands, Belgium, Denmark and Switzerland that “the use of drugs with the intention to hasten death without an explicit request of the patient is part of medical end-of-life practice in the studied countries, regardless of their legal framework, and it occurs in similar fashion.” The study, published in 2007, would also have been important evidence before the Court.

Strike 3: Not ‘remaining’ high

The Court's judgement states unequivocally that the LAWER (NVE) rate of the three countries ‘remains’ strikingly high. No specific evidence was supplied in the judgement to support this statement. Indeed, the judgement notes:

  • In section 28 that Dutch NVE had been “consistently declining.”
  • In section 91 that “the number of LAWER deaths has significantly declined in both [Dutch and Belgian] jurisdictions.”
  • In section 94 that “the trend in [Dutch] LAWER cases are declining in numbers (from 1,000 in 1990 to 550 in 2005)” and that in Belgium “the number of LAWER cases has declined since legalisation of assisted death.”
  • In section 101 that the NVE rates of both the Netherlands and Belgium had dropped.

 
Despite this clear and repeated evidence, the Court summarises in section 96 that the evidence cannot be “regarded as encouraging or satisfactory.”

But what does empirical research tell us about the NVE trends? In both the Netherlands and Belgium, since assisted dying was enshrined in statute and became effective in 2002, the rate of NVE has decreased significantly (Figure 2).7,9-11 In fact, the rate in the Netherlands is now similar to that in the UK, a country which has never had an assisted dying law and which provides the world’s gold standard in palliative care practice.

Non-voluntary euthanasia rates have decreased in the Netherlands and BelgiumFigure 2: Empirical trends in NVE rates before and after legalisation of assisted dying

These are critical yardsticks by which to judge practice in jurisdictions that have assisted dying laws with jurisdictions that don't. The UK study was published in 2009 and was readily available prior to the High Court’s hearings, yet appears not to have been presented in evidence.

The final (2010) Dutch NVE statistic in Figure 2 may or may not have been available to the Court: it was published in 2012 around the time the Court was taking evidence. The final (2013) Belgian statistic would not have been available to the Court as it was published in 2015.

Conclusion

While the High Court worked diligently within the scope of evidence brought before it:

  • The Court’s definition of LAWER is incorrect and incoherent;
  • Its statement that the NVE rates of the Netherlands and Switzerland are ‘strikingly high’ are evidentially wrong when compared with other countries without assisted dying laws;
  • Its implication that the higher NVE rate in Belgium was caused by assisted dying law reform is evidentially wrong; and
  • Its statement that the rates remain high is evidentially wrong.

 
The High Court's judgement does not provide defensible evidence or argument against assisted dying law reform.

Many lobbyists have repeated these incorrect statements, significantly misleading media, policy makers and legislators.

Now that the facts are readily available it’s appropriate to avoid repeating evidentially wrong statements, regardless of the apparent 'authority' of their source.
 

Summary of facts

  1. LAWER stands for "Life-ending Acts Without Explicit Request". Its practice is similar in countries with and without assisted dying laws.
  2. The NVE rates in the Netherlands and Switzerland are lower than the rate in Denmark, a country which has never had an assisted dying law.
  3. The NVE rate in Belgium appears higher, but was so long before assisted dying law reform and so cannot have been caused by such a law.
  4. The NVE rates of the Netherlands and Belgium have both decreased significantly since their assisted dying statutes came into effect in 2002.

References

  1. High Court of Ireland 2013, Fleming v Ireland & Ors - Determination, [2013] IEHC 2, Dublin.
  2. Boudreau, JD, Somerville, MA & Biller-Andorno, N 2013, 'Physician-assisted suicide: should not be permitted/should be permitted', New England Journal of Medicine, 368(15), pp. 1450-1452.
  3. Somerville, M 2016, 'Killing as kindness: The problem of dealing with suffering and death in a secular society', The Newman Rambler, 12(1), pp. 1-26.
  4. Keown, J 2014, 'A right to voluntary euthanasia? Confusion in Canada in Carter', Notre Dame Journal of Law, Ethics & Public Policy, 28(1), pp. 1-45.
  5. Pijnenborg, L, van der Maas, PJ, van Delden, JJM & Looman, CW 1993, 'Life-terminating acts without explicit request of patient', Lancet, 341(8854), pp. 1196-1199.
  6. 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.
  7. 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.
  8. Rietjens, JA, Bilsen, J, Fischer, S, Van Der Heide, A, Van Der Maas, PJ, Miccinessi, G, Norup, M, Onwuteaka-Philipsen, BD, Vrakking, AM & Van Der Wal, G 2007, 'Using drugs to end life without an explicit request of the patient', Death Studies, 31(3), Mar, pp. 205-21.
  9. Seale, C 2009, 'End-of-life decisions in the UK involving medical practitioners', Palliat Med, 23(3), pp. 198-204.
  10. 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.
  11. 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.
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Mr Max Bromson (seated) at Parliament House Canberra in June 2014. He died not long afterwards.

Assisted dying critic Mr Paul Russell has done it again. I’m beginning to think that he’s a tremendous asset to the pro-assisted-dying movement. Why would I say that?

Well, this time his pronouncements appear in National Right To Life News, the online newspaper of the USA Catholic-founded National Right To Life Committee, and in which Mr Russell represents ‘HOPE,’ his anti-euthanasia lobby platform founded by the Australian Family Association—itself Catholic-founded and backed.

The complaint

In his opinion piece, Mr Russell complained that Mr Max Bromson of Adelaide, Australia, who ended his own life after a long period of serious suffering from advanced cancer, lived far longer than his doctors had estimated.1

That he outlived his diagnosis by more than four years confirms the observation that qualifying periods in euthanasia and assisted suicide about ‘six months to live’ or similar, are really meaningless.” — Paul Russell

The pro-assisted-dying message

Mr Russell, in a single sentence, unequivocally demolishes the foundation of his own arguments in opposition to legalising assisted dying. He is a huge fan of the ‘vulnerable’ argument: that once legalised, people will quickly be pressured into assisted dying.

If his ‘vulnerable’ argument held true (a hypothesis that peer-reviewed scientific research contradicts), those with the means to peacefully end their lives would do so. And they wouldn’t take four years to think about it.

By explicitly pointing out that Mr Bromson had survived for much longer than expected (as fellow assisted-dying critic Mr Wesley Smith pointed out in another case), Mr Russell directly disproves the rhetoric of his ‘vulnerable’ argument.

People will quickly end their own lives... but survive far longer than expected: It's a spectacular flip-flop.

Conclusion

Thanks, Mr Russell, for pointing out that people don’t want to die—that they live as long as they can possibly bear it—and disproving your own nonsense. Keep up the good work!

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Footnote: Blind ignorance?

I’m also curious as to whether Mr Russell advances misinformation in blind ignorance, or whether the situation is worse. Who can say?

I have on a number of occasions explained simply and clearly why the west-coast-USA state assisted dying laws require that for the patient to qualify for assisted dying, one of the conditions is that the patient’s doctor must assess that the patient is likely to die within six months.

The reason is not that those with five months to live are deserving of the choice, but those with ten months to live are not, as Mr Russell bizarrely assumes.

The very important outcome is that when the doctor makes that assessment, the patient then automatically qualifies for free hospice care. It takes monetary considerations out of the equation, which is important in the context of the expensive USA healthcare system.

So, Mr Russell demonstrates profound ignorance at best by opining that the prognosis of time remaining must be superbly accurate, when it can’t be except possibly in the last days.

It’s about quality of life, not quantity; framed by hospice care being readily and freely available.

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References

  1. Russell, P. 2016, No charges in suicide case in South Australia, including “Dr. Death,” Philip Nitschke, viewed 3-Aug-2016, https://www.nationalrighttolifenews.org/2016/08/no-charges-in-suicide-case-in-south-australia-including-dr-death-philip-nitschke/

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Yesterday in a prominent opinion piece in The Age newspaper,1 palliative care specialists argued that palliative care is imperfect and in need of an injection of funds. I agree on both counts.

Nurse Peter Hudson, and doctors Mark Boughey and Jennifer Philip of the Centre for Palliative Care argued that instead of assisted dying as recommended by the recent Victorian Parliament committee report, increased funding of palliative care is ‘the answer.’

Key arguments

Here are the highlights of their opinion piece:
  1. They refer to assisted dying, a neutral expression now in common use amongst both lay commentators and scholars, as a euphemism. Instead they laboriously refer to assisted suicide (suicide is universally seen as a pejorative term with all its baggage about mental illness and substance abuse), and euthanasia (consistently omitting the qualifier ‘voluntary’).
  2. Dying at home should not be the gold standard (despite the great majority preferring it); instead, dying in hospital can be ‘preferred.’
  3. In a profound lack of self-reflection or consistent logic, they say that assisted dying ought to remain outlawed because its outcomes are uncertain. Even assuming the premise of the statement, this would be an identical argument to ban palliative care, whose outcomes are at least equally if not considerably more uncertain.
  4. They falsely imply that users of assisted dying not infrequently experience “very unfavourable” reactions to the drugs. This is simply untrue and I challenge them to provide the empirical evidence that they state is so very important.
  5. Tellingly, they describe a peaceful assisted death as “sanitised,” signalling their intrinsic disapproval of other’s choices.
  6. They say that focus should remain on increased resourcing of palliative care, failing to mention that the Parliamentary committee’s report indeed recommended increases in palliative care funding and improvement of evidence-based practice. Overseas evidence also reveals improvements in palliative care in jurisdictions with assisted dying legislation. There’s no false dichotomy between palliative care and assisted dying as the authors try to insinuate.
  7. They assume that medical interventionism (what they have to offer) is the correct and normative response, ignoring the fact that some people simply don’t want more interventions.
 

The filibuster

In a journal article recently published by two of the opinion piece authors,2 and repeated in principle in the Centre’s submission to and appearance before the Parliamentary inquiry,3,4 they say that:

“Increased resources and effort must be directed toward training, research, community engagement, and ensuring adequate resourcing for palliative care to benefit many before further consideration is given to allocating resources into legalising EAS to respond to the requests of a few.”

Notice two things about their recommendation—the filibuster.

Maximising what cannot be done

Firstly, they say we must not just ban assisted dying, but that it is dangerous even to talk about it: palliative care must be improved even “before further consideration is given.” The specific purpose of this part of the filibuster is to maximise what cannot be done: to position even mere conversation, let alone actual reform, as ‘unsafe.’

Maximising the delay

Secondly, nowhere in their argument do they provide a single quantitative metric (and which they strongly argue is necessary for the legalisation of assisted dying) by which the palliative care reforms they advocate might be judged: not a single dollar amount nor a single performance benchmark amongst their many recommendations.

How much will reforms cost, how long will they take, and what performance measure improvements would need to be achieved for the expenditure to be judged effective? What performance measures would need to be reached before it was then ‘safe’ to even consider assisted dying? The authors are entirely mute on these critical matters, while making precisely these evidential demands of assisted dying.

So, the opinionists’ argument allows them to indefinitely say that “more improvements are needed in palliative care before we even talk about assisted dying,” because further ‘improvements’ are always possible.

But all that was a ruse anyhow

In any case, the authors say in their submission to the Parliamentary inquiry that there are numerous problems (spurious, I argue) with legalising assisted dying; that they doubt they could be overcome; and then finally “it should not be construed that we would support the legalisation of EAS if efforts were made to address [the problems].”4, page 6 (Curiously, they omit the third, critical statement from their more public opinion piece.)

This truly exposes the classic filibuster… an open-ended call with no metrics, which therefore can be deemed never to have been met. How convenient. But, even if they were met, the authors still wouldn’t support reform. This begs the question:

If the authors are as so firmly evidence-based—as they take pains to emphasise—why would they not support a reform if the evidence endorsed it?

There must be something other than evidence that drives their entrenched opposition to assisted dying: something so important that it renders all their previous arguments null and void. What might that be?

Who are these people, anyway?

It’s informative to answer the question of who these three from the Centre for Palliative Care are. The Centre sounds like a neutral government body. It isn’t. Don’t get me wrong. I have no doubt that these three are skilled and compassionate practitioners and that the Centre delivers good services.

In reality the Center is a section of Melbourne’s St Vincent’s Hospital. That’s an organisation that proudly states “as a Catholic healthcare service we bring God’s love to those in need through the healing ministry of Jesus.”

I believe St V’s to be a high-quality healthcare institution, but too bad if the patient just wants evidence-based medical care and not the ‘healing ministry’ of a religious figure they may not subscribe to.

The reason this is important is this: what the three authors say about assisted dying is entirely consistent with the Vatican’s stance. I have no idea if any of the authors are Catholic, but what would be entirely surprising is if they published anything at odds with the views of the Vatican given their Centre is deeply embedded within the largest Catholic health and aged care service provider in the country.

For clarity and fairness, I once again place on the public record that I am agnostic.

The ‘Catholic card’

Before Messers Paul Russell, Alex Schadenberg and others leap onto their campaigning steeds to megaphone that I’m ‘playing the Catholic card’ (just wait for it!), let me be clear that I specifically am doing precisely that. For sure, The Catholic Church is not the only religious body resolutely opposed to anyone having the choice of assisted dying, but it’s the premier one.

And, Messers Russell et al would be absolutely right to point out that the authors didn’t raise a single religious argument, so let me save them the bother.

Religious opposition dressed up in secular garb

And that’s the point. It’s abundantly clear from multiple sources that religious opponents have actively decided that they will absolutely avoid using religious arguments because they know it will lose them the debate.

Media identity Andrew Denton’s Better Off Dead podcast series makes this avoidance abundantly clear from the Australian perspective. His insights, having attended a global anti-euthanasia conference in Adelaide, are important and revealing. 

From the North American perspective, a study just published by Associate Professor Ari Gandsman of the University of Ottawa in Death Studies5 reports uncanny North American similarities. Assisted dying opponents have actively decided to cease using religious arguments. Instead, their objective is to create an atmosphere of FUD: fear, uncertainty and doubt. It is only this now, they agree amongst themselves, that will keep assisted dying off the statute books. As Gandsman explains (and I paraphrase), religious opponents have moved from ‘it’s a sin’ to ‘but think about all the perceived risks!’

Again, I reiterate that the three opinion piece authors are likely to be fine nurses and doctors (I have never met any of them), but I do say that their incoherent and self-contradictory arguments against assisted dying, remaining opposed even ‘if’ the evidence for it stacks up, is neither their finest work, nor varies one iota from the religious anchor that the Vatican provides to their Centre’s services.

The importance of mutual respect

If a person says to me “I believe assisted dying is wrong,” I respect that view and admire their resolution. For themselves. Including if it is underpinned by religious belief. If you believe that assisted dying, or surrogacy, or other contentious issue is wrong, don’t participate in it. 

But don’t expect that your own view of your own God trumps everyone else’s God—or lack thereof. In Australia for example, the majority of citizens are not Catholic. And most of those who are—three out of four—disagree with the Vatican’s opposition to assisted dying. The Vatican’s view then is not particularly relevant to anyone but its most ardent adherents.

Respect in both directions is warranted but is rather lacking from the more religious end. My argument is not against Catholicism itself. There are very fine Catholics on both sides of the debate, doing their best to live a deliberatively ‘good’ life.

Conclusion

We can do without the incoherent and indefensible nonsense advanced in secular garb by the religiously opposed.

Be clear folks: the FUD campaign is on its last legs. I will be further exposing rubbish arguments posed by those with religious connections but couched in non-religious language.

In the meantime you can see the clumsy, failed attempt at a filibuster by these three opinionists for what it is.

 

References

  1. Hudson, P., Boughey, M. & Philip, J., 2016, Victoria's proposed euthanasia laws are flawed, Melbourne: Fairfax Media, Accessed 21 Jun 2016, http://www.theage.com.au/comment/victorias-proposed-euthanasia-laws-are-flawed-20160620-gpn9p2.html
  2. Hudson, P., Hudson, R., Philip, J., Boughey, M., Kelly, B. & Hertogh, C., 2015, Legalizing physician-assisted suicide and/or euthanasia: Pragmatic implications for palliative care, Palliative and Supportive Care, 13(5), 1399-1409.
  3. Hudson, P., 2015, Inquiry into end of life choices: Submission 905 to the Parliament of Victoria, Centre for Palliative Care, St Vincent’s Hospital, Melbourne.
  4. Hudson, P., Boughey, M. and Philip, J., 2016, Witness Appearance Transcript: Inquiry into end-of-life choices - Centre for Palliative Care, Parliament of Victoria, Melbourne, 24 Feb.
  5. Gandsman, A., 2016,“A recipe for elder abuse:” From sin to risk in anti-euthanasia activism. Death Studies, In press.
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Mrs Inga Peulich of the Victorian Parliament.

Mrs Inga Peulich is MLC for the Victorian state region of South-Eastern Metropolitan and is Shadow Minister for Multicultural Affairs and for Scrutiny of Government. She is a member of the Parliament's Legal and Social Issues Committee, which recently recommended assisted dying law reform.

She has previously made clear her personal opposition toward assisted dying law reform. It's no surprise then that she wrote a minority report against her own Committee's final recommendations. What is surprising is the incoherence of her report.

They're biased but I'm not

Mrs Peulich rails against the inquiry being held in the first place, saying that she outright opposed the call. It's curious then that she remained on the Committee once the inquiry was mandated by the Legislative Council.

Even more telling is that Mrs Peulich accuses her fellow Parliamentary Committee members of unmitigated bias—that they simply reached a foregone conclusion. Not only does such hubris demonstrate a breathtaking disregard for the dedication and professionalism of her fellow Parliamentarians, it reveals a comprehensive failure of self-reflection: that other members are biased for the possibility of a supportive stance, but she is not for her preset and entrenched opposition.

The criticism is all the more galling for the fact that Mrs Peulich missed a number of meetings to hear from expert witnesses. Other members were informed and their position changed or at least nuanced by the evidence and advice.

The ramble

Mrs Peulich's minority report then launches into a ramble of conjecture, raising many of the tired old discredited arguments against assisted dying without reference to a single cited fact; incoherently even making points that the Committees' final report (hundreds of pages, fully cited) can't support...and ones that I specifically, comprehensively and evidentially refuted in my submission to and expert witness appearance before the Committee.

At least one appropriate omission

I can say that in response to a question Mrs Peulich asked me about non-voluntary euthanasia in the Netherlands, in what she might have anticipated as a 'gotcha' moment, I used empirical scientific evidence to blast the premise of her question—that legalisation of voluntary euthanasia has increased the rate of Dutch non-voluntary euthanasia—out of the water. The rate has dropped dramatically, not increased. At least she didn't raise that hoary old Dutch chestnut directly in her report.

Selective perfectionism

It would be tedious to address every item of unsupported conjecture and misinformation in Mrs Peulich's report. However, one other claim is worthy of discussion. It's an argument she's made before. She says this in regard to assisted dying law reform:

"...people will die as a result of accident, error or misdiagnosis. Any accidental loss of life – even the loss of one life, means such a regime cannot be justified."

Putting aside for the moment the premise of the statement, Mrs Peulich's selectivity is remarkable.

Published scientific research shows that of hospital admissions (Australia), around 0.4% result in death as a consequence of preventable medical error.1 The study was published some twenty years ago, so let's assume that the error rate has dropped—by virtue of greatly improved record keeping, communication, transparency, procedures and technology since then—by a factor of ten: that is, a preventable medical error death rate of 0.04%.

That still means that at least dozens of Victorians die each year as a result of preventable medical error.

If Mrs Peulich argues that no system can be justified if it results in the erroneous loss of a single life, then she must equally argue for the closure and prohibition of the entire Victorian hospital system. Or admit that she's irrationally biased against the option of assisted dying.

Missing critical Oregon 'information'

Yet the most telling thing is what is missing from Mrs Peulich's minority report.

On April 8th 2010, as keynote speaker and in her capacity as member of the Victorian Parliament, at Australian Catholic University's Interfaith Symposium on Death and Dying, she made this unequivocal statement:

"The Oregon experience, which legislated the taking of medication to bring about euthanasia indicates unfortunately that it does occur, that older patients who are tapping into more expensive care are encouraged often to bring about their own earlier demise."

Such a situation would be a very, very serious matter indeed.

But did Mrs Peulich furnish any evidence to support her allegation? No, none whatsoever.

If she believes this matter to be true, and it would be of critical importance to the inquiry to which she was directly a party and would strongly support her case against reform, why does it not appear in her minority report?

Mrs Peulich, put up or apologise

The claim is bunkum. Having extensively studied dozens of reports about and scientific studies into practices in Oregon and personally interviewed key Oregonian stakeholders (for, against and neutral), I have found not a shred of evidence that supports Mrs Peulich's categorical assertion.

I expressly challenge Mrs Peulich to furnish the necessary, verifiable, authoritative evidence (not mere self-serving gossip and scuttlebutt), and to explain why it does not appear as evidence to her own Committee's investigation.

If she is unable to provide such evidence or satisfactorily explain its absence from her minority report, it is my view that she owes the people of Victoria an apology for the spreading of misinformation on the taxpayer's tab.

A dead bat to this challenge would only serve to highlight that her claims are rubbish and that this kind of approach deserves no place in the important public discourse about assisted dying.

 

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1. Wilson, Ross McL, Runciman, William B., Gibberd, Robert W., Harrison, Bernadette T., Newby, Liza & Hamilton, John D.. 1995. The Quality in Australian Healthcare Study. Medical Journal of Australia 163: 458-471. 

 


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The Australian Federal election is now officially 'on'. You can take Vote Compass' questionnaire and indicate your views on assisted dying for the terminally ill, amongst other things.

Again this election, Vote Compass is running a service that allows you to explore how your views align with various parties and candidates.

One of the key questions in the Vote Compass repertoir is to agree or disagree with the statement "Terminally ill patients should be able to legally end their own lives with medical assistance."

You can indicate your support for this long-overdue law reform by completing the questions at Vote Compass here.

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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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Lyle Shelton's bunkum tweet is broadcast on ABC's Q&A program

The Managing Director of the Australian Christian Lobby, Mr Lyle Shelton, is at it again.

Yesterday, he tweeted ABC's Q&A program as thousands of people do while it is on air. His tweet was broadcast live to air as shown above. What did he say as panelists were discussing assisted dying law reform?

"Sadly voluntary euthanasia quickly became involuntary euthanasia in Holland. #qanda" LyleShelton

Mr Shelton's claim is bunkum.

Confused language

Firstly, he's confused involuntary with non-voluntary euthanasia.

Involuntary euthanasia is the deliberate hastening of the death of an individual in contravention of the express wishes to the contrary of that individual.  Nobody (except the Australian Christian Lobby in its confusion) is seriously suggesting that involuntary euthanasia happens in the Netherlands, even as a 'result' of the country's euthanasia law.

Non-voluntary euthanasia is the deliberate hastening of the death of an individual without an explicit request from that individual. Increased doses of analgesics and sedatives are administered to alleviate intractable symptoms at the end of life, as a result of discussion between doctors and the patient's family (the patient is not currently competent to participate in decisions). The drugs may hasten death and if this happens, life is shortened by hours, or less often, days. Despite claims by some assisted dying opponents that this is unique to the Netherlands, scientific research shows clearly that the practice occurs all over the world and is not 'caused' by voluntary euthanasia laws.

ACL staff sing from the same hymn book

Daniel Flynn, Victorian Director of the Australian Christian Lobby, made a similar claim in a formal submission (#694) to the Victorian Parliament's Inquiry into End Of Life Choices:

"There is sufficient evidence to suggest that involuntary euthanasia is frequent in jurisdictions in which euthanasia has been legalised." [p 4.]

Not a shred—let alone 'sufficient'—evidence was offered to back up this silly myth, though it's hardly surprising given that there isn't any.

What does the evidence actually show?

The scientific evidence is crystal clear and it is the opposite of Lyle Shelton and the Australian Christian Lobby's claim. Since around 1985 the Netherlands had permitted assisted dying by regulation: under agreement amongst relevant authorities. The rate of non-voluntary euthanasia remained relatively unchanged under this arrangement (Figure 1). In 2002 the Netherlands' euthanasia Act came into effect, replacing regulatory arrangements with a comprehensive set of legislative (i.e. statutory) requirements.

 

dutchanduk-nve01.jpg
Figure 1: Netherlands and UK non-voluntary euthanasia rates

Since 2002, the rate of non-voluntary euthanasia in the Netherlands has dropped, not risen.1 The drop is statistically significant. The rate of non-voluntary euthanasia in the Netherlands is now around the same level as in the United Kingdom.2 The UK is generally accepted as the world's gold standard in palliative care practice and it does not have an assisted dying law.

Absolutely contrary to the claim of the Australian Christian Lobby's Lyle Shelton, the rate of non-voluntary euthanasia in the Netherlands has dropped, not risen. It's now similar to the rate in the UK, which has no assisted dying law.

ABC news standards

Since the ABC moved the Q&A program from its entertainment division to its news division there is a heighted obligation on the broadcaster to ensure that the show's content is reason- and evidence-based, and not merely a platform for anyone to promote silly misinformation in support of a perspective.

No doubt the ABC will rise suitably to the occasion of discouraging misinformation and ensuring that any is corrected.

We'll be watching the next episode of ABC Q&A closely to fact check anything Mr Shelton and others say about assisted dying law reform. Give us a bell if you spot anything you know or suspect is untrue.

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  1. 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, vol. 380, no. 9845, pp. 908-915.
  2. Seale, C 2009, 'End-of-life decisions in the UK involving medical practitioners', Palliative Medicine, vol. 23, no. 3, pp. 198-204.

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