Rhetoric: Slippery slope

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Update: Margaret Somerville is now Professor of Ethics at the Catholic University of Notre Dame Australia.

In the previous video a claim by Catholic Professor of Ethics Margaret Somerville was rebutted: that the Dutch and Belgians seek health care in Germany because they fear being killed by their own doctors and without being asked. In this video, she furthers her bizarre claim by referring to Dutch and Belgian non-voluntary euthanasia rates as 'proof' of her border-crossing healthcare thesis.

However, her cherry-picked statistic establishes nothing, whereas her claim is contradicted by robust research, which I discuss in this video.

It's unclear why Professor Somerville seems to be unaware of or ignores readily-available yet contradictory evidence of central importance to her claim.

This 'non-voluntary slippery slope' claim is another one that's popular amongst campaigners against assisted dying.

 

Transcript

Neil Francis: In the last video, we established as false, Professor Margaret Somerville’s absurd claim of the Dutch going to Germany for health care because they feared being killed by their doctors. But she goes on.

Margaret Somerville: In actual fact they’ve got good reason to fear that, uh, there’s a minimum of, a minimum of 500 cases a year, of doctors who administer euthanasia to people in the Netherlands, where it’s legal, and the patient does not know they’re being given euthanasia, and has not consented to it. Some reports put the figure as high as 2000 cases a year.

Neil Francis: And she makes a similar case for Belgium. So let’s look at the empirical evidence.

Neil Francis: What she’s referring to is non-voluntary euthanasia, or NVE. It occurs in every jurisdiction around the world. A study published in 2003 found these rates. You’ll notice that Italy had the lowest and Belgium the highest NVE rates. And at the time of this study, which countries had legalised assisted dying?

Neil Francis: Switzerland had since 1942, and the Netherlands since 1982. But none of the others had. So the Swiss and Dutch NVE rates, with assisted dying laws, were lower than Denmark’s, without one. And the higher Belgian rate wasn’t caused by an assisted dying law, because none existed at the time.

Neil Francis: But did the Belgian and Dutch NVE rates go up when each country legalised assisted dying by statute in 2002? Here’s what happened in Belgium: the rate didn’t go up — it went down, and the drop is highly statistically significant.

Neil Francis: And in the time since Professor Somerville made her misleading claim, it’s remained lower.

Neil Francis: And here’s what happened in the Netherlands. This rate before the Act is around 1,000 cases a year, and this one after the Act is around 500, the rate that Professor Somerville refers to in her claim as “the minimum”. What she failed to mention is that since statutory legalisation of assisted dying, the Dutch NVE rate dropped, not risen, and to a similar level as the UK, the world’s gold standard for palliative care, and which has never had an assisted dying law.

Neil Francis: And since Professor Somerville made her misleading claim, it’s dropped even further.

Neil Francis: If Professor believes that she has verifiable empirical evidence to back up her claims, let her produce it for examination. Until then, her non-voluntary euthanasia “slippery slope ”is nothing more than fear-mongering innuendo.

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

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

amauncoveredinfographicmar2017.jpg Infographic summary of 'AMA uncovered'

 

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

 

AMA policy review

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

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

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

Deeply flawed survey — against assisted dying

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

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

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

Yet supportive doctor responses

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

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

Some doctors oppose legalisation, not euthanasia itself

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

AMA not representative of Australian doctors

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

Hostile tweets by President during review

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

Indefensible conclusion by AMA Executive

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

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

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

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

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

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

Incoherent demands for policy consultation

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

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

Conclusison

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

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

 

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

 

Sixteen questions for the AMA

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

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

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Alex Schadenberg's latest shrill and misleading article

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

The Bill

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

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

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

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

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

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

(5) The patient ceases to be capable.

Mr Schadenberg fails to mention Section 2, which states:

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

What is the ORS range?

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

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

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

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

No ‘defence’

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

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

Wrong again…

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

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

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

Conclusion

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

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


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

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

Unrepresentative of Australian doctors

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

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

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

Biased survey

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

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

Survey results

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

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

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

Executive’s ‘interpretation’

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

Previous (2007) statement

‘Revised’ (2016) statement

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

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

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

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

Failure to respect diversity

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

Previous (2007) statement

‘Revised’ (2016) statement

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

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

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

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

Failure to respect the patient

The revised policy also says in part:

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

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

Was it a foregone conclusion?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Declining to correct misinformation

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

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

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

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

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

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

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

Spotlight on the AMA

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

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

Utterly resistant to modernisation?

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

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

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

Conclusion

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

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

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This article has been published in OnlineOpinion.


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

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

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

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

BMA comprehensively out of touch

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

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

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

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

Ignorant and disrespectful BMA stance

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

Appalling and trivialised ‘rationale’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hubris argues for ignoring the BMA itself

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

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

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

Conclusion

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

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

 

References

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

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

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

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

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

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

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

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

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

And she’s absolutely wrong.

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

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

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

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

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

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

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

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


Who is Dr Megan Best?

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

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

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

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

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

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

Their primary conclusion is that:

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

Key findings

Key findings include:

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

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

Complication rates

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

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

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

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

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

The importance of context

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

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

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

Conclusion

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

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

 

References

  1. Emanuel, EJ, Onwuteaka-Philipsen, BD, Urwin, JW & Cohen, J 2016, 'Attitudes and practices of euthanasia and physician-assisted suicide in the united states, canada, and europe', JAMA, 316(1), pp. 79-90.
  2. Moore, N, Ganse, EV, Parc, J-ML, Wall, R, Schneid, H, Farhan, M, Verrière, F & Pelen, F 1999, 'The PAIN Study: Paracetamol, Aspirin and Ibuprofen new tolerability study', Clinical Drug Investigation, 18(2), pp. 89-98.
  3. Anderson, O, Davis, R, Hanna, GB & Vincent, CA 2013, 'Surgical adverse events: a systematic review', Am J Surg, 206(2), pp. 253-62.
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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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