Rhetoric: Slippery slope

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Jeanne Smits' completely false statement in LifeSiteNews

Well it didn't take long. Recently I posted a fact-based report card on Dutch euthanasia practice, based on the actual data from the 2015 annual report (and all the earlier reports) of the Dutch Euthanasia Commission. Now, just a few days later, conservative religious opponents have begun publishing completely untrue statements about Dutch euthanasia practice.

Catholic blog LifeSiteNews' 'Paris correspondent' Jeanne Smits has bolted out of the misinformation blocks, assertively and categorically stating in respect of the small increase in number of euthanasia cases from 2014 to 2015, that:

"The rise is mainly due to the increase of euthanasia for demented, elderly people as well as psychiatric patients, two categories that raise even more questions than 'ordinary' euthanasia for untreatable physical pain."

Smits goes on to correctly report that dementia was an underlying factor in 109 of the cases in 2015 (against 81 in 2014) and psychiatric disorders in 56 patients (against 41 in 2014).

The total number of euthanasia cases increased from 5306 in 2014 to 5516 in 2015, an increase of 210 cases. The increase in dementia cases was 28 and in psychiatric disorders was 15. Therefore, underlying dementia accounted for 13% of the increase, and psychiatric disorders 7% of the increase.

Cherry-picking

Smits has cherry-picked just the dementia and psychiatric illness figures and presented them in a way that supports her story arc, painting a bleak picture.

But by no stretch of the imagination does dementia and psychiatric illness account "mainly" for the increase as she categorically states.

What didn't Smits report at all? Cancer: the Netherlands' leading cause of death. In 2015, cancer was the underlying condition in 4000 euthanasia cases, against 3888 in 2014, a rise of 112 cases or 53% of the increase. That compares with dementia at 13% and psychiatric illness at 7% (20% combined), which Smits selectively critiques as a 'sharp rise'.

In no way is Smits' statement true.

No, let's be frank: it's an outright lie. Cancer was the major underlying condition accounting for more than half of the small increase (4%) of cases in 2015.

More evidence refutes the claim

Comparing one years' data with just the preceding years' data can be misleading when the number of observations is low, as it is for dementia and psychiatric illness euthanasia cases. Fortunately, we have data for more than just the one year.

Since 2012 the Euthanasia Commission has consistently published specific figures for dementia and psychiatric illness cases, so we can compare a rise over four years rather than just one. On this basis as a proportion of total 2012 cases, there has been a 17.9% increase in cancer-related cases, a 1.6% increase in dementia cases, and a 1.0% increase in psychiatric illness cases.

Longitudinal data is even more clear than a single year. It unequivocally refutes Smits' silly claim.

Bull is spread

Does Smits' claim matter much? Won't it just slip into oblivion?

No. Michael Haverluck of the conservative Christian paper OneNewsNow has already picked up Smits' article and repeated her claim as gospel. It remains to be seen how many other anti-euthanasia bloggers republish this nonsense.

Unacceptable conduct

In my view, publishing such a categorical yet false statement — even when unintentional — without first properly checking the facts, is unacceptable conduct. The article (and its derivatives) ought to be withdrawn.


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

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

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

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

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

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

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

USA national suicide and unemployment rates

Figure 1: USA national suicide and unemployment rates

 

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

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

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

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

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

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

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


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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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One of the articles wrongly claiming 650 Dutch babies euthanized

Opponents of assisted dying have fallen prey to misinformation contagion about the Dutch Groningen Protocol, claiming that 650 babies would be or are euthanized every year. The claim is comprehensively and evidentially false.

Starting in 2013 and increasing in shrillness in 2015, numerous opponents of assisted dying law reform—many of whom are connected to conservative (Christian) sources—published online articles making false claims about the Dutch Groningen Protocol, wrongly claiming that up to 650 babies could be, would be or actually are ‘euthanized,’ ‘killed’ or ‘murdered’ every year under the Protocol’s provisions.

I provide a forensic analysis of the claim, demonstrating it to be comprehensively and evidentially false, in the latest edition of the Journal of Assisted Dying.

 

What is the Groningen Protocol?

  • A national Dutch Regulation (not statute) effective since late 2006 whose current name is so long that it remains convenient to use its old name, ‘Groningen Protocol,’ even though it has changed.
  • Permits, only as a last resort and with a number of strict conditions, the intentional ending of a newborn’s life when the newborn is in current (not merely anticipated) untreatable and unrelievable extremis.
  • Mandatory reporting of intentionally hastened deaths to a national Commission and the Board of Prosecutors General at The Hague.
  • Physician is not cleared until the case is deemed acceptable by the Commission and the Board and the Minister of Security and Justice.
  • The Regulation is entirely separate from and unrelated to the Dutch Euthanasia Act for competent adults.

Where did the '650 babies euthanized' claim come from?

In 2013 the Royal Dutch Medical Association (KNMG) published a media release that launched a major policy paper about end-of-life decisions for neonates. The media release stated that of the approximately 175,000 births in the Netherlands each year, around 650 newborns will die as a result of severe congenital defects.

Some of these babies die soon after birth, in the delivery room. Others die later in neonatal intensive care despite the best interventions attempting to keep them alive. Yet others die after futile treatment is withdrawn and palliative (comfort) care is administered to minimize suffering prior to death.

Only in a tiny minority of cases is there a medical intervention with an explicit intention to hasten the death of the newborn, who is in untreatable and unrelievable extremis.

Despite this clarity, opponents—mostly linked to conservative religious sources—jumped on the misinformation bandwagon and trumpeted that 650 babies either could be or would be or are actually ‘euthanized,’ ‘killed’ or ‘murdered’ every year in the Netherlands.

What's the actual evidence?

  • Neonatal euthanasia occurs around the world regardless of prohibition and is not caused by a protocol or regulation
    • For example, the rate in France, with no regulation, is much higher than the Netherlands.
  • Intentional hastening of neonatal death in the Netherlands is rare
    • Most neonatal deaths occur either quickly with no medical intervention, or intensive treatment proves futile and palliative (comfort) care is administered until death.
  • The (Groningen) Regulation has been further restricted since it was first formulated
    • It has not been 'relaxed' as claimed by some opponents.
  • The Regulation is separate from and completely unrelated to the Netherlands' Euthanasia Act
    • The Euthanasia Act is only for mentally competent adults (and 12-16 year olds with parental agreement).
  • Physicians do not receive black-letter law protection as they do under the Euthanasia Act
    • Reporting, investigation and acceptance requirements are even more rigorous than under the Euthanasia Act.
  • The rate of intention to hasten neonatal death has decreased since the Regulation came into effect
    • In eight years prior to Regulation there were twenty two reported cases, and only two in eight years since Regulation.
    • The rate of medical end-of-life decisions with an explicit intention to hasten death was 8–9% prior to Regulation, dropping to 1% after Regulation.
    • The use of neuromuscular blockers has decreased.
  • Physicians report improved communication with parents
    • Shared decision-making and better opportunities for parents to grieve the loss of their child.
  • There are clear explanations for the decrease in neonatal euthanasia in the Netherlands:
    • Physicians report they are fearful of prosecution under the Regulation, so they now more often administer palliative care not intended to hasten death.
    • A folate supplementation program for pregnant females has resulted in a substantial drop in the rate of spina bifida and related disorders.
    • An antenatal screening program at 20 weeks has resulted in a higher rate of pregnancy terminations for major congenital disorders.

In conclusion

Despite all these facts, in an epidemic of 'confirmation bias' that drove misinformation contagion, many anti-euthanasia commentators have published false claims about '650 babies euthanized' under the Dutch Groningen Protocol. I provide a forensic examination of the issue in the latest edition of the Journal of Assisted Dying.

This is not the first example of how opponents of assisted dying widely circulate information that is untrue (e.g. check out the Council of Europe Declaration 1859 case), and it won't be the last. However, for opponents of assisted dying to avoid egg on face, I'd recommend:

Best not to engage in
misinformation contagion.

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Neonatal deaths under Dutch Groningen Protocol very rare despite misinformation contagion


Author(s)

Neil Francis

Journal

Journal of Assisted Dying, vol. 1, no. 1, pp. 7–19.

Abstract

The Groningen Protocol specifies criteria for the potential termination of life in severely ill newborns in extremis with untreatable and unrelievable conditions. In September 2006 the Netherlands formally adopted a Regulation incorporating the Protocol. Despite the Regulation’s development through extensive professional consultation, endorsement by the Dutch Paediatric Association, empirical data showing a decrease rather than increase in use, and research showing that neonatal euthanasia occurs around the world in the absence of regulation, the Dutch Regulation has sparked controversy. More recently it has been claimed that hundreds of babies a year are killed under its provisions. Forensic analysis reveals the claim to be comprehensively and evidentially false. Wide online dissemination of the claim by mostly religious sources demonstrates confirmation bias and misinformation contagion.

Article keywords

Netherlands, Groningen Protocol, neonatal euthanasia, palliative sedation, neuromuscular blocker, non-treatment decision, confirmation bias, misinformation contagion, religion

Full PDF

Download the full PDF: Download the full article (230Kb)

Citation

Francis, N 2016, 'Neonatal deaths under Dutch Groningen Protocol very rare despite misinformation contagion', Journal of Assisted Dying, vol. 1, no. 1, pp. 7-19.

Download the citation in RIS format: RIS.gif


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Dr William Toffler (left) acknowledges no slippery slope cause-and-effect evidence, with Drs Bentz and Stevens

A new scholarly journal focused on end-of-life ethics, decision-making and practice has just been launched: the Journal of Assisted Dying. In the first article, claims by Oregon lobby group Physicians for Compassionate Care (PCC), including Doctors Bill (William) Toffler and Ken Stevens (and others) are assessed against empirical evidence and found to be completely wrong, or highly misleading as a result of selective use of data.

The new scholarly journal, the Journal of Assisted Dying, is dedicated to careful and holistic analysis of evidence in regard to the various forms of assisted dying that are lawful in a number of jurisdictions around the world... and to practices in jurisdictions where assisted dying remains illegal.

In the first article of a series on Oregon, I examine claims and speculations made by various doctors (and others who quote them), that Oregon has the second-highest suicide rate in the USA (or is always in the top 10), that Oregon's Death With Dignity Act has resulted a massive increase in the state's general suicide rate, and other astonishing statements.

Of course, the empirical evidence from the Oregon Health Authority and from the USA Centers for Disease Control and Prevention does not support these statements and interpretations, and I analyse and critique the evidence.

Some of the claims are just plain factually and hugely wrong. Others are the result of failing to read their sources more carefully, misunderstanding what the data actually represents. Still further claims are made on the basis of selectively-chosen statements from government reports, while omitting statements that are contrary to, or provide alternative and well-researched explanations for Oregon's recently rising general suicide rate.

Drs Toffler and Stevens have even published some of their claims and speculations in the British Medical Journal.1 It goes to show that even good journals sometimes publish bunkum:  their article was a letter to the editor rather than peer-reviewed research. Great care is required to sort real evidence from hype and opinion.

Ultimately, Dr Bill Toffler of PCC has acknowledged on video that there is no cause-and-effect evidence between Oregon's Death With Dignity Act and Oregon's suicide rate, an acknowledgement that went unchallenged by his two PCC colleagues present at the time, Dr Ken Stevens and Dr Chuck (Charles) Bentz. You can see Dr Toffler's statement here (at 10'50").

The Journal of Assisted Dying is an open-access journal, and you can read the full article here.

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1. Toffler, WL & Stevens, K 2015, 'Re: Assisted dying: law and practice around the world', BMJ, vol. 351, 19 Aug, p. h4481.


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Physician use of misinformation to speculate 'assisted dying suicide contagion' in Oregon


Author(s)

Neil Francis

Journal

Journal of Assisted Dying, vol. 1, no. 1, pp. 1–6.

Abstract

Background: Several physicians have speculated that Oregon’s general suicide rate is evidence of suicide contagion as a result of Oregon’s Death With Dignity Act (‘the Act’).
Methods: Search and analysis of physician and related online sources of Oregon suicide contagion speculation; retrieval and analysis of cited Centers for Disease Control and Prevention (CDC) and other publications relied upon; analysis of authoritative, public Government mortality data for Oregon and other USA states.
Results: Several physicians have speculated about Oregon suicide statistics in a manner that is not supported by the cited publications, or by public CDC mortality database data. The claims variously (a) misrepresent key data in the publications, (b) omit information in the publications that is at variance with suicide contagion speculation, and (c) overlook other significant information at variance with speculation. The physicians have previously acknowledged inability to prove perceived “slippery slope” effects of the Act. Other opponents of the Act have republished the physicians’ erroneous information.
Conclusions: Evidence advanced by several physicians to speculate that Oregon’s Death With Dignity Act causes suicide contagion in Oregon is variously false, misleading or highly selective—omitting key facts—and has arisen even though the physicians acknowledge they have no proof of ‘slippery slope’ effects.

Article keywords

suicide contagion, copycat suicide, Werther effect, slippery slope, misinformation, Oregon, Dr William Toffler, Dr Kenneth Stevens, Physicians for Compassionate Care

Full PDF

Download the full PDF: Download the full article (390Kb)

Citation

Francis, N 2016, 'Physician use of misinformation to speculate 'assisted dying suicide contagion' in Oregon', Journal of Assisted Dying, vol. 1, no. 1, pp. 1-6.

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

On Wednesday 19th November 2015, the Catholic Church appeared before the Victorian Parliament's Legal and Social Issues Committee. Monsignor Anthony Ireland, the Episcopal Vicar for Health, Aged and Disability Care, and Father Anthony Kerin, Episcopal Vicar for Life, Marriage and Family gave evidence about end-of-life decision making. They made a factually wrong allegation about Oregon during their testimony.

Anthony Ireland spoke first, making it clear that they were appearing before the Committee with delegated authority from the Catholic Archbishop of Melbourne (Denis Hart) and with the endorsement of the Victorian Catholic Bishops. He emphasised that "the Catholic Archdiocese of Melbourne does not come to this Committee with fanciful or frivolous arguments."

During question time. Committee Chair Edward O'Donohue asked the Vicars if they had any evidence from lawful jurisdictions to back up their claim that legalising assisted dying would result in a significant reduction in medical research. The Vicars flailed about with vague hypotheticals, but no evidence.

Committee Deputy Chair Nina Springle remarked that some of their testimony was inconsistent with direct evidence from lawful jurisdictions and invited them to reflect on the contradictions. To this, Anthony Kerin stated:

"We know, for example, since Oregon legislated, that the standard suicide rate has increased remarkably and alarmingly. It's not yet the largest rate in the US, but it's getting there, when Oregon had a very, very low suicide rate prior to that."

Let's not mince words: the allegation is comprehensively false. In fact it's three false statements all wrapped up into one.

The USA government's CDC mortaility database provides solid empirical data. Here's Oregon's longitudinal suicide rate statistics, including sixteen years before its Death With Dignity Act (DWDA), and sixteen years after.

Oregon suicide rate

Here are the pertinent facts about Oregon's general suicide rate:

  1. The average for the 16 years after the DWDA is lower than, but not statistically different from, the 16 years prior to the Act.
  2. There was a massive drop in the suicide rate two years after the DWDA came into effect, and the rate has risen only from there.
  3. The rise from 2000 onwards is repeated in the majority of USA states and in the national average. The trend increase in Oregon is not statistically different from the national trend increase.

 
By way of comparison, here's Vermont's suicide rate for the same period.

vermontsuiciderate.jpg

Now, Vermont didn't have an assisted dying law until 2013, and no assisted deaths occurred under the law in that year, so the suicide rate cannot have been affected by an assisted dying law. Yet the picture is similar to Oregon's.

Here's the USA national suicide rate for the same period, with the unemployment rate added.

USA suicide and unemployment rates

There are numerous and complex reasons for suicide and for changes in the rate, but a key one in this USA case is unemployment, which after falling in the 1990s rose abruptly from 2000 onwards.

Has Oregon's suicide rate been worsening relative to other USA states, though? The state annual suicide rankings are informative.

Oregon suicide ranking among all USA states (number 1 is worst)

Prior to the DWDA, the trend in Oregon's suicide ranking among all USA states was deteriorating (where ranking number one is the highest suicide rate). Since the Act came into effect, the trend is improving. The difference in trends is statistically significant. In the sixteen years since the Act came into effect, Oregon has appeared in the "top ten" six times, compared with twelve times in the 16 years prior to the Act.

So, let's examine the three elements of the Catholic Church's statement:

1. "Since Oregon legislated, the standard suicide rate has increased remarkably and alarmingly"

This statement is false by omission. It is critically relevant to mention that Oregon's suicide rate dropped massively two years after the DWDA came into effect. Only after 2000 did it begin to rise—like most states and nationally—and in response to a rising unemployment rate.

2. "Oregon had a very, very low suicide rate prior to that [the DWDA]"

This statement is completely false. Oregon's mean rate suicide for 16 years after the act is not significantly different from the mean for 16 years prior to the Act. Indeed, government data back to 1968 shows Oregon's general suicide rate has always been high and never "low", let alone "very, very low".

3. It's not yet the largest rate in the US, but it's getting there"

This statement is completely false. Oregon's suicide ranking amongst USA states was worsening prior to the DWDA, but has been improving since.

It's very disappointing indeed that the Catholic Archdiocese of Melbourne would offer such profoundly false testimony to a legislative committee making inquiries on behalf of the people of Victoria. The offense is all the more grevious because of the unequivocal manner in which the statement was made, and that the witnesses specifically stated they did not bring any fanciful or frivolous arguments to the Committee.

It's time to comprehensively stamp out false information about assisted dying, no matter how fervently it might be believed by its proponents. Watch this space: there's plenty more to come!


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ABC TV's Q&A panel discusses assisted dying law reform on 9th Nov 2015

In a recent opinion piece in the ABC’s Religion and Ethics section, Bernadette Tobin1 rails against assisted dying, commencing with the criticism that the ABC’s Q&A discussion on the subject this week “lacked precision.” But Tobin’s opinion piece itself commits exactly this offence, as I explain.

For the sake of brevity I’ll only quickly mention that Tobin’s piece also fails on the score of accuracy. For example, she wrongly asserts that “euthanasia” means a doctor administering lethal medication to a patient. It doesn’t. “Euthanasia” simply means “good death”: nothing more and nothing less, regardless of how it occurs. Tobin also asserts that voluntary euthanasia in lawful jurisdictions has caused non-voluntary euthanasia to develop. This is the polar opposite of published empirical research evidence.

But back to precision. Tobin employs two imprecise and deeply flawed arguments in her objection to assisted dying. She variously rolls them in together, so let’s unpack what they are: (A) the “it’s only fair” slippery slope, and (B) “it’s OK if you don’t mean it”.

A: The “It’s only fair” slippery slope

Tobin directly links assisted dying for the terminally ill to “anyone who is in pain, discomfort, constipated, incontinent, depressed, anxious and so on” by way of potential “benefit”. She conjectures that increasing the restrictions to who may qualify, and the process of qualification, would then be “unfair” to these others. She then goes on to extend the argument to those lacking in decisional capacity such as infants and those with Alzheimer’s. Surely, she says, “it would be ‘unfair’ to deny these people the ‘benefit’ that we will make available to those who are able to request it?

Slippery slope indeed. And it’s wrong. Let me illustrate how, using a topic familiar in political debate over recent years: same-sex marriage.

Opponents of same-sex marriage law reform, when using arguments of the kind Tobin offers (as they often do), say that we can’t allow two men to marry, or two women to marry, because then we would have to allow three or more people to marry. Further down the slippery slope, we would have to allow people to marry animals. Don’t laugh: such things have been argued.

Next—given that under the Corporations Act 2001 (Cth), companies, owners’ corporations and incorporated associations are at law ‘persons’, and now that persons may marry—it would be “unfair” (note that I’ve used imprecision quotation marks around the word as Tobin does) to disallow people from marrying companies and companies from marrying each other.

Finally, using Tobin’s own line of argument, it would be “unfair” to deny infants and those with Alzheimer’s being married off for the alleged “benefit” (those quotation marks again) that everyone else is enjoying, so we must as an unavoidable consequence of the first step of allowing same-sex marriage, allow arranged marriages for babies and those with advanced dementia.

By now it’s easy to spot two terminal flaws in Tobin’s argument.

Firstly, the use of just one criterion (“fairness”—which she leaves imprecisely undefined) as the sole basis for decision making about this legislative reform is indefensible. What about other critical factors such as well-informed, rational, decisional capacity, judging and weighing what a “benefit” is, in the face of intolerable and unrelievable suffering, consistent with one’s own values and beliefs, who may decide, and the right not to participate?

Secondly, any slippery slope’s purported summit (from which changes are argued only to slip downwards) is deeply rooted in the normativity of the present. We are used to marriage being between a man and a woman. In our relative comfort we accept it as ‘normal,’ ‘good’ and the ‘right thing’.

In decision-making scholarship this normativity is known as “anchoring”. Like an anchor around which a boat will swing according to the wind and tide, we take the pivot point (the anchor of the now), as the natural starting point for future decisions, comparing changes only to the present state of affairs.

But it isn’t a valid anchor, and assuming that it is seriously biases our thinking. We need cast our anchor back just one mooring from the current point to see how the anchor tints our decision-making spectacles:

We can’t allow a man and a woman to marry, because then it would be unfair to not allow two men to marry, or two women to marry, and then…”

Clearly, it is imperative that we outlaw marriage altogether.

The upshot of this slippery slope, when followed properly to its own logical conclusions, is that we must deny all rights because we can confect a slippery slope into a hypothetical moral abyss for any right.

B: It’s OK if you don’t mean it

Tobin further argues that relieving distressing symptoms “is good palliative care, even when that relief happens to hasten death.”

She doesn’t name it explicitly, but this is the doctrine of double effect, an argument first crafted in the thirteenth century by Catholic priest Thomas Aquinas. The doctrine suggests that a bad consequence of an action is justifiable if the agent did not intend the bad effect, if the intended good effect outweighs the bad effect, and if the agent applies diligence in attempting to minimise the bad effect. Notice that the doctrine speaks directly about the intentions of the agent and is silent on the views of the person upon whom the agent might act.

Tobin rails against a doctor intentionally administering a lethal dose to a patient (regardless of whether it is the dying patient’s most fervent wish) and slams the expressions “dying with dignity” and “aid in dying” as “fudges”.

Yet the doctrine of double effect, for which she argues in support, is itself a fudge because it says:

It’s OK to for a doctor to decide to and actually kill their patient (after all, they hastened the patient’s death), as long as they don’t mean to, and they mean well.”

What kind of standard is the secret stuff that goes on inside a doctor’s head without reference of any kind to the patient’s own views and desires, when compared to a fully informed, documented and tested request from the patient?

It’s no wonder that many scholars (as do I) consider the doctrine of double effect problematic.

--

Bernadette Tobin is the Director of the Plunkett Centre for Ethics, a joint initiative of St Vincent’s Hospital, Sydney, and Australian Catholic University (ACU). According to ACU, a core mission of the Centre is to “bring a Catholic perspective to all its endeavours”.2

It’s unsurprising then that I detected neither broad thrust nor any detail of Tobin’s ABC opinion piece that deviated from the views of the Vatican. So be it.

There are many points on which Tobin and I agree, such as the potential benefits of palliative care for the dying. I argue, though, that basic scrutiny of the proffered 'principles' reveal them as deeply flawed and unpersuasive.

 

References

1  Tobin, B 2015, Voluntary euthanasia: It can only be a way station to the non-voluntary, ABC Religion and Ethics, viewed 14 Nov 2015, <http://www.abc.net.au/religion/articles/2015/11/13/4351675.htm>.

2  Australian Catholic University 2015, About the Plunkett Centre for Ethics, viewed 14 Nov 2015, <https://www.acu.edu.au/about-acu/institutes-academies-and-centres/plunkett-centre-for-ethics/about-the-centre>.


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On 16th September 2015, the Victorian Director of the Australian Christian Lobby (ACL), Dan Flynn, appeared as a witness to the Victorian Parliament’s end of life choices inquiry being conducted by the Legal and Social Issues Committee. He made a number of mistaken statements, but what was most worrisome was the revelation of the ACL’s real agenda: to wind back patient rights more than a quarter century.

 

Out of touch

In his opening address, Mr Flynn opined that assisted dying was 'not supported' by a 'broad base' of Victorian Christians (not just the ACL). This belief is diametrically at odds with clear and repeated evidence from multiple sources.

In 2012, I reported on a Newspoll study into Australian attitudes towards assisted dying. Not only did a whopping majority of citizens support assisted dying, but so did a great majority of Anglicans, Catholics and other Christians (Francis 2012).

 

Australian attitudes to assisted dying law reform in 2012

Newspoll 2012: Australian attitudes to assisted dying law reform by religion (green=support, red=oppose)

These national results are reflected by a sample of over 60,000 Victorians through the VoteCompass system during the 2014 Victorian election (Stayner 2014). It confirms a substantial majority of Catholics, Protestants, other religious and non-religious Victorians support assisted dying law reform.

 

votecompassvicvereligion2014.jpg

VoteCompass 2014: Victorian attitudes to assisted dying law reform by religion (grey=population average)

Out of date

Mr Flynn then referred to a Tasmanian Parliament’s inquiry into assisted dying which rejected law reform. However, the inquiry to which he refers was held in 1998, when Oregon’s Death With Dignity Act had barely been established, the Northern Territory’s Rights of the Terminally Ill Act had been extinguished within just eight months of coming into operation, and the Dutch, Belgian, Luxembourg, Washington and other legislation and judgements did not yet exist.

So, the Tasmanian Parliament’s rejection came from a position of a then general lack of information. The Oregon law has been in effect since 1997, the Netherlands and Belgium since 2002, Washington since 2008, Luxembourg since 2009, and so on. There is now plenty of evidence that assisted dying law reform doesn’t cause slippery slopes that opponents love to theorise about.

Wrong about ‘United Nations’

Mr Flynn then said that the United Nations had in 2012 expressed concern about a ‘lax attitude’ towards euthanasia in Europe, specifically mentioning the Netherlands and Belgium. This is completely untrue. Because it’s easy to make a simple blooper during a presentation, we’ll put aside the fact that he meant to refer to a completely different organisation: the Council of Europe.

We know this because he read directly from Council of Europe declaration 1859 (Council of Europe Parliamentary Assembly 2012). His ACL submission (Australian Christian Lobby 2015) reports (as he read out) exactly one sentence of the declaration, with his added emphasis, as:

"Euthanasia, in the sense of the intentional killing by act or omission of a dependent human being for his or her alleged benefit, must always be prohibited."

But presented in this manner the statement is quite misleading. As I explain in a forensic analysis of the misinformation campaign about this resolution (Francis 2015), the resolution was utterly clear about its intent: it was not about euthanasia (it explicitly said so), but rather about advance care planning. What the resolution spoke against (in the one sentence conveyed above) is non-voluntary euthanasia, not voluntary euthanasia. Both sides of the assisted dying debate agree that non-voluntary euthanasia (one person deciding for a hastened death on behalf of another) is not acceptable. It is not contentious.

In no way did the Council of Europe's resolution critique voluntary euthanasia or comment on any jurisdiction in which it is legal. And, the United Nations source to which the ACL submission refers was released in 2001, fourteen years ago and at the time of the Netherlands' Euthanasia Act was before the Dutch Parliament. With then limited information about how such laws work in practice, it expressed concern about the upcoming Act.

Wrong about Belgium’s law and practice

Mr Flynn referred vaguely to two cases of euthanasia in Belgium in which persons who requested and received euthanasia were not experiencing intolerable pain, which Mr Flynn asserted was a required safeguard in Belgium’s euthanasia Act. This was another supposed example of transgression of safeguards.  Wrong again.

While the Belgian Euthanasia Act is officially published only in Dutch and French, a robust English translation has been prepared under the supervision of Professor Herman Nys of the Centre for Biomedical Ethics and Law at the Catholic University of Leuven (see Parliament of Belgium 2002). The word ‘pain’ does not appear in the Act… at all. What does the Act have to say about the legislature’s intent on who may qualify? The relevant clause in Section 1 says:

"the patient is in a medically futile condition of constant and unbearable physical or mental suffering that can not be alleviated, resulting from a serious and incurable disorder caused by illness or accident."

It’s abundantly clear: mental suffering from an illness or accident qualifies as much as physical suffering, and the suffering does not need to be ‘pain’ as Mr Flynn mistakenly asserted to the Parliamentary Committee.

Mr Flynn also stated that there are mobile end-of-life units in Belgium. There aren’t. (But there are in the Netherlands, and they must follow precisely all the same requirements as anyone else. They operate to provide choice to patients whose regular or reachable doctors disagree with assisted dying and therefore decline to evaluate whether the patient may qualify under the Act.)

Confused about Advance Care Directives

In further testimony, Mr Flynn opined that the degree to which a doctor should be allowed to override a patient’s Advance Care Directive (ACD) is in part influenced by whether the doctor can speak with the patient.

But if the patient can currently speak and participate in decision-making, the advance care directive doesn’t apply: it is mute and of no effect. An ACD only applies when the patient cannot currently participate in their own decision making. That’s (only) what it’s for.

Winding rights back more than a quarter century

But the most worrying aspect Mr Flynn’s testimony was the revelation of ACL’s opposition to the right to refuse unwanted medical treatment.

The Medical Treatment Act 1998 (Vic) has enshrined for now more than twenty five years a patient’s right to refuse any unwanted medical treatments. In 2003 the Supreme Court of Victoria determined that artificial nutrition and hydration (i.e. via tubes) is medical treatment and can therefore be refused under the Act.

But Mr Flynn repeatedly argued that withholding or withdrawing artificial nutrition and hydration, if the patient’s body could ‘absorb’ them, could amount to physician-assisted suicide, and that doctors must be allowed to override refusals. On the matter of patient autonomy, he said that some autonomy rests "with the patients, but a lot of the autonomy in fact is with the doctor”.

When asked if a Jehovah's Witness who refuses a life-saving and simple blood transfusion ought to be allowed to do so, he conceded that they should be entitled to, but that such a case was a “bit of an outlier”. He didn’t explain on what moral grounds one person could refuse a simple procedure to save their life, but another person mustn’t be allowed to even if the likelihood of saving life was doubtful.              

So, the ACL’s real agenda is revealed: it recommends winding back the legislative clock more than a quarter century so as to force patients to endure some medical interventions that they don’t want and firmly refuse, if the doctor wishes to proceed.

No wonder the Committee repeatedly questioned Mr Flynn to ensure they had heard and understood his testimony correctly. In conclusion, Committee Chair Edward O’Donohue observed that Mr Flynn’s evidence was “quite surprising” and “quite contrary” to wide evidence already given.

And it’s no wonder that Theo Mackaay, General Secretary of the Victorian Council of Churches—a group of 30 member churches representing mainstream Christianity—criticised the ACL as “fundamentally conservative” and expressed “deep concern that media portrayal of statements from an established and narrow focused lobby group is presented as being representative of the entire Christian community” (Uniting Church in Australia 2011).

-----

References

Australian Christian Lobby 2015, Submission to the Legal and Social Issues Committee on the Inquiry inito End of Life Choices, Parliament of Victoria, Melbourne, pp. 1-17.

Council of Europe Parliamentary Assembly 2012, Resolution 1859 (2012): Protecting human rights and dignity by taking into account previously expressed wishes of patients, Europe, 25 Jan, pp. 2.

Francis, N 2012, Australian public desire for legalisation of assisted dying in restricted circumstances, YourLastRight.com, Melbourne, pp. 11.

Francis, N 2015, Conservatives fudge Council of Europe declaration 1859, DyingForChoice.com, viewed 2 Jun 2015, <http://www.dyingforchoice.com/f-files/conservatives-fudge-council-europe-declaration-1859>.

Parliament of Belgium 2002, 'The Belgian Act on Euthanasia of May 28th 2002 (unofficial English translation)', Ethical Perspectives, vol. 9, no. 2-3, pp. 182-188.

Stayner, G 2014, Victorian election 2014: Electorate overwhelmingly back voluntary euthanasia, Vote Compass reveals, ABC News, viewed 4 Dec 2014, <http://www.abc.net.au/news/2014-11-23/victorians-back-voluntary-euthanasia-vote-compass/5910668>.

Uniting Church in Australia 2011, Australian Christian Lobby does not represent all Australian Christians, nor all Christian viewpoints, 8 Dec, Media Room, viewed 11 Dec 2011, <http://blogs.victas.uca.org.au/mediaroom/?p=971>.


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