Blog by Neil FrancisPosted on Sunday 4th October 2020 at 4:13am
There's a good reason why assisted dying opponents don't mention Switzerland. [Photo by Andrew Bossi]
Supposed Dutch suicide contagion from assisted dying
Recently, Dr Theo Boer, an Assistant Professor at a "black-stocking" (strongly conservative Protestant) theological college in the Netherlands, was at it again — criticising the Dutch euthanasia law to anyone who would listen: "don't follow the Dutch euthanasia law path because it leads to 'suicide contagion'".
I've exposed Prof. Boer's cherry-picked nonsense before. Astonishingly, he even ignores data from the Dutch Euthanasia Commission, despite the fact he used to serve on one of its five Regional Review Committees.
What he doesn't mention is that amongst the five Regions, the Region with by far the highest rate of assisted deaths had the second-lowest rate of general suicide, and the Region with the lowest assisted death rate had by far the highest general suicide rate (Figure 1) in 2014,1 the year Boer left his Committee and began bad-mouthing the Dutch law. Quite the opposite of "suicide contagion".
Figure 1: Dutch assisted death and general suicide rates by region, 2014
From multiple safeguards to just one
The Dutch euthanasia Act has a number of safeguards that stipulate who may qualify to access assisted dying in the Netherlands, and how qualification is assessed, implemented and reported to the authorities.
But there's another country that permits assisted dying with just one provision: Switzerland.
In effect since 1942, an exception in the Criminal Code permits assisted suicide, provided assistance is rendered for non-selfish motives. That's it. There's no legislated (or even government-regulated) requirements for age, illness or condition, decisional capacity, cooling off periods, or anything else.
In the 1980s, two assisted dying associations were formed to make assisted dying generally possible: Exit Deutsche Schweiz for German-speaking Swiss residents, and Exit A.D.M.D. for French-speaking residents.
Since then, several other smaller associations have been formed, including in 1998 Dignitas, which provides assistance to foreigners. (The main societies assist only Swiss residents.) The current membership of the societies, combined, is well in excess of 150,000 people, in a population of just 8.5 million. Assisted dying is often discussed openly in the media.
If "contagion" anywhere, in Switzerland, right?
Given that Switzerland has an abundance of the ingredients that religious opponents of assisted dying claim lead to "suicide contagion", you'd think they'd be shouting about Swiss "suicide contagion" from the rooftops.
But they don't mention Switzerland.
There's a powerful reason why: the data is not only unhelpful to their "contagion" theory, but actively hostile to it.
Latest official government data
I've written about Switzerland before, but, given the ongoing "suicide contagion" misinformation, I thought an update warranted. On request, my contact in the Swiss Federal Statistical Office (FSO) promptly re-supplied all publicly-available statistics of assisted deaths and general suicides, with the data now running up to 2017.
It makes for interesting reading. Figure 2 shows Switzerland's (CH) long-term general (non-assisted) suicide rate, along with the domestic (Swiss resident) and Dignitas (foreigner) assisted death rates. All the official (Australian Bureau of Statistics) longitudinal data I could find for Australia's (AU) general suicide rate is also included.
Figure 2: Swiss death rates 1969–2017; Australian suicide rates 1990–2017
Immediately obvious is that the Swiss general suicide rate has dropped massively and consistently since the two main assistance societies were formed in the early 1980s. And it's continued to drop even as the rate of assistance, and public discussion, has increased over the most recent three decades.
I also asked the FSO how many cases on record were of minors (persons under the age of majority or 18 years). The answer? None. I double-checked. Zero. Zip. No minors receiving assisted dying in Switzerland. Indeed, cases under the age of 35 years old are uncommon.
Consistent with best practice
Indeed, the data is consistent with suicide prevention. The societies help people get the medical care they need and consider assisted death only when other avenues have failed to provide acceptable relief. Every assisted death is reported as such by the association to the authorities — otherwise the unexpected death would result in a coronial inquiry.
Each association has clearly-defined processes and oversight by ethics specialists. Clients requesting access are assessed carefully by doctors. (In fact, the lethal medication can only be lawfully obtained by medical prescription.) The associations take their responsibilities very seriously.
The data is also consistent with substitution: that what would have been some violent and lonely suicides as a result of unrelievable suffering from intractable conditions, are now peaceful assisted deaths.
And for the record, despite the Swiss law being in effect since 1942 versus Dutch regulation from only 1984; and Swiss law having only one provision versus Dutch regulation/legislation with many; in 2017 the Swiss assisted dying rate, including Dignitas cases, as a percent of all deaths, was less than half that of the Netherlands' rate.
Reasons for requesting an assisted death
Exit Deutsche Schweiz, by far the largest of the Swiss associations, has published statistics of its cases (Figure 3).
In 2015, like other jurisdictions, cancer was by far the most common reason (40.8%) for requesting an assisted death. Polymorbidities (22.4%) was next, followed by refractory pain at 8.6%, lung diseases at 5.0% and Parkinsons at 4.3%.
Despite no government-regulated access requirements, assistance for mental illness was very low at 1.7% (Dutch 1.2% in 2015) and cases of dementia at 1.4% (Dutch 2.0%; Belgian combined mental/dementia 3.1% in 2015).
And compared to Australia?
In the 1990s, the Swiss general suicide rate, although falling, was significantly higher than Australia's (Figure 2) until 2010, when the rates were the same. Since 2010, the Swiss suicide rate (with no legislated procedures for its permitted assisted dying) has continued to drop, while Australia's (at that time with no assisted dying law at all), began to rise.
This difference highlights the clear anchoring bias exhibited by religious opponents who cherry-pick their data to try and claim the rise in the Dutch general suicide rate must be the result of "suicide contagion" from assisted dying, when Australia's rate also increased over the same time period, but in the complete absence of an assisted dying law. (Victoria's assisted dying legislation didn't come into effect until mid-2019.)
Further, the Swiss rate has continued to drop even with a significant increase in assisted dying.
Conclusion
Of course, general suicide is a serious issue. It has numerous well-known risk factors (e.g. mental health, substance abuse, unemployment, relationship breakdown, opportunity) and protective factors (e.g. hotlines, funding mental health programs, unemployment benefits, removing opportunity), none of which assisted dying opponents mention while cherry-picking their statistics.
Meanwhile, as legislators contemplate the specific safeguards contained in Bills before their legislatures, it's important to strike an appropriate balance between sufficient safeguards, and inappropriately requiring those considering an assisted death to climb Mount Everest with one hand tied behind their backs.
Switzerland shows that even in a jurisdiction without legislated practices, access to assisted dying is modest, with assistance groups establishing their own stringent ethical and procedural standards.
And it amply demonstrates even under those conditions, an absence of supposed "suicide contagion".
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1 Official Euthanasia Commission data and official Dutch government suicide statistics by region.
Fact file by Neil FrancisPosted on Thursday 10th September 2020 at 11:27pm
World-first report of VAD use amongst minors is now available for download.
Differences of opinion continue to be expressed regarding law reform to permit voluntary assisted dying (VAD) for minors: persons under the age of legal majority or adulthood, which in most jurisdictions is 18 years. Some claims are florid and ill-informed. To date, no cohesive report has been published regarding the actual use of VAD by minors in jurisdictions where it is lawful. This research aims to address that shortfall.
This study examines official evidence from lawful jurisdictions regarding the extent and nature of VAD amongst minors. Its aim is to facilitate calmer public discourse and more fully inform legislators considering VAD law reform proposals.
Findings
VAD is currently a lawful choice for minors in the Netherlands, Belgium, Switzerland and Colombia.
Dutch and Belgian legislation, and Colombian regulations, stipulate additional requirements regarding minors.
Available Dutch and Belgian data reveal very low rates of use, between zero and three cases per annum, with parental involvement in decision making.
There are no cases of VAD amongst minors on record in Switzerland.
No official case data is available from Colombia. However, given the extremely low rate of VAD use overall, cases amongst minors are highly unlikely.
While use of VAD laws by minors is rare, a review of case records reveals — as for adults — severe refractory underlying illness with extreme, unrelievable suffering.
Conclusions
Use of VAD by minors in lawful jurisdictions is rare, but nevertheless occurs with parental involvement in decision making, and otherwise as for adults: in cases of severe, refractory underlying illness with extreme, unrelievable suffering.
The F filesPosted on Saturday 18th November 2017 at 11:27pm
Jones, Paton and Kheriaty's articles demonstrate poor science and multiple, egregious instances of bias.
In 2015, Dr David Jones and Prof. David Paton published an article titled “How does legalization of physician-assisted suicide affect rates of suicide?” in the Southern Medical Journal. The article purported to establish suicide contagion from Oregon and Washington Death With Dignity Act (DWDA) deaths to “total suicides.” It also purported to establish no decrease in general suicide rates, which Jones & Paton argued should occur by substitution of assisted death for some general suicides. (Notice how these two ‘expected’ results — an anticipated rise and an anticipated fall in suicide rates — are at odds in principle.)
In my thorough and empirically-backed response, I expose the disgraceful playbook of these authors as they shambolically commit no fewer than ten deadly sins against science in the pursuit of their opposition to lawful assisted dying.
In 2015, Dr David Jones & Prof. David Paton published an article in the Southern Medical Journal titled “How does legalization of physician-assisted suicide affect rates of suicide?” This study examines the article, as well as an enthusiastic editorial of it by Dr Aaron Kheriaty in the same journal issue, both of which portray “suicide contagion” from Oregon and Washington’s death with dignity acts (DWDA).
However, while contagion from general suicides is a well-established phenomenon, there are multiple sound reasons to reject contagion theory in relation to assisted deaths, including:
Most healthcare professionals readily acknowledge key differences in the characteristics of assisted deaths: for example, a fully informed, tested and rational decision with shared decision-making.
Those using Oregon and Washington’s DWDAs are, by qualifying for it, already actively dying. Thus, they are choosing between two ways of dying rather than between living and dying.
Most of those using the DWDA discuss it with their families (expected, peaceful death), whereas most general suicides occur in isolation and without discussion (unexpected, often violent death).
Multiple studies show that while families of general suicide experience complicated bereavement, families of assisted dying cope at least as well as, and in some cases better than, the general population or those who considered but did not pursue assisted death.
Even if “suicide contagion from assisted dying” theory were sound, direct evidence from official government sources shows that the number of potential suicides in Oregon in 2014 would have been fewer than 2 in 855 cases: undetectable by general modelling methods.
Jones & Paton’s article title conveys an air of skilled and scientific neutrality. However, close examination of the article, and Kheriaty’s editorialisation of it, reveals least ten serious flaws or ‘scientific sins.’
The authors demonstrated little understanding of the complex issues surrounding suicide, willingness to unjustifiably equate assisted dying with general suicide, contentment with failing to search for, consider or include contrary evidence including from sources they cite to argue their case, unreasonable trust in a model that couldn’t hope to legitimately resolve their premises, satisfaction with executing their model amateurishly, a disposition to overstate confidence of causation in the absence of meaningful statistical correlations, and an inclination for emphasising results in accordance with their theories while de-emphasising or ignoring others.
Any of these flaws was serious enough to invalidate Jones & Paton’s article and Kheriaty’s conclusions of it, yet there is not one deadly flaw: there are at least ten.
Their claim of a supposed 6.3% suicide contagion rate from assisted dying in Oregon and Washington is a conceptual and mathematical farce.
The Southern Medical Journal is a peer-reviewed journal. However, it is difficult to reconcile the rigorous standards and sound reputation that peer review is intended to maintain, with the numerous, egregious flaws in this study and its dissemination.
Rather than inform the ongoing conversation about lawful assisted dying, the Jones & Paton and Kheriaty articles misinform and inflame it.
Given the numerous egregious flaws, both articles ought to be retracted.
Fact file by Neil FrancisPosted on Thursday 7th July 2016 at 10:19pm
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
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.
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.
Anderson, O, Davis, R, Hanna, GB & Vincent, CA 2013, 'Surgical adverse events: a systematic review', Am J Surg, 206(2), pp. 253-62.
Figure 1: Dutch assisted death and general suicide rates by region, 2014
Figure 2: Swiss death rates 1969–2017; Australian suicide rates 1990–2017
Figure 3: Reasons for pursuing assisted dying, Exit Deutsch Schweiz 2015
