Flapdoodle

An argument that superficially seems intuitively attractive, true or real, but is in fact meaningless or nonsensical.
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Branka van der Linden on the "HOPE" website.

HOPE’s Director, Branka van der Linden, is at it again, foisting more misleading information about voluntary assisted dying (VAD) on unwilling members of Parliament. I expose the rot and provide some background on Mrs van der Linden.

Van der Linden’s latest email to all WA MPs states:

Subject: WA Report relies on troubling Belgian study

 
[MP Salutation] --

Did you know that a study showing that one person in Belgium is euthanised every three days without their explicit consent also found that:

  • in more than 77 per cent of cases, the decision was not discussed with the patient;
  • in more than half of cases, the patient had never expressed a desire for their life to be ended; and
  • in more than half of the cases, the reason given was because killing the patient was the wish of the family?

 
Did you know that the WA majority report cited this study as evidence of assisted suicide and euthanasia reducing the incidence of unlawful activity?

Warm regards,

Branka van der Linden
Director, HOPE

 
Van der Linden’s method is to create an impression of calumny against VAD law reform. She uses a nice PR formula of three bullet points per communication. With repetition. It’s a method I expressly warned the WA Parliament to watch out for in my submission to its inquiry. The growing list of emails is now starting to look like ‘harassment’.

So let’s look at van der Linden’s claims — again. She’s talking about non-voluntary euthanasia (NVE) — again.

In her email to MPs, she complains that the WA majority report on end-of-life choices cited the study as evidence of the NVE rate reducing when VAD is legalised.

Well, the WA majority report formed that correct conclusion because that’s precisely what the cited study reported: drops in the NVE rates in both the Netherlands and Belgium after their euthanasia Acts came into effect in 2002.

While concerns ought to be expressed about the deliberate hastening of death without an explicit request from the patient with a view to improving knowledge and practices, it’s not caused by VAD laws as van der Linden desperately tries to imply.

Here are highly relevant things the cited study’s authors had to say, but van der Linden astonishingly ignores:

“The use of life-ending drugs without explicit patient request are not confined to countries where physician-assisted death is legal.”; and

“[NVE’s] occurrence has not risen since the legalisation of euthanasia in Belgium. On the contrary, the rate dropped from 3.2% in 1998 to 1.8% in 2007. In the Netherlands, the rate dropped slightly after legalization, from 0.7% to 0.4%” [The Belgian rate was 1.7% in a more recent replication of the research.]; and

The NVE cases found in the study “in reality resembles more intensified pain alleviation with a ‘double effect’, and death in many cases was not hastened.”

But let’s not let the facts get in the way of a good story. Van der Linden’s recent emails about VAD to MPs reveal astonishing ignorance and a willingness to overlook critical evidence contrary to her position, contained in the very source she cites.

The superficiality of her cherry-picking is kind of embarrassing: she holds an arts/law degree from Australian National University, so you’d expect more intelligent engagement.

It begs the question: who is Branka van der Linden? The “HOPE” website reveals little if anything.
 

Who is Branka van der Linden?

Branka Van der Linden is the current Director of anti-VAD website “HOPE (Preventing euthanasia and assisted suicide)”. HOPE is an initiative of the Australian Family Association, a Catholic lobby group established by Australia’s most famous lay Catholic, B. A. Santamaria.

HOPE’s founding Director and van der Linden’s predecessor, was Mr Paul Russell, the former Senior Officer for Family and Life at the Catholic Archdiocese of Adelaide.

It turns out that Branka van der Linden (née Seselja) is a sister of Catholic ACT Senator Zed Seselja who voted against David Leyonhjelm's recent Restoring Territory Rights (to legislate on VAD) Bill. But there’s more. Far more.

Branka, who attended Catholic St Clair’s College primary school and Padua Catholic High School, both in the ACT, is a “senior lawyer” at the Truth Justice and Healing Council, which provides services to the Australian Catholic Bishop’s Conference and Catholic Religious Australia in relation to the Catholic Church’s response to the Royal Commission into Institutional Responses to Child Sexual Abuse.

She’s advisory legal counsel for the lay Catholic St Vincent de Paul Society Canberra/Goulburn Territory Council. (And good on her for supporting this philanthropic work.)

She and her husband Shawn represent (or at least represented) the Australian Catholic Marriage and Family Council, and were representatives of the Catholic Archdiocese of Canberra & Goulburn on the National Family Pilgrimage to the (Catholic) World Meeting of Families in Philadelphia in 2015.

Husband Shawn has been described by the church as a “loyal Catholic servant” for nine years of service as the director of CatholicLIFE at the Catholic Archdiocese of Canberra and Goulburn.

And as if this weren’t clear enough, a sample of Branka’s Facebook Likes is equally informative:

A sample of Branka van der Linden’s Facebook Likes

  • Archbishop Anthony Fisher (Catholic)
  • Archbishop Samuel J. Aquila (Catholic)
  • Archbishop Mark Coleridge (Catholic)
  • Bishop Robert Barron (Catholic)
  • Marist College Canberra Faith Formation (Catholic)
  • St Thomas the Apostle Kambah (Catholic)
  • Campion College (Catholic)
  • Teaching Catholic Kids
  • Ascension (Catholic Church)
  • CathFamily
  • St Therese of Lixieux (Catholic)
  • Dominican Sisters of Saint Cecilia in Australia (Catholic)
  • Fusion Youth Group (Catholic)
  • St Clare’s College (Catholic)
  • Marist Canberra Football Club (Catholic)
  • Light To The Nations (Catholic)
  • Catholic Voices USA
  • Centre for Faith Enrichment (Catholic)
  • World Meeting of Families 2015 (Catholic)
  • Quidenham Carmelite Monastery (Catholic)
  • Denver Catholic
  • Catholic Mission – Canberra & Goulburn
  • XT3 (Catholic youth association)
  • Missionaries of God’s Love Darwin (Catholic)
  • Marist College Canberra (Catholic)
  • Life, Marriage & Family Office (Catholic)
  • Infant Jesus Parish, Morley (Catholic)
  • MGL Priests and Brothers (Catholic)
  • Catholic Mission – Sydney, Broken Bay, Parramatta
  • Youth Mission Team Australia (Catholic)
  • Summer School of Evangelisation – Bathurst (Catholic)
  • Missionaries of God’s Live Sisters (Catholic)
  • Sisterhood National Catholic Women’s Movement
  • My Family My Faith (Catholic)
  • Catholic Talk
  • The Catholic Weekly
  • The Catholic Leader
  • Mercatornet (Catholic blog site)
  • BioEdge (Catholic blog site)

It’s clear that Branka van der Linden, like her predecessor Paul Russell, is very deeply invested in Catholic tradition. I will be the first to say I firmly believe that is entirely her right.

Yet how curious it is that while repeatedly advancing (secular) misinformation about VAD, Branka van der Linden doesn’t mention her profound religious convictions. It's surprisingly similar to the approach evidenced by Catholic Professor of Ethics, Margaret Somerville; and Catholic (then) Victorian MP Daniel Mulino; and Catholic Editor of The Australian, Paul Kelly (who warmly quotes Mulino); and Catholic director of the Euthanasia Prevention Coalition, Alex Schadenberg...

You get the idea: perhaps there's a pattern?

One possible source of pattern

What was it that the Catholic Archbishop of Sydney, Anthony Fisher, said at the 2011 Catholic Bioethics Conference in relation to opposing the legalisation of VAD?

"The most effective messengers may also vary: bishops, for instance, are not always the best public spokespeople for the Church on such matters."; and

"...the man or woman in the street ... may well be open to persuasion that permissive laws and practices cannot be effectively narrowed to such circumstances"; and

"We need to research and propose new messages also and carefully consider who should deliver them, where and how."

Nowhere in his address does Fisher propose actually testing whether his calamitous assumptions about VAD are true.

Gosh, another coincidence.

Epilogue

I want to be absolutely clear that I am not using a person’s religious conviction as a reason to dismiss their ideas. That’s called an ad hominem attack: an attack against the person rather than the substance of the argument (even assuming it has any substance to assess).

What I have done here and elsewhere, and I will continue to do, is to expose arguments that are false, misleading, illogical or otherwise unmeritorious on the basis of empirical evidence and reasoning.

It just turns out that organised misinformation against VAD law reform comes from deeply religious circles, and those religious circles often avoid mentioning their religiosity while spreading such nonsense under a ‘veneer of secularism’.

It’s in the public’s interest to understand where most organised misinformation against VAD comes from.


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An article in 'Anasthesia' did NOT find high rates of regaining consciousness in contemporary VAD practice.

A recent article by Sinmyee et al, "Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying", published in the journal Anasthesia1 was an attempt to identify a professional standard for inducing and maintaining unconsciousness prior to voluntary assisted dying (VAD) death, a laudable aim.

However, the authors’ underlying premise of contemporary VAD practice failing to reliably maintain unconsciousness — potentially leading to 'inhumane deaths' — is not established by their cited sources. They cite exactly three sources to establish their claim: their citations 31, 32 and 33.

Citation 31 — Iserson et al 1992

This is a qualitative article by Ken Iserson and colleagues.2 Published in 1992, it outlines a single case of assisted suicide, forming the backdrop for several Californian ethics committees to comment.

Not only was this a single case rather tha a sample of dozens or hundreds of cases, but assisted dying was illegal right across the USA in 1992 and earlier. Therefore, the article is wholly uninformative to contemporary practice under assisted dying laws.

Citation 32 — Groenewoud et al 2000

This is a study by Johanna Groenewoud and colleagues.3 Published in 2000, it analyses Dutch data collected between 1990 to 1996 — long before the Netherlands’ 2001 euthanasia Act, which came into effect in 2002.

In 1997 the Dutch medical association (KNMG) formed the Support and Consultation on Euthanasia in Amsterdam (SCEA) network to assist doctors implement the practice more reliably. The successful program was made national (…in the Netherlands, SCEN) in 1999, with a four-year implementation resulting in strong consultation and positive outcomes.4

In addition, the KNMG and Dutch pharmacy association (KNMP) have improved their guidelines for euthanasia practice since 1996: in 1998, 2007 and most recently in 2012.5 Independent studies show that use of opioids (inappropriate method) was high in the Netherlands in 1995-96,6 but replaced entirely with (appropriate) barbiturates and neuromuscular relaxants in reported VAD cases in 2010.7

The most recent published report of the Dutch Euthanasia Commission, which assesses every reported case of VAD, did not note any failures of the VAD procedures.8

Citation 33 — Lalmohamed & Horikx 2010

This is a study by Arief Lalmohamed and Annamieke Horikx, published in 2010, of doctor responses to a survey the KNMP conducted between 2007 and 2009.9 The study reported on issues with the storage, preparation and administration of VAD drugs. It noted that the recommended dose of Thiopental was increased from 1500mg to 2000mg so that patient-dependent dosages need not be calculated.

The study noted one negative experience for some patients: pain on injection of Thiopental. Recommendations were made for preparation and administration of the drug to avoid this problem. No other negative patient outcomes were reported.

The upshot

Thus, of the three sources the authors employed to make the case of a significant and systematic problem in the conduct of contemporary VAD cases, none did so: the first was a single case outside the law in the early 1990s, the second a study from the early to mid 1990s from whence contemporary practice has greatly improved, and the third a 2010 pharmacological investigation that found some patients experiencing pain on injection and recommending improvements to avoid it. Nevertheless, Sinmyee et al concluded that:

“For all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and reawakening from coma (up to 4%), constituting failure of unconsciousness.”

These assertions are highly misleading in regard to contemporary VAD practice.

The most recent Oregon Death With Dignity Act annual report, covering all cases from 1997 to early 2019 reports that just eight of 1,467 deaths where lethal medication was consumed, resulted in the patient regaining consciousness.10 That’s an efficacy rate of 99.5%, a high standard for a medical procedure.

There have been no cases of regaining consciousness in Washington state under their Death With Dignity Act.11

In comparison, regaining consciousness under professional surgical anaesthesia is a problem12 with an incidence rate of around 0.13% in the USA13 though the rate appears to be much lower in the UK.14 Even over-the-counter analgesics like paracetamol, ibuprofen and aspirin have significant adverse effects rates of 14.5%, 13.7% and 18.7% (respectively).15

From unsubstantiated to polemical

While Sinmyee and colleagues were attempting, via their article in Anasthesia, to argue the case for improved VAD practice, it was inevitable that ginger groups opposing the legalisation of VAD would commandeer cherry-picked extracts from the article to further their cause, painting a picture of disaster and mayhem.

Sure enough, the Catholic-backed Euthanasia Prevention Coalition’s Alex Schadenberg ran with it, cherry picking the “190 times higher” rate the authors claim for “failure of unconsciousness” using their invalid citations. Schadenberg conspiratorially concluded that “the laws are designed to cover-up [sic] problems with the law”.16

Also, predictably, Catholic-backed HOPE’s Branka van der Linden followed suit, plucking quotes like “…failure rates of assisted dying by these other methods seems extraordinarily high” without similar context.17

It’s disappointing that the original article with its misleading statistics based on figures plucked from a single historical article and in the absence of considering significant intervening improvements, passed peer review. Its misinformation led to more nonsense being energetically pedalled by anti-VAD campaigners.

 

References

  1. Sinmyee, S, Pandit, VJ, Pascual, JM, Dahan, A, Heidegger, T, Kreienbühl, G, Lubarsky, DA & Pandit, JJ 2019, 'Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying', Anaesthesia, 74(5), pp. 630-637.
  2. Iserson, KV, Rasinski Gregory, D, Christensen, K & Ofstein, MR 1992, 'Willful death and painful decisions: A failed assisted suicide', Cambridge Quarterly of Healthcare Ethics, 1(2), pp. 147-158.
  3. Groenewoud, JH, van der Heide, A, Onwuteaka-Philipsen, B, Willems, DL, van der Maas, PJ & van der Wal, G 2000, 'Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands', New England Journal of Medicine, 342(8), pp. 551-556.
  4. Jansen-Van Der Weide, MC, Onwuteaka-Philipsen, BD & Van Der Wal, G 2004, 'Implementation of the project 'Support and Consultation on Euthanasia in the Netherlands' (SCEN)', Health Policy, 69(3), pp. 365-373.
  5. KNMG/KNMP 2012, Guidelines for the practice of euthanasia and physician-assisted suicide, Utrecht, pp. 56.
  6. van der Maas, PJ, van der Wal, G, Haverkate, I, de Graaff, CL, Kester, JG, Onwuteaka-Philipsen, BD, van der Heide, A, Bosma, JM & Willems, DL 1996, 'Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995', N Engl J Med, 335(22), pp. 1699-705.
  7. 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.
  8. Regional Euthanasia Review Committees (Netherlands) 2018, Annual report 2017, Arnhem, pp. 66.
  9. Lalmohamed, A & Horikx, A 2010, '[Experience with euthanasia since 2007: Analysis of problems with execution] Ervaringen met euthanastica sinds 2007: Onderzoek naar problemen in de uitvoering', Ned Tijdschr Geneeskd, 154(A1983), pp. 1-6.
  10. Oregon Health Authority 2019, Oregon Death With Dignity Act: 2018 data summary, Department of Human Services, Portland, pp. 16.
  11. Washington State Department of Health 2018, Washington State Department of Health 2017 Death with Dignity Act Report, Olympia, WA, pp. 15.
  12. Cook, TM, Andrade, J, Bogod, DG, Hitchman, JM, Jonker, WR, Lucas, N, Mackay, JH, Nimmo, AF, O'Connor, K, O'Sullivan, EP, Paul, RG, Palmer, JH, Plaat, F, Radcliffe, JJ, Sury, MR, Torevell, HE, Wang, M, Hainsworth, J, Pandit, JJ, Royal College of, A, the Association of Anaesthetists of Great, B & Ireland 2014, 'The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues', Anaesthesia, 69(10), pp. 1102-16.
  13. Sebel, PS, Bowdle, TA, Ghoneim, MM, Rampil, IJ, Padilla, RE, Gan, TJ & Domino, KB 2004, 'The incidence of awareness during anesthesia: A multicenter United States study', Anesthesia & Analgesia, 99(3), pp. 833-839.
  14. Thomas, G & Cook, TM 2016, 'The United Kingdom National Audit Projects: a narrative review', Southern African Journal of Anaesthesia and Analgesia, 22(2), pp. 38-45.
  15. 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.
  16. Schadenberg, A 2019, Assisted dying can cause inhumane deaths, Euthanasia Prevention Coalition, viewed 25 Feb 2019, http://alexschadenberg.blogspot.com/2019/02/assisted-dying-can-cause-inhumane-deaths.html.
  17. van der Linden, B 2019, The "myth" of a pain-free euthanasia death, HOPE, viewed 22 Mar 2019, https://www.noeuthanasia.org.au/the_myth_of_a_pain_free_euthanasia_death.
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Terminal sedation is not an argument against assisted dying law reform.

Opponents of assisted dying often claim that the appropriate response to refractory symptoms at end of life is terminal sedation — also known as palliative sedation or continuous deep sedation.e.g. 1 Terminal sedation is the administration of sedatives so as to render the patient unconscious until death. Thus, the patient’s active experience of suffering is removed, even if the underlying causes of the suffering are not.

Terminal sedation can help in some cases of end-of-life suffering, but it remains a problematic practice — and not a substitute for lawful assisted dying — for eight broad reasons.

1. Directly and foreseeably causing death

Unless the patient is already likely to die of her illness within a few days, it is the withholding of artificial nutrition and hydration during terminal sedation that causes the patient’s death. Lack of fluids causes circulatory collapse and organ failure within 14 days; less if the patient is frail.

In addition, at least one study has found that the terminal sedation medication itself can cause depression of respiration and/or circulation, directly resulting in death in 3.9% of cases.2 Another study purporting to show no survival difference in patients given terminal sedation3 has been exposed as deeply scientifically flawed.4

While opponents of assisted dying usually claim that the intention of terminal sedation is the relief of symptoms and not the hastening of death (their fundamental objection to assisted dying), in practice, terminal sedation can directly and foreseeably cause death.

2. Inapplicable prior to 2–14 days before death

A standard of practice in terminal sedation in many jurisdictions is that it should be used to address refractory symptoms only if the patient’s death is anticipated within hours or days, and in any case less than 14 days.5

However, intolerable and intractable symptoms often occur much earlier, for example amongst those with metastatic cancer where death is still weeks off, or those with a progressive degenerative neurological condition such as motor neuron disease, who may have several months to live.

Thus, terminal sedation is not a practical solution to intractable symptoms in many cases.

3. It doesn’t always help

Palliative Care Australia’s acknowledgement that even best practice can’t always alleviate intolerable suffering at end of life6 is confirmed by a study into terminal sedation practice which found that, in contrast to popular belief that it alleviates (the patients’ conscious awareness of) all suffering, it was ineffective in 17% of cases.7

4. It may violate the patient’s value system

Most calls for terminal sedation as “the answer” to assisted dying law reform focus on the views of the doctor, for whom this is another familiar “intervention”. However, terminal sedation may be unacceptable to the patient.

A patient may deeply believe that being forced to dehydrate to death — unconscious in a bed for a couple of weeks — to be an anathema to her most deeply-held values and sense of self as an active participant in her own life trajectory. This patient may profoundly prefer another route whose equally caused and foreseeable consequence is death: voluntary assisted dying, an option that gives her the chance to say goodbye to loved ones at a time of her own choosing.

5. It extinguishes the patient’s decisional capacity

Rendering the patient unconscious extinguishes her decision-making capacity. The patient can no longer participate in her own treatment decisions unless terminal sedation is ceased, she regains consciousness and becomes aware of her intolerable suffering once more.

6. Doctors’ intention not always clear-cut

When a doctor administers terminal sedation to a patient, the doctor’s intention is not always clear-cut. The doctor may intend to alleviate the patient’s suffering and/or intend to hasten death.

The administration of a single large bolus of sedatives is generally indicative of an intention to hasten death, in which case the doctor in likely to be investigated and prosecuted. However, the administration of increasing doses of sedatives is less clear: significantly increasing titrations of sedatives may be necessary to alleviate intractable symptoms, or they may be an intention to hasten death.

7. Risk of coercion

There is a conceptual risk that greedy relatives, service providers who need the patient’s bed, and others, might inappropriately persuade the patient to opt for a death hastened by terminal sedation, a similar theoretical risk to that in assisted dying.

However, unlike assisted dying which under statutory law is an express, fully informed, independently examined and documented desire and intention to hasten death, there are no statutory requirements in Australia regarding testing of desire, informedness, intention or possible coercion in terminal sedation. This is incoherent.

8. Worse experiences for the bereaved

Studies have found a significant minority of relatives of patients receiving terminal sedation are quite distressed by the experience. Problems causing distress include concern about the patient’s welfare and terminal sedation’s failure to address symptoms, burden of responsibility for making the decision, feeling unprepared for changes in the patient’s condition, short time to the patient’s death and whether terminal sedation had contributed to it, feeling that healthcare workers were insufficiently compassionate, and wondering if another approach would have been better.e.g. 8,9 Periods of longer terminal sedation may be more distressing than shorter periods.10

In contrast, an Oregon study found that the bereaved from assisted deaths appreciate the opportunity to say goodbye, to know that the choice was the deceased’s wish, that the deceased avoided prolonged suffering, that the choice was legal, and they were able to plan and prepare for the death.11

Another Oregon study found that the mental health outcomes of bereaved from assisted deaths were no different from the bereaved from natural deaths.12 Bereaved from assisted deaths were more likely to believe that the dying person’s wishes had been honoured and were less likely to have regrets about the death.

A Swiss study found the rate of complicated grief after assisted death was comparable to the general Swiss population,13[^] while a Dutch study found bereavement coping in cancer was better after assisted death than after non-assisted death.14

Incoherent professional association standards

Neither the Australian Medical Association nor Palliative Care Australia have guidelines for doctors for the practice of terminal sedation.[*] Indeed, even Palliative Care Australia’s carefully reviewed and updated national standards released in late 2018 don’t mention sedation at all.15

In contrast, in countries where assisted dying is now lawful, clear and specific frameworks have been developed to guide the practice of terminal sedation: in the Netherlands,16 Canada,17 and Belgium.18 This deliberative development and implementation points to continued improvement in (not deterioration of) professional medical practice across the board when assisted dying is legal.

Given the profound issues in terminal sedation as in voluntary assisted dying, the failure of the peak Australian medical associations to publish guidelines on terminal sedation, while opposing assisted dying for perceived issues in its implementation, is incoherent and indefensible.

Summary

Palliative and medical care can never address all profound suffering at the end of life, regardless of funding or organisation: some kinds of suffering have no relevant or effective medical interventions, and even terminal sedation may be inapplicable or ineffective. To claim that palliative care is always the answer is a “monstrous arrogance19 and “represents the last vestiges of [medical] paternalism”.20

 

"It is clear that improving palliative care will not remove the need for legalizing assisted dying, and that legalizing assisted dying need not harm palliative care.”21

 

While terminal (palliative) sedation may help a minority of patients, it's a problematic practice that is often not a practical solution to refractory symptoms at end of life.

Terminal sedation is not a substitute for lawful assisted dying choice.


[^]     Slightly elevated levels of PTSD were found amongst the bereaved (compared to the general population), but it was not established whether this would have been different from the trauma of experiencing continued suffering and deterioration or different from PTSD rates of those who had recently lost a loved one by any other means, including terminal sedation.

[*]     Revealed through direct correspondence between myself and the two associations.

 

References

  1. Somerville, M 2009, 'We can always relieve pain', Ottawa Citizen, (24 Jul).
  2. Morita, T, Chinone, Y, Ikenaga, M, Miyoshi, M, Nakaho, T, Nishitateno, K, Sakonji, M, Shima, Y, Suenaga, K, Takigawa, C, Kohara, H, Tani, K, Kawamura, Y, Matsubara, T, Watanabe, A, Yagi, Y, Sasaki, T, Higuchi, A, Kimura, H, Abo, H, Ozawa, T, Kizawa, Y, Uchitomi, Y, Japan Pain, PMR & Psycho-Oncology Study, G 2005, 'Efficacy and safety of palliative sedation therapy: a multicenter, prospective, observational study conducted on specialized palliative care units in Japan', J Pain Symptom Manage, 30(4), pp. 320-8.
  3. Maltoni, M, Pittureri, C, Scarpi, E, Piccinini, L, Martini, F, Turci, P, Montanari, L, Nanni, O & Amadori, D 2009, 'Palliative sedation therapy does not hasten death: results from a prospective multicenter study', Ann Oncol, 20(7), pp. 1163-9.
  4. Francis, N 2016, How bad research fuels dodgy claims, DyingForChoice.com, viewed 11 Mar 2016, http://www.dyingforchoice.com/f-files/how-bad-research-fuels-dodgy-claims.
  5. Twycross, R 2019, 'Reflections on palliative sedation', Palliative care, 12, pp. 1-16.
  6. Palliative Care Australia 2006, Policy statement on voluntary euthanasia, Canberra, pp. 2.
  7. Davis, MP 2009, 'Does palliative sedation always relieve symptoms?', Journal of Palliative Medicine, 12(10), pp. 875-877.
  8. Morita, T, Ikenaga, M, Adachi, I, Narabayashi, I, Kizawa, Y, Honke, Y, Kohara, H, Mukaiyama, T, Akechi, T & Uchitomi, Y 2004, 'Family experience with palliative sedation therapy for terminally ill cancer patients', Journal of Pain and Symptom Management, 28(6), pp. 557-565.
  9. Bruinsma, SM, Brown, J, van der Heide, A, Deliens, L, Anquinet, L, Payne, SA, Seymour, JE, Rietjens, JAC & on behalf of, U 2014, 'Making sense of continuous sedation in end-of-life care for cancer patients: an interview study with bereaved relatives in three European countries', Supportive Care in Cancer, 22(12), pp. 3243-3252.
  10. van Dooren, S, van Veluw, HT, van Zuylen, L, Rietjens, JA, Passchier, J & van der Rijt, CC 2009, 'Exploration of concerns of relatives during continuous palliative sedation of their family members with cancer', J Pain Symptom Manage, 38(3), pp. 452-459.
  11. Srinivasan, EG 2009, Bereavement experiences following a death under Oregon's Death With Dignity Act, Human Development and Family Studies, Oregon State University, pp. 127.
  12. Ganzini, L, Goy, ER, Dobscha, SK & Prigerson, H 2009, 'Mental health outcomes of family members of Oregonians who request physician aid in dying', J Pain Symptom Manage, 38(6), pp. 807-15.
  13. Wagner, B, Müller, J & Maercker, A 2012, 'Death by request in Switzerland: Posttraumatic stress disorder and complicated grief after witnessing assisted suicide', European Psychiatry, 27(7), pp. 542-546.
  14. Swarte, NB, van der Lee, ML, van der Bom, JG, van den Bout, J & Heintz, AP 2003, 'Effects of euthanasia on the bereaved family and friends: a cross sectional study', British Medical Journal, 327(7408), pp. 189-192.
  15. Palliative Care Australia 2018, National Palliative Care Standards, Griffith ACT, pp. 44.
  16. Verkerk, M, van Wijlick, E, Legemaate, J & de Graeff, A 2007, 'A national guideline for palliative sedation in the Netherlands', J Pain Symptom Manage, 34(6), pp. 666-70.
  17. Dean, MM, Cellarius, V, Henry, B, Oneschuk, D & Librach, LS 2012, 'Framework for continuous palliative sedation therapy in Canada', J Palliat Med, 15(8), pp. 870-9.
  18. Broeckaert, B, Mullie, A, Gielen, J, Desmet, M, Declerck, D, Vanden Berghe, P & FPZV Ethics Steering Group 2012, Palliative sedation guidelines, Federatie Palliatieve Zorg Vlaanderen, viewed 18 Sep 2015, http://www.pallialine.be/template.asp?f=rl_palliatieve_sedatie.htm.
  19. Hain, RDW 2014, 'Euthanasia: 10 myths', Archives of Disease in Childhood, 99(9), pp. 798-799.
  20. Horne, DC 2014, 'Re: Why the Assisted Dying Bill should become law in England and Wales', BMJ, 349, p. g4349/rr/759847.
  21. Downar, J, Boisvert, M & Smith, D 2014, 'Re: Why the Assisted Dying Bill should become law in England and Wales [response]', BMJ, 349, p. g4349/rr/760260.
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'HOPE' is pedalling assisted dying misinformation to politicians again.

The Catholic-backed anti-assisted-dying ginger group, HOPE, was represented for years by Paul Russell. He's retired and Branka van der Linden is now at the helm. But its penchant for pedaling egregious misinformation hasn't changed. Van der Linden recently sent an email to all WA members of parliament, containing three points.

Van der Linden's email reads:

 

Dear [MP salutation],

Did you know that the WA majority report that recommended assisted suicide for WA either dismissed or failed to report on the following statistics?

  • In the Netherlands in 2015, 431 people were euthanised without their explicit consent.
  • In Belgium, 8 per cent of all deaths were without explicit consent from the patient.
  • In Oregon in 2017, the ingestion status of 44 (out of 218) patients was ‘unknown’, making it impossible to ascertain if these 44 patients ended their lives voluntarily and without coercion.

Yours faithfully,

Branka van der Linden

Director, HOPE

 

The trouble is, all three claims by van der Linden are either directly false or egregiously misleading. Here are the actual facts:

FACT: Peer-reviewed scientific research shows that the non-voluntary euthanasia rate of both the Netherlands and Belgium has dropped significantly since their assisted dying Acts came into effect in 2002, consistent with more careful end-of-life decision making across the board.

Fiction 1: van der Linden improperly cherry-picked a single year’s statistic for each country (and, incoherently, a raw count for one but a percentage for the other), implying that lawful voluntary euthanasia increases non-voluntary euthanasia, when the opposite is true.

Fiction 2: van der Linden claimed Belgium’s non-voluntary euthanasia rate is 8%. It has never been anywhere near that figure: the most recent figure is 1.7% and it was 3.2% before Belgium’s euthanasia law.

FACT: Oregon’s health department actively matches death certificates with prescriptions issued for assisted dying. At any time some prescriptions have not been taken and the person may still be alive, and for the deceased, death certificates are still being processed. This naturally means that some prescription/death statuses will temporarily be ‘unknown’ to authorities, even though they will be later determined.

Fiction 3: van der Linden comically implies that this proper process is sinister.

It's curious how 'HOPE' likes to repeatedly demonstrate how HOPElessly uninformed it is about the actual facts and that its methods include cherry-picking data which it thinks supports its anti-assisted dying case, but which don't.

Western Australians deserve better than HOPE's silly propaganda campaign.


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A forensic analysis exposes Theo Boer's smoke and mirrors on 'suicide contagion'

In my most recent article in the Journal of Assisted Dying, I forensically analyse Dutch ethicist Professor Theo Boer’s 2017 paper purporting to find suicide contagion from assisted dying in the Netherlands. It doesn’t go well for Professor Boer, to put it mildly. You can find the full article here.

I also find an astonishing coincidence that occurred in 2014, the year Boer went feral against the Dutch euthanasia law.

Multiple fatal flaws

In the ‘analysis’ outlined in his article, Boer commits a number of fatal scientific no-noes, including failing to analyse the variable he actually surmised might cause suicide contagion, cherry-picking data that supported his conclusion while ignoring or offhandedly dismissing data at odds with his conclusion, and wrongly forming a causative conclusion from a simple correlation while failing to control for any confounding variables of which there are many.

A litany of scientific offences

In addition to the fatal flaws, Boer’s article contains numerous other scientific and academic offences. My forensic analysis concludes:

“In summary, Boer’s article contains a litany of scientific and scholarly failures. Its speculations are ill-informed, poorly-assembled, incoherent in places and mostly uncited, the data cherry-picked and invalidly interpreted, and the laissez faire methodology incapable of validly supporting its conclusion.
 

Boer conjures up mere smoke and mirrors to argue suicide contagion from VAD in the Netherlands. The article should be retracted.”

The article also reflects badly on the journal that published this smoke and mirrors: the Journal of Ethics in Mental Health. Neither peer review nor editorial effort identified or attempted to correct any of the nonsense in the article.

What was he thinking?

Professor Boer is an expert in Reformist Protestant theology. As a religious ethicist, it’s astonishing that he considered himself suited to conducting and publishing a ‘causative’ scientific study.

In his article, Boer proposed VAD as the only factor to contribute to changes in the Netherlands’ general suicide rate (and dismissed the Belgian data which contradicted his theory).

In reality, numerous risk and protective factors affect the suicide rate, and in the Netherlands as I’ve established using their official government data, just one factor — unemployment — explains 80% of the variance in the Dutch suicide rate since 1960. Boer casually dismisses this without providing the faintest fume of an empirical analysis himself.

Boer’s article did little but amply demonstrate his underlying anchoring and confirmation bias on the subject, his unfamiliarity with the complexity of suicide, and ignorance of proper scientific principles.

For good measure, he casually threw in a comment about “suicide contagion” or copycat suicides, without understanding that in suicide, copying is the method of causing death. But by definition, general suiciders don’t follow the provisions of the euthanasia Act.

His endeavour made as little sense as me writing a conclusive article about Reformist Protestant theology, about which I know very little.

A copycat analysis?

Coincidentally, the structure of the storyline, the litany of scientific offences committed, and the conclusions reached in Boer’s article were surprisingly similar to those in an ‘analysis’ of Oregon’s suicide rate in another paper by Jones and Paton. Like Boer, Jones and Paton start out by surmising that assisted dying ought to lower the general suicide rate, and conclude the opposite.

Boer approvingly cites the Jones and Paton article, even though a forensic analysis found no fewer than ten major scientific flaws in it and provided multiple sources of empirical evidence at odds with the article’s conclusions.

But Boer manages to cock even the citation up, referring to the article’s authors as Holmes and Paton.

Will the real Theo Boer please stand up?

Boer notes that he’s always been a euthanasia sceptic. Nevertheless, as a Reformist Protestant, he had long accepted assisted dying in “emergency” situations, of which intolerable and otherwise unrelievable suffering is a ‘qualifying’ criterion, and which is the substance of the Dutch euthanasia law (it’s regarded in legal circles as a law of “necessity”). He also opined that the Dutch model was a decent one that other jurisdictions could emulate.

Boer served as the ethicist member of one of the five Dutch euthanasia review commissions, examining every case reported to it between 2005 and 2014.

In 2014 he publicly quit his post on the review committee, slamming the Dutch assisted dying system. He’s been badmouthing it to anyone who will listen, since.

In preparation for this analysis, I asked Boer if his vocal opposition to the Dutch assisted dying model was now based on an in-principle opposition to assisted dying, or only in regard to more recent practice under the Dutch euthanasia Act. Despite a couple of iterations, I didn’t get a specific answer.

The law hasn’t changed

Here’s the point. While Boer repeatedly opines that things changed radically in the Netherlands around 2007, the country’s euthanasia Act hasn’t changed since it was passed in 2001 (and came into effect in 2002). Not. One. Word.

In addition, the Dutch Supreme Court determined in 1994 that individuals with mental (in the absence of concomitant physical) illness could qualify under the then regulatory euthanasia framework, and it was found that cases occurred every year.

And the 2001 Act formalised in statute the regulatory framework that had existed since at least 1984, when the Dutch medical association first published guidelines for euthanasia.

Thus, the Act reflects very long-standing practice, and it hasn’t changed since it was enacted, in contrast to Boer’s claim that things have radically changed.

Flimsy and incoherent ‘ethics’ part 1

This brings us to the first fatal incoherence of Boer’s “ethics”: that he now opposes the law because people with psychiatric illness and other conditions are, in slightly increasing numbers, availing themselves of the euthanasia law. It is these cases against which Boer rails, despite having previously said the Dutch model is a good example for the world, and having actively participated in the system.

Boer’s flip flop is to argue that a law that permits assisted dying under a range of medical conditions (and has done so for decades) is a good law, provided some of those who might qualify (like psychiatric cases) never use it.

Try and explain the ethics behind that position.

Flimsy and incoherent ‘ethics’ part 2

The second fatal incoherence of Boer’s ‘ethics’ is his repeated complaint that until around 2007, the numbers of euthanasia cases was “somewhat steady”, but increased after that. Never mind that the majority of the increase was still in relation to terminal cancer: Boer simply railed at the increased numbers as a major problem.

But, try and explain using ethical principles, why it is appropriate for 2,000 people a year to avail themselves of the euthanasia law, but inappropriate for 4,000 (who all qualify)?

Indeed, the Dutch euthanasia Act makes no mention of numbers: there is no legislated limit on the count of people who might choose to use the law. Rather, it is based on due care criteria, outlining the circumstances of who may qualify, and the process by which they may.

The legislature’s intent remains unchanged and is still being adhered to, though more people, the majority of whom have terminal cancer, are using the law.

It’s astonishing that a Professor of Ethics fails to reflect on the fatal incoherence of his own ‘ethical’ arguments.

What happened?

Boer, who had supported and promoted the Dutch euthanasia model suddenly and incoherently changed his position to vocally opposed in 2014. What happened?

One factor might shed some light. In 2014, Boer was appointed to the endowed professorship of Lindeboom Chair in Ethics in Healthcare at Kampen Theological University.

While Kampen Theological University is a Dutch Reformist Protestant institution and therefore may support assisted dying in “emergency” cases, the Lindeboom Institute, which endows Boer’s eponymous professorship, is less understanding.

The Lindeboom Institute was co-founded by several orthodox Christian institutions and cooperates with the Netherlands Evangelical University which studies science from an creationist Biblical perspective.

The Institute demands “biblically sound medical ethics” along with “Christian norms and values”. You’d be left wondering what that actually means, until you find on its website that the Board’s role is “the protection of people at all stages of life”.

In addition, participating organisations that fund the Lindeboom endowment, like the Dutch Patients Association, Pro Life Health Insurance and the Foundation for Christian Philosophy, are strongly opposed to assisted dying in any form.

It turns out that the authors of that other ‘analysis’ that commits numerous similar scientific offences which generate smoke and mirrors, Jones and Paton, are devout conservative Catholics.

Gosh. What a coincidence.


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Netherlands 'suicide contagion' from assisted dying: Theo Boer's smoke and mirrors


Author(s)

Neil Francis

Journal

Journal of Assisted Dying, vol. 4, no. 1, pp. 1–11.

Abstract

Background: Concerns had been raised about the scientific quality of a 2017 article by ethicist Theo Boer in which he theorised that lawful voluntary assisted dying (VAD) would potentially ‘dampen’ suicide rates, but drew the opposite conclusion: the suggestion that VAD cases have caused higher suicide rates.
Methods: A structured, forensic examination of the article was conducted.
Results: Numerous serious shortcomings were found, including (a) profound unfamiliarity with the complexity of suicide; (b) lack of a clear and specific pre-hoc methodology; (c) numerous unsupported speculations; (d) cherry-picked data and casual dismissal of data at odds with the conclusion; (e) a simple correlation interpreted as causation while failing to control for any confounding factors; (f) incoherent, contradictory and misleading statements; and (g) multiple editorial errors.
Conclusions: Boer’s article is poorly conceived and carelessly assembled, revealing unfamiliarity with both the subject matter and with scientific principles. The conclusions drawn are not supported by the article’s methodology or data. The article offers mere smoke and mirrors to conclude that VAD may increase suicide rates, at odds with wider evidence.

Article keywords

voluntary assisted dying, euthanasia, suicide contagion, Werther effect, Netherlands, methodology

Full PDF

Download the full PDF: Download the full article (5.4Mb)

Citation

Francis, N 2019, 'Netherlands "suicide contagion" from assisted dying: Theo Boer's smoke and mirrors', Journal of Assisted Dying, vol. 4, no. 1, pp. 1-11.

Download the citation in RIS format: RIS.gif


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The latest religious right 'think tank' lobby group, the Institute for Civil Society.

I challenge the latest religious right commentators opposing Victoria’s Voluntary Assisted Dying Bill to skip the flip-flopping and engage constructively.

They’re at it again. This time it’s the religious right’s latest ‘think tank’ front group, the impressively-named Institute for Civil Society. Sounds grand, doesn’t it?

But if you look into their lot in life, it’s to protect ‘religious freedoms.’ By that, they mean the right to lawfully discriminate against others of whom they disapprove, while at the same time arguing that they not be discriminated against.

Mark Sneddon and Sharon Rodrick of the ‘Institute’ published an opinion piece in Fairfax Media today.

In it, they slam the Victorian Government’s Voluntary Assisted Dying Bill, which was introduced into the Parliament recently.

They criticize the Bill for inadequate safeguards. (There are no fewer than 68 of them.)

The logical fallacy

They level several criticisms at the Bill to say it's not 'safe'. But they could have advanced any criticism of the Bill to claim, as they do, that “the vulnerable will be at risk” — a logical fallacy as I’ve pointed out before. The "vulnerable will be at risk", by circular definition, if the Bill is printed in black ink (as it is) instead of purple, but they didn't complain about the colour of the ink.

The flip-flop

The point is, they flip-flop because they’re remarkably inconsistent in their position. At the same time as pointing out supposed flaws in the Voluntary Assisted Dying Bill, demanding a much higher standard of proof about a number of things, they completely fail in their opinion piece to even mention — let alone demand the same level of safeguards for — an already-legal and equivalent hypothetical risk for the “vulnerable.”

Equivalent hypothetical risk in operation for nearly 30 years

In Victoria, patients have an inalienable right to refuse any and all medical treatment. No reason need be given, even if the treatment is life-saving. The Medical Treatment Act 1998, currently in force, has several safeguards to protect against coercion or undue influence. In Section 5(1), one doctor and “another person” (who can be anybody) must be satisfied that:

  • “the patient has clearly expressed or indicated a decision”; and
  • “the patient’s decision is made voluntarily and without inducement or compulsion”; and
  • “the patient has been informed” about their condition and “has appeared to understand that information”; and
  • “the patient is of sound mind and has attained the age of 18 years.”
     

They’re all the legislated safeguards for the refusal of life-saving medical treatment.

And how many cases of undue influence have been prosecuted in Victoria over the nearly 30 years the Medical Treatment Act 1998 has been in effect? Precisely none. Not one.

So much for Messrs Sneddon and Rodrick’s avaricious relatives lurking at every bedside.

A new, equivalent hypothetical risk

The Medical Treatment Planning and Decisions Act 2016, which will come into force in March next year and which extinguishes the Medical Treatment Act 1998 at that time, also contains several similar safeguards for the refusal of life-saving medical treatment.

In witnessing an Advance Care Directive (Section 17), the two signatories, only one of whom must be a medical doctor, must certify that:

  • the person “appeared to have decision-making capacity” in relation to the documented decisions; and
  • the person “appeared to understand the nature and effect of each statement”; and
  • “the person appeared to freely and voluntarily sign the document”; and
  • “the person signed the document in the presence of the two witnesses”; and
  • “the witness is not an appointed medical treatment decision maker for the person.”*
     

In Section 52 of the Act, a health practitioner is forbidden to administer medical treatment if they are aware the patient has refused it, however (lawfully) refused.

This Act was passed in the term of the current Parliament: that is, by the same State MPs who are now considering the Voluntary Assisted Dying Bill.

There was no great fracas over the sensible safeguards spelled out in the new Medical Treatment Planning and Decisions Act. There was no onslaught of “crisis!” op-ed screeds published in newspapers. There were no countless hours of talking heads tut-tutting and painting doomsday scenarios.

It was passed by the Parliament and accepted by the people as striking the right balance.

No safeguards at all in many cases

And that’s it: the sum-total of safeguards to refuse life-saving medical treatment in Victoria. However, if the patient refuses medical treatment verbally, there are no mandated safeguards at all in either old or new Act, because the statutory safeguards apply only to refusal given in writing.

Yet despite all this, Messrs Sneddon and Rodrick rail against safeguards against coercion and elder abuse only in regard to the Voluntary Assisted Dying Bill, in which the safeguards are of a significantly higher calibre, with, for example, mandatory multiple doctor opinions, documentation trail, multiple requests, no go-ahead until approval by an external authority, notifications of numerous kinds, oversight by a specially-established panel, and so on.

It’s obvious what a flip-flop Messrs Sneddon and Rodrick’s demands are in respect of decisions that will foreseably result in death.

Another embarrassing flip-flop

Messrs Sneddon and Rodrick particularly also complain at length at the supposedly ‘lax’ definition of decision-making capacity in the Voluntary Assisted Dying Bill.

That’s a major and embarrassing flip-flop. Here’s why.

The section of the Voluntary Assisted Dying Bill that stipulates those requirements (Section 4) is the same section number 4 that governs the right to refuse of life-saving medical treatment in the Medical Treatment Planning and Decisions Act 2016. Only a few words have been changed to alter the context from refusal of treatment to consideration of assisted dying. Otherwise, the Sections are identical.

Messrs Sneddon and Rodrick don't point this out in their opinion piece. Indeed, I was unable to find online any evidence that they had published any complaint about the provisions when the Medical Treatment Planning and Decisions Act was in debate, nor since. If they have, I’d be happy for them to point it out.

Is it all a strategic ruse, anyhow?

It’s pertinent to ask if the objections are a ruse anyhow, because, as Andrew Denton has rightly pointed out, a key opponent strategy is not to give an outright “no” to assisted dying Bills, but to say only “not this Bill” and create an atmosphere of FUD (fear, uncertainty and doubt) so that it is defeated.

A typical ruse example

By way of example, I’ve published an account of how Victorian MP Daniel Mulino published outrageous misinformation about assisted dying. As a result, we had an extended conversation, during which he acknowledged that he had indeed published misinformation. At the end of the conversation I asked if he could support the Government’s Voluntary Assisted Dying Bill. (He’s a member of said Government.)

No, it’s too liberal, he said, pointing to Oregon’s Death With Dignity Act, now in force for nearly 20 years, as a more conservative approach. So I asked him if he would support a Bill like Oregon’s.

No, he said, there were still concerns about it.

By now you’ve spotted the merely incremental withdrawal of supposed possible support. So I asked him outright if there was any form of assisted dying Bill he could support.

The relevant word within a long discourse: No.

And there’s the answer that belies the political strategy. It doesn’t matter one whit what provisions are included in an assisted dying Bill, just criticize a bunch of provisions and create FUD to defeat it.

 

A direct challenge to Messrs Sneddon and Rodrick

If “doubters of this Bill” are genuine about permitting assisted dying in some defined circumstances, the duty is on them to define those circumstances and recommend wording to enact it.

And that’s the challenge I throw down directly to Messrs Sneddon and Rodrick. Don’t just bitch and gripe: define precisely what provisions and wording you think would be acceptable.

If you fail to stipulate what you deem acceptable, then your opposition to “this flawed Bill” is, like the supposedly ‘soft’ opposition of other campaigners in the negative, merely a ruse.

And that’s rather suggested by your deliberate use of the term “killing” for what most Australians believe to be an understandable and welcome release. But let’s give you the benefit of the doubt… for now.

Will you rise to the constructive challenge, or lurk in the shadows merely making snide remarks and flip-flopping?

----

* Section 62 of the Act also requires a doctor to notify the Public Advocate if “significant treatment” is refused — but only if it is refused by a substitute decision maker on behalf of the patient: not by the patient herself. And “significant treatment” is defined as treatments (not non-treatments) which are likely to have a serious impact on the patient (bodily intrusion, risk to life, side effects or distress). “Significant treatment” in the Act does not mean treatment whose refusal may result in death.


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The Age reports on the three AMA dcotors' appearance at Spring Street

As reported in The Age, on Tuesday this week three AMA doctors fronted the Victorian Parliament to spread the word about their perceived horrors of an assisted dying law. Their arguments don’t hold water and politicians should see them for what they are: utter nonsense.

Doctors Stephen Parnis, Mukesh Haikerwal and Mark Yates say they will continue to lobby politicians.

With what?

Here is the ‘substance’ of their arguments — a sticky blomonge of the same old confected and discredited claims.

The vulnerable will be at risk

Dr Parnis said that such a law “puts the most frail and vulnerable in our community — the dying — at profound risk,” pointing to coercion, and patients not getting the medical care they need.

As I’ve explained before, the claim is flapdoodle — circular nonsense.

It’s a circular argument (a logical fallacy) because “the vulnerable” are by definition those “at risk” and vice versa. While the circularity makes the claim about assisted dying risks seem true, it's a false imputation.

By way of comparison, we could equally say that “the vulnerable will be at risk if we wear yellow socks on Wednesdays,” so we should outlaw that as well. Or anything else of which we disapprove and make our argument seem valid by attaching it to “the vulnerable being at risk.”

Let’s not talk about it

Dr Yates argued that the Parliament should not be pursing “divisive legislation.” That’s also a false argument because it's merely an appeal to emotion: avoiding legislating anything upon which there is any disagreement and discomfort. The consequence of this argument is to not legislate at all.

Patient trust in doctors

They also argued that assisted dying legislation would “change the doctor-patient relationship” — by which they mean “damage the relationship,” or they wouldn’t have mentioned it.

Again, as I have shown before, the empirical evidence from around the world is consistent with improved, not damaged, patient trust in doctors where assisted dying is legal.

The massive AMA flip-flop

But, as I’ve also pointed out before, the real telltale of the AMA doctors’ farcical representation to the Victorian Parliament is this: while opposing assisted dying legislation because patients might be pressured, subtly or otherwise, to choose death, the AMA officially endorses the right to refuse medical treatment, which includes life-saving treatment.

The hypothetical risk of patients being encouraged to refuse life-saving medical treatment is identical in kind to that of assisted dying. Yet in Victoria, the right to refuse is protected by just three statutory safeguards, while the assisted dying legislation is founded on no fewer than 68 safeguards.

So the AMA incoherently promotes one hypothetical pressure-to-die pathway with only three protections, while cruelly opposing a parallel path with an armada of protections. Let's award 10 out of 10 for the impressive flip-flop manoeuvre.

Conclusion

The AMA doctors’ claims are without merit and advancing them does no favours to their professional credibility.


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Victorian MP Daniel Mulino's minority report contains multiple serious errors and misinformation.

Last year, the Victorian Parliament's Legal and Social Issues Committee concluded an extensive investigation into end of life choices, publishing a report of over 400 pages recommending improvements to palliative care and for assisted dying. Catholic-backed Shop, Distributive and Allied Employees' Association (‘shoppies’ union) Labor member of the Victorian Parliament Mr Daniel Mulino furnished his own minority report, opposing the majority recommendation for assisted dying law reform. That’s entirely his right. However, his report contains multiple, serious cases of misinformation. He must withdraw his report.

Daniel Mulino, Labor parliamentary member for the Victorian Region of Eastern Victoria,1 and a member of the Catholic-backed ‘shoppies’ union,2 was a member of the Legal and Social Issues Committee that thoroughly investigated end of life decision making and produced a 400+ page report in 2016 making recommendations for law reform and regulation.

Mr Mulino furnished a “minority report” as an addendum to the main report in order to oppose the Committee’s recommendation that assisted dying be legalised.3

Promoted by Catholics to Catholics

Mr Paul Russell, South Australian publisher of the Catholic anti-euthanasia website ‘HOPE,’§ says this of Mr Mulino’s minority report in the Catholic lawyer association’s blog:4

Daniel Mulino MLC's analysis should be read first, before the Majority Report. It forms not only a sound academic and rigorous approach but also, by implication, is damning of the narrow, outcome focus of the Majority Report.”

How sweet of Mr Russell to so generously plug Mr Mulino’s report. But, in gushing about the ‘sound academic and rigorous approach’ he claims to be in it, shows that he doesn't understand what constitutes proper and sound evidence, and that he's easily impressed by charts and lots of ‘literature’ citations.

Numerous fundamental faults

The reality is very different.

Rather than bore you with a mind-numbing blow-by-blow dissertation on the numerous fundamental faults in Mr Mulino’s report, I’ll demonstrate how the report cherry-picks, misquotes and misunderstands its way through the evidence, via four revealing examples.

Example 1. Cherry-picking ‘helpful’ data

Mr Mulino’s minority report illustrates the rise in number of assisted deaths in the Netherlands and Belgium, and produces some statistics (Figures 1 & 2 are directly from his minority report).

mulinocharts1and2.gif Figures 1 and 2 (of Mr Mulino’s minority report): Assisted deaths in Belgium and the Netherlands

Note that Belgian data is for the years 2003–15, but the Netherlands only for the years 2008–15. That’s odd, because the euthanasia Acts for both countries came into effect in 2002, and so 2003 was the first full year for both.

Mr Mulino doesn’t point out that his report treats the two countries differentially, and provides no explanation as to why. We might notice, however, that the dicrepancy has the consequence of making his claims look 'better.'

Using Mr Mulino’s presentation style, Figure 3 illustrates all the relevant data for the Netherlands.

netherlandsfullfig2.gif Figure 3: The full Netherlands data
Source: Official Euthanasia Commission reports

As you can see, there is a virtual flatline between 2003 and 2007. Indeed, there is even a tiny drop in numbers between 2005–06. This is an inconvenient truth to Mr Mulino’s thesis that there has been a consistent massive rise in numbers. It also substantially reduces the compound annual growth rate he wrongly quotes for just 2008–15.

He’s also cherry-picked only raw data. In fact, the only valid way to compare year to year, and jurisdiction to jurisdiction, is to use the rate for each year: that is, the number of assisted deaths as a proportion of total deaths in the same year and jurisdiction, so that you’re comparing apples with apples. It's necessary because the total deaths count goes down and (mostly) up a bit each year. The official government statistics for total deaths by year for both countries are readily available online, so there’s no excuse for not using them.

When you calculate the rates, you get validly-comparable results, as I illustrate in Figure 4.

dutchbelgianratesto2015.gifFigure 4: Rate of assisted dying as a percent off all deaths in the Netherlands and Belgium 2003–2015
Sources: Official government statistics; Euthanasia Commission reports

As I explain in my detailed research whitepaper on Benelux assisted dying,5 these are sigmoid (stretched-S) shaped curves which are typical of human behaviour change. And there is a drop in the rate in both countries in 2015, which Mr Mulino doesn’t report.

My Benelux whitepaper also reports the data from Luxembourg (Figure 5), which Mr Mulino fails to mention, even though it has legislation, since 2009, almost identical to the Netherlands and Belgium, and the Luxembourg government's data is freely available online.

dutchbelgianluxratesto2015.gifFigure 5: Rate of assisted dying in the three lawful Benelux countries
Sources: Official government statistics; Euthanasia Commission reports

Luxembourg’s data (yellow in Figure 5; no data available yet for 2015), is also an inconvenient truth to the case Mr Mulino attempts to prosecute. There’s no substantial rise.

Example 2. Comparing apples with oranges: mis-matching data

Mr Mulino again fails to compare apples with apples. Take, for example, his vocal claim that the annual total death counts for the Netherlands decreased at the same time as the total counts for assisted dying increased.

When you look at the data he’s used (the citation for the negative total deaths trend he quotes in his Table 2), you find that he’s used total death data for 2000­–10, which is falling, while his assisted dying data is for 2008­–15, which is rising.

This just isn’t on: it’s completely invalid to compare data like this from one period with data from another period to claim or imply a causal relationship. Of what possible relevance is the total death data for 2000–02, while his total deaths data for 2011–15 is missing? I illustrate the full story in Figure 6.

 

mulinomismatcheddata.gifFigure 6: Netherlands total and assisted deaths for different periods
Sources: Official government statistics; Euthanasia Commission reports

The solid blue and orange lines are data Mr Mulino used and reported, and their dotted ends are data that he omitted. It’s easy to see that the total deaths data his report inappropriately relies upon has a negative (downwards) slope (left-hand blue dashes), while the matching total deaths data he should have used has a positive (upwards) slope (right-hand blue dashes). Valid comparison gives lie to his claim.

Example 3. White is the new black: Misquoting the opposite

Mr Mulino’s report also argues that there’s ample evidence that a significant proportion of people with depression are gaining access to assisted dying:

“Ganzini et al, in a broad ranging review of instances of assisted dying in Oregon, found that twenty percent of the patients had symptoms of depression.” [Italics mine]

This assertion is nonchalantly plucked from the review6 without reading it properly, seemingly to support his thesis. In fact, the source does the exact opposite. Figure 7 is an image of the Abstract, where it says in large print, right up front:

Twenty percent of the patients had symptoms of depression; none of these patients received a prescription for a lethal medication.” [Emphasis is mine]

ganziniabstract2000.gifFigure 7: The paper Abstract articulates exactly the opposite of Mr Mulino’s claim
Source: Ganzini et al 20006

Had Mr Mulino bothered to read either the abstract or the methodology of this study properly, he would have realised that the doctor sample was of those eligible to prescribe under Oregon’s Death With Dignity Act, not just those who had, and that none of the study's patients who were assessed with possible depression had accessed an assisted death.

It's not like the information was hard to find — his report cites literally half a sentence to support his claim, when the full sentence says the opposite.

Example 4. Any port in a storm: Cherry-picking, misunderstanding and misrepresenting out-of-date data

In attempting to establish a 'slippery slope' from voluntary, to non-voluntary euthanasia (NVE) — a practice where doctors may hasten death (e.g. by administering increasing doses of opioids) when the patient hasn’t explicitly requested it — Mr Mulino states in his minority report:

“Two countries with the highest rates of this type of end-of-life (Belgium at 1.5% and the Netherlands at 0.60%) allowed the practice of euthanasia and assisted dying.”

Oh dear, Mr Mulino's report cherry-picks again. Just look at his source.7 The study, published in 2003, contains Table 2, with the relevant data in it (Figure 8).

vanderheide2003table2.gifFigure 8: Table 2 from the 2003 study Mr Mulino cites
Source: van der Heide et al 20037

There are no fewer than five major offences Mr Mulino commits here.

Firstly, look at the table. I’ve highlighted the line in yellow from which Mr Mulino draws his figures of 1.5% for Belgium and 0.60% for the Netherlands. You can immediately and easily see that Denmark’s rate of 0.67% is higher than the Netherlands' of 0.60%.

So, Mr Mulino’s statement mentioning only Belgium and the Netherlands with “highest NVE rates” is misleading. He failed to either report or explain why Denmark’s rate is higher than the Netherlands, while Denmark doesn’t have an assisted dying law; the opposite of his thesis.

Secondly, he also fails to mention Switzerland’s NVE rate of 0.42%, or to explain that it’s lower than the Netherlands and Belgium. That’s highly relevant, because Switzerland has the world’s oldest assisted dying law — in effect since 1942 — and its statute contains none of the safeguards in the Belgian and Dutch Acts. This too is at odds with Mr Mulino’s thesis.

Thirdly, if Mr Mulino had read the study properly instead of just cherry-picking convenient figures from it, he would have noticed in the methodology section that the fieldwork (doctors filling in questionnaires) was completed in 2001 and early 2002, that is, before either the Netherlands or Belgian Acts came into effect later in 2002 (the Netherlands in April and Belgium in September).

Thus, the Dutch and Belgian data points Mr Mulino advances as ‘evidence’ of an NVE ‘slippery slope’ from legislated assisted dying have nothing whatever to do with assisted deaths under their Euthanasia Acts, because neither Act existed at the time the study was conducted.

Fourthly, he is resorting here to a single point-in-time study, which has little to no scientific power to establish ‘causation’. To really establish causation, as a minimum you have to assess longitudinal data, which I show in Figure 9. It demonstrates the precise opposite of Mr Mulino's ‘slippery slope’ thesis that voluntary euthanasia causes NVE, which if true would lead to a significant increase in the NVE rate in both countries after statutory legalisation.

dutchbelgianuknverates.gifFigure 9: Longitudinal NVE rates in the Netherlands, Belgium and the UK
Sources: Netherlands8; Belgium9; UK10

Both the Dutch and Belgian NVE rates have dropped with high statistical significance since their euthanasia Acts came into effect. Indeed, the NVE rate in the Netherlands is now similar to the rate in the UK, which is acknowledged as the world’s gold standard in palliative care and which has never had an assisted dying law. This is consistent with assisted dying law reform shining a bright light on all end of life practices.

It’s not like he simply didn’t know

Fifthly, it’s particularly disappointing that Mr Mulino’s report only cherry-picked outdated data in an attempt to ‘prove’ his case when I had already directly furnished the current relevant evidence to his Committee as a properly-researched formal submission: Figure 9 above is Figure 19 in my submission, and I provided the peer-reviewed research citations for the data.11

Not only that, but the official transcript of my appearance as an expert witness before the parliamentary Committee confirms that Mr Mulino specifically quizzed me on that Figure 19 and I pointed out the sources of its data:12

Mr MULINO — Figure 19, for example.

Mr FRANCIS — The reference should be in the text. The last sentence on the previous page gives you the citations for that data.

Mr MULINO — Okay.”

Even further, when fellow-Committee-member and Catholic assisted dying opponent Mrs Inga Peulich asked about the same thing (with Mr Mulino present) — “1,000 of those who have been accidentally euthanased in the Netherlands” — I literally put the chart up on the projection screen and explained it in full to the Committee until they had no more questions. The “1000” figure is the approximate rate prior to the Dutch Euthanasia Act, while the rate has dropped significantly since.

The evidence is irrefutable: it’s not like Mr Mulino was merely blissfully unaware of the relevant data contradicting his NVE ‘slippery slope’ claim. His minority report expressly overlooks this robust evidence and instead refers inapproriately to selective and outdated data that seemed to, but didn’t, support his argument.

Five major offences in a single citation: surely Mr Mulino’s report — far from ‘academic and rigorous’ — sets a new record?

A common religious thread?

The NVE ‘slippery slope’ claim is also popular amongst and spread by the Catholic Archdioceses of Melbourne,13 Sydney14 and Brisbane,15 as well as by other Catholic anti-assisted dying lobbyists such as Alex Schadenberg,16 Paul Russell,17 and Professor of Ethics at the Catholic University of Notre Dame Australia, Margaret Somerville.18

Indeed, Mr Mulino’s minority report appears amongst 11 Catholic responses against assisted dying law reform published by the Catholic Archdiocese of Melbourne (Figure 10).

cam-mulino-report.jpg Figure 10: Daniel Mulino’s minority report appears amongst Catholic responses on the Catholic Archdiocese of Melbourne’s website19

Indeed, Mr Mulino’s linked document doesn’t seem to emanate from his parliamentary office or from wider parliamentary services: the PDF file's metadata reveals that it was authored, electronically at least, by “mmacdonald”.

Calls to both Mr Mulino's electorate office and to the Parliament of Victoria confirm there is no "M Macdonald" at either. I did, however, find online one Matthew Macdonald, researcher and Executive Officer of the Catholic Archdiocese of Melbourne’s (CAM) Office for Life, Marriage and Family — in other words, the same organisation that published the list in Figure 10 containing the link to Mr Mulino’s minority report.

Mr Macdonald is also listed as the CAM's official contact person in its submission (#705) opposing assisted dying to the Victorian Parliament's inquiry into end of life choices.20 Both the CAM and Mulino reports also refer to a journal paper by Catholic doctor José Pereira,21 and neither report mentions the subsequent evidential rebuttal outlining why Pereira's claims were merely "smoke and mirrors".22 Even more curiously, the Pereira paper is included in Mr Merlino's minority report bibliography, though his report doesn't actually cite it as the CAM submission does.

The CAM parliamentary submission was authorised and signed by Episcopal Vicars Anthony Ireland and Anthony Kerin, who also appeared as witnesses before the parliamentary Committee, during which they told, as I've explained, a whopping great falsehood about Oregon.23

Conclusion

Contrary to Paul Russell’s enthusiastic claim that Daniel Mulino’s minority report provides a ‘rigorous’ case against assisted dying law reform, the report merely serves as further evidence of how those implacably opposed to assisted dying can cherry-pick, misunderstand and rather desperately clutch their way through their ‘evidence.’

Mr Russell is not an academic expert and one can understand his limited capacity to judge whether work is ‘scholarly.’ However, Mr Mulino holds a PhD in economics from Yale,* so it’s quite astonishing that he published a ‘researched’ report containing multiple major flaws, including outdated and cherry-picked data contrary to more recent, direct and relevant evidence of which he was specifically aware, actively inquired into and had explained and cited to him in full.

These anomolies beg the question: did Matthew McDonald or someone else at the Catholic Archdiocese of Melbourne write Mr Mulino’s report for him? Mr Mulino needs to explain himself, since regardless of who authoried it, he signed it off in his own name and is therefore ultimately responsible for it.

Given the multiple fundamental errors, the honourable course for Mr Mulino to pursue is to withdraw his minority report.

The question is: will he rise to the occasion?

 

Addendum: A missed opportunity for primary research

Mr Mulino — as well as Mrs Peulich who also wrote a minority report against assisted dying — declined to join other members of the parliamentary Committee on an official overseas fact-finding tour to jurisdictions where assisted dying is lawful. This was a critical opportunity for Committee members to directly quiz proponents, opponents, researchers, regulators, legislators and others with direct experience. It would have given them invaluable opportunities to directly examine and test  assumptions, hypotheses and performance. How curious then that these two non-participataing Committee members each furnished a minority report opposing the majority recommendation to legalise assisted dying in Victoria.

 

---------------

§    The HOPE website is an initiative of the Australian Family Association (AFA), a faith-based organisation founded by Australia’s most famous Catholic, B. A. Santamaria. Mr Russell is a former Vice President of the AFA, and a former Senior Officer for Family and Life at the Catholic Archdiocese of Adelaide.

*    While Mr Mulino holds a PhD and would be entitled to be addressed as “Dr”, his Parliamentary title is “Mr”.

References

  1. Parliament of Victoria 2017, Daniel Mulino, viewed 20 Mar 2017, http://www.parliament.vic.gov.au/members/details/1764-daniel-mulino.
  2. Tomazin, F 2016, Explainer: The push towards a dying-with-dignity policy in Victoria, Fairfax Media, viewed 3 Dec 2016, https://www.theage.com.au/victoria/explainer-the-push-towards-a-dyingwithdignity-policy-in-victoria-20161203-gt3bso.html.
  3. Legal and Social Issues Committee 2016, Inquiry into end of life choices. Final report, Parliament of Victoria, Melbourne, pp. 444.
  4. Russell, P 2016, End-of-life choices report: A sugar coated poison pill for Victoria, Melbourne Catholic Lawyers Association, viewed 14 Jun 2016, http://www.catholiclawyers.com.au/latest-news/853-end-of-life-choices-report-a-sugar-coated-poison-pill-for-victoria.
  5. Francis, N 2016, Assisted dying practice in Benelux: Whitepaper 1, DyingForChoice.com, viewed 13 Nov 2016, http://www.dyingforchoice.com/resources/fact-files/assisted-dying-benelux-whitepaper-1.
  6. Ganzini, L, Nelson, HD, Schmidt, TA, Kraemer, DF, Delorit, MA & Lee, MA 2000, 'Physicians' experiences with the Oregon Death with Dignity Act', New England Journal of Medicine, 342(8), pp. 557-563.
  7. 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.
  8. 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.
  9. 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.
  10. Seale, C 2009, 'End-of-life decisions in the UK involving medical practitioners', Palliat Med, 23(3), pp. 198-204.
  11. Francis, N 2015, Submission to the Parliament of Victoria Standing Committee on Legal and Social Issues on the Inquiry into End of Life Choices, DyingForChoice.com, Melbourne, pp. 51.
  12. Parliament of Victoria 2015, Standing Committee on Legal and Social Issues inquiry into end-of-life choices: Witness-Mr Neil Francis, DyingForChoice.com, Melbourne, pp. 10.
  13. The Catholic Leader 2010, No to euthanasia – Yes to genuine care, Catholic Archdiocese of Brisbane, viewed 15 Dec 2010, https://catholicleader.com.au/analysis/no-to-euthanasia-yes-to-genuine-care_70380.
  14. Catholic Archdiocese of Sydney 2017, Experts warn against following overseas experience with euthanasia, viewed 12 Mar 2017, https://www.catholicweekly.com.au/2017/2017120_1449.shtml.
  15. Catholic Archdiocese of Brisbane 2010, No to euthanasia - yes to genuine care, The Catholic Leader, viewed 25 Feb 2012, https://catholicleader.com.au/analysis/no-to-euthanasia-yes-to-genuine-care_70380.
  16. Schadenberg, A 2013, Exposing vulnerable people to euthanasia and assisted suicide, Ross Lattner, London ON.
  17. Russell, P 2015, Submission 926: Submission to the Victorian Legal and Social Issues Committee inquiry into end of life choices, HOPE, Melbourne, pp. 56.
  18. Francis, N 2017, Margaret Somerville misleading claim - 'Non-voluntary euthanasia slippery slope', DyingForChoice.com, viewed 19 Apr 2017, http://www.dyingforchoice.com/resources/videos/margaret-somerville-misleading-claim-non-voluntary-euthanasia-slippery-slope.
  19. Catholic Archdiocese of Melbourne 2017, Why now in Victoria?, viewed 3 Aug 2017, https://www.cam.org.au/euthanasia/Be-Informed/Why-now-in-Victoria.
  20. Catholic Archdiocese of Melbourne 2015, Submission to the Legal & Social Issues Committee: Inquiry into end of life choices, Submission 705, Melbourne, pp. 16.
  21. Pereira, J 2011, 'Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls', Current Oncology, vol. 18, no. 2, pp. e38-48.
  22. Downie, J, Chambaere, K & Bernheim, JL 2012, 'Pereira's attack on legalizing euthanasia or assisted suicide: smoke and mirrors', Current Oncology, vol. 19, no. 3, Jun, pp. 133-8.
  23. Francis, N 2015, Catholic Church misinforms Parliamentary inquiry, DyingForChoice.com, viewed 25 Nov 2015, http://www.dyingforchoice.com/blogs/catholic-church-misinforms-parliamentary-inquiry.

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

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

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

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

BMA comprehensively out of touch

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

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

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

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

Ignorant and disrespectful BMA stance

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

Appalling and trivialised ‘rationale’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hubris argues for ignoring the BMA itself

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

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

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

Conclusion

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

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

 

References

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