Blog by Neil FrancisPosted on Saturday 8th August 2020 at 8:39am
A recent article in The Guardian reports that most Queensland churchgoers support voluntary assisted dying (VAD), citing a recent YouGov poll commissioned by the Clem Jones Trust.
In fact, attitudes in support of VAD have been strengthening across Australia for many years, and the last few are no exception. In this analysis I explain, using impeccable Australian Election Study (AES) data gathered by a specialist team at Australian National University.
Each federal election, the AES gathers extensive demographic and attitudinal data from a substantial sample of Australians. That means we have comparable snapshots from each election in recent times, including 2019, 2016, 2013, 2010 and 2007 (though attitudes toward VAD have been asked only since 2016).
First up, given the well-documented strong connection between higher religiosity and less favourable attitudes towards VAD, let’s take a quick look at Australia’s changing religious landscape.
Abandoning religion: from trickle to torrent
Since federation, periodic census data collected by the Australian Bureau of Statistics (ABS) confirms a long-term decline in religious affiliation (Figure 1).
Figure 1: Religious affiliation in Australia by census year (ABS data) NOTE: Figures are nett of typically 10% non-response
Even this data generally overstates actual religious affiliation, compared with repeated good-quality polls. Census data has pegged religious affiliation typically 4-8% higher than do most polls.
That’s because until the most recent census (2016), collections had primarily or exclusively used a single, massive booklet for household completion. Mr Jones was unlikely to upset Mrs Jones by ticking the “No religion” box when he thinks she’s sure the family is Anglican, and she can see his answers. In contrast, relatives are not looking over the shoulder of an opinion poll respondent, which allows them to be more frank.
Additionally, a formal booklet is more likely to prompt respondents to answer in terms of historical household identity (a lagging indicator), while ad hoc surveys are more likely to prompt answers in terms of recent, pragmatic attitudes and practices (current indicator).
Abandoning religious identity
AES data clearly shows that for major denominations, Australians are leaving institutionalised religion in droves (Figure 2).
Figure 2: Religious affiliation by federal election year (AES data)
Over just 12 years Catholic affiliation has dropped from 28% to 21% (a drop of 26% of its flock); Anglican from 21% to 15% (-29%); and Uniting/Methodist from 8% to 4% (-52%). In total, minor Christian denominations have remained around the same, while non-Christian denominations have experienced a small increase, mostly from immigration.
But by far the most dramatic change over the 12 years is that No Religion has soared from 26% to 41% of the population, an increase of 61%. The largest increase was between 2016 and 2019, most likely a result of Australians’ dismay at the 2017 reports of the royal commission into institutional responses to the sexual abuse of children. It found that most offenses occurred in religious institutions, more than half of them in the Catholic church alone.
Abandoning religious practice
Not only have Australians been abandoning religious identity, but for the most part increasingly abandoning religious practice (Figure 3).
Figure 3: Almost never/never attend religious services (AES data)
At the same time as many Australians have abandoned religious identity, those still identifying with Catholic, Uniting, and non-Christians faiths are attending services less than before.
Overall, service attendance has remained about the same amongst minor Christian denominations, and there has been an increase amongst Anglicans (actually because far more Notionals — people who identify with a denomination but never attend religious services — have “left” the Anglican church).
Indeed, in 2019, fewer than half of Australians (47%) ever attend religious services, just a third (32%) attend more often than once in a blue moon, and a mere 16% are consistent attenders.
Clerics might still be talking, but fewer Australians than ever want to listen.
Abandonment to continue
Australians will continue to abandon religion given that most younger Australians reject religion at the same time that older, more religious Australians pass away (Figure 4).
Figure 4: Religion by age cohort 2019 (AES data)
This picture is even more dire for clerics than it was just three years earlier in 2016 (Figure 5).
Figure 5: Religion by age cohort 2016 (AES data)
Over the next 25 years the Catholic church and minor Christian denominations will struggle, while the Anglican and Uniting churches will almost cease to exist if current trends continue.
An integrated measure of religion
For further analysis, we’ll use the Australian Religious Identity 6-Factor (ARI6) model. It segments on the combined basis of religious attitudes and behaviour across a spectrum from Rejecters to Devouts.
Unsurprisingly over the past decade, Devouts have remained firmly entrenched in their faith (Figure 6), while there has been a small downward trend amongst Regulars.
Figure 6: Australian Religious Identity 6-Factor (ARI6) by year (AES data)
Most of the abandonment of religion in recent years has been amongst Occasionals, those who identify with a religious denomination but rarely attend services. This begs the question as to whether clerics were right to assume that they spoke for many in their flocks in the first place.
Attitudes toward VAD — Overall
Between 2016 and 2019 there was a small but statistically non-significant increase in total support for VAD, while there was no change in total opposition (Figure 7).
Figure 7: Australian adult attitudes toward VAD by year (AES data)
What is readily apparent, though, is a substantial increase in the number of Australians strongly in support of VAD (from 43% to 53%), while total opposition has remained tiny at fewer than one in ten Australians (9%).
Attitudes toward VAD — Religious affiliation
Amongst Australians who still count themselves as religiously affiliated in 2019, a majority of all religions except minor Christian denominations clearly favour VAD (Figure 8), including three quarters (74%) of Catholics, four in five Anglicans (78%) and Uniting/Methodists (81%), and almost all non-Christian religious (96%) and non-religious (92%).
Even amongst the minor Christian denominations with nearly half (49%) in support, just one in five (20%) were opposed to VAD, the rest being neutral.
Figure 8: Attitudes toward VAD by religious affiliation 2019 (AES data)
Strong support amongst Catholics increased massively from 36% in 2016 to 48% (close to half in strong support) in 2019, highlighting the irony of Catholic clergy continuing to actively oppose VAD law reform.
Given the tiny minorities opposed across the religious spectrum, those clerics who continue to vocally oppose the legalisation of VAD — including some employing serious misinformation — in no way are speaking for the majority of their flocks.
Attitudes toward VAD — Religiosity
Unsurprisingly, given the vast body of existing scholarly research evidence, opposition to VAD is largely religious (Figure 9).
Figure 9: Attitudes toward VAD by ARI6 2019 (AES data)
Nearly half of all opposition to VAD (44%) is of Devouts, with an additional quarter (26%) amongst Regulars and Occasionals, and a smaller proportion (17%) from Notionals.
Tellingly, even amongst the most religious, opposition to VAD has dropped significantly in just three years since 2016 (Figure 10). Opposition to VAD amongst Devouts dropped from nearly half (46%) to just over a third (35%), and amongst Regulars from 25% to just 15%.
Figure 10: Attitudes toward VAD by ARI6 2016 (AES data)
For 2019, proportions of the most opposed religious segment, Devouts, are almost evenly split amongst supporters, neutrals and opposers.
Amongst the next most religious, Regulars, supporters outnumber opponents by three to one, and in all the other segments supporters outnumber opponents by more than ten to one.
The evidence is clear: even amongst the most religious Australians, opposition to VAD is melting away.
The lowdown for politicians
What does this mean for legislators, who the community is asking to legalise VAD with responsible safeguards? Figure 11 shows VAD attitudes of Australians by the political party they identify with.
Figure 11: Attitudes toward VAD by political party identity 2019 (AES data)
It’s obvious why VAD Bills have been sponsored by Greens members and/or facilitated by Labor governments.
In contrast, Australian Coalition parliamentary parties (with notable exceptions of a handful of Coalition members) have steadfastly obstructed consideration and passage of VAD Bills. This is not because the party machinery is representing the broader Coalition voter, whose overall support stands at 74% versus a tiny 13% opposed. Rather, it’s because of the (widely reported) takeover of the party machinery by the religious right.
The natural home of VAD opponents is minor right parties, comprising overall a slight majority (53%) opposed to VAD. [Addendum: those identifying with minor right parties comprise just 3.1% of the adult Australian population.]
Given that minor right party voters are most likely to give their major party preference flow to the Coalition, the real concern for Coalition election strategists is to minimise first preferences going to a minor right party in the one or two electorates (if any) in which such a minor party win might even be on the cards.
The lowdown for election candidates
It’s been a firm belief among the political class for a long time that candidates openly supporting VAD would be punished at the polls on election day, with little to no downside for candidates opposed to VAD. That, however, is fake news.
A 2012 Newspoll survey asked voters if, all other things being equal, they would change their vote if their otherwise preferred election candidate’s stance was the opposite of their own (support vs opposition). (Full disclosure: as CEO of YourLastRight.com I commissioned the survey.)
VAD-supporting voters stated they would punish their preferred candidate (opposing VAD) at three times the net rate that VAD-opposing voters would punish a supporting candidate. I’ve subsequently published various other observations that are consistent with this finding.
Now that strong support for VAD amongst the Australian public is significantly higher than it was in 2016 (let alone 2012), it would be foolhardy for any supportive politician to hide their light under a bushel, or for an opposed candidate to effectively thumb their nose at the majority of voters.
I’m reminded of a favourite remark of Sir Humphrey Appleby (Nigel Hawthorn) in the 1980s British political comedy series Yes Minister, who would gently point out his Minister’s policy folly (Jim Hacker played by Paul Eddington) with the light remark, “that would be very courageous, Minister!”
It’s now a very courageous candidate indeed who believes their personal opposition to VAD ought to trump the support of the vast majority of their constituency. And, given the ongoing abandonment of religion in Australia, such candidates will soon find themselves on the wrong side of history.
The lowdown for campaigners and voters
Given that most Australians — increasingly including the religious — are in favour of responsible VAD law reform, and with a growing proportion strongly in support, it’s more important than ever to determine election candidates’ real attitudes toward VAD.
Some candidates provide prompt and candid responses to help voters decide. But many candidates obfuscate, either failing to respond at all or responding with non-answers such as they haven’t seen specific legislation yet so cannot answer, or cynically stating only the obvious such as “opinions vary” and it can be “an emotive issue”.
The key action with obfuscators is to get a real answer to the question “could there be any version of a VAD Bill that could enjoy your support?” And assume those who still obfuscate would have said “no”, had they been candid.
Blog by Neil FrancisPosted on Friday 21st June 2019 at 10:00pm
The Catholic Church's video which blatantlly misrepresents Belgium
The Catholic Archdiocese of Sydney has released a video which blatantly misrepresents scholarly research about non-voluntary euthanasia practices in Belgium. The lead author of the peer-reviewed research has slammed the video as "cherry-picked", "scaremongering" and "appalling". His full statement about the video appears below.
Back in 1998, non-voluntary euthanasia — or NVE — was carefully studied by Belgian scholars. It’s a problematic practice, even though often the medication doctors administered didn’t actually hasten death. They found it occured in 3.2% of all deaths.
In 2002, the Belgium parliament legalised voluntary assisted dying — or VAD.
In 2007, the Belgian scholars repeated their study and found that NVE had dropped by nearly HALF, to 1.8% of all deaths. Again in 2013, it was found to remain at a lower level, 1.7% (Figure 1).
Figure 1: Belgium's NVE rate has dropped dramatically since VAD was legalised
Thus, the State shining a bright light on end-of-life practices, including VAD, has resulted in improvements.
NVE has also been found to occur in every jurisdiction that’s been studied, VAD law or not, including Australia and New Zealand (Figure 2).
Figure 2: NVE has been found in every jurisdiction that's been studied
But the Catholic church would have you believe otherwise.
In a recent video, the Catholic Archdiocese of Sydney grotesquely misrepresented a single statistic from the Belgian studies. Using cold colours and the sound of a flatlining heartbeat, the Catholic video claims Belgium’s VAD law has caused its NVE. It’s a chilling confection of innuendo that thumbs its nose at the facts.
The Belgian study the church relies on expressly points out the significant NVE drop, so it’s not like they wouldn’t know.
Figure 3: The study expressly points out the significant drop
It's no wonder that lead scholar of the Belgian research, Assistant Professor Kenneth Chambaere, called the Church’s video “cherry-picked", “a blatant misrepresentation”, “scaremongering” and “appalling”. Professor Chambaere's full response appears below.
Despite the unambiguous evidence, multiple Catholic lobbyists have used cherry-picked NVE rates in a similar way, like:
I’ve directly corrected their misleading claims before. Yet here we go again with the same unconscionable nonsense.
Interestingly, at a 2011 Catholic conference, Archbishop Anthony Fisher said:
“the man or woman in the street … may well be open to persuasion that permissive laws … cannot be effectively narrowed to such practices”
and
“we need to research and propose new messages”
Note that the Archbishop proposed... new messages. In his address he didn't propose to examine if his assumed calamities were valid or not.
The Church is entitled to opinions, but promoting misinformation doesn’t seem to be very Christian. The Church should withdraw its grotesque propaganda and apologise.
In conclusion, repeating fake news doesn’t make it true. The fact remains that Belgium’s NVE practice was considerably higher before it legalised VAD, and dropped significantly after.
Prof. Kenneth Chambaere's response in full
On viewing the Catholic Archdiocese of Sydney's video on Belgian NVE, which cites Prof. Chambaere's 2007 study, Prof. Chambaere made the following statement:
13th July 2019
Recently, a Vimeo video of the Archdiocese of Sydney on 'Debate on Euthanasia Laws' was brought to my attention: https://vimeo.com/339920133.
As lead author of the cited research, I was appalled at the video's blatant misrepresentation of the robust and honest research that we have been conducting in Belgium. It is quite frankly an insult to us as researchers who day in day out work to generate reliable and trustworthy insights into end-of-life practice in Belgium.
It is clear to me that the video has cherry-picked results from our studies to the effect of scaremongering among the public. As researchers, we fully grasp the emotional, ethical and societal gravity of the euthanasia practice and therefore also euthanasia research, and we never take it lightly. We believe we are always as objective and impartial as possible, as is to be expected of independent and free research. This only adds to my duty as a scientist to respond to the video in question and correct its mistakes. The general public and politicians must have access to reliable and correct evidence.
First of all, the figures shown in the video do not concern euthanasia practices at all. Euthanasia is by definition always at the explicit request of the patient. What the figures do refer to are physician acts to hasten a dying patient's death without their explicit request, a separate type of end-of-life practice altogether (see further).
Secondly, yes, this problematic practice does exist in Belgium. But so does it exist in every other country where anyone has had the audacity to conduct research into it, euthanasia law or no euthanasia law.
Thirdly, the incidence of such practices has halved since the euthanasia law was enacted in Belgium.
Conclusion: acts of hastening death without explicit request are not a by-product of euthanasia legislation, and if anything, euthanasia legislation seems to decrease the occurrence of these practices. This conclusion features prominently in the paper cited in the video.
This practice even exist in Australia, and in significant numbers, according to one (potentially outdated) study. While this study was not identical to ours in Belgium, it still provides clear evidence of its occurrence in Australian end-of-life practice. The authors of the video ask whether Victoria will become like Belgium? If it means diminishing rates of these questionable practices, then surely becoming more like Belgium is a good thing!
Lastly, a 2014 detailed analysis in CMAJ Open clarified much about what these cases of hastening death without explicit request entail. I quote our conclusion here: "Most of the cases we studied did not fit the label of "nonvoluntary life-ending" for at least one of the following reasons: the drugs were administered with a focus on symptom control; a hastened death was highly unlikely; or the act was taken in accordance with the patient's previously expressed wishes. Thus, we recommend a more nuanced view of life-ending acts without explicit patient request in the debate on physician-assisted dying."
This is not to condone or excuse physicians who engage in such practices, but it is important to know and be clear about what we are focusing our societal discussions on.
The question then is, why did the authors of the video overlook these clear conclusions during their extensive review of the evidence? It is very difficult to see how our research could be misrepresented in the way it has been in the video. The research is very clear and it does not support the claims made in the video. I urge anyone relying on the large body of peer-reviewed evidence to analyse it carefully, and if necessary consult with the authors, before communicating to the general public.
Assistant Professor Kenneth Chambaere
End of Life Care Research Group
Vrije Universiteit Brussel
Belgium
The Catholic Archdiocese of Sydney has released a grotesque and appalling video that blatantly misrepresents Belgium's non-voluntary euthanasia practices as being 'caused' by their voluntary assisted dying law. They're not.
“Belgian scholars have researched the country's non-voluntary euthanasia rate (or NVE) over a number of years.
Their findings unambiguously show that Belgium's NVE rate was much higher BEFORE it legalised voluntary assisted dying (or VAD), and dropped significantly afterwards.
Yet the Catholic Archdiocese of Sydney has released a grotesque video which cherry-picks just the 2007 figure to claim that Belgium's VAD law has caused its NVE practices.
But the NVE drop is no secret: it's expressly stated in the very research the Church cites.
It's no wonder that lead researcher, Assistant Professor Kenneth Chambaere, called the Church’s video “cherry-picked", “a blatant misrepresentation”, “scaremongering” and “appalling”.
The video casts serious doubts over the Church's competence in assessing scholarly evidence, and calls into question its desire to avoid misinformation.
To conclude, Belgium's NVE rate dropped dramatically, and has remained lower, after it legalised voluntary assisted dying.”
Blog by Neil FrancisPosted on Tuesday 18th June 2019 at 7:00pm
The Parliament of Victoria passed the Voluntary Assisted Dying Act in 2017
Victoria's Voluntary Assisted Dying Act (2017) has now come into effect. Including 68 safeguards, the Act gives Victorians with a terminal illness another option to consider at end of life, if it is of interest to them. As overseas evidence shows, the possible choice of voluntary assisted dying provides comfort and relief for the terminally ill and their loved ones. It demonstrates that the State respects the wider range of alternatives that dying patients may choose to pursue when faced with intolerable and unrelievable suffering.
The Act contains what is arguably the world's most detailed and carefully laid out safeguards.
Key aspects of the provisions are:
The person must be 18 years or over; and
Be ordinarily resident in Victoria and an Australian citizen or permanent resident; and
Have decision-making capacity in relation to voluntary assisted dying; and
Be diagnosed with an incurable disease, illness or medical condition that:
is advanced, progressive and will cause death; and
is expected to cause death within 12 months; and
is causing suffering that cannot be relieved in a manner the person deems tolerable; and
Doctors and other healthcare workers are not permitted to raise assisted dying — only to respond to formal patient requests.
The person must make three formal requests, the second of which must be written and witnessed by two independent people.
The person must make the request themselves. Nobody else is authorised to make the request, and the request cannot be made via an advance care directive.
Ordinarily, the minimum timeframe between first request and opportunity to take the medication is ten days.
The person must maintain decisional capacity at all three requests.
Two doctors must reach independent assessments that the person qualifies.
Only doctors who have completed specialist training for voluntary assisted dying may participate.
Any healthcare worker may decline to participate for any reason, without penalty.
A prescription dispensed for the purpose of voluntary assisted dying must be kept in a locked box and any unused portion returned to the pharmacy after death.
The person must self-administer the medication; except if the person is unable to, a doctor may administer. An independent witness is required if the doctor administers.
Establishment of an authority to receive assisted dying reports, to assess reports, and to refer unacceptable cases to disciplinary or prosecutorial authorities.
For Parliament to review summary reports; twice in the first two years and annually thereafter; a formal review at five years.
More information about the Act and how to access voluntary assisted dying are available from Health Victoria.
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Full list of safeguards in Victoria's voluntary assisted dying framework
Access
Voluntary
Limited to 18 years and over
Residency requirement [Victorian resident and Australian citizen or permanent resident]
Limited to those with decision-making capacity
Must be diagnosed with condition that meets restrictive set of criteria [advanced, progressive and will cause death]
End of life is clearly defined [death expected within weeks or months, not more than 12 months]
End of life condition combined with requirement for suffering
All of the eligibility criteria must be met
Mental illness alone does not satisfy the eligibility criteria
Disability alone does not satisfy the eligibility criteria
Request
Must be initiated by the person themselves
No substitute decision makers allowed
Cannot be included as part of an advance directive
Health practitioner prohibited from raising voluntary assisted dying
Person must make three separate requests
Must have written request [witnessed in the presence of a medical practitioner]
Two independent witnesses to request [exclusions for family members, beneficiaries, paid providers]
Specified time must elapse between requests [first and third requests must be at least 10 days apart with exception when death imminent]
Additional time required to elapse between steps of completing process [second assessment and third request must be at least one day apart
Must use independent accredited interpreter [if an interpreter is required]
No obligation to proceed, may withdraw at any time
Assessment
Eligibility and voluntariness assessed by medical practitioners
Must be two separate and independent assessments by medical practitioners
Assessing medical practitioners must have high level of training/experience
Assessing medical practitioners must have undertaken prescribed training [to identify capacity and abuse issues]
Requirement to properly inform person of diagnosis, prognosis and treatment options, palliative care, etc, [by both assessing medical practitioners]
Referral for further independent assessment if there is doubt about decision-making capacity
Coordinating medical practitioner must confirm in writing that they are satisfied that all of the requirements have been met
Medication management
Person required to appoint contact person who will return medication if unused
Medical practitioner must obtain a permit to prescribe the medication to the person
Medication must be labelled for use, safe handling, storage and disposal
Pharmacist also required to inform the person about administration and obligations
Medication must be stored in a locked box
Administration
Medication must be self-administered [except in exceptional circumstances]
If physical incapacity, medical practitioner may administer
Additional certification required if administered by medical practitioner
Witness present if medical practitioner administers
Practitioner protections
Health practitioner may conscientiously object to participating
Explicit protection for health practitioners who are present at time of person self-administering
Explicit protection for health practitioners acting in good faith without negligence within the legislation
Mandatory notification by any health practitioner if another health practitioner acting outside legislation
Voluntary notification by a member of the public of a health practitioner acting outside legislation
Mandatory reporting
Reporting forms set out in legislation
Reporting mandated at a range of points and from a range of participants to support accuracy
First assessment reported [to Board]
Second assessment reported [to Board]
Final certification for authorisation reported [to Board, incorporates written declaration and contact person nomination]
Additional form reported [to Board] if medication administered by medical practitioner
Prescription authorisation reported by DHHS [to Board]
Dispensing of medication reported [to Board]
Return of unused medication to pharmacist reported [to Board]
Death notification data reported [to BDM and collected by Board]
Offences
New offence to induce a person, through dishonesty or undue influence, to request voluntary assisted dying
New offence to induce a person, through dishonesty or undue influence, to self-administer the lethal dose of medication
New offence to falsify records related to voluntary assisted dying
New offence of failing to report on voluntary assisted dying
Existing criminal offences for the crimes of murder and aiding and abetting suicide continue to apply to those who act outside the legislation
Oversight
Guiding principles included in legislation
Board is an independent statutory body
Board functions described in legislation
Board reviews compliance
Board reviews all cases of [and each attempt to access] voluntary assisted dying
Board has referral powers for breaches
Board also has quality assurance and improvement functions
Board has expanded multidisciplinary membership
Board reports to publicly [to Parliament every six months for first two years, thereafter annually
Five year review of the legislation
Guidelines to be developed for supporting implementation
Blog by Neil FrancisPosted on Thursday 23rd May 2019 at 2:39am
Palliative care specialist advances incoherent reasons to oppose VAD.
Director of Palliative Care at Cabrini Health, Associate Professor Natasha Michael, yesterday published an opinion piece in The Age newspaper. In it, she rails against Victoria’s voluntary assisted dying (VAD) Act which comes into effect on 19th June. Instead she articulates an arrogant and prescriptive view of what Australians should and shouldn’t be allowed, consistent with Catholic dogma, as I uncover.
Michael, along with fellow devout Catholic Dr Stephen Parnis, ‘tirelessly’ opposed the introduction of Victoria’s VAD law. They continue to actively oppose it, and her opinion piece reveals her spurious ‘reasoning’.
The Catholic Healthcare brick wall
More than half of all palliative care services in Australia are delivered through Catholic institutions, of which Cabrini Health is one arm. These institutions have determined that VAD will not be available in any of their facilities or via any of their services, even if the individual patient and doctor are supportive.
This arbitrarily limits access to lawful choice by citizens.
Confected ‘institutional conscience’
I say ‘arbitrarily’ because ‘institutional conscience’ is a confection: it doesn’t really exist. Only real persons have conscience. The fabricated dictates of any institution — presented as ‘moral rules’ — extinguish the actual real conscience of those who exist within it: at least, those whose conscience differs.
The upshot is that a specific cohort of religious, celibate men in Rome dictate whether Australian citizens can or can’t obtain lawful healthcare services from half the service providers.
So let’s examine what the institutional ‘conscience’ has to say.
Disgraceful framing in headline
“We can’t let voluntary assisted dying negate our commitment to the ill”, Michael’s article headline screams.
Firstly, VAD is not available to the “ill”. It’s available only to those with terminal illness and intolerable suffering, according to 68 criteria.
Secondly, Michael invokes a false dichotomy of “negating a commitment”. VAD does not “negate a commitment”. Indeed, to fail to hear and respect a persistent, fully informed and tested request for VAD that meets all the criteria is to negate palliative care’s commitment to honour the patient’s deeply held values, beliefs and decisions.
Medical-coloured glasses
“The introduction of voluntary assisted dying legislation in Victoria on June 19 will remind us of the occasional failure of medicine,” Michael says.
That’s it. The patient’s death is a failure of medicine, as though a person’s death is a medical event rather than a deeply human and private one of personhood.
It also flags the common but immature medical assumption that “death = failure”. Death is inevitable, not a “failure”. The key question about death for people with terminal illness is “how”, and Michael presumes to prescribe the “how”: being receptacles for interventions that she and her colleagues provide.
Let’s be clear. Many people are helped enormously by palliative care. That’s a great credit to the discipline’s specialists.
However, as Palliative Care Australia acknowledges, even the best palliative care can’t relieve all excruciating, debilitating and humiliating refractory symptoms.
Michael’s answer to this sometimes “failure” of medical interventions? Deliver more interventions, whether the patient considers them consistent with his own values, beliefs and circumstances or not.
They’re very heavily medical-coloured glasses indeed.
Three faux ‘threats’
Michael then invokes three faux ‘threats’ supposedly caused by lawful VAD in Victoria.
Faux threat 1: “Validating suicide as an acceptable choice”.
Michael exposes her own bias here: that all self-hastening of deaths are the same — that there is no meaningful difference between a dying person who is fully informed and whose rational choice for a peaceful assisted death has been extensively tested, with the violent and impulsive action of a person suffering a temporary, resolvable personal crisis, be it mental illness, substance abuse, intimate relationship breakdown or other circumstance.
Michael is pretty much on her own here. Most Australian doctors make a clear distinction between these very different contexts.
Faux threat 2: “accepting substandard medical care by supporting the lack of rigour in defining [VAD] eligibility”.
Michael overlooks that there is a major lack of rigour in existing, lawful end-of-life choices.
There are no statutory requirements for a patient to refuse medical treatment, even if the treatment would be life-saving.
There are no statutory requirements for the voluntary refusal of food and fluids in order to die, either.
More critically, despite terminal sedation being a common end-of-life medical practice but ethically problematic (including that it may hasten death and may not alleviate intractable symptoms), not only is there no statutory requirement for its practice, but neither the Australian Medical Association nor Palliative Care Australia have official guidelines on its practice.
Thus, in railing against the staggering 68 standards of practice prescribed in Victoria’s VAD law — vastly more than any other in the world — as a “lack of rigour”, Michael makes no mention of three other major life-end choices that have no such standards, including her own discipline’s terminal sedation.
Doctor, heal thyself (and thine own systems).
Faux threat 3: “introducing into the healthcare curriculum the intentional ending of life as acceptable medical treatment”
Michael creates a misleading impression here. By referring to ‘curriculum’ you might think that all medical students would have to undergo training on how to end lives, or be ‘indoctrinated’ to accept VAD. That is not true.
To be able to prescribe lethal medication under Victoria’s legislation, the doctor must undergo additional training in relation to that procedure. Doctors will only receive the training if they self-nominate for it: it’s not compulsory.
If, by ‘curriculum’ Michael means only “VAD might be discussed” in medical school, then she would have to articulate why termination of pregnancy (to which the Catholic church objects) should not be discussed, either. Nor the transfusion of blood, since many Jehovah’s Witnesses object to the procedure.
Own failure in palliative care principles
Nowhere in her opinion piece does Michael acknowledge that the patient may deeply hold values and beliefs that validly favour VAD. Thus, Michael offends the first principle of palliative care which is to make the patient the centre of care and to honour as much as possible the patient’s values, beliefs, attitudes and wishes.
Indeed, in her conclusion, Michael states that palliative care “remains committed to the ongoing accompaniment of our patients. Not abandoning them” and which is “the only plausible method of compassion and care.”
This surely is the most egregious and arrogant self-interest of all: patients must subject themselves to being accompanied by palliative care staff and their ‘interventions’ whether they want more or not.
On the contrary, to fail to hear and respect a genuine, informed and persistent request for a peaceful hastened death from a dying patient for whom this accords most firmly with his deeply held values and beliefs, is to abandon the patient.
Conclusion
Michael is of course entitled to her personal stance, and I celebrate her right to hold her views: for herself.
However, her ‘requirement’ that all Victorians be denied access to an option that four out of five believe to be moral — and instead subject themselves to interventions administered by Michael and her colleagues — reveals an unattractive arrogance.
It’s a shame that Catholic bioethics doesn’t teach more about reflection, especially as to whether one’s own beliefs ought to dictate and limit the choices of others with equally firmly held, though different, values.
In the meantime, Victorians are pawns to the tyranny of the Vatican as to whether there is a local healthcare facility that will hear and examine their request for a peaceful, assisted death in the face of terminal illness.
The F filesPosted on Tuesday 9th April 2019 at 7:15am
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
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.
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.
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.
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.
KNMG/KNMP 2012, Guidelines for the practice of euthanasia and physician-assisted suicide, Utrecht, pp. 56.
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.
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.
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.
Oregon Health Authority 2019, Oregon Death With Dignity Act: 2018 data summary, Department of Human Services, Portland, pp. 16.
Washington State Department of Health 2018, Washington State Department of Health 2017 Death with Dignity Act Report, Olympia, WA, pp. 15.
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.
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.
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.
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.
Fact file by Neil FrancisPosted on Monday 8th April 2019 at 2:47am
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 arrogance”19 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
Somerville, M 2009, 'We can always relieve pain', Ottawa Citizen, (24 Jul).
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.
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.
Twycross, R 2019, 'Reflections on palliative sedation', Palliative care, 12, pp. 1-16.
Palliative Care Australia 2006, Policy statement on voluntary euthanasia, Canberra, pp. 2.
Davis, MP 2009, 'Does palliative sedation always relieve symptoms?', Journal of Palliative Medicine, 12(10), pp. 875-877.
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.
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.
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.
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.
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.
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.
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.
Palliative Care Australia 2018, National Palliative Care Standards, Griffith ACT, pp. 44.
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.
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.
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.
Hain, RDW 2014, 'Euthanasia: 10 myths', Archives of Disease in Childhood, 99(9), pp. 798-799.
Horne, DC 2014, 'Re: Why the Assisted Dying Bill should become law in England and Wales', BMJ, 349, p. g4349/rr/759847.
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.
Blog by Neil FrancisPosted on Monday 1st April 2019 at 9:59pm
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.
Blog by Neil FrancisPosted on Thursday 28th February 2019 at 6:12pm
The Belgian Euthanasia Commission has released its summary report for 2018
Belgium's Federal Commission for Control and Evaluation of Euthanasia has released a summary report of cases for the 2018 calendar year. Numbers have stabilised, with a tiny 1.8% increase on the figures for the previous year. All cases were found to have met the essential conditions of the Euthanasia Act. Below is an English translation of the report.
Belgium Euthanasia - Figures for the year 2018
By Jan Eyckmans
Posted on 28/02/2019
These figures relate to the registration documents for euthanasia carried out between 1 January 2018 and 31 December 2018 examined by the Commission. A more detailed analysis of euthanasia reported in 2018 will be made in the next biennial report of the Commission (gathering data for 2018 and 2019).
The number of reports received during this period was 2357. The majority were written in Dutch, concerned patients aged 60 to 89 years and slightly more women. Most often, euthanasia took place at home.
The main conditions causing the euthanasia claims were either cancers or a combination of several conditions (polypathologies) that were not likely to improve and that caused more and more serious disabilities up to organ failure. Death of patients was usually expected in the near future. Patients whose death is clearly not expected in the short term suffered mostly from polypathologies, while the death of cancer patients is rarely considered such.
Requests for euthanasia on the basis of mental disorders and behavior remain marginal (2.4% of all euthanasia). Like all euthanasia records, they comply with the legal requirements (patient capable, written request, medical situation without solution, constant suffering, intolerable and unbearable, caused by a serious and incurable condition, application and repeated request).
No euthanasia of unemancipated minors was recorded in 2018.
The Commission considered that all the declarations received met the essential conditions of the law and none were transmitted to the public prosecutor.
Detailed figures
The number of reports received in 2018 was 2357. The number of recorded euthanasia remained stable (only 1.8% increase).
The number of registration documents in French continues to increase (76% NL / 24% FR).
67.1% of the patients were older than 70 years and 41% were over 80 years old. Euthanasia in patients under 40 remains very limited (1.7%). It is mainly patients in the 60, 70, and 80 age groups who request euthanasia (75.8%). The largest group of patients is between 80 and 89 years old (29.9%).
In 2018, no statement regarding the euthanasia of minors was recorded.
The number of euthanasia in the home (46.8%) is still increasing, while those in the hospital are still decreasing (36.1%). The number of euthanasia in nursing homes and nursing homes continues to increase (14.3%). This corresponds to the patient's wish to end his life at home.
In the vast majority of cases (85.4%), the physician estimated that patient deaths were predictable in the near future.
For the majority of patients, several types of physical and psychological suffering (not to be confused with psychiatric conditions) were observed simultaneously (78.7%). These sufferings were always the consequence of one or more serious and incurable conditions.
Less than 1% of euthanasia involved unconscious patients who made an advance declaration.
The conditions causing the euthanasia were mostly tumours (cancers) (61.4%), polypathologies (18.6%), diseases of the nervous system (8.3%), circulatory system diseases. (3.8%), diseases of the respiratory system (2.4%) and mental and behavioural disorders (2.4%).
Blog by Neil FrancisPosted on Friday 4th January 2019 at 11:43pm
Victoria has shown what happens at the ballot box to candidates who oppose VAD
Many news outlets are reporting that Victoria's voluntary assisted dying (VAD) Act comes into effect mid-year, and how other Parliaments around the country are likely to implement similar reforms. Moves are afoot in Western Australia, Queensland, NSW and Tasmania, with other jurisdictions to follow. Marshall Perron, former Chief Minister of the Northern Territory and architect of the first VAD law in Australia, has penned a media release to highlight how VAD influenced the Victorian election. The result wasn't pretty for opponents of VAD law reform.
Media release - Marshall Perron
Parliamentarians traditionally shy away from supporting voluntary assisted dying (VAD), believing it is politically toxic to do so. Victoria, under the Andrews government, has changed all that by showing the opposite to be true.
After legislating VAD – Victoria is the first Australian state to do so – Andrews won a thumping victory at the 2018 Victoria State election.
Former NT Chief Minister Marshall Perron said there is a common perception that the political class has not been listening to its constituents. VAD is a classic example.
There were multiple reasons for Victoria’s election result, and VAD was clearly one of them. With unprecedented 80-85% public support, it should be no surprise that Victorian candidates who supported VAD polled more strongly.
In the previous parliament, almost all Liberal members voted against the VAD legislation. The party suffered an average 6.04% swing against it in the State election.
In addition, two of the staunchest Liberal opponents of the VAD bill lost their seats. In the lower house, Robert Clark was tossed out as the Member for Box Hill, a seat he’d comfortably held for a quarter century. In the upper house, Inga Peulich was rejected by voters in South Eastern Metropolitan, a Region she’d represented for three terms.
Dying With Dignity Victoria and Andrew Denton ran targeted campaigns focusing on four electorates – Burwood, Albert Park, Bentleigh and Prahran. They used Robo calls, advertising, social media and face to face meetings to inform voters about where their candidates stood on VAD.
The Liberal candidates (one a sitting member) in these four electorates all opposed VAD. They suffered an average 10.1% drop in primary votes compared with the average drop in the Liberal vote overall of 6.04%.
The Liberal sitting member lost his seat. In the other three seats the sitting Labor and Greens members, who all supported VAD, were returned with significantly increased votes. The results for these four electorates were, compared to the 2014 election:
In Burwood, Liberal member Grahame Watt lost his seat with a 6.47% swing against. Labor candidate and VAD supporter Will Fowles was elected.
In Albert Park, Labor member and VAD supporter Martin Foley was returned with a massive 10.17% increase (two party preferred). The Liberal primary vote dropped 10.24%.
In Bentleigh, Labor member and VAD supporter Nick Staikos was returned with a massive 11.27% increase. The Liberal primary vote dropped 12.59%.
In Prahran, Greens member and VAD supporter Sam Hibbens was returned with a 7.0% increase. The Liberal vote dropped 10.29%.
Mr Perron, who introduced the world’s first successful VAD legislation in the Northern Territory in 1995 said candidates can increasingly expect to lose support when they ignore the wishes of the voters they seek to represent.
In a contest tighter than the Victorian election turned out to be, a handful of seats retained or lost on VAD could determine the outcome.
Figure 1: Religious affiliation in Australia by census year (ABS data)
Figure 2: Religious affiliation by federal election year (AES data)
Figure 3: Almost never/never attend religious services (AES data)
Figure 4: Religion by age cohort 2019 (AES data)
Figure 5: Religion by age cohort 2016 (AES data)
Figure 6: Australian Religious Identity 6-Factor (ARI6) by year (AES data)
Figure 7: Australian adult attitudes toward VAD by year (AES data)
Figure 8: Attitudes toward VAD by religious affiliation 2019 (AES data)
Figure 9: Attitudes toward VAD by ARI6 2019 (AES data)
Figure 10: Attitudes toward VAD by ARI6 2016 (AES data)
Figure 11: Attitudes toward VAD by political party identity 2019 (AES data)
