Voluntary euthanasia (VE)

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Branka van der Linden on the anti-VAD "HOPE" website

I haven’t written for a while, but was prompted to do so by my friend and colleague Ian Wood. He pointed me to an email just sent about by Branka van der Linden of the anti-VAD “HOPE” blog site.

I've written about Ms van der Linden's musings before, including:

 

What’s the big deal?

In her email, Ms van der Linden wrote provocatively against the Netherlands’ voluntary assisted dying (VAD) law, citing a recently-published medical journal study of Dutch VAD cases that involved people with intellectual disabilities or autism spectrum disorder (or both). The study is a legitimate examination of cases published by the Dutch Euthanasia Commissions, and contains numerous observations and some qualifications.

The first whopper

Mr van der Linden cherry-picks a single item from the study — that a majority of qualifying cases examined reported feeling socially isolated and lonely — and presses that into strong emotional words about “not caring” for people.

She failed to identify any other important aspect of either the study, or Dutch law, including:

  • The article reported that two thirds (67%) of the cases had profound somatic (physical) conditions as well. Comorbidities are very common in Dutch VAD cases.
  • The Dutch law requires:
    • The request to be well-considered
    • The patient’s suffering to be lasting and unbearable
    • The patient to be fully informed
    • The patient holding the conviction that there was no other reasonable solution, and
    • The attending doctor consulting a second doctor who also furnishes a written opinion about the qualification criteria.
       

So much for context and balance.

And she goes on.

The second whopper

Ms van der Linden then categorically and confidently states that:

“Like every other country that has legalised euthanasia, the debate in the Netherlands was initially about euthanasia for those with terminal illnesses. That has now shifted to approving requests for euthanasia for people with autism. This is the inevitable trajectory once a jurisdiction approves euthanasia laws.”

So much hyperbole. Let’s examine the facts:

  1. Netherlands: The Dutch VAD law was legislated in 2001 and came into effect early 2002. It allowed non-terminal cases (including psychological) to qualify right from the outset.
  2. Netherlands: Prior to the legislation, there was a period, from the 1980s, where VAD was approved by regulation (not legislation). Was that for terminal-only cases? Nope. Right from the outset, Dutch law permitted non-terminal cases.
     

So, Ms van der Linden’s claims about the Netherlands are foundationally false.

Now, on to the “inevitable trajectory” claim.

  1. Belgium: Changed from terminal-only to non-terminal? Nope. (Non-terminal from the outset.)
  2. Luxembourg: Changed from terminal-only to non-terminal? Nope. (Non-terminal from the outset.)
  3. Switzerland: Changed? Nope. (There have been no statutory qualification criteria since 1942.)
  4. USA states: Any of the lawful USA states, including Oregon where VAD law has been in effect since 1997, changed from terminal-only to non-terminal? Nope.
  5. Australia: Any state changed from terminal-only to non-terminal? Nope.
     

Ms van der Linden’s claim is contradicted by so much evidence.

  1. Canada: There is one notable jurisdiction where qualification criteria have changed, and that’s Canada. Changes have been many years in the making, involving nation-wide conversation and debate, steered by its legislature and most senior court. Many points have been thrashed out as representatives consider the issues and settle on what a majority of the nation's own citizenry (not Ms van der Linden) believes is appropriate.
     

Importantly, it’s worth noting that even with additions to qualification criteria set in law in Canada, they are still considerably more restrictive than in Switzerland — because Swiss legislation doesn’t stipulate any qualifying criteria. Yet Switzerland’s assisted dying rate is lower than Canada’s. It’s a cultural difference.

Changes to qualification criteria are very much the exception, not “inevitable” as Ms van der Linden wrongly states.

Two claims — both whoppers

It’s hard to imagine that Ms van der Linden, being so immersed in the VAD subject as she is, could be so unaware of the most fundamental facts. But maybe she is, despite the facts being easy to source. Such ignorance renders her an “unreliable witness”.

To my mind, repeatedly failing to establish the actual facts while confidently stating “counter-facts” that are not true — especially in order to influence others in support of one's personal ideological position — would be consistent with an impoverished sense of ethics.

Conclusion

I admire and respect Ms van der Linden’s passion for doggedly pursuing what she believes is right, and I’m thankful we live in a robust democracy that allows people to express and debate views consistent with their internal values.

What, I argue, isn’t worthy of admiration or respect is to repeatedly misinform one’s audience by failing to undertake the most basic checking to determine if what one is saying is fundamentally true, let alone balanced or contextually relevant.


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Marion Harris published an eye-wateringly illogical op-ed in The Australian

Dr Marion Harris recently published another op-ed, this one in The Australian, against legalising voluntary assisted dying for the terminally ill. Her “reasoning” is inane, failing the basics of Logic 101 and offering up misinformation about palliative care. It also comprehensively fails to mention her deep underpinning Catholic ideology.

Dr Marion Harris is an experienced Melbourne-based oncologist. Having practiced for some twenty years, she’s co-authored research papers published in the peer-reviewed medical literature regarding the assessment of treatments for particular kinds of cancer.

You’d think that such experience and attention to evidence and proper deduction would give rise to a moderate and thoughtful approach towards legal VAD (even if opposed) and on other more general matters. But she offers quite strident nonsensical arguments.

Inane logical flaw

The lead reason that Dr Harris advances against VAD is that people will feel coerced to take the option. She cites three cases of people who decided to pursue intensive medical treatment for cancer instead of pursuing VAD, and who she states would all have been eligible for VAD. This means she says that they would have been expected to die within six months. She then notes they’re all alive and doing well — relatively speaking, with significant medical conditions — more than a year later, due to pursuing intensive medical interventions.

I emailed Dr Harris and she confirmed that these were indeed Victorian medical cases personally known to her.

With the chosen cases outlined, she claims that “the option of VAD ignores these possibilities [of further treatment]”. That is, in the state of Victoria where she works and where VAD is legal as she acknowledged in her article, she opines that VAD would stymie such medical interventions.

So, Dr Harris argues, using three cases of patients pursuing further treatment in a state with lawful VAD, that patients will not pursue further treatment if VAD were to be made lawful. (Her op-ed is clearly aimed at NSW MPs who are currently considering VAD legislation.)

It’s as whacky as the theory that the reason you never see elephants hiding in treetops is because they’re good at it.

And it flies in the face of clear documentary evidence of careful practice published by Victoria’s own Voluntary Assisted Dying Review Board, which Dr Harris doesn’t mention. We can only wonder why not.

Dr Harris inanely argues that people won't pursue medical treatment if VAD is legal, by describing three cases in which they did while VAD was legal.

Hubris?

A possible explanation for Dr Harris’ claim that people will be vulnerable to VAD when it is legal is that while she refuses to participate, doctors who do participate would not offer any and all available medical interventions that might help. But this this would be a shabby accusation against other doctors. Indeed, VAD law mandates that the patient be fully informed about treatment options as one of the qualification criteria should they apply.

Such an opinion about medical colleagues might also suggest a certain level of hubris and harsh attitudes about others. So perhaps this is not what she means, though other explanations for her conclusion are more elusive. We can only wonder, because Dr Harris has publicly stated in writing:

  • “People are free to suicide but no-one has the right to expecct [sic] their govt to kill them on request.”
  • “Boo hoo Ita … cry us a river … get over yourself” in response to ABC Chair Ita Buttrose saying she felt disrespected by Communications Minister Paul Fletcher.
  • “Ha ha – nailed it” in response to a post “@JoeBiden ankle injury update ….. cause was falling over a box of @realDonaldTrump ballots in his basement.”
  • “Very true” in response to a post stating that if Victoria’s Chief Medical Officer Professor Brett Sutton were put “in charge of climate emergencies he’d issue matches to every pyromaniac in Victoria, punch holes in the fire hoses at every CFA, then stand back and giggle while the state burned.”
     

She’s also retweeted comments that Donald Trump is the only person who can save the world from the Chinese Communist Party, and that the 2020 USA presidential election was “stolen” by election fraud.

Misrepresenting palliative care

In her article, Dr Harris argues again that palliative care is “the answer” despite both Palliative Care Australia and the Australian and New Zealand Society for Palliative Medicine clearly stating that palliative care can’t help everyone, and that a small minority suffer badly leading up to death.

While a small but meaningful minority, such cases of suffering in extremis are not “very rare” as Dr Harris wrongly states.

Dr Harris wrongly states that palliative care eliminates the need for VAD legislation. The peak bodies for palliative care in Australia state that while palliative care helps many people, it can't help everyone. Nor should we expect palliative care to be the only medical discipline to be infallible. That would be cherry-picked, confected nonsense.

A bright spot

In her favour, Dr Harris does at least acknowledge in her article that people can have “genuinely chosen a VAD pathway for themselves”.

The Catholic Communicators’ Guild

I’ve written before about the Catholic Church and its network of anti-VAD communicators, many of whom don’t reveal their religious ideology. One can only wonder, given Archbishop Anthony Fisher’s active call to find willing “spokespeople” for the Church, if it has directly recruited Dr Harris to its anti-VAD campaign — or whether she’s merely a privately motivated individual.

Either way, there’s no shortage of evidence of Dr Harris’ very, very deep Catholic roots indeed. On Twitter, she follows, for example:

  • Pope Francis.
  • Vatican News.
  • Catholic Bishop Tim Harris, the church’s spokesperson against VAD.
  • Catholic Archbishop Anthony Fisher (Sydney).
  • Catholic Bishop Richard (‘Down’) Unders (also Opus Dei: Sydney).
  • Catholic Archbishop Peter Commensoli (Melbourne).
  • Catholic Archbishop Mark Coleridge (Brisbane).
  • Jeremy Stuparich, Public Policy Director, Australian Catholic Bishops Conference.
  • Xavier Symonds, Research Fellow, Plunkett (Catholic) Centre for Ethics.
  • National Catholic Register.
  • Catholic News Agency.
  • Catholic Arena (Catholic news and opinion).
  • The Catholic Leader.
  • Father Andrew McDonald (Canadian Catholic priest).
  • The Society of St Sebastian (Catholic and Orthodox).
     

She warmly retweets posts from Catholic sources. Her posts are also consistent with the Catholic Church’s stances on sexuality and abortion, though her attitudes in denial of global warming are inconsistent with the Vatican’s, which supports efforts to combat it.

Indeed, in June 2021 she co-authored a similar op-ed also in The Australian, again replete with Catholic talking points. The other author was Emeritus Professor of Medicine Haydn Walters. What The Australian failed to declare is that Dr Walters is a board member of the innocuously named “Christopher Dawson Centre for Cultural Studies”. The stated aim of this organisation, nestled directly within the Catholic Archdiocese of Hobart (it shares the church's head office address), is chillingly arrogant: “to promote awareness of the Catholic Intellectual Tradition and Cultural Patrimony as essential components of human civilization”.

Dr Harris even directly defends the Church. For example, in response to a post criticising the Church as incoherent for saying it would never abandon people who choose assisted dying, yet says it is likely to deny last rites and pastoral care for those who do, Dr Harris wrote:

  • Well the church is actually correct - the person is about to have an elective assisted suicide which is very different to a natural death so it does seem reasonable to question giving last rites - it’s the persons choice to select VAD and choices have consequences…”

Dr Harris provides ample evidence that she is a devout and traditional Catholic. That is her right. Curiously, though, she never mentions personal religious foundations for her views on VAD which align so strongly with Catholic Church talking points.

Conclusion

Dr Marion Harris’ anti-VAD tirades follow the same talking points as the Catholic Church and its network of communicators. In the current op-ed alone, she’s crafted an inane failure of logic, and employed misinformation about palliative care, to curry fear of responsible VAD law reform.

The invective apparent in some of her musings does her reputation no favours. While her personal view to never participate in VAD is deserving of respect, I argue that denying others their own choice of conscience, especially on the basis of misinformation and dumb logical falsehood, is not.

 

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For the record

For those wanting to run the "religious persecution" flag up the pole, this article is not for you. I wholeheartedly endorse Dr Harris's right to both her religion and her personal rejection of VAD. This article does not claim that Dr Harris's arguments are wrong because they are Catholic. It is to say, with appropriate reasoning (which Dr Harris failed to employ) and evidence that the claims she makes about VAD in her op-ed are illogical and poorly informed. They are an offence to acknowledging and protecting the different and deeply held ethical views of others.

The link I make to Catholicism is to point out how much of the nonsense promoted against VAD law reform is a malodorous vapour emanating from a seeming (and not infrequently actual) coordinated effort of a Catholic Church intent on imposing its views on all Australians, Catholic or not. Most Australians are not Catholic. And most lay Australian Catholics support VAD.

As I explain in a separate research series about Religiosity in Australia, the Church's intransigent attempts to trample the consciences of its own flock (let alone all Australians) is one of the reasons citizens have been abandoning the pews in droves in recent times.


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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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Margaret Somerville's latest and repeated misinformation deserves censure.

If there’s one thing you have to admire about Margo Somerville, Catholic Professor of Bioethics at the University of Notre Dame Australia, it’s her persistence in the face of being called out for misrepresenting facts about assisted dying. She’s at it again.

Today in the Sydney Morning Herald, Somerville was quoted spruiking her credentials via a recent publication in the peer-reviewed Journal of Palliative Care.1 Since I study the professional literature, I’m aware of said article, which was published several weeks ago. It's a shocker.

The authority bias

Somerville shows herself to again to not care much for the full facts. She seems more comfortable with calling on the ‘authority bias’: advancing her credentials as a “Professor of Bioethics” along with nine “international counterparts” in the authorship of said paper.

I’ll spare you a blow-by-blow analysis of how the JPC article skilfully employs reassuringly professional tones to stake a wholly one-sided and shockingly ill-informed stance against assisted dying law reform.

A very telling example of misinformation

Let’s look at just one very telling example: the statistics that the authors quote about non-voluntary euthanasia (NVE) rates in Belgium and the Netherlands. NVE is a doctor’s act of hastening a patient’s death without a current request from the patient. The authors say that:

“Administration of lethal drugs without patient request occurred in 1.7% of all deaths in the Flanders region of Belgium alone and 0.2% of all deaths in the Netherlands.”

Are these figures correct? Yes indeed they are... as at the date of the cited sources. However, they are just cherry-picked tidbits from a larger and very different smorgasboard of evidence.

A throbbing great falsehood with warts

Do the figures mean what the authors say they mean? In no uncertain terms, absolutely and incontrovertibly not.

The authors don’t just coyly suggest, imply or impute that those NVE rates are caused by the legalisation of assisted dying, they directly claim it. Right in front the statistics, they state categorically that:

“Allowing voluntary euthanasia has led to non-voluntary euthanasia.”

Let’s put this the politest way we can: that’s a throbbing great falsehood with warts on it. The authors would have known this if they’d paid attention to published research facts beyond their own opinions.

Comprehensively ignoring peer-reviewed facts

Had the paper’s authors (and the supposed peer reviewers) actually known much about the subject matter, they wouldn’t have referred to those figures, because they’re massively unhelpful to the case the authors attempt to prosecute. Here are three central published facts about the case:

Fact 1: Before the Netherlands’ euthanasia Act came into effect, the NVE rate was 0.7%. Then in the next research round with the Act in place it had dropped to 0.5%, and the round after that, to 0.2%. The last is the figure the authors quote as evidence that “VE leads to NVE”, despite the fact that the rate had massively dropped, not risen.

Fact 2: Before Belgium’s euthanasia Act came into effect, the NVE rate was 3.2% [typo 3.5% corrected]. Then in the next research round with the Act in place it had dropped to 1.7%, the figure the authors quote. Again, the rate had massively dropped, not risen.

Fact 3: The rate of NVE in the United Kingdom was researched around the same time as the later Dutch figures, and found to be 0.3%.2 The UK has never had an assisted dying law, so the 0.3% NVE rate, which is higher than the Dutch 0.2% rate the authors quote, can't have been caused by one.

So, these three key published facts — known to most of us with an interest in lawful assisted dying — squarely contradict the authors' VE-causing-NVE claim. It's at the very least astonishing and inexcusable that all the numerous authors and peer reviewers of this “scholarly” article either didn’t know, or “overlooked”, them.

Indeed, despite holding one of the world’s largest scholarly libraries on published assisted dying research, I know of no study that establishes a VE-to-NVE link. All the evidence is contrary.

Not the first time

We could perhaps be a little forgiving if the authors just got a statistic wrong. After all, we're all human. But there are ten authors, plus peer reviewers. And there’s the egregious offence the authors committed in making an unequivocal but false claim about the data. Did none of them know what they were talking about or bother to check?

In this case I’m wholly unforgiving. That's because I’ve called Somerville out multiple times before for misrepresenting data, including for misrepresenting Belgian and Dutch NVE data precisely as she does again in this JPC article. We’ve even publicly exchanged words about it via the ABC’s Religion and Ethics portal. It’s not like she simply didn’t know.

I’ve also called Somerville out for wrongly claiming that Dutch Minister of Health Dr Els Borst regretted the euthanasia law; and wrongly claiming the Dutch elderly go to German hospitals and nursing homes for healthcare for fear of being euthanased in the Netherlands, including that NVE actually does occur in German nursing homes, despite, as Somerville notes, “their strict prohibition on euthanasia”.

This rubbish deserves censure and ridicule

While I argue strongly that different views about assisted dying law reform are welcome in a robust democracy, repeatedly spreading such egregious misinformation about assisted dying is an embarrassment to and unworthy of scholarly attribution to professorship. Such rubbish deserves to be rejected, censured and ridiculed.

 

References

  1. Sprung, CL, Somerville, MA, Radbruch, L, Collet, NS, Duttge, G, Piva, JP, Antonelli, M, Sulmasy, DP, Lemmens, W & Ely, EW 2018, 'Physician-assisted suicide and euthanasia: Emerging issues from a global perspective', Journal of Palliative Care.
  2. Seale, C 2009, 'End-of-life decisions in the UK involving medical practitioners', Palliat Med, 23(3), pp. 198-204.

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Physician consultation and end of life decision quality improves under VAD law

Two DyingForChoice.com reports to the Western Australia Parliament committee inquiry into end of life choices furnish clear evidence from multiple peer-reviewed research papers that the quality of a broad range of end-of-life decision types have improved in jurisdictions with voluntary assisted dying (VAD) laws.

Training and decision making has improved under VAD

In the first report, studies show that the quality of palliative care education and the quality of decision making has improved when VAD is legalised: (PDF 0.6Mb).

Where decision making is best and worst

In the second report, studies show that clearly inappropriate doctor decisions (unilaterally making end of life decisions about a patient without involving the patient or her family) are lowest in the Netherlands with its extensive experience in VAD, and highest in Italy with its strong opposition to VAD: (PDF 0.2Mb).

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A DyingForChoice.com editorial appears in the Jan/Feb 2018 edition of LivingNow

A DyingForChoice.com editorial in the Jan/Feb 2018 issue of lifestyle magazine, LivingNow, explains why assisted dying law reform in Australia has taken so long, and why it will accelerate from here.

Download the editorial (PDF 3.5Mb)

Visit LivingNow


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Those actively opposing assisted dying laws are Australia's most religious. Photo: Donaldytong

A claim was recently made on ABC’s QandA that at least 70% of Catholics and Anglicans support assisted dying. The claim was challenged and a FactCheck prepared and vetted by scholars. They concluded that some but not all polls supported the statement. I show unambiguously that relevant polls do. I show further, as I have in the past, that opposition is largely associated with Australia's most religious.

Get the full, detailed report here.

Known polls

In 2007, a Newspoll survey found that 74% of Catholics and 81% of Anglicans support assisted dying. The 2016 Australian Election Study (AES), run by scholars at Australian National University, found almost identical rates: 74% of Catholics and 79% of Anglicans. Although a majority of all religious denomination groups support assisted dying, opposition is highest among minor Christian denominations (Figure 1).

adattitudesreligdenomination.gifFigure 1: Attitudes toward assisted dying by major religious denominations
Source: AES 2016. Note: Chr. = Christian

A significant majority of support for assisted dying was also found across all age groups, education levels, income levels, states, and major political party affiliations and religious denominations, with support amongst Australians overall at 77%.

Casting doubt

However, another poll cited in the FactCheck found far less support: the 2011 National Church Life Survey (NCLS). It found just 28% of Catholics and 25% of Anglicans supported assisted dying.

The problem with the NCLS poll is that it didn’t take a valid sample of Australian Catholics and Anglicans. It sampled mostly or only those who frequently attend religious services.

Views vary widely by attendance frequency

Figure 2 shows the level of support amongst the Australian public, by frequency of attending religious services. While just 2.4% of those who never attend religious services oppose assisted dying, 46.1% of those attending at least once a week oppose it.

adattitudesreligiosity.gifFigure 2: Attitudes toward assisted dying by frequency of attending religious services
Source: AES 2016

NCLS poll cannot answer the question

The NCLS results were even more negative than the AES ‘at least once a week’ results. That’s explained by the NCLS methodology. Firstly, occasional attenders were underrepresented, and non-attenders were excluded altogether. Secondly, more church employees (the most deeply committed and aligned with church policies) than others would have participated. Thirdly, responders may have felt pressured to toe the church line because the survey forms were collected by the churches themselves. And fourthly, those who disagreed with the church line would be less likely to participate.

ABC QandA question answered

So we can discount the NCLS poll because it was not suited to answer the question about all Australian Catholics and Anglicans.

On that basis, it is not only reasonable to say that “up to 70% of Catholics and Anglicans support assisted dying,” but to say that “at least 70% of Catholics and Anglicans support assisted dying.”

Religious connections of opposers

But, back to the opposition of assisted dying. AES data shows that 92% of those opposing and 94% of those strongly opposing assisted dying have a religious affiliation (self-identify with a religious denomination) or attend religious services. So, while a tiny minority of opposers had no religious affiliation nor attended religious services, almost all those opposing have a religious connection.

Frequent service attendance entrenches opposition

If we focus in on those who identify with a religious denomination and who disagree with assisted dying, we find that there’s a massive difference in opposition to assisted dying between the ‘at least once a week’ attenders and everyone else (Figure 3).

adattitudesreligiosityopposers.gifFigure 3: Frequency of attending religious services amongst those with a religious affiliation and who disagree with assisted dying
Source: AES 2016

Not only are the majority of opposers weekly religious service attenders, but weekly attenders are more likely to be strongly opposed. This highlights the strong alignment with and commitment to religious teachings, which (with rare exceptions) oppose assisted dying.

If we define the most religious Australians as those who attend religious services monthly or more often and who self-identify with a religious denomination (“Regulars” in Figure 4), and who make up just 15.7% of the population, their attitudes are remarkably more opposed to assisted dying than all other Australians — by a factor of more than eleven to one.

adattitudesregularssum.gifFigure 4: Attitudes by religious service attendance plus denomination affiliation (“Regulars”)
Source: AES 2016

Amongst the 84.3% of Australians who are not “Regulars”, almost all of them (85.7%) agree with assisted dying, and almost none of them (3.6%) disagree.

Demographic differences explained by religiosity

The variation in attitudes toward assisted dying by general demographics is largely explained by religiosity — defined here as ‘the frequency of attending religious services’.

For example, the increased opposition amongst older Australians is explained by their increased religiosity. The same applies to religious denomination affiliation (e.g. Catholics attend services more often than Anglicans), education, urban versus rural residence, and political party first preference.

Religiosity was the only variable that independently explained variations in opposition to assisted dying.

The double whammy — affiliation and attendance

Also informative is the comparison of those with or without a religious affiliation versus those who do and don’t attend religious services. (Australians fall into all four categories.)

Amongst those with no religious affiliation, people who do attend religious services are only slightly less likely (than those who don’t attend) to support assisted dying (-7%), and their difference in attitude is mostly to neutrality.

However, of those with a religious affiliation, people who do attend religious services are significantly less likely to support assisted dying (-27%), and the majority of their difference in attitude is opposition rather than neutrality.

Thus, those more deeply aligned with their religious denomination through service attendance are significantly more likely to oppose assisted dying.

Moderated by personal experience

The 2007 Newspoll study asked respondents if they had personal experience of someone close who was hopelessly ill and had wanted voluntary euthanasia.

Amongst those with no religious affiliation, this personal experience increased support for assisted dying by just 3.7%, because support was already very high: from 90.9% to 94.6%.

However, amongst those with a religious affiliation, personal experience increased support for assisted dying markedly by 15.2%: from 72.4% to 87.6%.

Thus, those attending religious services, yet with close, personal experience of hopeless illness with a desire for assisted dying, were significantly less likely to align with opposed religious doctrine.

The most religious are a small minority

With so much opposition amongst Australia’s most religious, why is overall support for assisted dying so high? It’s because Australia’s most religious are a small minority of the population.

Nearly half (48%) of Australians never attend religious services, two thirds (65%) attend less than once a year or never, and three quarters (75%) attend once a year or less, including never.

Those who attend religious services frequently (weekly or more often) comprise just 12% of the population, while those who attend regularly (monthly or more often which includes the weeklies) comprise 16%.

Religion in Australia has been declining for decades, and the fall is likely to continue (see Appendix A of the full report, here), meaning that support for assisted dying is likely to increase in the future.

Conclusions

I’ve previously demonstrated how all the signatories to a major anti-assisted dying advertisement were deeply connected with religion. The AES and other studies further our understanding of wider public attitudes toward assisted dying in Australia. They show that while a substantial majority of Australians support assisted dying, almost all the opposition to it is connected with religion, particularly amongst the most religious who are a small minority of the population.

Despite the religious connection of those opposed, there is ample, robust evidence that a great majority of Catholic and Anglican Australians support assisted dying, backing the claim made on national television.

Clergy opposing assisted dying are not representing the broader views of their flocks. Perhaps they may not see that as their role, and perhaps this misalignment of attitudes and beliefs is an example of why religion in Australia is declining.

However, reflecting the views of the great majority of the constituency is the role of politicians, who would do well to take note of this robust evidence of a significant majority of support for assisted dying.

Get the full, detailed report here.

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antiassisteddyingadtheageheraldsun14jun08.gif

You only have to look to understand who is campaigning against your right to choose an assisted death in the face of intolerable and unrelievable suffering.

A case in point is a massive advertisement published in both of Melbourne’s daily newspapers: News Corp’s The Herald Sun (right-wing) and Fairfax Media’s The Age (left-wing). The ad was published in 2008 when Victorian MLC Colleen Hartland introduced the Medical Treatment (Physician Assisted Dying) Bill into the State legislature.

The Catholic Archbishop of Melbourne, Denis Hart, also sent the advertisement as a letter to all members of the Victorian Parliament.1

So, who are the advertisement’s signatories? I’ve listed them all in Table 1.
 

Table 1: Signatories to the 2008 Victorian anti-assisted-dying advertisement

Rt Rev. Graham Bradbeer
Moderator, Presbyterian Church of Victoria

The Rev. Fr Graeme A. Michell, FSSM
Parish Priest, Anglican Catholic Parish of St Mary the Virgin, Melbourne

Rev. Ross Carter
Uniting Church in Australia

Pastor Graham Nelson
Senior Pastor, Life Ministry Centre

Rev. Dr Max Champion
National Chair of the Assembly of Confessing Congregations within the Uniting Church in Australia

Rev. David Palmer
Convenor Church and Nation Committee, Presbyterian Church of Victoria

Pastor Mark Conner
Senior Minister of CityLife Church

Rev. Greg Pietsch
President, Victorian District, Lutheran Church of Australia

Dr Denise Cooper-Clarke
Adjunct Lecturer, Ridley Melbourne Mission and Ministry College

Marlene Pietsch
[Director of the Lutheran School of Theology]
Lutheran Church of Australia

Rabbi Dr Shimon Cowen
Director Institute for Judaism and Civilization

Very Rev. Dr Michael Protopopov
Dean - Russian Orthodox Church in Australia

Rev. Megan Curlis-Gibson
St Hilary’s Anglican Church, Kew

Marcia Riordan
Respect Life Office, Catholic Archdiocese of Melbourne

Archbishop Dr Philip Freier
Anglican Church of Melbourne

Metropolitan Archbishop Paul Saliba
Primate of Antiochian Orthodox Archdiocese of Australia, New Zealand & the Philippines

Imam Riad Galil
West Heidelburg Mosque
Member of the Victorian Board of Imams

Bishop Peter Stasiuk CSSR DD
Eparchy of Saints Peter and Paul of Melbourne, for Ukrainian Catholics in Australia and New Zealand

Rev. Father James Grant SSC
Chaplains Without Borders,
Melbourne Anglican Diocese

Dale Stephenson
Senior Pastor Crossway Baptist Church

Assoc. Professor Afif Hadj MB BS (Melb) FRACS
Director of Surgery, Director of Medical Training, Maroondah Hospital (A Monash University Teaching Hospital)

Pastor Peter Stevens
Victorian State Officer
Festival of Light Australia

Archbishop Denis Hart
Catholic Archdiocese of Melbourne

Dr Nicholas Tonti-Filippini
Associate Dean, JPII Institute for Marriage and Family Melbourne

Rev. Fr Geoff Harvey
Priest of the Good Shepherd Antiochian Orthodox Mission Parish, based at Monash University

Rob Ward
Victorian State Director Australian Christian Lobby

Assoc. Professor Rosalie Hudson
Aged Care & Palliative Care consultant/educator

Jim Zubic
President of Orthodox Chaplaincy Association

Peter McHugh
Senior Pastor Christian City Church, Whitehorse

Persons in blue: Career is religion

 

Almost all of them are religious by career

To save you a lot of time assessing who these people are, I’ve coloured in blue all the folks whose job it is to espouse religion — at least, their own hierarchy’s view of it.

That’s 27 of the 29 signatories who by career are intensely immersed in their own religious perspective of the world; established and promoted through institutional doctrine.

But what about the other two?

What about the other two signatories, Assoc. Prof. Afif Hadi and Assoc. Prof. Rosalie Hudson (in yellow)?

Notice that Prof. Afif Hadi’s entry lists only his surgery profession. Highly relevant, but not mentioned, is that he was President (previously Vice Chairman) of the Australian and New Zealand Board of Trustees, Antiochian Orthodox Archdiocese of Australia and New Zealand. As head of the Board of the Archdiocese, his religious signature is intimately entwined with another: Metropolitan Archbishop Paul Saliba, the Primate of the Antiochian Orthodox Archdiocese.

Assoc. Prof. Rosalie Hudson’s listing too, mentions only seemingly secular links. What is omitted is that she is or was Chair of the University of Divinity (a multi-faith religious institution) Human Research Ethics Committee, Secretary of the Uniting Church’s committee on bioethics, a member of the Interfaith Committee, and an Academic Associate at Charles Sturt University’s School of Theology.

Thus, both Prof. Hadi and Assoc. Prof. Hudson are also deeply rooted in religious faith. The point is not to make any criticism of their faith or practice, but merely to observe the deeply religious connections to opposing assisted dying law reform. It’s worth mentioning that both Hadi and Hudson do valuable charity work.

So, all of them are deeply religious

A pertinent question to ask is: ‘What proportion of the signatories are neutral, scholarly researchers who have studied the empirical evidence from jurisdictions where assisted dying is already lawful?’ Answer: None of them. Enough said.

And what proportion of the signatories to this anti-assisted dying advertisement are very deeply invested in organised religion? The simple answer is as usual: 100%, all of them.

Disconnected from their flocks

Critically, these career-religious fail to reflect the views of their own flocks. We know from repeated polls, for example, that three out of four Australian Catholics, more than three out of four Uniting Church members, and four out of five Anglicans (Church of England) support assisted dying law reform.

How have the religious hierarchy become so out of touch? Perhaps Mr Ian Wood, co-founder of Christians Supporting Choice for Voluntary Euthanasia might be able to offer his own insights.

This kind of clerical disconnect from the contemporary will of the people is one of the key reasons Australians are deserting religion in droves, as successive censuses show.

Conclusion

The evidence is irrefutable. Those who are actively organised to oppose your right to choose an assisted death are deeply religious, even when they use seemingly secular arguments (more on those later).

They are entitled to their opinions for themselves. But what right do they have to deny the vast majority of Australians, who do not agree with their views, the right to choose?

To phrase it in the personal, why does the Catholic Archbishop of Melbourrne, Denis Hart, think it appropriate to demand that Mr Geoff Drummond, a Buddhist, should have suffered against his will at the end of life for the Archbishop's version of faith, rather than Mr Drummond's own spiritual beliefs? Why does Rabbi Shimon Cowen think it appropriate to demand that Mr Alan Rosendorff, a fellow Jew, should have suffered against his will at the end of life for the Rabbi's version of faith, rather than Mr Rosendorff's own carefully-considered and deeply-held views? And why does Imam Riad Galil think it appropriate to demand that Mr Peter Short, not a Muslim, should have suffered against his will at the end of life for the Imam's beliefs, rather than his own?

Perhaps hubris remains alive and well amongst religious conservatives?

-----

Declaration: In fairness to those mentioned in this article, I openly declare that I am agnostic.

 

References

  1. Bradbeer, G, Rt Rev., Carter, R, Rev., Champion, M, Rev. Dr, Conner, M, Pastor, Cooper-Clarke, D, Dr, Cowen, S, Rabbi Dr, Curlis-Gibson, M, Rev., Freier, P, Archbishop Dr, Galil, R, Imam, Grant SSC, J, Rev. Fr, Hadj, A, Assoc. Prof., Hart, D, Archbishop, Harvey, G, Rev. Fr, Hudson, R, Assoc. Prof., McHugh, P, Michell, GA, Rev. Fr, Nelson, G, Pastor, Palmer, D, Rev., Pietsch, G, Rev., Pietsch, M, Protopopov, M, Very Rev. Dr, Riordan, M, Saliba, P, Metropolitan Archbishop, Stasiuk, P, Bishop, Stephenson, D, Stevens, P, Pastor, Tonti-Filippini, N, Dr, Ward, R & Zubic, J 2008, Reject physician assisted dying - An open letter to Victorian MPs, Catholic Archdiocese of Melbourne, viewed 13 Jun 2008, http://www.cam.org.au/Euthanasia.aspx.

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Palliative Care Australia's position statement on assisted dying.

I’ve written previously about palliative care specialists trying to filibuster assisted dying law reform. In this F file, I reveal how Australia’s peak body for palliative care (PC), Palliative Care Australia (PCA), segues from a state of ignorance to its own filibuster that would stall assisted dying choice.

First up, let me say that I hold deep admiration for the generally excellent services PC specialists provide at the bedside. I believe that PC deserves strong support and good funding. The peak body’s leadership in regard to its stance on assisted dying, however, is of a dramatically lower calibre.

Revised policy statement

In PCA’s latest incarnation of its Position Statement on ‘Euthanasia and physician assisted suicide’,1 the organisation says that:

“Public discussion and policy development on issues related to euthanasia and physician assisted suicide should be informed by research. There is insufficient research into euthanasia and physician assisted suicide.” — Palliative Care Australia, Position Statement

One can only agree wholeheartedly with the first sentence. Of course public discussion and policy development should be informed by research wherever possible.

The filibuster

And there follows the filibuster rub — PCA unequivocally claims that there is insufficient research. The logical consequence of PCA's juxtaposition is that we ought to muzzle public discussion and policy development because, PCA alleges, there is insufficient research to inform it.

Certainly in terms of Australia there are only a handful of published studies into attitudes and practices. But assisted dying is illegal in Australia. There are very substantial ethical and legal issues when it comes to conducting research.

Who is PCA to claim "insufficient research"?

PCA is the peak body for PC, a specific discipline within medicine that represents (well-paid) doctors. It runs a staffed office in Fyshwick ACT, and is overseen by a Board and Executive. It has a key purpose of lobbying in the halls of power in the Federal Parliament, and, presumably on the basis of the statement above, has a goal of ensuring that government PC policy (and funding) is informed by research. You'd think it might have some resources and connections to go looking for some research evidence.

A revealing comparison

In comparison, I conduct my assisted dying law reform work on a completely pro-bono basis, as a single individual, in my spare time. I have a formal literature collection on end-of-life decision making, including assisted dying, of currently over six thousand articles. I’m not talking about mere opinion published in the media: I’m talking about articles published in professional journals and in official government and agency reports.

I just ran a quick check across my database, looking for items specifically in respect of assisted dying (not medical or palliative care in general) in the Netherlands, Belgium and Oregon, where assisted dying has been legal for some time. Here’s what I found.

In respect of assisted dying the Netherlands I hold 366 journal articles and 25 official reports. For Belgium, I hold 152 journal articles and 11 official reports. And for Oregon I hold 144 journal articles and 32 official reports.

That’s a total of 662 journal articles and 68 official reports in respect of three lawful assisted dying jurisdictions. And that doesn’t count any holdings of book chapters, conference papers and the like. The journal article count will be somewhat overstated because a minority of journal papers are about more than one lawful jurisdiction (e.g. the Netherlands and Belgium). So let’s estimate that downwards to, say, a mere 400 journal articles.

That’s an abundance of evidence from and review about jurisdictions where assisted dying is legal. Could we always know more about assisted dying? Sure.

Double standards when it comes to evidence

We could also know a lot more about PC. I recently asked PCA for a simple but critical headline statistic — one you’d think was necessary to inform policy about PC resources and funding: “what proportion of Australians who experience a non-sudden death (i.e. deaths where PC might be relevant) actually receive PC?”

PCA kindly responded, but the answer in a nutshell was “we don’t know.”

But I wouldn't suggest for a moment that we muzzle “public discussion and policy development on issues related to PC” because the peak body hasn't done enough research to calculate (or even estimate) a fundamental policy-informing statistic.

Conclusion

The Australian community would be better served if PCA acquainted itself with the extensive available literature on assisted dying in lawful jurisdictions (as well as headline PC statistics), and dropped its inappropriate filibuster.

 

References

  1. Palliative Care Australia 2016, Euthanasia and physician assisted suicide: Position statement, viewed 1 Sep 2016, <http://palliativecare.org.au/download/2448/>.
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Dr Megan Best and the AMA profoundly misrepresent what this research says.

In my report about Dr Megan Best misreporting research findings about assisted dying practice in Belgium, I said that I would ask the Australian Medical Association (AMA) to publish a correction statement. I did just that, posting a courteous notice explaining the misinformation and requesting the correction, as a comment to their online article. What happened next was supremely revealing about how the conservative medical establishment opposes your right to choose assisted dying. I expose six reprehensible aspects of Dr Megan Best’s ‘expert’ opinion and MJA InSight’s response to my report.

 

Response 1—Try to bury the correction request

How did the AMA respond? Well, first of all, they simply deleted my post from the Medical Journal of Australia article (in MJA InSight).1

Subsequently, AMA member Dr Rosemary Jones posted my advice and request for correction. They dared not delete the post of a member, because Dr Jones’ post remains and MJA InSight have now responded… in a fashion.

Response 2—Plead it’s not the AMA

First up, Cate Swannell, editor of MJA InSight as well as “MJA news and online,” wrote that MJA InSight is:

“…editorially independent from the AMA and the AMA does not influence our content and editorial decisions in any way, shape or form … Thanks.” — Cate Swannell

It would be fair to take Ms Swannell’s word for it that the AMA doesn’t make a habit of sticking its nose into individual items at the Medical Journal of Australia (MJA). But consider this: MJA, of which MJA InSight is a part, is published by a wholly owned subsidiary of the AMA. That is, even in the absence of direct influence, one might reasonably expect that the AMA has broader, long-term influence over “content and editorial decisions.” After all, a core purpose of establishing a wholly-owned subsidiary is to help promote owner’s interests (which at present are officially and trenchantly opposed to the legalisation of assisted dying).

Those interests are further intertwined at DoctorPortal which is co-owned and operated by the AMA and its entity that publishes MJA. The portal includes the ‘MJA Bookshop’ where doctors must log in using their AMA credentials to obtain discounts.

MJA InSight is in real and practical terms a publication of the AMA.

Refresher: The original allegations

Before we cover the further AMA responses, let’s remind ourselves of the ‘expert opinion’ the AMA obtained from Dr Megan Best about Belgian assisted dying practice as published in MJA InSight:

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

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

Response 3—Confirm the ‘cherry-picking’ misrepresentation

Here’s how Sarah Colyer, author of the article in which Dr Best’s nonsense was quoted, responded to Dr Rosemary Jones’ objections:

“…there are two findings related to the involvement of palliative care doctors in the study. First, the study found palliative care physicians were less likely to be the legally-required ‘second doctor’ to sign off on the decision for euthanasia, as more GPs took on the role.” — Sarah Colyer

What a profound fudge. The paper does not say that. There is a notional mathematical decrease in palliative care (PC) ‘sign-offs,’ but with a p value of 0.3 it is not in the slightest bit statistically significant. In other words, it is not possible to validly assert that it became “less likely.” And this is the reason that the researchers correctly didn’t draw such an inference in their discussion and conclusions.

This is extraordinary. In its defence, this AMA publication confirms and defends that Dr Best had cherry-picked a supposed trend with no statistical significance and which seems to (but doesn’t) support opposition to assisted dying law reform, while utterly failing to mention a highly significant trend (p = 0.001) in the opposite direction, present in the very same table of data (Table 3 of the cited research paper).2

While the original MJA article reported on both data series, it failed to identify that one was in no way statistically significant while the other was highly so.

Response 4—Execute an impressive flip-flop

“Second, and as Sarah Edelman is quoted saying, 39% of patients had contact with palliative care teams in the lead up to euthanasia (but these doctors were not necessarily involved in sign-off).” — Sarah Colyer

Both Dr Megan Best, and Sarah Collyer in defence, express concern about what they see as the insufficient ‘signing off’ or approval of assisted dying by Belgian PC specialists. Yet Palliative Care Australia explicitly states that:

“The practice of palliative care does not include euthanasia or physician assisted suicide. Palliative care does not intend to hasten or postpone death.” — Palliative Care Australia3

So on the one hand Australia's national PC body demands that PC have nothing whatever to do with assisted dying, while an Australian PC specialist (who is opposed to assisted dying) demands that it must: not just ‘incidental’ involvement to ensure the patient is well-informed as to what PC may offer, but to directly insert itself in the assisted dying approval process.

What an impressive ‘must not, yet must’ flip-flop.

Response 5—Confirm bias about consultations

Sarah Colyer goes on to say:

“Although this latter figure is an increase from 33%, the article makes clear that this is more about palliative care doctors being ‘notified’ than necessarily having any professional input into the decision-making process.” — Sarah Collyer

If my point 3 above exposed a ‘profound’ fudge, this is a spectacular one. Indeed it’s utter fiction. Nowhere in the cited research report do the data or authors suggest in any way that PC teams were merely ‘notified.’ They were consulted. The word is used explicitly in no fewer than seventeen times specifically in relation to PC. What is a professional ‘consultation’?: “a meeting or discussion to obtain advice.”

To suggest that these are mere ‘notifications’ is absurd: why would a physician even bother to formally ‘notify’ other relevant carers if he or she had no intention of the notification having any meaningful consequence?

The only outcome of this ‘notification’ fiction is to make Belgian physicians seem careless or disinterested—a shabby and biased approach to describing overseas colleagues who engage in lawful conduct of which the commentators (at least, Dr Best) personally disapprove.

Response 6—Demonstrate fundamental ignorance about research

Remember that Dr Best complained about her perception of a low assisted dying PC consult rate as obstructing the “opportunity to improve life to the extent that euthanasia is no longer necessary”. Sarah Colyer defends and amplifies the ‘low consult rate’ message of the Belgian research:

“Although Dr Edelman and the study authors said this [increase in palliative care consults] was a positive development, Dr Best and another respected palliative care doctor who provided background for the article said it was still overall a very low rate of palliative care involvement.” — Sarah Colyer

These remarks reveal a deep ignorance about research evidence. The reported data the 'experts' criticised was only in respect of PC involvement after a request for assisted dying. It did not include any PC consults that occurred in the patient’s care trajectory prior to the assisted dying request. (Indeed, the assisted dying request may in some cases have developed as a consequence of palliative futility.) The research authors are even explicit about this:

“The reporting form does not record whether patients have previously received palliative care.” — Dierickx, Deliens, Cohen et al2

Contrary to Best and Colyer’s indefensible assumption, empirical research evidence indicates that around 74% of assisted dying cases in 2013 at least in Flanders, the Dutch-speaking larger half of Belgium, involved specialist PC services.4 The Dierckx et al2 data is also in respect only of PC-primary-specialist consults. Many Belgian physicians, especially but not only many oncologists, themselves hold PC sub-specialty endorsements, yet only their primary organ or disease specialty is recorded on the report forms.

The 74% PC consult figure of course by definition excludes those who made a request but who subsequently rescinded it (i.e. not captured in the data because there was no assisted death). The patient may have rescinded their request as a consequence of PC consultation. Other published scientific research indicates that in 2013 around 18% of Belgian assisted dying requesters revoked their request.5

Indeed, more than half (59%) of Belgian patients making a request in 2013 died before the consulting team had reached a decision, and 7.5% of requests were denied by physicians because the patient wasn’t terminally ill even though that is not a requirement of the law.5 The wider evidence suggests that Belgian doctors remain conservative and cautious rather than pursuing poor practice as Dr Best and Ms Colyer invalidly attempt to conclude.

What is “very low”?

Just for good measure, let’s compare a Belgian assisted dying 74% PC consult rate with the general PC rate in Australia (where assisted dying is illegal). There’s precious little data around and Palliative Care Australia didn’t respond to two requests. [Addendum 5th Oct: Palliative Care Australia responded but advised that to the best of their knowledge the specific statistics were not available.] The closest relevant official data I could find with hours of intensive research, reports that in 2011-12, 39.5% of hospital inpatients who died received PC consults.6 Of course, PC consults can only be relevant in respect of non-sudden deaths because there’s no opportunity to make such decisions in a relatively sudden death. About two thirds of all deaths are not ‘sudden,’ so let’s adjust up the original figure to reflect that, resulting in a hospital non-sudden-death PC consult rate of around 60%.

Half (50%) of all deaths in Australia occur in hospitals, 38% in residential and community (i.e. other institutionalised) care, and just 12% elsewhere (mostly at home).6 Let’s say for the sake of argument (and lack of data) that the PC consult rate for other institutions is similar to hospitals. Let’s also assume that of (two thirds non-sudden) deaths at home, all of them received palliative care consults. That raises the Australian PC consult rate to around 68% of all non-sudden deaths. Maybe the real figure is somewhat higher or lower.

But it is wholly incorrect to conclude, given Belgium’s Flemish PC consult rate for assisted dying at 74%, that the Belgian palliative care consult rate is “very low” as the two ‘expert’ PC commentators wrongly assert and Sarah Colyer reports on the basis of data about a different measure.

Conclusion

The AMA widely promotes evidence-based decision making, but it has comprehensively offended its standard in regard to this issue. The AMA’s response to this further critique will give the Australian public a strong indication as to its intent, ethics and credibility. Of course, I'll let you know how they respond.

As for Dr Megan Best offering such ill-considered and evidence-defying nonsense as ‘expert opinion,’ I would hope that she permanently retires from offering commentary.

Now at least you can see the kinds of rubbish arguments that the conservative medical establishment uses to justify opposing your right to consider an assisted death.

 

Inexpert opinion via the AMA’s MJA

Through its MJA InSight article and response, the AMA has published and defended misinformation against assisted dying, a choice that the overwhelming majority of Australians want on the table, but which the AMA explicitly opposes.

  1. First up, the AMA tried to bury my critique of its incoherent and incorrect ‘expert opinion’ by deleting the critique.
  2. Then it tried to argue that its published misinformation was nothing to do with the AMA.
  3. It confirmed that it had reported a cherry-picked non-significant ‘trend’ from a research paper’s data that was, coincidentally, consistent with AMA opposition to assisted dying, while omitting to mention a highly statistically significant trend—in the same table of data—that contradicted the AMA and commentators’ stance.
  4. Its article and critique response argued that PC must be involved in approving assisted dying requests at the same time that Palliative Care Australia insists that assisted dying is nothing to do with PC.
  5. It fictionally asserted that the Belgian research paper suggested PC specialists were merely ‘notified,’ while the research paper said no such thing and referred repeatedly to ‘consultation.’
  6. It ignorantly claimed that the Belgian PC consult rate was “very low” (when it isn’t) on the basis of what happened only after an assisted dying request, ignoring that PC consults can and do occur before an assisted dying request.

 

References

  1. Colyer, S 2016, Belgian euthanasia model splits Aussie experts, MJA InSight, viewed 26 Sep 2016, https://insightplus.mja.com.au/2016/37/belgian-euthanasia-model-splits-aussie-experts/.
  2. Dierickx, S, Deliens, L, Cohen, J & Chambaere, K 2016, 'Euthanasia in Belgium: Trends in reported cases between 2003 and 2013', CMAJ, September 12, 2016.
  3. Palliative Care Australia 2016, Euthanasia and physician assisted suicide: Position statement, viewed 1 Sep 2016, https://palliativecare.org.au/mediarelease/integrating-palliative-care-into-covid-19-planning/.
  4. Chambaere, K, Vander Stichele, R, Mortier, F, Cohen, J & Deliens, L 2015, 'Recent trends in euthanasia and other end-of-life practices in Belgium', N Engl J Med, 372(12), pp. 1179-1181.
  5. Dierickx, S, Deliens, L, Cohen, J & Chambaere, K 2015, 'Comparison of the expression and granting of requests for euthanasia in Belgium in 2007 vs 2013', JAMA Internal Medicine, 175(10), pp. 1703-1706.
  6. Swerissen, H & Duckett, S 2014, Dying well, Grattan Institute, Carlton, Victoria, pp. 37.

 

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