Maddy’s Misrepresentations

I see that Madeleine Bunting is giving us the benefit of her views on the subject of euthanasia. I really find it irritating that she can so wilfully misrepresent Terry Prachett’s position:

"My life, my death, my choice," declared Pratchett. But this slogan is deeply deceptive; there is nothing to stop anyone committing suicide. The point Pratchett was making was quite different: "My life, my choice, you kill me."

No, Madeleine, that was not the point he was making. He quite clearly said that he wanted to die at a time of his choosing, and at his own hand:

I remember what George said and vowed that rather than let Alzheimer’s take me, I would take it. I would live my life as ever to the full and die, ­before the disease mounted its last ­attack, in my own home, in a chair on the lawn, with a brandy in my hand to wash down whatever modern ­version of the "Brompton cocktail" some ­helpful medic could supply. And with ­Thomas Tallis on my iPod, I would shake hands with Death.

Bunting really is economical with the truth at times. I note that she also throws in the emotive observation that:

It is estimated that in the Netherlands, where assisted dying is legal, one in five are euthanised without consent.

Of course, she doesn’t back up this with a reference. Had she done so, readers might have become aware that this factoid doesn’t tell the whole story. It comes from a report published in 1999 in the Journal of Medical Ethics: Voluntary Euthanasia Under Control? Further Empirical Evidence from the Netherlands. The report was written by H. Jochemsen of the Lindeboom Institute here in the Netherlands, and J. Keown of Cambridge University. Both are well-known opponents of euthanasia. The Lindeboom Institute is an organisation that “works within the Christian tradition and therefore finds its authoritative direction and inspiration in de [sic] Bible”. God spare me from these god-botherers who presume to deny me the right to choose.

The report states:

Nine hundred patients had their lives ended without explicit request in 1995, representing 0.7% of all deaths, only a slight decrease on the 0.8% so terminated in 1990. In other words, of the 4,500 (3,200 + 400 + 900) cases in which doctors admitted they actively and intentionally terminated life, one in five involved no explicit request.

Of course, as the authors concede, the majority of these 900 cases were because the patients in question were simply not competent to make a request:

The main reason for not discussing the issue with the patient was stated to be the patient’s incompetence (due, for example, to dementia). But not all patients whose lives were terminated without an explicit request were incompetent. In 15% of cases where no discussion took place but could have, the doctor did not discuss the termination of life because the doctor thought that the termination of the patient’s life was clearly in the patient’s best interests.

Furthermore, in a third of the 900 cases, there had been a discussion with the patient about the possible termination of life, and some 50% of these patients were fully competent, yet their lives were terminated without an explicit request. Moreover, in I7% of the 900 cases, treatment alternatives were thought to be available by the attending physician.

Yes, but as the authors themselves let slip, that 17% of cases were people who explicitly refused the treatment alternatives, and chose active euthanasia instead. Still, I agree that instances of non-voluntary euthanasia need to be treated seriously, but I question Jochemsen and Keown’s view that the Netherlands is on a slippery slope. As has been pointed out by others, such as Deldin and Magnusson, we simply do not know whether the prevalence of non-voluntary euthanasia has increased over what it was in the past.

And further, I really wish people would not conflate active euthanasia (i.e. me exercising my free will and dying at a time of my own choosing) and non-voluntary euthanasia, which at the least-worst end of the spectrum is also known as mercy-killing. In my view, they are not the same thing at all.

Update: since I wrote the above, someone has posted a comment to Buntings’ article, with data from studies published later than the Jochemsen & Keown study quoted above. They are strong evidence that the Netherlands is not on a slippery slope at all.

The incidence of the different circumstances of death in the Netherlands since 1995 has been determined in several successive robust epidemiological studies (Onwuteaka-Philipsen et al., Lancet. 2003;362: 395-399). In 2005, of all deaths in the Netherlands, not 20% but 0.4% were the result of the ending of life without an explicit request by the patient (van der Heide et al., New England Journal of Medicine. 2007;356:1957-1965). In the UK, the figure was 0.33%, i.e. quite similar to the 0.4% in the Netherlands (Seale, Palliative Medicine 2006; 20: 3-10). These instances have been found to be in dying patients who had become incompetent, were compassionate and are generally considered ethically acceptable (Rietjens et al. Death Studies 2007;31:205-221).

In 2005 in the Netherlands euthanasia was given in 1.7% of deaths and physician-assisted suicide occurred in 0.1%. These rates were somewhat lower than in 2001. Since the legalisation of euthanasia in Belgium its overall incidence changed little, but the care with which it is carried out improved markedly (Bilsen et al. New England Journal of Medicine 2009; 361: 1119-1121). If cases of euthanasia with no or only perfunctory precautions came to light, there would be prosecution. And if in the future there were to be evidence for anyone requesting euthanasia because of e.g. a waiting list for palliative care, there would be an outcry. Thus, legal euthanasia is one more safeguard against the health-care system falling short of its duty to offer optimal care at the end of life. In Belgium, legal euthanasia and palliative care are not opposites, but complementary and synergistic (Bernheim et al., British Medical Journal 2008;336:864-867).

All available data also put to rest Ms Bunting’s allegation that legal euthanasia imperils vulnerable patients. Compared with background populations, rates of assisted dying in Oregon and in the Netherlands showed no evidence of heightened risk for the elderly, women, the uninsured, people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses or racial or ethnic minorities (Battin et al. Journal of Medical Ethics. 2007;33:591-597).

About Geoff Coupe

I'm a British citizen, although I have lived and worked in the Netherlands since 1983. I came here on a three year assignment, but fell in love with the country, and one Dutchman in particular, and so have stayed here ever since. On the 13th December 2006 I also became a Dutch citizen.
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