SAVES is not affiliated with Exit International / Dr Philip Nitschke and opposes the public availability of a 'peaceful pill'.

John Keown, an anti-voluntary euthanasia campaigner based in the UK, gave a lecture tour in Australia in July this year in which he vehemently attacked voluntary euthanasia with particular reference to its practice in the Netherlands. His views were widely reported in the media with little or no attempt to challenge their validity. He doubtless achieved his clear purpose of undermining the steady progress towards legalising voluntary euthanasia in Australia.

In the following article, voluntary euthanasia campaigner, Fred Cohen, demonstrates the strong bias that John Keown brings to presenting the results of published research on the practice of voluntary euthanasia in the Netherlands and in Australia. Fred is President of the Hemlock Society Branch of the Delaware Valley in Pennsylvania. Now retired, he has had a distinguished career in business and in academia.

Fred's article was posted to ERGO!'s electronic mailing list on 18 July 99 and is reproduced here with his permission. ERGO! (Euthanasia Research & Guidance Organisation) was founded by Derek Humphry, author of Final Exit.

The February 1999 Journal of Medical Ethics carried an article entitled "Voluntary Euthanasia Under Control? Further Data from the Netherlands." This deftly executed paper presents a mind numbing array of statistics which seem to support the authors' conclusion that euthanasia in Holland is out of control and that "the Dutch have slid down the slippery slope."

The article is having significant impact upon the ongoing debate. Opponents of euthanasia hail the work as proof of their dire predictions, while many staunch supporters of the right-to-die are shaken by what seems to be damning evidence of widespread abuses in the Netherlands. Indeed, many feel compelled to stop debating the Dutch experience and to divert attention to excellent results being obtained in Oregon. It would therefore seem worthwhile to invest a little time in review and thoughtful analysis of the subject article.

The authors, Henk Jochemsen, PhD, and John Keown, DPhil, carry credentials that command academic respect. They properly announce that their analysis is based largely upon data from the 1995 van der Maas survey of euthanasia in the Netherlands, and they note that the data and methodology of that survey are accepted at face value.

As previously mentioned, the article is cleverly executed. However, close inspection reveals a number of fatal flaws. First, putting aside the fact that most of the quoted statistics do not relate directly to the central issue, the manner in which the numbers are presented removes any lingering doubt as to the authors' agenda. For instance, in dealing with cases classified as "Life-Terminating Actions Without Explicit Request," the following statement: "The physicians thought that life was shortened by one to four weeks in 3% of cases but by more than a month in 6%."

One must immediately wonder why the authors omit the fact that if these data are correct, then 91% of the cases involved hastening death by less than one week, a fact certainly as worthy of explicit highlighting as are those quoted. This type of presentation extends to numerous other areas, and suggests a strong bias.

For the purpose of simplifying discussion, we will use the term "non-voluntary euthanasia" to include all cases of reported life terminating actions without specific formal request, and the term "incidence of non-voluntary euthanasia" to describe the ratio of those deaths to the total deaths in a given year. In this context, the most serious problem we find in the subject paper relates to its conclusion that the incidence of non-voluntary euthanasia in Holland supports a logical inference that "The Dutch had slid down the slippery slope."

A valid inference on this subject demands consideration of the following facts:

• The definition of a slope requires, at a minimum, two points of reference.
• The only relevant data presented by the authors are the 1990 and 1995 van der Maas surveys.
• The 1995 survey showed a slightly LOWER incidence of non-voluntary euthanasia (0.7%) than did the 1990 survey (0.8%).

There is additional evidence of severe bias in the omission of important relevant data that was available to the authors. In 1996, Kuhse et al, using an officially authorised English translation of the van der Maas questionnaire, conducted a similar survey in Australia, a country in which euthanasia is illegal. Their findings, published in the Medical Journal of Australia (see reference), were that the incidence of non-voluntary euthanasia in Australia during the survey year was 3.5%. In other words, in a country where voluntary euthanasia is illegal, the incidence of non-voluntary euthanasia was found to be 400% greater than in the Netherlands!

The bias indicated by failure to consider the Australian data is pale by comparison with another example, namely the following statement:

"It is therefore surprising that an American commentator should observe that the similarity between the findings in respect of 1990 and 1995 shows that the Dutch are apparently not descending a slippery slope. This observation quite overlooks the fact that the first survey showed that the descent had already occurred by 1990"

This inference is mind-boggling in its utter disregard for the rudiments of scientific inquiry. If reliable data exist on the incidence of non-voluntary euthanasia in the Netherlands prior to 1990 (and we know of none), they should have been cited. In making the offending inference, the authors presume that prior to the decriminalisation of voluntary euthanasia in Holland, the incidence of non-voluntary euthanasia was substantially lower than the levels indicated in the 1990 and 1995 van der Maas surveys . . . a presumption utterly without foundation. Especially when considered in the light of the Australian data, one must wonder how the authors dare to matter-of-factly set forth such a bizarre proposition.

There are numerous other aspects of the subject article that deserve criticism, but the one that we find most distressing is the statement:

"The Dutch reaction to the survey's findings was also revealing: the cases of non-voluntary euthanasia it disclosed, far from being criticised, were largely condoned. In short, the survey indicated that, in less than a decade, the Dutch had slid down the slippery slope."

This allegation is an insult to the good people of the Netherlands, a people whose compassionate policies for dealing with difficult social problems are admired by most of the world. Because the Dutch live with and fully understand the actions of their doctors in end-of-life situations, they know that the shrill accusations of opponents of euthanasia are based upon deliberate misinterpretations of survey data. The Dutch know from personal experience that the vast majority of deaths officially classified as "non-voluntary euthanasia" involve such factors as doctors acting upon wishes previously expressed by patients but not formalised in writing, and upon numerous humane considerations which are not illuminated by the rather narrow questions of surveys. It is for this reason that an ever increasing and already overwhelming majority of the Netherlands' citizens supports its countries policies on physician assistance in hastening death.

Because the people of the Netherlands refuse to accept the specious arguments of opponents of euthanasia, the authors accuse them of moral decay. This writer submits that such an allegation is academically irresponsible and morally reprehensible.

Supporters of the right-to-die should note that there has yet to be a case reported in which any Dutch or Australian doctor was found to have hastened death for any other reason than compassion for the patient. It is for this reason that the agents of the religious right are compelled to resort to obfuscation, distortion and sleight-of-hand. Armed with the facts and an understanding of the methods of opponents, we should not hesitate to cite the Netherlands experience as a positive factor in the ongoing debate.

Reference: End-of-life decisions in Australian medical practice, Helga Kuhse, Peter Singer, Peter Baume, Malcolm Clark and Maurice Rickard MJA 1997; 166: 191