Peter Saunders


Dutch doctors turn to ‘continuous deep sedation’ to keep official euthanasia figures low

Peter Saunders

The Lancet has just published an article purporting to show that euthanasia rates have not increased in the Netherlands since legalisation in 2002.

This news will probably be seized upon by enthusiasts for decriminalisation in the UK and elsewhere but the figures are not at all what they seem at first sight and the press release sent out by the journal is selective and misleading in its reporting of the facts.

If you read the press release sent by the Lancet (reproduced by Medical Xpress) it all seems cut and dried. There were about 4,050 cases of euthanasia or assisted suicide in 2010 (2.8% of all deaths) and this was only slightly up from the 2001 figure of 3,800 (2.6%).

But if you read the abstract along with the full article and accompanying comment you get a very different picture altogether.

Most news outlets will do neither but will simply propagate the press release which is why it is important to look at the original sources.

Thus far, the Daily Telegraph is the only national newspaper to cover the story.

The key fact which should alert people to something odd going on is the reference to ‘continuous deep sedation’ in the Netherlands which appears in the article’s abstract but tellingly (and perhaps even disingenuously) not in the Lancet press release.

The abstract states, ‘Continuous deep sedation until death occurred more frequently in 2010 (12.3% [11.6—13.1; 789 of 6861]) than in 2005 (8.2% [7.8—8.6; 521 of 9965]).’

But what was the rate of ‘continuous deep sedation until death’ in 2001 and previously?

On examining the article we learn from table 1 that it was not measured in 1990 and 1995 and was 5.6% in 2001. In other words there has been a steady increase in this category of cases which in 2010 accounted for 16,700 deaths.

Over the same period the number of deaths after ‘intensified alleviation of symptoms’ has also increased from 20.1% to 36.4% and now accounts for over 49,500 deaths annually.

There is nothing new about any of these figures. They have all been published in reviews of Netherlands practice before in peer-reviewed medical journals (in total five studies covering 1990, 1995, 2001, 2005 and 2010).

But the accompanying comment piece in the Lancet by Brendan Lo raises some very interesting questions indeed.

It acknowledges that the line between euthanasia and ‘the less controversial, much more common practice’ of ‘continuous deep sedation’ ‘can be blurred in clinical practice’ and noted that in other studies ‘physicians also misclassify some cases of euthanasia’.

In other words, it says, ‘physicians who say they are undertaking palliative sedation sometimes cross the line to euthanasia’.

Whilst the paper claims that the level of involuntary euthanasia has decreased since 1991 from 0.7% to 0.2% of all deaths (ie. deliberate killing with lethal drugs without consent), it also acknowledges that ‘in 42% of cases classified by the investigators as intensified alleviation of symptoms, the physician did not discuss the decision with the patient, relatives or another physician’.

The Lancet comment concludes by saying that ‘an in-depth analysis of these cases might reveal more widespread conceptual confusions or flaws in practice’ and recommends that ‘additional information from in-depth interviews in ethically problematic cases is needed’.

In other words it is not at all clear how many of these two categories of ‘continuous deep sedation’ and ‘intensified alleviation of symptoms’ involved the explicit intention to end life.

But the huge increase in number of patients dying in each of these categories since legalisation in 2002 is very suspicious indeed.

It appears that Dutch doctors have kept the euthanasia figures low simply by choosing to end patients’ lives in ways other than administering paralysing drugs (muscle relaxants) or barbiturates.

In other words they are making more decisions to end life than before legalisation but are just carrying it out and recording it differently.

The practice of ‘continuous deep sedation’ has been questioned before. A 2010 Mayo Clinic article drew the following stark conclusions:

‘Published literature has not discerned end-of-life palliative versus life-shortening effects of pharmacologically maintaining continuous deep sedation until death (i.e., dying in deep sleep) compared with common sedation practices relieving distress in the final conscious phase of dying. Continuous deep sedation predictably suppresses brainstem vital centers and shortens life. Continuous deep sedation remains controversial as palliation for existential suffering and in elective death requests by discontinuation of chronic ventilation or circulatory support with mechanical devices. Continuous deep sedation contravenes the double-effect principle because: (1) it induces permanent coma (intent of action) for the contingency relief of suffering and for social isolation (desired outcomes) and (2) because of its predictable and proportional life-shortening effect. Continuous deep sedation should be distinguished from common sedation practices for palliation and characterized instead as physician-assisted death.’

Other authors have proposed the term ‘early terminal sedation’ for the particularly contentious practice of giving deep, continuous sedation to patients who are not imminently dying without provision of hydration or nutrition, with the end result that death is hastened. This is in reality a form of euthanasia and seems to be increasingly common in the Netherlands despite not being labelled as such.

The UK should take warning. At present it appears that palliative sedation as practised in the UK, which is aimed primarily at reducing anxiety at the end of life, is very different from that practised in the Netherlands, which seems to be aimed at producing deep sedation and shortening life.

But the Dutch figures seem to reveal incremental extension after legalisation which is being carefully and skilfully disguised by the way the figures are being presented.

The Lancet report, far from providing reassurance, actually raises more questions than it gives answers and it is very difficult indeed to extract the substance from the spin.

The lesson is clear. Don’t rely on the Lancet’s specious press release or superficial reports in newspapers and medical magazines. Read the original paper and ask serious questions!

Reprinted with permission from Peter Saunders’ blog.

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Therapists to offer sex change drugs to nine-year-olds

Peter Saunders

Children as young as nine are to be prescribed drugs which delay the onset of puberty as the first step towards a sex change operation (Mail on Sunday and Daily Telegraph).

Doctors at the Tavistock and Portman NHS Foundation Trust said a trial of the treatment on ‘gender dysphoria’ patients aged 12 to 14 had been successful and it could now be offered even earlier.

Monthly injections of the drugs, known as hypothalamic blockers, are used to slow the development of the children’s sexual organs by blocking the production of the hormones testosterone and oestrogen.

The rationale is that by delaying the onset of sexual maturation this gives more time for gender conflicted youngsters to decide whether they wish to embark on hormone treatment and surgery aimed at changing their gender. 

Most people will be shocked at this news but it is actually a logical consequence of accepting four prior ideological presuppositions – that gender is a social construct, that personal autonomy should trump other considerations, that emotional suffering should be avoided at all costs and that technology should be used to achieve these ends. 

There are obvious safety concerns - although the gender treatment is reversible, the long-term effects on brain development, bone growth and fertility have not yet been fully evaluated.

But safety considerations aside, using hormones to suppress puberty in transgender children is highly controversial, not least because of deep societal disagreements about the causes and nature of transsexuality and the effectiveness and appropriateness of transgender therapies per se.  This means that therapists remain strongly divided about the best way of handling the issue.

Transgender people are born with the anatomy and physiology of one sex but believe that they belong to the opposite sex.  Should therapy therefore be aimed at changing bodies (using hormones and surgery) to match a person’s beliefs or should it rather be aimed at helping people to adjust mentally to accepting the bodies they were born with? Even more fundamentally, is ‘gender dsyphoria’ a mental disorder or is it just a normal variant like eye or skin colour?

Up until recently ‘gender identity disorder’ was classified as a mental disorder (in the Psychiatric diagnostic inventory DSM-IV) but it has now been reclassified and renamed ‘gender dysphoria’ (in the DSM-V).  This change was strongly ideologically driven and many psychologists and psychiatrists dispute the reclassification. They still see ‘gender identity disorder’ as a kind of body dysphoria, whereby a person has an unshakeable false belief that they are one sex when in fact they are the other. It has been likened to anorexia nervosa, where the affected individual is convinced she is fat whilst being grossly underweight.

Those who supported the reclassification however, take the view that gender identity is biologically fixed and determined and that it is harmful to affected individuals to deny them sex change therapy or to 'force' them to live with the body they were born with. Some even hold to the strongly postmodern view that gender, regardless of what one’s genes or hormones suggest, is simply a social construct, even a matter of choice. If you wish to appreciate how passionately these views are held, then try expressing a traditional understanding on twitter using the hashtag #lgbt!  

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Is gender identity fixed as male or female or is it more of a spectrum or continuum? Can it change over time? How effective is therapy in changing the strength and orientation of one’s beliefs? How might suppression of puberty using hormonal treatment affect bone, brain and sexual development?

Research is still at an early stage with many of these questions and strong ideological convictions one way or the other mean that scientific objectivity about the real effects of sex change therapy may always be a matter of contention.  It is perhaps not surprising that both opinion and research in this whole area is often driven by powerful ideological vested interests.

Complicating this is the fact that gender identity may change in an individual over time, and that it may be very difficult to predict the outcome of for any particular person. Some children are much more appropriately described as ‘gender nonconforming’ or ‘gender-fluid’ rather than transgender. In many others gender identity may change with time.

Toronto specialist Ken Zucker, who opposes the use of sex change therapies, claims that only about 12% of boys and girls with gender dysphoria will still have persistent dysphoria as adults. This fact alone should lead even the most committed supporters of early intervention to err strongly on the side of caution.

The CMF File ‘Gender Identity Disorder’ goes into the issue in more detail and also looks at biblical principles which can be applied.

The Bible teaches that human beings are created in God's image and of two sexes – male and female (Genesis 1:27). Jesus drew on this when he commented, 'haven't you read, that at the beginning the Creator “made them male and female”, and said, “For this reason a man will leave his father and mother and be united to his wife, and the two will become one flesh” (Matthew 19:4-5).

The Old Testament command 'you shall not commit adultery' also indicates that sexual intercourse should only occur within the framework of marriage (Exodus 20:14). Sex outside the marriage bond is wrong, whether with someone of the same or opposite sex (Leviticus 18:22, 20:10).

The ideal pattern for existence was spoilt at the Fall when mankind rebelled against God's rules. One consequence of this is that moral values, sexual patterns and also biology (genes and hormones) have become distorted.

The good news at the centre of Christianity is that Jesus, through his death and resurrection, gives people new life and power to change. On top of this, there will be a time in the future when all rebellion against God's plans will come to an end and a perfect relationship with God can be fully restored. This brings the hope that transsexual people may find support as they seek to live in ways that are honest to the way God made them, and open to God's ideals.

It's worth noting that the Bible regards celibacy as a high calling. Jesus was fully human and male, but never married nor had sexual intercourse. He also taught that marriage is not for everyone (Matthew 19:12).  It is important to acknowledge this, as for some people, battling with gender conflict may be a life long process.

Reprinted with permission from PJ Saunders

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Why assisted suicide should not be legalised in Britain

Peter Saunders

I have recently been published in a head to head with Sir Terence English in the Oxford Mail on whether assisted suicide should be legalised in Britain. My contribution to the debate is reproduced below. Perhaps not surprisingly I have said ‘no’.

Any change in the law to allow assisted suicide or euthanasia would inevitably place pressure on vulnerable people to end their lives for fear of being a financial, emotional or care burden upon others.
The ‘right to die’ would so easily become the ‘duty to die’. This would especially affect people who are disabled, elderly, sick or depressed and would be greatly accentuated at this time of economic recession with families and health budgets under pressure.
Elder abuse and neglect by families, carers and institutions are already real and dangerous and would be made worse.
Any so-called ‘safeguards’ against abuse, such as limiting it to certain categories of people, will not work.
This is because exactly the same arguments – autonomy and compassion – would apply to people outside the categories decided upon and so any law allowing it for some would immediately be challenged under equality legislation.
If for terminally ill people, why not for those who have chronic illnesses but are ‘suffering unbearably’?
If for adults why not for ‘Gillick competent’ children? If for the mentally competent why not for people with dementia who ‘would have wanted it’?
The news coming from other jurisdictions which have gone down this route, particularly Belgium and the Netherlands, shows a pattern of incremental extension and pushing of the boundaries – an increase in cases year on year, a widening of categories of people to be included and people being killed without their consent.
Belgium has recently legalised euthanasia for children and in the Netherlands babies with spina bifida and people with dementia are already put to death.
This is why British parliaments have rightly rejected the legalisation of assisted suicide in Britain three times in the last seven years and why the vast majority of UK doctors, almost all medical groups including the British Medication Association (BMA), Royal College of Physicians (RCP) and Royal College of General Practitioners (RCGP), and all major disabled people’s advocacy groups are also opposed.
Persistent requests for euthanasia are extremely rare if people are properly cared for, so our real priority must be to ensure that good care addressing people’s physical, psychological, social and spiritual needs is accessible to all.
This issue is understandably an emotive one but hard cases make bad law and even in a free democratic society there are limits to human freedom. Our present law with its blanket prohibition on all medical killing does not need changing.
The penalties it holds in reserve act as a strong deterrent to exploitation and abuse whilst giving discretion to prosecutors and judges to temper justice with mercy.
Reprinted with permission from PJ Saunders

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Royal College of Ob/Gyn bars pro-life doctors from receiving its degrees and diplomas

Peter Saunders

Doctors and nurses who have a moral objection to prescribing ‘contraceptives’ which act by killing human embryos are to be barred from receiving diplomas in sexual and reproductive health even if they undertake the necessary training according to new guidelines.

Under new rules issued by the Faculty of Sexual and Reproductive Health (FSRH) earlier this year these doctors and nurses are also to be barred from membership of the faculty and from specialty training.

The FSRH is a faculty of the Royal College of Obstetricians and Gynaecologists established on the 26th March 1993 as the Faculty of Family Planning and Reproductive Health Care. In 2007 it changed its name to the Faculty of Sexual and Reproductive Healthcare.

Whilst many contraceptives act by preventing the union of sperm and egg, some, including most IUCDs (intrauterine contraceptive devices) and the morning-after pill EllaOne (ulipristal acetate), also act by preventing the implantation of an early embryo. In other words they are embryocidal or abortifacient, rather than truly contra-ceptive.

Many doctors, of all faiths and none, have a moral objection to destroying human life and wish therefore to avoid using drugs or methods which act after fertilisation.

In fact this position was once held by the British Medical Association (BMA) when it adopted the Declaration of Geneva in 1948. This states, ‘I will maintain the utmost respect for human life from the time of conception even against threat’.

But in 1983 the words ‘from the time of conception’ were amended to ‘from its beginning’ due to sensitivities about increasing medical involvement in abortion. The word 'beginning' was left undefined, giving doctors the opportunity to argue, contrary to the biological reality, that early human life was not actually human life at all.

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Now it seems that doctors who wish to abide by the original wording of the Declaration of Geneva are to be barred from practising in certain medical specialties. This is an extraordinary about face.

The Faculty may argue that they are not barring doctors and nurses from practising, but simply from obtaining certain qualifications. But as many job appointments will be conditional on applicants having these qualifications this is effectively also a bar on practice.

Interestingly doctors who have a moral objection to abortion are still able to complete the Faculty’s qualifications because the Abortion Act 1967 contains a conscience clause which protects them. But there is no law protecting those who object to destroying human embryos.

Many Christians believe that every human life, regardless of age, sex, race, degree of disability or any other biological characteristic, is worthy of the utmost respect, wonder, empathy and protection.

This is based on the idea, taught in the Bible, that human beings are made in the image of God. In a society which is becoming more hostile to Christian faith and values it is perhaps not surprising that we are seeing institutional discrimination of this kind.

Perhaps it is time for Christian doctors and nurses, and others who share their prolife views, to set up an alternative training programme.

Reprinted with permission from PJ Saunders

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