53 e-Letters

  • Changes in Oregon’s assisted dying law and practice

    We thank Gideonse & Coombes Lee for reading our paper. Their criticism of our analysis is at variance with official reports from the Oregon Health Authority.(1)

    There may be many reasons why there has been a socio-economic change in those accessing an assisted death, but the percentage of those stating financial concerns in their assisted death continues to rise and was 8.2% in 2023, not 5.1% as they claim. The fact that nearly 1 in 10 have this concern requires further examination.

    Oregon produces no details behind prolonged assisted deaths, except that half took between 54 minutes and 137 hours. They also provide no details on how soon after ingestion nine patients re-awakened. Notably, these unwanted events are not included as complications. Washington reported in 2021 that 16% took more than 2 hours to die.(2) It is often claimed that assisted deaths are quick, so the complication of prolonged deaths deserves closer examination.

    It is remarkable to claim that Oregon destroys its confidential patient records in order to protect confidentiality. No health or business organisation is allowed to do this with confidential records since it is counter to good practice. Transparency requires many to keep their records for at least 10 years and this contrasts with the approximately 18 months in Oregon. The key point we made is that this destruction of essential data makes it impossible to carry out retrospective analysis of Oregon’s assisted deaths....

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  • Assisted suicide and capital punishment: a mistaken analogy.

    The ‘no competing interest’ declaration in Doré’s paper[1] opposing assisted dying/assisted suicide (ADS) is highly misleading. In September 2019, he was among 911 Christian signatories to an open letter opposing abortion services in Northern Ireland.[2] It includes: ‘As Christians we believe that the 6th Commandment is binding upon all of humanity. “You shall not murder” (Exodus 20:13)’, a belief evidently rejected by the Spanish Inquisition when condemning its last heretic in 1826. His objections to ADS may therefore be equally religion-based.

    Most opposition to ADS has doctrinal origins but surveys repeatedly show that believers, including former Archbishop John Carey, are almost as supportive of ADS as the general UK population. Doré exemplifies recent trends among religious opponents to conceal the beliefs that typically inform their opposition, because they realise Bible-based arguments carry decreasing weight IN AN increasingly secular Britain. Very religious physicians are over-represented in UK palliative care,[3] forcing those who support ADS to do so anonymously lest they damage their careers.[4]

    Comparing capital punishment, an involuntary and generally unwanted procedure, with desired, voluntary and usually long-considered ADS is a major category error. Capital punishment ended in European countries not primarily because of rare mistaken convictions but because its Biblical ‘eye for an eye’ principle was increasingly challenged. Hanging was...

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  • Further response to ‘Assisted suicide and capital punishment
    Dr Regnard claims that I 'find comfort in the belief that any sceptic or critic of assisted dying must be driven by religious fanaticism' That is untrue. Last year, I sent him my critique of two prominent unbelieving opponents of AD, Douglas Murray and Kevin Yuill. [1] Far from being 'desperate to claim that assisted dying is safe' I have argued repeatedly (including emails to Dr Regnard) that occasional difficulties in swallowing or absorbing the full oral dose of prescribed AD medication is a strong argument for direct third-party administration, as preferred by over 99% of Canadian AD patients who have a choice. 


    Although Dr Doré cites a paper as proof that the quality of death in AD is not superior to that in patients requesting but not receiving AD,[2] it actually shows the opposite. "Family members of those choosing [AD] reported greater symptom control, particularly in regard to control over surroundings, better functioning, better energy, and better control of bowel and bladder."  He claims that 'in no way is religion mentioned' and 'in no form do I have a paid role, nor any role within any spiritual or religious organisation' but does not question the evidence that he is very religious. This is consistent with the increasing tendency of religious opponents of AD to disguise the doctrinal basis of their opposition[3] and deliberat...
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  • Assisted suicide and faith: a mistaken analogy

    In responding to a rational discussion by Doré,(1) Brewer’s reply was not surprising.(2) He finds comfort in the belief that any sceptic or critic of assisted dying must be driven by religious fanaticism. That prejudice might excuse his mention of the Spanish Inquisition and quoting the bible; but it does not excuse personal criticism of a colleague’s rational arguments on the basis of unsubstantiated claims of religious intransigence.

    As an agnostic, I may share Brewer’s scepticism of religion. Unlike Brewer, I am aware of many agnostics, atheists and humanists who have deep concerns around assisted dying, and many others with religious beliefs whose concerns are driven by strong secular arguments. Brewer is desperate to claim that assisted dying is safe despite the increasing evidence of abuse and lack of monitoring.(3) Fanaticism does not need religion to be damaging.

    1) Doré M. Assisted suicide and capital punishment: a mirror image? BMJ Supportive and Palliative Care. 2023 Jun 27: https://spcare.bmj.com/content/early/2023/06/26/spcare-2023-004380
    2) Brewer C. Assisted suicide and capital punishment: a mistaken analogy. BMJ Supportive and Palliative Care. 2023 Jul 14: https://spcare.bmj.com/content/early/2023/06/26/spcare-2023-004380.respo...
    3) Coelho R, Maher J, Gain...

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  • Assisted suicide and capital punishment: a mirror image?

    Thank you for reading the paper. I do not have a competing interest as Brewer accuses (1), in no form do I have a paid role, nor any role within any spiritual or religious organisation.

    To state it clearly, in no way is religion mentioned, illuded to, nor is it a formulation of any of the arguments in this paper, my expertise is simply that of a palliative care physician.

    I will explain a misconception he has outlined. My comparison to capital punishment is based upon the legal standard we have set in the UK, ‘that no-one incorrect should be killed’.

    Given incorrect diagnosis, incorrect prognosis and especially autonomy being fluctuant, relational and social it is inevitable some will be killed incorrectly. The individual autonomy difference between capital punishment and assisted suicide doesn’t mute the point, rather it outlines even greater uncertainty resulting in incorrect deaths. Choosing assisted suicide based upon an incorrect diagnosis for example is not a valid choice. Choosing assisted suicide based upon social circumstances is simply facilitating suicide. Choosing assisted suicide based upon a unlikely future and fear of it, is not a rationally made choice. Brewer states he is a rationalist, indeed an ex-psychiatrist, is it thus not prudent to realise and explore the reason behind a choice rather than blindly accept the choice? Indeed, is this not the basis of suicide prevention?

    Furthermore, suffering does not appear to diminish...

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  • Hospice Virtual Wellbeing Support during the COVID-19 Pandemic

    We have read with interest your letter about the changing face of day hospices since the onset of the COVID-19 pandemic. We would like to share our experience of support provided by our Wellbeing Centre team during this time which has evolved and developed into what is currently an entirely virtual service. This has been a challenging but also an extremely positive experience with an enthusiastic response from our patients wanting to engage in our extensive virtual offer of hospice wellbeing services.

    In March 2020, we began by offering 3 virtual sessions per week. This has grown exponentially over the year and we are now offering up to 4 sessions per day with a total of 18 sessions per week supporting, on average, 23 patients per day. We have provided multiple types of support including yoga and other exercise classes, guided relaxation, art, Q&A sessions with our doctors, discussion support groups, carers’ groups, management of breathlessness and pain, and anxiety and fatigue management.

    Age range of attendees of the virtual sessions have been between 40 to 90 years old, and from early to late in their disease trajectory. Between April 2020 and April 2021, we had 4,603 attendances with 413 referrals to the service.

    We have conducted service evaluations to evaluate this new way of providing support to our patients and the feedback indicates that patients are keen for support to continue to be provided virtually.

    “Keep at it even after loc...

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  • ‘Future Care Planning’ - perhaps the way forward?

    I approve of the direction-of-travel of the approach in Wales, which it seems to me is more reflective and encompassing of the complexity of end-of-life than is the now widely-adopted ‘ReSPECT’ in England. The term Future Care Planning as used in Wales, explicitly includes planning made when a patient lacks capacity – for example, if the planning takes place when a patient is ‘comatose’ or ‘deeply unconscious’. Whereas the ReSPECT process, generates a main ReSPECT form (ref 1) which tells readers in its section 1 ‘The ReSPECT process starts with conversations between a person and a healthcare professional’. So, presumably any planning ahead which is only embarked on after a patient has already become unable to engage in conversation, should not be captured by either the ReSPECT process or by the ReSPECT form.

    I believe that many NHS Trusts in England, in adopting ReSPECT have moved too far in the direction of trying to create a form which seeks to be ‘all things to all readers’ - whereas in Wales, as we can read in the paper by Taubert and Bounds ‘The approach seeks to cater for the disparate need of the Welsh population; there is not merely one format for multiple scenarios, but a choice of approaches, communication strategies and documents to suit bespoke needs.’.

    I have only two issues with the paper. One is this sentence, which is in fact from the European Association for Palliative Care definition of ACP: ‘It encourages individuals to identify a person...

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  • Doubts about some quantitative information

    With much interest I have read this article. Unfortunately I noticed various inconsistencies within 1) the tables as well as in 2) the textual description about quantitative results:

    1) Tables

    Table 3 Patient clinical characteristics
    a. Main diagnosis SAH/Other: 12(5) should read 12(4), assuming 12 is correct;
    b. Main diagnosis HU/Other: 14(6) should read 14(5), assuming 14 is correct;
    c. Disease modifying treatment in the 3 months prior to admission*: The numbers add up to exactly the given N. Why *?
    d. Disease modifying treatment in the 3 months prior to admission*: Yes. Currently 85(31), 67(24) and 92(34). Assuming absolute figures are correct, the percentages should read: (32), (25) and (35) respectively;
    e. Mental status (oriented) on admission: Unknown for SAH and HU. Currently 21(7) and 41(15). Assuming absolute figures are correct, the percentages should read (8) and (16) respectively.

    Table 4 Reported multidimensional care needs on admission
    It seems that the figures stated under 'Domain of care needs noted on admission' do not coincide with the figures under 'No of dimensions of care needs by patient'. Two examples. There are 267 in the need of Physical care within VDH. However when adding up the Physical dimensions below, the total is 269 (76+65+34+19+42+15+6+12). Second example: There are 48 in need of Spiritual care within HU. However when adding up the Spiritual dimensions below, th...

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  • Claims and Facts about Oregon's Death with Dignity Act at 25 years

    This article provides a simplistic perspective, relying heavily on correlation, not causation, to make unproven claims about Oregon’s medical aid-in-dying law and erroneously comparing it to euthanasia laws outside the United States.

    Claim: “...there was an increase in patients feeling a burden and describing financial concerns as reasons for choosing an assisted death.” (p. 1) “Detailed studies are needed to explain the marked change in medical funding for PAS patients in Oregon.” (p. 5)

    Facts: While the Oregon Health Authority (OHA) reports insurance status, it doesn’t report whether patients used their insurance for medical aid in dying. Only 5.1% of people in Oregon who qualified for medical aid in dying since 1998 noted the financial burden among their reasons for requesting it.

    Claim: "The 2022 report states that the combinations [of medications] have resulted in longer times from ingestion to death…" (p. 3)

    Facts: The median time has risen, but it is still typically less than an hour from ingestion to death. Very few patients experience a significant delay between ingestion and death. Otherwise, there would be a higher median time.

    Claim: “Unfortunately the destruction of OHA records after 1 year makes retrospective analysis impossible.” (p. 4).

    Facts: OHA’s public explanation: “The State KC does collect the names of patients in order to cross-check death certificates. However, the law guarantees the confidential...

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  • Could topical ophthalmic beta-blockers be given per orum for this indication?

    As we use atropine and pilocarpine eye drops orally, could betaxolol a beta-1 selective beta-blocker be used to reduce stringy saliva? Especially when swallowing is impaired?