Friday, 18 September 2015

The Battin study does not prove that vulnerable people are not at risk from legalised assisted suicide

This report has been reproduced with permission from the Euthanasia-Free New Zealand Website

The Battin study is often quoted by pro-euthanasia advocates to support their claim that legal assisted suicide does not pose a risk to vulnerable people. The absolute claim that “vulnerable people are not at risk” is not supported by this study, because it identified a heightened risk to one vulnerable group: people with AIDS.

Subsequent research has also invalidated the study’s conclusion that other vulnerable groups are not at risk. 

For example, studies published in 2009 and 2010 show that vulnerable groups, such as the elderly and mentally incompetent, are indeed at a higher risk of being killed by euthanasia without their consent.

The Battin study was based on wrong assumptions and there are several issues with its scope and methodology. The case is not proven.

What is the Battin study about?

Margaret Battin and others analysed data up to 2005 from Oregon and The Netherlands to find out whether there is evidence that the lives of people identified as vulnerable are more frequently ended with assistance from a physician than those of the background population.

“These groups were analysed and compared with background populations: the elderly, women, the uninsured (Oregon only), people with low educational status, the poor, the physically disabled or chronically ill, people with sometimes stigmatised illnesses like AIDS, minors, people with psychiatric illnesses including depression, and racial or ethnic minorities.

“The study found that the only group with a heightened risk was people with AIDS. Where assisted dying is already legal, there is no current evidence [emphasis ours] for the claim that legalised PAS or euthanasia will have disproportionate impact on patients in vulnerable groups. Those who received physician‐assisted dying in the jurisdictions studied appeared to enjoy comparative social, economic, educational, professional and other privileges.”

The Battin study is based on wrong assumptions

  • It assumed the elderly consist only of people aged 85 and older. No mention was made of people aged 65 to 84.
  • It assumed women are more vulnerable than men when it comes to suicide and assisted suicide.
  • It assumed depressed people are not vulnerable to assisted suicide.
  • It assumed vulnerability is limited to physical characteristics and conditions.
  • It assumed the poor are more vulnerable to physician-assisted suicide than the rich.
  • It assumed only terminally ill people receive physician-assisted suicide in Oregon.
  • It assumed a person cannot belong to more than one vulnerable group, i.e. be both elderly and disabled.  Battin et al treated vulnerable groups as separate and mutually exclusive.
Other limitations and issues with the Battin study

  • Three vulnerable groups, who feature in statistics and studies on assisted suicide and euthanasia, were ignored in the Battin study: Those who suffer from depression, the mentally incompetent, and the unconscious or comatose.
  • The study is based on data only up to 2005, when the Dutch euthanasia situation was relatively stable. According to Prof Theo Boer, a former member of a Dutch Regional Euthanasia Committee who has reviewed 4000 cases over 9 years, there has been a dramatic increase in euthanasia deaths since 2008. He recommends that the cause of this surge be investigated.  He was in favour of euthanasia, but has changed his mind. 

“I was wrong, terribly wrong in fact, to believe that regulated euthanasia would work.”

“In hindsight, the stabilization in the numbers was just a temporary pause. Beginning in 2008, the numbers of these deaths show an increase of 15% annually, year after year.”

“Other developments include a shift in the type of patients who receive these treatments. Whereas in the first years after 2002 hardly any patients with psychiatric illnesses or dementia appear in reports, these numbers are now sharply on the rise. Cases have been reported in which a large part of the suffering of those given euthanasia or assisted suicide consisted in being aged, lonely or bereaved. Some of these patients could have lived for years or decades.

  • It’s limited to data from only two jurisdictions, and jurisdictions with very different social, cultural and legal environments as well as assisted-suicide reporting requirements. The study should not be used to make generalisations about the effect of legal euthanasia and assisted suicide in other parts of the world.

“We recognize that substantial differences in the methodologies of the source studies make it impossible to determine with certainty [emphasis ours] the actual incidence of assisted dying in several of the vulnerable groups studied. Our question is whether the available data show evidence of heightened risk to persons in vulnerable groups.”

  • The source data didn’t include data on disability.
In reference to the group “people with chronic physical or mental disabilities or chronic non-terminal illnesses”, the authors stated “no data to calculate denominator; probably 10 cases or fewer per year.”  The word “probably” is hardly conclusive!

Expert critiques of the Battin study

The Battin study has been criticized by Prof Ilora G. Finlay and Rob George in the Journal of Medical Ethics, as well as by Dr George Seber, a statistician and counsellor.

Based on these expert opinions, as well as subsequent studies, Euthanasia-Free NZ concludes that the Battin study is unreliable and inconclusive.

Discredited by a statistician

Prof George Seber, an internationally-respected statistician, as well as an experienced counsellor, is of the opinion that “the case is not proven”.

He wrote an email to Euthanasia-Free NZ stating,

“The Battin et al. paper has some unresolved problems that may invalidate its findings.

“In endeavouring to look for differences between pairs of groups it is important to look at the numbers in overlapping groups, for example the numbers in two-group overlaps like gender and age, and those in three-group overlaps like gender, age, and vulnerability (e.g. with disabilities), etc. If there is “interaction” between groups it is not valid to compare groups in pairs without taking into account any interactions. Are there interactions? It seems likely that  the following might have an effect: (1) women live longer than men, (2) men may be more disabled than women in a certain age groups, (3) women network better than men and networks of friends are very important when it comes to psychological health.

“A major problem is how to compare suicide-assisted deaths with deaths in the population at large. It could be a case of comparing apples and oranges! For example, some people may die by accident or after a short illness and are not relevant to the comparison. We need to compare the numbers of people in both populations who have similar ages and are in similar situations (e.g. similar vulnerability).

“Another concern I have is about the fact that there is no mention of the  methods used to compare proportions. Some methods are still commonly used these days that are not  appropriate (cf. Seber , 2013a).

“Another worrying feature is the confusion over the role of depression and the so-called right of euthanasia. As a trained counsellor I can say  that depression is the most treatable of all mental illnesses and it is strongly linked to suicide without assistance (Seber, 2013b). I don’t believe it is grounds for assisted suicide or euthanasia.  It is known, for example, that women seem to be about twice as prone to depression than men, and the elderly are more prone as the life-span has been significantly increased so there is an age factor relating to depression as well.

“In summary, the case is not proven. Further research and statistical analysis is needed.”

George  A. F.  Seber, PhD, FRSNZ, Dip. Counsel., MNZCCA.
Emeritus Professor of Statistics, University of Auckland, New Zealand

Discredited by peers in the same journal

  • Battin limits vulnerability to physical characteristics such as race, gender and socioeconomic status only. Finlay and George argue,
“Vulnerability to PAS cannot be categorised simply by reference to race, gender or other socioeconomic status and that the impetus to seek PAS derives from factors, including emotional state, reactions to loss, personality type and situation and possibly to PAS contagion, all factors that apply across the social spectrum. Contrary to the conclusions drawn by Battin et al, the highest resort to PAS in Oregon is among the elderly and, on the basis of research published since Battin et alreported, that there is reason to believe that some terminally ill patients in Oregon are taking their own lives with lethal drugs supplied by doctors despite having had depression at the time when they were assessed and cleared for PAS.”

  • Battin defines the elderly as people over 85 and finds that those people are not at heightened risk as compared to people aged 18-64.  Finley and George point out that people over 65 are generally defined as elderly in our society and note that Battin’s study does not mention at all the age group between 65 and 85.  Finlay and George also quarrel with Battin’s comparison of natural death rates of people 85 and older with assisted suicide rates in that age cohort, pointing out that, “Since the death rates from non-PAS causes among persons aged 85 years or over are naturally very high, it follows that almost any rate of PAS in this age bracket is likely to show up as proportionately less than the rate of death from other causes.”  In fact, they write, 68% of PAS deaths are among people over 65.  The elderly do seem to be vulnerable to PAS.
  • Finlay and George quarrel with Battin’s choice of which groups to investigate for vulnerability.  For example, she investigates whether women are more vulnerable to PAS than men and finds that they are not.  Finlay and George find her discovery unimpressive, since studies done all over the world have shown men are more likely to commit suicide than women.   Battin cites the affluence and high educational level of PAS users as proof that the poor are not vulnerable. Finlay and George ask whether Battin has overlooked the possibility that there is a particular vulnerability among the affluent and educated, a vulnerability marked by an aversion to suffering, an isolating individualism seen as “dignity”, and a need for control.  They believe Battin’s work may have been distorted by her seeing “the concept of vulnerability from one perspective only, as something to which only less educated or less wealthy persons might succumb.”  They also suggest the possibility that Compassion and Dying, now Compassion and Choices, represented at the hearings by George Eighmey, may exert an unintended coercion on individuals they guide through the PAS process.  Finally, they point to the coercive influence among the affluent of fashion and political correctness.
  • Finlay and George question Battin’s conclusion that only the terminally ill are receiving PAS in Oregon, pointing out, as Dr. Bentz did in his testimony to Health and Welfare, that the Oregon reports are based on “voluntary” reporting by doctors who are motivated to state that they acted within the law; those same doctors label their patients as terminal.  They note that one patient lived for three years after getting a PAS prescription; he was clearly not terminally ill when he got it.  They point to the difficulty of prognosticating and also to the blurring, purposeful or not, of the boundaries between chronic illness and terminal illness; for example they note that “…illnesses such as multiple sclerosis, Parkinson’s disease and cardiopulmonary disease pretty well universally have a chronic and disabling prelude before they become predictably terminal as defined by less than 6 months to live.”  Battin , they point out, discusses chronic and disabling terminal illness in a way that blurs the lines, if they can be drawn at all.
  • Lastly, Finlay and George do point out, as Battin said, that some depressed patients seem to have received PAS.


Battin, M. P., Van der Heide, A. and Ganzini, L.  et al. Legal physician-assisted dying in Oregon and The Netherlands: Evidence concerning the impact on patients in ‘vulnerable’ groups. J Med Ethics 2007(37):591-97.

Finlay, I. G. and George, R. Legal physician-assisted suicide in Oregon and The Netherlands: evidence concerning the impact on patients in vulnerable groups – another perspective on Oregon’s data. J Med Ethics 2011(37):171-174   doi:10.1136/jme.2010.037044

Seber, G. A. F. (2013a). Statistical models for proportions and probabilities. Springer Briefs in Statistics: Berlin.

Seber, G. A. F.  (2013b). Counseling Issues: A handbook for counselors and psychotherapists. Xlibris Publishing.

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