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 have been shaken by what seems to be damning evidence of widespread abuses in the Netherlands. It would therefore seem worthwhile 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. It would also seem fair to highlight the fact that in more than 85% of these cases, death was hastened by no more than 24 hours. 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%). The only responsible inference that can be made from the data cited is that between 1990 and 1995 the incidence of non-voluntary euthanasia in the Netherlands decreased slightly. There is no possible way in which the referenced data can be construed as suggesting "The Dutch had slid down the slippery slope." Such a claim fails to meet the most basic requirements of logical inference. It is at best a gross error . . . and at worst deliberately misleading.

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 authorized 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 JMA1 , 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 on-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(n44). 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 decriminalization 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 unsupportable allegation is a gratuitous 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 formalized 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 credible report of any Dutch doctor having been 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 intellectual 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.

An abstract of the Jochumsen and Keown article is available at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list uids=10070633&dopt=Abstract

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