People will die because of mistaken diagnosis or prognosis

Even with modern technology, doctors cannot accurately diagnose terminal illness or estimate the time to death in every case. Countless people given only a short time to live have recovered and survived long-term. But with euthanasia the result is always final – there is no second chance.

  • Both medical diagnosis and prognosis are matters of probability, not certainty.  Diagnosis is not a process guaranteeing 100% accuracy.

  • There are several cases of people who outlived the prognosis given by their doctor. One notable example is Lecretia Seales, the Wellington lawyer who requested legal assisted suicide from the High Court in May 2015. According to an article published in The Listener, “At first, Seales was given only weeks to live…. Since then, the predicted weeks have stretched into three-and-a-half full and active years.”[1]  She died six months after that article was published.

 

We believe it is unwise to assume that doctors can accurately diagnose terminal illness and correctly predict the time to death. We are concerned that legalising euthanasia and assisted suicide will inevitably lead to the killing of people who are either wrongly diagnosed or given an unduly pessimistic prognosis.
 
In response, the Voluntary Euthanasia Society makes two points:

1. That “mistaken diagnosis at the stage where a person might request assistance to end their life is very rare…” and

2. “Almost always the action occurs in the last few weeks before death is likely and its approach is self-evident.”

Neither of these responses are satisfactory or even correct.  They do not negate our statement and at best they are half-truths.  Worse, they demonstrate a characteristic common to the pro-euthanasia movement: a lack of compassion towards those who are inadvertently caught up in its coils.  The Voluntary Euthanasia Society is prepared to accept a certain level of ‘collateral damage’ (mistaken killing) in order to achieve its aims and objectives.  It is noticeable that none of the research coming out of the Netherlands, Belgium and Oregon, and none of the visiting pro-euthanasia experts such as Dr. Rob Jonquiere [2] ever expresses any sorrow for the thousands of people who have been euthanized either as a result of poor diagnosis or, in the case of many elderly and disabled people, without their explicit request.  Instead these people are treated purely as research statistics and the doctors who do these things need ‘more education’ so that they won’t do it so often.  How different this feels to our nation’s stance when we abolished capital punishment in 1961 largely on the grounds that one innocent person hanged was one too many! And what a contrast too, to the doctrine of informed consent that the so-called ‘Cartwright case’ forever – we had hoped, – been imprinted deep in the ethos of modern New Zealand medicine. [3] 
 

Death resulting from incorrect diagnosis and / or prognosis

 
Both diagnosis and prognosis are matters of probability.  Diagnosis is not a process guaranteeing 100% accuracy.  Recent analyses of discrepancies between clinical and autopsy diagnosis reveal that despite modern scanning and other laboratory tests, post-mortem findings are in complete agreement with pre-death diagnoses in only about half the cases. [4] One study found that in 10% of cases, the patient would have been expected to live had a correct clinical diagnosis been made. [5]  There are numerous articles in the literature of unnecessary euthanasia deaths. The following are illustrative.
 
 

Results of incorrect diagnosis

 
Dr. Jack Kevorkian, the so called “American Doctor Death”, claimed to have participated in about 130 deaths by euthanasia. A review of the medical records of 69 of them revealed that only 25% had a terminal condition (i.e. had an estimated six months or less to live) and five had autopsies that showed no significant disease at all. [6] 
 
In 2013, Dignitas, the Swiss Suicide Clinic in Basel, killed Pietro D’Amico a 62-year-old magistrate from Calabria in Southern Italy, after he was incorrectly diagnosed by Italian and Swiss doctors as having a life-threatening illness. However, an autopsy carried out by the University of Basel’s Institute of Forensic Medicine failed to find any trace of such an illness. [7] 

Nancy Crick, a patient who had received advice from pro-euthanasia campaigner Dr. Philip Nitschke, died in an assisted suicide surrounded by family members.  She allegedly had metastatic bowel cancer.  However, in one of the few cases where autopsy has been performed following a death by assisted suicide, no evidence of cancer was found, although she did have extensive adhesions from old surgery. [8] 
 
A 60-year-old man admitted to North Shore Hospital (Auckland, New Zealand) for palliative care with the diagnosis of inoperable gastric cancer did not deteriorate as expected. On reviewing his case record from the referring hospital medical staff discovered that the diagnosis had been made following a gastroscopy that showed a large fungating tumour in the stomach.  It was so ’obviously’ a gastric cancer that no biopsy was undertaken. A follow-up gastroscopy performed at the same hospital revealed that the lesion had shrunk to about 1.5cm in diameter.  A biopsy showed it to be an eminently treatable chronic gastric ulcer – not a cancer. The two may be similar in appearance.  When this new diagnosis was reported back to the patient, he took some time to come to grips with the idea that he wasn’t going to die any time soon after all.  The point however is that had euthanasia or assisted suicide been legal and had this patient requested it before the true state of affairs had been revealed, he would have been considered a prime candidate.
 
A second patient, a 78-year-old man with back pain was referred to the North Shore Hospital for palliative care from an orthopaedic unit.  The diagnosis was cancer of the spine.  The palliative care team was concerned about a slight but persistently raised temperature and some increase in his blood white cell count.  A review of his case notes showed that the lesion had been biopsied but not cultured, a situation that was soon remedied.  Material from the biopsy showed Acid Fast Bacilli typical of tuberculosis, sometimes called Pott’s Disease of the Spine. It is treatable with antibiotics. This man also would have been considered to be an ideal candidate for euthanasia had it been available and had he requested it.
 
In the vast majority of cases of euthanasia, the true diagnosis will never be verified at an autopsy because none of the legislation proposed for altering the law requires post-mortem verification.  Moreover, the doctor completing the death certificate is required to certify that death was due to some natural cause, not euthanasia or assisted suicide. [9] Hence, if the doctor chooses not to report the case to the responsible authorities, a major issue overseas, there is no reliable way to track down deceased subjects for a later review.
 
 

Problems with Prognosis

 
Prognosis (predicting how long a person will live for) is notoriously inaccurate beyond a few days.  Every doctor has had his or her share of wildly incorrect prognoses.  The following case is illustrative.
 
Art Buchwald, the well-known American author, was told by his doctor in February 2006 that he had only a few weeks to live because he refused to receive dialysis. The doctor recommended that he move into hospice care.  After spending several months saying goodbye to family and friends he had not died and after three months was discharged from the hospice. [10] He went home and wrote a new book entitled: “Too Soon to say Goodbye”. He died on 17 January 2007, eleven months after receiving the initial terrible prognosis. [11] 
 
A palliative care specialist colleague of mine recently stated that the ‘worst’ case she had personally seen was a man to whom she gave a prognosis of six weeks.  20 years later this man survives in apparent good health.  Another patient with breast cancer was given a prognosis of less than five years by a respected cancer specialist, but died 23 years later.
 
There is no doubt that if euthanasia and assisted suicide are declared legal, numbers of New Zealanders will be killed on account of disease they thought they had, indeed were told they had, but actually did not have.  The pro-euthanasia advocates seem totally unconcerned by this phenomenon.  Even if their protest that such things would occur only very rarely were true, which it is not, the question arises: who should we have compassion for?  The person who is insisting that he/she should be able to choose the time and mode of their death, or the people whose lives will have been shortened because they chose voluntary euthanasia as the way to manage a disease they misguidedly thought they had?
 
The 1980s and 1990s were times when a great deal of interest was shown by research workers into the way people deal psychologically with being given bad news: e.g. told that they have cancer.  The research showed that the immediate reaction to such news tends to be a mixture of disbelief, (denial), confusion, shock and ‘numbness.’ Once the initial confusion and panic settles, Greer and Watson, leading researchers in this area, identified five ways in which people begin to adjust [12]. Some see a challenge to be won.  Some retreat into denial.  Some adopt a fatalistic view – “it’s out of my hands”.  Some succumb to hopelessness: “what’s the point of going on?” Some become pre-occupied by anxiety and worry.  Often, people swing from one extreme to another in the weeks of months following the reception of the news.  It is well recognised that it is during this relatively early phase, attempting to cope with shocking news and when hope seems lost, that many people are most susceptible to suggestions that they should consider “getting it over with,” or “well, you know there’s always euthanasia, Mum.”
 
‘Superman’ Christopher Reeves’ experience is an example of this phenomenon.  In the days and weeks following the accident that left him quadriplegic, he began to experience suicidal depression.  “Maybe I should just check out”, he told his wife.  It was only the unqualified love of his wife and family that got him through that phase of post-traumatic reaction. [13] 
 
Another example is Christopher Jones, who wrote the following a few months before dying from terminal cancer,
 
“My reflection on this experience centres on the fact that at three periods – the diagnosis of secondary cancer, the traumatic experience of chemotherapy, and the prognosis of incurability – I was subject to extreme stress and a sense of hopelessness, and I might have been open to the option of ending my life by legal means, had these existed. The legal prohibition of this course was immensely helpful in removing it as a live option, thus constraining me to respond to my situation more creatively and hopefully. In hindsight, I now know that had I taken this course, I would have been denied the unexpected and joyful experience of being ‘recalled to life’ as I now am.” [14] 
 
In summary, the evidence does not support the Voluntary Euthanasia Society’s assertions that erroneous diagnosis is rare and that most requests for euthanasia arise at the very end of life.  Indeed, their own portrayal of the average applicant for euthanasia is hardly consistent with some poor soul requesting euthanasia in the last two or three weeks of life.  Most high-profile voluntary euthanasia campaigners are not just cognitively aware, but is capable of arguing his or her supposed ‘rights’, adroitly handling the news media and television, representing their views in a personal blog and maybe even challenging Parliament.

References

[1]  Macfie, R. (2015, January 8). Dying wishes. The Listener. Retrieved from http://www.listener.co.nz/current-affairs/health-current-affairs/dying-wishes/

[2]  Communications Director, World Federation of Right to Die Societies, of which the Voluntary Euthanasia Society is a member.

[3]  Coney, S. (1988). The unfortunate experiment. London, Auckland, New York: Penguin Books.

[4] Perkins, G. D. et al. (2003). Discrepancies between clinical and post-mortem diagnoses in critically ill patients. Critical Care, 7, R129-132. Retrieved from http://www.ccforum.com/content/7/6/R129.

[5] Royal College of Pathologists. (1993). The autopsy and audit.  Quoted in: Roulston, J., et al. (2005). Discrepancies between clinical and autopsy diagnosis and the value of post-mortem histology; a meta-analysis and review. Histopathology, 47, 551-559. 

[6]  Roscoe, L. A., Malphurs, M. A., Dragovic, L. J. & Cohen, D. (2000). Dr. Jack Kevorkian and cases of euthanasia in Oakland County Mich. 1990 – 1998. N Eng. J Med. 343, 1735 – 1736.

[7] The Local. (2013, July 11). Botched diagnosis led to Italian’s assisted death. Retrieved from http://www.thelocal.it/20130711/medical-error-led-to-italians-assisted-suicide.

[8]  The Sydney Morning Herald. (2004, June 8). Post mortem reveals euthanasia crusader clear of cancer. Retrieved from http://www.smh.com.au/articles/2004/06/08/1086460287366.html?from=storylhs.

[9]  See for example the End of Life Choice Bill (2015), clauses 25 and 28. Retrieved from http://www.parliament.nz/resource/en-nz/51HOH_MEMBILL191_1/8943d950dbc6ab474deeebad36145c68e612ebb9.

[10]  Buchwald, A. (2006, May 23). Heaven can wait. The Washington Post. Retrieved from http://www.washingtonpost.com/wp-dyn/content/article/2006/05/22/AR2006052201778.html

[11]  Folkenflik, D. (2007, January 18). Columnist Art Buchwald leaves us laughing. NPR. Retrieved from http://www.npr.org/templates/story/story.php?storyId=5249437.

[12]  Greer, S., Watson, M. (1987). Mental adjustment to cancer: its measurement and prognostic importance. Cancer Surveys, 6, 439-453.

[13]  Reeves, C. Quoted in: Johnston, B. P. (1998). Death as a salesman (2nd ed.). p.129. Sacramento Ca. USA: New Regency Publishing.

[14]  Jones, C. (2014, July 13). Right to die: There were times when I would have ended my life if it were legal – coming out the other side I’m glad it wasn’t. The Independent. Retrieved from http://www.independent.co.uk/life-style/health-and-families/features/right-to-die-there-were-times-when-i-would-have-ended-my-life-if-it-were-legal-coming-out-the-other-9602300.html.

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