Category: health

Pamala Paul: Ideology impedes gender treatement in U.S.

July 13, 2024 • 10:45 am

If you’ve followed this website regularly, you’ll know that the UK’s Cass Review, which evaluated and criticized the NHS’s treatment of gender dysphoria, has been widely accepted in the UK, causing the country to slow down on “affirmative care”, following the lead of other European countries.  No longer will the NHS run a conveyer belt from childhood gender dysphoria to universal acceptance by therapists that a dysphoric child needs to transition, and from there on to puberty blockers, other hormones, and then, perhaps, surgery.  (See here, and here, for example.)

Despite the realization of European doctors and therapists that unbridled “affirmative care” is not only dangerous, but isn’t very effective, the United States has resolutely ignored Cass’s review, persisting in offering affirmative care despite the paucity of evidence that it works. Even the Biden Administration, with its increasing wokeness, has been lax about dealing with gender issues.

This is all discussed in a new article by NYT op-ed writer Pamela Paul—a thorough and sensible piece of reporting that will nevertheless infuriate gender ideologues and all the “progressive” NYT writers who beef on the paper’s Slack channel.

Gender issues are one thing that the Biden administration has fouled up, and here’s one example from Paul.  (WPATH is The World Professional Association for Transgender Health, which isn’t very attuned to what the rest of the world is doing, but obstinately fights for affirmative care, no matter what):

The Biden administration has essentially ceded the issue to the progressive wing of the Democratic Party, incorporating gender-affirming protocols into Department of Health and Human Services policy. Moreover, recently revealed emails indicate that President Biden’s assistant secretary of health, Dr. Rachel Levine, a pediatrician and transgender woman, successfully pushed WPATH to remove age requirements from its guidelines for gender medicine before their publication, because — mixing political and public health concerns — she thought supporters of gender treatment bans might cite them to show that the procedures are harmful. (WPATH’s draft guidelines had originally recommended age minimums of 14 for cross-sex hormones, 15 for mastectomies, 16 for breast augmentation or facial surgery and 17 for genital surgeries or hysterectomies.)

Now there are no guidelines! Surgery and hormones at any age!

Paul is heterodox and brave, but her piece is now the third I’ve seen where the NYT reports objectively and sometimes critically on affirmative care. The progressive staffers, of course, got in a tizzy about the previous pieces, and Paul’s will increase their ire even more. But the fact that a Left-leaning paper is willing to publish stuff like this—it’s well referenced, too—may signal a sea change in the attitudes of “progressivists” towards affirmative care in the US. Click to read; you can also find the piece archived here archived here:

I’ve written about nearly all of what Paul says, but if you haven’t followed the controversy, her piece is the place to start.  As I’ve said, I think that in a decade or two Americans will look back at the dosing and mutilating of American adolescents and ask, “What were we thinking?”  Of course many people are happy with their medical transitioning, but remember that many cases of gender dysphoria in children and adolescents who aren’t treated with affirmative therapy tend to “resolve,” often with the young people becoming gay.  If you can cure dysphoria that way rather than by permanently changing bodies with hormones and surgery, then that’s surely a route worth investigating.

Here’s a long quotation from Paul’s piece, which is itself long:

Imagine a comprehensive review of research on a treatment for children found “remarkably weak evidence” that it was effective. Now imagine the medical establishment shrugged off the conclusions and continued providing the same unproven and life-altering treatment to its young patients.

This is where we are with gender medicine in the United States.

It’s been three months since the release of the Cass Review, an independent assessment of gender treatment for youths commissioned by England’s National Health Service. The four-year review of research, led by Dr. Hilary Cass, one of Britain’s top pediatricians, found no definitive proof that gender dysphoria in children or teenagers was resolved or alleviated by what advocates call gender-affirming care, in which a young person’s declared “gender identity” is affirmed and supported with social transition, puberty blockers and/or cross-sex hormones. Nor, she said, is there clear evidence that transitioning kids decreases the likelihood that gender dysphoric youths will turn to suicide, as adherents of gender-affirming care claim. These findings backed up what critics of this approach have been saying for years.

“The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” Cass concluded. Instead, she wrote, mental health providers and pediatricians should provide holistic psychological care and psychosocial support for young people without defaulting to gender reassignment treatments until further research is conducted.

After the release of Cass’s findings, the British government issued an emergency ban on puberty blockers for people under 18. Medical societies, government officials and legislative panels in Germany, France, Switzerland, Scotland, the Netherlands and Belgium have proposed moving away from a medical approach to gender issues, in some cases directly acknowledging the Cass Review. Scandinavian countries have been moving away from the gender-affirming model for the past few years. Reem Alsalem, the United Nations special rapporteur on violence against women and girls, called the review’s recommendations “seminal” and said that policies on gender treatments have “breached fundamental principles” of children’s human rights, with “devastating consequences.”

But in the United States, federal agencies and professional associations that have staunchly supported the gender-affirming care model greeted the Cass Review with silence or utter disregard.

There’s been no response from the Department of Health and Human Services, whose website says that “gender-affirming care improves the mental health and overall well-being of gender diverse children and adolescents” and which previously pushed to eliminate recommended age minimums for gender surgery. Nor has there been a response from the American Medical Association, which also backs gender-affirming care for pediatric patients.

When I reached out to H.H.S. officials, they declined to speak on the record. The A.M.A. referred me to the American Academy of Pediatrics and the Endocrine Society. The Endocrine Society, the primary professional organization of endocrinologists, told me, “the Cass Review does not contain any new research that would contradict the recommendations made in” the society’s own guidelines. (Cass’s mandate was to assess the quality and importance of existing research.)

Who is to blame for the situation in America? Ideologues—and those include WPATH, the many doctors and therapists who push affirmative therapy onto young people, and, of course, the Biden administration, especially Rachel Levine. It is worth considering that it may have been unwise to put the issue of age limits (i.e., none) on affirmative care and surgery into the hands of a transgender woman.

Why is this happening in the U.S. while Europe has taken a more cautious and sensible attitude towards this type of therapy? Paul gives several reasons, which includes more pervasive “progressive” ideology in the U.S., the fact that centralized medical care like that in Europe makes it harder to “give patients what they ask for” (and no, not all kids who ask for gender transitioning should automatically get it), and the litigious climate of the U.S., which make doctors hesitant to change course because they could get sued for admitting they were wrong.

I’m a big fan of Paul, not because she’s “antiwoke,” but because she’s sensible and has the courage to speak truths that will get her demonized in the fraternity of NYT “progressives”.  And, of course, because we tend to have confluent opinions.  We also agree on how gender dysphoric young people should be treated, and I’ll finish with Paul’s take, which agrees with the conclusions of The Cass Review:

The Cass Review recommends a more holistic approach to treating gender dysphoria in kids. This involves untangling gender discomfort from common pre-existing conditions like autism spectrum disorder and A.D.H.D. and treating it alongside frequent comorbidities, which include anxiety, self-harm and eating disorders. A mental health counselor can help children with any difficulties during puberty and in coming to terms with their sexual orientation — without pathologizing either.

The goal throughout is to help. This includes working with kids to understand the causes of their gender dysphoria, relieve its symptoms, help resolve it or, in a case that proves persistent, consistent and insistent, help kids understand the pros and cons of pursuing gender reassignment for when they enter adulthood.

Once again we see ideology not only impeding science, but screwing up people’s lives.

The lab leak theory for the origin of the Covid virus is once again deep-sixed

July 1, 2024 • 9:30 am

Yes, I fell for a recent NYT article (June 3) by Alina Chan, a piece dismantled in the article below by infectious disease specialist Paul Offit.  Chan’s piece was called “Why the pandemic probably started in a lab, in 5 key points,” and it was a long and animated op-ed.  Being ignorant of the data, I took her bait and said that Chan’s article buttressed my own view that a lab-leak theory was becoming increasingly credible. (She’s a postdoctoral fellow at the Broad Institute.)

But since I consider Offit the most credible source of information about Covid, I’ve now let go of the bait, and agree with his arguments, in the Substack article below, that a wet-market origin of the Covid virus is the best hypothesis by far.

I guess a lot of other people fell for Chan’s article, too, but I’m especially culpable because I already knew Offfit’s arguments, for last March I’d posted his defense of the “wet market theory” for the origin of Covid.  I simply forgot!

From the new piece, here’s Offit dismissing the lab-leak theory once again:

On June 3, 2024, the New York Times published an op-ed titled, “Why the Pandemic Probably Started in a Lab, in 5 Key Points.” The article was written by Alina Chan, a molecular biologist at the Broad Institute in Boston. Chan had also written a book titled Viral: The Search for the Origin of Covid-19, which also supported the notion that SARS-CoV-2 virus was created in a Wuhan laboratory. Chan’s book has been roundly criticized by scientists who investigated the events in Wuhan. Nonetheless, two thirds of the American public, independent of political affiliation, believe that SARS-CoV-2 virus leaked from a Wuhan laboratory.

Chan’s book, by the way, was coauthored by Matt Ridley.

Click below if you want to see Offit defending the wet-market theory, and, along the way, making Chan and the NYT—which should have had an expert vet her assertions—look sloppy and ignorant.

First, Offit isn’t alone in his opinion; in fact, a wet-market origin seems to be the consensus of Those Who Know:

In her op-ed, Chan wrote, “Although how the pandemic started has been hotly debated, a growing volume of evidence — gleaned from public records released under the Freedom of Information Act, digital sleuthing through online databases, scientific papers analyzing the virus and its spread, and leaks from within the U.S. government — suggests that the pandemic most likely occurred because a virus escaped from a research lab in Wuhan, China. If so, it would be the most costly accident in the history of science.” Chan was wrong to claim the existence of a “growing body of evidence.” On the contrary, her op-ed contained only conspiracies, innuendos, and blatantly false claims. Although several scientists have stepped forward to counter Chan’s claims, the best single take-down was by Dr. Vincent Racaniello, a virologist who hosts a popular podcast called This Week in Virology (TWiV).

In a one-hour video, the TWiV team addressed each of the “Five Key Points” proffered by Chan. The group consisted of Vincent Racaniello (virologist), Alan Dove (microbiologist), Rich Condit (viral geneticist), Brianne Barker (immunologist), and Jolene Ramsey (microbiologist). The video was released on June 10, 2024, one week after Chan’s publication in the New York Times. This wasn’t the first time that the TWiV team had discussed the origin of SARS-CoV-2; it was the ninth. Previous guests have included evolutionary biologists who had directly investigated the events in Wuhan; specifically, Michael Worobey, Kristian Anderson, Eddie Holmes, Marion Koopmans, and Robert Garry, who had collectively published a paper in the journal Science in 2022 titled, “The Huanan Seafood Wholesale Market in Wuhan Was the Early Epicenter of the COVID-19 Pandemic.” This paper showed that all the early cases of SARS-CoV-2 clustered around the southwestern section of a wet market in Wuhan where animals susceptible to coronavirus were illegally sold and inadequately housed. Worobey and his team had shown that 1) the early cases had direct or indirect contact with the market and 2) none of the early cases occurred around the Wuhan Institute of Virology. This single paper was devastating to Chan’s hypothesis.

Chan’s arguments about a lab leak are already cast into doubt by Worobey et al.’s paper described in the second paragraph above (I haven’t heard the TWiV podcast, but readers say it’s very good.)  The epidemiology alone is almost dispositive.

But Offit goes on to dismantle each of Chan’s five arguments.  I’ll put them in bold and give a very brief summary of his refutation.

1.) “Bat corona spillover events in humans are rare.” Not true: many people who live near bats show antibodies indicating exposure to coronaviruses from bats. Further, the potential for spillover events is high given the frequency of contact between humans and carriers like civets.

2.) The Wuhan lab was researching how to make bat coronaviruses more infectious. Although the Wuhan lab studied coronaviruses, there’s not the slightest evidence that those viruses could be precursors to those causing covid.

3.) The Wuhan lab worked under insufficiently strict biohazard conditions. Offit says that the conditions were “Biosafety Laboratory-2”, which, even if the Chinese viriologists were working with SARS-CoV-2, are considered “adequate”.  But they weren’t working with that virus!

4.) Chan says that there was “no way to distinguish between the market [origin] and a [human] superspreader.” Further, she said, “not a single infected animal has ever been shown to be infected with SARS-CoV-2.”  Here Offit destroys her, and I’ll have to quote him.

Re distinguishing origins:

It is at this point that Chan’s op-ed defies common sense. Two different lineages of SARS-CoV-2 virus were detected early in the outbreak. Chan would have us believe that two different SARS-CoV-2 viruses were created in the laboratory and then taken directly by human superspreaders to the southwestern section of the Huanan Wholesale Seafood Market exactly where you would have expected an animal-to-human spillover event to occur. Why didn’t one or both superspreaders go to any of the 10,000 other places in Wuhan to begin a pandemic.

And re the lack of infected animals:

Chan wrote, “Not a single infected animal has ever been shown to be infected with SARS-CoV-2.” When the outbreak began, Chinese authorities shut down the Huanan Wholesale Seafood Market, disinfected the area, and killed the animals likely to have served as intermediates between bats and humans. In other words, no animals were available to test. This was in direct contrast to SARS-1, another animal-to-human spillover event that originated in a Foshan, China, wet market. In that case, the market continued to operate. For that reason, animals that were the likely source of SARS-1 were available for testing. This is perhaps Chan’s most disingenuous comment. You can’t go back in time and test animals that no longer exist.

This relates to Chan’s fifth point:

5.) “Chinese authorities have not done an intense search for animals infected with SARS-CoV-2.”  Again I’ll quote Offit:

True. Mostly because all the animals in the southwestern section of the Huanan Wholesale Seafood Market were immediately slaughtered. Researchers did, however, find genetic evidence of SARS-CoV-2 virus in carts, drains, a feather-and-hair remover, a metal cage, and machines that process animals after they’ve been slaughtered in wet market stalls that were at the epicenter of the outbreak. In the same specimens, they found mammalian DNA consistent with raccoon dogs, bamboo rats, and palm civets, all likely intermediate hosts as bat coronaviruses spilled into the human population.

Given Offit’s credentials and accomplishments, and his strong defense of the wet-market theory above, I agree with his conclusion that the evidence for a wet-market origin is “overwhelming.”  And yes, given that he knows his onions, I’ll apologize for having been so credible with respect to Chan’s NYT article.  The first thing to correct is Chan’s piece, but I don’t expect that the NYT, who could have had her piece looked at by people like Offit, went with it.  And that despite the fact that in 2021 the paper had already reported controversies about Chan’s theories, which included the lab-leak hypothesis.

But let’s put aside the paper’s lack of due diligence, for it’s really important to pinpoint the origin of this virus.  If we want to prevent future pandemics, we need to know whether wet markets can give rise to them, for in that case we can do something tangible to prevent them. On the other hand, if foreign scientists were manipulating coronaviruses and an infectious one escaped the lab, there’s not much we can do.

Fortunately, the first hypothesis seems to be the case, and Offit suggests several fixes: hold the Chinese government accountable for not supervising wet markets, including those that sell illegal animals prone to carrying bat-derived viruses (Offit says that 31 of 38 species in the market were animals protected under Chinese law). Further, he argues that once there’s evidence of a pandemic starting, the Chinese government must allow international teams of scientists into the country, which they didn’t at first dp in Wuhan.  Offit ends by saying, “It’s time we put aside the fruitless, dead-end hypothesis of a lab leak and do the work that is necessary to prevent the next pandemic.”

I’ll keep an eye out for further developments, and again I’m sorry for being credulous about Chan’s paper.  She may be craving the limelight, or may really passionately believe she’s right (or both), but given that the evidence against her theory was already known when she published her op-ed, she’s not acting like a good scientist. And in this case,sloppy science can put people in severe danger.

 

h/t: Frau Katze

The Lancet, apparently off its meds, takes the position that sex is non-binary and that it can change within an individual

June 4, 2024 • 11:45 am

Among all scientific or medical journals, The Lancet is the most woke, and I’ve written about it several times before, once calling it the “medical Scientific American“. For a fuller account of its wokeness, which seems to be entirely the doing of editor Richard Horton, see this piece from the site The Daily Skeptic, which summarizes a lot of craziness in the journal.  The latest mishigass is the long (11-page set of “author guidelines” that you can read by clicking on the link below:

And right near the beginning, on page 2, you read the guidelines for using the terms “sex and gender”.  The bolding of the headers is theirs (I’ve put these in caps), but I’ve taken the liberty of putting in bold several select sections of the text.

REPORTING SEX-BASED AND GENDER-BASED ANALYSES 

Reporting guidance

For research involving or pertaining to humans, animals, model organisms, or eukaryotic cells, investigators should integrate sex-based and gender-based analyses into their research design according to evolving funder/sponsor requirements and best practices within a field. Authors should address their research’s sex and/or gender dimensions in their manuscript. In cases where they cannot, they should discuss this as a limitation to their research’s generalisability. With research involving cells and model organisms, researchers should use the term “sex”. With research involving humans, researchers should consider which terms best describe their data (see Definitions section below). Authors can refer to the Sex and Gender Equity in Research (SAGER) Guidelines and the SAGER guidelines checklist. They offer systematic approaches to the use and editorial review of sex and gender information in study design, data analysis, outcome reporting, and research interpretation. However, there is no single, universally agreed-upon set of guidelines for defining sex and gender or reporting sex-based and gender-based analyses.

DEFINITIONS

In human research, the term “sex” carries multiple definitions. It often refers to an umbrella term for a set of biological attributes associated with physical and physiological features (eg, chromosomal genotype, hormonal levels, internal and external anatomy). It can also signify a sex categorisation, most often designated at birth (“sex assigned at birth”) based on a newborn’s visible external anatomy. The term “gender” generally refers to socially constructed roles, behaviours, and identities of women, men, and gender-diverse people that occur in a historical and cultural context, and might vary across societies and over time. Gender influences how people view themselves and each other, how they behave and interact, and how power is distributed in society. Sex and gender are often incorrectly portrayed as binary (female/male or woman/man), concordant, and static. However, these constructs exist along a spectrum that includes additional sex categorisations and gender identities, such as people who are intersex/have differences of sex development (DSD), or identify as non-binary. In any given person, sex and gender might not align, and both can change. Sex and gender are not entirely discrete concepts and their definitions continue to evolve. Biology and society influence both, and many languages do not distinguish between them. Since the terms “sex” and “gender” can be ambiguous, authors should describe the methods they use to gather and report sex-related and/or gender-related data (eg, self-report or physician-report, specific biological attributes, current sex/gender, sex assigned at birth, etc) and discuss the potential limitations of those methods. This will enhance the research’s precision, rigor, and reproducibility, and avoid ambiguity or conflation of terms and the constructs to which they refer. Authors should use the term “sex assigned at birth” rather than “biological sex”, “birth sex” or “natal sex” as it is more accurate and inclusive. When ascertaining gender and sex, researchers should use a two-step process: (1) ask for gender identity allowing for multiple options and (2) if relevant to the research question, ask for sex assigned at birth. In addition to this defining guidance and the SAGER guidelines, you can find further information about reporting sex and gender in research studies on Elsevier’s diversity, equity, and inclusion in the publishing author guide available here.

Note that everything referred to here deals with HUMANS, as this is a medical journal. Note that the editors specify that “sex” has multiple definitions, but in so doing mix up the way sex is determined in humans (chromosomes carrying sex-determining genes), the way it is observed at birth (usually via genitalia), and the way it is defined (whether an individual has the apparatus for producing big, immobile gametes (“females”) or small, mobile gametes (“males”).

Biologists agree about the gametic definition of sex, which produces the sex binary that I’ve discussed so often, and that definition is not ambiguous. (Note that there are no cases of hermaphrodites in humans that are functional as both males and females, so even if you considere hermaphrodites to be members of a “third sex”, and I don’t, they don’t exist in our species.)

The editors also state twice that sex is “not static” and can change, but biological sex cannot change. What can change is gender—unless you use a hormonally-based definition of sex, which is not tenable and was used only to determine which group someone could compete in athletically. (The Olympics has now abandoned that approach.)

Finally, note that The Lancet recommends the term “sex assigned at birth,” which is simply wrong. Sex is not ASSIGNED at birth, it is observed at birth, but observed using characters like genitalia that are almost always concordant with biological sex but may not be infallible indicators of biological sex.  But regardless, sex is never “assigned” but exists.  The exceptions to the sex binary—individuals who are truly intersex—comprise about 0.018% of people, or about 1 in 5600. As I always say, “that’s as close to binary as you can come.”

Finally, why do the editorial guidelines imply that sex is not “static”?  There is only one reason I can think of, and that’s trying to push on the journal’s readers a gender-activist ideology.  If you truly believe that a transwoman is a woman in terms of biological sex, or a transman is a man in terms of biological sex, then yes, you can say that sex is malleable. But this is not accurate, for using the biological definitions of sex, a transwoman remains a biological man and a transman remains a biological women. (This of course is not to demean them or say that they’re somehow morally unequal to the rest of us; it’s just biology.) In the end, biological sex is not malleable but static.

As the Daily Skeptic notes at the end of its piece:

The Lancet’s guidelines on sex conclude by explicitly telling authors to use the term “sex assigned at birth” because it is “more accurate and inclusive”. I’m imagining a future Lancet article on Elizabeth Garrett Anderson: “She was the first person who’d been assigned ‘female’ at birth to qualify as a doctor in Britain, and she went on to found the first medical school to train people who’d been assigned ‘female’ at birth. All in all, she was a truly remarkable person who’d been assigned ‘female’ at birth.”

If this were some obscure Gender Studies periodical, it wouldn’t really matter. But we’re talking about the world’s second most cited medical journal. It’s read by doctors, surgeons, researchers and all the people to whom we’ve entrusted our health. How can they maintain our trust when they can’t seem to tell the difference between a man and a woman?

Indeed!

h/t: Luana

Is it unethical to allow doctor-assisted suicide for mental illness?

May 30, 2024 • 11:30 am

I may have mentioned this case before, but it’s one that’s guaranteed to cause arguments, for it involves the Netherlands’ policy of allowing doctor-assisted suicide of patients with incurable and debilitating mental illness. The description is at the Free Press, and you can read about Zoraya ter Beck by clicking on the screenshot below:

The U.S, has no such policy, although the following states and countries have medical aid in dying for physical illnesses (see the Wikipedia article for notes and qualifications):

Physician-assisted suicide is legal in some countries, under certain circumstances, including Austria, Belgium, Canada, Luxembourg, the Netherlands, New Zealand, Portugal, Spain, Switzerland, parts of the United States (California, Colorado, Hawaii, Maine,Montana, New Jersey, New Mexico, Oregon, Vermont, Washington and Washington DC) and Australia (New South Wales, Queensland, South Australia,Tasmania, Victoria and Western Australia). The Constitutional Courts of Colombia, Germany and Italylegalized assisted suicide, but their governments have not legislated or regulated the practice yet.

I haven’t looked carefully at all these places to see if they allow physician-assisted suicide for the mentally ill, but as far as I know the Netherlands is unique in this respect. Canada was supposed to allow it, but has put it on hold.

Opposition to general euthanasia is often based on religion (“God will take you when it’s time”), and opposition to euthanasia for mental illness is based on the supposition that the illness may be temporary, so that people might recover and be glad they didn’t choose doctor-assisted suicide.

In my view, not only should people with any intractable illness that causes great pain should be allowed to die legally, and I don’t exempt mental illness. In fact, severe depression or bipolar disorder can be the equivalent of cancer: although mental illness might not kill you by itself, it can make life not worth living, so that death would seem to be an ethical choice for both the patient and the state. Further, at least in the Netherlands there are sufficient protections in place to ensure that a person who has a good chance of recovering will not be euthanized, and that the illness must be intractable as judged from previous medical interventions.

But I digress: click to read (it’s archived here):

The details:

Even as a child, Zoraya ter Beek had a persistent wish to die. Growing up in the quaint Dutch town of Oldenzaal, she never felt as if she fit in. At the age of 21, she was diagnosed with autism; a year later, she started wearing a “Do Not Resuscitate” tag around her neck. Last Wednesday, her wish was finally granted: after a three-year wait, Zoraya ended her life through physician-assisted suicide. She had just turned 29.

. . . .Zoraya received little or no support from her family. When she turned 18, she moved out of her childhood home to live with her boyfriend, Stein. He was ten years older than her, and her parents didn’t approve of the age difference. When I first contacted her, Zoraya had been estranged from her mother and three older sisters for six years. Her father died last year from cancer.

As a young adult, Zoraya felt unable to study, or embark on a career. She told me Stein, who is an IT programmer, was worried about how she felt, and encouraged her to get therapy. Over the course of a decade, she tried everything to relieve the symptoms of her mental illness—including, at last, 33 rounds of electroconvulsive therapy, where electric currents jolt the brain.

Zoraya’s last treatment was in August 2020, after which she says her psychiatrist told her: “There’s nothing more we can do for you. It’s never going to get any better.”

“After we heard that, we all kind of knew what that meant,” Zoraya told me, referring not only to herself but her boyfriend, her friends, and her doctors. “I was always very clear: if it doesn’t get better, I can’t do this.”

I ask you: who would insist that this young woman, in deep pain from mental illness that could not be cured or even helped, stay alive? And why?

And so Zoraya went ahead:

Earlier this month, she told The Guardian: “People think that when you’re mentally ill, you can’t think straight, which is insulting.”

“In the Netherlands,” she added, “we’ve had this law for more than 20 years. There are really strict rules, and it’s really safe.”

Zoraya had great faith in not only the law but also the medical profession.

“Doctors want to help people feel better,” she told me. “Doctors don’t become doctors to kill people, even if that’s what you’re wishing for.”

Nevertheless, Zoraya had a plan B—or, as she called it, an “escape plan”—in case her application didn’t get final approval. It was a suicide kit, which she told me she’d obtained from Exit International, an NGO that advocates for the legalization of voluntary euthanasia.

In the end, she didn’t need it. Zoraya had hoped to be euthanized on her birthday, May 2. But there had been some last-minute bureaucratic delays. Nevertheless, her assisted suicide was approved a couple of weeks ago.

Another argument against assisted suicide for the mentally ill is that it could lead to a “slippery slope,” in which people who aren’t that ill, or pretend that they’re suffering, use it as an exit when they could be cured. But although the number of cases of euthanasia for mental illness is increasing, I know the Netherlands’ criteria are sufficiently strict to halt any slope. The increasing numbers reflects, I think, the public’s increasing acceptance of euthanasia as a humane way to end a miserable life, as well as increasing dissemination of information:

The fact is an increasing number of people suffering from mental illness in the Netherlands are choosing to end their lives. Zoraya is right that the assisted dying law has been around for years, but even as recently as 2010, there were only two recorded cases of medically assisted suicide that involved psychiatric suffering. Last year, there were 138.

But Zoraya is all on board with the regulations as they are, and agrees that they should be strict. And so, with the help of a doctor, she ended her life:

Zoraya told me she didn’t want a funeral, because she didn’t think her friends would want to say goodbye. But she did want her boyfriend to be with her at the end. When I spoke to her, she described how she wanted to die:

I will take my place on the couch. [The doctor] will once again ask if I am sure, and she will start up the procedure and wish me a good journey. Or, in my case, a nice nap, because I hate it if people say, “Safe journey.” I’m not going anywhere.

On Wednesday, a friend of hers posted an announcement on X: “Zoraya passed away today at 1:25 p.m. Or as she saw it herself: she went to sleep.”

Few details of her death have been reported—except that her boyfriend was at her side.

It’s sad to envision this, but we are not at the point where conditions like Zoraya’s can be treated. But again, who can gainsay that she did what was best for her? Who could be so churlish as to say she must stay alive.

The answer: the faithful.

If you want to see religious jobs who argue that prayer and recognize the value of suffering should have kept her alive, read this article in the Catholic Herald: “Zoraya ter Beek deserved doctors who cherished her life as precious.”  A quote from that:

As Catholics, we have a powerful message to tell that there is value to be found in suffering: when we step into church, we are met with the sight of Christ crucified, and are reminded of the agony he bore because he loved us. In fact, it’s because Christ experienced being human that we can be sure that he understands and cares for us in our suffering. Still, most of us are not lawmakers. We’re not campaigners or politicians. Trying to justify our Catholic beliefs to the world can seem overwhelming – almost pointless, when our faith is so often denigrated.

As Catholics, we must continue to remind ourselves of the power of prayer; not exclusively praying for a change of heart of those in positions of power who may choose to legalise assisted dying, though that is of course important, but rather praying in order to cultivate closeness to God in our own lives. We must rely on God first, and only then can we show others that we can help them bear their pain. We must confide in the one who bore the greatest pain for us, and petition, in prayer, to be given the strength to imitate his goodness and his compassion in our own lives. Finally, we must never lose hope, even in cases where a person appears determined to die. We must pray for them to the very end, for by God’s grace, no soul is ever truly beyond saving.

This is the maliciousness of religion: keep the suffering going, for superstition tells us that God will make it all right in the end.  It’s horrible.

Here she is in a video made by The Free Press:

The Lancet extols Indigenous Traditional Knowledge

April 25, 2024 • 11:15 am

The British medical journal The Lancet has become infamous for being woke (its editor is beyond redemption), and is most infamous for the cover below.  As I once said, its wokeness makes it the British version of Scientific American, though it deals with original research and is entirely (or supposed to be entirely) medical in nature.

The journal has just become a bit more infamous by publishing a glowing paean to “Indigenous Peoples and their knowledges” (is “knowledge” suppose to be plural here?), seemingly making the knowledge of indigenous people coequal to the knowledge produced by modern science. In other words, it’s adopting what seems to be the national policy of science education in New Zealand.

Click to read; it’s free (the pdf is here). The authors are from Uganda, Canada, Tanzania, New Zealand (of course), the U.S., and Canada:

The main message, besides the boilerplate about oppression, is that indigenous people have knowledge that is essential in helping us solve not only the problem of global warming, but also “health discourse.”

Now you know that’s not really true. While indigenous people may have some observations bearing on the effects of both human health and especially global warming, it’s up to both national politics and international science to address global warming. (I don’t have much confidence they’ll remedy the problem.) And it’s up to modern medicine to deal with health issues. We’re way beyond the days of herbal cures and chanting. To say that indigenous “knowledges” is not only important, but “the optimal way forward” (see below) is to indulge in hyperbolic and performative rhetoric.

But let me give a few quotes.

Indigenous Dene Elder Francois Paulette from northern Canada talked about climate change at the 2015 Parliament of the World Regions and warned “Your way of life is killing my way of life.”
He ended his speech with the words: “Rise! It’s time to stand up for our future.”More than 8 years after this speech, an estimated 68% of the Northwest Territories, Canada, which includes the Dene Peoples territory, was evacuated due to 238 wildfires. Communities lost their homes and hunting and food-foraging areas and were exposed to poor air quality for months on end. Elder Francois’ words still ring true today for many Indigenous Peoples around the globe. We are still far away from the world understanding the impacts of climate change on Indigenous communities and the need to move towards efficient and comprehensive action for planetary health.

 

Indigenous Peoples have experienced historical and ongoing colonialism, ecocide, epistemicide, racism, and severe marginalisation and are disproportionately affected by poverty and reduced life expectancy.Yet despite these challenges they continue to protect and steward about 80% of all the remaining biodiversity on Earth. For Indigenous Peoples, every day is Earth Day, with the basis of their lives underpinned by a healthy relationship with the planet and extensive Indigenous Traditional Knowledges (ITK) developed over millennia. However, Indigenous leadership within planetary health practice to shape research, policy, and practice is still challenged by a multitude of factors.

It’s simply not true that indigenous people steward 80% of the Earth’s biodiversity. First of all, the reference seems to be talking only about Australia. Second, the reference appears to show that 80% of the Earth’s biodiversity occurs in areas occupied by indigenous people. There’s no evidence I can find that the locals are “stewarding” that biodiversity beyond the statement, “This highlights how indigenous communities have mastered how to live alongside nature in a way that other communities have not.” It seems that living in areas with biodiversity is equivalent to “stewarding” that biodiversity. But we know that’s not true. In many cases indigenous people have destroyed biodiversity, like the extensive burning of natural forest by the Māori or the burning of prairie by Native Americans not to preserve it, but to get food, as well as their mass slaughter of bison by driving them o0ver the cliffs. That killed far more animals than they can use. What kind of “stewarding” is that?

ITK is also extolled for its “practical knowledge”; and indeed, that’s where it excels: understanding the place and rhythm of where food grows, how to catch that food, how to make stuff that one needs to live (knives, baskets, and so on). But ITK is not equivalent to modern science in many ways that are important: ITK is not generally driven by hypothesis testing, double-blind congrolled experiments, statistics, an atmosphere of doubt, and so on. While ITK is a bag of practical observations, modern science is a bag of tools for finding out stuff.

The article also has the obligatory denigration of “western” science, too, and a denial that indigenous “ways of knowing,” contain more than empirical fact. But in fact ITK, like New Zealand’s Mātauranga Māori, comprises far more than practical knowledge, including religion, mythology, traditional stories, superstition, morality, and guidlines for living. My bolding below:

ITK is increasingly informing climate and biodiversity solutions.  Although this is positive for Indigenous recognition, Indigenous Peoples who hold this knowledge are not usually directly involved in leading such efforts due to structural marginalisation. Implementation movements need to ensure that Indigenous Peoples and their rights are platformed first and foremost within any discussion around ITK. Additionally, ITK is often deemed myth or legend, or faces erasure within western-based institutions, despite it being replete with practical understandings of ecology, meteorology, and the relationship to the environmental rhythms gained over generations of observation and experimentation. Scientific disciplines, including within the medical and health sciences fields, therefore continue to largely marginalise ITK and there are expectations that it should conform to a western standard of evidence as the sole grading rubric of validity—a demonstration of the continuing effects of colonisation.

Well, yes, we need to bring as many voices as possible within science, but by “voices,” I don’t mean “ethnic groups”. I mean we should cast the net as wide as possible looking for scientific talent, and if we find a bit of practical indigenous knowledge to help move science forward, well, so much the better. But in the end, the statement in bold gives away the authors’ desire to “decolonize” modern science: “western standards of evidence” are apparently not the only standards of evidence for judging knowledge. But if they aren’t, what other standards should we use?  Tradition, superstition, and so on? Modern science is simply a toolkit of methods used to ascertain what is true. And there are no other ways to find out what’s “valid” beyond that. (I’m using “science” as “science construed broadly” here, as, for example, what a mechanic does to find out where the problem is in a car.) If the authors think there are ways of knowing beyond this, let them tell us. As it is, you won’t find a single example in this article besides the unsubstantiated claim that indigenous people “steward” 80% of the world’s biodiversity.

It’s hard for me to go on, as this article suffers from the diagnostic problem of all such sacralizations of indigenous knowledge: a lack of examples of how indigenous knowledge has contributed to modern knowledge. A few anecdotes will not suffice. After all, the National Science Foundation has just allocated $29 million to establish a “Center for Braiding Indigenous Knowledges and Science (CBIKS)”, and there had better be substantial payoff to justify that kind of dosh.

The article goes on, but the ideas are familiar: because indigenous people were oppressed and treated badly (often true!), their “knowledges” should be seen as almost sacred, but certainly very valuable, and coequal to “western” science. But if you look at the advances that modern science has made in just 150 years in physics, chemistry, biology, and so on, none of them would even be possible with indigenous knowledge. Yet that knowledge is to be considered highly important, and, without it, say the authors, science is blinkered:

Without meaningful engagement and data representation, Indigenous initiatives are sidelined or neglected. Indigenous Peoples and their knowledges should not just be “considered” within climate change and health discourse and practice, which is typically the case now, but platformed as the optimal way forward.

Platformed as the optimal way forward? What does that mean? Why can’t ITK just be “considered”?  Finally, we hear once again the notion that ITK is one of two essential eyes in science’s way of finding knowledge (I believe this metaphor comes from Canada’s First People):

 Researchers, practitioners, and policy makers need “to see from one eye with the strengths of Indigenous ways of knowing, and to see from the other eye with the strengths of western ways of knowing, and to use both of these eyes together” for the survival of our planet. We need to understand that Ko au te awa, ko te awa ko au (I am the river, and the river is me).

You see how both eyes are considered necessary and coequal to move science forward? I don’t think that’s the case.  Indigenous ways of knowing can, as I’ve said, add practical knowledge to what modern science has found, but it’s by no means a coequal “eye.” And I don’t understand why I have to adopt the mantra that the river is me to study hydrology. After all, I never learned much about genetics from thinking “I am the fruit fly, and the fruit fly is me.”

I’ll regard indigenous knowledge as more important when its promoters start giving us examples—real examples, not anecdotes about catching eels—of how it has made, or can make, important contributions to empirical knowledge.  We shall see what the NSF’s $29 million produces.

Guest post: The new Cass Review

April 18, 2024 • 9:15 am

The final version of the Cass Review (formally the “Independent Review of Gender Identity Services for Children and Young People”) was issued on April 10. Here’s a brief summary by the CBC, noting that doctors and others have griped about it:

A long-anticipated — and contentious — national review of gender-affirming care for youth in England was released last week, resulting in headlines across the U.K. saying that gender medicine is “built on shaky foundations.”

The Cass Review, chaired by pediatrician Hilary Cass, was commissioned by England’s National Health Service (NHS) in 2020.

Even before the final report was published, the review has led to significant changes for youth gender medicine in England, where the debate over transgender care has become increasingly heated, with complaints of both long waiting lists and medical treatments being too readily available to youth.

Last month, the Cass Review findings led to a ban on the prescription of puberty-suppressing hormones except for youth enrolled in clinical research.

That’s a move away from the standard of care supported by many international medical bodies, including the Canadian Pediatric Society (CPS), the American Academy of Pediatrics and World Professional Association for Transgender Health. Though several European countries including Sweden have also restricted access to puberty blockers and other medical treatments for youth.

The report cites a systematic review of evidence, commissioned as part of the Cass Review, which found “a lack of high-quality research” that puberty blockers can help young people with gender dysphoria.

While experts in the field say more studies should be done, Canadian doctors who spoke to CBC News disagree with the finding that there isn’t enough evidence puberty blockers can help.

I had no time to read the long report, and didn’t think that just regurgitating a summary for the readers was sufficient. But reader Jez told me he was going through it, and I asked him if he wouldn’t mind writing his take for this site. He kindly agreed, and so, without further ado. . . .

First, though, Jez notes

“The Cass Review’s final report (and its other publications) are available here.

 

THE CASS REVIEW: A READER’S TAKE

by Jez Grove

Since around 2014, the number of children and young people presenting at gender clinics in the Western world has surged and the patient profile has switched dramatically from predominantly pre-pubertal males to teenage females. Both changes are unexplained. The treatment offered to these patients has also significantly shifted: a psychosocial and psychotherapeutic approach has given way to many being offered medical treatment with puberty blockers (gonadotropin-releasing hormone analogues, GnRH) and cross-sex hormones.

In September 2020, Dr Hilary Cass, a retired consultant paediatrician and former President of the Royal College of Paediatrics and Child Health, was appointed to undertake a full review into how NHS England* “should most appropriately assess, diagnose and care for children and young people who present with gender incongruence and gender identity issues [and] to make recommendations on how to improve services […] and ensure that the best model/s for safe and effective services are commissioned”. [Cass Review Final Report, henceforeth “CRFR”, Appendix 1: Terms of Reference]

The Cass Review’s Interim Report (2022) highlighted that a lack of evidence on the medium- and long-term outcomes of the treatments that children and young people were receiving was limiting the advice that the Review could give. In response, it commissioned an independent research programme to provide “the best available collation of published evidence, as well as qualitative and quantitative research to fill knowledge gaps” and set up a Clinical Expert Group to help it interpret the findings. [CRFR, p. 25]

The Interim Review also warned that social transitioning (changing, name, appearance and pronouns, etc.):

. . . .“may not be thought of as an intervention or treatment, because it is not something that happens within health services. However, it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning. There are different views on the benefits versus the harms of early social transition. Whatever position one takes, it is important to acknowledge that it is not a neutral act, and better information is needed about outcomes”. [Cass Review Interim Report, henceforth”CRIR”; pp 62-63]

The findings of the Interim Report led to the closure of the Gender Identity Development Service (GIDS) last month.

Last week, the Cass Review published its Final Report. Dr Cass begins it with an apparent effort to placate her critics; her opening sentences read:

“This Review is not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves, or rolling back on people’s rights to healthcare. It is about what the healthcare approach should be, and how best to help the growing number of children and young people who are looking for support from the NHS in relation to their gender identity”. [CRFR, Foreword from the Chair, p. 12]

However, she is not blind to the problems that have developed in this area of healthcare:

“It often takes many years before strongly positive research findings are incorporated into practice. There are many reasons for this. One is that doctors can be cautious in implementing new findings, particularly when their own clinical experience is telling them the current approach they have used over many years is the right one for their patients. Quite the reverse happened in the field of gender care for children. Based on a single Dutch study, which suggested that puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence, the practice spread at pace to other countries. This was closely followed by a greater readiness to start masculinising/feminising hormones in mid-teens, and the extension of this approach to a wider group of adolescents who would not have met the inclusion criteria for the original Dutch study. Some practitioners abandoned normal clinical approaches to holistic assessment, which has meant that this group of young people have been exceptionalised compared to other young people with similarly complex presentations. They deserve very much better”. [CRFR, Foreword from the Chair, pp. 13-14]

The problems with the evidence base that sparked the Review persist, with Cass writing that the independent research programme she had commissioned

. . . .“has shown that there continues to be a lack of high-quality evidence in this area and disappointingly […], attempts to improve the evidence base have been thwarted by a lack of cooperation from the adult gender services.  The Review has therefore had to base its recommendations on the currently available evidence, supplemented by its own extensive programme of engagement”. [CRFR, p. 20]

The failure of the UK’s adult gender services to cooperate is perhaps the most shocking revelation in the report. As Cass notes,

“When clinicians talk to patients about what interventions may be best for them, they usually refer to the longer-term benefits and risks of different options, based on outcome data from other people who have been through a similar care pathway. This information is not currently available for interventions in children and young people with gender incongruence or gender dysphoria, so young people and their families have to make decisions without an adequate picture of the potential impacts and outcomes”. [CRFR, p. 33]

A quantitative data linkage study was intended to

. . . “use existing data held by the NHS, including data from GIDS, hospital wards, outpatient clinics, emergency departments and NHS adult GDCs, to track the journeys of all young people (approximately 9,000) referred to the GIDS service through the system to provide a population-level evidence base of the different pathways people take and the outcomes. This type of research is usual practice in the NHS when looking to improve health services and care received.  However, this has not been the case for gender-questioning children and young people and the hope was that this data linkage would go some way to redress this imbalance”. [Cass Review Final Report, p. 190]

Despite its “not particularly unusual” methodology, it took more than a year for the study to receive ethics approval from the Health Research Authority (HRA); Cass considers the “robust scrutiny and consideration [to be] entirely appropriate given the sensitivity of the subject matter”. [Ibid.] The independent research team “undertook stakeholder engagement and developed the patient notifications and communications resources to explain the research and provide information about how to opt-out of the study should an individual choose to do so. […] In January 2024, the Review received a letter from NHS England stating that, despite efforts to encourage the participation of the NHS gender clinics, the necessary co-operation had not been forthcoming”. [Ibid.] Appendix 4 of the Review sets out the details and history of the “thwarted” study.

The proposed linkage study had been complicated by the fact that, uniquely, GIDS patients are issued new National Health Service (NHS) numbers when registering their new gender identity. Cass notes:

“From a research perspective, the issuing of new NHS numbers makes it more difficult to identify the long-term outcomes for a patient population for whom the evidence base is weak”. [CRFR, p. 229]

The UK government had to bring forward a special legislative instrument to facilitate linking the patients’ new and old NHS records; NHS England had vowed to pursue the thwarted research before the special instrument’s powers expire in 2027.

There are other serious unintended consequences of allowing young patients to change their NHS numbers. Cass writes,

“Safeguarding professionals have described a range of situations where this has put children/young people at risk. These include young people attending hospital after self-harm not being identifiable as a child already on a child protection order; records of previous trauma and/or physical ill health being lost; people who do not have parental responsibility changing a child’s name and gender; children being re-registered as the opposite gender in infancy; children on the child protection register being untraceable after moving to a new area”. [CRFR, p. 229]

While Cass has been unable to use a stronger evidence base, she has provided a valuable service in bringing together an independent and thorough assessment of the existing research in areas related to the assessment, diagnosis, and treatment of gender-confused children and young people and suggested a way forward.

The Review gives:

  • An overview of the patient profile, including mental health and neurodiversity, adverse childhood experiences, theories about the rise in referrals and the change in case mix, and the weak evidence with regard to suicidality.
  • An important appraisal and synthesis of the available international guidelines. Cass notes,

“For many of the guidelines it was difficult to detect what evidence had been reviewed and how this informed development of the recommendations. For example, most of the guidelines described insufficient evidence about the risks and benefits of medical treatment in adolescents, particularly in relation to long-term outcomes. Despite this, many then went on to cite this same evidence to recommend medical treatments.

Alternatively, they referred to other guidelines that recommend medical treatments as their basis for making the same recommendations. Early versions of two international guidelines, the Endocrine Society 2009 and World Professional Association for Transgender Healthcare (WPATH) 7 guidelines influenced nearly all the other guidelines. These two guidelines are also closely interlinked, with WPATH adopting Endocrine Society recommendations, and acting as a co-sponsor and providing input to drafts of the Endocrine Society guideline. WPATH 8 cited many of the other national and regional guidelines to support some of its recommendations, despite these guidelines having been considerably influenced by WPATH 7. The links between the various guidelines are demonstrated in the graphics in the guideline appraisal paper (Hewitt et al., Guidelines 1: Appraisal).

The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.” [Cass Review Final Report, p. 130]

  • An overview of the existing clinical approach and clinical management and recommendations to improve them.
  • Recommendations for a new service model for NHS England, including follow-through services for 17-25 years-olds to ensure continuity at “a potentially vulnerable stage in their journey” and “allow clinical and research follow-up data to be collected”. [CRFR, p. 225] She also stresses the needs for detransitioners to be supported and warns of the dangers of private healthcare providers outside the NHS not following its policies.
  • Finally, she cautions that, while innovation in healthcare is important, there must be a “proportionate level of monitoring, oversight, and regulation that does not stifle progress, but prevents creep of unproven approaches into clinical practice. Innovation must draw from and contribute to the evidence base”. [Cass Review Final Report, p. 231]

To critics who say the Cass Review tells us nothing new, surely the onus is on them to justify continuing to provide children and young people with “gender-affirming care”, care for which we already knew there is no reliable evidence on the medium-and long-term outcomes.

______________________

* Health is devolved in the UK; Scotland, Wales, and Northern Ireland (and indeed all other  healthcare services) are free to ignore the Cass Review’s findings, but may be unwise to do so.

Is assisted dying moral for patients with severe, deblilitating, and incurable mental illness?

April 14, 2024 • 10:00 am

UPDATE: I forgot one argument of which readers reminded me: the “slippery slope argument.”  To wit:

5. Assisted suicide laws could lead to a “slippery slope” condition whereby shady doctors allow people to be medically euthanized for curable conditions, or even to allow relatives to kill their grandmothers.  Yes, this is a danger, though one that can be ameliorated with sufficient stringent vetting laws.  The “kill your grandmother” argument can be prevented completely, and certifying certain doctors and shrinks for their objectivity in vetting would be another good step. But when weighed against the suffering eliminated by assisted dying laws, I think the slippery-slope argument, while surely worth considering, is outweighed.

________________________

Assisted suicide for people who have severe and incurable mental illness has always seemed a no-brainer to me, but I’m surprised at the number of people who push back when I bring this up.  But, if the procedure is implemented properly, the objections to it don’t seem tenable, and in the end seem to resemble arguments against abortion.  That is, the pusher-backers say that people in tough spots shouldn’t have control over their bodies, that the procedure might spread if it’s allowed, and, underneath the objections of many, we find religious feelings—in this case feelings like “God will take you when He’s ready, not when you’re ready.”

Yet it seems to me undeniable that some cases of mental illness, like the main one documented in the Free Press article below, are so severe that they resemble terminal illnesses—illnesses for which enlightened people would favor assisted suicide (I might use the term “euthanasia”) in this post.  If you’re terminally depressed, in horrible mental pain all the time, constantly thinking about suicide, and have tried every possible remedy without any success, then why aren’t you in a position similar to that of a cancer patient who, having tried all remedies, now faces a finite term of horrible pain ending certain death? (I presume you’re aware that even in states not permitting assisted suicide, doctors often mercifully end the lives of such patients by giving them an overdose of morphine.)

The difference with mental illness is that death is not certain and the pain will last a lifetime. Sure, maybe researchers will come up with a cure for an intractable mental illness, but that also holds for terminal physical illnesses. People with bad prognoses often hope that a cure will be discovered before they die.

Now for the state to effect euthanasia, there must of course be restrictions.  Beyond that, anybody has, in my view, the right to kill themselves by other means, like hanging, shooting, or jumping in front of a train. That kind of suicide is illegal, though I think the illegality is nuts. But for the government to help you die, it’s not proper to provide anybody with the means of euthanasia. There are many reasons, but I won’t enumerate them.

Naturally, in places where euthanasia is officially legal (see the map below), there are such restrictions for the physically ill:

Physician-assisted suicide is legal in some countries, under certain circumstances, including Austria, Belgium, Canada, Germany, Luxembourg, the Netherlands, New Zealand, Portugal, Spain, Switzerland, parts of the United States and all six states of Australia. The constitutional courts of Colombia, Germany and Italy legalized assisted suicide, but their governments have not legislated or regulated the practice yet.

In most of those states or countries, to qualify for legal assistance, individuals who seek a physician-assisted suicide must meet certain criteria, including: they are of sound mind, voluntarily and repeatedly expressing their wish to die, and taking the specified, lethal dose by their own hand. The laws vary in scope from place to place. In the United States, PAS [physician-assisted suicide] is limited to those who have a prognosis of six months or less to live. In other countries such as Germany, Canada, Switzerland, Spain, Italy, Austria, Belgium and the Netherlands, a terminal diagnosis is not a requirement and voluntary euthanasia is additionally allowed.

Below is a map of where assisted suicide is legal throughout the world, and there aren’t many places. The states in the U.S. where it’s legal include Maine, Hawaii, Washington D.C., Washington State, Colorado, New Mexico, New Jersey, Vermont, and Oregon. But in no state is assisted suicide permitted for those with mental illness. For physical illnesses or other conditions that are likely to kill you in a few months, here are the general criteria in the U.S.:

  • an adult as defined by the state
  • a resident of the state where the law is in effect
  • capable of using the prescribed medications without assistance
  • able to make your own healthcare decisions and communicate them
  • living with a terminal illness that is expected to cause death within 6 months as verified by qualified healthcare professionals

Places where assisted dying is legal (see the key for variations):

Vgonzalez630, CC BY-SA 4.0, via Wikimedia Commons

Places that permit euthanasia for those with mental illnesses include only the Netherlands, Belgium, Luxembourg, Switzerland, and—perhaps after 2027—Canada. I haven’t looked up the criteria for state assistance for euthanasia for the mentally ill in all four countries, but here are the criteria for the Netherlands given in the Free Press article below by writer Rupa Subramanya.

Dutch law requires those seeking assisted suicide to show they are in great pain, have no alternative, and are acting of their own volition. They also must get sign-off from at least two doctors, including a psychiatrist. The process can take a few years, culminating with a doctor giving the patient a fatal medication or, if done by oneself, a cup filled with poison to drink. When it’s over, a government panel reviews the case to ensure everything was above board.

Click below to read the article. The woman pictured, Zoraya ter Beek, suffered her whole short life from depression, autism, and borderline personality disorder, and said she was in constant pain. Nothing helped, and eventually the doctors and shrinks said there was nothing more that they could do for her. Tired of living, she applied for and qualified for assisted suicide. She is still alive but scheduled to die in May. (That isn’t final, of course, for I’ve read of such patients who change their minds at the last minute, willing to go on but heartened by the fact that at any time they could choose to die.) Her boyfriend loves her, but agrees with her decision.

Here are some of the objections to assisted suicide for mental illness, and my responses (all text is mine).

1.) The patient could get better but, by taking their life, are depriving themselves of a livable and perhaps enjoyable future. Yes, but that’s true of even physical illnesses. Besides, the prognosis must be confirmed by several doctors and examined post facto by the state.  And I would ask those who make this argument, “Who are you to tell someone that they must go on living when they’re in intractable pain?”  For those of us who have been severely depressed, it’s hard to convey to others that this kind of severe and prolonged mental pain is fully capable of making you wish to die.

2.) It’s up to God to determine when you die, not you.  As an atheist, or even as a rationalist, I find this argument bogus. Here it’s similar to the religious argument against abortion, assisted suicide for physical illnesses, or, as Peter Singer discusses, euthanasia for newborn babies who have a condition that will cause them to suffer and, ultimately, kill them with certainty in a short time. Besides, are you going to base medical decisions on assuming that there’s a god for which we have no good empirical evidence? Isn’t medical treatment supposed to be based on empirical criteria?  Do you tell a dying atheist that you can’t increase the morphine drip because God doesn’t want that?

Here’s a quote from the article:

All this pointed to a “dystopian view of the future,” said Theo Boer, the healthcare ethics professor.

“Whether or not you’re religious, killing yourself, taking your own life, saying that I’m done with life before life is done with me, I think that reflects a poverty of spirit,” Boer told me.

. . . . Theo Boer, the bioethicist, acknowledged that none of the suicides in the Bible is condemned, but he added that they are not lionized or commemorated either.

“Suicide in the Bible belongs in the realm of the tragic, and the tragic should not be condemned—nor should it be regulated or celebrated,” he said.

This palaver, including the phrases “Life is done with me” and “poverty of spirit” seems to reflect religious belief, but it’s already clear from opposition to euthanasia in many places (especially the U.S.) that we shouldn’t cut short what is up to God to determine. But if God is omnipotent, wouldn’t He be behind a mentally ill person’s decision to have assisted euthanasia?

3.) It’s contagious.  There are several statistics given in the article about assisted dying increasing over time. Most are for physical conditions, with only one for mental illness (my bolding)

In 2001, the Netherlands became the first country in the world to make euthanasia legal. Since then, the number of people who increasingly choose to die is startling.

In 2022, the most recent year for which there is data, Dutch officials recorded 8,720 cases of euthanasia, a 13.7 percent increase from 2021, when there were 7,666 cases. To put this in perspective, there were a total of 170,100 deaths in the Netherlands in 2022—meaning euthanasia cases comprised more than 5 percent.

“This upward trend, in both the absolute and relative numbers, has been visible for a number of years,” the country’s Regional Euthanasia Review Committee’s 2022 Annual Report states. What’s more, the number of euthanized people between the ages of 18 and 40 jumped from 77 in 2021 to 86 in 2022. And the number of people with psychiatric disorders who choose euthanasia is rising: In 2011, there were just 13 cases; in 2013, there were 42; and by 2021, there were 115. 

This trend is not limited to the Netherlands. From 2018 to 2021, countries where euthanasia or assisted suicide is most popular saw sizable increases in the number of people signing up to die: In the United States, where ten states and the District of Columbia have physician-assisted suicide, there was a 53 percent jump; in Canada, 125 percent.

But why wouldn’t you expect the numbers to rise as people become aware that they have this alternative? It’s not written about very often, so you have to see articles like this to find out about it.  But even so, this is a question of ethics, not of statistics.  If the regulations are sufficiently rational and stringent that they prohibit spur-of-the-moment suicides or mental conditions for which every possible cure hasn’t been tried, why should we care about the increase? And wouldn’t you want the ability to die a peaceful and painless death if you had a condition that could be terminated in a peaceful way, at a time and place of your choosing, and when you are surrounded by loved ones? (This is, as I’ve learned, the way it usually occurs.)

4.) It hurts those who are left behind.  I’ve heard this argument used often against those who discuss self-inflicted suicide. “If you kill yourself, think of all the people who will miss you and be in pain.” But this seems eminently selfish to me.  Everybody who dies before their friends, relatives, and loved ones (and that means all of us) faces that as a certainty.  If someone’s in intractable physical pain and dying of cancer, would you tell them to hang on for your sake? Of course not! The same holds for incurable mental illnesses. It’s selfish and boorish to ask someone to stay alive for the sake of your—or other people’s—feelings.

For #5, see the update at top. 

For some people, suicide is simply a no-go zone, which is why suicide hotlines exist to talk those who wish to die out of that wish. But that’s different, for someone who calls a hotline has a good chance that they’re simply emitting a cry for help, and want to be talked out of it. (However, some do kill themselves.) That’s why I think those hotlines are great things. But assisted dying with stringent criteria needed to qualify, and the use of drugs that assure a painless death, are not equivalent to a suicide hotline.

I’m sure that ethical philosophers have discussed this issue before, and feel free to cite articles below if you know of them (I don’t).  These are of course tentative ideas that I’ve thought about for a long time (note: I’m NOT a candidate!), and were given shape by the article above, but I’m willing to listen to other points of view. If you have them, or if you agree with what I’ve said, weigh in below. But do read the Free Press piece.