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Effects of euthanasia on the bereaved family and friends: a cross sectional study

Journal article and commentary thereon

This article by Nikkie B Swarte of the Utrecht university medical centre, Netherlands, et al. appeared in the 26 July 2003 British Medical Journal. The commentary which follows is by Dr Greg Pike of the Southern Cross Bioethics Institute, Plympton, South Australia. This paper has several difficulties. These are listed below.

Without knowing the questions asked, it is difficult to know whether a bias has been introduced by the specific wording in some questions, eg question on religiosity.
Partners, parents, children, siblings and friends of those who died were all lumped together, even though one would expect them to grieve very differently. It is a big assumption that the two groups could be matched effectively given the complexity of confounders involved in a grief response.
Relatives and friends of euthanasia patients were more likely to be described as 'other' (ie cousins, in-laws & friends rather than partners, siblings or children). This difference between the two groups was not discussed, even though it would be expected that, since the respondents in the control group (relatives and friends of those who died naturally) were more closely related to the patient, they would grieve more. In their analysis, the authors say they have compensated for this difference. However, the means by which they did so are all important, and we are not told.
Relatives and friends of euthanasia patients were less religious - this was not discussed even though in their analysis, the authors say they compensated for this factor. But if this factor was a simple yes/no question on religiosity, then the two groups could still have different belief systems but this would be undisclosed and hence could not be taken into account.
Relatives and friends of euthanasia patients were more educated - this was not discussed, even though it was compensated for. Again, the means of compensation are all-important. Furthermore, it is an interesting possibility that 'more educated' might mean more inculcated into the ethos of a rationalized chosen death.
An attempt was made to assess personality differences among participants by use of a test for neuroticism - however, this is acknowledged by the authors to be limited, since there are many other facets of personality.
The authors suggest that their results could be explained by the "capacity of patients to acknowledge their prognosis", and that in the group who died of natural causes, what was occurring was "prognostic denial of deeply distressed patients." They suggest that the families and friends may have colluded in this denial and therefore experienced greater grief afterwards as a result. What the authors are really saying is that patients who died of natural causes didn't face up to their impending death and neither did their family or friends, who were then not able to cope as well with their grief compared with the family and friends of those who chose euthanasia. But there is no evidence given for 'prognostic denial.' It is purely speculative.
The following is one of the concluding sentences: "There is a need for open awareness of impending death and for careful and thoughtful planning for where and how the death ought to occur." In the context of what the authors conclude, this implies that a natural death does not have as much "open awareness of impending death". But there is no evidence given to suggest this. Moreover, to suggest that "there is a need for ... careful and thoughtful planning for where and how the death ought to occur" is an endorsement of euthanasia even though the authors later say that "our results should not be interpreted as a plea for euthanasia."
This study assumes that grief responses were accurately stated and not influenced by the views of participants about the legitimacy of euthanasia. If participants understated their grief, even subconsciously, in order to support the decision of their loved one, the results could become skewed if one group did so differently compared to the other.
In their introduction the authors note that "lack of religion or spiritual belief" has been identified as a "risk factor for developing traumatic grief." Even though in this study the authors say they have compensated for religiosity, there appears to be little difference before and after such adjustment. Therefore, in this study religiosity does not appear to protect against traumatic grief, and if anything may exacerbate it. This discrepancy compared to other studies remains a contradiction.

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