Monthly Archives

October 2016

Peter Saunders – The slippery slope of euthanasia – The evidence

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Disabled newborns are being killed LEGALLY in The Netherlands: here’s the proof 
LifeSiteNews 14 May 2013
Family First Comment: In case you thought the ‘slippery slope’ was questionable, Dr Peter Saunders who spoke at our Forum on the Family last year puts it beyond doubt that the slippery slope is well greased and working fast.

In an interview this morning on BBC Five Live on the Paul Lamb case I was asked by the presenter Nicky Campbell about evidence for a slippery slope following the legalisation of euthanasia in other jurisdictions.
In my answer I mentioned the steady escalation in numbers of cases in Belgium and the Netherlands (see here and here) and said that one third of nurses had carried out euthanasia illegally in Belgium and that one third of cases in some parts of Belgium had been involuntary, although the law did not allow this.
I also mentioned the ‘Groningen Protocol’ under which disabled babies had been given lethal injections in the Netherlands.
Campbell appeared not to know about this and asked me on air to email him information about it to which I agreed. Another BBC journalist phoned me after the interview to check my sources.
I sent her a link to the original paper on the ‘Groningen Protocol’ from the New England Medical Journal in 2005.
The full reference is ‘Verhagen E, Sauer P. “The Groningen Protocol—Euthenasia in Severely Ill Newborns.” New England Journal of Medicine 2005; 352(10):959-62’
It says that ‘Twenty-two cases of euthanasia in newborns have been reported to district attorneys’ offices in the Netherlands during the past seven years’ but also highlights underreporting:

‘Given that the national survey indicated that such procedures are performed in 15 to 20 newborns per year, the fact that an average of three cases were reported annually suggests that most cases are simply not being reported.’

The 22 babies killed all had spina bifida and/or hydrocephalus – conditions which many disabled people live with in Britain today (Here is another report on the protocol from CBHD citing the 22 documented cases).
Under the ‘Groningen Protocol’ the termination of a child’s life (under age 12) is acceptable if four requirements were properly fulfilled:

  1. The presence of hopeless and unbearable suffering
  2. The consent of the parents to termination of life
  3. Medical consultation having taken place
  4. Careful execution of the termination

More recent reports suggest there has been a reduction in cases of direct newborn euthanasia in the Netherlands since 2005 because of 1. More efficient prenatal detection and late abortion 2. More use of ‘terminal sedation’ not recorded officially as euthanasia 3. Continued underreporting.
Other issues I mentioned to the BBC in my email included:
1. Almost half of Belgium’s euthanasia nurses have admitted to killing without consent, despite the fact that involuntary euthanasia is illegal in Belgium and that nurses are not allowed to perform even voluntary euthanasia.
2. In Belgium, nearly half of all cases of euthanasia are not reported to the Federal Control and Evaluation Committee. Legal requirements were more frequently not met in unreported cases than in reported cases and a written request for euthanasia was absent in 88%.
3. A recent study found that in the Flemish part of Belgium, 66 of 208 cases of ‘euthanasia’ (32%) occurred in the absence of request or consent.
4. According to a recent report Belgium is now the ‘world leader’ in organ removal after euthanasia with at least nine cases since 2005 but suggestions are that there would have been many more had more euthanasia patients had transplantable organs.
5. The stunning 5,000% increase in Belgian euthanasia cases in eleven years since legalisation.
6. Summary of recent developments in Netherlands documenting a 15-20% increase in euthanasia cases per year since 2006 (gives good overview of overall situation).
7. The latest Lancet paper on the subject giving 12.3% as the figure for terminal sedation deaths in the Netherlands and summarising other past papers in NEJM/Lancet
READ MORE: https://www.lifesitenews.com/blogs/disabled-newborns-are-being-killed-legally-in-the-netherlands-heres-the-pro

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Legalise euthanasia, and compassionate society dies too

By | Recent News

The Australian 4 October 2016
Family First Comment: “The justification for euthanasia lies in human rights, individual autonomy and relieving pain — all worthy ideas, and that may prompt the question: why then is euthanasia still opposed by most nations, most medical professional bodies around the world and the Australian Medical Association? The reason is not hard to find. It is because crossing the threshold to euthanasia is the ultimate step in medical, moral and social terms. A polity is never the same afterwards and a society is never the same. It changes forever the doctor-patient bond. It is because, in brutal but honest terms, more people will be put at risk by the legislation than will be granted relief as beneficiaries. The argument against euthanasia has endured for many years: it leads, on balance, to a less compassionate society that creates a new series of moral and practical hazards for itself. It is a disproportionate response to the real problem of patient pain that needs more care and money.”
If you love your parents, respect your children, care for your society and think compassionately about your world then it is time to open your heart and brain to what happens when a jurisdiction legalises killing or, as it is called, euthanasia.
The justification for euthanasia lies in human rights, individual autonomy and relieving pain — all worthy ideas, and that may prompt the question: why then is euthanasia still opposed by most nations, most medical professional bodies around the world and the Australian Medical Association?
The reason is not hard to find. It is because crossing the threshold to euthanasia is the ultimate step in medical, moral and social terms. A polity is never the same afterwards and a society is never the same. It changes forever the doctor-patient bond. It is because, in brutal but honest terms, more people will be put at risk by the legislation than will be granted relief as beneficiaries.
The argument against euthanasia has endured for many years: it leads, on balance, to a less compassionate society that creates a new series of moral and practical hazards for itself. It is a disproportionate response to the real problem of patient pain that needs more care and money. It is because a society that legalises killing has to change fundamentally in terms of the ethics of its doctors, its medical ethos, its family relationships and its principles of human life. Belgium, having legalised euthanasia in 2002, offers a tragic picture of what can happen to a country just a few short years later.
In this debate the principle of individual autonomy is vital. Adults, as much as possible, should be able to exercise choices over their medical treatment. That means declining treatment that can keep them alive. There is no real dispute about that.
Euthanasia is different: it is an act that terminates life. It is, therefore, by definition not a private affair; not just about a patient’s right. It is a public and society-wide issue because it involves the state legalising killing subject to certain conditions. That is a grave step and it concerns everyone.
AMA head Michael Gannon tells Inquirer: “The current policy of the AMA is that doctors should not involve themselves in any treatment that has as its aim the ending of a patient’s life. This is consistent with the policy position of most medical associations around the world and reflects 2000 years of medical ethics.”
There are three foundational points in this debate. First, in relative terms the proportion of people dying in acute pain is declining because palliative care methods have been enhanced. There is wide agreement among experts that most physical pain at life’s end can now be managed — this is a critical trend but cannot conceal the fact painful deaths still exist and become the main argument for legal change. But euthanasia should not be seen as a substitute for palliative care — that would be a medical and moral blunder.
Second, where euthanasia is legalised the record is clear — its availability generates rapid and ever expanding use and wider legal boundaries. Its rate and practice quickly exceeds the small number of cases based on the original criteria of unacceptable pain — witness Belgium, The Netherlands, Switzerland and Oregon. In Belgium, figures for sanctioned killings and assisted suicide rose from 235 in 2003 to 2012 by last year. In the Netherlands they rose from 2331 in 2008 to 5516 last year.
These figures come from Labor MLC Daniel Mulino’s minority report in the recent Victorian parliament committee report recommending euthanasia. His conclusion is that “the negative consequences arising from legislation far outweighs the benefits arising in that minority of cases”.
Experience in other jurisdictions leads to the unambiguous conclusion: the threshold event is the original legalising of euthanasia. After this there is only one debate — it is over when and how to expand the sanctioned killings. Claims made in Victoria that strict safeguards will be implemented and sustained are simply untenable and defy the lived overseas experience as well as political reality. There are many questions. If you sanction killing for end-of-life pain relief, how can you deny this right to people in pain who aren’t dying? If you give this right to adults, how can you deny this right to children? If you give this right to people in physical pain, how can you deny this right to people with mental illness? If you give this right to people with mental illness, how can you deny this right to people who are exhausted with life?
Third, culture and values will change to justify the death process. Consider the situation of one of Belgium’s most famous doctors, Wim Distelmans, applauded as a human rights champion. Having killed more than 100 patients, he is a celebrity, gives talks around the nation and is lauded as a man who “cannot stand injustice”. He told Der Spiegel that giving a lethal injection is an act of “unconditional love”.
In Belgium, because so many are killed, the act must be converted into the exemplar of moral and medical compassion.
“Who am I to convince patients that they have to suffer longer than they want?” Distelmans said in one of the most astonishing articles of our time (“The Death Treatment” by Rachel Aviv, The New Yorker, June 22, 2015).
It is the story of how an adult son, Tom Mortier, sought justice after Distelmans killed his mother without Mortier’s knowledge. Distelmans was appointed chairman of the Federal Control and Evaluation Commission, whose job is to assess that doctors have complied with Belgian law. He told The New Yorker: “We at the commission are confronted more and more with patients who are tired of dealing with a sum of small ailments — they are what we call ‘tired of life’.”
Though their suffering derived from social as well as medical concerns, Distelmans said he regarded their pain as incurable. The article reported that 13 per cent of Belgians who were euthanised last year did not have a terminal condition. In Belgium euthanasia and suicide march together — it also has the second highest suicide rate (excluding euthanasia) in western Europe.
The most chilling aspect in a chilling story was Distelmans’s moral superiority in dealing with Mortier, prompting Mortier to write later: “I loved my mother for more than 30 years and I wanted her to live; Dr Distelmans loved her so much — ‘unconditionally’ — that after a few brief consultations over six months he gave her a ­lethal injection.”
Once you sanction euthanasia you open the door to euthanasia creep. The human heart will ­always respond to the incentives of the law. Cross the threshold and doctors will be encouraged to think it is their job to promote the end-of-life. Sick people, thinking of families, feel obliged to offer up their deaths. Less worthy people exploit the death process for gain. In Belgium children can now be euthanised. Would this have been acceptable when euthanasia was legalised in 2002? No way.
The article quoted a professor of psychiatry at the University of Leuven, Dirk De Wachter, calling euthanasia a humanist solution to a humanist dilemma. “What is life worth when there is no God?” he asked. “What is life worth when I am not successful?”
There are an infinite number of similar questions: what is life worth when you are lonely or depressed? De Wachter said he had recently ­euthanised a woman, not suffering from clinical depression but in a condition where “it was impossible for her to have a goal in life”.
Pro-euthanasia advocates in Australia are split when dealing with Belgium and The Netherlands between defending their practices or saying they are not relevant to our debate. The latter is false. These countries are highly relevant — as classic studies in how the euthanasia culture takes grips of a nation’s moral sense. It is sanctioned in terms of love, liberation and compassion — the ultimate service one human can render another.
The recent Victorian parliamentary report Inquiry into End of Life Choices recommended that people be assisted to die by being prescribed a lethal drug to be taken by themselves or administered by a doctor. It outlined a series of strict guidelines as eligibility criteria — approval by a primary doctor and a second doctor only for patients suffering at the end of life. The condition must be serious and incurable. The ­request must come from the ­patient and be free of coercion, be properly informed and be made three times: verbal, written, then verbal again.
There is significant support for euthanasia in the Victorian cabinet and in the opposing frontbench. A bill is certain in the life of the present parliament. Expectations are that it will be passed.
The AMA’s Gannon says the association is conducting a review of its euthanasia policy. He says this is “routine” and not prompted by “recent events”. He highlights the paradox of euthanasia. “It is only a rich country issue,” Gannon says. “There is no one in the developing world talking about terminating the lives of patients.” The AMA review will be completed in mid-November.
The pro-euthanasia group within the AMA hopes to shift its policy from opposition to neutral, mirroring the shift made in Canada — and that would be a significant step. In its evaluation the AMA must focus beyond the issue of patient autonomy to confront the question of doctor-patient ­relations and how they would change under euthanasia.
A critical feature of the Victorian report is the belief that a small number of people seeking euthanasia can be helped without any significant downside for ­society. It seeks to achieve this through robust eligibility criteria and the repudiation of any “slippery slope” problem with euthanasia in jurisdictions such as Oregon, The Netherlands and Switzerland.
Such optimism is heroic and typical of the euthanasia debate. It is echoed in nation after nation, year after year. It testifies to the deepest humanist conviction that mankind and wise governments can introduce euthanasia regimes with the necessary legal safeguards and the necessary regulatory protections to manage the promotion of death to ensure only net gains for the social order.
It is surely extraordinary that people sceptical of the ability of governments to get trains running on time fool themselves into thinking they can confidently manage a regime that sanctions the termination of human life.
The minority report from Mulino provides statistics showing there has been a sustained increase in deaths in all ­jurisdictions, no evidence that growth rates are plateauing with compound annual growth rates ranging from 13 to 22 per cent, which Mulino says has to be ­regarded as “extremely high”. He says the total number of cases in Belgium has increased by 756 per cent over 12 years and in Oregon is 725 per cent higher across the 17 years since initial legislation.
What sort of society is evolving if these growth rates continue? Why cannot we rationally confront and answer these questions? What drives the rise in deaths?
Munilo says the evidence ­reveals euthanasia and assisted suicide regimes “come under ­immediate pressure as soon as these schemes are enacted”. First, there is pressure to widen the law and second is the pressure to ­interpret more generously its ­implementation. And we think Australia is exempt?
There are many examples. In Canada, there are advisory group recommendations to extend the law to children. In Belgium ­extending euthanasia to dementia patients is under examination. The Netherlands is considering allowing patients to make pre-­dementia declarations.
The trend and logic is unassailable: once legislated the principle of euthanasia is settled and the practice of euthanasia is widened, if not by law then by administrative laxity and de facto regulatory sanction. Of course, many euthanasia cases are never declared.
A 2012 report by the European Institute of Bioethics said: “Initially legalised under very strict conditions, euthanasia has gradually become a very normal and even ordinary act to which patients are deemed to have a right.”
Many advocates in Australia use the rights language. Once this takes hold, then holding back the tide is near impossible. The ­upshot in The Netherlands is that the type of patients seeking euthanasia has changed with a shift to those with psychiatric illness. ­Mobile clinics offering free lethal injections are now in operation.
Mulino refers to an Oregon Public Health Division report looking at 132 deaths and finding that 48 per cent listed being a burden on family, friends or caregivers was a concern. When the Belgian law was passed politicians insisted that patients with psychiatric disorders, dementia or ­depression would be excluded — yet the prospect now is for an ­escalation in these categories.
Vulnerable people are right to feel uneasy if Australia crosses the legal threshold. In truth, it is virtually impossible to ensure all acts of euthanasia are voluntary. The elderly, lonely, handicapped and indigenous need to think how such laws mat affect them and their self-esteem.
In short, the foundational claims in the majority Victorian report of no “slippery slope” and effective “safeguards” do not pass the test of evidence, experience or careful analysis. This goes to the question of whether Australia will legislate on false and misleading assumptions that reflect ideological and political propositions.
On the pivotal and related issue of palliative care, Australia suffers a moral and humanitarian failure — and the Victorian report has responded with a strong set of recommendations.
Palliative Care Australia chief executive Liz Callaghan tells Inquirer: “The practice of palliative care does not include euthanasia or physician-assisted suicide, and palliative care does not intend to hasten or postpone death. PCA believes the Australian government needs to ­increase access to palliative care.
“Currently 70 per cent of Australians want to die at home but only 14 per cent do. We believe more needs to be done to ensure that this can happen. Access to integrated, comprehensive support and pain/symptom management is often inadequate, inequitable or may not meet patient needs.”
Callaghan says evidence is that pain management improved from 2011 to last year based on data collection from 115 spec­ialist palliative care services looking after 20,000 patients needing pain management. She says PCA believes more needs to be done to ensure people are better educated about their end of life care choices and palliative care. The PCA believes any ­request for euthanasia requires “a respectful and compassionate ­response”, with Callaghan saying euthanasia is an issue for parliaments.
It is ironic this week that more evidence has emerged about the shocking impact of suicide in this country, particularly for Australians aged in the 15 to 44 age group. How, pray, does legalising euthanasia help the campaign against suicide? The most bizarre notion this week was the suggestion that legalising euthanasia may lower the suicide rate.
In many ways this entire debate is about how to interpret love and care in the context of death. Hug the person you love. But realise this is also about deciding the degree of discretion doctors have dealing with death. It may be good for a doctor to follow a patient’s wish for a lethal injection but that must be assessed against the total social impact of a regime that allows life to be terminated.
If we proceed then life will change, there will be a “slippery slope”, your relationship with your doctor will be different, the vulnerable will have reason to feel uneasy, the push to make euthanasia a right will be inevitable, the frail will feel obliged to volunteer and our values as a community will shift more quickly than you appreciate.
http://www.theaustralian.com.au/opinion/columnists/paul-kelly/legalise-euthanasia-and-compassionate-society-dies-too/news-story/edac86177f0480632d02da83a2225c6d

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EDITORIAL: Be Aware and Beware of What You Demand – A Case Against State-Backed Euthanasia

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Evening Report 4 October 2016
In my editorial titled: Be Aware and Beware of What You Demand – A Case Against State-Backed Euthanasia, I reflect back to the mid-1990s to an investigation I wrote that exposed how the government was to enforce exclusion criteria designed to prevent people from accessing life-saving but expensive treatments. If you were blind, intellectually disabled, had a history of mental illness, anti-social behaviour, a criminal conviction – you would be excluded from having renal dialysis. The experience of reporting this confirmed my resolve against state-backed-euthanasia. Here’s why…

Back in the mid 1990s Jenny Shipley (then Minister of Health in the Bolger National Government) established a governmental body called the Core Health Services Committee (CHSC) which was chaired by former broadcaster Sharon Crosbie. 

The CHSC was known to exist, but no one paid much attention to it, and also getting information out of it was problematic as it would cite commercial confidentiality as a reason for withholding information. So a lot of its work went under the radar.

Back then, National had created a commercial model that replaced health boards with Regional Funding Authorities (RHAs) and hospitals became Crown Health Enterprises. It wasn’t until 2000, that the new Helen Clark-led Labour-Alliance Government disestablished the RHAs and CHEs and reestablished publicly elected health boards, and, hospitals became public hospitals once again.

But back in the early to mid-1990s the Core Health Services Committee was accountable directly to the Minister of Health, Jenny Shipley, and was tasked with creating health funding frameworks, protocols, criteria that the then RHAs would rely upon when deciding what health services the government would pay Crown Health Enterprises (CHEs) for – when providing health ‘services’ to ‘clients’ (patients).

The Core Health Services Committee was tasked to evaluate a way of reducing the cost-burden on the Government for health services and come up with a set of criteria that CHEs and doctors would have to abide by when deciding which ‘clients’ (patients) would get treatment and, importantly, who would not.

In August 1994, I became aware that the Core Health Services Committee had been evaluating the most costly procedures, including renal dialysis treatment for people with end-stage renal failure. I was told by sources that the CHSC had drafted a document that included a framework for how expensive treatments would be handled, and that the Minister of Health had approved the plan.

Generally, there are two types of criteria:

inclusion – (meaning patients that met certain criteria would be eligible for treatment)

exclusion – (meaning those that could be labeled as possessing or exhibiting specific criteria would exclude then from being offered treatment.

In August 1994, I was leaked documents that displayed how the Minister had approved the CHSC protocols that used exclusion criteria and that the protocols had been presented to doctors and the exclusion criteria enforced.

What this meant was people who presented with end stage renal failure, and who required dialysis to stay alive, would be excluded from getting this life-saving treatment if they were deemed:

* to be blind

* to have an intellectual disability

* had a history of mental illness

* exhibited or expressed anti-social behaviour

* had a history of imprisonment

* had an unrelated health condition that may cause complications

* were over the age of 65-years…

The set of exclusion criteria continued on. 

Without a public debate having ensured, CHE doctors were required to administer the changes and CHEs were required to report back to the RHAs with details on how the exclusion criteria was being applied.

Up until then, doctors and clinicians had decided on whether a patient would get dialysis treatment – the assessment was based on what health benefits a patient could expect, and were not required to consider exclusion criteria that were determined by the State.

The doctors silently rebelled and, as a journalist, as I mentioned above, I was leaked the CHSC protocols and exclusion criteria documents.

I sought a legal view from the Human Rights Commission, whose legal team suggested the criteria would be illegal under the act should it be brought into force by any other body excluding a government entity.

At that time, the Government had passed a human rights act but had excluded government entities (at that time) from having to act within that law.

The day the investigation was published, a political furore ensued. The article was tabled in Parliament (in those days a news article could be tabled before The House) and Labour’s then health spokesperson, Lianne Dalziel, raised it during Parliament’s question time (Question number 7 if I remember right). And, once question time concluded, the issue was the focus of an urgent debate.

During the debate, former prime minister David Lange delivered a stinging and passionate attack on the National Government’s ethics and morals. Lange said (ref. http://www.vdig.net/hansard/archive.jsp?y=1994&m=09&d=01&o=44&p=56):

“Look at this thing in south Auckland. There was an extraordinary defence by the Minister—the determining factor is one’s condition. I have to tell members that those key ethical principles are not determined by one’s condition, and they are not determined by one’s state; they are determined by one’s status.”

David Lange continued: insisting that the criterial that the Minister of Health had approved and defended was akin to the State standing on the dialysis pipe to prevent the flow of this life-saving treatment from reaching the patient.

He continued: “If one is intellectually handicapped, the drip goes off. If one is intellectually handicapped, one does not get what is called end-stage renal treatment, and that means one dies. They (the Government) are very good at euphemisms—“modernisation”. The word “euthanasia” does not come into it; it is “determination of end-stage renal treatment”.”

And Lange summarised: “Let us come back to the crude reality of it. Value judgments are being made about people’s lives, and those value judgments will be affected by whether they are people of influence, standing, or status. If they are psychiatrically disturbed or if they are intellectually disabled, the tap is turned off; they stand on the air pipe, and they talk about it in terms of core ethical commitments. I absolutely repudiate that.”

The Minister Jenny Shipley replied: “The core health services committee has made some valuable recommendations about the areas on which attention should be focused. The core services committee has actually begun to assist this country to grapple with some of the most difficult ethical issues that are before us.”

She continued: “I am fascinated that some members of the Opposition are dismissive of our actually having the courage to address ethical questions in the field of medicine. It is true that every country in the world is in a similar position to us. There are issues that we know have to be spoken about, and what happens?

“In Parliament today Opposition members could not resist the temptation of picking up a piece of information, which they know is a gerrymandered interpretation of the core services committee discussion document, and politicising it. People in need of renal failure treatment actually do need to be able to be assessed and treated on a clinical basis. The core services committee raises some extremely important questions that allow clinical judgments to be made,” Jenny Shipley said.

Through the next month I followed up with articles revealing how the Core Health Services Committee and the Minister had agreed upon exclusion criteria for other life-saving treatments including coronary care and oncology care health services. The impact, should it have been fully rolled out, would have been considerable.

Within a month or two, the Core Health Services Committee criteria had been withdrawn from use, and the CHSC itself was later disestablished – doctors were again able to decide who should and should not get treatment based on a patient’s benefit and outcome.

From then on, when I would contact the Minister of Health’s office for comment on issues, I would be referred to as Goebbels (which I ignored apart from noting the irony).

Shortly after around March 1995, the Minister of Health Shipley stood staunch arguing that a south Auckland man who became the human face of her policy called James McKeown ought not receive dialysis treatment. 

Shipley went on TVNZ’s Holmes Show arguing why the man ought to be left to die from his condition. 

She identified clinical reasons for her argument. South Auckland Health’s then CEO, Dr Lester Levy, returned from holiday to stand between the minister and his hospital’s patient – Levy ordered that James receive dialysis. 

In Parliament (ref. http://www.vdig.net/hansard/content.jsp?id=45370Lianne Dalziel asked: “Has the Minister received any advice on whether the statements made on television were a breach of patient confidentiality, and does she intend to resign should they be a breach of the Privacy Act?”

The Minister Jenny Shipley replied: “As I have said, this matter is before the Privacy Commissioner now. The issue of whether Mr McKeown, by disclosing a significant amount of his personal circumstance but not the complete story, forwent his right to privilege in the first place is an important matter that the Privacy Commissioner will rule on during the consideration of the three complaints that are before him.”

It was a clear case of the State’s Minister insisting and commanding her view over an ill and humble man from Otara.

The Privacy Commissioner did indeed issue a ruling. Shipley was found to have breached James McKeown’ privacy and was forced to make an apology.  She did so.

A year later I revisited James and asked how his extended life had been: “It’s great he said, I enjoy my days, I have a flutter on the races, I’m happy.” A year and a half after Shipley had argued that his treatment ought to stop, James slipped away feeling that his doctors at least valued his life.

Prologue: The whole experience confirmed my resolve that we as a country’s peoples should never allow the State (irrespective of what party is in power) to interfere, nor legislate, against a born human being’s moral right to life and ethical right to access life-saving treatments.

Be Aware and Beware of What You Demand.
http://eveningreport.nz/2016/10/04/editorial-be-aware-and-beware-of-what-you-demand-a-case-against-state-backed-euthanasia/

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