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Oregon on the euthanasia slippery slope

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Frank Brennan |  27 June 2011

Americans love conversation and public disputation about contested moral and ethical issues. Given the Australian Greens' continuing fascination with euthanasia, I decided to visit Oregon which has had a physician assisted suicide law in place since 1997.

In 2010, 96 Oregonians asked their doctors to prescribe a deadly barbiturate which they could ingest causing their own deaths; 65 of them went ahead and did so. This mode of dying accounts for just 0.2 per cent of deaths in Oregon. In the Netherlands, euthanasia accounts for ten times that percentage of deaths, and almost a third of them occur without the patient's explicit request.

I met with representatives from Providence Health, the largest Catholic health provider in the state; Physicians for Compassion, doctors who have strong ethical objections to their colleagues prescribing deadly medications; medical personnel from the Oregon Health Sciences University (OHSU), the institution through which most of the suicide procedures are instituted; and with Barbara Coombs Lee, president of Compassion and Choices, the principal national advocacy group espousing 'physician assisted death'.

Coombs Lee eschews use of the word 'suicide', suggesting that it implies that the terminally ill are mentally ill. She insists, 'Assisted suicide, committed by a physician or anyone else, remains a felony in Oregon. If a physician aided or abetted the suicide of her mentally ill patient, she would and should be prosecuted.'

When seeking my meeting with Ms Coombs Lee, I wrote:

I am an Australian lawyer and Jesuit priest. I serve on the national board of St Vincent's Health Care, one of the major health providers in Australia. I am attending the Catholic health conference in Atlanta in early June. On my way home, I will take the opportunity to come to Portland to check out your physician assisted suicide law. I am keen to hear a variety of perspectives on the workings of the Oregon law. Is there any chance I could meet with you?

She replied:

I'm grateful for your curiosity, but would not anticipate your learning anything to impact your Catholic perspective on aid in dying. Our view is Catholic providers should not obstruct a patient's request for aid in dying (distinguished from suicide) and should facilitate referral to cooperating physicians in appropriate cases. The states of Oregon and Washington publish yearly reports and these are available on the States' websites. They would be good general data sources. Our website also has a large body of data. We don't get many requests for dialogue from priests, outside a debate setting, but I'm game.

This was too good a challenge for me. I replied, 'I'm game if you are.'

Jack Kevorkian, known as Dr Death, had just died, and of natural causes. The liberal New York Times carried an opinion piece headed 'Dr Kevorkian's victims', pointing out that 60 per cent of those assisted in death, or killed, by Kevorkian 'weren't actually terminally ill. In several cases, autopsies revealed 'no anatomical evidence of disease'.

Kevorkian believed people had a right to commit suicide and a right to receive assistance in committing suicide, regardless of whether they were terminally ill or in great pain. Coombs Lee was very careful to distinguish the aims of her organisation from the modus operandi of Kevorkian.

She said, 'We don't think euthanasia is good public policy. For us, the patient being in control from beginning to end is crucially important. Even if very restricted in movement, we think it important that the patient have the consolation of knowing that they are always in control — that they can stop the procedure at any time.'

Since then, she has told the Medscape Medical News that Kevorkian was a flamboyant provocateur: 'He never said to other physicians, "Let's develop a standard of care".'

Critics of physician assisted suicide and opponents of Compassion and Choices claim that physician assisted suicide is a step on the slippery slope to euthanasia which has been pragmatically abandoned by such groups for the moment because of its rejection by Californian voters in 1988. Ed Pellegrino, the greatest American bioethicist of the age, once pointed out that:

[T]he slippery slope is not a myth. Historically it has been a reality in world affairs. Once a moral precept is breached a psychological and logical process is set in motion which follows what I would call the law of infinite regress of moral exceptions. One exception leads logically and psychologically to another. In small increments a moral norm eventually obliterates itself. The process always begins with some putative good reason, like compassion, freedom of choice, or liberty. By small increments it overwhelms its own justifications.'

The highly respected Daniel Callahan from the Hastings Center speaks of the organised obfuscation of the advocates for physician assisted suicide. Having abandoned euthanasia after 1988, they now want to avoid the term 'suicide' as one newspaper reporter has called it 'a killer at the ballot box'. Using phrases like 'medically assisted death', 'hastened death', and 'patient-directed aid in dying', Callahan thinks the advocates are disguising their real activity and purpose which is the 'medicalisation of autonomy' and the 'medical legitimation' of suicide.

Barbara Glidewell, who had been the OHSU Ombudsman for 35 years, was responsible during the first 12 years of Oregon's Death With Dignity Act for facilitating the patient-provider process for terminally ill, adult patients making a voluntary request to access the law. She told me that in 2010 the most frequent end-of-life concern expressed by patients seeking physician aid in dying was loss of autonomy (96 per cent), with only 10.2 per cent expressing concern about inadequate pain control. 

Chuck Bentz, one of the Physicians for Compassion, shared with me the story of his patients, a 76-year-old athletic man with a melanoma. Chuck had known this patient and his wife for over a decade. He provided a referral to a reputable oncologist. According to Bentz this is what happened:

As he went through his chemotherapy and radiation therapy, he became less able to do this activity, causing a depression, which was documented by his radiation oncologist. At his final visit with his medical oncologist, he expressed a wish for doctor-assisted suicide. Rather than taking the time and effort to address his depression, or ask me to respond to his depression as his primary care physician and as someone who knew him, the medical oncologist called me and asked me to be the 'second opinion' for his assisted-suicide. The oncologist told me that secobarbital 'works very well' for patients like this, and that she had done this many times.

Bentz objected and advised that there were better ways to address his patient's needs at this time. Next he knew, his patient was dead, from a lethal overdose. He obtained the death certificate which wrongly listed the cause of death as melanoma. And all is said to be well in the State of Oregon.

Bentz is concerned that this law impacts adversely not only on the doctor-patient relationship, but also on the professional relationships between doctors. The American Medial Association still regards physician assisted suicide as unethical.

Callahan says, 'In the case of Oregon, we have been assured that all is well, that no abuses are occurring. In their confidence and firmness those assurances are the equal of those expressed in the Netherlands prior to its confidential surveys', which revealed that doctors regularly euthanase patients without their consent or without sufficient regard for the mental state of the patient.

The US Catholic Bishops, worried that physician assisted suicide will spread beyond Oregon and Washington, have just issued a statement, To live each day with dignity. Coombs Lee replied, 'We welcome the bishops' clear statement that opposition to aid in dying is a matter of religious belief. We find it unacceptable to impose the teachings of one religion on everyone in a pluralistic society.'

But you don't have to be Catholic to think that doctors should do no harm, that patients are free to forego futile or burdensome treatment, and that palliative care be utilised to relieve pain. Suicide will occur from time to time, but why the need to enact laws conferring medical legitimation on it and increasing its likelihood?

I return home pleased to know that even the Oregonians and advocates like Coombs Lee are trying to draw a bright line between euthanasia and physician assisted suicide. I still worry about the slippery slope for vulnerable patients who might think they have no option but to take their own lives. I remain committed to the simple Hippocratic Oath, 'Do no harm.' Don't take life. Care for the dying by relieving their suffering. And that's not just because I'm Catholic.

 


 

Frank BrennanFrank Brennan is professor of law at the Public Policy Institute, Australian Catholic University and adjunct professor at the College of Law and the National Centre for Indigenous Studies, Australian National University. His Camino Group lecture The Value of Human Life — The Question of Euthanasia is available here.

 



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I liked reading this article because I've increasingly had to deal with these ethics over decades since my father was a Chief Hospital Pharmacist at Nepean District Hospital, Penrith, New South Wales, Australia 1969-1982. When I heard my father speak of Doctors assisting Patients' deaths & subsequently standing for our 2007 Australian Parliament with our Australian Democrats Party & being rung & asked by the Euthenasia Advocate & subsequently being told that Jesus' Crucifixion was a form of State assisted suicide. I thought that was interesting take on the crux of Christianity.

Clearly, globally, these ethical questions remain and legally, legal fiction based Legislatures since 1066 have held the balance of people's lives. Life times will tell into our futures what will ultimately happen.

Matthew Fowler 28 June 2011

Frank your Oregon euthanasia slippery slope report's ‘oh so predictably catholic’. I agree the slippery slope is not a myth; once a moral precept is breached a psychological and logical process is set in motion and overwhelms its own justifications.'

This happened/s with clergy sexual abuse and church cover up in Victoria and certainly in Ireland with the Fern and Ryan Government Reports. Bishops know exact details of pedophile priests like Ridsdale, Baker, Gwillam, Gannon and O’Donnell and send them from parish to parish, defend them, set up in-house procedures. They get away with one case, and then another and so are on the slippery slope of cover up and avoid the proper police procedures, pastoral healing, adequate legal fees and compensation. Eventually some Bishops like Coleridge, Hart and Malone acknowledge their slippery slope and give qualified apologies to salve their conscience and protect church assets and ‘the faithful’.

After 36 years in the Catholic ministry, Canberra's Mark Coleridge finally confessed publically that it took "people like me a tragically long time" to see the faces and hear the voices of sexual abuse survivors in the church. He could have added that he was on your slippery slope. Michael Parer

Michael Parer 28 June 2011

This is a great article, I still believe in legal (though not assisted beyond supplying drugs, the patient has to do it) suicide for the terminally ill (with a very rigorous pre-decision process including interviews, talks with pain councillors, general councillors and a mental health check (ALL mental or emotional instability would prevent the procedure, including out of sad necessity if the patient is deemed to be in such great pain that they are not of right mind) from a trained professional).

Despite this i find what you've said about the ease with which one exception can mean more very interesting.

L. O'Brien 28 June 2011

"I will give no deadly drug nor perform any operation for a criminal purpose, even if solicited,nor will I suggest any such counsel"
The Hippocratic Oath - Hippocrates 460-370 BC

The slippery slope is very real. Abortion of over 100,000 human lives in this country each year proceeds apace despite the fact that it is still a criminal offence in some states to procure or perform it. So entrenched is abortion that the Yellow Pages in NSW advertise "LEGAL" abortion flying in the face of the criminal code which has never and still doesn't permit abortion. The legality of abortion can only be determined in NSW by a court judgement in a prosecuted case of abortion. It is interesting that we are so caring about the enviroment in our enlightened society and legislate to protect it but fail to respect and protect God's supreme creation. When The Supreme Being chose to walk with his creation on this planet He did not choose to come as a tree or the Great Ocean Road, a parrott or a rare frog, but as the greatest of His creation, a human being. The human being on this planet walks as the image of god.

The fundamental failure of our society is that we cannot see (or refuse to see) the image of God in our fellow human beings, in human life itself, regardless of what age that human life might be - a baby in the womb, a toddler, a shy young girl, a macho young man or a beloved parent now old and incontinent with a failed memory. Our love for the planet should pale in significance compared with our love for each other. Sadly we live in a society where the reverse is the fact of it.

It is interesting, Fr Brennan, that the two killers you mention in your article today were women. Women also form the preponderance of abortionists ("family planners") in this country. We have even appointed a women abortionist as a professor of obstetrics in this country, charged with educating our future doctors. Isn't it a curious thing that the very womb of God's greatest creation would appear to value itself least."And Jesus wept"

john frawley 28 June 2011

Thanks, Frank, for the clearest treatment of this issue I have read. I've always had doubts about the validity of the 'slippery slope' argument but you build up a case for it that can't be easily dismissed.

Joe Castley 28 June 2011

Good article. On the Hippocratic Oath - and I confess I don't know the situation in Australian medical schools - it is, perhaps significantly, no longer customary in many schools of medicine. The taking of any oath ranges from retention of some form of the Hippocratic (possibly 'modernised' or bowdlerised in some other way), total abandonment of any oath, or substitution with a humanistic variant.

Other elements of the Hippocratic Oath are instructive: no sexual contact with patients; no payment for services rendered...

Alistair P D Bain 28 June 2011

A well rounded and informative article.

Helen Clarke R.S.C. 28 June 2011

A very good article and all of it quite true. Thanks for laying the issues out so well. It highlights to me why taking concepts of "Catholic healthcare" and "Catholic medical and nursing education" seriously is so important. As head of a Catholic clinical medical school, it seems far from certain to me that either church authorities or boards of Catholic hospitals,necessarily do "get it", in understanding how important it is to work collaboratively to maintain social and professional standards and draw some pretty firm lines in the sand against the secular 'opposition'. We are very fortunate in having some great resources that we are not necessarily using as well as we could.

Haydn Walters 28 June 2011

"Suicide", from Latin, "to kill oneself". A simple word, now stigmatic, in that a view exists it should apply only to the mentally ill. People need to know more about the seriously mentally ill. They live and die from the treatable but incurable biological brain diseases of schizophrenia, bipolar 1 and/or severe affective disorders. To express the opinion that, if physician-assisted death is allowed, this should not apply to the seriously mentally ill assumes these sufferers incapable of rational thought. More stigma. My daughter Anne, at 40, had suffered paranoid schizophrenia for 20 years, the most destructive form of this disease; she was severely paranoid and yet rational. Her creativity and talent as a photographer, her enjoyment of life, her pleasure with friends, her energy and motivation, all disintegrated through these years. After two previous attempts,she ended her lost and despairing life, finding peace in a sure way. She placed her beautiful head on a railway line and waited. Anne had said to me, after her 2nd attempt to end this unbearable life "if you helped me they'd get you for murder". But surely it can be accepted that nobody should ever have to die suffering,in despair and fearfully alone?

Caroline Storm 28 June 2011

I don't believe there is a slippery slope if the decision to end life is taken as the only way to relieve suffering. It's a strange sort of religion that thinks being biologically alive is more important than anything else. If you have to make the decision for someone else, it is a difficult thing to do and perhaps, like abortion, there is no perfect answer. I could only do it because I knew it was what the person would have wanted. It was the best thing to do in the circumstances. I very much hope that euthanasia becomes legal for anyone over the age of 80 who wants it - I'm fairly sure that I will want it if I get to that age.

Russell 28 June 2011

Thanks Frank.

I have no problems with euthanasia provided it is preceded a clearly-expressed request from the patient.

That said, there must be no cover-up, no use of euphemism anywhere in the process. If death is by assisted self-termination, then the death certificate must state that.

I'd go a bit further, however; the death certificate must also state the terminal illness from which the person suffered.

David Arthur 28 June 2011

I think Frank Brennan has adequately justified his "slippery slope" hypothesis in mentioning that in the Netherlands, "doctors regularly euthanase patients without their consent or without sufficient regard for the mental state of the patient."

There are rational arguments against euthanasia,or whatever politically correct alternative term that its advocates want to use. Legal euthanasia would put pressure on ill people, because they might feel like a burden to relatives; there is an incentive for unethical beneficiaries to suggest to the doctor that the sick person wants to die, etc. Ther may be unethical doctors who can profit from such situations. How long will it then be before we get to the stage that the government mandates euthanasia for people with terminal illnesses, in order to save taxpayer's money? Or when people reach pension age, so that the pension does not need to be paid? That might seem far-fetched right now, but the gate is left open for it to happen in future if euthanasia is legalised.

Frank S 28 June 2011

I have grave concerns about euthanasia. It is not just people with religious beliefs who are concerned about this issue; many people in the disability sector are also opposed to this issue. This link provides further detail:
http://www.bioethicsanddisability.org/why.html

In response to Russell:
Perhaps Fr Frank could provide clarity, but I understand that the Church is amenable to appropriate medical treatment where the patient may risk death, and/or the withdrawal of *artificial* means of keeping a person alive. As I understand it, the Church opposes *intentionally* causing death.

Moira Byrne Garton 29 June 2011

It is interesting to note, as Frank lerned himself when he ws here in Oregon, that many more people legally obtain the means to commit suicide than actually use those means; this stays with me as somehow a telling detail. I can well imagine the fear and darkness and despair that someone who is certifiably terminally ill, in great pain, with no hope of recovery, fearful of the terrible cost of care and the terrible burden placed on family financially and emotionally, would feel; and while I believe, with the great American visionary Cardinal Joe Bernardin, that life is holy and taking it for whatever reson is wrong (ie wars are organized murders, abortion is murder, executing prisoners is murder, 'just war' is rationalization), yet I can imagine that darkness.

Brian Doyle 29 June 2011

Re clarification sought by Moira:
To quote the Catholic Health Australia Code of Ethics: “The fundamental ethical principle …is that treatments may legitimately be forgone (withheld or withdrawn) if they are therapeutically futile, overly burdensome to the patient or not reasonably available without disproportionate hardship to the patient, carers or others.”

Frank Brennan SJ 29 June 2011

Thanks for the clarification, Fr Frank. It is as I thought - I just couldn't remember where I'd read it. Thank you.

Moira Byrne Garton 29 June 2011

I have over some 40 odd years withheld treatment and turned off life support ventilators preliminatory to harvesting kidneys and other organs for transplantation as (at the time that I first started doing this) the only Catholic transplantation surgeon in this country,when there was no secular or moral law nor any medical ethics to guide such action.

My ethical framework for doing these things came from Fr Tom Johnston SJ, Rector of the university college I attended as a student. I was dismayed to read from Fr Brennan today that The Catholic Health Australia Code of Ethics states that "treatments may be legitimately withdrawn if ... they are not reasonably available without disproportionate hardship to the patient, CARERS OR OTHERS." Perhaps the carer has grown weary at the constant demand or found a potential new partner. P

john frawley 29 June 2011

Well noted, John Frawley. A Catholic position would be held without the addition of those last three words (capitalised in your reproduction). I wonder why they were included? I hope not for the reasons you suggest.

Moira Byrne Garton 29 June 2011

In addressing Dr Frawley’s concerns, the Code states at 1.14: “The benefits of treatment include preservation of life, maintenance or improvement of health, and relief of discomfort. They do not include deliberately shortening the life of a person who is sometimes wrongly described as “better off dead” nor exploiting a person's body for the benefit of others. The burdens of treatment to be properly taken into account may include pain, discomfort, loss of lucidity, breathlessness, extreme agitation, alienation, repugnance and cost to the patient. In some cases, the burdens of treatment may also include excessive demands on family, carers or healthcare resources. Judgments about the futility of a treatment outcome must be distinguished from judgments about the “futility of a person’s life”: the former are legitimate, the latter are not.”

Frank Brennan SJ 29 June 2011

Hit the wrong button again. Must be getting old!
Thank you, Fr Brennan,for taking the time to address my earlier comment which was incomplete when printed.I was making the point that one human life can not be balanced against another. The effect of an illness on others such as carers and relatives is irrelevant to the care of the patient. I have seen too much of self-interest dealing with life and death issues in the surgical world of transplantation that is shocking beyond belief: demands on patients who have received a transplant from donors or donors relatives for financial reward, unbelievably for sexual favours, and various other demands in the interest of relatives and carers such as requests to turn off ventilators to expedite inheritance and to relieve relatives of burden. This latter is frequently the final motivator in seeking euthanasia. My objection to the quoted Catholic Healthcare Code was that it balances the patient's life against the convenience or distress of others and should be removed from the code. Perhaps the ethics should be left with the doctors who actually spend their lives running risks with their fellow human beings lives in the struggle against suffering and untimely or avoidable death. I suspect that if I started writing the engineering specifications for a CBD skyscraper, the darned thing would fall down very smartly.

john frawley 01 July 2011

There is much cause for reflection on Ed Pellegrino's observation of, 'the law of infinite regress of moral exceptions'.

I have two quandaries.

The first is that people are assisted to die in hospitals and aged care facilities all the time. A medical decision is made to increase the morphine dosage, under the premise of pain relief. Is this an example of 'the regress of moral exceptions?'

I have heard it said that in traditional, nomadic, desert societies, in a harsh season, a woman bearing twins may have to commit matricide with one of the twins in order that both might not perish. This is done with logic and compassion and not without grief.

Shane Howard 01 July 2011

I do think the checks and balances, structures and legal arrangements of any possible assisted death must be robustly debated and if implemented, reviewed regularly. However, I am pretty sure that if I am vomiting half digested matter that smells like faeces and I am going to die, I do not wish myself or my family to experience this for any longer than I choose. Having said that, we don't truly know what we will do in any situation until we are there, which is why any incidence of assisted dying must be highly scrutinised and with the right to change one's position until the final moment.

Caz Coleman 01 July 2011

"But you don't have to be Catholic to think that doctors should do no harm, that patients are free to forego futile or burdensome treatment, and that palliative care be utilised to relieve pain. Suicide will occur from time to time, but why the need to enact laws conferring medical legitimation on it and increasing its likelihood?"

Because "increasing its likelihood" is what it's all about.

My brother-in-law was a very religious (Presbyterian) man. I understand that the modern Catholic view is that he was not automatically damned for eternity for his non-Catholicism. But be that as it may.

He had very painful, incurable and terminal cancer, which had invaded many of his internal organs. At one stage towards the end of his long drawn out death (ie over two painful years) he begged his sister (my wife) to bring his shotgun, loaded. By that stage, he was bedridden. He wanted to blow his own brains out. Suicide: he wanted to "increase its likelihood."

My wife, horrified, refused. Whereupon the pallitaive care nurse was called. She went to him and said "Bill, [not his real name] would you like me to increase your morphine dosage: so that you remain unconscious for the rest of your life?"

He immediately agreed. So he spent the rest of his life in morphiated oblivion.

The law (which is an ass) was observed. Formalities were observed. He was never given a fatal dose, he was just kept unconscious. So he had nothing one could describe as 'life' between the time he asked his sister for the shotgun and the minute of the hour of the day he finally died: wishing all along to be finally out of it.

The Holy Catholic Church, whose hierarchy from the paedophile priests right up to the Holy Father in Rome has believed in covering the paedophilia scandal up, and thereby living and perpetrating a massive lie, is one of the obstacles that continues to stand between people like Bill and the end to their suffering under any number of God-created diseases, such as cancer.

The killing of people, persuading the old and the infirm to no longer be a burden is a furphy, easily got around. But it is used as an excuse and a device to prevent people like Bill from having the choice on ending their suffering.

The issue of euthanasia is fundamentally a power struggle. Slippery slope be damned.

(You won't publish this because it is 415 words long. Too bad.)

O. Puhleez 02 July 2011

My brother did not respond to various treatments for severe long cancer which had spread to his spine and other bones. Breathing and movements were increasingly painful despite stronger pain relief. He choice to die rather than be on ongoing burden on his family. His family supported him and his GP made the necessary arrangements so that he could die at peacefully home surrounded by his family. They could say goodbye in familiar surroundings and are thankful for the strength of character, wisdom, and concern for them.
He may have lived a few more months, but with severely reduced quality of life and at considerable medical expense. But what for? So that his wife and children could see his further physical decline, his painful breathing, inability to keep food down, incontinence. At least his wife, 4 children and 9 grandchildren remember him as a good-looking man, in high spirits endeavouring to remain independent. If he had waited he would have become more and more dependent upon others, with the associated loss of dignity and self esteem.
Fr Frank, you, like my brother-in-law, also a jesuit, why do you force your views upon others? We are angry with the Catholic Church and stopped going to Mass. You can have your church, with is outdated teachings. Thousands of children in Africa die every day from poverty and treatable disease, yet the Catholic Church does very little to enable them to live a worthwhile life.

Bernardus Leeman 03 July 2011

Bernardus, I no more force my views on you than you do on me. In a democracy, we all have the privilege and duty of expressing our views about the common good, the public interest, and human flourishing, do we not? You may be angry with the Catholic Church but I still have the right to participate in the public square. I would ask only that my arguments be treated on their merits and not rejected only on the grounds of angry identification of my church membership.

Frank Brennan SJ 04 July 2011

I may not have read carefully enough...did you provide even one example of someone being "euthanized"? Or even harmed? There may be a logical slippery slope, but it seems that in practice we're not even sliding down it a little bit. The only example given was reported exclusively from the perspective of a PCP who felt left out of the decision-making process. No evidence (other than his stated belief) was provided to support the PCP's contention that the patient was depressed. Also: Ed Pellegrino is a great physician, a lovely man, and a very prominent ethicist, but "greatest ethicist of the age"? This seems like padding your argument from authority.

Thomas Cochrane 06 July 2011

There’s been some interesting follow-up discussion on this piece on the US Commonweal site at http://www.commonwealmagazine.org/blog/?p=14233

Frank Brennan SJ 06 July 2011

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