Doctors favour legalising assisted suicide for dying patients
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7472.939-b (Published 21 October 2004) Cite this as: BMJ 2004;329:939
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Evan Harris MP, GP and member of the BMA Ethics Committee expressed
his anger on UK Radio4 that the BMA Ethics Committee is too worried about
public reaction to state its real position. Is it likely to erode public
confidence - or is being straightforward about difficult issues more
likely to engender a mature and confident relationship with 'the public?
What is the purpose of such a committee and what are its
responsibilities?
Competing interests:
None declared
Competing interests: No competing interests
To the British Medical Journal
http://bmj.bmjjournals.com/cgi/eletters/329/7472/939-b
Re: Assisted Suicide’s Slippery Slope
Dear Editor,
John Keown states in “Assisted Suicide’s Slippery Slope” that the
slippery slope is inherent within legislation of physician-assisted
suicide. Mr. Keown suggests that in the Netherlands the slippery slope
already exists. As a Professor at an Institute of Ethics, Mr. Keown should
know that proof has to be given for statements like this. He does not give
us this.
In the Netherlands, data has been collected about the last phase of life
of patients and this has been published in the Lancet (Onwuteaka-Philipsen
BD, et al. Euthanasia and other end-of-life decisions in the Netherlands
in 1990,1995 and 2001. Lancet 2003; 362: 395-99.) Through undertaking and
publishing this research, an unknown and suppressed part of medical
practice in the Netherlands has been opened up. (No signs of a slippery
slope have been found.)
Mr Keown writes that cases of assisted suicide have been concealed by
Dutch doctors. However, it is well known that in the U.S.A. as in the rest
of the world, assisted suicide is carried out and then concealed: Further,
patients who are suffering badly and at the verge of death, can recieve
painkillers and/or sedation that may also play a role in the dying-proces.
The Dutch are decent people, as are their doctors. We, Dutch doctors, do
not “kill” our own patients. On the contrary, we assist in scientific
research to help us further understand, in an open and honest way, the
last phase of life of our patients.
I am intrigued as to why Mr Keown directs his attention to the Dutch. It
may actually be more beneficial for all concerned if he places his efforts
in trying to obtain data about the way doctors in his own country, the
U.S.A., act when their suffering patients are at the end of their life.
Perhaps he does not seek to do this because if he does, he will most
certainly be confronted with the hypocrasy that we in the Netherlands have
now overcome.
Competing interests:
SCEN: consulting physician in assisted dying
Competing interests: No competing interests
The exchange between Prof Clive Seale and Mr MF Smith is all the more
illuminating when one takes the suggestion of Smith to visit the website
and read the full report. A few pertinent facts can also be gleaned about
Medix (UK) from the information in the Website.
Although a survey organization is expected to receive remuneration
for conducting the survey, the offer of rewards for filling in
questionnaires can raise questions about the participants. The Website
states that “By completing online questionnaires, members share in Medix's
revenues? as well as “participants are advised of the reward offered for
participation?when answering surveys. It can give the impression of a
selection bias for registering with Medix.
The admission by Smith that the actual response rate is 19% as
opposed to the misleading 95% “acceptance rate?in the report itself,
together with the fact only the first 1000 responses is accepted also
casts doubt on the information provided by the survey. That the surveys
quoted by Smith (GP contracts and consultant contracts) obtained the same
results as the more respectable BMA surveys on the same topics does not
imply that the results of this survey can predict the outcome of a similar
survey by the BMA. There is another question raised by Smith’s response.
Only 968 doctors were involved in the first 1000 responses; where do the
other 32 responses come from?
So this is a survey taken from the first 1000 responses of a group of
some 5200 doctors (working backwards from the 19% response rate)
registered on a Website which rewards them for answering questionnaires.
Is the result reliable? I am beginning to have my doubts.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
The news item fails to take into account the important fact that all
of medicine entails risk to patients, and good symptom control in frail
patients at the end of their lives even more so. When many of my collegues
prescribe increasing doses of opiates to patients who are dying and in
pain and distress, they often do so in the mistaken belief that they are
'helping the patient on his way', largely as a result of articles such as
the above. However, if a patient is not in any pain or distress, such
medication is not indicated, and generally not given. If it is given in
appropriate dosage for the pain or distress, then prosecution should not
be an issue. If it is given in an innappropriate dosage, or without
symptoms, then a doctor should rightly beware. R v Cox established many
years ago that the endogenous opiates released as a by product of death
were not regarded as palliative care i.e one cannot kill to cure. There is
even a notion that effective symptom control is 'life-prolonging'. Telling
doctors who are attempting to make a patient's last days easier that they
are being intellectually dishonest, should drop the pretense and offer a
fast, lethal intervention instead seems rather cynical.
Competing interests:
None declared
Competing interests: No competing interests
Professor Seale comments that "reporting in the BMJ of the Medix survey gives me further concern for the reputation of survey research in this area amongst UK doctors".
The survey was not designed for academic publication, but empirical evidence does suggest that Medix surveys may be reasonably representative of doctors' views.
Using the same approach, a sample of 500 Medix general practice (GP) members gave a 76% "yes" result for the outcome of the June 2003 GP contract ballot by the British Medical Association (BMA); the actual "yes" result was 79%. The exercise was repeated for the October 2003 consultant contract ballot with a 62% "yes" result from 165 Medix consultant grade members against an actual 61% result. Surely, timely information collected in a reasonable mannger informs almost any debate better than contemporaneous ignorance or exquisitely conducted, but posthumous, academic research?
Professor Seale’s gratuitous comment about the survey favouring "respondents with time on their hands" might apply to any survey respondent. Unfortunately, this comment seems to belittle the contribution of the 968 full and part time UK doctors who donated their valuable time to resolving this important professional issue.
Regarding response rate, the Medix survey rate was 19%. Only the first 1000 responses were accepted, so this rate was expected. Professor Seale was unaware that only 19 out of 1000 respondents responded only to this particular Medix survey, otherwise he might not have suspected respondents of having an "active interest" in the subject. Any link between using email and an unusual interest in assisted suicide is unproven, even among those who receive hundreds of unsolicited emails per week (see "Dear email correspondent", this issue).
Just as more information on doctors’ views on assisted suicide informs that debate, so too it improves survey approaches. Medix has offered Professor Seale the opportunity to conduct his survey on the internet with Medix members and compare results with his postal surveys. We hope to report these results to the BMJ in due course.
Competing interests:
The respondent is a director of Medix UK.
Competing interests: No competing interests
Those doctors who reportedly favour the legalisation of physician-
assisted suicide may well be unware of the 'slippery slope' inherent in
any such proposal, and of the inability of 'safeguards' to prevent a
slide.
If assisted suicide for the terminally ill who are suffering
unbearably, why not for those who are not terminally ill or suffering
unbearably? (The Dutch hold that a patient who is not even physically ill,
let alone terminal, may qualify and that even grief may amount to
'unbearable suffering'.)
If assisted suicide, why not voluntary euthanasia? (The Dutch realise
the indefensibility of any such distinction and allow both.)
If voluntary euthanasia, why not non-voluntary euthanasia? (The Dutch
began by permitting the former and now accept the latter in certain cases.
They are surely consistent: if being killed can be a benefit, why deny
this benefit to those who cannot request it?)
As for 'stringent safeguards', advocates of legalisation point to the
Dutch guidelines as a model. These have, however, proved a conspicuous
failure. To cite but one illustration: a clear majority of cases of
assisted suicide and voluntary euthanasia have been improperly concealed
by Dutch doctors, in breach of the guideline requiring reporting.
Expert bodies around the globe have concluded that the way forward
lies in better caring, not easier killing. Legalisation would be a
dangerous and distracting development, and the BMA is to be commended for
maintaining its opposition.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor
Your correspondent’s recent report (1) of a Medix survey of British
doctors’ opinions about the legalisation of assisted suicide demonstrates
a worrying failure to follow the usual BMJ concerns with conflicts of
interest, or to appreciate the serious limitations of a social survey with
an unknown response rate and dubious representativeness.
A visit to the full report on the Medix web site (http://www.medix-
uk.com/) reveals that this survey was sponsored by the Voluntary
Euthanasia Society, a fact not mentioned by your correspondent.
The original Medix report describes an ‘acceptance rate’ for the
survey of 95%. Having personally communicated with the Medix researchers I
have established that this, however, is not a response rate, referring
only to those registered members of the Medix network (whose
representativeness of the population of UK doctors can only be guessed at)
who chose to reply to the survey when they logged on to the site. Since
several thousand members were emailed with a request to respond, the 1000
responders represent a small (and unreported) proportion of the original
(non random) sample. The response is likely to favour respondents with
time on their hands, members of Medix who gave out their emails to the
organisation, and with an active interest in the subject that may have
motivated them to volunteer a response.
I am at present conducting a postal survey of UK doctors regarding
end of life decision making, funded by the Nuffield Foundation. This is
based on a carefully selected random sample, using a questionnaire already
used in other countries (2,3), enabling international comparisons. With
the avalanche of paperwork experienced by many UK doctors, achieving an
adequate response rate to this survey is a concern. The reporting in the
BMJ of the Medix survey gives me further concern for the reputation of
survey research in this area amongst UK doctors.
Appearing on the day that the BMA gave evidence to the House of Lords
select committee on the Assisted Dying for the Terminally Ill Bill, this
is clearly a VES publicity stunt and the BMJ has acted as conduit for
misinformation on an important public issue.
Yours sincerely,
Clive Seale
Professor of Sociology
References
(1) Zosia Kmietowicz Doctors favour legalising assisted suicide for
dying patients. BMJ 2004;329:939
(2) Kuhse H, Singer P, Baume P, Clark M, Rickard M. (1997) End-of-
life decisions in Australian medical practice. Medical Journal of
Australia 166: 191-6.
(3) Mitchell, K and Owens, G. (2003) National survey of medical
decisions at end of life made by New Zealand general practitioners. BMJ
327: 202-3
Competing interests:
None declared
Competing interests: No competing interests
Readers are advised to consult the full report of the survey at www.medix-uk.com.
Competing interests:
The respondent is a director of Medix UK plc.
Competing interests: No competing interests
Even more illuminating facts behind the Medix survey
Dr Au-Yeung expresses his doubts about the Medix survey, as well he might. Surveys are imprecise instruments and it is important that readers form their own views about how reliable or representative they might be.
The only claim of Medix in respect to the survey report is that 1000 UK medical doctors responded and that their responses were reported faithfully. No claims were made as to reliability or representation, nor was the survey approach discussed. Medix did not provide interpretation of the results. The figure of 968 doctors refers to full or part time doctors (as opposed to retired or not in clinical practice); this breakdown was reported in the survey.
In my response to Professor Seale, I volunteered the worst case response rate of 19%. The survey was stopped when 1000 responses were received, as per the sponsor’s (the Voluntary Euthanasia Society) instructions. This naturally had the effect of fixing the response rate in advance. Readers must take this into account when assessing the value of the survey.
Medix members respond to some surveys for remuneration and volunteer to respond to other surveys for no remuneration. No remuneration was offered for this particular survey. It is difficult to see the bias Dr Au-Yeung projects, even if remuneration is offered. Surely he is not proposing that doctors interested in remuneration may have a particular bias in terms of euthanasia? Significant self-selection in that respondents might have joined Medix to respond to this survey is discounted by the information that only 19 of the 1000 respondents (1.9%) have responded only to this survey.
My personal view is that the Medix survey is likely to be reasonably representative of doctors’ views on the subject. Two previous Medix surveys of similar configuration in 2003 demonstrated significant predictive power when compared with actual events. In addition, the power of 1000 responses in a total population of some 100000 is quite high. One hopes that Dr Au-Yeung’s concerns about the survey are not an attempt to "shoot the messenger" because he does not care for the message.
Competing interests:
The respondent is a director of Medix UK.
Competing interests: No competing interests