Changes in BMA policy on assisted dying
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7518.686 (Published 22 September 2005) Cite this as: BMJ 2005;331:686
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No longer seeing euthanasia/physician assisted suicide as a black and
white issue is not, as suggested by Ann Sommerville, a sign of maturity in
the British Medical Association. It is, however, a further marker of the
drift from the principles which have under-pinned our profession for
centuries. We have moved from the desire, at the very least, to do no
harm, (Hippocratic Oath), to the incredible notion that killing the
patient could actually be seen as good medicine!
Competing interests:
None declared
Competing interests: No competing interests
I do understand Dr Thick's views and actually did not think that
my point of view will be misused and the points he mentioned will be
understood in this way.I described an example that happened in TV,and I was
among a lot of people at that time who refused such excuse for killing
patients to relieve them. I tried to discuss the things that might come
to the mind of suffering patients about their full right to decide,but I
did not mention that this is accepted from my or my society's point of
view,because I think the doctor has a limit to practice and this limit
will not allow him to take such decisions. And if certain legislations are to
be arranged regarding this issue they should be clear cut,without
ignoring both the patient and the doctor.
Competing interests:
None declared
Competing interests: No competing interests
Sir, Dr Jaafir (re big issue conflict) puts to us that most
compelling situation in which doing the best for our patient includes
accepting death, even to the point of challenging our ethical duty to do
no harm. Leaving aside the sharp irony of his society’s apparent readiness
to take the life of the doctor, the complex issue of euthanasia and
physician assisted dying includes the practical too.
Yesterday an elderly heckler was held by police under new counter
terrorism laws after being ejected from the Labour Party conference. This
is exactly the sort of thing we were reassured could never happen, when
those new laws were being prepared. But if man has a tool, he will use it
when expedient, be it nuclear bomb or centralised computer health record.
We betray the role of physician when we are even just neutral about
physician assisted suicide. In practice, our society has too much to lose
were it to discard belief in the sanctity of life.
Competing interests:
None declared
Competing interests: No competing interests
I am from an Arabic country,and as you all know,letting the patient
decide to die means suicide,which is not allowed at all,but the first time
this issue was discussed in public,was 4 years ago,via an Egyptian series
which showed a young doctor who was very reputable in her hospital and
very kind with her patients. This was till an old man came with a terminal lung
cancer who was very like her dead father,and the high doses of
morphine were not working,so he called her and asked her to let him rest in
peace with his beloved wife,and she refused many times till she responded
to him and injected him with anaesthetic agent,then he
died with a smile on his face,and it was decided that she should be killed
for doing this but, at last,his relatives asked to release her because she
was the most kind one to their father.
This issue is very difficult to solve,because there is no obvious
borders or any clear limits or conditions as we are dealing with very
wide range of dying cases every day,but if we discuss this regarding the
support or the amendment,it is as the following:
We learned in medical school that the priority of a doctor is not
the diagnosis or the drug or anything else,but it is the patients
themselves, their feelings and how important that they should know and be
involved in every little step we decide to take during their management
and they should approve these actions. For example, a patient refused to have
surgery under local anaesthesia and wants to be completely unaware during
the operation, we should respond to his demand if there is no related
risks. So the question is why do we not allow the patient to take
this final decision,because they had been involved in everything
before? So why at the most relieving request can we not respond? We do not
feel what they feel,so we cannot decide because medical ethics do not
allow us to kill a patient but only to cure them or relieve them,but
sometimes allowing them to die will give them the most relief they had
ever experienced in their life.
Actually it is difficult to approve or amend this issue but putting
legislations and arrangements is essential to put a first step on
this difficult path, and the first thing is to define death in a way that
would help in solving this issue.
Competing interests:
None declared
Competing interests: No competing interests
Sir
I would like to register my unease and concern about the forthcoming
euthanasia debate. I have a special interest in palliative medicine and
strongly believe that euthanasia has no place in palliative medicine.
To palliate is to control symptoms and ultimately to facilitate a
natural death with dignity for patients. We must not allow our profession
to take life however honourable the intention. I believe that we will
undermine public confidnce in the palliative care services particularly if
euthanasia becomes a 'therapeutic option' which we will be expected to
offer to patients.
I feel most strongly that to have euthanasia in our therapeutic
armoury would undermine irreversibly the special relationship between
doctors and their patients expecting care and consideration in their final
illness.
Dr Paul Barker
Competing interests:
None declared
Competing interests: No competing interests
We wish to challenge Sommerville’s view that it is acceptable for the
BMA to adopt a neutral stance on assisted dying.1 This reversal in BMA
policy will considerably strengthen the position of those wishing to
change the law.
We believe that the proposed legislation allowing assisted suicide
will fundamentally affect the practice of all doctors and it is therefore
imperative that the BMA should reflect the genuine view of its membership.
Both the Association for Palliative Medicine (APM) and Royal College of
General Practitioners (RCGP) made strenuous efforts to ascertain their
members’ views. This is in sharp contrast to the BMA where a tiny
majority (eleven delegates) effected a major shift in policy without
reasonable attempts to consult the membership.
The APM survey demonstrated that over 90% of practising palliative
medicine physicians opposed a change in the law. The RCGP members also
supported a position of opposition. 2
As the ethics committee of the APM we can be confident that we continue to
represent the views of our members in opposing the proposed legislation on
assisted dying.
1. Sommerville A. Changes in BMA policy on assisted dying. BMJ
2005;331:686-8 (24th September)
2. RCGP Statement on Assisted Dying; www.rcgp.org.uk/press/2005/0067.asp
accessed on 28th September 2005.
Competing interests:
None declared
Competing interests: No competing interests
Editor- In the article by Ann Sommerville[1] and in the BMA’s new
position of neutrality regarding assisted suicide there is an assumption
that neutrality on this issue is possible. This is not so. There is an
incompatibility between the prevention of suicide and the approval of
suicide. Removing the lethal means to suicide is central to the clinical
treatment of a suicidal patient, whereas providing the lethal means is
central to the assisted suicide model. These models are based on
incompatible assumptions about the value of protecting human life. Any
attempt to mix these models results in confusion and endangers seriously
ill patients.
In the same article Ann Sommerville argues that Oregon has assisted
dying (assisted suicide) without appreciable problems. How would anyone
know?
The Oregon Health Department (OHD) has to rely on the words of doctors who
prescribed the drugs. Relatives or other caregivers are not interviewed
and neither are doctors who refuse to prescribe drugs for assisted
suicide. The key witness of course is dead. The OHD has no authority to
ensure compliance with reporting requirements. There is no penalty for
doctors who do not report prescribing lethal doses of drugs. We simply do
not know the extent of assisted suicide in Oregon. The Oregon Health
Department has refused to allow access even to anonymised records for
independent review.
Pain control in Oregon seems to have worsened according to a study
comparing relatives’ reports of pain in patients who died before the law
was changed with other reports of pain control in patients who died after
1998.[2]
The term ‘rational suicide’ has now entered psychiatry. This is the
notion that for some people, suicide can be a valid option. Proponents
argue that a decision to commit suicide should be viewed as rational by
anyone with a ‘hopeless condition’. This includes patients with ‘mentally
debilitating or deteriorating conditions, or a quality of life that is no
longer acceptable to the individual.’[3] By definition that would include
everyone who is suicidal. If this kind of thinking becomes widespread we
will be well down the road to death on demand.
Medical involvement in assisted suicide or euthanasia crosses
boundaries into the territory of value judgments. No longer is the
discussion of whether the treatment is worthwhile but whether the
patient’s life is worthwhile. This is dangerous and increases medical
paternalism.
There is no such thing as neutrality on assisted suicide or
euthanasia.
1 Sommerville A. Changes in BMA policy on assisted dying. BMJ
2005;331:686-688
2 Fromme EK, Tilden VP, Drach LL, Tolle SW. Increased family reports
of pain or distress in dying Oregonians: 1996 to 2002. J Palliative Med
2004;7(3):431-442.
3 Werth JL, Cobia DC. Empirically based criteria for rational
suicide: a survey of psychotherapists. Suicide Life Threat Behav
1995;25(2):231-40.
Competing interests:
None declared
Competing interests: No competing interests
The Oregon Medical Association (OMA)clarified its policy position on
assisted suicide and Oregon's assisted suicide law, at the OMA House of
Delegates meeting on 1 May 2005 when they adopted the following policy
report:
"In May 1994 the OMA stated that it neither supported nor opposes the
concept of physician assisted suicide. In May 1997 the OMA stated that it
is opposed to Oregon's physician assisted suicide law (ORS Chapter 127.800
-897."
I hope the BMA will follow the example of the OMA in going from a position
of neutrality to a position of opposition regarding the House of Lords'
Assisted Dying for the Terminally Ill Bill.
Competing interests:
None declared
Competing interests: No competing interests
Sommerville reports data from Oregon showing that the recipients of
assisted suicide are "younger with above average educational attainment
... not marginalised ... [and without] depression, lack of social support
and fear of being a financial drain on family members as factors in their
choice." This can be taken to imply that older, poorly educated,
marginalised and isolated patients are not adversely affected by the
legalisation of physician assisted suicide. This is not necessarily the
case. Although we have no evidence that vulnerable patients are receiving
assisted suicide in large numbers in Oregon, this does not exclude
significant adverse effects resulting from a change in the law.
The House of Lords (HoL.) Select Committee on the Assisted Dying for
the Terminally Ill (ADTI.) Bill heard evidence that vulnerable patients
may constantly fear assistance in dying (Prof. van den Eynden to HoL.
Select Committee on ADTI. Bill) and that the rest of their lives may be
spent worrying about whether they should opt to die and if so when (Dr. F.
Randall to HoL. Select Committee on ADTI. Bill). Although less extreme
than death, such concerns clearly have the ability to significantly impair
the quality of life of many terminally ill patients.
The consequences of a change in the law may be widespread, indirect
and not immediately obvious, but this does make them trivial concerns.
Sommerville A. 'Changes in BMA policy on assisted dying' BMJ. 2005;
331: 686-688
HoL. Select Committee on ADTI. Bill 'Assisted Dying for the Terminally Ill
Bill [HL], Volume II, HL paper 86-II. London: Stationery office, 2005
Competing interests:
None declared
Competing interests: No competing interests
What does neutrality mean?
The results of a voting process at the 2005 BMA Annual Meeting appear
central to Ann Somerville’s explanation of how and why the BMA has changed
its policy on assisted dying (1). Therefore I am shocked that this data
has not been presented to the usual high standard of the BMJ. For example,
why are we denied a proper description of the methodology, including the
nature of the study population and why they were considered representative
of BMA membership as a whole? What was the exact wording of the questions
under vote, and were the results to each question publicised before asking
the next? What safeguards ensured that the electronic voting process
remained uninfluenced by perceived peer-pressure in an open meeting, and
why isn’t every potential vote accounted for? These questions are just the
tip of the iceberg. Had Somerville’s paper adopted the standard format for
a piece of research, it would surely have been rejected on numerous counts
including poor study design, unrepresentative sampling and incomplete
results. Yet this is apparently the very research upon which the BMA has
changed its stance on assisted dying. On a matter of such importance, I
urge the BMJ to republish the work in a more scientific and transparent
format so that we can examine the true strength of evidence for ourselves.
Since when has parliament and society required the BMA’s permission
to decide upon the issue of assisted dying, as indicated in Box 1? Are
there other legal areas where the BMA has such authority?
Data from Oregon offers little reassurance that uptake for assisted
death is low or that a slippery slope scenario is avoidable (2). In 2003,
1-in-260 deaths from cancer and 1-in-40 deaths from amyotrophic lateral
sclerosis, HIV or AIDS were assisted deaths. An apparently
disproportionate number of younger adults had lost autonomy and the
ability to engage in enjoyable activities to the extent that they
considered assisted suicide the preferred solution. Doesn’t the acceptance
of such a wish at face value represent a slippery slope regarding our
concern for others?
I believe that we could achieve a great deal if the same energy being
put into the assisted dying debate were applied to helping the seriously
ill appreciate their retained or salvageable autonomy and helping them
engage in enjoyable new activities. Furtherance of skills and abilities in
this area for those in need of them will never happen if we simply assist
with death on request. If we debate the creation of a legal framework for
assisted self-destruction without seriously addressing the underlying
losses of autonomy and enjoyment that drive people to suicidal ideation,
then the seriously ill would not be totally unjustified in thinking that
society considers them financially draining, a burden unworthy of greater
support, and lacking further prospect of quality life. Whilst this might
be the opinion of some, it is not mine. How can one be neutral upon this?
1. Sommerville A. Changes in BMA policy on assisted dying. BMJ
2005;331:686-688.
2. Oregon Departmant of Human Services. Sixth Annual Roport on Oregon’s
Death with Dignity Act. Portland: DHS, 2004.
http://egov.oregon.gov/DHS/ph/pas/docs/year6.pdf (Accessed 4 October 2005)
Competing interests:
Hospice doctor
Competing interests: No competing interests