BMA responds to articles on assisted dyingBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k911 (Published 27 February 2018) Cite this as: BMJ 2018;360:k911
All rapid responses
I welcome your recent response but I must say I do not feel that you have answered the questions put to you. The concluding remarks, 'The standard of palliative care is clearly inconsistent throughout England, and the priority of the government and doctors must be to provide the best quality care to patients as they reach the end of their lives, regardless of where they live or their medical condition,' are perhaps the most telling. The inference appears to be that this in some way lends a justification for your view on PAD, though how this conclusion is reached is not clear to me. You must be aware that this goal is not achievable across vast swathes of the country.
Standards in palliative care is a topic that arises on a frequent basis in UK medical literature. As with mental health, a lack of overall funds, and a lack of funds directed towards this specific problem, combined with increasing requirements placed upon the resources available, is not an equation that is easily balanced. One could argue it is not being balanced at all. I cannot recall the last time a patient of mine was successful in gaining a place in a hospice. There is very little in the way of relationship between morality and economics. The capitalist tradition does not frequently correlate to human values, the NHS's approach to palliative care fulfils this to the extreme. In these circumstances what precisely constitutes 'best quality care', this winter I saw frequent evidence of poor palliative practice. This was not 'intentional', wider service needs are balanced against the individual across a back drop of staff, bed, bay and even corridor shortages. Outlying a palliative patient from medical HDU to surgery to make room for a 'salvageable' young T1DM, the only bed swap available, both fulfils and deviates from best practice depending on your point of view.
Whether intent truly makes a difference to the morality of the action is the decision that will dominate the debate of the next generation of doctors, this theme is consistently avoided by the UK institutions. To return to John Locke, a tree is still considered a tree despite the variation between forms. A lethal dose of pain relief is always a lethal dose even when directed at intractable pain. I fear the NHS may again be on the wrong side of history, it will be interesting to assess again when the next generation of clinicians inherit the mantle.
Competing interests: No competing interests
I welcome Dr Mowat's response on behalf of the BMA and her acknowledgement that doctors hold a range of views on assisted dying. Unfortunately, she does not answer the criticisms in the original piece which called for the BMA to poll its members on the subject of assisted dying and to adopt a neutral stance in the meantime.
BMA policy against assisted dying is the result of a vote held amongst 313 doctors (from a total BMA membership of 156,000) on a motion at the 2016 ARM. On a prior motion, half of those present had voted not to hold a debate on the matter at all. How can this be taken to fairly represent the views of the profession? No reason is offered for not polling the membership to inform policy, as some of the Royal Medical Colleges and the Royal College of Nursing have done.
Dr Mowat’s reply suggests that the BMA ‘recently tackled this topic’ with a ‘major research project’. The BMA did carry out a major research project but the primary focus was on end-of-life care, and there was only a limited attempt to look at assisted dying from the point of view of its effect on the doctor patient relationship. The research itself acknowledged that doctors who participated in this exercise were ‘more likely to come with pre-formed views and many found it difficult to separate their views on this topic from their wider views on physician-assisted dying and whether it should be legalised.’  Therefore the justification offered by Dr Mowat for such methodology appears flawed.
While Dr Mowat acknowledges the standard of palliative care is inconsistent throughout England, she provides no clear argument for why this supports the BMA’s stance on assisted dying, which one can only assume is the implication made. In fact, such a comment ignores the very clear evidence from jurisdictions that have changed the law, such as California, USA, which shows that assisted dying leads to improved communication around all aspects of end-of-life care .
It is noteworthy that the Californian Medical Association (CMA) was neutral on assisted dying when the law was passed in 2015. It was this stance that enabled the Association to engage with law makers and help shape legislation. CMA President, Dr Luther Cobb, said at the time:
'Collaborative conversations that enhance safeguards for both physicians and patients were possible because of CMA’s shift in policy' 
The BMA is on the wrong side of history with regard to assisted dying as attested by the increasing number of jurisdictions adopting legislation around the world. If our representative body demonstrates such reluctance to engage in constructive dialogue, then we risk silencing large sections of the profession, sacrificing opportunities to contribute our expertise to legislation and jeopardising the trust our patients hold in us.
 End-of-life care and physician-assisted dying, Volume 2: Public dialogue research https://www.bma.org.uk/collective-voice/policy-and-research/ethics/end-o...
 There's an unforeseen benefit to California's physician-assisted death law http://www.latimes.com/health/la-me-end-of-life-care-20170821-htmlstory....
 California Medical Association removes opposition to physician aid in dying bill http://www.cmanet.org/news/press-detail/?article=california-medical-asso...
Competing interests: Former Chair of Healthcare Professionals for Assisted Dying and patron of Dignity in Dying
This article seems to have two titles: 'BMA responds to articles on assisted dying', and Anthea Mowat's initial title which included the word 'physician' as in 'physician assisted dying.'
Many doctors (I suggest most, as BMA policy) oppose PAD on the grounds that is is antithetical for a physician to actively seek the death of a patient.
But many other doctors (perhaps even most) accept that society is now moving to an acceptance of euthanasia in carefully regulated circumstances - recognising that the final act which leads to death (the giving of an iv or oral medication) can be in the hands of any trained, competent, and regulated person. A doctor might prescribe, but then stand back and allow others to carry out the necessary procedures - if that is desired and legal.
The final practitioner might be a nurse, a retired doctor who is no longer registered with the GMC, a lawyer, a priest, or a member of a new profession developed for the purpose. Practicing doctors do not have to be involved in the final act.
This is not hypocrisy - there can be a clear distinction in the responsibilities.
Until this distinction is made, conflation of PAD with AD is too confusing for any meaningful survey to be made of BMA members, or doctors more generally.
Competing interests: No competing interests