Assisted dying: the debate continuesBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l576 (Published 07 February 2019) Cite this as: BMJ 2019;364:l576
All rapid responses
Dear Drs Mowat and Chisholm 
I have been a BMA member for almost 25 years, and I have never been asked by my regional representative / or the national body? my opinion on the matter of Assisted Dying.
When Representatives stand for election, I have yet to come across a ‘manifesto’ that states the candidates stand on Assisted Dying.
I suspect this true for the majority of the BMA membership
It was therefore with disappointment that I read the recent piece in the BMJ that the BMA’s opposition to Assisted Dying
While the policy may appear to be a ‘deliberative and democratic process’ technically, I think you will agree that, the ARM falls far from the standard of being able to truly reflect the views of the BMA membership, given the above caveats.
In the piece you said, unless you hear otherwise, the focus will be on opposing a shift in position
I am therefore writing as a member to ask for an open debate and poll of the BMA membership on this matter.
I would be satisfied by a simple Yes/No poll asking the BMA membership if they would like a poll akin to the RCP on Assisted Dying.
We have as BMA members been polled on more complex matters. And I think the membership is sophisticated and intelligent enough to decide whether it would like to have an RCP like poll or not on this important issue.
I would be grateful for your consideration of this request from a long standing member
Dr Roshan Agarwal FRCP PhD
Consultant Medical Oncologist
Visiting Professor of Cancer Studies
1 Mowat A, Chisholm J. Assisted dying: why the BMA does not poll members on nuanced ethical questions. BMJ 2019;364:l593. doi: https://doi.org/10.1136/bmj.l593 (Published 06 February 2019)
Competing interests: No competing interests
The debate on assisted dying remains polarised. Areas of agreement are needed. The one thing that both sides of this argument can agree on is that care of the dying in this country is still not as good as it should be.
Assisted deaths will only account for a small percentage of the total number dying so why are we devoting so much time and effort to such a small number?
When both sides of this debate agree that care of the dying is as good as it can be, then we need to start polling members and organisations such as the Royal Colleges and BMA can start truly having a position. Then we can decide if a change in the law for the small number who may benefit is the right thing to do.
Until that time can we devote our time and energy to work together to improve the care of the many hundreds of thousands who die every year in less than ideal circumstances?
Competing interests: No competing interests
Alleviating Suffering is not by Eliminating the Patient
Ref: Assisted dying: the debate continues
BMJ 2019; 364: l576 (Published 07 February 2019)
There is now mounting evidence to believe that human beings may survive after physical extinction. This finding has never been in the equation of the medical debate on assisted dying even though it is one of its most significant philosophical aspects. It is highly important to promote a broader view of consciousness among medical experts to prompt them to search for reasons for their patients’ suffering beyond the prevailing neurobiological model of mind. Medical reductionism is the assumption that nothing can be greater than the sum of the bodily parts -- the whole is the same as the sum of the parts -- and non-reductionism is the supposition that the whole is greater than the sum of the parts. Medical reductionism has been rampaging through this caring profession un-noticeably in modern times, and it is also a fatal ideology for patients and unrewarding for carers in the psycho-spiritual perspective.
The reductionists do not have the conceptual model and intellectual tools to study many non-ordinary mental states. They have to accept the limit of their approach to scientifically investigated phenomena like near death experiences, collective apparitional experiences, death bed visions, supernormal states, certain kinds of mediumship, children remembering previous lives, electronic communications, etc (1,2,3,4,5,6,7). There is compelling evidence to support the claims of enhanced cognitive faculties in near death experiences when the brain is truly underactive (8,9). The combined body of evidence for discarnate survival is overwhelming – so great that it may be regarded as scientifically cogent (10). This emerging scientific view, coupled with the wisdom of the faith traditions, challenges the rationality of supporting assisted dying. The following are examples of scientific evidences for discarnate existence that are commonly cited:
1. Clinical death experiences
2. Pre-death visions
3. Shared death experiences
4. Collective apparitions
5. Some forms of mediumistic incidents, particularly ones that involve cross-correspondence, drop-in communications and physical phenomena
6. Children’s memories of previous lives
7. Electronic voice phenomena
8. Instrumental trans-communications
9. Transplant cases
10. Scientifically studied Marian apparitions
The multi-specialities Professor Gary Schwartz of Arizona University claims to have invented a device to communicate with discarnate spirits, and he is aware of the potential negative consequences (11,12). Schwartz claims to have worked with black boxes in his laboratory, using a software programme that has generated proof that there is a spirit world by measuring light (12,13). Even though such an experiment might offer foolproof evidence of after death existence, it can also provide fake information about the discarnate dimensions. What we can know about discarnate existence are only the dim symbols of an incomprehensible reality. But, this scientific evidence is a helpful pointer towards faith traditions.
While Professor Schwartz and the Soul Phone Foundation team are experimenting with the proto-type of Soul Phone despite grumbling and criticism from peers, at Medjugorje in Bosnia, scientific studies have confirmed a mystical manifestation that has been going on for 37 years (14). The Medjugorje visionaries claim that they are experiencing a Marian apparition who identified herself as the Queen of Peace for the last 37 years, and she is appearing there to guide the world in the present social, political and spiritual crisis (15). Kelly et al argue that computational theories about consciousness cannot explain the introverted or extroverted mystical experiences of a pure undifferentiated consciousness (16). Before they accelerate the death process, physicians should have at least a vague idea where the discarnate personalities are transitioning to. All faith traditions unanimously promulgate the view that the departed ones would be slotted according to their moral gravity in the different spiritual dimensions.
It is the sanctity of life and its sufferings that make assisted dying immoral and unethical. It has to be pointed out that a belief in after death existence without the associated appreciation of the sanctity of life and meaning of human sufferings can also be death promotional. There is important common ground between all faith traditions on the issue of assisted dying and that all faith traditions oppose it for similar reasons in order to espouse a sanctity of life position. Some of the investigatory books in survival research have been ultra-optimistic about the prospects of discarnate existence and have downplayed the sacredness of terrestrial existence. Science has limitations in understanding the sanctity of life; we have to rely on Holy books and revelations including Marian apparitions. It is not an exaggeration to state that every breath in the bodily existence is precious. The material world may be pleasant and unpleasant illusions, but they offer spirit nourishing experiences. We arrive in the terrestrial dimensions with a definite syllabus and we need to exist in this earthly school until we complete the syllabus.
Through suicide, a person is simply changing the location of their suffering. While wrapped in the physical planet by space and time, we are in an advantageous position for inducing personality changes swiftly, whereas in the timeless state of discarnate existence changes are sluggish and personality development is much slower (17). Pre-death visions and shared death visions indicate that deceased relatives and other expert spiritual agencies come to assist the transition of dying people like midwives and obstetricians help a child's birth (3,18). People who take their own life may not get such benevolent spiritual assistance. Lord Alton argues that a forced death, as opposed to a natural one, may deprive a person of their final “healing moment” (19). Chico Xavier literature suggest that spiritual agencies might even hasten the death process in their own ways in cases where the death process is prolonged (20); the timing of death is a matter of spiritistic decision. Assisted dying or euthanasia is incompatible with the theological view that it is the weakest and the vulnerable who can teach us the values of life, and the concepts of euthanasia or assisted dying have the hidden message of neglecting them. The right to die would soon deteriorate into the duty to die to prepare room for the fittest ones. Alleviating suffering is not by eliminating the patient.
No funding and no conflicts of interests
1. Betty Stafford. Heaven and Hell unveiled. Guildford: White Crow Books, 2014.
2. Fontana David. Life beyond Death. London: Watkins Publishing, 2009.
3. Osis Karles & Haraldsson Erlendur. At the hour of death, New York: Avon Books, 1977.
4. Schwartz E. Gary. The Afterlife Experiments. New York: Atria Books, 2002.
5. Stevenson Ian. Reincarnation and biology. Westport, USA: Praeger Publishers, 1997.
6. Moody Raymond. Life after death. New York: Bantam, 1975.
7. Moody Raymond. Light Beyond. New York: Bantam, 1988.
8. Fenwick Peter and Elizabeth. The Truth in the Light. White Crow Books, 2012.
9. Fenwick Peter. The Art of Dying. London: Continuum, 2008.
10. Tymn Michael. An Interview with Dr Vernon Neppe. The Search Light. Vol 21, No 4, 2002.
11. Schwartz E. Gary. The Sacred Promise: How science is Discovering Spirit’s Collaboration with Us in Our Daily Lives. New York: Atria Books, 2011a.
12. Schwartz E. Gary. Photonic measurement of Apparent Presence of Spirit Using a Computer Automated System.drgaryschwatz.com, 2011b.
13. Schwartz E. Gary. After life communications. Florida: ASCS Publications, 2014.
14. Laurentin Rene and Joyeux Prof. Henv. Scientific and Medical Studies on the Apparitions at Medjugorje, Dublin, Mount Salus Press, 1987.
15. Soldo Mirjana, Bloomfield Sean and Musa Miljenko. My Heart Will Triumph. LLC: Catholic Book Shop, 2016.
16. Kelly Edward; Kelly Emily Williams; Crabtree Adam; Gauld Alan; Grosso Michael; Greyson Bruce. The Irreducible Mind. Lanham: Rowman& Littlefield Inc, 2006.
17. Pandarakalam James Paul. Physicians Involved Assisted Suicide.BJMP2018;11(1):a1102
18. Moody Raymond. The Last Laugh: A new philosophy of near-death experiences, apparitions and the paranormal. Charlottesville, VA: Hampton Roads, 1999.
19. Xavier Francisco Candido. Nosso Lar. Brazil: Brasilian Spiritist Federation, 2011.
Dr James Paul Pandarakalam,
North West Boroughs Healthcare NHS Foundation Trust,
Hollins park Hospital,
Warrington WA2 8WN, U. K.
Competing interests: No competing interests
It is difficult to fathom the stance of the BMJ to recommend Doctors take a neutral stance on assisted dying deeming it a 'matter for society rather than the medical profession'. I would even go so far as to say it is a completely unethical stance to take. Doctors have an immense wealth of experience of treating the living and the dying - that can be used to inform the debate, to raise awareness of the various issues at hand that affect not just the profession but society at large.
1) The medical profession is part of society and has a right, as does the rest of society, to air their views on this matter. To deny doctors a voice on this subject is to deny them their human rights as people.
2) Assisted dying if implemented would affect the lives of doctors as the ones legally obliged to write the prescription for the medication that will kill the patient. As such the voice of doctors deserves to be heard and not neutered given the personal and professional implications. There is evidence to suggest that doctors are detrimentally affected by being involved in these practices.
3) For aeons Drs have been trained to heal and preserve life - not kill - it is fundamental to the practice of medicine and respects the fact that there is more to the process of life, living and dying than just what we see with our eyes.
4) It is clear from experience in the Netherlands (NT) and Belgium that once opened, the assisted dying doors just get wider and wider until it is no longer just the terminally ill - but the tired of living, the depressed, and those with non-life threatening conditions. Next step is euthanasia - as the arguments go that it is unfair to deprive those who cannot take the medication themselves of the right to end their life - and this is happening in NT and Belgium - where it has also been extended to children.
5) Those who feel a burden (and there are many), who are vulnerable, disabled and without a voice are currently protected by the law - removing that safeguard undoubtedly renders them vulnerable to coercion, abuse and killing.
6) Even with the law we see people who take the law into their own hands e.g. Gosport - but how much easier would it be for this to occur and be repeated up and down the country were assisted dying made legal? Especially in a resource limited health service, with a rising elderly and demented population in need of costly nursing care? IF we are appalled by Gosport then we should take all action to prevent similar occurring on a legal basis under the name of AD.
7) It makes a nonsense of having suicide prevention programmes on the one hand and promoting/legalising assisted dying on the other - instead of counselling and helping someone who is suicidal are we now to support and respect their 'autonomous' choice - given the shift and trajectory in assisted dying cases to include those who are depressed/tired of living, etc.? Once permitted it cannot be contained to just those with terminal disease. And even where it starts out like that - there are many cases where people who were supposed to be dead within 6 months to warrant the prescription, who are still alive 1, 2 and 3 years down the line.
8) There is still much to be gained in the field of palliative care and healing - we have by no means exhausted the potential for healing and helping people address the sources of suffering in their life. Exchanging palliative care for AD will limit the expansion, innovation and development of palliative care services further - AD becomes the easy option rather than help people with their physical, emotional, mental and spiritual suffering. However, by addressing the latter in full it is possible for someone with terminal cancer to approach the end of life with grace, contentment, ease and a quality of being that most would not think possible.
9) The only way to reduce and keep risks, abuse and mis-use to a minimum is to keep assisted dying and euthanasia illegal.
10) AD devalues and cheapens life - and when we do that to one life, we do it to all.
Much more could be said but it is clear to me that forcing doctors to take a neutral stance is just a tactic to neuter their professional and personal voice in order to advance the case of those who support AD. It is perhaps worth considering and asking why doctors, despite seeing huge amounts of suffering, are more opposed to AD than the general public and that what they have to say on the matter is possibly worth hearing rather than silencing?
Competing interests: No competing interests
Assisted Dying in India
On 9 March 2018 the Supreme Court of India legalised passive euthanasia by means of the withdrawal of life support to patients in a permanent vegetative state.
There are different euthanasia laws in each country.
It can be classified into five types - voluntary, non-voluntary, involuntary, passive and active.
India joins countries like the Netherlands, Canada, Belgium, Colombia and Luxembourg in legalising passive euthanasia.
In India some are against it because of religious and moral reasons.
With religious beliefs against premature death held strongly in India, the right to life may weigh over the right to die with dignity that has been granted legal sanction by the apex court.
Even though the Supreme Court of India has recognised the right to die with dignity as a fundamental right, major hurdles might be posed by religious communities, who may oppose euthanasia in India.
In Hinduism Atma-gatha, meaning suicide—the intention to voluntary kill—was prohibited in Hindu culture.
Indian Muslims may also not favour euthanasia. Muslims believe that no one has a right to die before the time decided by God.
According to both Sunnis and Shias, killing a terminally ill person, whether through active euthanasia (physician assisted suicide) or passive euthanasia (stopping life support or medicine), is considered as an act of disobedience against God.
Indian Christians, especially the Catholic Bishops of India, are also against euthanasia. The Catholic Church forever promotes the sanctity of life, thus euthanasia is contrary to its teachings.
Competing interests: No competing interests