Assisted dying and the RCP poll: what do The BMJ’s readers think?BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l787 (Published 20 February 2019) Cite this as: BMJ 2019;364:l787
All rapid responses
Despite my job as a Consultant Liaison Psychiatrist, I doubt very much that I would be writing this had I not been a patient myself. As virtually all doctors will have done, I have seen patients who have received the most devastating news and have had to come to terms (or not) with the fact that their life is being cruelly cut much much shorter than they could ever have imagined. We sympathise and hopefully empathise with them. We see their shock and distress and sense the fear of their loved ones who will be left in grief. But do we really understand or comprehend what they are going through? We all go through life aware that we will die one day. Aware that our family and friends will die, either before or after us. But that doesn't stop the youthful illusion of immortality that we have which, as we age, seems to morph into something more akin to denial. I was no different. Whilst I agreed with the personal autonomy argument in favour of assisted dying on one hand, the counter arguments weighed heavily against. My training led me to worry that many people requesting such interventions may be depressed or otherwise mentally ill. I was concerned about the pressure from malevolent family or carers or from society in the wider sense as the population ages. More naively, I also felt that people need us as doctors to always protect them and that we, on the whole, know better than our patients...that is until something happened to me.
At a time in my life in my mid thirties when I least expected it, things changed overnight. I had just started my first consultant post my partner and I were just about to buy our dream house. I had been checked out for a lump nine months earlier and been cleared. However something didn't seem right and I contacted the hospital. I was asked to come in that afternoon and the following day was diagnosed with breast cancer. The whirlwind that followed is difficult even now, ten years on, to think about and it is hard to explain those emotions. Due to my age, tumour characteristics and the extent of lymph node spread the treatment was severe and my medical knowledge an added burden as I was well aware of the sobering prognosis. It was then that my whole appreciation and perception of what our patients go through changed radically. I could no longer put off thoughts of death for another few decades. I could no longer have the luxury of believing I had many years to realise my hopes and ambitions. The stark reality of my mortality was staring me straight in the face. Although this may sound patronising to some, it is not something that anyone can properly imagine until they are in that position. Even now, having been through this experience myself, it is difficult to put myself fully back in that place and completely recall how I felt. What I do know, however, is that at that time it became overwhelmingly important to be able to have the choice how my life should end if it came to that. We can sanitise dying as much as we want and use arguments about how far palliative care has come (which undeniably is true) but the harsh fact remains that a prolonged death is a terrifying, unacceptable prospect to many when actually faced with that situation.
I fully understand the reluctance of many doctors to embrace the concept of assisted dying as it does seem to go against what we are trained to do. However this is an area where we must not let our misplaced paternalism dominate. The public often see things differently from doctors. That does not necessarily make them wrong. There are many other factors that come into peoples' decisions which even as professionals we may not properly comprehend until we have experienced something similar ourselves. It is arrogant to think that we always know best. With the right safeguards there is no reason why capacitous, mentally well patients shouldn't be able to exert free control over their mode of death and we should have the humility and flexibility to accept that. I am one of the lucky ones. I am still living my life and appreciate every day more than I could ever have done before. However I now possess insight that has opened my eyes and altered so many of my beliefs and attitudes. For those that would argue that this is just an emotional response, that doesn't matter. What does matter is the reality of the situation when you're in it. Sadly this is not something that can be taught or intellectualised over but only experienced.
Competing interests: No competing interests
An acknowledgement of the level of dissatisfaction with the BMJ’s stance on assisted dying is welcome, however brief.(1) And yet the leaflet from Healthcare Professionals for Assisted Dying (HPAD) keeps falling out of BMJ issues. Given this journal’s desire to present all views,(2) we feel the claims of colleagues in the HPAD leaflet deserve examination.
Zoe Norris claims that there is a taboo about assisted dying. The taboo around death is the problem, but in countries were assisted dying or euthanasia are permitted it is this assistance and the timing of it that can become the distressing taboo.(3) Harriet Copperman rightly believes that we should learn from patients’ perspectives. However, that demands that we also listen to the vulnerable, whose voices are often lost or ignored. Jacky Davis asserts that assisted dying laws elsewhere demonstrate greater choice and a protected society. Yet even Lord Falconer’s commission on assisted dying had to acknowledge any change in the law would present a real risk of pressure, both direct and indirect on people.(4) Henry Marsh believes that it is no longer appropriate to use the adage ‘Where there’s life there’s hope’. But this is an argument for not pursuing medical intervention at any cost. The issue is whether there is a duty for doctors to enable assisted dying. Robin Francis’ personal experience led him to believe that assisted dying would ease the fear of not being in control at the end. And yet, fear of the future is a fear of the unknown. The unknown only exists through poor knowledge and inadequate communication. These are not reasons to end an individual’s life.
Sir John Temple believes that doctors should play a more constructive role in the debate. That is already happening because we are not neutral. The role of the doctor in assisted dying goes to the core identity of our profession and cannot be based on reflexive responses to polls.(5) But before deciding what a change in law may look like we need to identify why the law needs changing at all. David Nicholl explains how he saw safeguards working in one individual, and yet 30% of Belgian euthanasia deaths in 2010 were without consent.(6) Finally, Clare Gerada promotes the view that medical organisations should be neutral. Neutrality means that either the medical bodies do not know or, worse, they do not care. Doctors cannot be neutral, let alone their professional bodies.
Promoting neutrality in advance of any knowledge of what legislation is planned binds the hands of the profession when advocating safeguards.(7) It is time to stop demands for neutrality and instead encourage debate, especially allowing the problems of assisted dying and euthanasia to be openly aired and discussed.(8) Clare Gerada once said, “The RCGP stops bad things happening by being at the right meeting at the right time with the right people and giving the right coherent argument.” (9)
1. Hurley R. Assisted dying and the RCP poll: what do The BMJ’s readers think? BMJ 2019; 36: l787. doi: https://doi.org/10.1136/bmj.l787 (Checked 20 Feb19)
2. Hurley R. Editorial response to Nicola S Wright and David J Jones about HPAD insert. https://www.bmj.com/content/364/bmj.l412/rr-15 (Checked 19Feb19)
3. Wernicke F. Response to Why I decided to provide assisted dying. https://www.bmj.com/content/364/bmj.l412/rr-12 (Checked 19Feb19)
4. Commission on Assisted Dying. London: Demos, 2011. http://www.demos.co.uk/files/476_CoAD_FinalReport_158x240_I_web_single-N... (Checked 19Feb19)
5. The Conversation. The murky issue of whether the public supports assisted dying. October 5, 2017. https://theconversation.com/the-murky-issue-of-whether-the-public-suppor... (Checked 19Feb19)
6. Pereira J. Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls. Curr Oncol. 2011; 18(2): e38–e45.
7. Mowat A, Chisholm J. Assisted dying: why the BMA does not poll members on nuanced ethical questions BMJ 2019;364:l593 https://doi.org/10.1136/bmj.l593 (Checked 20Feb19)
8. Herx L, Chary S, Dubland E, Henderson D, Lapointe B, Fainsinger R, Schulz V. Take off the rose-coloured glasses. A response to Drs Buchman and Blackmer BMJ 2019; 36: 1412. doi: https://doi.org/10.1136/bmj.l412 (Checked 19Feb19)
9. Moberly T. “We’re on the same side, really”: medical profession turns to soft power to influence policy. BMJ 2019; 364: 1707. doi: https://doi.org/10.1136/bmj.l707 (Checked 19Feb19)
Competing interests: No competing interests
It appears that in the areas of assisted dying, freedom of conscience on abortion and contraception and decriminalisation of illicit drugs, (and add to that in the wider community LGBT+ issues, the creation/evolution debate and climate change) one is not allowed to have a contrary opinion in public, and it is made to appear in all forms of media that any fair and reasonable person could not possibly think contrary to what is made out to be the standard or "accepted" position.
This must not be the case, and organisations whose primary responsibility is to report the news (which include the BMJ), rather than an organisation formed to promote the views of its members, must expend more effort to BE neutral, not just to APPEAR neutral superficially, especially when it comes to issues where there is a great divide between opinions.
Competing interests: I have a contrary opinion on some of the issues mentioned.
The BMJ should be congratulated for putting their own spin on what the readers said about assisted dying. The summary by Richard Hurley of readers responses turns something true and genuine (respondents real thoughts on the issue) into a neutral report of what he cherry picked they said. This cannot be credible as the BMJ's attempt to placate the masses by offering a token fig leaf of reasonableness and fair play to the very many who oppose assisted dying.The BMJ should on the contrary, invite some distinguished opponent of assisted dying with supporting opinion pieces (as they gave to the pro -assisted dying side) to expound on why assisted dying is a big mistake and a risk to health care and human rights. The majority of rapid responses were against assisted dying and came from Canada (and gave the opposite view to that expressed by Jeff Blackmer et al), from palliative care, from the disabled (who are most at risk of being disenfranchised), and from experienced doctors. The ability to manipulate the many by the few and to sway public opinion by commandeering the loudspeaker (the press/media/BMJ) is an unfortunate an abuse of position, power and influence that we witness in media all the time.
If the Journal is a record of fact and seeks truth and transparency in research and reporting, it should not be afraid to ask the defining questions and as in any reputable publication - hear both sides equally.
Competing interests: No competing interests