Palliative medicine doctors in the UK have a plurality of views on assisted dying, but you wouldn’t know it
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj.q2351 (Published 30 October 2024) Cite this as: BMJ 2024;387:q2351Linked Opinion
David Oliver: If assisted dying is legalised, can we safeguard against misuse?
Linked Opinion
I’m a nurse and Isle of Man politician: healthcare professionals must feel able to engage with the debate on safe assisted dying law
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Dear Editor
We are grateful to the writers of Rapid Responses to our recent Opinion article,[1] as they reflect a plurality of views on assisted dying (AD) – exactly what we were trying to say does exist within palliative medicine, even though our specialty’s Association for Palliative Medicine (APM) does not allow its expression.
Dr Sarah Cox, APM President, focused on the breakdown of members’ responses to its survey, showing that the large majority (70-84%) of those who responded were not in favour of legalised AD; and similar proportions would be unwilling to participate in the process.[2]) We do not contest these figures, but wanted to express our concern that the views of the one in four or five who dissent, are being overlooked by our professional body in APM communications both internally to members and more importantly, to the outside world.
Dr Cox cites the recent APM position paper: “The APM acknowledges that, while a substantial majority of APM members oppose AD, some of our members have a different view.”[2] But what are those dissenting views? Dr Cox further wrote “The APMs position statement on assisted dying acknowledges the variation in views of our members”. But really, does it? Out of 338 words, there are just 21 words that say there is dissent.[3] The rest of the position paper is devoted to defining AD, and repeating the APM’s opposition to changing the law on the basis of 3 ‘concerns’ – protection of vulnerable, frail people; lack of funding for specialist palliative care; and concern about trust and impact on doctor-patient relationships. Nowhere does the position paper recognise any refutations of these concerns based on dissenters’ experience and publications;[4,5,6] or through published views from other palliative medicine doctors working comfortably alongside legalised AD.[7]
We had argued in our Opinion paper that the APM had misinformed members about the recent joint letter from the CMOs by saying it contained “advice to doctors in terms of speaking about their concerns on [AD]”. But the CMOs’ letter clearly recognised that doctors could hold a range of views.[8] We believe that coupling the mis-stating of ‘concern’ with a template for members to write back with the APM’s own pre-formed concerns was, at best, poor writing and was likely to lead to the same being forwarded.
The APM’s approach is in keeping with past experience, for example in their one-sided evidence to the Health and Social Care Select Committee’s consultation on assisted dying in 2023.[9] A reasonable conclusion to draw is that if members dissent from the majority, they lose their right to be represented in any communications. That does not foster constructive debate and exploration of this important issue.
We encourage the APM to facilitate an open conversation within the membership, by giving voice to the full range of opinions that do exist. Of course we do not expect that a minority should change the position of the APM away from opposition to change in the law. However, we believe there is room for debate about a move to a position of neutrality, in keeping with many medical bodies including the Royal College of Physicians, to which we all belong.
Our cumulative experience at consultant level in palliative medicine challenges the APM’s position that all it needs to relieve suffering at the end of life is to increase funding for palliative care. We know that there are limits to what even the best specialist medical and holistic care can offer, when rational, mentally competent people with a short prognosis have declared a settled wish to have their anticipated death, on a date and place of their choosing.
Sam H Ahmedzai, Brockhampton, Herefordshire, UK
Samuel Fingas, Sheffield, UK
And three anonymous co-authors
References
1. Ahmedzai SH, Fingas S, et al, 2024. Palliative medicine doctors in the UK have a plurality of views on assisted dying, but you wouldn’t know it. https://doi.org/10.1136/bmj.q2351
2. Cox S, 2024. Association for Palliative Medicine refutes accusations of misleading and stifling debate. https://www.bmj.com/content/387/bmj.q2351/rr-1
3. Association for Palliative Medicine, 2024. APM Position statement on assisted dying.
4. Ahmedzai SH, 2012. My journey from anti to pro assisted dying. https://doi.org/10.1136/bmj.e4592
5. Fingas SK, 2021. Jersey is set to allow assisted dying. https://doi.org/10.1136/bmj.n2917
6. Scheffer R, 2013. The law should be changed to allow assisted dying. https://doi.org/10.1136/bmj.f4895
7. Buchman S, 2019. Why I decided to provide assisted dying: it is truly patient centred care. https://doi.org/10.1136/bmj.l412
8. UK chief medical officers and NHS England National Medical Director, 2024. Assisted Dying debate: Advice to doctors. https://www.gov.uk/government/publications/assisted-dying-bill-de- bate-advice-to-doctors
9. Association for Palliative Medicine, 2023. A submission by the Association for Palliative Medicine of Great Britain and Ireland for the Health and Social Care call for evidence for inquiry in assisted dying Jan 2023.
Competing interests: 1. Personal: Invited speaker at Jersey Citizens’ Jury on assisted dying, April 2021. All work online, no costs or fees. 2. Personal: Member of Medical Advisory Group to Liam McArthur MSP for his Scottish Parliament Bill on Assisted Dying, 2022-2024. All work online, no costs or fees. 3. Personal: Provided advice on palliative and end of life and assisted dying issues, to Isle of Man ‘House of Keys’ at request of Alex Allison, MHK. Work done was by email and also a visit to Isle of Man in May 2024 with one night stay. Travelling costs and accommodation covered by Dignity in Dying. 4. Personal: Invited to speak to SNP fringe meeting on assisted dying at SNP party conference, Edinburgh, September 2024. Cost of one night accommodation covered by Dignity in Dying.
Dear Editor
Sir:
‘Palliative medicine doctors have a plurality of views’ (BMJ 2 November p148) is a welcome corrective and rebuttal commentary on the alleged one-sided perspective on assisted dying of the Association for Palliative Medicine (APM).
In moving to a position of openness to legal change, we should bear in mind that it is the harm of death that makes killing wrong, and not the other way round – it is not the wrong of killing that makes death harmful.
If dying is not harmful because it would be in the best interests of a person, dying painfully and horribly, if they were dead, then killing is no longer a wrong.
One might ask whether a person’s suffering is the result of the inflexible pursuit of a moral principle and, if so, whether it is right to seek to achieve a sense of moral purity at the expense of the suffering of others.
The ‘spectrum of opinions’ in APM to which Ahmedzai et al draw attention and endorse is indeed laudable.
Noel Scott, psychiatrist, Belfast
Competing interests: No competing interests
Dear Editor
Dr Ahmedzai and his palliative care colleagues must be commended for their bravery in speaking out about the rigid control over the assisted dying debate by certain palliative care doctors attempting to stifle open discussion, aiming to block any change in the law. All doctors should surely make up their own minds and not be harassed into taking a stance that conflicts with their conscience.
Competing interests: No competing interests
Dear Editor
In Canada in 2022, only 8% of deaths in Medical Assistance in Dying (MAID) involved palliative care specialists [1]. Psychiatry, the specialism mostly likely to address suicidality, accounted for just 0.8% of deaths. However, the majority, 67.7%, of deaths involved family practitioners.
Accordingly, it seems unlikely that there is any significant silent plurality of palliative care physicians’ views, as these authors imply.
The risk for the UK is that assisted dying may become similarly dominated by a wide range of general practitioners (GPs)* who may lack the experience, knowledge and training of those specialists who care for dying, suicidal, and seriously ill patients. This could result in the premature deaths of people who might otherwise have chosen a natural death with the benefit of appropriate referrals to palliative, psychiatric, or other relevant specialist care.
Some palliative care clinicians consider this scenario a medical error [2].
* This is not to disparage GPs, only to point out they play a different role in care.
1 Health Canada. Fourth annual report on medical assistance in dying in Canada 2022. Ottawa: Government of Canada 2023. https://www.canada.ca/en/health-canada/services/publications/health-syst...
2 Gallagher R, Passmore MJ, Baldwin C. Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error. Medical Hypotheses. 2020;142:109727. doi: 10.1016/j.mehy.2020.109727
Competing interests: No competing interests
Dear Editor
On behalf of the Association for Palliative Medicine of Great Britain and Ireland (APM), we welcome discussion around assisted dying. However, we have been misrepresented in comments raised in this journal by Prof Sam Ahmedzai, Dr Fingas and three colleagues (BMJ Opinion Oct 30th).
We understand and respect the range of views among Palliative Medicine professionals around assisted dying. However, repeated surveys have demonstrated that the majority of palliative medicine doctors (70-84%) are not in favour of legalising assisted dying and 75-84% of them would be unwilling to participate in the process. The APMs position statement on assisted dying acknowledges the variation in views of our members. (https://apmonline.org/wp-content/uploads/APM-Position-Statement-on-Assis...)
Our approach has been to respond to the view of the majority of our members, whilst again acknowledging that this is not the view of all. In response to calls from our members, we made available a template letter to send to MPs and resources including the House of Commons Health and Social Care Committee Assisted Dying/Assisted Suicide Report, 20 February 2024, the Policy Institute (Kings) Complex Life and Death Decisions Group publication on assisted dying and Chris Whitty’s Chief Medical Officer letter giving advice to those wishing to speak on this topic. The template for APM members to edit “as they see fit”, and the other three are helpful non-partisan resources.
We are surprised and distressed that the authors consider this approach leaves some in fear of repercussions. We have been open in all our communications, including listening to the pro-assisted dying view with openness and respect. We reject the representation of the APM as misinforming on palliative medicine doctor’s stance and of stifling debate.
We have included a session in our next conference in Belfast, where we hope we will see Prof Ahmedzai and his colleagues.
Competing interests: No competing interests
Dear Editor,
The Association of Palliative Medicine accurately and correctly represents its members' views. In several independent polls, palliative medicine doctors have consistently made it clear the majority (up to 84%) are opposed to changing the law on assisted dying.(1) Expecting a change to neutrality because a small minority has a different view is akin to being neutral on speeding because a few people want to drive fast. Interestingly, Ahmedzai et al. see neutrality as ‘dropping opposition’, as if ignoring the majority's view is acceptable.
A palliative medicine colleague has described the current assisted dying debate as a doubles tennis match. Two players are hurling balls at their opponents ignoring where they hit or hurt, but the other two players are next to the net and have started to talk to each other. Those who persist in attacking their opponents need to step aside and leave it to those prepared to talk.
1. Association for Palliative Medicine. Position Statement on Assisted Dying. October 2024. https://apmonline.org/wp-content/uploads/APM-Position-Statement-on-Assis...
Competing interests: CR provides the text and evidence for the website Keep Assisted Dying Out of Healthcare (www.kadoh.uk). This receives no funding from any external group or campaign.
Dear Editor,
I thank the authors for their opinion piece but wish they had been more precise in some of their phrasing.
First, they have repeated the benign-sounding term “assisted dying”. This obfuscates the reality of the proposed change in law to permit assisted suicide. It conflates a natural process with active killing.
There is evidence from a Survation poll in 2021 [1] to suggest that the majority of the public were unable correctly to identify that this would mean an active intervention to end life.
Second, the change in position of the BMA and RCP was not to one of support but to one of studied neutrality. When these organisations chose to hold a neutral stance, such decisions were made with the caveat that dropping opposition was not the same as active support, and yet the authors seem to have interpreted neutrality as endorsement.
Last, I am surprised that the authors identify themselves as the underdog in this debate: they are on the side of the Prime Minister, influential MPs, a former Archbishop of Canterbury, active lobby groups such as Humanists UK and the voice of celebrities such as Esther Rantzen being amplified by the Daily Express.
I welcome open and honest debate about this sensitive topic but it cannot be seriously discussed if we are unclear about the meaning of what is being put before Parliament.
1 Survation APPG for Dying Well Survey July 2021. Dying Well. https://www.dyingwell.co.uk/wp-content/uploads/2021/09/Survation-Assiste...
Competing interests: No competing interests
Re: Palliative medicine doctors in the UK have a plurality of views on assisted dying, but you wouldn’t know it
Dear Editor,
Prof Ahmedzai et al.[1] suggest that there is less of a consensus against assisted dying among palliative care specialists than the Association for Palliative Medicine makes out.
I wonder how the correspondents feel about the recent letter[2] from a cohort of seven medical MPs asking Parliament to support the bill legalising assisted suicide, which goes even further to suggest a consensus in favour.
The letter was shared by lead signatory and GP, Dr Simon Opher MP. The co-signatories number another GP, a pharmacist, an operating department practitioner, an adult nurse, and two surgeons. They advertise their credentials to their fellow MPs by stating ‘many of us have extensive experience in palliative and terminal care’.
They claim that ‘For too many years, palliative staff, GPs, and community teams have been caught between the law… and our compassionate care for patients, whom we know wish us to curtail their suffering’, and lament that ‘…the law places an awful burden on us as clinicians’. Parliament is seemingly being told that palliative specialists, and those working with them, are desperate for a change in the law.
They support their position by stating ‘Many doctors already administer large amounts of opiates in terminal care to relieve pain, but they are also aware that by doing so they might bring forward the time of death.’ This argument reveals that the signatories are lacking in expertise in palliative care. If they were specialists, they would surely know that the ‘double effect’ of opiates, that the prescription of opiates in end-of-life care hastens death, is an unhelpful myth.[3,4] Evidence consistently shows that use of higher doses of morphine in the terminal phase is not associated with shorter survival.[5,6,7]
There are many nuanced and important arguments in favour of and against assisted dying, but this is not one of them. It is a dangerous misconception which often acts as a barrier between patients and good analgesia, and contributes to a fear of palliative care as a whole.[8,9]
In summary, these MPs give the impression that palliative staff are generally in favour of assisted dying. They all doubtless have experience of working with dying patients and palliative care teams. However, they are not, as their colleagues in Parliament are being led to believe, providing an accurate picture of up-to-date practice or opinion in palliative care. They should set the record straight.
1. Ahmedzai SH, Fingas S, et al, 2024. Palliative medicine doctors in the UK have a plurality of views on assisted dying, but you wouldn’t know it. BMJ 2024;387:q2351 https://doi.org/10.1136/bmj.q2351
2. Dr Simon Opher on Instagram [Internet] [cited 2024 Nov 11]. Available from: https://www.instagram.com/p/DB1E0Q1MDLr/?img_index=1
3. Regnard C. Double effect is a myth leading a double life BMJ 2007; 334 :440 https://doi.org/10.1136/bmj.39136.502361.FA
4. Coyle S, Elverson J, Harlow T, Jordan A, McNamara P, O'Neill C, Quibell R, Regnard C, Spiller J, Stephenson J. The myth that shames us all. The Lancet. 2018 Oct 6;392(10154):1196.
5. Bercovitch M, Adunsky A. Patterns of high-dose morphine use in a home-care hospice service: should we be afraid of it? Cancer 2004;101(6):1473–7.
6. Thorns A, Sykes N. Opioid use in last week of life and implications for end-of-life decision-making. Lancet (London, England) 2000; 356(9227):398–9.
7. López-Saca JM, Guzmán JL, Centeno C. A systematic review of the influence of opioids on advanced cancer patient survival. Current Opinion in Supportive and Palliative Care. 2013 Dec 1;7(4):424-30.
8. Oldenmenger WH, Smitt PA, van Dooren S, Stoter G, van der Rijt CC. A systematic review on barriers hindering adequate cancer pain management and interventions to reduce them: a critical appraisal. European journal of cancer. 2009 May 1;45(8):1370-80.
9. Maltoni M. Opioids, pain, and fear. Annals of oncology. 2008 Jan 1;19(1):5-7.
Competing interests: No competing interests