Intended for healthcare professionals

Feature Assisted Dying

Conscientious objection: will doctors be able to opt out of assisted dying?

BMJ 2024; 387 doi: https://doi.org/10.1136/bmj.q2358 (Published 30 October 2024) Cite this as: BMJ 2024;387:q2358

Linked Feature

What is it like for doctors working under assisted dying laws?

Linked Feature

Assisted dying laws around the world

  1. Erin Dean, freelance health journalist
  1. UK
  1. erin{at}erindeanwriting.com

The potential for a new assisted dying law has pushed a medically divisive issue back up the news agenda, reports Erin Dean

On 15 October the backbench Labour MP Kim Leadbeater introduced the Terminally Ill Adults (End of Life) Bill,1 which would give terminally ill people in England and Wales the right to end their lives.

The text of the bill is yet to be published: this will come before its second reading at the end of November. However, it’s expected to be similar to a bill tabled in the House of Lords by the former Labour lord chancellor Charlie Falconer,2 and it would allow terminally ill adults believed to have no more than six months to live to receive medical help to die.

Falconer’s bill also includes a clause on conscientious objection, which states that “a person is not under any duty (whether by contract or arising from any statutory or other legal requirement) to participate in anything authorised by this Act to which that person has a conscientious objection.”

Previous bills to legalise assisted dying in the British Isles—including the last attempt in England and Wales in 2015, as well as legislation currently being considered in Scotland, the Isle of Man, and Jersey—also include clauses on conscientious objection. Internationally, countries with assisted dying legislation also include such a caveat, says the BMA.3

Conscientious objection allows a professional to opt out of a practice that they regard as morally wrong, says Mary Neal, a reader in law at the University of Strathclyde who has previously advised the Scottish parliament on assisted dying. The best known example in medicine relates to termination of pregnancy, as a doctor’s right not to participate is enshrined in the 1967 Abortion Act.

Doctors’ views

In 2020 the BMA conducted a survey of its members on physician assisted dying.4 Of the 28 986 members who responded (19.35% of all members who were invited to participate), half (50%) said they believed that doctors should be permitted to prescribe life ending drugs for eligible patients to self-administer. Four in 10 (39%) opposed this idea, and a further one in 10 (11%) were undecided.

In 2021 the BMA moved from opposition to a neutral position on legalising physician assisted dying, and it called for a form of conscientious objection that would allow doctors who want to participate in the process to opt in, rather than those who don’t want to having to opt out.5 The Royal College of Surgeons of England and the Royal College of Physicians also have a neutral stance.

Andrew Green, chair of the BMA’s medical ethics committee, says, “It’s an issue which strikes absolutely at the heart of what it is to be human and what it is to be a doctor.” He says some doctors believe that their fundamental obligation is to relieve suffering and are willing to support a patient seeking assisted dying on that basis, while others believe that helping someone to end their life is incompatible with their role. “It’s not surprising that people have very valid and very strong feelings on both sides,” says Green.

He explains that it shouldn’t be part of any doctor’s normal job to undertake or participate in assisted dying. “It should be something that doctors who have an interest in it choose to do, and then those doctors get resourced, and they get the training and the support they need,” he says.

Green argues that this would ensure that patients got the best care. “Obviously it doesn’t mean that the doctor doesn’t have duties towards the patient,” he says. “And the requirements that apply at the moment to abortion services, for example, would continue, so doctors could not be obstructive. They would have to ensure that the patient had the means to get advice from somebody else.”

He adds that the BMA has been in talks with Leadbeater and with those involved in the Scotland bill to ensure that the views of the profession are heard. He argues that the opt-in approach has advantages for patients too, as they can then be sure that any doctor they engage with will be fully engaged with the process themselves, as well as being resourced, fully trained, and fully competent.

“All those things are important in all aspects of medicine,” says Green. “But when it’s something as vital as someone’s last day, it’s really important that those requirements can be met, and we believe that’s far more likely with an opt-in system.” Doctors should also be able to opt out of being involved in assisted dying for any reason, not just issues of conscience, he adds. They shouldn’t need to say what their reasons are, but considerations may include the emotional impact, the time involved, and being adequately trained.

Research in Canada has found that some doctors use conscientious objection to avoid taking part in assisted dying when other reasons, including their emotional burden, may be behind their choice.6

Jacky Davis, chair of Healthcare Professionals for Assisted Dying, which is affiliated to the campaign group Dignity in Dying, says that protecting conscientious participation is as important as conscientious objection. “Everyone understands that we have to protect the doctors who don’t want to be involved. But we also have to support and train the doctors who do want to participate,” she says.

Over a third (36%) of doctors in the BMA survey indicated that they would be prepared to actively participate in the process of prescribing life ending drugs if legalised. A quarter (26%) said that they would be willing to actively participate in the process of administering life ending drugs if legalised. This would mean that there were more than enough doctors to meet demand, says Davis.

Parallels with abortion

However, some point out that, even with a conscientious objection clause in place, it could be hard for a doctor not to be part of the assisted dying pathway in some way. Drawing the line between protecting patients’ rights and those of doctors who don’t wish to be involved is a difficult area.

The BMA’s view is that assisted dying isn’t a “treatment option” in the conventional sense, and it would want to see specific provision in any legislation to make clear that there’s no duty on doctors to raise the option of assisted dying with patients if it were legalised. BMA guidance says, “Doctors should be trusted to use their professional judgement to decide when and if a discussion about assisted dying would be appropriate, taking their cue from the patient as they do on all other issues.”7

The policy memorandum of the Scottish assisted dying bill makes it clear that there will be a duty of referral for doctors who conscientiously object, says Neal. Similarly, doctors who conscientiously object under the Abortion Act still have a legal duty to make a prompt referral to another practitioner, she says.

“Some doctors take a reasonable view that even referring somebody is involvement and makes them complicit [in something they consider immoral],” says Neal. “If you think about why such a duty is imposed, it’s to ensure that the practice can still go ahead.”

Existing clauses on conscientious objection often state that healthcare professionals don’t have to “participate”; however, in 2014 the UK Supreme Court found that for the Abortion Act this covered only those activities directly involved in performing a termination, says Neal. This ruling found that two Catholic midwives in Scotland didn’t have the right to refuse to help other nurses with abortion procedures or planning.8

Internationally, “the tendency has just been to transplant abortion-style conscience clauses into the assisted dying context, but this is arguably inappropriate,” says Neal. She points out that both the BMA and the Royal Pharmaceutical Society “call for something more robust than the ‘standard’ abortion-style conscience clause for assisted dying.”

The BMA says that any system to deliver assisted dying needs to be a “separate service” and that patients should have an information service where doctors can direct them for advice. This is the BMA’s approach to dealing with doctors who don’t want to refer: they can instead direct patients to this service. A spokesperson said, “Doctors with an objection could fulfil their professional obligations to their patient by directing them to that information service or to another doctor who would be willing to make the referral.”

Alberto Giubilini, senior research fellow at the Uehiro Oxford Institute, University of Oxford, says that it shouldn’t be down to an individual doctor to declare that they won’t offer a legally approved aspect of healthcare, and therefore he doesn’t agree with conscientious objection.

“Doctors are licensed by the society they operate in to do certain things that other people cannot do” he says. “If society thinks that medically assisted dying is part of proper healthcare, the argument I make is that you have to do it because it’s part of the social contract which determines what it means to be a profession.”

Giubilini is concerned that conscientious objection can lead to some doctors refusing to refer, despite guidance telling them that they must—which can leave patients without the care they want or need. This has happened in Italy, he says, where some 70% of doctors conscientiously object to abortion and women can find getting a referral difficult.

Institutional opt-outs

The Association for Palliative Medicine, which opposes legalising assisted dying, is also in favour of the opt-in model for doctors if the practice became legal. If doctors worked for organisations where assisted dying was offered it would be hard for them not to be drawn in, says the association’s honorary secretary, Matthew Doré.

He says, “In Canada, when patients want to have an assisted death in an institution where some staff conscientiously object, the staff can be made to feel that it’s discriminatory of them to transfer a patient elsewhere, or they can be put under pressure not to do so, from an organisational reputational position.

“Then you’re almost forced to be involved with it. Individual conscientious objection is very hard to contain in a multidisciplinary organisation. It’s seen as secondary to a patient’s rights, and you’re portrayed as difficult and not a team player.”

Internationally, some legislation allows institutions to opt out of offering assisted dying, such as in the Australian states of South Australia, Queensland, and New South Wales.9 In Victoria, the Department of Health has published guidance stating that health services can decide whether to support access to voluntary assisted dying.10 In New Zealand one hospice provides assisted dying on its premises, while the other 31 hospices don’t, says Hospice New Zealand.11

Davis says that institutional opt-outs can be unhelpful. “In Oregon, USA, few doctors are involved in assisted dying, and one reason for that is that they have many institutions which are run by religious organisations that won’t allow employed doctors to participate.

“When I was at a conference in Oregon, we heard terrible stories about families not supportive of assisted dying deliberately moving their dying loved ones into institutions where they couldn’t have an assisted death, even though the patient was desperate for one.”

The regulator’s view

The General Medical Council (GMC) says that while personal beliefs and values are central to the lives of doctors and patients, a doctor’s conscientious objection must not act as a “barrier to a patient’s access to appropriate care to meet their needs.”12

Doctors should be open with employers and colleagues about their conscientious objection, and printed information about a service should include information about services not provided for this reason, says the regulator.

The GMC’s Good Medical Practice guidance13 states that where doctors do decide to conscientiously object, they must tell the patient that they don’t provide the procedure or treatment and that the patient has the right to discuss their care with another practitioner who doesn’t object; and they must “make sure that the patient has enough information to arrange to see another doctor who does not hold the same objection as you.”

If the law does change, says Colin Melville, GMC medical director and director of education and standards, “we would review and, where necessary, amend our guidance.” He adds, “We would also take part in implementation work to ensure that doctors receive the support they need to practise in accordance with the law and the professional standards of their regulators.

“This is a sensitive topic with strongly held views. Understandably, doctors may choose to engage with this important debate, and our guidance is there to help them do so in line with our core guidance, Good Medical Practice, while maintaining public confidence in the profession.”

Footnotes

  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References