Doctors Due to Weigh In on Assisted Dying Vote at Upcoming BMA Meeting

Becky McCall

September 10, 2021

Editor's note, 14 September 2021: BMA members voted 49% for assisted dying, 48% against, and 3% abstained. The organisation has now moved to a neutral stance.

One of the arguments against assisted dying – that many UK doctors do not support it – could be about to change pending the outcome of a debate at the British Medical Association’s (BMA) annual representatives meeting (ARM) next week.

Assisted dying is illegal in the UK, and many doctors’ apparent opposition to a change in the law has long stymied any movement on this topic in parliament. A second reading of a private member’s bill to change the law on this issue, brought by Baroness Molly Meacher of Spitalfields earlier this year, will take place in October.

But at next Tuesday’s BMA ARM, there will be a members’ debate, including calls for the association to change its stance from opposing legalisation to one primarily of neutrality.

If the outcome is in favour of a revised position then this could potentially support calls to legalise assisted dying as a choice for terminally ill, mentally competent adults in their final months of life, by having a doctor prescribe lethal doses of drugs for patients to take themselves.

Neutral Position

Baroness Meacher told Medscape News UK that: "The BMA adopting a neutral position on the topic is about representing doctors’ views fairly and accurately to society and to parliamentarians. It also allows doctors a seat at the table to help ensure legislation works for them as well as for their patients."

A 2020 survey by the BMA found that 61% of members want the association to drop its opposition to law change. "In the face of those results, maintaining its current stance is untenable. It silences doctors in this important debate," said Baroness Meacher.

"Adopting a stance of engaged neutrality would respect the diversity of thought, ending polarisation and allowing a more constructive, fair and open debate as my bill progresses."

BMJ Articles

This week’s BMJ features a series of essays, features, and opinion pieces on assisted dying. Dr Jacky Davis, consultant radiologist at the Whittington Hospital, London, and chair of Healthcare Professionals for Assisted Dying wrote one of the opinion pieces, in which she points out: “Evidence is vital. For too long the assisted dying debate has been conducted on opinion rather than fact. Opponents of assisted dying have always declared with confidence that doctors opposed such legislation without any evidence to support it.”

Former Health Secretary for England, Matt Hancock, requested the Office for National Statistics (ONS) to produce data on suicides by terminally ill people and on assisted deaths in Switzerland of British nationals, highlighting the importance of an evidence-based debate. 

Dr Davis told Medscape News UK, that around 80% of the population want a change in the law, and that the law needed to reflect the majority will of the population. It is currently thought that around 50 British citizens a year seek help to die in Switzerland, and as many as 14% of UK suicides are among people with terminal or chronic illness. "If a law isn’t working for the people, then something needs to be done about it," she said. "Thousands of people, every year, take their own lives; some go to Dignitas [a Swiss-based clinic that provides a range of services for the terminally ill including accompanied suicide] or suffer bad deaths, and our opponents dismiss their suffering based on hypothetical arguments with no evidence behind them."

BMA Assisted Dying Survey and Upcoming Vote

The BMA membership survey on physician-assisted dying garnered a response rate of 19%. It found a majority (61%) disagreed with the BMA’s current stance of opposition to assisted dying, with 40% in favour of the BMA supporting a change in the law, and 21% saying the BMA should take a neutral position. The remaining 39% were opposed (33%) or undecided (6%) about any change in the law.

Next week, at the meeting, BMA delegates will have the opportunity to decide whether to change its policy in line with what the membership have voted for," said Dr Davis. 

Reflecting on the upcoming parliamentary debate, she also noted that when politicians take time to properly examine the evidence, they realise the law against assisted dying does not work. "They also realise it is possible to produce a law with appropriate safeguards, such as patients being terminally ill with 6 months or less to live, being of sound mind and fixed determination, as well as the safeguard of their request being assessed by two doctors and one judge."  

In this week’s editorial, BMJ editor-in-chief, Fiona Godlee and co-authors highlight that the journal has previously called for doctors to take a position of "engaged neutrality… because doctors should not obstruct a decision that is for society and parliament to make".

Neutrality is far from an abdication of responsibility, they say. Instead, they believe that it enables organisations to facilitate and fully engage with essential societal conversations about death and what it means to die well.

The Royal College of Physicians (RCP) adopted a neutral position on assisted dying in 2019 after a membership survey found a similar range of views (31.6% voted for a supportive stance and 43.4% voted for the RCP to maintain opposition). The Royal College of Nursing has been neutral on the issue since 2009.

"No professional should be obliged to participate. But doctors who oppose assisted dying should not stand in the way of colleagues who find it ethically justifiable to assist a dying patient’s death. Nor should they stand in the way of dying patients who reasonably are asking for doctors’ help to end their life," Fiona Godlee concludes.

Opposition to Law Change – Palliative Care

A large tranche of the opposition to a change in the law comes from palliative care doctors, among whom 70% are in opposition, but this figure dropped to around 40% within other specialties which are most involved in caring for dying patients: general practitioners (39%), oncologists (44%), and geriatricians (44%), according to the 2020 BMA survey.

Dr Davis explained that many [other] doctors lack familiarity with the issues around assisted dying. "It just doesn’t cross their doorstep. Most doctors would be astonished to hear that at least 200 million people globally have access to assisted dying. It’s a big movement."

In June this year, Jersey held a citizen’s jury that voted 78% in favour of legalising assisted dying. This is the first part of the UK to formally decide on what they want in this respect.

Scotland is due to hold a public consultation on a law change with the lodging of the ‘Assisted Dying Scotland’ Members Bill with the Scottish Parliament in June 2021. In the US, assisted dying as an option for terminally ill, mentally competent adults in their final months of life is legal in 11 jurisdictions; in Australia, assisted dying has been legal since 2019 in some jurisdictions, Spain passed a law allowing assisted dying in March 2021 to be implemented later this year; Ireland is examining the issue now, likewise Austria and Germany, and right-to-die laws are in place in Belgium, the Netherlands and Luxembourg. Switzerland accepts foreign nationals for assisted dying, and Canada introduced laws to permit it in 2016.

Fundamental facts about how assisted dying is carried out are hard to find. It can take a tumbler of 50-100 barbiturate tablets to induce a cardiac arrest that records show, in the worst-case scenario, can take up to 108 hours to take effect, Baroness Ilora Finlay of Llandaff, FMedSci, professor of palliative medicine, and campaigner against law change, told Medscape UK.

Dignity in Dying, the UK based group campaigning for law change, explained that in Oregon, where assisted dying has been law for 23 years, medication usually takes 30 minutes between ingestion and death, which is peaceful and swift, as opposed to a death possibly prolonged over days, weeks, or months. 

However, palliative care doctors have long been opposed to assisted dying. "Many have strong religious beliefs, but these doctors actually deal with a relatively small proportion of deaths. GPs handle more," remarked Dr Davis, who sits on the board of Dignity in Dying.

In 2019, an anonymous publication in the BMJ written by palliative care doctors highlighted that their specialists do not dare to support assisted dying. "There’s a culture of secrecy and repression and a trainee would find their career hindered if they supported assisted dying," Dr Davis added.

Medscape UK asked Baroness Finlay why this opposition persisted and whether religion played a role. "There is no evidence that palliative care physicians object on religious grounds," she said, adding that the specialism is incompatible with assisted dying because: "Palliative care is both about trying to improve quality of life during whatever time the patient has left, and accepting natural dying with support for patients through that process.

"It is not about cutting life off prematurely with massive doses of lethal drugs," she said. "Pain is not the main reason that people opt for assisted dying. Data from the Oregon health department [most extensive data globally] shows that both in the aggregate, over 23 years, and in the last year, pain comes way down the list of reasons to choose assisted dying. The main reasons are existential and around issues of control."

Baroness Finlay also highlighted that the 2020 BMA survey shows that of doctors who actively care for these patients, the results paint a highly varied picture. In clinical oncology, 29% supported, and 44% were against a change in the law; in general practice 34% supported, and 39% were against; in geriatric medicine 27% supported, 44% were against; and in palliative medicine 7% supported and 70% against. "It is very clear that the doctors who are looking after these patients are not wanting the law to change," she said.

The crossbench peer also pointed out that there was a difference between doctors who support a change in the law and those who would prescribe drugs for a patient to self-administer and end their own life. She referred to the BMA survey results that showed that over 50% of those in clinical oncology (60%), general practice (50%), geriatric medicine (56%), and palliative care (76%) would not be prepared to participate.

Balancing Wishes of Both Society and Medics 

Regarding the general public’s understanding of the topic, Baroness Finlay drew attention to the Survation Poll of the public in August which showed that 57% don’t know what is involved in assisted dying, with 43% thinking it was about providing lethal drugs to people with less than 6 months to live; 42% thought it was the right to stop life-saving treatment; 10% thought it was hospice care, and 5% did not know what the term meant.

She also highlighted what she believes is a fundamental misunderstanding across society about the reasons why people opt for assisted dying. "It’s because of loneliness, not feeling you have a role in life, fear that your family will find you a financial burden, for example. These are all societal issues around how we behave to each other and where we feel we are as a community. They aren’t rectified by a chemical pill. It’s not a doctor’s role to give lethal drugs as a solution to that social despair."  

On October 22, views for and against law change will be debated, extending the discussion initiated by Lord Falconer in 2014. Back then, the Bill was unable to progress further due to the end of the session prior to the 2015 General Election.

Under the assisted dying rules proposed by the UK Bill, doctors would be required to prescribe the necessary drugs and an eligible patient would self-administer. To be eligible the patient would need to be over 18 years, terminally ill with 6 months or less to live and fully mentally competent, and be judged as making a clear, settled decision of their own volition. Two independent doctors and a High Court judge must be satisfied that an individual meets these requirements. A prescription for life-ending medication would then be granted, which the individual could take at a time and place of their choosing.

Due to their central role in participating in assisted dying, few would deny that support from doctors is essential for the law to change. The BMA survey results show their views are split on the issue and most doctors’ organisations take no position on the issue. But society has a strong voice too, and the UK public has shown consistent support for legalisation, with representative polls finding 73% support in 2021, 84% in 2019, and 82% in 2015, writes Fiona Godlee.

Looking ahead to next week’s BMA debate, Baroness Meacher emphasises that doctors from a range of specialties care for dying people, and hold a range of views on assisted dying. "The BMA exists to represent all its membership, not just individual groups within it."

The RCP, to which most palliative care doctors belong, has shown that it is possible to have a neutral position and also acknowledge and put forward concerns that some palliative care doctors might have on this issue, she added. "Neutrality will not silence anyone; it allows all doctors to be represented in the debate. Opposition merely represents the minority and denies the majority a voice."

Essentially, whether an individual agrees with assisted dying or not, it could reasonably be argued that the Bill is as much about peace of mind, removing much of the fear and anxiety, as the act of death itself.  "The Bill is an insurance policy against intolerable suffering as we die. The simple fact of its existence would provide immeasurable comfort and peace of mind to dying people, whether or not they ultimately choose this option," said Baroness Meacher.

Over two decades of the law permitting assisted dying in Oregon, about 35% who are granted a prescription to assist death never take it. "This Bill will benefit many more terminally ill people than the relative few who will take up this option," concludes the Baroness.

COI: Dr Davis is on the board of Dying in Dignity. Baroness Meacher is Chair of Dignity in Dying. Baroness Finlay is on the board of Living and Dying Well.

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