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The risks of neutrality on assisted suicide – lessons from abroad

CMF Blogs occasionally include posts by guest authors on a variety of topics.
The views expressed do not necessarily reflect those of CMF.

Medicine has held a long-established opposition to assistance with suicide.

Ira Byock, an American Palliative care physician, believes this is necessary so that:  ‘the power of medicine is not used against vulnerable people’. One of the roles of medicine is the need to balance our duties to the individual with our duties to society. This is particularly challenging when societies around the world are changing (with a small number of countries permitting assisted dying) and when those wanting change are themselves from within the medical profession.

However, the UK has been resistant to a change in the law which may be because the UK is the birthplace of modern palliative care that affirms death as a natural process and intends neither to hasten nor delay it. In fact it has been argued that palliative care and assisted death are not compatible with each other.

Against this background the Royal College of Physicians (RCP) has taken the controversial step to ‘adopt a position of neutrality’ on the issue of ‘assisted dying ‘ (an umbrella term that has been taken on by assisted suicide advocates but which has no meaning in law and refers to the more accurate term, assisted suicide and euthanasia.).

The RCP has stated that ‘neutrality means the RCP neither supports or opposes a change in the law’ and that by ‘remaining neutral it can reflect the differing views of its fellows and members in discussion with government and others’.

The RCP’s announcement has created a lot of controversy; the framing of their poll of members is highly irregular  and for many assisted suicide is not something that a medical body can be neutral on.

There are (at least) three reasons why the RCP’s assertions are highly disingenuous, and concerning:

  1. Adopt a neutral position’. The RCP is currently opposed to assisted dying. So, this would be not so much the ‘adoption’ of a position but moving away from the established position of opposition. This act of movement is highly significant in and of itself. In the Canadian Supreme Court case of Rodriguez in 1993 it was identified that there had to be a change in either legislative, medical or societal views in order to cross the current line of prohibition of assisted dying.

If we accept figures from organisations such as Dignity in Dying (figures that have been challenged here and here) then it would seem, that in the UK, superficial societal support for change has been consistently high. Yet in spite of this Parliament overwhelmingly rejected an attempt to change the law in 2015. With society and Parliament, in effect, ‘stuck’ any movement by the medical profession will be grasped by pro assisted suicide lobbyists as the window of opportunity needed to push for change. This is made evident by Dignity in Dying  ‘welcoming’ the RCP position of neutrality. Also, the RCGP poll of GPs in 2014 found that many of the doctors who voted neutral did so because they wanted to see the law changed. One could argue the college is playing into the hands of pro assisted suicide pressure groups who will use the new ‘neutral’ position to change the law.

  1. Neutral neither supports or opposes a change in the law’. Sadly, evidence already exists that ‘neutral’ is a dangerous stance when the profession does not know the details of the legislation being proposed. In Oregon the medical association went ‘neutral’ six months before the public vote that brought in a new law permitting assisted suicide. This law, known as the Oregon Death with Dignity Act, allows terminally ill Oregonians to self-administer lethal medication prescribed by a doctor (see a blog on this here). Altmann and Collins in their 2007 analysis of the Oregon Death with Dignity Act identified that at the time legislation was being drafted the strongest input came from the politically active, unified and well-resourced voices of pro lobbyists, they make note of the fact the medical association was neutral and those opposing had little impact. The Oregon Medical Association (OMA) went on to declare the draft bill as ‘deeply flawed’ and supported its repeal (as recorded in the OMA house of delegates annual meeting, 2005) but it was too little too late, and the bill was enacted after a second public vote in 1997.

In Canada the Canadian Medical Association (CMA) went ‘neutral’ before the ground breaking Supreme Court decision in the case of Carter in 2015. This case paved the way for assisted suicide and euthanasia in Canada which became available in 2016. The CMA policy contained the so-called ‘neutral’ statement that the CMA ‘supports the rights of patients to have access to all legal end of life options’. This ‘neutrality’ has been described as providing a blank cheque for the Supreme Court of Canada to legalize euthansia and physician assisted suicide on any terms acceptable to the judges. Since this decision, the medical profession has been told that not only will it be integral to development and provision of assisted suicide and euthanasia but it should also recognise that the voice of the physician should be just one among many.

It seems wholly foolish for the RCP to agree a position of neutrality ahead of any knowledge of what legislation is planned. It is tantamount to binding the profession’s hands. Indeed this is exactly what the BMA found when it went neutral for one year; their ability to engage in discussion was hindered and they returned to a position of opposition so they could be better placed to intervene and advocate for safeguards.

  1. Allows the college the ability to reflect the differing views of its members’: In the UK assisted suicide is illegal; it is strange logic and an abdication of responsibility to suggest the purpose of the RCP is to reflect views contrary to the current law without having a specific view itself. The Canadian Medical Association has identified ‘neutrality’ as a ‘third way that supports all its members’. But one of the key challenges after the Carter judgement was to ensure there are doctors willing to provide ‘medical assistance in dying’. However, intentional killing is not something the majority of doctors want to do. For example, in Oregon 92 doctors prescribed lethal medication out of a pool of 11,500.  Canadian doctors who did not want to be involved in euthanasia or physician assisted suicide discovered that the CMA was slow to respond to concerns about freedom of conscience  against moves by state regulators to compel physicians to act contrary to their values. The CMA’s policy of neutrality meant that when assisted suicide and euthanasia were legalized, its ability to ‘support all its members’ was in conflict with its policy to support access to the provisions of the law. The RCP must learn lessons from Canada, arguably it is opposition to change, and not ‘neutrality’, that provides an organisation such as the RCP the best opportunity to fight for protections for all its membership.

The RCP seems to think ‘neutral’ represents non-judgemental support of all views both in its membership and society. But it has a duty, beyond appearing equitable, to protect the interests of its membership and society. With its current plan to move to a so-called ‘neutral’ stance on assisted dying it risks actively weakening its ability to provide this protection.

Dr Rosemarie Anthony-Pillai, Consultant in Palliative Medicine.

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