Memorandum by the British Medical Association
1. The British Medical Association (BMA)
is a voluntary professional association representing UK doctors
in all branches of medicine. It has 128,000 membersalmost
80 per cent of UK practising doctors. It is a democratic institution
in which members elect the colleagues who decide policy. (See
2. Like any sector of the population, doctors
express a range of views on sensitive moral and social issues,
including the care of people at the end of life. The BMA seeks
to reflect this in its policies while also providing as clear
guidance as is possible about the majority view of its membership.
Policy is established at annual meetings by its Representative
Body (RB) which consists of 589 BMA members elected or appointed
to represent all branches of medicine. Prior to the annual meeting,
issues under consideration and work done by the BMA are publicised
in the annual report to members, as well as on the web, in journals
and circulars. Local Divisions discuss topics raised in the annual
report and any other issues they consider important for national
debate. These are submitted by divisions as motions to the annual
meeting where debates get wide coverage in the medical press and
BMA POLICY AND
OF UK DOCTORS
3. The concept of a "good death"
is a vital part of health care (see "Caring for patients
at the end of life", chapter 10 of the BMA's 2003 edition
of Medical Ethics Today.) The association does not accept, however,
that deliberately bringing about an individual's death is a valid
or essential part of that concept. It opposes euthanasia and physician
assisted suicide (PAS). Details of BMA policy on euthanasia and
PAS are set out in Medical Ethics Today where chapter 11 outlines
the BMA's views.
Distinction between withdrawing treatment and
actively ending a patient's life
4. Health professionals can withhold or
withdraw life prolonging treatment if the patient refuses it or
if it fails to benefit the patient. They may foresee that death
will result but, in the BMA's view, this recognition of medicine's
limitations is fundamentally different to using medical skills
actively to assist suicide.
5. The BMA recognises that some people think
that, where death is the inevitable outcome, the decision to stop
active treatment is morally equivalent to euthanasia or that it
necessarily involves a judgement that the patient's life is not
worth living. Some also argue that active steps to end a patient's
lifeif dignified, quick, painless and at the patient's
own informed requestmay be preferable to withdrawing treatment
which may result in a more prolonged death.
6. However appealing this argument may appear,
the BMA does not agree that the acceptance of an option for treatment
withdrawal is inextricably linked to an acceptance of euthanasia
or PAS. The association's approach to end of life treatment decisions
focuses, not on anyone's assessment of the value of the patient's
life, but rather on the effectiveness or otherwise of the treatment.
Thus, an assessment for an individual patient that treatment has
become ineffective or is more burdensome than beneficial is not
equivalent to engineering that person's death or saying that the
patient's life is not worth living.
7. Rather, it is a recognition that there
comes a point for all patients when further active treatment is
unable to help them.
History of BMA stance
8. BMA policy opposing euthanasia was established
by the RB at the 1969 annual meeting. In 1971, the BMA reviewed
the arguments and issued a report rejecting medical participation
in euthanasia. In 1988, a BMA working party again reviewed the
issues, especially the increasing recognition of patient autonomy
in all aspects of decision making. It took evidence from a wide
spectrum of opinion but finally recommended that euthanasia should
9. By 1997, PAS was also the subject of
policy. At the annual meeting, the RB recognised "that there
is a wide spectrum of views about the issues of physician assisted
suicide and euthanasia" but nevertheless it strongly opposed
any changes in law "for the time being". This wording
meant the issues had to be kept under review and in 1998 the RB
called for a national PAS conference.
10. Accordingly in 2000, 50 doctors from
all sectors of medicine participated in a two-day BMA debate on
PAS. Nominated by local BMA Divisions, these participants reflected
a wide range of ages, medical specialties, personal opinions and
professional seniority. The aim was for them to examine the arguments,
the evidence from other countries and reach a workable consensus.
11. Prior to this, a discussion pack setting
out the main arguments, highlighting sample cases and information
from other jurisdictions was disseminated in electronic and paper
form. An electronic debating forum was opened on the BMA's web
site at http://www.bma.org.uk/ap.nsf/Content/_hub+physician+ assisted+suicide.
The resulting 200 substantial contributions were used in the planning
of the conference.
12. The conference consensus was a rejection
of any change in law on PAS. A common anxiety shared by all participantsregardless
of their personal moral stancefocussed on the risks for
very vulnerable or dependent individuals, if assisted suicide
13. At the 2000 annual meeting, the RB endorsed
the conference's recommendation opposing any change in law on
physician assisted suicide.
14. At the 2003 annual meeting this view
was re-iterated again, following further debate. The RB resolved
"that the BMA should take clear note of grass roots concern
15. By such methods as local Divisions debating
policy and drafting motions, democratic election to the BMA's
representative body and BMA council, by electronic consultation,
articles in BMA journals and frequent presentation of policies
to grass-roots members in ethics fora, considerable efforts are
made to gauge any changes in members' opinions.
16. Early BMA policy statements categorically
rejected the notion of euthanasia whereas recent ones are less
dogmatic and acknowledge the existence of a wide spectrum of views
within the profession. Nevertheless, repeated discussion within
the BMA has led to the current consensus that the law should not,
at present, be changed to permit euthanasia or PAS.
Other surveys of doctors' views
17. The BMA keeps abreast of relevant surveys
of doctors and patients' views although these are not invariably
reliable markers of public opinion since much depends on how questions
are presented. It recognises, however, that some doctors believe
that euthanasia and PAS are morally justified in exceptional circumstances.
Chapter 11 of Medical Ethics Today, for example, notes a 1996
survey of health professionals' views. (McLean SAM, Britton A.
Sometimes a small victory. Glasgow: Institute of Law and Ethics
in Medicine, 1996.) Although this indicated that 48 per cent of
the 804 doctors surveyed favoured legal change to allow PAS in
specified circumstances, the BMA maintained its opposition. The
association argued that even though there might be strong arguments
in some individual cases, the potentially harmful effects for
society as a whole lead it to oppose any lessening of the ban
on intentional killing. Whilst a convincing argument might be
made for justifying euthanasia or PAS in an individual case, the
BMA considers it more difficult to justify its availability as
a matter of public policy.
18. We note in the same survey that some
respondents perceived a moral difference between euthanasia and
PAS and that among those who supported the possibility of hastening
patients' deaths, there was a preference for PAS over euthanasia.
We felt that this might be explained as doctors considering themselves
less responsible or culpable where the patient rather than the
doctor takes the actual step to end life. Nevertheless, in the
BMA's view, even if there is a perceived distinction about who
is ultimately in control, euthanasia and PAS are inextricably
linked and the moral arguments for and against each are similar.
19. The notion of ending a human life deliberately
is a profound and disturbing concept, particularly for health
professionals whose training is generally orientated to improve
and prolong effective human functioning where possible.
20. Arguments for legislation permitting
voluntary euthanasia and PAS are generally based on competent
individuals' rights to control what happens to them. Respect for
autonomy, patient empowerment and informed self determination
are salient features of such arguments. It may also be suggested
that society's respect for their human rights entitles patients
to obtain assistance to end their lives in certain circumstances.
21. As its publications show, the BMA welcomes
the recognition given to patient autonomy and the greater informed
participation of individuals in their own health management. Nevertheless,
it sees individuals' autonomy as carrying less weight where their
preferences seriously affect others' ability to choose freely.
Clearly, the rights of some should not disproportionately undermine
the rights of others. Permitting euthanasia or PAS might benefit
some well informed and articulate people who are sure of their
wishes. It might also impinge pejoratively and seriously on others.
22. Thus, although there may be (and many
believe that there are) exceptional cases in which euthanasia
or PAS is perceived to be the best option for the individual,
the BMA fears that the impact of a general lifting of the ban
on intentional killing could detrimentally affect the rights of
very vulnerable people to be free from pressure. Logically, if
PAS is seen as a good option for the strong and determined, it
may also be seen as best for the depressed and unsure. The disadvantages
for the impressionable or undecided could well outweigh the benefits
for the minority wishing to commit suicide with assistance. Legalising
PAS could also fundamentally alter the ethos of medicine, which
might disadvantage society.
23. In the BMA's view:
Legalising assisted suicide would
affect some patients' ability to trust doctors and to trust medical
If assisted suicide were an available
option, there would inevitably be pressure for all seriously ill
people to consider it even if they would not otherwise entertain
such an idea.
PAS might be seen as desirable not
only for people able to choose for themselves but for others who
are vulnerable in terms of being elderly, dependent, disabled
or extremely ill.
24. If doctors are authorised to kill or
help kill, however carefully circumscribed the situation, they
acquire an additional role which the BMA believes is alien to
the one of care giver and healer. The traditional doctor-patient
relationship is founded on trust, which risks being impaired if
the doctor's role also encompasses intentional killing.
25. Even a loss of trust based more on patients'
fears and misperceptions than on the reality of PAS could be damaging.
In debates preceding the brief legalisation of euthanasia and
PAS in Australia's Northern Territory, there was evidence of considerable
disquiet from the indigenous Aboriginal population. The Australian
Select Committee on Euthanasia reported that some Aborigines were
afraid to attend health clinics and hospitals for fear of doctors
having "the power to kill" (Select Committee on Euthanasia.
Report of the inquiry on the right of the individual or the
common good? Vol 2. Darwin: Legislative Assembly of the Northern
26. Health professionals explaining all
options for the management of terminal illness would have to include
mention of assisted suicide if this was available. The BMA is
concerned that patients might feel obliged to choose that option
if they feel themselves to be burdensome to others or concerned,
for example, about the financial implications for their families
of a long terminal illness. By removing legal barriers to the
previously "unthinkable" and permitting people to be
killed, society would open up new possibilities of action and
thus engender a frame of mind whereby some individuals may feel
pressured to explore fully the extent of those new options. The
choice of exercising a right to die at a chosen and convenient
time could become an issue all individuals would have to take
into account, even though they might otherwise not have entertained
27. Of patients who made use of Oregon's
Death with Dignity Act during its first five years, 44 per cent
cited their fear of being a burden to their family, friends, and
carers as part of their reasoning for wanting to end their life
(Department of Human Services. Fifth annual report on Oregon's
Death with Dignity Act. Oregon: DHS, 2003: 20). Clearly, it
is common for sick people to worry about the effect of their illness
on relatives but the BMA would be unhappy about a situation where
such worries trigger premature deaths.
28. As is made clear above, the BMA fears
that a change of the law would make PAS an option to be considered
by any seriously ill person and some might feel pressured to choose
it, contrary to their own inclination. The UN Human Rights Committee
considering the Dutch criteria for euthanasia and PAS, concluded
that the Dutch system "may fail to detect and prevent situations
where undue pressure could lead to these criteria being circumvented"
(United Nations Human Rights Committee. Concluding observations
of the Human Rights Committee: Netherlands. Geneva: United
Nations, 2001. (CCPR/CO/72/NET)).
29. If PAS were available, society's apparent
endorsement of premature death, could confirm some patients' sense
of worthlessness. It could contribute to a perception that some
individuals are less valuable or it might influence decisions
about medical research funding for some apparently intractable
health problems since the sufferers might be seen as having an
alternative way out.
30. Patients may have a misplaced fear of
PAS being chosen for them. Despite euthanasia being only permissible
at patients' request in Holland, families apparently request it
more than patients themselves, presumably perceiving their loved
one's circumstances as intolerable. (Fenigsen R Mercy, murder
and morality: perspectives on euthanasia. A case against Dutch
euthanasia. Hastings Cent Rep 1989;19(1)(suppl): S22-30.)
As a result, some elderly people fear their lives will be ended
without their consent. (Segers JH. Elderly persons on the subject
of euthanasia. Issues Law Med 1988;3:429-37.) Patient groups
who feel marginalised within the health care system may be susceptible
to such anxieties. The fact that such fears may be ill-founded
does not necessarily diminish their impact.
31. The Bill's second proposition is that there
needs to be legal provision for pain relief. In the BMA's view,
this is unnecessary and plays on public fears about the possibility
of intolerable or unrelieved pain at the end of life. We believe
that the law and ethical position are already clear on the right
of patients to receive effective pain and symptom relief. BMA
publications and advice strongly emphasise this and if doctors
have any uncertainty, they can discuss them with the association's
ethics advisory service. Patients' rights to effective symptom
controland doctors' ability to prescribe appropriatelyare
not compromised by the fact that medication might have the side
effect of shortening some patients' lifespan. Control of pain
and other distressing symptoms must continue to be a paramount
consideration for health professionals in order to achieve the
best quality of whatever life remains for their patients.
1. Withdrawing life-prolonging treatment
is accepted and not considered morally equivalent to euthanasia
2. Doctors have their own personal views
on the moral acceptance or otherwise of assisted suicide. Despite
the wide range of views among the BMA's membership, the BMA has
had clear policy for many years that the law should not be changed
to permit euthanasia or PAS in the UK.
3. The issue has been repeatedly debated
within the association over recent decades and present policy
that the law should not be changed "for the time being"
implies that it will continue to be so.
4. The BMA has great respect for the concept
of patient autonomy and recognises that patients are not only
benefited by physical and clinical improvements but are also benefited
by having their own values respected. Nevertheless, the association
fears that in the case of euthanasia and assisted suicide, the
potential benefits for some are only achievable at a high cost
5. It would be unacceptable to put vulnerable
people in the position of feeling they had to consider precipitating
the end of their lives.
6. Provision in the Bill to permit pain
relief is unnecessary.
3 September 2004