Select Committee on Assisted Dying for the Terminally Ill Bill Minutes of Evidence


Memorandum by the British Medical Association

INTRODUCTIONTHE 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 members—almost 80 per cent of UK practising doctors. It is a democratic institution in which members elect the colleagues who decide policy. (See http://www.bma.org.uk/ap.nsf/Content/About+the+BMA+-+History+and+ structure)

  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 other media.

BMA POLICY AND THE VIEWS 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 life—if dignified, quick, painless and at the patient's own informed request—may 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 remain illegal.

  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 participants—regardless of their personal moral stance—focussed on the risks for very vulnerable or dependent individuals, if assisted suicide were legalised.

  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 against euthanasia".

  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.

THE ARGUMENTS BEHIND THE BMA'S POSITION

  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 advice.

    —  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.

    Doctor-patient relationship

      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 Territory, 1995).

    Unwanted choices

      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 the notion.

      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.

    The vulnerable

      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.

    PROVISION FOR TERMINALLY ILL INDIVIDUALS TO RECEIVE PAIN RELIEVING MEDICATION

      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 control—and doctors' ability to prescribe appropriately—are 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.

    SUMMARY

      1.  Withdrawing life-prolonging treatment is accepted and not considered morally equivalent to euthanasia or PAS.

      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 for others.

      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



 
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