Five anonymous palliative care doctors say that although views diverge among specialists, palliative medicine’s professional association is stifling any free speech on assisted dying

We are five consultants, with between us 94 years of consultant level experience in palliative medicine.  We share concerns about the way that our specialty’s medical colleagues represent assisted dying in the media, including in this journal.

The Royal College of Physicians recently announced its intention to survey all its members and fellows on whether it should adopt a neutral position on this issue. Since then there has been an outpouring of strong opinions in the British media from the officers and members of the Association for Palliative Medicine (APM).^1,2  Almost all of these criticise the RCP for daring to suggest that it should not follow the APM’s absolute opposition to a change in British law to allow for specific forms of assisted dying. Fortunately, The BMJ has restored some balance by publishing articles from Canadian physicians who actually have experience of providing assisted dying.^3,4

Critics suggest that the possibility of the highly regarded physicians’ college being “neutral” is opening the door to an irreversible breakdown of medical standards and trust with the public; a dereliction of thousands of years of Hippocratic practices and—worst of all—that this would lead directly to doctors being asked to “kill” patients.  In our view, these assertions are indefensible and morally repugnant interpretations of a perfectly reasonable attempt by the college to survey its membership and, importantly, to use neutrality to facilitate an unimpeded discussion about this topic.

We are unaware of any evidence that other jurisdictions that have legalised forms of assisted dying have seen loss of faith in the medical profession by the public; there is no evidence that assisted dying is inconsistent with the tenets of modern evidence based medicine; and, most of all, the assertion that doctors in the UK might be called on to “kill” patients is blatant scaremongering in its worst form.

Other medical disciplines, and the public at large, might be forgiven for thinking that these opinions are representative of the palliative medicine specialty as a whole. We would like to open another side to this discussion.  As consultants in palliative medicine, we undoubtedly see the same spectrum of patients and their carers, as the APM writers do. We have no reason to suspect that our colleagues are any less sympathetic, compassionate, and proficient in our art, as we believe we are.

However, we beg to differ that assisted dying is inherently a “bad thing,” and we believe it is our mature and professional responsibility to have an open discussion regarding this subject. It is important to do this since many of the dying people whom we care for have expressed that assisted dying should be an option that they could access.

We would like to address the charge that legalising assisted dying would lead to doctors being asked—possibly even forced by unspecified insidious means—to “kill” patients. We believe that our colleagues, whom we have enormous respect for, have failed to read and understand the terms of recent attempts to bring assisted dying to the UK, and are confusing “assisted dying” with “voluntary euthanasia.” An example is the Falconer Commission which made it very clear that the act of dying would be at the competent patient’s repeated request, facilitated by a doctor writing a prescription, for a lethal “draught” that would have to be taken by the conscious patient by his or her own hand.⁵ We would challenge that this could in any way be construed as “killing.”

The authors of this letter have wanted and tried in different ways to engender an open and fair discussion about this subject with our specialist colleagues, in the hospices, hospitals and community settings in which we use our craft.  We note that the last time a British palliative medicine doctor wrote about changing his viewpoint on assisted dying, he was subjected to intense criticism and ostracism by his peers.⁶

All of us have been rebutted or stifled from airing this topic.  We believe that there may be many more colleagues—especially trainees and early career consultants—who do not share the views of the officers of the APM, but we suspect they are intimidated and inhibited from openly sharing the views that we have put forward here.  The APM has consistently emailed all its members whenever a situation like the RCP’s survey, or when a case is coming to the British courts of justice for hearing a patient’s request for assisted dying, with the clear and unequivocal direction that members are to oppose these developments.  There is no concession to the possibility that other doctors practising high quality and ethical specialist palliative medicine may hold an alternative opinion or just want to hear about different options.

We hope readers understand why we agreed to write only with anonymity, at least until there is a climate of open and fair discussion in our speciality where doctors do not fear being criticised, ostracised, or worst of all—having their careers threatened.  We commend the RCP’s move to bring more open discussion to the medical community, but hope that our chosen specialty does not continue to deny its own members that freedom.

References:

1. Profitt A. Doctors cannot be neutral on assisted dying. Spectator, 29 January 2019.
2. Abson C, Anthony Pillar R, Biggar N, Brennan S, et al. Physicians protest. The Times, 1 February 2019.
3. Buchman S. Why I decided to provide assisted dying: it is truly patient centred care. BMJ; 2019:364:1412
4. Blackmer J. Commentary: How the Canadian Medical Association found a third way to support all its members on assisted dying. BMJ 2019;364:1415.
5. The Commission on Assisted Dying. The current legal status of assisted dying is inadequate and incoherent. Demos: London. 2011.
6. Ahmedzai SH. My journey from anti to pro assisted dying. BMJ 2012;345:e4592.