Aneez Esmail and Sam Everington explain why they are taking their college to court for ignoring its members
It is more important than ever that doctors have confidence in the organisations that represent them. This is why we are taking the Royal College of General Practitioners (RCGP) to court over its refusal to listen to its members on assisted dying.
For many years the medical profession has been in a predicament: how does it reconcile its historic opposition to assisted dying with overwhelming public demand for law change?
Recently, the BMA and medical royal colleges have made significant progress in bridging this gap because they have found that there is appetite for a different approach among doctors on the ground.
In 2019, the Royal College of Physicians (RCP) dropped its opposition to a change in the law after a survey of its members revealed opposition to law change had fallen to under 50%. It has now adopted a neutral stance on whether or not the law should change. A survey of cancer doctors conducted at the same time showed similar results, which led the Faculty of Clinical Oncology at the Royal College of Radiologists to state it would not oppose legislation either. As was recognised by The Times when these decisions were announced, “It is no longer quite so easy to say that doctors oppose assisted dying.”
Last summer, delegates at the BMA’s annual representative meeting (ARM) agreed it was time for the BMA to carry out a survey of its members. Despite the BMA’s assisted dying policy being quoted extensively in Parliament over many years, this was the first time in the organisation’s history that its members would be polled.
The poll results were announced on 8 October 2020. Forty per cent of respondents said the BMA should support a law change that would allow doctors to prescribe drugs to eligible patients for self-administration to bring on death. This is compared to 33% who said the BMA should maintain its current policy of opposition and 21% who said it should take a neutral stance (6% were undecided). This will not automatically change BMA policy to oppose assisted dying in all forms. That will only change if members of the BMA ARM vote to do so at the next meeting in 2021. However, it is worth reflecting that only four years ago ARM delegates had debated whether or not to debate assisted dying at all—the BMA has already come a long way.
As GPs we had hoped that, like the RCP and BMA, our representative body would not seek to hold back the tide, but instead move forward in a sensible, mature direction on this issue. The RCGP had reaffirmed its opposition to assisted dying in 2013, but in June 2019 agreed to survey the membership to see if views had shifted since then. Similar to the RCP survey, the results illustrated a split in opinion, but crucially the percentage of respondents who wanted the college to oppose assisted dying had fallen considerably from 77% to 47% in just six years. Forty per cent voted for the college to alter its stance towards supporting a change in the law “providing there is a regulatory framework and appropriate safeguarding processes in place,” while 11% supported a neutral stance (2% were undecided). Evidently, there had been a huge shift in views.
Yet in February, the RCGP council voted to retain its policy of outright opposition to law change. Council papers reveal this was following discussion with the college’s ethics committee and its Assisted Dying Steering Group. RCGP members have not been told who was on the steering group. Despite the college setting out to test how its members’ views had evolved, it later claimed that comparisons with the 2013 figures were not possible.
A majority of RCGP members voted for a change in policy (to either support or neutrality) but this was ignored. Why? The minutes of February’s council meeting show concerns were raised about how a shift to a neutral policy “could be seen by lobbyists.” With opinion divided—but the appetite for change growing—surely a neutral position is the only reasonable and logical compromise? Neutrality would allow the college to respect the views of all its members and empower its policy team to contribute GPs’ expertise to this debate without bias. Why was the council steered away from this position?
What is worrying is that the RCGP is now out of step with the rest of the profession and, in our view, its credibility is undermined. While other bodies demonstrate willingness to engage in debates constructively, in our view, the RCGP has gone rogue. In the past it might have been able to get away with this by hiding behind the perceived opposition of doctors, but any mandate that may have once existed has evaporated.
We contacted senior members of the college because of our concerns about how this decision had been made.
The chair of RCGP council, Professor Martin Marshall, provided assurances that the process was rigorous but said that releasing further details would not be “helpful to anyone.” He also suggested that the college deliberately opted not to do media work to explain its actions and that there is no desire to “get into debates about it” (personal correspondence, 23 February 2020).
Sadly, this response reminded us of what happened when we tried to expose a culture of widespread racial discrimination within the medical profession. Our efforts to expose wrongdoing then were met with defensiveness, threats, and a refusal to cooperate. We were told to back off. The same is happening now. But just as we didn’t back off then, we won’t back off now.
On 18 September Bindman’s LLP, acting on our behalf and along with the Good Law Project and Dignity in Dying, wrote to the leadership of the RCGP to notify them of our intentions to pursue legal proceedings unless they are prepared to address our concerns.
We believe the college has made serious errors and has failed to act with transparency. If it refuses to acknowledge this, it will jeopardise trust in the profession at a time when it is needed most. The era of medical bodies dictating to the rest of society on issues such as assisted dying is over. Some at the RCGP may not have realised this but its members clearly have. We all have a stake in what happens next.
Aneez Esmail is a professor of general practice, Division of Population Health, Health Services Research & Primary Care, University of Manchester. Twitter @aneezesmail
Sam Everington is a GP in Tower Hamlets and chair of NHS Tower Hamlets Clinical Commissioning Group.
Competing interests: AE is on the board of Dignity in Dying.