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Why is the editor of the BMJ making such a strong case for the BMA going neutral on 'assisted dying' on such shaky evidence?

more: Articles, Medical Opinion, Articles/Medical Opinion

18th June 2012

There are questions about why the editor of the BMJ is making such a strong case for 'assisted dying.'

Questions over BMJ editorial
The British Medical Journal this week published three articles aimed at neutralising medical opposition to euthanasia. 

There was nothing surprising about this. The BMJ's record of editorial bias on euthanasia and assisted suicide has been noted before and the deputy editor Tony Delamothe, who has previously written passionately on the subject is a named supporter of the pressure group 'Healthcare Professionals for Assisted Dying' (HPAD).

HPAD were responsible for penning two of this week's articles. Not bad coverage for a group representing fewer than 0.25% of Britain's 240,000 doctors! 

One of these was a comment piece from Ray Tallis, HPAD chairman, which called for the BMA and Royal Medical Colleges to take a position of 'studied neutrality' on 'assisted dying'. 

The second was an emotive plea for a change in the law from the daughter of HPAD's founder who died of pancreatic cancer.

But the third article was an editorial by Fiona Godlee (pictured), the journal's editor in chief saying that the BMJ 'supports' HPAD's call. Godlee has hinted at her support for assisted dying before, but has never gone quite this far. 

The significance of this move is that the British Medical Association is about to debate a motion calling for the doctors' trade union to take a neutral position on the issue. HPAD, which operates under the auspices of Dignity in Dying, the former Voluntary Euthanasia Society, flooded the BMA this year with no less than nine almost identical motions calling for neutrality.

DID in turn are planning a mass lobby of parliament a week later on 4 July in support of a new bill seeking to decriminalise assisted suicide. 

In other words, this is all part of a carefully orchestrated campaign. 

Godlee and Delamothe are of course entitled to their individual opinions, provided of course that they remain transparent about their ideological vested interests. 

But we do expect Britain's highest circulation medical journal, which many regard as the mouthpiece of the medical profession in Britain, to deal with controversial subjects in an even-handed and evidence-based way. 

Earlier this week the BMJ issued a press release about the articles in an attempt to bring them to international attention. I was asked to comment at the time and was interested to see how it presented the story. 

The press release bore the provocative title, 'BMJ supports call for medical bodies to stop opposing assisted dying' and the first three paragraphs read as follows:

'The BMJ today supports a call for leading UK medical bodies to stop opposing assisted dying for terminally ill, mentally competent adults. Healthcare Professionals for Assisted Dying (HPAD), wants the BMA and royal colleges to move their position from opposition to neutrality. The call comes as a new poll commissioned by Dignity in Dying found that, of 1000 GPs, 62% support neutrality.'

I thought that the prominence given in the press release to the BMJ's call for neutrality and the 62% figure were particularly telling, given that in Godlee's editorial they featured only in the very final paragraph. 

Clearly the BMJ, and Godlee as editor, wanted to give the call and the survey a huge level of publicity.

According to the BMJ Godlee qualified as a doctor in 1985 and in 1994 spent a year at Harvard University as a Harkness Fellow, evaluating efforts to bridge the gap between medical research and practice. 

On returning to the UK, she led the development of BMJ Clinical Evidence, which evaluates the best available evidence on the benefits and harms of treatments and is now provided worldwide to over a million clinicians in 9 languages.

So she is a person who is both well qualified to judge evidence and also a stickler for claims in peer-reviewed journals being soundly evidence-based. 

So I was most interested to see the strength of the evidence for this 62% figure. This was referenced in footnote 17 of her article, but this footnote merely provided a link to the HPAD website events page

From there was a further link to PJ Online which could only be viewed by paid-up subscribers.

I thought this was rather odd and so pointed it out both on this blog and in a rapid response to the BMJ website. 

Sometime within the next 24 hours (one can imagine anxious phone calls to HPAD from BMJ editorial staff - perhaps Godlee or Delamothe themselves) HPAD posted the link and one can now access both a joint press release from DID and HPAD and a copy of the poll results.

I wonder whether Godlee herself had seen these before she wrote her article (and if so why she did not link to them directly) or whether she simply took HPAD's say so (through 'personal communication'?) as unadulterated truth. My guess is that we might never know. 

As it turned out the poll was conducted by medeConnect Healthcare Insight (the research arm of Doctors.Net.UK) between 16 and 22 May 2012 who asked 1004 GPs an online question.

So what was the question DID actually asked which elicited this 62% response? You have to go to the 2nd footnote of the press release to find out but it read as follows:

'Opinion polls indicate that doctors are divided on the issue of assisted dying for the terminally ill, with approximately 60% opposed to change. Do you agree or disagree that medical bodies (RCGP, BMA) should adopt a position of studied neutrality* on the issue of assisted dying for terminally ill, competent adults.*A position of studied neutrality indicates that a medical organisation is neither supportive of, nor opposed to a change in the law on assisted dying. A neutral position recognises and respects the diversity of personal and religious views of its members and their patients, and encourages open discussion.'

To this 12% voted 'strongly agree', 50% 'agree', 7% 'don't know', 21% 'disagree' and 11% 'strongly disagree'. 12% plus 50% equals 62%. 

Of course, the value of polls such as this depends both on the reputability of the polling agency (and medeConnect is highly regarded) and also on the quality of the question. 

Some observations:

1.The term 'assisted dying' is not defined in the question and has no meaning in law. It was actually a term invented by the pro-euthanasia lobby and is generally used as a euphemism for both euthanasia and assisted suicide. However different groups define it in very different ways. But what did the respondents actually understand by it? 

2.'Terminally ill' is similarly a term with a range of meaning to different people. DID define it as having less than twelve months to live, although they are unclear if this means with or without treatment. This is the definition they will be using when they use these figures to campaign, but is this what the respondents will have understood?

3.The clear intent of DID and HPAD was to use this figure to campaign for the BMA to take a neutral position on 'assisted dying' in order to neutralise opposition for a new private member's bill in parliament during the next year. Might respondents have voted differently if they had known this? I wonder. 

4.The question states that about '60% of doctors are opposed to change' but does not say what change. If this was meant to mean 'opposed to a change in the law to allow assisted suicide and euthanasia to be legalised' then why did it not say so? And where did the '60%' figure come from given that Godlee herself quotes the 2009 Seale study's figure of 65%. 

5.The most important question from a pollster's point of view, however, is why DID chose to insert the information they did in the first sentence of the question. Because the giving of this information, that seems to have been intended to influence the result, thereby makes this group not representative of all GPs who might be asked. The context has changed. In short, this group has been primed.

Pollsters know that the way a question is asked can have a strong bearing on the responses received. That is why there are strict codes about the phrasing of questions. It will be interesting to see if this question actually breaches the national research society code. 

But to labour the point let me illustrate how the introductory sentence in the question might have been worded in other ways that may have achieved a different result:

'Opinion polls indicate that 95% of specialists in palliative medicine are opposed to a change in the law to allow assisted suicide or euthanasia for terminally ill patients. Do you agree or disagree that medical bodies (RCGP, BMA) should adopt a position of studied neutrality* on the issue of assisted dying for terminally ill, competent adults.'

Or perhaps:

'A small group of doctors called HPAD, representing less 0.25% of all doctors in the UK and closely affiliated to the former voluntary euthanasia society, is intending to introduce a motion to the BMA annual meeting in order to move the BMA to a neutral position on assisted dying, thereby neutralising medical opposition to a new private members bill to be introduced very soon. Do you agree or disagree that medical bodies (RCGP, BMA) should adopt a position of studied neutrality* on the issue of assisted dying for terminally ill, competent adults.'

I was interested to see that Godlee had also quoted another study from DID to support the following statement in her article. 

'When asked in a poll on whether they would want the option of assisted dying for themselves, a third of the 1000 general practitioners surveyed said they would, a third said they would not, and the remainder were unsure'

The reference again was to a webpage, interestingly this time on DID's website. 

This time background information about the question on the site was not available so I emailed DID for a copy of the poll itself (I wonder if Godlee went this far or simply gave the web reference possibly supplied to her by HPAD/DID? ) To DID's credit they sent the information to me within the hour.

The question read as follows:

'If you were terminally ill and suffering unbearably at the end of life with only months or weeks to live, and palliative care options had been explored, would you personally want the choice of legalised medical help to die so you could control the time of your death?'

Well that is not how Godlee has presented it, but then I am assuming that she did not actually read the question. It is noteworthy that only 33% of 1,001 GPs said yes to a question worded this way but it demonstrates powerfully the strong opposition there is to a change in the law within the medical profession at large.

Is Godlee just being sloppy in her use of this data? Or does she have an agenda that she is pursuing with such passion that she has inadvertently let her usual high standards for seeking strong evidence slip? 

As someone who helps pay her salary through my BMA subscription, I would like to know. I suspect I am not alone in this.

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