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RCGP consultation: drilling down

more: Articles, Medical Opinion, Articles/Medical Opinion

25th March 2020

Further details of the Royal College of General Practitioners' consultation of members in 2019 show that those whose votes kept the College opposed did so because of the risk to vulnerable patients.

RCGP consultation: drilling down

On behalf of the RCGP, polling organisation Savanta ComRes interviewed 6,674 RCGP members online between 1 November and 13 December 2019. The consultation (which defined 'assisted dying' as 'the act of intentionally assisting a person to end their own life', encompassing those living with disabilities, psychological conditions and old age, not just terminal illnesses) was open to all of the College's 53,000 members, and asked three questions.

The headline figures were released when the College's position was renewed in February:

The RCGP should oppose a change in the law on assisted dying 3,144 (47%)

The RCGP should support a change in the law on assisted dying, providing there is a regulatory framework and appropriate safeguarding processes in place 2,684 (40%)

The RCGP should be neutral on the topic of the law on assisted dying 701 (11%)

I wish to abstain 145 (2%)

The results are reproduced in full at the end, but first, some observations:

Among those who favoured continued opposition, the vast majority (89%) believe that 'changing the law may put vulnerable patients at risk'. Patient care and the ability of doctors to maintain trust underpin medical opposition to assisted suicide, with 73% saying 'medical professionals should [not] be involved in assisted dying' and 46% saying that 'any benefit to the autonomy of the individual is outweighed by the potential harm to the doctor-patient relationship.'

Interestingly, 37% were not convinced that 'there is the resource in the NHS or relevant regulatory bodies to provide or oversee the delivery of assisted dying.' In relation to the NHS, this might include the difficulty for generalists of assessing mental capacity and discounting coercion, and also the ability to guard against suffering as a part of the assisted suicide process. In terms of regulators, this might be a recognition that assisted suicide laws proposed in recent years envisage judicial oversight (which would require new structures, staffing and resourcing), while countries like Belgium and the Netherlands have been slow to prosecute (and loathe to punish) erring doctors.

Among those who wished the College to be actively in favour of change, 84% cited 'choice and agency' - contrasting starkly with the overwhelming majority of doctors backing continued opposition, who recognise that for vulnerable patients already living with constrained 'choice and agency' (due, for example, to poverty or disability), a law indicating that suicide is acceptable and indeed reasonable for people like them would pose a grave risk.

75% of those who wanted active support believe that 'legalising assisted dying allows regulation of something which people may take upon themselves or have family members help them do.' To argue that contravention of a law is a reason for its repeal remains an absurd proposition. 52% held that 'this is primarily a societal issue and in my opinion society has moved on and wants a change in the law.' Leaving aside the many grave issues surrounding public opinion polling, this is a wholly illogical viewpoint given that doctors are essential participants in every legalised form of assisted suicide and euthanasia, and it is appropriate - indeed essential - that their views on ethics and safety be heard.

We would offer the same rebuttal to those favouring neutrality who said 'the medical professions should allow legislators to form their own opinion on this and decide whether and how to change the law' (30%) and that 'it is not the RCGP's place to take a firm position on a societal issue' (28%). Appropriately, given how poorly neutrality would serve the College and its members, no one reason united its small cohort of backers. Note, though, that 18% said 'this issue is too contentious for the RCGP to take a position on'. No, this issue - of life and death at the hands of doctors - is too contentious not to take a position on.

The final substantive question concerned the 'level of involvement, if any… GPs should have in the process' should assisted suicide be legalised, with five options proffered. None was supported by a majority of respondents, and more than a third (35%) said that 'no model of assisted dying should involve GPs at any level.' Curiously, despite 40% of GPs apparently favouring active College support for legalising assisted suicide, only 7% consider that 'GPs should be responsible for prescribing drugs for assisted dying.'

The most interesting and encouraging aspect of this final question is the question itself.

If assisted dying were to be legalised, what level of involvement, if any, do you think GPs should have in the process (provided that they do not conscientiously object to taking part)?

Suggested answers included 'GPs should be responsible for referring a patient to a specialist team or clinic as a first step in the process of assisted dying'; read alongside the caveat in the question, it is clear that the RCGP considers it beyond question that any law should allow for unfettered conscience rights. This is important when we consider that in Canada, the College of Physicians and Surgeons of Ontario, backed by the courts, demands that doctors with ethical objections must still facilitate euthanasia and assisted suicide by making 'effective referrals.' The UK Supreme Court confirmed this principle in UK law in a 2014 ruling concerning abortion, in a case where nurses objected to 'delegating, supervising and/or supporting staff to participate in and provide care to patients throughout the termination process.' Thus, doctors have yet more reason to act with caution and reject 'neutrality'.

Doctors have every right to express their principled objection to a fundamental shift in the practice of medicine which would create a major threat to vulnerable patients and from which they could not meaningfully absent themselves. Let lawmakers take note.

The results in full

Q1. Across the UK, under current laws in each country, assisted dying is illegal. The Royal College of General Practitioners has decided to consult its members on what its position on assisted dying should be. The College takes positions on significant ethical issues to ensure that it can influence the debate around government policy in the best interests of its members and our patients. Please select one of the following statements:

The RCGP should oppose a change in the law on assisted dying 3,144 (47%)

The RCGP should support a change in the law on assisted dying, providing there is a regulatory framework and appropriate safeguarding processes in place 2,684 (40%)

The RCGP should be neutral on the topic of the law on assisted dying 701 (11%)

I wish to abstain 145 (2%)

Q2. Please select all the reasons that support your view on what the College's position on assisted dying should be.

Of the 3,144 who said the RCGP should oppose a change in the law on assisted dying

Changing the law may put vulnerable patients at risk 2,812 (89%)

I do not agree that medical professionals should be involved in assisted dying 2,291 (73%)

I have a moral objection to assisted dying 2,083 (66%)

I have an objection to assisted dying because of my religious beliefs 1,668 (53%)

Any benefit to the autonomy of the individual is outweighed by the potential harm to the doctor-patient relationship 1,445 (46%)

I do not think there is the resource in the NHS or relevant regulatory bodies to provide or oversee the delivery of assisted dying 1,173 (37%)

I worry that legalising assisted dying might lead to other state interventions into healthcare 1,155 (37%)

Any change in the law should come from society or politicians and the RCGP should not take a position on matters such as this 226 (7%)

Of the 2,684 who said the RCGP should support a change in the law on assisted dying, providing there is a regulatory framework and appropriate safeguarding processes in place:

People should have choice and agency over their own life 2,251 (84%)

By supporting a change in the law RCGP can be involved in planning the practice of assisted dying 2,098 (78%)

Legalising assisted dying allows regulation of something which people may take upon themselves or have family members help them do 2,005 (75%)

This is primarily a societal issue and in my opinion society has moved on and wants a change in the law 1,401 (52%)

Of the 701 who said the RCGP should be neutral on the topic of the law on assisted dying

The RCGP should be able to represent the views of all of its members irrespective of whether they oppose or support a change in the law 414 (59%)

It is unclear what the legal and practical frameworks for assisted dying would be 401 (57%)

The RCGP could serve the interests of its members better by being neutral on this issue when influencing the planning of care and regulation 328 (47%)

I believe the medical professions should allow legislators to form their own opinion on this and decide whether and how to change the law 212 (30%)

It is not the RCGP's place to take a firm position on a societal issue 199 (28%)

This issue is too contentious for the RCGP to take a position on 129 (18%)

Q3. If assisted dying were to be legalised, what level of involvement, if any, do you think GPs should have in the process (provided that they do not conscientiously object to taking part)?

GPs should be responsible for referring a patient to a specialist team or clinic as a first step in the process of assisted dying 2,994 (45%)

GPs should support or counsel a patient and their family, friends and companions whilst they are making any decision on assisted dying 2,797 (42%)

GPs should provide verification as to a patient's eligibility for assisted dying, such as legal or written testimony 1,079 (16%)

GPs should be responsible for prescribing drugs for assisted dying (provided that a formal verification process is in place) 476 (7%)

No model of assisted dying should involve GPs at any level 2,322 (35%)

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