Saturday, 16 June 2012

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

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.


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

    Because you are Doctors, not law makers. It isn't the role of Doctors to decide what the law should be. Therefore a neutral position is the only correct position to take for a Doctor.

    The editor of the BMJ has taken the correct stance, your position Peter is incorrect as you are using professional medical position to back your beliefs.

    We do not live in a theocracy in the UK, therefore your position is invalid.

    1. Doctors aren't neutral on much else. And given that they will be the ones administering or prescribing the lethal drugs they have both a right and a responsibility to take a collective view.

      HPAD/DID's aim in moving the BMA neutral is to neutralise opposition to a new bill seeking to legalise assisted suicide and euthanasia. This is an issue on which the BMA should have a position.

      And throughout its history it has, except for one year, always been opposed.

    2. I completely disagree, once again I say that Doctors are healers not lawmakers. I am more than happy for our democratic system to consult Doctors who will hopefully state the facts and present the case for and against, but I have no wish for a Doctor to have the right to say whether I can live or die.

      And I have no wish for you or your church to have any say whatsoever about my life, it is none of your business, nor is it the business of anyone else who believes in sky gods.

      If specific Doctors do not wish to help provide this public service I believe it should be their right to refuse to do so and to refer to a Doctor who will assist the patient. I would expect there would be special centres set up if the practice was allowed and those places would probably be away from the main hospitals and have their own full time staff who had chosen to be there.

      As I have said before, I have seen 2 people die from untreatable cancer and both left their mark on me - the one I remember best (in the best way, not more clearly) was the one who I believe was helped out by a very kind Doctor who responded to the wishes of his patient. I am grateful to him for sparing her suffering and that of the wider family.

      Assisted dying can be a glorious thing, if the person is allowed to make the decision for themselves and go at the time they choose, it is not necessarily the nasty and deceitful business you portray it to be.

    3. I think "newsengland" has shown passion about this subject that may have moved the debate towards personal or organization attack. "And I have no wish for you ror your church to have any say whatsoever about my life, it is none of your business, nor is it the business of anyone else who believes in sky gods". From a neutral position, this is a person attack to Peter. Peter was only carefully picking the evidence of the BMJ publications and it was not about any church to decide about anyone's life or death in a hospital in Britain. So not sure what it newsengland was on about.
      "Assisted dying can be a glorious thing" again did any evidence suggest so? I suppose for some culture and believe system, honour killing for putting a shame on the family is also a glorious thing for those in it, and is none of anyone's business?
      If talks about emotional cases, I also had a few where families are pressuring relatives to die indirectly, for their house to be given to their sons or daughters, or even driving the person to end their own life. Yes everyone can say there will be a safeguard in place, another institution... but I think we know enough now that instituations do fail often and continue to do so, often after years and spending millions on enquries, we end up with some announcement of "we will learn from our mistakes" "we apologize sincerely and our hearts goes to the family" etc... no one is going to jail, but the person died, no turn back. If you said there should be some sort of centre where people can go and get help to die, can't you see just another massive scandle is on the way?
      Yes, I agreed that we are healers and not law maker, but we are in the business of dealing with life and death daily. I know the position of opposing assist dying or suicide is not ideal but is the safest option sofar.
      People at the end of the day, can still kill themselves if they really want to, and if rather to legalise the whole business, make it into a "business - with demand and supply" with lots of lots of safeguarding in place... aren't we already have that safeguarding in place in British Law, which such act is illegal until otherwise challenged in court? Then the judge can judge it, which is the judge's got paid to do... rather than by doctors who are ourselves divided on this issue anyway and subjected to emotional believes and passion influence.


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