New draft guidance from the BMA will enable doctors to dehydrate and sedate to death large numbers of non-dying patients with dementia, stroke or brain damage

This story was broken on 13 August 2018 by the Daily Mail. 

Is it justifiable to withdraw food and fluids from patients with dementia, stroke and brain injury who are not imminently dying?

New ‘confidential’ draft guidance from the British Medical Association (BMA) - the doctors’ trade union - says ‘yes’ provided that a doctor believes it is in the patient’s ‘best interests’.

The 77-page ‘confidential’ document, which is currently out for ‘consultation’ (although only to a few selected individuals), has been prepared by the BMA in conjunction with the Royal College of Physicians (RCP) and the doctors’ regulatory authority, the General Medical Council (GMC).

I understand from the BMA that it will not be open for public consultation at any point before publication in the autumn.

The draft guidance builds on case and statute law and on previous practice guidelines and has huge implications for the care of some of the most vulnerable people in England and Wales.

It comes complete with a six-page executive summary, flow charts and tick box forms to smooth the decision-making process.

The guidance says it is based on the current legal position which it defines as follows:

·         Clinically assisted nutrition and hydration (CANH) - essentially food and fluids by a fine tube through the nose or through the skin into the stomach -  is a form of medical treatment

·         Treatment should only be provided when it is in a patient’s 'best interests'

·         Decision makers should start from the presumption that it is in a patient’s best interests to receive life-sustaining treatment but that presumption may be overturned in individual cases

·         All decisions should be made in accordance with the Mental Capacity Act 2005 (see also my blog post on the recent Supreme Court judgment)

It focuses on three categories of patients where CANH is the ‘primary life-sustaining treatment being provided’ and who ‘lack the capacity to make the decision for themselves’: those with ‘degenerative conditions’ (eg. Dementia, Parkinson’s etc); those who have suffered a sudden-onset, or rapidly progressing brain injury and have multiple comorbidities or frailty’ (eg. stroke); previously healthy patients who are in a vegetative state (VS) or minimally conscious state (MCS) following a sudden onset brain injury.

It makes it crystal clear that it does not cover patients who imminently dying and ‘expected to die within hours or days’ but rather those who ‘could go on living for some time if CANH is provided’.

So in summary, the guidance decrees that dementia, stroke and brain injured patients who lack mental capacity but are not imminently dying can be starved and dehydrated to death in their supposed ‘best interests’.

Who makes these decisions? If there is an advance directive for refusal of treatment (ADRT) then the patient does (or at least has). If there is an appointed health and welfare attorney then they do, and if it’s not the case that ‘all parties agree’ then it falls to the Court of Protection. But in the remainder of cases – which must by any reckoning be the vast majority – it is ‘usually a consultant or general practitioner’.

No second opinion need be obtained unless there is ‘reasonable doubt about the diagnosis or prognosis, or where the healthcare team has limited experience of the condition in question’ and even if the patient is suffering from PVS or MCS ‘it is not necessary to wait until (investigations) have been completed’ if there is not ‘sufficient evidence’ that they will ‘affect the outcome of the best interests assessment’ (Executive Summary para 14).

In other words, the diagnosis and prognosis are irrelevant if the decision is made that death is in the patient’s ‘best interests’. This is especially disturbing given that PVS and MCS are extremely difficult to diagnose, many patients have some degree of awareness and some later wake up.

And how are best interests to be determined? Decision makers must take into account ‘the individual’s past and present views, wishes, values and beliefs’ and in order to do this should consult ‘those engaged in caring for the patient or interested in his or her welfare’. This would ‘usually include family members and could also include friends and colleagues’.

So, what determines ‘best interests in a given case’?

It boils down to whether CANH is able to ‘provide a quality of life the patient would find acceptable’ (ES p23). Otherwise continuing to provide CANH is ‘forcing them to continue a life they would not have wanted’ (ES p16).

So, by a subtle twist, providing basic sustenance (food and fluids by tube) to someone who ‘would not have wanted’ to be in this ‘condition’ is a form of abuse. How very convenient.

The issue here, of course, is that most normal people do not think that they will find life with dementia, stroke or brain injury ‘acceptable’ and CANH – food and fluids - does not reverse these conditions just as it does not reverse cancer, diabetes, disabliity or mental illness.

This is precisely because CANH is not actually ‘treatment’ but rather part of basic care. But it does not follow that they should therefore have their lives ended. In fact, research shows that people who are sick value the quality of life they have left much more than they would expect to when well. 

British parliaments have consistently refused to legalise euthanasia or assisted suicide for people with a quality of life they would not find ‘acceptable’ or would not ‘have wanted’. But the BMA is saying that to end these lives by starvation and dehydration, rather than with a lethal injection or drinking poison, is perfectly acceptable.

This is actually nothing other than euthanasia by stealth – euthanasia by the back door. 

It might, and has, been argued that starving and dehydrating people to death over two to three weeks is actually less compassionate than killing them quickly with lethal drugs.

What safeguards are there against abuse of this new guidance? Very few it appears.

There is a section reminding doctors that the GMC requires ‘a second medical opinion’ from a suitably qualified ‘senior clinician’ where it is proposed ‘not to start, or to stop CANH and the patient is not within hours or days of death’. This clinician should (note not must) ‘examine the patient and review the medical records’.

A ‘detailed record’ of the decision-making process should be kept and a ‘model proforma’ (see below) is ‘recommended’.  Decisions should be subject to ‘internal audit and review’ and ‘external review’ by the Care Quality Commission and Healthcare Inspectorate Wales but health professionals need to ‘contribute to’ ‘relevant national data collection’ only if it ‘exists’.

So, no legal, or even ethical, obligations – just suggested ‘best practice’.

Quite how oversight or accountability will be possible is unclear as the death certificates need not make any reference to the fact that the patient died from starvation and dehydration after a feeding tube was removed. Instead ‘the original brain injury or medical condition should be given as the primary cause of death’ (2.11). And so, the doctor’s tracks are perfectly covered.

The body of the draft guidance contains a flow chart (page 19) outlining the decision-making procedure.  

The simple ‘recommended’ ‘checklist’ (appendix 4), which could be filled out in a few minutes, could be the only record that remains in the patient’s notes (see inserts).

What is largely disguised here in a lengthy and turgid 77-page document that few doctors or carers will ever read is a simple mechanism for ending the lives of dementia, stroke and PVS patients who are not imminently dying and who otherwise could live for months, years or even decades.

A decision is made by a GP or hospital consultant, on the basis of information about the patient gathered from relatives or carers, that they would not ‘have wanted’ to live this way.

A simple tick-box form is completed, the tube is removed and the patient in question is dehydrated, starved and sedated to death. The true cause of death is not recorded in the death certificate.

I’m not suggesting that large numbers of doctors will not undertake these assessments and decisions with integrity and diligence. But the problem is with the protocol itself. Also, it will only require a few to cut corners out of laziness or driven by malice, ideology or vested interest. This mechanism of ending vulnerable people’s lives – essentially a conveyor belt from nursing home and hospital bed to the morgue – is open to the most extraordinary abuse at every level by health professionals, family members and health institutions who might have an interest, financial or emotional, in a given patient’s death.

Imagine the busy nursing home filled with dependent but non-dying stroke, dementia and brain injured patients whose relatives seldom visit. Feeding tubes have been placed by staff because they are far more convenient than standing over patients and feeding them with a spoon. Wards are understaffed and the patients are difficult to care for.

A visiting GP makes a decision that it is not in a certain patient’s ‘best interests’ to live. Relatives are consulted and agree that their ‘loved ones’ would not ‘have wanted’ to live like this.  A ‘second opinion’ is obtained. Forms are filled out. The tube is removed and the patient moved to a side room to receive ‘palliative care’ consisting of deep sedation until they have died two to three weeks later from dehydration.

The death certificate is falsified with only the underlying condition being recorded. No data are collected and there is no proper internal audit. Everyone is too busy and distracted. No questions are asked or answers given. They are not required as this is all ‘good practice’ approved by the BMA. The police do not investigate. The CPS does not prosecute. The courts are not involved. Parliament turns a blind eye as it lacks the stomach to review the relevant legislation. It is easier to leave it to the doctors and their professional ‘guidance’.

This is a recipe for euthanasia by stealth, but all in the name of autonomy and ‘best interests’ – the very worst kind of doctor paternalism justified on the grounds that the patient would ‘have wanted’ it.

There are conceivably tens of thousands of patients in England and Wales who are vulnerable to the use and abuse of this ‘guidance’. It will be almost impossible to work out what has happened in a given case and there are no legal mechanisms in place for bringing abusers to justice.

How did we get here? This whole process has transpired by a small series of steps – each following logically from the one before and endorsed in case law, statute law, regulations and guidelines going back to the Law Lord’s decision on Hillsborough victim Tony Bland who was the first to die in this way. But the trickle is about to become a flood.

Once we accept that food and fluids by tube is ‘medical treatment’ rather than basic care and that providing this basic sustenance to someone with a medical condition they would not find ‘acceptable’ is not in their ‘best interests’, then we are inviting professionals to devise a simple scheme whereby the starvation of large numbers of non-dying but expensive and ‘burdensome’ patients can be achieved simply and efficiently, and largely undetected, without involving the courts.

When it came to light a few years ago that some doctors were misusing a palliative care tool called the Liverpool Care Pathway to starve, dehydrate and sedate non-dying patients to death there was a national outcry.

One might have expected to see a similar reaction to this draft BMA guidance.  But thus far there has been not a whimper.

I am astounded that no MP or prominent doctor has yet raised any concerns about it. I wonder how long it will be.

You can read CMF’s official response to the BMA draft guidance here.

Doctors debate the complete decriminalisation of abortion at BMA ARM

Doctors could back the complete decriminalisation of abortion in Britain next week.

On Tuesday 27 June the British Medical Association annual representative meeting in Bournemouth will vote on a motion seeking to end all legal restrictions on abortion.

Currently, abortion remains illegal in Britain under the Offences Against the Person Act 1861. Under this law both mothers attempting to abort on their own, or any other person (including doctors) seeking to help them, are potentially liable to life imprisonment.

But under the Abortion Act 1967 doctors can authorise abortion on several grounds relating to the health of mother or baby. Although the Abortion Act was intended to be restrictive, allowing abortion only in strictly limited circumstances, its provisions are very liberally interpreted leading to the situation where one in every five pregnancies ends in abortion. 

There have been over eight million abortions in Britain since the abortion act came into being 50 years ago this year.  Department of Health figures for England and Wales released earlier this month show that there were 190,406 abortions in 2016 and that 98% of these were carried out on mental health grounds.

So in practice, although abortion is still technically illegal, the law is widely flouted and we have a situation tantamount to abortion on demand.

Now some doctors are seeking to decriminalise abortion completely.

The six part motion (motion 50), from the BMA agenda committee, is to be proposed by the BMA’s City and Hackney Division. It reads as follows:

That this meeting:

i) supports the principles set out in part three of the February 2017 BMA discussion paper on decriminalisation of abortion;

ii) believes that abortion should be decriminalised in respect of health professionals administering abortions within the context of their clinical practice;

iii) believes that abortion should be decriminalised in respect of women procuring and administering the means of their own abortion;

iv) believes that decriminalisation should apply only up to viability in respect of health professionals;

v) believes that decriminalisation should apply only up to viability in respect of women procuring and administering the means of their own abortion;

vi) believes that abortion should be regulated in the same way as other medical treatments.

It is likely that each part will be considered separately by the 500 BMA delegates with each section receiving a majority vote becoming official BMA policy.

The votes will follow an hour long presentation of a 52-page discussion paper on abortion decriminalisation which the BMA claims is ‘neutral’.

The British Pregnancy Advisory Service (BPAS), the country’s leading abortion provider, and the Royal College of Midwives (RCM) have campaigned heavily for a change in the law in recent months.

This culminated earlier this year in parliament voting by 172 votes 142 to support Diana Johnson’s radical Reproductive Health (Access to Terminations) Bill, which seeks to remove all legal restrictions on abortion (more here).

As this was a Ten Minute Rule Bill it will not become law but it is most likely that a very similar bill will be reintroduced following the Queen’s Speech later this month, either in the House of Lords or House of Commons.

In theory, Johnson’s bill would have made the 1967 Abortion Act defunct by scrapping section 58 and 59 of the Offences Against the Person Act, which make carrying out abortions, or supplying drugs or equipment for that purpose, illegal.

Johnson implied that the 1929 Infant Life (Preservation) Act, which makes it illegal to destroy a child ‘capable of being born alive’ (the act defines this as 28 weeks although many babies born as early as 23-24 weeks now survive), may also be scrapped under her plans. If so this would make abortion legal for any and every reason right up to term.

The BMA motion has been deliberately crafted to match the terms of Johnson’s bill as part of a wider campaign to change the law.

Johnson’s Bill is primarily backed by private abortion provider BPAS. The decriminalisation campaign specifically acknowledges that they are campaigning for a situation that would remove all gestational time limits for abortion. This position was affirmed by BPAS CEO, Ann Furedi, who said at the London launch of the campaign, ‘I want to be very, very clear and blunt... there should be no legal upper limit.’

If such a bill were to become law, and this would be far more likely with BMA backing, abortions could be carried out legally in any location, for any reason, potentially at any stage during pregnancy.

Without legislation on abortion, practices such as sex-selective abortions, mail-order abortions and school nurses handing out abortions pills on school premises would all be perfectly legal. The conscience clause would also fall, meaning that health professionals might be forced to carry out abortions or lose their licenses to practise.

Last year the Royal College of Midwives support for the BPAS’ abortion up-to-birth campaign caused widespread condemnation from midwives, the media and the general public against this extreme proposal. Over 1,000 midwives have now signed the open letter asking for RCM position to be revoked.

If the BMA were to pass motion 50 it would be signalling that abortion should be treated in the same way as surgical procedures like having one’s appendix or tonsils taken out – requiring consent only.

It would also put the doctors’ trade union at odds with its historical ethical code and with public opinion in Britain.

The Hippocratic Oath forbids abortion in all circumstances and the Declaration of Geneva requires that doctors show the utmost respect for human life from the time of conception.

But this new motion, if passed, would entrench doctors’ position as abortion’s greatest facilitators.

In the last few years, polls have consistently shown that a larger proportion of women want more, not fewer restrictions on abortion. A ComRes poll in May 2017 found that only 1% of women wanted to see the time limit for abortion extended above 24 weeks and only 1% of women wanted to see the time limit for abortion extended through to birth.

The same poll found that 70% of women wanted to see the abortion time limit reduced to 20 weeks or below and that 91% of women favour a total and explicit ban on sex-selective abortion. Clearly, women want the law to be stricter on the legality and regulation of abortion, not laxer.

The BMA must not bow to the will of this small and extreme pressure group. Motion 50 needs to be voted down. 

If you are a doctor or medical student, you can sign an open letter to the Chair of the ARM calling for the rejection of Motion 50. If not, you can still sign the Citizen Go petition.

BMA rejects attempt to push it neutral on assisted suicide by 2 to 1 majority

Today the Annual Representative Meeting (ARM) of the British Medical Association (BMA) in Belfast voted against going neutral on assisted suicide by a two to one majority (see detail here).

Delegates rejected motion 80, ‘that this meeting believes that the BMA should adopt a neutral stance on assisted dying’, by 198 to 115 (63% to 37%).

The debate took place after a previous motion affirming that ‘it is not appropriate at this time to debate whether or not to change existing BMA policy’ was defeated by 164 to 160.

The BMA, the UK doctors’ trade union, has been opposed to the legalisation of assisted suicide and euthanasia for every year of its history with the exception of 2005-6 when it was neutral for just twelve months.

Fifteen doctors spoke during an impassioned debate on the two motions but the final vote was decisive, and reflected the 65% opposition to legalising assisted suicide shown in most opinion polls.

Dr Mark Porter, the Chair of BMA Council, noted that the debate marked the eighth time in 13 years that the BMA had considered the matter, and stated that ‘nobody can credibly say this issue has been suppressed or obfuscated’. Dr Andrew Mowat, who moved Motion 79, went further, describing the constant returns to the issue as a ‘neverendum’; Dr Gary Wannan simply mused, ‘we’ve been here before...’

The Royal College of Physicians, Royal College of General Practitioners and British Geriatrics Society are all officially opposed to a change in the law along with 82% of Association for Palliative Medicine members.  Amongst all doctors, this latter group carries the greatest weight in this debate due to their understanding of the vulnerability of dying patients and their knowledge of treatments to alleviate their symptoms.

British parliaments have consistently resisted any move to legalise any form of assisted suicide or euthanasia. There have been a dozen unsuccessful attempts in the last twelve years. Last year the Marris Bill in the House of Commons and the Harvie Bill in the Scottish Parliament were defeated by 330-118 and 82-36 respectively.

Assisted suicide and euthanasia are contrary to all historic codes of medical ethics, including the Hippocratic Oath, the Declaration of Geneva, the International Code of Medical Ethics and the Statement of Marbella.

Neutrality on this particular issue would have given assisted suicide a status that no other issue enjoys. Doctors, quite understandably, are strongly opinionated and also have a responsibility to lead. The BMA is a democratic body which takes clear positions on a whole variety of health and health-related issues.

Furthermore, to drop medical opposition to the legalisation of assisted suicide and euthanasia at a time of economic austerity would have been highly dangerous. Many families and the NHS itself are under huge financial strain and the pressure vulnerable people might face to end their lives so as not to be a financial (or emotional) burden on others is potentially immense.

In rejecting an attempt to move it neutral at its ARM in 2012 the BMA said that neutrality was the worst of all positions. This was based on bitter experience. When the BMA took a neutral position for a year in 2005/2006 we saw huge pressure to change the law by way of the Joffe Bill. Throughout that crucial debate, which had the potential of changing the shape of medicine in this country, the BMA was forced to remain silent and took no part in the debate. Were it to go neutral again it would be similarly gagged and doctors would have no collective voice.

Going neutral would also have played into the hands of a longstanding campaign led by a small pressure group with a strong political agenda. 

Healthcare Professionals for Assisted Dying (HPAD), which is affiliated to the pressure group ‘Dignity in Dying’ (formerly the Voluntary Euthanasia Society), at last count had just over 500 supporters, representing fewer than 0.25% of Britain’s 240,000 doctors.

Instead the BMA ARM wisely gave short shrift to this latest neutrality proposal and signalled by the margin of defeat that this matter should now be settled for the foreseeable future. 

The BMA should reject this latest attempt to push it neutral on assisted suicide and euthanasia

Tomorrow, 21 June, the Annual Representative Meeting (ARM) of the British Medical Association (BMA) will consider two motions on assisted suicide.

The BMA is the UK’s professional association and registered trade union for doctors and currently has 170,000 members.

It has been opposed to the legalisation of assisted suicide and euthanasia for every year of its history with the exception of 2005-6 when it was neutral for just twelve months.

The first motion (79 on the agenda) affirms that ‘it is not appropriate at this time to debate whether or not to change existing BMA policy’.

Only if this is not passed will debate take place on the second motion (80): ‘that this meeting believes that the BMA should adopt a neutral stance on assisted dying’.

A total of 29 motions were put forward on this issue – of which 21 upheld current BMA policy and only 8 opposed it; 27 motions did not make the cut of the agenda committee.

The use of the term ‘assisted dying’ is especially interesting as it is a form of words developed by the pro-euthanasia lobby that is vaguely defined and has no meaning in law. So it raises the question as to what the BMA would actually be going neutral on?

British parliaments have consistently resisted any move to legalise any form of assisted suicide or euthanasia. There have been a dozen unsuccessful attempts in the last twelve years. Last year the Marris Bill in the House of Commons and the Harvie Bill in the Scottish Parliament were defeated by 330-118 and 82-36 respectively.

The majority of doctors are opposed to a change in the law. Opinion polls show an average of 65% doctors opposing the legalisation of assisted suicide and/or euthanasia with the remainder undecided or in favour. The Royal College of Physicians, Royal College of General Practitioners and British Geriatrics Society are officially opposed.

82% of Association for Palliative Medicine members oppose a change in the law, with 72% saying a bill allowing assisted suicide even for imminently dying people would have an adverse effect on the delivery of palliative care. Amongst all doctors, these voices carry the greatest weight in this debate due to their understanding of the vulnerability of dying patients and their knowledge of treatments to alleviate their symptoms.

Assisted suicide and euthanasia are contrary to all historic codes of medical ethics, including the Hippocratic Oath, the Declaration of Geneva, the International Code of Medical Ethics and the Statement of Marbella. Neutrality would be a quantum change for the profession and against the international tide.

Furthermore, neutrality on this particular issue would give assisted suicide a status that no other issue enjoys. Doctors, quite understandably, are strongly opinionated and also have a responsibility to lead. The BMA is a democratic body which takes clear positions on a whole variety of health and health-related issues. Why should assisted suicide and euthanasia enjoy a position which no other issue shares, especially when doctors will actually be the ones carrying it out?

Furthermore, to drop medical opposition to the legalisation of assisted suicide and euthanasia at a time of economic austerity could be highly dangerous. Many families and the NHS itself are under huge financial strain and the pressure vulnerable people might face to end their lives so as not to be a financial (or emotional) burden on others is potentially immense.

Were the BMA to drop its opposition, and as a consequence a law were to be passed, it would also leave the medical profession hugely divided at a time when, perhaps, more than any other time in British history, we need to be united as advocates for our patients and for the highest priorities in a struggling health service.

The British Medical Association (BMA) rejected an attempt to move it neutral at its ARM in 2012 saying that neutrality was the worst of all positions. This was based on bitter experience. When the BMA took a neutral position for a year in 2005/2006 we saw huge pressure to change the law by way of the Joffe Bill. Throughout that crucial debate, which had the potential of changing the shape of medicine in this country, the BMA was forced to remain silent and took no part in the debate. Were it to go neutral again it would be similarly gagged and doctors would have no collective voice.

Going neutral would instead play into the hands of a longstanding campaign led by a small pressure group with a strong political agenda. Healthcare Professionals for Assisted Dying (HPAD), which is affiliated to the pressure group ‘Dignity in Dying’ (formerly the Voluntary Euthanasia Society), at last count had just over 500 supporters, representing fewer than 0.25% of Britain’s 240,000 doctors.

The BMA has been historically opposed to a change in the law on assisted suicide and euthanasia for good reasons. These reasons have not changed.

Going neutral would be inappropriate, undemocratic and potentially highly dangerous. It would also be playing into the hands of a small unrepresentative pressure group and giving an advantage to only one side of the debate. Furthermore it would communicate confused messages to the public at a critical time and divide the profession at a time when a united doctors’ voice is needed more than ever.

The BMA ARM would be wise to give short shrift to this latest neutrality proposal. The issue has been debated to death in recent years and the views of parliament and the medical profession in this country are settled.

There are many more pressing and crucial matters on the ARM agenda. It is time to give this one a well-deserved rest. 

Letter from BMA Council Chair Mark Porter on deal agreed today with government

A deal on the Junior doctors contract has been agreed today by the BMA and government. It is still subject to referendum but this is a fantastic step forward and a wonderful answer to prayer.       BBC coverage here and Twitter here Congratulations to all those who worked together so hard over so many weeks to make it possible Deo Gloria! Letter from BMA Council Chair Mark Porter Dear Dr Saunders, Today, an agreement has been reached between the BMA and the government on a new contract for junior doctors in England. The agreement, after many months of negotiation, also addresses wider issues about safe working conditions, recruitment, and the maintenance of high-quality care. It comes after an extraordinary year. Junior doctors have been forced to take industrial action five times. On each occasion, they have looked to, and received, the strong support of consultants, SAS doctors, GPs and medical students. We have demonstrated beyond doubt that we are one profession. Junior doctors across the country have inspired us with their passion and resilience in defending high-quality patient care. There have been many times when their right to a safe and fair contract has gone unheeded. But now, after talks in which all parties took a positive and constructive approach, we have the basis of a new contract. The considerable progress made in recent week's means we now have:  − recognition of junior doctors’ work and contribution across every day of the week − proper consideration of and provision for equality in the contract, including the chance for accelerated training for those who take time out for caring responsibilities − improved flexible pay premia for specialties such as emergency medicine and psychiatry to address the recruitment and retention crisis in these areas  − more rigorous oversight of the new guardian role to ensure safe working. The new contract will be published at the end of May. During June, it will be explained in a series of roadshows, and then put to a referendum of junior doctors. We will be publishing more details of the agreement as soon as possible on the BMA website. We have come a very long way since the original proposals were made last July. None of the progress made in negotiations would have been possible without the consistent and inspiring support of all doctors. The support of our patients has also been critical. They knew we had common cause in protecting and improving the quality of patient care. No-one would have chosen the situation we have had to face over the last 10 months. But in adversity we have seen doctor after doctor stand up with passion and integrity for the quality of patient care. The NHS faces some profoundly difficult challenges, but with such commitment from doctors, and a spirit of engagement from employers, we can make progress in other areas too. Thank you. What we have achieved for the profession, we have achieved with the unity of support of the profession. Yours sincerely

Mark Porter BMA council chair

BMA calls on new parliament to debate six priorities for NHS

The British Medical Association (BMA) has today called on the newly elected UK parliament for ‘an open and honest debate about the NHS, focused on six priorities’ as follows:  

1. Address the funding shortfall for health

UK investment in health has slipped proportionately behind France, Germany, Denmark and Austria, and should be restored to a comparative level of GDP.

Increases in NHS funding based on unrealistic assumptions will not meet patient need. For example, an extra £8bn a year by 2020-21 overlooks the fact that an annual £22bn of efficiency savings will need to have been made by that time in order to close the £30bn funding gap on current services predicted by NHS England. There is still no credible plan, or commitment to invest enough, to enable this unprecedented scale of efficiency savings to be made. A good start would be for the government to fund NHS capital projects directly and to renegotiate existing PFI contracts to ensure a better deal for the nation, bringing our hospitals back into public ownership.

2. Remove market competition in healthcare

The Health and Social Care Act 2012 was a wasteful distraction from the real challenges in delivering healthcare and should be repealed.

A truly national health service needs an accountable leader; the health secretary’s statutory responsibilities to secure and provide universal and comprehensive healthcare must be restored and explicitly stated. The bureaucracy of competitive markets in the NHS in England hinders integration and prevents providers working together around patients’ needs. The government should use the NHS as its default provider, and not allow it to be destabilised by rival commercial providers.

3. Increase, retain and value doctors

Doctors are voting with their feet in neglected areas and services; the government has to recognise the need to improve working conditions.

Increasing the numbers of doctors in understaffed specialties such as general practice, psychiatry and emergency medicine will be impossible without this. Fair pay awards require that the independence of the Doctors’ and Dentists’ Pay Review Body (DDRB) should be restored and respected. Efficiency savings targets in the NHS should no longer be met at the expense of staff pay.

4. Maintain safeguards for patients and doctors

We must not return to the age of exhausted doctors; safeguards for patients and doctors assured by the Working Time Regulations must remain in place.

Seven-day services across the NHS should only be developed in response to clear patient demand and need, most acutely in urgent hospital care. Any proposals that dramatically change ways of working must follow rigorous analysis, have clear funding plans, and have workforce arrangements that protect both patient safety and doctors’ welfare.

5. Restore investment in general practice

General practice is the bedrock of many NHS services and the gatekeeper to the rest; it plays a vital role in all communities.

Significant investment in the workforce and facilities is overdue in order to meet rising patient need, in particular, that from older patients and those living with multiple conditions. The government must work more effectively with the profession to attract motivated doctors to work in general practice, and must invest in upgrading practice premises, delivering the ambition of true community care.

6. Prioritise health and wellbeing and strengthen ill-health prevention

Unhealthy lifestyle behaviours, such as poor nutrition, smoking and alcohol consumption, have a significant impact on quality of life and life expectancy and also place a huge burden on health services.

The government must tackle these behaviours and the industries that drive them, taking effective action to reduce health inequalities across society, improve the medical and social care of children, and develop a generation-long commitment to improve the public’s health. Health and well-being must be prioritised in all policy areas across government.

HPAD gets slapped down at the BMA ARM

The British Medical Association (BMA) has always been opposed to euthanasia and assisted suicide. That is, apart from just one year, 2005, when under the influence of then Ethics chief Michael Wilks, it temporarily went neutral.

The BMA’s opposition to a change in the law has long infuriated advocates of assisted suicide, not least a small but vocal group of doctors who believe that they should be able in some circumstances to help their patients kill themselves.

In fact, campaigning for the legalisation of assisted suicide seems to be a major preoccupation (obsession even) for high profile retired secular humanist doctors (more here). Quite why is another story. 

Every year at the BMA annual representative meeting, this small group of retired doctors, now assembled under the umbrella ‘Healthcare professionals for assisted dying’ (HPAD), the medical arm of the former voluntary euthanasia society, floods the BMA with motions calling for a change in the law. And almost every year the matter gets debated and the BMA policy remains unchanged.

This year was no exception. HPAD members sent in motions from all over the country calling for a referendum amongst BMA members on euthanasia neutrality.

But not surprisingly, the BMA’s agenda committee relegated them to the ‘grey’ part of the programme – ‘unlikely to be reached’ – and prioritised other ethical issues instead.

Not to be outdone HPAD did everything that it could behind (and in front of) the scenes to force a debate. The matter eventually came to a head when HPAD chair Ray Tallis (pictured) attempted to highjack the Chair of Council’s Q & A session. You can watch the video here but it went as follows:

Raymond Tallis: ‘(I am) Raymond Tallis, North West Division, Declaration of Interest, Chair of Heathcare Professions for Assisted Dying: I am deeply curious to know why when twelve motions at least were submitted to survey the views of the BMA on neutrality regarding the issue of assisted dying that this motion did not actually make the agenda.  Given that the motion is extremely timely we know that Lord Falconer’s bill is receiving its second reading in the House of Lords in a couple of weeks I can only conclude and this may be the conclusion of some people in the represented body that people were afraid of doing a survey on neutrality as they were worried about the findings’.

Chairman’s response: ‘Thank you Ray.  I believe I answered that question earlier on. That is not a question for the Chairman of Council as I believe you know very well.  You had the opportunity to ask the RB (representative body) to prioritise that motion, the RB chose to disagree with you through the democratic process.  I do not want to hear any more about this because the RB said no. Next question…’

Well that was short shrift. But I expect Tallis and HPAD will be back again next year. He murmured at the end that he remained ‘unchastened’.

Meanwhile we can be thankful that the BMA has again stood on the principle that doctors should not kill their patients.

In June 1947 the BMA published a statement on ‘War Crimes and Medicine’ which it later submitted to the General Assembly of the World Medical Association in September1947.

It concluded: ‘Although there have been many changes in Medicine, the spirit of the Hippocratic Oath cannot change and can be reaffirmed by the profession. It enjoins…The duty of curing, the greatest crime being co-operation in the destruction of life by murder, suicide and abortion.’ 

Well they’ve done an about face since 1947 on abortion, but at least for now, they are standing firm on ‘murder’ and suicide. All is not yet lost.

Doctors cannot encourage or assist suicide: Official

Almost a year after its consultation closed, the UK General Medical Council issued on 31 January its guidance about what doctors can and cannot do with patients who consult them about assistance with suicide.

Contrary to the spin suggested by Dignity in Dying (the former Voluntary Euthanasia Society) and its satellite, Healthcare Professionals for Assisted Dying, the only clarification which could remotely be seen as a concession is that doctors who respond to a valid request and solely hand over the medical records required by Dignitas for confirmation of diagnosis are unlikely to face sanction by the GMC.

Otherwise, the 6-page guidance for the GMC’s pre-hearing investigators ‘considering allegations about a doctor’s involvement in encouraging or assisting suicide’ upholds the law as it stands and sends no signals at all to suggest the profession endorses assistance with suicide. Although of course the GMC recognises its neutral role and states ‘Nothing… should…be taken to imply that the GMC supports or opposes a change in…law’, the guidance helpfully underlines the law and the profession’s position.

Action concerning a doctor’s fitness to practise is certain when:

•a doctor has been convicted of encouraging or assisting suicide

and probable when

•a doctor has accepted a caution and/or has been the subject of an adverse determination by another regulatory body for encouraging or assisting suicide
•the doctor’s encouragement or assistance depended upon the use of privileges conferred by a licence to practise medicine (such as prescribing) or took place in the context of a doctor-patient relationship
•the doctor knew, or should reasonably have known, that their actions would encourage or assist suicide
•the doctor acted with intent to encourage or assist suicide

Also likely to lead to action are:

•encouraging a person to commit suicide, for example by suggesting it (whether prompted or unprompted) as a ‘treatment’ option in dealing with the person’s disease or condition
•providing practical assistance, for example by helping a person who wishes to commit suicide to travel to the place where they will be assisted to do so
•writing reports knowing, or having reasonable suspicion, that the reports will be used to enable the person to obtain encouragement or assistance in committing suicide
•providing information or advice about other sources of information about assisted suicide
•providing information or advice about methods of committing suicide, and what each method involves from a medical perspective

Guidance follows about ‘realistic prospects’ for proof, and the only ‘Allegations that will not normally give rise to a question of impaired fitness to practise’ because of their lawfulness or their distance from the encouragement or assistance include:

•providing advice or information limited to the doctor’s understanding of the law relating to encouraging or assisting suicide
•providing access to a patient’s records where a subject access request has been made in accordance with the terms of the Data Protection Act 1998
•providing information or evidence in the context of legal proceedings relating to encouraging or assisting suicide

Wisely, the GMC has also released shorter 2-page guidance aimed at patients and those close to them, which summarises the principles and the legal limits detailed for doctors.

Clarifying that ‘respect for a patient’s autonomy cannot justify illegal action’, doctors should ‘limit any advice or information about suicide to an explanation that it is a criminal offence to encourage or assist a person to commit or attempt suicide’.

The position of doctors is now clear to all and does not need changing.

The BMA has welcomed the guidance and the Medical Defence Union (MDU) has not revised its previous warning that doctors who provide medical reports for patients seeking assisted suicide abroad could be prosecuted.

BMA Ethics Debate – Great results on both abortion and euthanasia

This morning the British Medical Association Annual Representative Meeting debated two motions on abortion and one on euthanasia.

Here is a record of the debates as they happened from the BMA blog.

Motion 328 called for the meeting to support the universal availability of non-directive counselling for women considering abortion.

It said that the counselling should be in accordance with NHS standards and independent of the abortion provider if women so wished.

328 Motion by THE AGENDA COMMITTEE (MOTION TO BE PROPOSED BY THE HARROGATE DIVISION):
That this Meeting:-
i) supports the universal availability of neutral counselling for women considering abortion;
ii) believes that any counselling provided for women considering abortion should accord with NHS standards;
iii) believes that women considering abortion should be able to access counselling that is
independent of the abortion provider;
iv) deplores picketing and intimidation around abortion services.

Dr Mark Pickering, in proposing the motion, said the issue was about extending choice for women, not limiting it.

Professor Wendy Savage responded that she had been the press officer for a woman's choice organisation for 35 years. She said it was 'an absolute insult' to professionals to require so-called independent counselling. She said the pros and cons would be explained in any operation. She said most 'independent' counsellors were not actually independent.

But the meeting supported the provision of non-directive counselling for women considering abortion and also condemned the picketing and intimidation around abortion services.

This is a great result for women facing the crisis of unplanned pregnancy and should encourage parliament to make moves in the direction of independent counselling provision.

Motion 329 called for the meeting to back a call stating that abortion on the grounds of gender alone is unacceptable.

329 Motion by THE AGENDA COMMITTEE (MOTION TO BE PROPOSED BY THE GREENWICH, AND BROMLEY DIVISION):
That this Meeting believes that abortion on the grounds of gender alone is unacceptable and demands that :
i) such practice should cease forthwith;
ii) the law should be changed to make this practice illegal in the UK.

GP Kackie Applebee said the meeting had to be careful about passing any issue that sought to limit abortion. She called on the meeting not to jeopardise a woman's right to choose.

But GP Paddy Glackin maintained that the motion was not a slippery slope. He was cheered as he said the motion was saying that female infanticide was a gross violation of human rights.

However, after a passionate debate the motion was judged ‘not competent’ and was not passed.

Motion 332 called for the BMA to adopt a neutral position on ‘assisted dying’.

It had been brought forward by members of the pressure group ‘Healthcare Professionals for Assisted Dying’(HPAD) in an attempt to neutralise medical opposition to assisted suicide and euthanasia ahead of a new parliamentary bill calling for legalisation. HPAD is closely affiliated to Dignity in Dying, the former Voluntary Euthanasia Society and this motion was part of a carefully orchestrated campaign.

I have previously argued on this blog why I believe that going neutral on assisted suicide would be a very dangerous move indeed.

332 Motion by THE AGENDA COMMITTEE (MOTION TO BE PROPOSED BY THE SHROPSHIRE DIVISION):
That this Meeting:-
i) believes that assisted dying is a matter for society and not for the medical profession;
ii) believes that the BMA should adopt a neutral position on change in the law on assisted dying.

The proposer Professor Raymond Tallis argued that the current situation was 'morally repugnant' and said that the BMA should adopt a policy of studied neutrality on the issue of assisted dying.

Speaking against, Dai Samuel said an 'act of kindness' could lead to 14 years in prison, and added that he was there to care for patients and could not countenance something that he considered akin to murder.

John McGough encouraged doctors to accept that some colleagues do support assisted dying.

Speaking against, medical student Rebecca Briscow said the medical profession cannot be excluded from the decision and that a position of neutrality would be a breach of patient trust. She warns that physician-assisted dying is cheap - and dangerous - and that doctors must be the safeguard.

Farah Jameel responded that keeping a patient alive isn’t always the right answer, and that there was no right or wrong answer for assisted dying. She said a position of neutrality was key.

Also speaking in support, Isky Gordon related an anecdote about a colleague - who went on to be exonerated by the GMC and police - being investigated for the treatment of a terminally ill and mentally competent patient.

Professor Baroness Illora Finlay said that the public would not understand why the BMA won't express a view on the prescription of potentially lethal drugs. 'The safeguards proposed are no more than a checklist.' She believed neutrality would tell parliament that the BMA saw this as acceptable.

Speaking for the motion, Tom Henderson admitted it was 'uncomfortable' to shift away from opposition to assisted dying. He says there were legal and accepted options for some people - those who could fly to Switzerland for example - but others were 'condemned' to suffer. He said neutrality would allow a balanced view of a complex argument.

Ethics Chairman Tony Calland argued that we must approach this with a logical head and not an emotional heart. If the law changed the medical profession would be involved so it was important that we stayed engaged in the debate.

BMA Chairman Hamish Meldrum said a position of neutrality would exclude doctors from the debate and urged the meeting to reject the motion.

Both parts of the motion were lost.

In rejecting this move the BMA has sent out a strong message that doctors must play a leading role in this debate which could otherwise be far too easily swayed by celebrity endorsement and media outlets who have consistently acted as the cheerleaders for assisted suicide and euthanasia.

Majority medical opinion remains opposed to assisted dying and this vote is a victory for common sense. I hope that the BMA will now continue its valuable work in campaigning for high quality compassionate care for patients at the end of life.

Why the BMA should not go neutral on assisted suicide and euthanasia

This Wednesday, 27 June, the British Medical Association Annual Representative Meeting (ARM) will vote on a motion to go neutral on assisted suicide and euthanasia.

The BMA, the trade union for doctors, has been opposed to a change in the law for all but one year of its 180 year history.

But those proposing the motion will claim that this is an issue on which doctors are divided and where most members of the public favour a change in the law. Furthermore, they will argue that the British Medical Journal favours a neutral stance and that a poll published last week has shown that 62% of doctors agree.

The motion reads as follows:

* 332 Motion by THE AGENDA COMMITTEE (MOTION TO BE PROPOSED BY THE SHROPSHIRE DIVISION):
That this Meeting:-
i) believes that assisted dying is a matter for society and not for the medical profession;
ii) believes that the BMA should adopt a neutral position on change in the law on assisted dying.

So why not support it? Ten reasons:

1. If the BMA chooses to go neutral on this particular issue, it will be giving the issue a status that no other issue enjoys. Doctors, quite understandably, are strongly opinionated and also have a responsibility to lead. The BMA is a democratic body which takes clear positions on a whole variety of issues on the basis of a majority vote. This week the association will vote on issues as broadly ranging as Syria, torture, tobacco and the future of the NHS. Why should assisted suicide and euthanasia enjoy a position which no other issue shares, especially when doctors will actually be the ones carrying it out?

2. It will further damage doctors’ public profile. The industrial action over pensions has not been well received by all sections of the community, and however justifiable we regard it, it will not look good for doctors to take a strong position on their own financial interests but to have no position at all over whether doctors, to put it bluntly, should have the power, in some circumstances, to kill their patients.

3. This motion is part of a campaign led by a small pressure group with a particular political agenda. Healthcare Professionals for Assisted Dying (HPAD), which is strongly affiliated to the pressure group ‘Dignity in Dying’ (formerly the Voluntary Euthanasia Society) has 520 supporters, representing fewer than 0.25% of Britain’s 240,000 doctors. But they have flooded this year’s ARM with no less than nine motions calling for the association to go neutral. This is in line with HPAD’s and DID’s clearly stated campaign objectives to legalise ‘assisted dying’ and is aimed at neutralising medical opposition ahead of a new bill being introduced to parliament over the next year. DID is planning a mass lobby of parliament to support such a bill next week on 4 July. A neutral vote will be a vote for the success of this campaign.

4. The 62% support figure from DID/HPAD of doctors favouring a switch to neutrality is based on a questionable poll. Although widely trumpeted by the British Medical Journal, the poll was based on an unbalanced question which is currently the subject of a formal complaint to the Market Research Society. It was asked over a month ago without any clear definition of key terms such as ‘assisted dying’ and ‘terminally ill’ and was framed in an unbalanced way with a stem aimed at priming respondents. An on-line poll run last week by the BMJ after HPAD and DID had launched their campaign ran 82% against neutrality.

5. If the BMA goes neutral this week it will lead inevitably to a new attempt to change the law at parliamentary level over the next twelve months. In the only previous year in which the BMA took a neutral position (2005/6) we saw huge pressure to change the law by way of the Joffe Bill. Throughout that crucial debate, which had the potential of changing the shape of medicine in this country, the BMA was forced to remain silent and took no part in the debate. The same scenario would arise again. Doctors would have no collective voice.

6. The motion itself is broadly and vaguely worded. Were it to go through, this would not be simply a vote for ‘assisted suicide for mentally competent adults with less than twelve months to live’ as sought by DID and other campaigners. The motion simply talks about ‘assisted dying’, a term which is variously defined and which has no meaning in law. So it is not at all clear what doctors would actually be signing up to be neutral on. Does it include assisted suicide or euthanasia or both, and for which categories of patients?

7. The majority of doctors are opposed to a change in the law. Opinion polls show an average of 65% doctors opposing the legalisation of assisted suicide and/or euthanasia with the remainder undecided or in favour. Palliative Medicine Physicians are 95% opposed and the Royal Colleges of General Practitioners and Physicians (RCGP and RCP) are both opposed. Why choose to go neutral on an issue where there is such a strong majority amongst doctors?

8. Assisted suicide and euthanasia are contrary to all historic codes of medical ethics, including the Hippocratic Oath, the Declaration of Geneva, the International Code of Medical Ethics and the Statement of Marbella. Neutrality would be a quantum change for the profession and against the international tide.

9. To drop medical opposition to the legalisation of assisted suicide and euthanasia at a time of economic recession could be highly dangerous. Many families and the NHS itself are under huge financial strain and the pressure vulnerable people might face to end their lives so as not to be a financial (or emotional) burden on others is potentially immense.

10. Were the BMA To drop its opposition, and as a consequence a law were to be passed, it would leave the medical profession hugely divided at a time when, perhaps, more than any other time in British history, we need to be united as advocates for our patients and for the highest priorities in a struggling health service.

For the BMA to go neutral on assisted suicide and euthanasia would be inappropriate, undemocratic and potentially highly dangerous. It would also be playing into the hands of a small unrepresentative pressure group and giving an advantage to only one side of the debate. Furthermore it would communicate confused messages to the public at a critical time and divide the profession at a time when a united doctors’ voice is needed more than ever.

Let’s resist it!

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 doctors.net 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.