World Medical Association urged to change policy against
euthanasia, assisted suicide
Canadian & Royal Dutch Medical Association want censure dropped
13 February, 2018
Sean Murphy*
The President of the World Federation of the Catholic Medical Associations has disclosed that the Canadian Medical Association (CMA) and Royal Dutch Medical Association (RDMA) have asked the World Medical Association to change its policy against euthanasia and physician assisted suicide.
The WMA issued a Declaration on Euthanasia in 19871
and a Resolution on Euthanasia in 2002;2
they are now identical. The WMA Statement on Physician Assisted Suicide was made in 1992 and reaffirmed in 2005 and 2015:
Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically. However the right to decline medical is a basic right of the patient, and the physician does not act unethically even if respecting such a wish results in the death of the patient.3
Writing to the President of the World Medical Association, Dr. John Lee
of the World Federation noted that the CMA and RDMA wanted the condemnation
withdrawn and replaced with the following:
8. The WMA does not support euthanasia or physician assisted suicide, but WMA does not condemn physicians who follow their own conscience in deciding whether or not to participate in these activities, within the bounds of the legislation, in those jurisdictions where euthanasia and/or physician assisted dying are legalized.
9. No physician should be forced to participate in euthanasia or assisted suicide against their personal moral beliefs. Equally, no conscientiously objecting physician should be forced to refer a patient directly to another physician. Jurisdictions that legalize euthanasia or physician assisted suicide must provide mechanisms that will ensure access for those patients who meet the appropriate requirements. Physicians, individually or collectively, must not be made responsible for ensuring access.4
Dr. Lee also expressed opposition to a planned revision to the Declaration of Oslo concerning abortion, which, he said, would require objecting physicians to refer for abortions and even to provide them. However, he commented at greater length on the proposed change to WMA policy on euthanasia and assisted suicide.
Based on the Canadian experience, acceptance of the ethical neutrality of medically-assisted death has resulted in almost immediate challenges for physicians who are unable to refer because of moral, religious, or ethical concerns. It is a serious problem, with physicians put in the impossible position of having to choose between their conscience and being allowed to continue to care for their patients.4
The Canadian roots of the CMA/RDMA proposal
Dr. Lee's observations about developments in parts of Canada are accurate,
and it is significant that the text of paragraph 8 is very similar to the resolution used by the CMA Board of Directors
as the basis for reversing CMA policy against euthanasia and assisted suicide.
| CMA Resolution (2014)5 |
|
CMA/RDMA Proposed WMA Policy |
|
The Canadian Medical Association supports the right of all physicians, within the bounds of existing legislation, to follow their conscience when deciding whether to provide medical aid in dying as defined in CMA's policy on euthanasia and assisted suicide.
|
|
8. The WMA does not support euthanasia or physician assisted suicide,
but WMA does not condemn physicians who follow their own conscience in deciding whether or not to participate in these activities, within the bounds of the legislation, in those jurisdictions where euthanasia and/or physician assisted dying are legalized.
|
Two differences are apparent. First, the CMA resolution was silent on the Association's position on euthanasia and assisted suicide, but the CMA/RDMA proposal clearly states that the WMA does not support the procedures. Second, the CMA resolution affirmed
"support" for physicians who legally provide euthanasia or assisted suicide, but the CMA/RDMA proposal says only that the WMA "does not condemn" those who do.
From the perspective of WMA members opposed to euthanasia and assisted suicide, these differences may be reassuring. Nonetheless, the proposal must entail some significant change from current policy, or the CMA and RDMA would not have proposed it.
Not ethically neutral
What is actually entailed by the proposal is that the WMA withdraw declarations that euthanasia and assisted suicide are unethical and/or inconsistent with medical practice, and pass no judgement on the decisions of national medical associations and individual physicians to provide the services in accordance with national law. Euthanasia and assisted suicide would pass from being absolutely ethically unacceptable practices to practices that could be accepted in at least some situations, a point to be settled by those directly involved, and not by the WMA.
But why not simply say that? Why the declaration of non-support?
Three explanations are possible, and they are not mutually exclusive.
- First, the overwhelming majority of WMA members are opposed to euthanasia or assisted suicide, and would surely oppose the change in policy if they believed that it implied their support for the procedures. The explicit declaration to the contrary could be expected to mollify them and minimize opposition arising from this concern.
- Second, WMA policies play out in jurisdictions with different legal and political systems, cultures and traditions. Hence, it would be very difficult to anticipate all of the global consequences that might flow from a WMA statement of support for legal euthanasia or assisted suicide, or support for physicians who provide the services. Thus, an explicit statement of non-support might be offered for purely prudential reasons.
- Third, the expression of continued non-support could be understood to mean that the WMA continues to believe that euthanasia and physician assisted suicide, though not ethically precluded, are inadvisable for unspecified reasons.
In assessing the significance of the CMA/RDMA
proposal, it is instructive to apply the approach they recommend to other WMA
policies. The
WMA Resolution on Physician Participation in Capital
Punishment states:
RESOLVED, that it is unethical for physicians to
participate in capital punishment, in any way, or during any step of the
execution process, including its planning and the instruction and/or
training of persons to perform executions.
The World Medical Association
REQUESTS firmly its constituent members to advise all
physicians that any participation in capital punishment as stated above is
unethical.
URGES its constituent members to lobby actively
national governments and legislators against any participation of physicians
in capital punishment.6
Rewritten following the CMA/RDMA model:
The WMA does not support capital punishment,
but WMA does not condemn physicians who follow their own conscience in
deciding whether or not to participate in capital punishment, within the
bounds of the legislation, in those jurisdictions where capital
punishment is legal.
The resolution on capital punishment does not address the ethics
of execution, but only physician participation. A closer
parallel to policies on euthanasia and assisted suicide is provided by the
WMA Statement on Female Genital Mutilation,7
which
condemns both the practice and physician participation. Adopting the
CMA/RDMA model:
The WMA does not support female genital mutilation,
but WMA does not condemn physicians who follow their own conscience in
deciding whether or not to participate in female genital mutilation, within the
bounds of the legislation, in those jurisdictions where female genital
mutilation is legal.
These comparisons indicate that the CMA/RDMA
proposal is not ethically neutral, but would involve a radical revision of the ethical position of the WMA
in favour of the practice of euthanasia and assisted suicide. It would
involve acceptance of the procedures as consistent with medical ethics, or
at least not so inconsistent as to preclude tolerance of the practices.
Acceptance of legal euthanasia/assisted suicide in all circumstances
Moreover, like the CMA's own
resolution, the CMA/RDMA proposal is completely unrestricted with
respect to the circumstances in which physicians may provide euthanasia and
assisted suicide in accordance with national law. In Canada,
psychiatric patients suffering from other irremediable disorders are
eligible for euthanasia and assisted suicide. In a World Medical
Journal article, the CMA's Dr. Jeff Blackmer acknowledges that the possibility of providing
euthanasia and assisted suicide as treatments for psychiatric disorders and
dementia is being considered.8 Euthanasia
for dementia patients in the Netherlands has become increasingly frequent,
leading to the resignation of a medical ethicist from one of the regional
euthanasia review committees.9
The CMA/RDMA proposal would commit the WMA to
at least tolerating euthanasia
and assisted suicide and physician participation in the practices in all such circumstances,
and in any other situations that might ultimately be approved by law in other
countries.
Physician freedom of conscience
The second proposed policy statement (para. 9) addresses physician
freedom of conscience:
9. No physician should be forced to participate in euthanasia or assisted
suicide against their personal moral beliefs. Equally, no conscientiously
objecting physician should be forced to refer a patient directly to
another physician. Jurisdictions that legalize euthanasia or physician
assisted suicide must provide mechanisms that will ensure access for those
patients who meet the appropriate requirements. Physicians, individually
or collectively, must not be made responsible for ensuring access.
The first sentence in the paragraph is essential
and sound, though "personal" is superfluous. At this point, demands
that physicians must personally provide euthanasia or assisted suicide are
only beginning to be made and are still rare.10,11
The second sentence addresses the most
common and contentious issue: demands that physicians who, for reasons of
conscience, are unwilling to kill patients or help them commit suicide must
promptly refer them to someone who will. An undetermined number of physicians are
unwilling to refer patients for euthanasia or assisted suicide because they reasonably construe such conduct as entailing
morally unacceptable complicity in wrongdoing. The most common demand
they face is direct referral to
another physician. However, these physicians would be equally
unwilling to refer a patient to an entity or agency designed to operate as a
euthanasia delivery service, as was proposed by an official Canadian
advisory group.12 This is not precluded
by the CMA/RDMA proposal.
The third and fourth sentences resolve conflicts
between patient demands for services and physician freedom of conscience,
including refusal to refer, by implying that the state or some other entity
is responsible for ensuring access to euthanasia and assisted suicide: that
neither the medical profession as a whole nor individual physcians have an
obligation to do so.
While this is a sound approach,
and the protection of conscience provision is generally commendable, it has
been rejected by Canada's largest medical regulator.
The College of Physicians and Surgeons of Ontario took
the position that physicians who object to physician-assisted dying requests
have a positive obligation to make an effective referral. An effective
referral, as described by the Ontario College, is a referral made in good
faith to a non-objecting available and accessible physician, other health
care professional, or agency. The College noted that the medical community
has an obligation to ensure access and that conscientious objection should
not create barriers.13
This reflects the effects of a sustained campaign to compel physicians to
refer for other morally contested services like abortion, which, in effect, has been a dress rehearsal to compel them to refer for euthanasia. The reasoning used to justify the former is also
used to justify the latter, as is abundantly clear from the Canadian
experience.
The College of Physicians and Surgeons of Ontario imposed mandatory referral for all morally contested services
except euthanasia and assisted suicide in 2015,14
and extended the policy to include euthanasia and assisted suicide in 201615
because "there was no qualitative difference" between euthanasia and
assisted suicide "and other health care services."16
This reasoning was unanimously approved by three Ontario Superior Court
judges. They ruled against physicians who believe it is wrong to kill
their patients or arrange for someone else to kill them.17
In effect, the ruling gives the state the power to compel citizens to be
parties to homicide and suicide, notwithstanding conscientious or religious
convictions to the contrary.
Conclusion
While Dr. Lee noted that the proposed protection of conscience provisions in paragraph 9 were "very welcome and necessary," he warned that they were insufficient, since "assurances put in place to gain acceptance of a controversial procedure quickly disappear once a procedure has gained acceptability by the medical mainstream."4
Ironically, this is exemplified by the Royal Dutch Medical Association,
which, contrary to the CMA/RDMA proposal, demands that objecting physicians
refer patients for euthanasia, even though Dutch law does not require it.18
The decidedly ambiguous position of the RDMA and the experience of
embattled physicians in Canada indicate that the WMA should not revise its
policies on euthanasia, assisted suicide or other morally contested
procedures without first adopting a robust policy defending freedom of
conscience for physicians and other health care workers. This is necessary
to protect the medical profession from increasingly aggressive attempts at
ethical cleansing by the state or other powerful interests, attempts that
are not always effectively opposed by national medical associations.
Notes
1. World Medical Association, Declaration on Euthanasia. Adopted by the 39th World Medical Assembly, Madrid, Spain, October 1987 and reafrmed by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005 and reafrmed by the 200th WMA Council Session, Oslo, Norway, April 2015 (Accessed 2017-11-26).
2. World Medical Association, Resolution on Euthanasia. Adopted by the 53rd WMA General Assembly, Washington, DC, USA, October 2002 and reafrmed with minor revision by the 194th WMA Council Session, Bali, Indonesia, April 2013 (Accessed 2017-11-26).
3. World Medical Association, Statement on Physician Assisted Suicide. Adopted by the 44th World Medical Assembly, Marbella, Spain, September 1992 and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005 and reafrmed by the 200th WMA Council Session, Oslo, Norway, April 2015 (Accessed 2017-11-26).
4.
Letter to the President, World Medical Association from Dr. John Lee, President, World Federation of the Catholic Medical Associations, 16 February, 2018 (Accessed 2018-03-01)
5.
Canadian Medical Association.
147th
General Council Delegates' Motions: End-of-Life Care: Motion DM 5-6
(Accessed 2018-05-26).
6.
WMA Resolution on Physician Participation in
Capital Punishment. Adopted by the 34th
World Medical Assembly, Lisbon, Portugal, September/October 1981 and
amended by the 52nd WMA General Assembly, Edinburgh,
Scotland, October 2000 and the 59th WMA General Assembly,
Seoul, Korea, October 2008 (Accessed 2018-06-06).
7.
WMA Statement on Female Genital Mutilation.
Adopted by the 45th World Medical Assembly, Budapest,
Hungary, October 1993 and editorially revised by the 170th WMA
Council Session, Divonne-les-Bains, France, May 2005 and revised by the
67th WMA General Assembly, Taipei, Taiwan, October 2016.
(Accessed 2018-06-03).
8. Blackmer J.
Assisted Dying and the Work
of the Canadian Medical Association. World Medical Association
Journal. 2017 Oct; 63(3):6-9 (Accessed
2018-05-24).
9. Caldwell S.
Dutch euthanasia regulator quits over dementia killings. Catholic
Herald, 23 January, 2018 (Accessed 2018-07-12).
10. Savulescu J, Schuklenk U.
Doctors have
no right to refuse medical assistance in dying, abortion or
contraception. Bioethics 2017;31(3):162-170
(Accessed 2018-06-04).
11. Attaran A. The Limits of Conscientious
and Religious Objection to Physician-Assisted Dying after the Supreme
Court’s Decision in Carter v Canada. Health L Can 2016; 36(3)
86-98.
12. Murphy S. A "uniquely Canadian approach" to freedom of
conscience: Provincial-Territorial Experts recommend coercion to ensure
delivery of euthanasia and assisted suicide.
C2.4. Objecting physicians must act as
critical enablers of therapeutic homicide and suicide (Recommendation 33, p.
44-45).
13.
External Panel on Options for a Legislative Response to Carter v.
Canada, Consultations on Physician Assisted Dying: Summary of Results
and Key Findings - Final Report (15 December, 2015), p. 100.
(Accessed 2017-12-12).
14. College of Physicians and Surgeons of Ontario.
Professional Obligations and Human Rights (March, 2015), p. 5 (Accessed
2018-06-13).
15. College of Physicians and Surgeons of Ontario.
Medical Assistance in Dying (July, 2017) (Accessed 2018-06-13).
16. The
Christian Medical and Dental Society of Canada v. College of Physicians and
Surgeons of Ontario, 2018 ONSC 579 (Can LII), para. 169, p. 33
(Accessed 2018-06-15).
17. The
Christian Medical and Dental Society of Canada v. College of Physicians and
Surgeons of Ontario, 2018 ONSC 579 (Can LII), para. 169, p. 33
(Accessed 2018-06-15).
18. Royal Dutch Medical Association [Koninklijke
Nederlandsche Maatschappij tot bevordering der Geneeskunst (KNMG)].
The Role of the Physician in the Voluntary Termination of
Life. Utrecht, Netherlands:KNMG; 2011 Jun 23, p. 33 (Accessed 2018-05-31).