The public debate about assisted suicide is constantly being argued and reargued in the media, courts, and institutions. Just five years after it last polled its membership on the legalisation of assisted suicide, the Royal College of Physicians (RCP) is going to repeat this task. The principled opposition of the RCP to the legalisation of assisted suicide has been of great significance to the anti-assisted suicide movement. It has also told ill and disabled people that our doctors are present to support us to live, not waiting to end our lives. The fact that the RCP is polling its members so soon after last time is concerning.
When its members were polled in 2014, the majority, 58%, would not participate in ‘assisted dying’. At that time, 44% of members felt the RCP should continue opposing a change in the law to permit assisted suicide, with a further 31% preferring to be “neutral / no stance”. It maintained its position opposing assisted suicide, but that is now up for debate. Based on the results from the last survey, they are likely to move to a neutral position – not because of a shift in opinion, but because of a shift in the questions.
This blog is going to focus primarily on my concerns around process and effect rather than the roots of my opposition to assisted suicide. I want to explore whether the approach the RCP is taking towards polling its members introduces bias into the system. I will also touch on whether direct democracy is the most ethical way of solving these disputes, and finally. I will consider some of the unintended effects that might occur if the RCP shifted from opposition to neutrality. While my opposition to assisted suicide is steadfast, that will not be the focus of this blog. I have discussed the risks to disabled people of legalising it extensively elsewhere (1), (2).
Alterations to the survey questions – introducing bias
Surveys of the members of the RCP in 2006 and 2014 used several similar questions, in order to track the changing opinions of members. The RCP have stated that in their 2019 survey “following feedback from fellows and members, we have slightly altered the questions. The new questions are similar enough to the ones we asked previously that we will be able to track change in opinion over time if it exists, but the most important thing is to know what fellows and members think now.” This statement is not accurate – the alteration to the questions is neither neutral nor slight, and makes it impossible to compare the results of the surveys. The change in language will entail an introduction of bias.
In 2014, members were asked “Do you support a change in the law to permit assisted suicide by the terminally ill with the assistance of doctors?”, while in 2019, they will be asked whether they support “Do you support a change in the law to permit assisted dying?”. This change in terminology is already reflective of a shift in position – with no transparency on how or why this shift was made.
“Assisted dying” is typically the preferred phrase of pro “assisted dying” lobbying bodies such as Dignity in Dying, who maintain that there is a meaningful distinction between this and assisted suicide. Assisted suicide is the term typically preferred by activists opposed to its legalisation. Language and phrasing appear to have a significant effect on populations answering survey questions on this topic. By reframing it from “suicide” to “”dying”, the implication is of the doctor assisting someone in an ongoing natural process, rather than intervening to directly and deliberately end a patient’s life prematurely. This change in language to a softer gentler word will affect the answers people give.
Furthermore the question in 2014 focused on “do you support a change in the law to permit assisted suicide by the terminally ill with the assistance of doctors?” while in 2019, the members are being asked “do you support a change in the law to permit assisted dying?”. The definitions given for “assisted dying” in the consultation document clarify that this refers to terminally ill patients, but that clarification has been removed from the text of the question. The new framing will allow quotes from the results of the survey to be used to support a legalisation far more broad than simply for terminally ill patients.
In 2014 members were asked “What should the College’s position be on ‘assisted dying’ as defined in the RCP’s consultation document.” The options were “In favour“, “Opposed“, and “Neutral/no stance“. In 2019, members are being asked “What should the RCP’s position be on whether or not there should be a change in the law to permit assisted dying?” and the options are “In favour“, “Opposed“, and “Neutral“. The phrasing of the question is different – it is no longer referencing the consultation document to define exactly what “assisted dying” means. This allows the question to be removed from its context and used with a media spin in the future to argue that doctors would support a legalisation far broader than the people answering “In favour” might have intended.
The change in options is also significant. A neutral position, and not taking a stance, are very different things. A neutral position implies members being poised between supporting it and being opposed to it, while not taking a stance suggests that the RCP has chosen to remove itself from having a single firm position in the debate. Members are now forced to select between three active positions in 2019.
These alterations will have an impact on how people respond to the survey. Despite the assertions of the RCP, they make the data on percentage support for various measures broadly incomparable between years. The introduction of such a significant degree of bias through altering the questions is only part of the problem.
Shifting the goalposts
In 2014, the position of the RCP was that the majority position was that taken. In answer to the question “What should the College’s position be on ‘assisted dying’ as defined in the RCP’s consultation document.”, 44% of respondents answered “opposed“, a further 31% answered “neutral/no stance“, and 25% answered “in favour“. This was a clear majority in favour of opposing it, and as a result the RCP maintained its position in opposing assisted suicide.
For the 2019 survey, it has been decided that unless there is a ⅔ majority either in favour of ‘assisted dying’ or opposed to it, the RCP will take a neutral position. This looks fair at first glance – but it is not. It would theoretically be possible for an additional 20% of respondents to oppose ‘assisted dying’, taking the percentage from 44% to 64%, and the RCP still to shift their position closer to that of supporting assisted dying. The change to this decision more-or-less guarantees that the RCP will move to a neutral position.
Here, someone might argue that taking a neutral position or having no stance (which are not the same thing, despite being grouped together in the 2014 question) is not a shift towards assisted suicide. Certainly if the RCP had not had a position on assisted suicide previously then their decision to be neutral unless there was a significant majority in favour of a position would be appropriate. However, as they currently maintain an opposition, a shift towards neutrality is also a shift away from opposition. This potential change in position would be celebrated by advocates of ‘assisted dying’ as another step towards full legalisation.
If the RCP were set on moving the goalposts to require a ⅔ majority to formally support or oppose ‘assisted dying’, it might have been more appropriate to say that they would take no stance without that, rather than that they would take a neutral position. Taking a neutral position is an active shift from opposition towards assisted suicide, while stepping away and not taking an active stance in the debate would have better reflected the disagreements between these camps and the challenges inherent in taking a position.
Democracy in ethics
I have considerable concern about direct democracy as a method of solving ethical and philosophical dilemmas. The debate over assisted suicide is one that goes to the heart of medicine – how do doctors best serve the needs and desires of patients, what may patients ask of their doctors, and whether palliative care truly has the capacity to give patients the lack of discomfort they wish for. However, it also goes to the heart of ethics – choice, autonomy, obligation to act, beneficience, non-maleficience, equity.
One problem with referenda is that the population being polled haven’t had adequate time and energy to commit to understanding all the issues on all sides of the debate. Doctors responding to this consultation may not have had the time to read a considerable amount of material on the implications of their choice. They might not have considered all the issues, and their vote might be easily swayed by emotional considerations.
This is an argument in favour of representative democracy instead of direct democracy, that the population cannot adequately learn everything about a single topic and make a fully informed decision, and thus they elect representatives to whom they delegate that responsibility.
I believe that polling the vast membership of the RCP is not the best way for it to evolve its stance on assisted suicide. A process of seeking consensus is needed when it’s such a contentious issue. As it stands, there is no agreement between competing camps, and the RCP shifting its position following a survey consultation is not going to mend those divisions.
A shift in position from opposition to neutral is not a neutral act. It would embolden activists in favour of assisted suicide to push again for legal change, but it could also have a very real impact on the care patients receive. While a change in RCP position would not change the legal framework under which doctors must operate, it could easily have the effect of subtly changing how doctors face decisions at the end of patient lives. When a doctor is faced with a terminally ill patient in considerable pain and asking about assisted suicide, what dose of opiates should they prescribe, and to what extent does the doctrine of double effect apply.
This could manifest in a process of encouraging leniency in decision-making. The Liverpool Care Pathway identified patients who were actively dying, then focused on their symptom management rather than providing treatments designed to extend life. It was accused of hastening the deaths of patients who might otherwise have survived through sedation and dehydration. It also had a significant impact on elderly people, who feared being put on it.
A change in position could also reduce trust in the doctors on the part of ill and disabled patients. Many disabled people don’t believe the medical system values our lives (often with good reason), and a belief that our doctors were supporting assisted suicide could reduce trust in the treatment they propose.
The change in the framing of the questions and weighting of the results appears designed to legitimise the use of ‘assisted dying’ rather than ‘assisted suicide’, and to force the RCP closer to supporting it. It will be very difficult to compare percentages to the 2014 survey with the significance of the change in the questions, and the results of this survey may have effects beyond the intended one of knowing “what fellows and members think now.”.