The Australian Medical Association (AMA) executive (policy group) recently concluded a major review of its official policy on assisted dying. The last major review was in 2007. Through a deeply flawed process the AMA executive continues to expressly disrespect the diversity of views amongst Australian doctors - a diversity confirmed by its own review - and hasn't altered its opposition to assisted dying in any meaningful way.
Unrepresentative of Australian doctors
The AMA promotes itself as "leading Australia's doctors," yet more than two thirds of Australian doctors (70.5%) are not members. Its executive might like to think it's leading, but most Australian doctors aren't following. Claimed representation is particularly important when it comes to professional medical practice policies, because the AMA behaves as though its policies apply to all Australian doctors.
So who did the AMA consult in conducting its major review of policy on assisted dying? Only its own members. In other words, the AMA claims to represent all Australian doctors, but in reality consulted less than a third of them in the setting of assisted dying policy. As AMA member Dr Rosemary Jones pointed out, some doctors eschew the AMA becauseof its opposed stance towards assisted dying. That creates a key sampling bias in the AMA's study… against assisted dying.
Further, the response rate to its survey of members was around 13%, meaning that only the most engaged AMA members (thus around 4% of all Australian doctors) offered a voice.
There are numerous flaws in the AMA's survey. Here's just one. In the preamble to the questionnaire, the AMA expressly told responding doctors (who, remember, are AMA members and probably don't want to tick off their association) what its official policy on certain end-of-life decisions were. Then, in the first questions, it asked the doctor whether they agreed with the policies: strategies certain to result in substantial confirmation and acquiescence biases.
This just isn't on. As a professional social and market researcher, I sent a detailed critique of the many problems with the survey to AMA President Dr Michael Gannon. I received a courteous but dismissive response from administration. A highly-respected Fellow of the Australian Market & Social Research Society sent a similar critique, also receiving a non-committal reply.
While the AMA hasn't published the survey results in detail yet, key headline statistics have been reported. What did the AMA discover on the basis of a methodology swayed against assisted dying?
- Around four out of ten doctors believe that doctors should be involved in assisted dying cases, while around five out of ten thought they shouldn't. One out of ten had no view either way.
- If assisted dying were legalised, a majority said that doctors should be the ones to do this work.
That's a clear message that a substantial proportion of doctors think assisted dying can not only be legitimate practice, but is the business of the medical profession - at least for those who wish to participate.
And what did the AMA executive make of these important insights after deliberating on them for months? Here are the AMA's previous and 'revised' core policy statements:
Previous (2007) statement
'Revised' (2016) statement
"The AMA believes that medical practitioners should not be involved in interventions that have as their primary intention the ending of a person's life. This does not include the discontinuation of futile treatment."
"The AMA believes that doctors should not be involved in interventions that have as their primary intention the ending of a person's life. This does not include the discontinuation of treatments that are of no medical benefit to a dying patient."
Despite the gratuitous change of a few words after a year of 'research,' the statement remains unchanged.
Doctors and the public have a right to ask, "What part of the evidence that there is a genuine diversity of respectable views, did you miss?"
Failure to respect diversity
The executive might argue that it did listen. Here are its statements about diversity:
Previous (2007) statement
'Revised' (2016) statement
"The AMA recognises that there are divergent views regarding euthanasia and physician-assisted suicide."
"The AMA recognises there are divergent views within the medical profession and the broader community in relation to euthanasia and physician assisted suicide."
Despite an increase in wordiness, this statement too remains unchanged.
The AMA executive says it recognises that there are divergent views, but by continuing to insist that no doctor should be involved in assisted dying, it reveals that it doesn't respect some of them. How does it justify this hubris?
Failure to respect the patient
The revised policy also says in part:
Doctors should … endeavour to uphold the patient's values, preferences and goals of care.
The sting in the policy tail is, given the AMA's wholly opposed stance toward assisted dying, that the doctor should only uphold patient values, preferences and goals of care if the AMA executive approves of them.
Was it a foregone conclusion?
I was unsurprised at the AMA executive's continued opposition to assisted dying. The signals were clear.
While the policy review was in play, AMA President Dr Michael Gannon made a series of tweets and media comments, all unsupportive of or directly opposed to assisted dying. Here's a few.
In response to an article in The Australian "Catholic stance allows eased exit", he tweeted a faux 'competition' between palliative care and assisted dying:
13 Aug 2016: Different views society on assisted dying. Hope all agree improved PalliativeCare access a priority @westaustralian
He also tweeted in support of the 'doctrine of double effect', a controversial policy (which the AMA promotes as uncontroversial) that contends it's quite OK for a doctor to hasten a patient's death after all… provided they don't really mean to: hardly a robust or verifiable standard.
24 Aug 2016: Doctors should be careful, must obey the law and understand their code of #ethics. Double effect is not #Euthanasia
In an article in The Australian on 15th September, Dr Gannon argued against assisted dying on the basis of it being 'extremely complex.' If complexity were a reason to oppose anything, the AMA would be opposed to the entire healthcare system: it's incredibly complex. His argument collapses at the slightest inspection.
18 Sep 2016: Hippocratic medicine older than some of the world's great religions, every political ideology, trend #ethics @medwma
Dr Gannon then invokes the Hippocratic Oath, which bans assisted dying. That's cherry-picking at its best: doctors do not take the Hippocratic Oath: it swears allegiance to ancient Greek gods, forbids women from entering the profession and outlaws surgery, amongst other things.
19 Sep 2016: Agree @DrSallyCockburn admire #euthanasia work done by @CMA_Docs. Equally careful, compassionate, intelligent approach from @TheBMA #ethics
He commends the British Medical Association's "intelligent approach" against assisted dying: an approach I have comprehensively exposedas superficial and ill-informed fear-mongering, fiction, flip-flop and hubris.
1 Oct 2016: It is inevitable that if #Euthanasia laws are passed, they will over time be expanded to include children, mentally ill, vulnerable #ethic
Dr Gannon demonstrated ignorance of basic facts with this remark. In Oregon, which has the world's oldest specific assisted dying framework (in effect since 1997), there have been no changes in who may qualify. He also ignores peer-reviewed research showing no 'slippery slope' for the supposed 'vulnerable'. Canadian Professor Harvey Chochinov, Chair of his government's expert panel which investigated legislative options for assisted dying, confirmed the lack of this 'slippery slope' in a keynote address at Swinburne University last week.
11 Nov 2016: Doctors maintain this Trust with everyday care for patients, by upholding #DeclarationOfGeneva @medwma @juliamedew @Rania_Spooner #ethics
He also claimed that assisted dying would erode patient trust in doctors, at odds with the fact that people's trust in doctors is high amongst OECD countries with assisted dying laws. Indeed, trust in doctors amongst Dutch, Belgian and Swiss citizens is significantly higher than Australians' trust in our own doctors.
During the review period, Dr Gannon also repeatedly promoted the (medical) Declaration of Geneva (e.g. see previous tweet), which states that doctors must not participate in assisted dying. If the Declaration's canonical opposition was indeed the authoritative stance on assisted dying, then why would it be relevant for the AMA to conduct a review process of its policy?
Declining to correct misinformation
In September, the Medical Journal of Australia (MJA: a wholly-owned subsidiary of the AMA), published a news report containing significant misinformation. It painted a negative and hostile picture about assisted dying in Belgium. I published a critique of why the opinion was wrong, and commented on the online MJA article with a link to my correction. The MJA promptly deleted my comment.
AMA member Dr Rosemary Jones then put up the same objection, which they couldn't delete because it was from a member. The MJA then responded, but only to dig in its heels to defend the misinformation and reveal even more serious flaws in its information and logic.
I wrote a further research-backed analysis of why its defensive arguments were even more wrong than the original and posted a note and link on the original MJA article page (Figure 1). Once again, my post has been deleted.
Figure 1: The second post on MJA insight which was subsequently deleted.
The result of this is that erroneous information about Belgium remains published on the MJA site as though it is correct, while failing to mention or acknowledge that it has been soundly refuted.
It's disappointing that the AMA and its President continue to make such uninformed remarks given that Dr Gannon claims to be a stickler for scientific evidence:
18 Aug 2016:Being a doctor is a huge privilege. Also carries responsibility to provide accurate scientific info, act ethically.
Spotlight on the AMA
Doctors and the public have a right to ask legitimate questions of the AMA. Firstly, what was the likelihood of a real change to the AMA's entrenched opposition toward doctor participation in assisted dying?
Secondly, given the AMA's entrenched opposition, how can it expect its demands to be consulted about any potential law reform to be treated seriously? If assisted dying is nothing to do with doctors, why is what doctors think relevant?
Utterly resistant to change?
At its 2016 AGM, AMA member Dr Harry Hemley noted that the AMA largely represented its more hard-core, long-term older members and warned of the AMA's increasing irrelevance and impotence. He moved an urgency motion to commission a review and report with "recommendations for a plan, vision and determination that will lead to re-invigorating and sustaining the AMA."
Figure 2: Dr Harry Hemley speaks to his urgency motion to investigate organisational reform
Note that the motion wasn't in relation to an actual or particular reform, but merely to investigate reform and to provide a strategic report for consideration.
The motion was defeated. The future doesn't look rosy for the AMA.
The AMA is deeply out of touch with Australians on the issue of assisted dying. It represents fewer than a third of Australian doctors and has failed to respect the very range of perspectives it obtained by consulting its members. It further strains its credibility by insisting that doctors must not be involved in assisted dying, yet demanding to be consulted on any law reform to permit it.
If the AMA is to become relevant to contemporary society it must move on from the 'old boy' approach to medicine and adopt a stance of neutrality toward assisted dying. Only neutrality will demonstrate respect for the true range of respectable views amongst Australian doctors.