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In my previous post I wrote about why we (including the media) should pay less attention to the pronouncements of the AMA on voluntary assisted dying, and instead look at organisations that better represent the population/s for which they speak. While there’s a general belief that the AMA represents most, or at least many, doctors, that’s far from true. Even taking that into account, however, the AMA’s stated position on behalf of its members isn’t as representative as it appears.

In 2015, the AMA (Federal) announced that it would review its policy on ‘euthanasia and doctor-assisted suicide’ , which had previously been unremittingly negative – a position that had, in turn, affected the willingness of politicians and the public alike to support various incarnations of assisted dying legislation. The review process, which concluded in 2016, included an online survey in which 3700 members participated. The conclusion? The AMA continues to oppose any legislation around assisted dying, but wants its members involved should such legislation come to pass.

A logical assumption from this is that the majority of AMA members, if not Australian doctors in toto, oppose voluntary assisted dying. But Neil Francis of Dying for Choice analysed the review process, in a fascinating report titled AMA Uncovered,  in which he examines design flaws that encouraged desired responses, on the analysis of results, and on the way the survey was selectively publicized to justify the policy. The full report runs to 50 pages, but I’ve summarised what I see as the key aspects to take into account when assessing the AMA’s ‘revised’ position.

Doctors often underestimate the severity of patient symptoms but want significantly less medical end-of-life care for themselves. Nearly nine out of ten USA doctors would not want intensive end-of-life treatment they provide to others. Yet patient death, despite its inevitability, is often regarded by doctors as a ‘failure’ of medicine, with many still uneasy even about withholding and withdrawing life-preserving interventions. – p.15

There are three main areas to appreciate about the original report, as unpacked by Francis.

First, the data comes from an opt-in survey that captured just over 3,700 AMA-affiliated doctors; as the AMA represents just under 30% of Australian medical practitioners, respondents to the survey represent 12% of AMA membership, and only 3.6% of Australian doctors.

What the methodology variations suggest is deeply-entrenched hostility towards assisted dying that has flowed through to substantial biases is the survey design. These in turn will result in significantly more negative responses toward assisted dying in later questions than if the AMA’s policy had been revealed later in the questionnaire, after doctors had been asked their attitudes about various facets of assisted dying. – p. 21

Second, the survey is multiply flawed, a fact that was brought to the AMA Executive’s attention and dismissed.  The most important of these flaws are briefly listed below:

  • the way questions are worded means responses are less likely to be genuine reflections of respondents’ beliefs and more likely to be weighted toward an anti-assisted dying response (see p. 16 of the critique for specific analysis)
  • the survey omits suffering or intolerable pain from its definition of euthanasia/assisted dying
  • the survey definition of euthanasia/assisted dying includes neither voluntariness or competence, both of which are key requirements
  • some established life-limiting practices (withholding/withdrawing treatment, the doctrine of double effect) are defined as separate to euthanasia/assisted dying
  • the introductory statements prime participants to lean towards then-current, anti-euthanasia/assisted dying policy
  • multiple questions presuppose a response in the framing of the question (e.g. “Do you agree…” or “To what extent do you agree…”
  • the first two questions separate ‘good medical practice’ and ‘clinically appropriate’ treatment when they’re dependent components of appropriate professional practice
  • similar, often successive, questions are differently constructed for no apparent reason
  • at least one question rolls two aspects of euthanasia/assisted dying together: being compelled to participate in the practice and (if unwilling) being compelled to refer a patient to another practitioner
  • Third, despite these significant methodological flaws, Francis notes these outcomes, which don’t correlate with the AMA’s ‘revised’ position:

  • 68% of respondents agreed suffering can’t always be relieved with even optimal palliative care
  • 60% want doctors to perform lawful assisted dying (i.e. be involved if it’s legislated)
  • just over half of those (32% of respondents) were prepared to be involved
  • 52% said this is a legitimate intervention
  • 50% disagreed with the AMA policy against E/AD “under any circumstances”
  • over half of 20-29 year old respondents agree with euthanasia/assisted dying, compared with a third of those 70+
  • when a question was reframed to ask about legalized euthanasia/assisted dying, approval rates jumped, indicating some resistance is because of illegality, not the act itself
  • 35% of respondents thought euthanasia/assisted dying should be lawful
  • A couple of additional notes:

  • Swiss, Dutch, and Belgian populations rank in the top 3 when it comes to trust in doctors (Aus is tenth); they have AD laws
  • the AMA has published and not corrected information about E/AD that they know is false, including that palliative care deteriorated in Belgium; the opposite is true
  • despite claims by many opponents, including AMA President Dr. Gannon, there has been no slippery slope targeting minors, incompetent people, or the vulnerable, in any jurisdiction (see pp. 31-32)
  • an overwhelming majority of Australian doctors (SA: 89%, Vic 93%, NSW: 96%) believe patient suicide can be rational

 

Many Australian doctors don’t believe that the law is as important as medical and family consensus when making such decisions, and are inclined to ignore the law anyhow. – p. 19

Finally, and worryingly, it seems as though much of the opposition to or concern about this legislation is that a sizeable proportion of doctors don’t want this practice legalized. From the report, Francis notes that:

  • complementary research demonstrates 25% of Aus MDs support E/AD but don’t want it regulated/performed with oversight!
  • a significant proportion of doctors already deliberately assist patients to die, with neither protection of law nor, necessarily, patient consent
  •  

    In a 2006 study “25% doctors were not opposed to euthanasia itself yet were opposed to its legalisation. In other words, a quarter of doctors thought ‘private’ euthanasia practice acceptable, but didn’t want the practice legalised.” The researchers said this was “in significant part due to ‘the resistance of doctors to further intrusion by the law and bureaucracy on their clinical and professional autonomy.’” – p. 25

    I leave you with this observation by Francis, which should be particularly alarming for all of us (including opponents to voluntary assisted dying) who champion voluntariness, competence, and consent:

    Francis 1Francis, p. 39