The Norwegian Medical Association should continue to oppose assisted dying

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    The Norwegian Medical Association has long taken a clear stance against the legalisation of assisted dying. Recently, the British Medical Association moved to a neutral stance. Is it now time for the Norwegian Medical Association to change its course?

    Illustration: Tiril Haug Johne
    Illustration: Tiril Haug Johne

    In recent years, a growing number of countries have legalised and introduced assisted dying. In Norway, only the Progress Party and the Green Party (as of September 2021) have spoken in favour of evaluating or introducing assisted dying, while the general population has repeatedly shown a positive attitude towards assisted dying in opinion polls (1). You get the feeling that 'assisted dying is on its way', also in Norway, and that it is just a question of time (2). Here we will argue that the Norwegian Medical Association should continue to oppose assisted dying.

    What is the Norwegian Medical Association's view on assisted dying?

    What is the Norwegian Medical Association's view on assisted dying?

    The Norwegian Medical Association has taken a clear stance against the legalisation of assisted dying. Chapter I section 5 of the Code of Ethics for Doctors, which was revised at a meeting of the Executive Board in 2021, confirms that the Norwegian Medical Association remains opposed to assisted dying Box 1). Opposition to assisted dying is deeply rooted among doctors, many of whom cite the Hippocratic oath and its prohibition against prescribing a lethal drug ((3). The Chair of the Medical Ethics Council said in 2015 that assisted dying represents 'the opposite of what doctors are supposed to do' (4).

    Box 1 Code of Ethics for Doctors, Chapter 1 section 5, adopted at the meeting of the Representative Body of the Norwegian Medical Association in 2021.

    Doctors shall not provide euthanasia or assisted suicide, both of which are actions in which the doctor deliberately helps to accelerate the time of death. The limitation of life-sustaining or futile treatment is not regarded as assisted dying because in such cases the patient dies as a result of the underlying illness. The same applies to palliative sedation, where the aim is to control symptoms that cannot be relieved in any other way.

    However, there are doctors both in Norway and internationally who have a positive view of assisted dying. A 2019 study of attitudes among Norwegian doctors showed that 31 % strongly or partially agreed that doctor-assisted suicide should be allowed for those with a terminal illness and short remaining life expectancy (5). A growing number of countries are permitting assisted dying, and ever more doctors are becoming involved in the process as a result. Consequently, in 2019, the World Medical Association altered its stance on assisted dying, adopting a less judgmental attitude to doctors who chose to provide this (6). In September 2021, the British Medical Association decided to abandon its stated opposition to assisted dying and assume a neutral position (7). The decision was justified by opinion polls showing that the majority of British doctors were no longer opposed to assisted dying. It is also claimed that assisted dying is a political issue that society must address through ordinary legislative processes, and that it is not the role of medical professionals to hinder this (8).

    Should the Norwegian Medical Association change its stance?

    Should the Norwegian Medical Association change its stance?

    Should we in Norway follow the same path as the UK? In principle, the Norwegian Medical Association shall represent all its members and their opinions, including those who believe that assisted dying is justified and should be permitted. Should it be up to the representative democracy of the Association to decide what individual doctors can choose to do on the basis of their own convictions? In other bioethical issues, the Association has accepted that society determines the legal framework, and that the job of doctors is to offer the general population the health services that are legally regulated in Norway. According to opinion polls, the population clearly supports assisted dying. Is it right, then, for us to block it?

    Not a neutral issue

    Not a neutral issue

    Each individual case of assisted dying represents a unique, complex and challenging ethical issue in which the relationship between the patient and doctor as well as the surrounding framework determine whether it is seen as right or wrong to provide assisted dying. Even though opinion polls often use stylised, simple cases to elicit opinions, assisted dying practices are, in reality, characterised by grey areas. In contrast, the societal debate on assisted dying is more clear-cut: it concerns saying yes or no to the legalisation of assisted dying. While the individual can 'partially agree' that assisted dying should be allowed, society cannot 'partially' allow assisted dying. The clear yes/no dichotomy of the response options only serves to polarise the debate. What is at stake – life or death – triggers strong emotions and serious consequences. One cannot be neutral when it comes to assisted dying.

    While the individual can 'partially agree' that assisted dying should be allowed, society cannot 'partially' allow assisted dying

    We are of the opinion, therefore, that a 'neutral' stance on assisted dying is a non-position. The legalisation of assisted dying may have a major impact on the doctor's work situation. Experiences from countries that have permitted assisted dying indicate that a large number of practising doctors, and not least GPs, will be exposed to and involved in assisted dying if it is legalised (9). The literature shows that doctors may find this a heavy burden (10–12). Even though it is often taken for granted that Norwegian doctors will be able to reserve the right to refuse to provide assisted dying (13), experience from the Norwegian abortion debate on doctors' reservation rights and from Canada, where assisted dying was legalised in 2016, among others, indicates that such reservation rights will very quickly come under pressure (14).

    What does 'partially agree' mean?

    What does 'partially agree' mean?

    Even though 31 % of Norwegian doctors say they 'strongly agree' or 'partially agree' that physician-assisted suicide should be permitted, the 2019 survey shows that only 9 % 'strongly agree' (5). Similarly, only 9 % of the doctors surveyed said that they would be willing to provide assisted dying if it is permitted in Norway. The 22 % who say they 'partially agree', can just as well be grouped with the 11 % who 'neither agree nor disagree', and the 11 % who say they 'partially disagree'. This may apply to doctors who see arguments both in favour of and against legalising assisted dying, but who have not as yet reached a clear conclusion that Norwegian law, which currently forbids assisted dying, should be changed. These may be doctors who in principle may be open to allowing assisted dying, but who would set requirements for how this could be done in an acceptable fashion. Meanwhile, the survey shows that almost half (47 %) 'strongly disagree' that physician-assisted suicide should be permitted, and even more are opposed to providing euthanasia or assisted dying to people who are not dying.

    The 2019 opinion poll should not be interpreted as meaning that a large percentage of Norwegian doctors actually believe that assisted dying should be introduced in Norway

    We are of the opinion, therefore, that the 2019 opinion poll should not be interpreted as meaning that a large percentage of Norwegian doctors actually believe that assisted dying should be introduced in Norway. Fewer than one in ten are ready to accept assisted dying, almost half are strongly against, and we know little about the opinions of the 40 % in between. In particular, we do not know what criteria would have to be met in terms of patient selection, medical conditions, forms of assisted dying, control mechanisms, rights of reservation etc. that would make assisted dying acceptable to them.

    What form should an assisted dying law take?

    What form should an assisted dying law take?

    Though some doctors are positive to assisted dying and would like to see it introduced in Norway, so far there have been few proposals as to the specific formulation of an assisted dying law. In contrast, the 'no' side can refer to specific legislation, i.e. the prohibition set out in the Norwegian Penal Code (sections 276 and 277) and the Code of Ethics for Doctors, which prohibits doctors from providing assisted dying. If the Norwegian Medical Association were to adopt a more liberal stance to assisted dying, it should be clearly specified what such a change would entail. Should we allow physician-assisted suicide in line with the 'Oregon model' (15), or go for euthanasia in line with the Dutch (16) or Canadian model? Should it apply to terminal patients only, or be independent of remaining life expectancy? Should mental illness rule out assisted dying, or should intractable mental illness rather be an independent indication? What about advance directives for assisted dying in the event of the onset of dementia?

    Clarification of these questions is fundamental if the Norwegian Medical Association is to consider changing its attitude to the legalisation of assisted dying.

    Neutral means more positive

    Neutral means more positive

    The Norwegian Medical Association has been a strong opponent of the legalisation of assisted dying. We believe that this is one of the main reasons why the legislature has not shown interest in making efforts to legalise it. If the Association were to change its stance, e.g. by taking up a neutral position, an important obstacle to legalisation would be removed. We believe that such a shift would be regarded as clearly signalling a more positive attitude to assisted dying among doctors.

    This effect was seen in Canada and the US state of California, both of which legalised assisted dying in 2016 after the national medical association went from opposing assisted dying to a neutral stance (17). We believe that the same philosophy underlies efforts to persuade the British Medical Association to 'go neutral'. This will act as a seismic shift that can result in the national political debate coming down on the side of legalisation.

    This shift in attitude would be acceptable in Norway if it is really what the Norwegian Medical Association and its members want. However, we do not believe this to be the case. A number of opinion polls, and opinions expressed in meetings with our Norwegian colleagues, indicate that opposition to assisted dying is widespread among doctors, not least in those areas of the medical profession that work most closely with severely ill and dying patients. We would warn the Norwegian Medical Association, therefore, against adopting a 'pseudo-neutral' stance to assisted dying, unless its members really want to increase the chances that providing assisted dying becomes a part of Norwegian doctors' everyday life.

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