A growing number of doctors in Norway no longer support the Norwegian Medical Association's view on assisted dying. A number of medical associations internationally have taken a neutral stance. The Norwegian Medical Association should consider doing the same.
In line with changes in public opinion and the growing number of countries legalising assisted dying, a number of medical associations have changed their position on assisted dying, including in Germany and Canada (1, 2) . The British Medical Association recently abandoned its expressed opposition to assisted dying in favour of a neutral stance (3) . This change was based on the fact that the majority of British doctors no longer oppose it. Additionally, assisted dying is an ethical and political issue that the population should be able to take a stand on through ordinary democratic processes. In parallel with these broader changes, the World Medical Association (WMA) has chosen a less judgmental attitude towards doctors who practise assisted dying (4) .
The Norwegian Medical Association has long been a strong opponent of assisted dying, but the number of members supporting assisted dying in one form or another has been growing (5) . In a survey from 2016, 31 % of Norwegian doctors either agreed or strongly agreed that active assisted dying should be allowed for people with a terminal illness and a short life expectancy (6) .
Assisted dying is a multifaceted, complex topic that involves various parties and requires a number of factors to be considered. There are no definitive answers. Experiences from countries that have legalised assisted dying show that its regulation and practice can vary considerably, as can the consequences for patients and healthcare personnel (7) . Some countries have regulated both euthanasia and physician-assisted dying, while others have exclusively regulated variants of physician-assisted dying. There is generally widespread support for assisted dying among doctors in countries where this is practised, and there is no evidence to suggest that the practice is abused or that vulnerable patient groups are pressured into accepting assisted dying (8, 9) . To categorically oppose assisted dying in all potential circumstances and with all real or conceivable forms of regulation is to ignore the complex nature of this serious matter.
To categorically oppose assisted dying in all potential circumstances and with all real or conceivable forms of regulation is to ignore the complex nature of this serious matter
Given the diverse opinions among Norwegian doctors and the political development in the field, we believe it is time for the Norwegian Medical Association to reconsider its categorical position. Our views on assisted dying differ, but we are concerned that opponents in influential positions are drowning out a significant proportion of colleagues with opposing views. For example, in a recent article in the Journal of the Norwegian Medical Association, Siri Brelin and Morten Horn – a member and former member of the Council for Medical Ethics respectively – did not mince their words when cautioning the Norwegian Medical Association against changing its position (10) .
Horn and Brelin are concerned that a more neutral position will remove 'a major obstacle' to legalisation (10) . The 'right answer' is a foregone conclusion for them, and the Norwegian Medical Association's position is a useful obstacle to democratic change processes. However, the Norwegian Medical Association is not, quite rightly, an instrument for opponents of assisted dying with strong opinions; it is a democratic association that is there to represent its members.
Norwegian Medical Association shaping the agenda
Norwegian Medical Association shaping the agenda
The Norwegian Medical Association is also helping shape the agenda of the public discourse on assisted dying. Despite clear support for assisted dying in the general population, politicians are reluctant to put the issue on the agenda. Similarly, few doctors have publicly come forward with a more nuanced position than that of the Norwegian Medical Association (11) . It is not unreasonable to assume that this is partly due to the Norwegian Medical Association's clear support for a total ban. A shift towards a more neutral position will foster openness about assisted dying, which will help highlight the diversity of opinion among doctors and the rest of the population.
A shift towards a more neutral position will foster openness about assisted dying
Some believe it is not possible to take a neutral stance on the issue (10) ; you either support the introduction of assisted dying or you do not. However, we believe that individuals, as well as the organisations that represent them, do not necessarily have to take a clear political stand. Assisted dying is more of an ethical and political issue than a medical issue. It is not the place of the Norwegian Medical Association to obstruct conclusions arrived at by the majority of the population through democratic processes.
It is also not necessary for the Norwegian Medical Association to provide definitive answers to all the questions relating to assisted dying in order to depart from its support for a total ban. If that were the case, the Norwegian Medical Association would also need a clear justification for why a total ban is the best solution, even for competent, suffering patients with a terminal illness and short life expectancy who desperately want to decide how their lives should end. If, however, a bill was presented in the Storting, the Norwegian Medical Association would have to respond to it and submit a consultation statement that reflects the views of its members. Given the international developments in the field, it is presumably only a matter of time before this happens. We hope that the Norwegian Medical Association invites a broad exchange of opinions where all members have the opportunity to be heard. Norway needs an open, sober and informative debate on assisted dying.