Abstract

For decades, the World Medical Association (WMA) has held that euthanasia and physician assisted suicide are unethical and must be condemned by the medical profession, notwithstanding acceptance of the practices in some jurisdictions.

In 2015, the Canadian Medical Association (CMA) and Royal Dutch Medical Association (RDMA) argued that the World Medical Association should change this policy.  The following year they submitted a proposal to the WMA Council setting out the changes they wished to see.  After discussion, the proposal was withdrawn with a view to encouraging discussion of the subject among national associations.  Four conferences subsequently held in WMA regions in Asia-Oceania, Latin America, Africa and Europe demonstrated overwhelming opposition to euthanasia and assisted suicide, and no appetite for the procedures outside Europe and the European diaspora.  The subject is to be considered again at the 2018 WMA ethics conference in Iceland.

The CMA/RDMA have reintroduced the proposal with some revisions.  It will be considered at the WMA Medical Ethics Committee meeting in October, 2018.  As it is likely that the CMA and RDMA will continue to lobby for a change in WMA policy on euthanasia and assisted suicide, an associate WMA member asked the Protection of Conscience Project to review and comment on the CMA/RDMA proposals.

The Project does not take a position on the acceptability of euthanasia or assisted suicide.  From the perspective of the Project, legalization of euthanasia or assisted suicide or a change of WMA policy against the procedures is of concern only to the extent that legalization or change threatens to disadvantage or punish physicians who refuse to do what they believe to be wrong.

The proposal's opening disclaimer of non-support for euthanasia and assisted suicide is meaningless rhetoric contradicted by other elements of the proposal.  In particular, it recommends that physicians or other health care providers should perform euthanasia and assisted suicide where they are legal. If accepted, the C/RDMA proposal would be fully effective in encouraging legalization of euthanasia and assisted suicide and physician participation in both practices.

Further, the proposal posits a right to euthanasia and assisted suicide that is unrestricted with respect to eligibility criteria and other conditions under which they might be provided.  For example, it does not limit provision of the procedures to terminal illness, does not preclude the procedures as a response to mental illness, disability, or chronic medical conditions, and does not require access to palliative care as a prerequisite.  It does not limit provision of the services to adults: adolescents, children and infants are not excluded.

Legalization in accordance with the C/RDMA proposal would thus expose the overwhelming majority the world's physicians represented by WMA members to demands that could generate serious conflicts of conscience and ultimately place those unwilling to provide or cooperate in providing the services in serious professional jeopardy.

The protection of conscience provisions are unclear and fail to adequately consider the issue of complicity. They do not afford sufficient protection for objecting physicians, especially in light of the increased probability of conflict due to the virtually unrestricted scope of the proposal.  The provisions are not well-grounded and internally inconsistent. Finally, they are contradicted by RDMA, thus bringing into question the credibility of the proposal as a whole.

Notwithstanding warnings that the WMA will "lose credibility or become "irrelevant" if it does not act quickly to change its policies, the duty to exercise due diligence is especially important when the power of the state is likely to be invoked against physicians who refuse to be parties to homicide and suicide.  This has been demonstrated clearly in Canada, where the CMA acted precipitously and without adequate reflection or foresight in reversing its policy against euthanasia and assisted suicide.

The WMA should not change its policy on euthanasia and physician assisted suicide without first establishing a sound and robust policy to protect physician freedom of conscience.  This cannot be accomplished within the narrow perspective afforded by controversies about particular morally contested procedures.  The Project recommends, instead, a general, stand-alone policy on freedom of conscience based upon a broad and principled approach that recognizes that freedom of conscience serves the fundamental good and dignity of the physician as a human person, not merely professional autonomy or independence.

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TABLE OF CONTENTS

I.    BACKGROUND

• I.1    The World Medical Association
• I.2    WMA policy on euthanasia and physician assisted suicide
• I.3    Minimum standard for changing WMA ethics policies
• I.4    Advocacy for change
• I.5    Timeline for change
  • I.5.1    Standard policy change
  • I.5.2    Changing bylaws to effect policy change
• I.6    Changing policy in other national associations

II.    PROPOSALS FOR CHANGE

• II.1    Oslo: April, 2015
  • Policy revision survey
  • Ethics Committee meeting: reaffirm policies
  • Council meeting: physician assisted suicide policy discussed, reaffirmed
  • CMA implies withdrawal from WMA over physician assisted suicide
• II.2    Moscow: October, 2015
• II.3    Buenos Aires: April, 2016
• II.4    Taipei (October, 2016)

III.    REGIONAL WMA CONFERENCES

• III.1    Summary
• III.2    Latin America: Rio De Janeiro (March, 2017)
• III.3    Oceania and Asia: Tokyo (September, 2017)
• III.4     Europe: Vatican City (November, 2017)
  • Overview
  • Canadian Medical Association representation
  • Euthanasia and assisted suicide
  • Protection of conscience
  • Euthanasia and the Nazi regime
• III.5     Africa: Abuja (February, 2018)

IV.    MEETINGS AND NEW PROPOSALS

• IV.1    MEC and Council meetings (April, 2017)
• IV.2    MEC and Council meetings (October, 2017)
• IV.3    Canada and Netherlands on "assisted dying" in WM Journal (October, 2017)
  • Euthanasia in the Netherlands
  • The Work of the Canadian Medical Association
• IV.4    MEC and Council meetings (April, 2018)
• IV.5    New proposal re:  "Policy Consistency" (3 July, 2018)
• IV.6    CMA & RDMA introduce revised EAS proposal

V.    2018 WMA ETHICS CONFERENCE, ICELAND

• V.1    Organizers
• V.2    Programme

VI.    CONTENTS OF THE CMA/RDMA PROPOSAL

• VI.1    Introduction
• VI.2    Related WMA policies
• VI.3    Preamble
  • VI.3.1    Irrelevant or uncontroversial assertions
  • VI.3.2    Rights claims
  • VI.3.3    Assertion of need
  • VI.3.4    Conflict between euthanasia/assisted suicide and medical practice
  • VI.3.5    Palliative care not a prerequisite for euthanasia/assisted suicide
• VI.4    Recommendations
  • VI.4.3    The WMA does not support/does not condemn
  • VI.4.4    Physician freedom of conscience
  • VI.4.5    Palliative care

VII.    ANALYSIS OF THE CMA/RDMA PROPOSAL

• VII.1    Overview
• VII.2    Foundational statement
  • VII.2.1    Rhetorical disclaimer
  • VII.2.2    Foundational statement applied to capital punishment
  • VII.2.3    Foundational statement applied to female genital mutilation
  • VII.2.4    Virtually unlimited and evolving criteria
• VII.3    Palliative care
• VII.4    Physician freedom of conscience
  • VII.4.1    Referral, participation and complicity
  • VII.4.2    The obligation to ensure access
  • VII.4.3    Commitment to euthanasia/assisted suicide, not conscience
• VII.5    Arguments
  • VII.5.1    Introduction
  • VII.5.2    Rights claims
  • VII.5.3    Patient priority
  • VII.5.4    Moral/ethical uncertainty
  • VII.5.5    Pragmatism
  • VII.5.6    Lack of consensus
  • VII.5.7    Non-proliferation
  • VII.5.8    Proportional rarity
  • VII.5.9    Diversity and culture
• VII.6    Conclusions
  • VII.6.1    Foundational statement, palliative care, protection of conscience
  • VII.6.2     Arguments

VIII.    STRATEGY AND TACTICS

• VIII.1    Strategy for change
• VIII.2    Tactics
  • VIII.2.1    Incrementalism
  • VIII.2.2    From suicide to euthanasia
  • VIII.2.3    From "The WMA does not support" to physicians should perform
  • VIII.2.4    From "last resort" to optional treatment
• VIII.3    The need for due diligence

IX.    PROJECT RESPONSE

• IX.1    Preliminaries
• IX.2    The issue
• IX.3    Relevant considerations
  • IX.3.1    Most physicians refuse
  • IX.3.2    Physician obligation to provide or facilitate medical treatment
  • IX.3.3    Rights claims
  • IX.3.4    Likelihood of conflict
• IX.4    Response to the issue

X.    PROJECT RECOMMENDATION

• X.1    Conscience in the medical profession
• X.2    A broad and principled approach
• X.3    Avoiding authoritarian "neutrality"
• X.4    A stand-alone general protection of conscience policy

APPENDIX "A"
WMA GENERAL ASSEMBLY AND POLICY DEVELOPMENT

• A1.    General Assembly
  • General Assembly documents
  • General Assembly rules of procedure
  • Voting in the General Assembly
  • Secret ballots
  • Delegate registration
• A2.    Policy Development
  • Submitting ideas for policy development
  • Accessing on-line WMA working documents, procedural guides, etc
  • Joining committees

APPENDIX "B"
CMA APPROVAL OF EUTHANASIA AND ASSISTED SUICIDE

• B1.    Canadian Medical Association (CMA) General Council (August, 2013)
• B2.    CMA Board decides to shape the debate and the law
  • The decision
  • Shaping the debate and the law: in brief
• B3.    CMA Board revises euthanasia and assisted suicide policy (December, 2013)
  •  CMA studies euthanasia & assisted suicide (January-June, 2014)
  • CMA announces plan to intervene in Carter v. Canada (April, 2014)
• B4.    CMA applies for intervener status in Carter v. Canada (June, 2014)
• B5.    CMA Board resolution on euthanasia and assisted suicide (June-July, 2014)
• B6.    CMA General Council (August, 2014)
  • Briefing materials
  • Adoption of resolution on freedom of conscience (19 August, 2014)
• B7.    CMA officials comment (August-September, 2014)
• B8.    CMA intervention in Carter v. Canada
• B9.    CMA Board approves euthanasia and assisted suicide (December, 2014)
  • Policy against euthanasia and assisted suicide reversed
• B10.    Effects of the policy change
  • A  blank cheque for the Supreme Court
  • A professional obligation to kill
  • A limit on refusing to kill
  • Other foreseeable unforeseen consequences
  • Physician freedom of conscience
• B11.    Postscript

APPENDIX "C"
2016 and 2018 C/RDMA PROPOSALS COMPARED

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I. BACKGROUND

I.1    The World Medical Association

I.1.1     The World Medical Association (WMA) is comprised of 115 national medical associations (constituent members)1 that are "broadly representative of the physicians in their countries," which are "not subject to, or controlled by, any office or agency of government."2

I.1.2    In addition, individual physicians may become associate members. The associate members form a group analogous to a national association. They may vote in an Annual Associate Members Meeting and, through their chosen representatives, participate (but apparently not vote) in the WMA General Assembly.2 The associate members' group may also be consulted by standing committees and the WMA executive about policy development.

I.1.3     The WMA is organized in six regions: Africa, Asia, Europe, Latin America, North America and the Pacific.3 Its working languages are English, Spanish and French.

I.1.4     The WMA Council is the executive of the organization, the members of which are elected every two years by the WMA General Assembly. Members of the Council are drawn from the six WMA regions.3 The Council meets twice yearly, in the spring and in autumn. After the Council meeting in autumn, delegations from all constituent members assemble in the General Assembly, "the supreme decision-making body of the WMA."4

I.1.5     The WMA has three standing committees: Medical Ethics, Finance and Planning, and Socio-Medical Affairs.3

I.1.6     The Secretary General of the WMA is the chief executive officer of the organization and the head of the Secretariat, full time administrators in Ferney-Volataire France.3

I.1.7    The WMA General Assembly is the governing body of the Association, responsible for approving permanent WMA policy.  It meets annually in the fall.  The power of national associations is determined by the number of their members.  Each association is permitted one vote for every 10,000 members, but must be present at the Assembly to vote; proxy votes are not allowed.5 (See Appendix "A" for more information on the General Assembly and policy development.)

I.2    WMA policy on euthanasia and physician assisted suicide

I.2.1    The WMA issued a Declaration on Euthanasia in 1987, reaffirming it in 2005 and 2015:

Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient's own request or at the request of close relatives, is unethical. This does not prevent the physician from respecting the desire of a patient to allow the natural process of death to follow its course in the terminal phase of sickness.6

I.2.2    The WMA Resolution on Euthanasia, originally adopted in 2002, was reaffirmed with a minor revision in 2013.7  The Declaration and Resolution are now identical.

I.2.3    The WMA Statement on Physician Assisted Suicide was made in 1992 and reaffirmed in 2005 and 2015:

Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically. However the right to decline medical is a basic right of the patient, and the physician does not act unethically even if respecting such a wish results in the death of the patient.8

I.3    Minimum standard for changing WMA ethics policies

I.3.1    In order to ensure that its ethical policies reflect a consensus among its members, the WMA insists that new or revised ethics policies must be accepted by a vote of at least 75% in the General Assembly.9 

I.3.2    This is a WMA bylaw10 that can be changed by a 2/3 majority vote in the General Assembly, subject to the following conditions:

• The amendment must be received by the General Secretariat at least three months before the meeting at which it will be considered (apparently the Council meeting), though the Council may waive the limit.
• The amendment must be translated into the three WMA official languages and distributed to delegates before the (Council) meeting.
• The Council will transmit the amendment to the General Assembly with a recommendation for approval, non-approval or amendment.11

I.4    Advocacy for change

I.4.1    The Collectif des Médecins Contre L'Euthanasie (Physcians' Alliance Against Euthanasia), a Canadian physicians' organization, responding to Dr. Blackmer's tweets from the Vatican, criticized CMA attempts to change WMA policy:

Why has Dr. Blackmer not taken a more balanced approach, which would truly reflect the unease felt by Canadian doctors about euthanasia, and show greater respect for physicians in other countries, whose views and circumstances are often very different from our own? How in short, can any spokesperson of the CMA legitimately presume to leverage the unwilling acquiescence of Canadian doctors, confronted with an unpleasant legal reality, into a positive mandate to promote the ethics of euthanasia on the international stage ?12

I.4.2     Notwithstanding such criticism, the efforts of the CMA and RDMA to change WMA policy (III.4.11), are understandable.  Both associations and their members who provide or facilitate euthanasia or assisted suicide are currently denounced by WMA policy for unethical conduct.  However, both associations believe that euthanasia and physician assisted suicide can be provided by physicians without contradicting the norms of medical ethics.  Dr. Blackmer, responding to the Collectif, explains:

[W]e support the rights of our members to decide whether or not to participate, based on their moral conscience and the parameters set forth in law and regulation. This is the position we use to advocate at the WMA and elsewhere. . .

. . . It is up to individual physicians in Canada to decide whether or not they will provide this service, and many who opt not to will do so because they do not believe it is ethical, for religious reasons or otherwise.

Given that the CMA supports fully the rights of physicians who do elect to participate, we would not then turn around and condemn them as being unethical when they do so. This is the official position of the CMA. It was arrived at as part of an open and transparent process and debate. It is the position we will continue to promote in Canada and internationally.

The WMA has a policy that condemns any physician who participates in assisted dying as being, by definition, unethical. For obvious reasons, the CMA finds this position extremely problematic, since it labels hundreds of Canadian physicians as being unethical for participating in a legal activity with the support of their medical organizations.13

I.4.3     From the CMA/RDMA perspective, the WMA is mistaken in opposing the procedures and opposing physician participation.  In these circumstances, their continued lobbying is to be expected, as they believe that WMA policy is unjust.  They will likely be joined by other national medical associations that adopt similar positions.  It is also likely that the CMA will repeat its threat to quit the WMA if the WMA does not withdraw its condemnation of euthanasia and assisted suicide; it is not inconceivable that the RDMA might do the same.

I.4.4    The tactic could be used to force change by threatening to split the WMA and deprive it of income and support from influential quarters.  At this stage, such threats are likely tactical bluffs.  The CMA derives considerable prestige and influence from its position as a founding member of the WMA in addition to beneficent, humanitarian and professional motivations for involvement.  As long as it believes that it can succeed in changing WMA policy, it is doubtful that it would sacrifice all of these advantages and interests by quitting the organization.      

I.5    Timeline for change

I.5.1    Standard policy change

I.5.1.1    Standard WMA procedures appear to preclude any change to WMA policy on euthanasia and assisted suicide at the General Assembly in the fall of 2018 (Appendix "A").  However, that does not prevent a motion being proposed to give some kind of direction to the Executive Council on the subject.

I.5.1.2     The CMA/RDMA proposal introduced in Buenos Aires in April, 2016 was withdrawn during the Council meeting, so it was not scrutinized by national associations (II.3).  It was revised and reintroduced in July, 2018 and is scheduled for discussion at the Medical Ethics Committee meeting on 3 October, 2018.14  Unless the meeting is rescheduled, it will precede the major ethics conference presentations on euthanasia and assisted suicide on 4 October (V.2).  Hence, a decision by the Ethics Committee concerning the proposal will not be informed by the proceedings at the ethics conference.

I.5.1.3     The Council and General Assembly will meet following the ethics conference.  It seems likely that the CMA and RDMA their supporters will argue that the proposal should be circulated to national associations for comment, so that the document and feedback could be considered by the Medical Ethics Committee and Council at their regular meetings in April, 2019.  Approval by the Council at that stage would mean that a change in policy could be debated was early as October at the 2019 WMA General Assembly in Tbilisi, Georgia. 

I.5.1.4    A new proposal by a nominally unaffiliated group of associate members (IV.5) is arguably an ethics policy because it would allow exceptions to WMA ethics policies.  It has yet to be approved by associate members.  It if is approved in October, 2018, it is unlikely to be considered by the Medical Ethics Committee and Council before the spring of 2019.  If it continues through the development process, it seems unlikely the proposal would reach the General Assembly before the fall of 2020.

I.5.2    Changing bylaws to effect policy change

I.5.2.1    Under current rules, the euthanasia and assisted suicide policies cannot be changed unless the change is approved by a vote of at least 75% in the annual General Assembly (I.3).  Constituent members may have more than one vote, corresponding to the size of their associations: one vote per 10,000 members, but must be present to vote (I.1.7).  Nonetheless, the results of the regional meetings indicate that the CMA and RDMA will find it very difficult to reverse the existing consensus against euthanasia and assisted suicide, which is essentially what would be necessary if their proposal (or a revised version of it) is to be approved.

I.5.2.2    If the consensus cannot be reversed, it remains possible to change the standard by which consensus is established.  For example, it could be argued that new policies should be approved by a lesser percentage or simple majority; revisions to existing policies should be approved by a lesser percentage or simple majority; existing policies should be revoked if, upon challenge, they are not sustained by a vote of at least 75% (i.e., they no longer meet the standard of consensus).

I.5.2.3    Changes to the standard by which consensus on ethical policy is established can only be made by amending WMA bylaws (I.3.2).  It is possible that such a change might be discussed formally or informally during the ethics conference in Iceland, and an amendment submitted to Council in time for the 2019 General Assembly.  In that case, one would expect submission of the CMA/RDMA proposal to be delayed until 2020, as attempting to change both the bylaw and the euthanasia/assisted suicide policy at the same Assembly would be more likely to be identified as a coordinated tactic, potentially provoking opposition that could defeat both measures.

I.6    Changing policy in other national associations

I.6.1    While it is possible that the CMA and RDMA could attempt to change the WMA consensus standard in order to secure a change of euthanasia/assisted suicide policy, doing so would require more time, energy and resources and would have to overcome resistance within the WMA.  Further, there is no guarantee of success.

I.6.2    Rather than continuing to work solely within the WMA structure, the CMA and RDMA could attempt to change euthanasia and assisted suicide policy within other national associations, especially those with larger memberships that have more votes at the General Assembly.  This could be done in parallel with lobbying within the WMA and would complement and support it, since it would secure votes needed to make the WMA policy change.  Moreover, it may be easier to change policy in national associations, which may not be impeded by obstacles like a 75% level of approval for changes to ethics policies.

I.6.3    The most promising targets for this approach would be associations in Europe and the European diaspora where there is an appetite for euthanasia and assisted suicide, especially  in Australia, New Zealand and the United States.  All of the elements of the strategy described above could be applied to lobbying within national associations.

I.6.4    There are strong public lobbies in Australia, New Zealand and the United States in favour of legalization.  The Royal New Zealand College of General Practitioners has already adopted an approach to legalization of euthanasia and assisted suicide similar to the CMA/RDMA proposal.15 Since Vermont, Washington, Oregon, California Washington D.C. and Colorado have legalized assisted suicide, the American Medical Association (AMA) is increasingly susceptible to an appeal to lack of consensus as a reason to change its policy.  Moreover, it appears that the majority of the AMA House of Delegates is now in favour of assisted suicide, and may be prepared to reverse AMA policy against the procedure next year.16

I.6.5    CMA and RDMA officials can do some lobbying at the executive level of other national organizations, at least informally.  However, it would be more appropriate and more productive to support members of other national associations in their internal lobbying.  For example, CMA members of the Canadian Association of MAID Assessors and Providers could connect with like-minded members in other national associations, and members of other national associations could invite CMA officials to make presentations at meetings, including national association assemblies.

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Notes

1.    World Medical Association. Members List [Internet]. [Cited 2018 Sep 28].

2.    World Medical Association. Members: Who can be a WMA member?  [Internet]. [Updated 2018; cited 2018 Sep 28].

3.    World Medical Association. Structure [Internet]. [Updated 2018; cited 2018 Sep 28].

4.    World Medical Association. What we do - events [Internet]. [Updated 2018; cited 2018 Sep 28].

5.    World Medical Association.  Articles and Bylaws of the World Medical Association [Internet]. [Updated 2016 Oct; cited 2018 Sep 28]. ["WMA Bylaws"] Chapter 4, Section 6 (A). 

6.  World Medical Association. Declaration on Euthanasia [Internet]. 2015 Apr [Cited 2018 Sep 28].

7.  World Medical Association. Resolution on Euthanasia [Internet]. 2013 Apr [Cited 2018 Sep 28].

8.  World Medical Association. Statement on Physician Assisted Suicide [Internet]. 2015 Apr [Cited 2018 Sep 28].

9.   Williams JR.  Medical Ethics Manual [Internet]. 3rd ed. World Medical Association;2015  [Cited 2018 Sept 28] p. 25.

10.  WMA Bylaws, Chapter 4, Section 6 (C).

11.  WMA Bylaws, Chapter X.

12.    Canada before the World Medical Association: Representation, or Misrepresentation?  [Internet]. Collectif des Médecins Contre L'Euthanasie; 2018 Jan31 [Cited 2018 Sept 28].

13.    Blackmer J.  Letter from Dr. Jeff Blackmer, Vice President, Medical Professionalism, Canadian Medical Association, to Physicians' Alliance Against Euthanasia [Internet]. Collectif des Médecins Contre L'Euthanasie; 2018 Apr 30 [Cited 2018 Sep28].

14.    World Medical Association.  MEC 210/Agenda/Oct2018: Agenda of the Medical Ethics Committee.

15.    Malloy T.  Letter to the Justice Commitee on the End of Life Choice Bill [Internet]. Royal New Zealand College of General Practitioners; 2018 Mar 6 [Cited 2018 Sep 28].

16.    Recker J.  AMA to review its stance on physician-assisted suicide.  Chicago Sun Times, 11 June, 2018 (Accessed 2018-06-11).