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II.    PROPOSALS FOR CHANGE

II.1    Oslo: April, 2015

Policy revision survey

II.1.1    On 5 February, 2015, the WMA Secretariat sent a memo to members seeking their opinions about the need to revise policies adopted or last revised in 2005, including the policies on euthanasia and assisted suicide.  18 national associations replied, though not all with respect to every policy.  Of the 18 respondent associations, 15 recommended reaffirmation of the euthanasia policy and 14 recommended reaffirmation of the assisted suicide policy.  Only the Netherlands, Taiwan and Canada recommended changes.1

II.1.2    Unsurprisingly, the Royal Dutch Medical Association (RDMA) recommended major revision of both euthanasia and assisted suicide policies.  The Taiwan Medical Association (TMA) recommended major revision of the euthanasia policy, but reaffirmation of the Statement on Physician Assisted Suicide (though it later affirmed both policies: III.3.4). The Canadian Medical Association (CMA) recommended reaffirmation of the Declaration on Euthanasia, but a major revision of the physician assisted suicide policy, suggesting that the WMA "may wish to adopt a more nuanced approach to this issue."1

Ethics Committee meeting: reaffirm policies

II.1.3    Dr. Jeff Blackmer of the CMA was present at the meeting of the WMA Medical Ethics Committee in Oslo on 17 April, 2015.  The CMA was not a member of the Committee; Dr. Blackmer was there by virtue of his position as a WMA facilitator.2  However, during discussion of the survey results, the CMA (presumably Blackmer) "offered to write an alternative paper addressing these complex issues," (i.e., euthanasia and assisted suicide).  In fact, CMA officials were hardly in a position to be offering expert advice on euthanasia and assisted suicide to the WMA, given its own undeveloped and unstable position on the issues at the time (B10.10-18). The offer was not accepted, nor was it recorded in the minutes of the meeting because "the CMA, not being a member of the MEC, could not submit a motion and such proposal had not been moved by a committee member."3  Consistent with the results of the survey, the Committee recommended that the Declaration on Euthanasia and the Statement on Physician Assisted Suicide be reaffirmed.2

Council meeting: physician assisted suicide policy discussed, reaffirmed

II.1.4    38 national associations were represented at the WMA Council meeting the next day.  The Canadian delegation consisted of seven members, including Dr. Blackmer and past CMA President Dr. Louis Francescutti.  There were two Royal Dutch Medical Association representatives and three from Taiwan.  The Canadian delegation was among the four largest; Japan, Norway and the USA each fielded nine representatives.4

II.1.5    The Declaration on Euthanasia was reaffirmed.5  However, the Royal Dutch Medical Association representative, Professor van der Gaag, selected the policy on assisted suicide for individual consideration.  Noting that there had been "increased public discussion" of the subject and policy changes allowing it in some circumstances, he argued that it was important for physicians "to engage in discussion of the issue rather than simply reaffirming the WMA Statement."  Responding to contrary remarks from a German representative, he said that, even where physician assisted suicide was legal, "very few people make use of the option."6

II.1.6    Dr. Francescutti of the CMA warned that "by ignoring public opinion physicians would not serve their patients well."

He described impending legal changes in Canada prompted by public pressure to allow physician-assisted suicide, which led the CMA to rule that, regardless of the new expected legislation, physicians should be allowed to follow their conscience. He also commented on the need for good palliative care.6

II.1.7    A Polish representative spoke against assisted suicide, but WMA President, Dr. Xavier Deau (France), while observing that physicians have a duty to preserve life and accompany dying patients (good palliative care being essential), countered that "physicians are answerable only to their own conscience and should not be blind and deaf to the wishes of patients."  He added, "The WMA should adjust policies in accordance with the progression of ideas in society, failing which it will lose credibility."7

II.1.8    Prof. Montgomery (Germany) suggested that the Statement on Physician Assisted Suicide be reaffirmed, and that the RDMA develop a paper on the subject for future discussion.  Dr. Blackmer (CMA) "expressed his disappointment at the reluctance to discuss this issue," offering to support the RDMA in preparing the paper.7

II.1.9   Dr. Pälve (Finland) commented that public attitudes favourable to assisted suicide had generated discussion in Finland, but physicians remained unwilling to carry it out.  Dr. Yokokura (Japan), noting that "dying with dignity" had been discussed at length in Japan, emphasized the importance of discussion "to identify a clear way forward."  Similarly, Dr. Jorge (Brazil) stressed the WMA's role in finding "consensus and an international voice for the medical profession," welcomed the discussion prompted by the RDMA, and suggested changing WMA procedures to facilitate such developments.7

II.1.10    This was opposed by Dr. Dearden (Britain), who noted that national associations had already agreed to reaffirm the statements, which, he argued, "should reflect the international physician community, rather than changes occurring in a few countries."  He observed that it would be contrary to WMA procedures for Council to solicit papers at that stage, and moved that the Council should reaffirm the statement as recommended by the Medical Ethics Committee.7  

II.1.11    Dr. Blackmer argued that only 16 of 111 members had responded to the survey, and that some members of the Medical Ethics Committee who recommended reaffirming the statement "may simply have gone along with the suggestion of the Secretariat."7,8 He added that decisions that seemed clear had, in the past, sometimes been amended following discussion.  Dr. Dearden repeated his motion, pointing out that it did not exclude members from developing new papers.7

II.1.12    Past WMA President Dr. Johnson cautioned participants about the need to adhere to established procedures to retain the confidence of WMA members.  Dr. Mungherera (Uganda) reminded Council that many African countries had the death penalty, and warned that it might be undesirable to revisit policies at the behest of individual national associations when ethical standards have already been established by the WMA.7

II.1.13    Prof. van der Gaag (Netherlands) referred to the CMA's offer during the Medical Ethics Committee meeting to prepare an alternative paper, but the Secretary General explained that the offer was not considered part of the discussion, since the CMA was not a member of the Ethics Committee (II.I.3).9

II.1.14    Council then reaffirmed the Statement on Physician Assisted Suicide and approved the Ethics Committee report, but Dr. Bernard, the CMA representative, protested that the policy review process "excluded discussion."  He asked for a review of procedures by the WMA Executive Committee.10

CMA implies withdrawal from WMA over physician assisted suicide

II.1.15    Near the end of the Council session, Dr. Blackmer spoke at length to express his disenchantment with the WMA.11  He noted that the CMA was undergoing a major review of its operations, and that he was now questioning the value of its continued commitment to participation in the WMA. He complained that "considerations of geographical balance" had prevented the election of a CMA candidate as Chair of the Socio-Medical Affairs Committee.12

Dr Blackmer stated that his comments were not connected with the loss of the election, but rather deep concern about other, more important issues, such as a failure to focus on substantive issues of concern to the physicians of the world. He described the discussion on the topic of physician-assisted suicide as showing that the organisation is unwilling to discuss difficult issues or take into account the views of other countries or the public. He stated that, "if we cannot discuss controversial issues with an open mind, the WMA is not serving its members or patients and risks becoming irrelevant or obstructive."

Dr Blackmer described the past few days as disappointing and shared the view of his delegation that fundamental changes are needed within the WMA.11

II.1.16    In closing, Dr. Blackmer said that the CMA delegation would report on the Council meeting to the CMA Executive and Board and solicit the opinions of CMA members "on how their dues should be used with respect to international engagement and global membership." He promised to update the Council on this point at the next meeting in Moscow.11  His remarks clearly implied that the Canadian Medical Association might withdraw from the WMA because of its unwillingness to reconsider its position on physician assisted suicide. 

II.2    Moscow: October, 2015

II.2.1    At the Medical Ethics Committee meeting, the Secretary General said, "An international discussion is taking place on end of life care and euthanasia and the WMA should also enter this debate."  He added that the WMA would organize a session on the subject at the Bioethics, Medical Ethics and Health Law Conference in Naples the following month.  Although not a member of the Committee, and not listed among the participants, Dr. Jeff Blackmer reported that the CMA and RDMA were preparing a paper on "end of life care and assisted dying" and would present it in 2016.13 

II.2.2    The report of the Medical Ethics Committee, including the above information, was accepted by the Council without comment.  There is no record that Dr. Blackmer provided an update on the CMA position vis-á-vis membership in the WMA, although he may well have discussed it privately with others while in Moscow.14

II.3    Buenos Aires: April, 2016

II.3.1    In February, 2016, Canada and the Netherlands submitted a paper to the WMA Secretariat proposing reconsideration of WMA positions on both euthanasia and assisted suicide, summarized as follows:

Several jurisdictions in Europe, North America and South America have legalized certain forms of assisted dying under specific conditions. In these cases, such legalization has been a result of extensive legislative processes, court decisions and debate in society. In all of these locales, some physicians have agreed to provide euthanasia or assistance in dying out of compassion for their patients, in order to alleviate intractable and hopeless suffering.

It is suggested that the WMA should no longer condemn physicians who want to follow their own conscience in deciding whether or not to participate in these activities, within the bounds of the legislation, in those jurisdictions where euthanasia and/or physician assisted dying are legalized.15

II.3.2    The second paragraph of the summary is noteworthy because it is very similar to the resolution proposed by the CMA executive and adopted by the CMA General Assembly in August, 2015.  On the basis of this resolution (which was described as a neutral position), the CMA executive later affirmed both euthanasia and assisted suicide as legitimate forms of medical treatment (Appendix "B").  The substance of the CMA/RDMA proposal will be considered in Part V.

II.3.3    The document was presented by the RDMA to the Medical Ethics Committee at its meeting in Buenos Aires in April.  A CMA representative (not identified in the record) explained the background and development of the proposal.  The Committee discussed the proposal and recommended that it be circulated for comment by national associations.16

II.3.4    Dr. Jeff Blackmer and Dr. Louis Francescutti were part of the Canadian delegation at the Council meeting the following day.  In introducing the subject, the RDMA admitted that it was "very controversial" and suggested that the circulation of the CMA-RDMA proposal be delayed for at least a year "to allow for additional open discussion and exchange of information and ideas, possibly through workshops organized as part of WMA meetings and regionally by NMAs."17

II.3.5     During discussion, the Council considered how such workshops or meetings might be organized.  It was suggested that the CMA-RMDA proposal be circulated to national associations to inform discussion at meetings and workshops, and a suggestion that a working group should be formed to address it.  It was agreed that the matter be referred to the Executive Committee to develop plans responsive to the ideas proposed during the Council meeting.  The RDMA and CMA withdrew the proposal, so it was not circulated to national associations.17

II.4    Taipei (October, 2016)

II.4.1    The Secretary General reported in October on the plans made by the Executive Committee concerning the policies on euthanasia and physician assisted suicide; the latter is referred to in the Medical Ethics Committee report as "physician assisted dying."  He reported that a first workshop would be hosted by the Brazilian Medical Association for the Latin America region, and that it was hoped that the African and Asian regions would organize similar gatherings.18  The subject was not discussed at the October Council meeting, but Prof. Rutger Jan van der Gaag (RDMA) told the Council that the Junior Doctors Network held a meeting on end-of-life care that was "very respectful and dignified," the format of which might be used at the regional meetings.19

Notes

1.  World Medical Association. MEC 200/Policy Review/Apr2015: Classification of 2005 Policies on Medical Ethics.

2.  World Medical Association. MEC 200/Report/Apr2015: Report of the Medical Ethics Committee, 17 April, 2013, p. 1.

3.  World Medical Association. Council 200/Minutes/Apr2015: Minutes of the 200th Council Session, 16 and 18 April, 2015 [Council Minutes (18 April 2015) ] p. 9.

4.  Council Minutes (18 April 2015), p. 19, 21.

5.  Council Minutes (18 April 2015), p. 7, section 8.1.3.2.

6.  Council Minutes (18 April 2015), p. 7, section 8.1.6.

7.  Council Minutes (18 April 2015), p. 8, section 8.1.6.

8.  The minutes state, "Dr Blackmer pointed out that only 16 out of 111 members had responded and suggested that some may simply have gone along with the suggestion of the Secretariat."  Since the reference to 16 out of 111 members pertains to the circulation of the survey, and the Secretariat did not make any suggestions in requesting feedback, "some" must refer to members of the Medical Ethics Committee, since the Secretariat did suggest reaffirmation to the Committee.

9.  Council Minutes (18 April 2015), p. 9, section 8.1.6.

10.  Council Minutes (18 April 2015), p. 9, section 8.1.5.

11.  Council Minutes (18 April 2015), p. 17-18, section 10.7.

12.  One of the three committees responsible for WMA operations; the other two are the Medical Ethics Committee and the Finance and Planning Committee.  An American had been elected Council chair, which apparently prevented the election of someone else from North American as Chair of the Socio-Medical Affairs Committee.

13.  World Medical Association. MEC 201/Report/Oct2015: Report of the Medical Ethics Committee (14 October, 2015), p. 2.

14.  World Medical Association. Council 201/Minutes/Oct2015: Minutes of the 201st Council Session, 14 and 16 October, 2015.

15.  World Medical Association. MEC 203/Euthanasia-Physician Assisted Dying/Apr2016: Proposed WMA Reconsideration of the Statement on Euthanasia and Physician Assisted Dying (February, 2016).

16.  World Medical Association. MEC 203/Report/Apr2016, Report of the Medical Ethics Committee (29 April, 2016), p. 3.

17.  World Medical Association. Council 203/Minutes/Apr2016, Minutes of the 203rd Council Session (28 and 30 April, 2016), p. 6-7.

18.  World, Medical Association. MEC 204/Report/Oct2016: Report of the Medical Ethics Committee (19 October, 2016), p. 2

19.  World Medical Association. Council 204/Minutes/Oct2016: Minutes of the 204th Council Session (19 and 21 October, 2016), p. 13.