VII.    ANALYSIS OF THE CMA/RDMA PROPOSAL

VII.1    Overview

VII.1.1    The CMA/RDMA proposal would replace existing WMA policies against euthanasia and physician assisted suicide.  The principal elements of the recommended policy are a foundational statement, a protection of conscience provision and statements on palliative care.

VII.1.2    The assertion in the foundational statement that "[t]he WMA does not support or sanction" the procedures is meaningless rhetoric.  The document actually requires the WMA to affirm that physicians should provide euthanasia and assisted suicide in the document if they are legalized.

VII.1.3    Statements about palliative care are unremarkable.  The recommendations do not require access to or the unsuccessful application of palliative care as a prerequisite for euthanasia or assisted suicide.  Euthanasia and assisted suicide are not to be considered exceptional treatments of last resort.

VII.1.4    The provision concerning physician freedom of conscience does not adequately address the issue of complicity or moral responsibility, is unclear with respect to the meaning of participation, and provides inadequate protection for those who refuse to collaborate in providing or facilitating access to the procedures.  The recommendation that physicians should provide euthanasia and assisted suicide undermines an assertion that they should not be made responsible for ensuring access to the procedures.  The provision does not reflect a developed understanding of the subject and is actually contradicted by the RDMA.

VII.1.5     A number of arguments advanced in support of the proposal are addressed following discussion of the principal elements of the policy. These can be contested on their own terms, or are persuasive only to the extent that one accepts the contested assumptions underlying them.

VII.2    Foundational statement

VII.2.1    Rhetorical disclaimer

VII.2.1.1    The core element in the foundational statement appears in the penultimate sentence in 2018C/RDMA §9 (VI.4.13), italicized below:

9. . . .The WMA does not support or sanction euthanasia or physician assisted death, but also does not condemn or label as unethical those physicians who follow their own conscience in deciding whether or not to participate in these activities, within the bounds of applicable legislation, in those jurisdictions where euthanasia and/or physician assisted death are legalized and follow a person's voluntary and well-considered request. (Emphasis added)

Attitudes toward euthanasia and physician assisted death are evolving and are a matter of individual conviction and conscience that should be respected.

VII.2.1.2    The opening disclaimer (underlined) has merely rhetorical force.  It is contradicted by 2018C/RDMA 11, which states that euthanasia and physician assisted suicide should be performed by competent physicians or health care providers where the procedures are legal.

VII.2.1.3    The practical significance of the C/RDMA proposal can be assessed by applying its recommendations to the WMA Resolution on Physician Participation in Capital Punishment and the WMA Statement on Female Genital Mutilation.

VII.2.2    Foundational statement applied to capital punishment

VII.2.2.1    The WMA Resolution on Physician Participation in Capital Punishment states:

VII.2.2.2    Rewritten according to the C/RDMA proposal:

VII.2.3    Foundational statement applied to female genital mutilation       

VII.2.3.1    The resolution on capital punishment does not address the ethics of execution, but only physician participation.  A closer parallel to policies on euthanasia and assisted suicide is provided by the WMA Statement on Female Genital Mutilation,2 which condemns both the practice and physician participation.  Once more applying recommendations from the CMA and RDMA:

VII.2.3.2    These comparisons demonstrate that the foundational statement's assertion that the WMA "does not support or sanction" euthanasia or assisted suicide is meaningless, while the withdrawal of disapproval would be fully effective in encouraging legalization of euthanasia and assisted suicide and physician participation in both practices. Taken as a whole, were the WMA to accept the proposal it would affirm that the procedures are consistent with medical ethics if provided in response to a "voluntary and well considered request." 

VII.2.4    Virtually unlimited and evolving criteria

VII.2.4.1    According to the proposal, apart from legality, voluntariness and sufficient reflection are sufficient to justify the provision of euthanasia and assisted suicide. It imposes no other conditions or restrictions on the procedures. It does not require that requests be contemporaneous with provision of the services, so it permits euthanasia and assisted suicide for incompetent patients (including dementia patients, stroke victims, etc.) based upon voluntary and well considered requests made in an advance directive drawn up before they became incompetent,  Acceptance of the proposal by the WMA would support euthanasia and assisted suicide in such cases, and for non-terminal chronic conditions or disabilities, for adolescents, children and infants, and for forms of mental illness or psychological disorders that do not compromise medical decision making capacity.

VII.2.4.2    Consistent with this, 2018C/RDMA §9 also commits the WMA to unconditional respect for evolving attitudes toward euthanasia and assisted suicide.  As attitudes evolve, so do criteria for the procedures.  All evidence to date demonstrates that the evolution is exclusively in the direction of expanded access. and the context of the recommendation suggests that this is the meaning intended. Thus, the unconditional commitment to respect evolving attitudes translates into an unconditional commitment to support euthanasia and assisted suicide for any reason and under any circumstances deemed sufficient in law.

VII.3    Palliative care

VII.3.1    The foundational statement is complemented by unremarkable statements about palliative care. However, the revisions warrant attention.  The proposal states that palliative care is part of good medical care "when it is available" - a qualification added in 2018 (VI.3.5).  The 2016 proposal stated that euthanasia and assisted suicide should never be substitutes for palliative care (2016C/RDMA §10); this has been softened to "not."  Finally, the single restrictive element in the 2016 proposal has been deleted (struck out below):

12.  The WMA also calls on all members to work to ensure access to high quality palliative care services for those in need. Euthanasia and physician assisted death should not be a substitute for palliative care. but should be seen as a last resort for those whose intractable and hopeless suffering cannot be alleviated through any other ordinary means.

VII.3.2    By striking out the restriction, the CMA and RDMA demonstrate that they do not believe that euthanasia and assisted suicide should be last resorts in alleviating otherwise uncontrollable suffering, and do not want such a restriction imposed by the WMA.

VII.3.3    The revisions support the view that access to effective palliative care is not a prerequisite for euthanasia and assisted suicide.  When palliative care is not available (and it is not available in most parts of the world, including most parts of Canada), euthanasia and assisted suicide would not be substitutes, but the only treatments available, and therefore acceptable.  When palliative care is available, the removal of the "last resort" restriction makes clear that euthanasia and assisted suicide remain options, not substitutes. WMA acceptance of the proposal would thus support the provision of euthanasia and assisted suicide as ordinary forms of medical treatment.

VII.4    Physician freedom of conscience

VII.4.1    Referral, participation and complicity

VII.4.1.1    The main protection of conscience provision has been revised to reduce the scope of protection for referral (red text below), and it distinguishes between participation and referral (underlined below).

10. No physician should be forced to participate in euthanasia or assisted death against their personal moral beliefs. Equally, no physician should be forced to refer a patient to another physician in order to provide assistance in dying.

VII.4.1.2    The CMA and RDMA recommend that physicians should be protected only from being forced to refer directly to someone willing to provide euthanasia or assisted suicide.  This seems to imply that only direct referral to an EAS provider is a matter of concern (since no other kind of referral is mentioned) and that even direct referral does not constitute participation.

VII.4.1.3    In any case, the provision does not preclude compulsory referral to physicians for consultations preliminary to lethal injection by someone else, nor does it preclude compulsory referral to service delivery coordinators whose main function is to ensure access to euthanasia and assisted suicide.  Many objecting physicians consider such referrals to be unacceptable.  The provision does not protect them.

VII.4.1.4    Leaving aside the uncertainty about what the CMA and RDMA intend by the distinction between referral and participation, the provision does not adequately address the issue of complicity or moral responsibility, which is the basis for concern about referral and other forms of facilitation or participation, such as the falsification of death certificates.3

VII.4.2    The obligation to ensure access

VII.4.2.1    The proposal requires the WMA to affirm that physicians or health care provider should perform euthanasia and assisted suicide where the procedures are legal. On the other hand, it states, "Physicians, individually or collectively, must not be made responsible for ensuring access," and insists that the state "must provide mechanisms that will ensure access" to the services (2018C/RDMA §11, VI.4.4.3).

VII.4.2.2    Insistence that physicians must not be made individually or collectively responsible for ensuring access is most welcome, but it is easier said than done, especially within the recommended policy framework.

VII.4.2.3    Physicians are generally understood to have an obligation to provide or ensure access to medical treatment when it is required.  In accepting the proposal, the WMA would recognize euthanasia and assisted suicide as medical treatments that should be provided by physicians. It would thus be difficult for the WMA to insist that physicians do not have an individual or collective obligation to provide them, and the state may not be receptive to their arguments.  The CMA initially accepted such an obligation when it declared euthanasia and assisted suicide to be forms of end-of-life-care, and this has had serious adverse consequences for objecting physicians in Canada.4,5

VII.4.3    Commitment to euthanasia/assisted suicide, not conscience

VII.4.3.1    The protection of conscience provisions of the proposal are not underwritten by WMA policies about freedom of conscience and do not reflect a developed understanding of the subject.  The only explicit reference to conscience occurs in a recommendation to unconditionally respect evolving attitudes toward euthanasia and assisted suicide (VII.2.4.2). The context suggests that this is intended to maximize expansion of the services, not safeguard physician freedom of conscience.

VII.4.3.2    The broader the criteria for euthanasia and assisted suicide, the more likely conflicts of conscience are likely to occur. Since the proposal imposes virtually no restrictions on the criteria or circumstances under which euthanasia and assisted suicide may be provided, it maximizes the likelihood of conflict.

VII.4.3.3    Moreover, in practice, the protection of conscience provisions will face significant opposition.  For example, the recommendations about referral and responsibility for access have been rejected by Canada's largest medical regulator:

The College of Physicians and Surgeons of Ontario took the position that physicians who object to physician-assisted dying requests have a positive obligation to make an effective referral. An effective referral, as described by the Ontario College, is a referral made in good faith to a non-objecting available and accessible physician, other health care professional, or agency. The College noted that the medical community has an obligation to ensure access and that conscientious objection should not create barriers.6

VII.4.3.4    This is, in fact, the position of the RDMA.  Absolutely contradicting the recommendation it purports to support, the RDMA demands that Dutch physicians unwilling to kill patients or help them commit suicide or assisted suicide have "a moral and professional duty" to help them find a colleague willing to do so  - even though Dutch law does not require it (IV.3.6, IV.3.7 ).  This demonstrates that the RDMA is primarily committed to ensuring access to euthanasia and assisted suicide, even at the expense of physician freedom of conscience.  The contradiction brings the credibility of the entire proposal into question.

VII.4.3.5    To sum up, the protection of conscience provisions in the proposal are unclear about the relationship between participation and referral.  They fail to adequately consider the issue of complicity, and thus 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 recommendation that physicians should not be responsible for ensuring access to euthanasia and assisted suicide is at odds with the recommendation that they should provide the services.  The provisions are not well-grounded; certainly the rationale supporting them is unarticulated.  They are actually rejected by one of the co-authors of the proposal. 

VII.5    Arguments

VII.5.1    Introduction

VII.5.1.1    Having established what the proposal actually entails, it is necessary to consider the arguments offered to convince the WMA to accept it. With the exception of rights claims, these are not found in the document but have been advanced elsewhere.

VII.5.1.2    The analysis here is not concerned with the morality or acceptability of euthanasia and assisted suicide. Such questions are outside the scope of the Project’s interests. The point here is to demonstrate that the arguments fail on their own terms, or are persuasive only to the extent that one accepts the contested assumptions underlying them.

VII.5.2    Rights claims

Argument

VII.5.2.1    The sole justification offered for the change is that patients "must be free to decide for themselves what treatments they want and the manner and circumstances of their death and may not be forced to die in ways they would not wish" (VI.3.2). On this view, refusal to provide or help to arrange for euthanasia or assisted suicide is a denial of human rights and perhaps constitutional rights - precisely the view of many EAS supporters in Canada.

Response

VII.5.2.2    This justification, proposed as self-evident, actually consists of contested autonomy based rights claims that have grave implications for physicians, inasmuch as they can be understood to imply a professional obligation to kill (VI.3.2.3 , B10.5). If the WMA accepts the C/RDMA proposal it would affirm these contested rights claims, disenfranchise those who hold contrary views, and provide significant support for coercive legislation and policies.

VII.5.3    Patient priority

Argument

VII.5.3.1    Patient priority, autonomy, and the importance of compassion for patients are widely understood to be central to medical practice. The CMA's Dr. Francescutti alluded to this when he warned the WMA Council that they "would not serve their patients well" by refusing to heed public opinion about assisted suicide. (II.1.6; see also Dr. Blackmer, II.1.15)

VII.5.3.2    Physicians who, for reasons of conscience, refuse to provide or refer patients for euthanasia and assisted suicide are callous, selfish, disrespectful, judgemental and unprofessional.

Response

VII.5.3.3    Even if one accepts principles of patient priority, autonomy and the importance of compassion, these can be understood in different ways. It does not follow that one must conclude that euthanasia and assisted suicide are morally/ethically acceptable.

VII.5.3.4    Physicians who object to euthanasia and assisted suicide for reasons of conscience reasonably refuse to anything that would entail unacceptable moral complicity, including support, encouragement or referral. In this they act no differently than colleagues confronted with demands to participate in or facilitate what they believe to be wrong, such as executions by lethal injection or female genital mutilation.

VII.5.4    Moral/ethical uncertainty

Argument

VII.5.4.1    Physicians who do not object to euthanasia and assisted suicide may be uncomfortable providing them. Others may be uncertain about the ethics of the procedures. These physicians may wish to resolve their discomfort or uncertainty in favour of patients clearly seeking the services and physicians willing to provide them.

VII.5.4.2    Other physicians who consider euthanasia and assisted suicide are immoral may also believe that they can avoid unacceptable complicity in the procedures by referring patients to a willing colleague. Alternatively, they may be doubtful about the ethics of referral.

VII.5.5.3    All of these physicians would be willing to refer patients to colleagues who seem to be motivated by compassion and other patient-centred principles traditionally associated with medical practice.

VII.5.4.4    Current WMA policy is unfair not only because it condemns physicians who provide euthanasia, but because it impedes physicians who do not object to connecting willing patients with willing colleagues. Adopting the proposal would simply nullify the condemnation and allow physicians to do what many are willing to do.

Response

VII.5.4.5    The argument depends either on the moral/ethical acceptability of euthanasia and assisted suicide or upon moral/ethical uncertainty about the procedures. However, those who reject euthanasia and assisted suicide for reasons of conscience can produce cogent arguments to support their position, and the disagreement or uncertainty of others is not evidence that their position is doubtful.

VII.5.4.6    Like individual physicians (VII.5.3.4) if the WMA finds euthanasia and assisted suicide ethically unacceptable, it acts consistently and reasonably — not unfairly — if it maintains a policy against the procedures and refuses to do anything that would entail unacceptable moral complicity, including support or encouragement.

VII.5.5    Pragmatism

Argument

VII.5.5.1    Positions for and against euthanasia and assisted suicide, when firmly held and rationally defended, usually rest upon different interpretations or concepts of rights, patient priority, autonomy, compassion, beneficence, non-maleficence, justice, solidarity, respect or reverence for human life and other principles. In the absence of agreement about underlying principles and concepts, disputes about the morality of euthanasia and assisted suicide are difficult or impossible to resolve to everyone’s satisfaction. Dr. Blackmer calls this the problem of intractability (IV.3.13-14).

VII.5.5.2    "[T]he way forward," he says, "is not to engage in further debate on the rightness or wrongness of assisted dying,"7 but, as CMA President Dr. Chris Simpson put it, to  "[move] away from a yes-no dichotomy, as to whether assisted dying should be legalized toward a more balanced and nuanced discussion."8 (See also II.1.2)

Response

VII.5.5.3    While urging the WMA to take this path forward, Dr. Blackmer does not say where the path leads.  Dr. Simpson suggests it leads to "a more balanced and nuanced discussion," but does not say what the discussion is about.  The answer is found in an editorial in the Canadian Medical Association Journal: Physician-assisted death: time to move beyond Yes or No.  "Whether or not physicians individually or collectively agree with physician-assisted death," wrote the authors, "[it is time for the "yes" or "no" debate to give way to a constructive dialogue about policies and guidelines for legal physician-assisted death," including such things as eligibility, consent, equitable access, effective methods, and the obligations of conscientious objectors.9

VII.5.5.4    In other words, the CMA and RDMA want moral and ethical debate about physician participation in euthanasia and assisted suicide to end, and practical discussion about how physicians should provide the services to begin. Contrary moral/ethical beliefs are simply ignored. Dr. Blackmer's "way forward" is to nullify continued opposition on moral/ethical grounds.  Dr. Simpson provides balance and nuance to the "yes" or "no" debate by eliminating the "no." This exemplifies what Project Advisor Jay Budziszewski calls "bad faith authoritarianism . . . a dishonest way of advancing a moral view by pretending to have no moral view."10

VII.5.5    In this case, "unreflective" is arguably more fitting than "dishonest."  Certainly, without reference to ethics of some sort, the WMA cannot follow Dr. Blackmer's advice to decide how to respond to legalization of physician assisted suicide and euthanasia.  The CMA did not set ethics aside when it purported to unite the Canadian medical profession behind the view that euthanasia and physician assisted suicide can be legitimate forms of medical treatment (B9.) - hardly an ethically neutral viewpoint.  Later the CMA did, indeed, delete references to ethical and even medical criteria from its policy on euthanasia and assisted suicide,11 but this means only that the CMA has chosen the law as its ethical standard, not that it has dispensed with ethics altogether.

VII.5.6    Lack of consensus

Argument

VII.5.6.1    To secure approval of the resolution upon which it based the reversal of CMA policy against euthanasia and assisted suicide, the CMA executive stressed the lack of agreement among Canadian physicians with respect to the procedures (B2.4, B5.6). 

VII.5.6.2     At the European regional end-of-life conference, Dr. Blackmer took note of Professor Urban Wiesing’s assertion that there is no consensus on the ethics of physician assisted suicide and euthanasia (III.4.20).  Dr. Blackmer has since cited lack of consensus in suggesting that objecting physicians should support the right of colleagues to provide euthanasia and assisted suicide.12 (Prof. Weising will be speaking at the WMA ethics conference in Iceland on Good Conduct of Physicians.) 

VII.5.6.3    The Preamble of the CMA/RDMA proposal notes that physicians in some countries are legally providing the services (VI.3.3.1), obviously because they do not agree with the WMA position. 

Response

VII.5.6.4     The claim that current WMA policy does not reflect a consensus and should be replaced by the proposed C/RDMA policy is untenable for three reasons.

VII.5.6.5    First: even if there were no consensus in favour of current WMA policy against euthanasia and assisted suicide, there is no consensus in favour of the proposed C/RDMA policy supporting the procedures. If lack of consensus is fatal to one, it is equally fatal to the other.

VII.5.6.6    Second: as the four regional meetings on end-of-life care demonstrated, there is a consensus within the WMA that euthanasia and assisted suicide are morally/the four regional meetings on end-of-life care demonstrated, there is a consensus within the WMA that euthanasia and assisted suicide are morally or at least ethically unacceptable ethically unacceptable (III.1.2).  The CMA and RDMA can argue, at best, that some physicians in some countries disagree with WMA. The mere existence of disagreement does not disturb the consensus and does not warrant a change of policy. 

VII.5.6.7     Finally: WMA ethics policies are based, not on lack of consensus, but upon a consensus identified by 75% approval (I.3).  The CMA and RDMA may eventually succeed in gaining that level of support for their proposal, but, in the meantime, an appeal to a purported lack of consensus is specious.

VII.5.7    Non-proliferation

Argument

VII.5.7.1    The CMA and RDMA claim that they are not attempting to change the policies or practices of other national associations, but only protecting their own members (III.4.3, III.4.11).

VII.5.7.2    The proposal is presented as a kind of neutral option that does not require the WMA to support euthanasia or physician assisted suicide, does not involve significant change, and would affect only physicians legally providing the services by relieving them of accusations of unethical conduct.

Response

VII.5.7.3    The argument that changing WMA policy would have not significant influence on the policies of national associations would make sense only if WMA policies actually have no significant influence. Surely, however, they do, and are meant to, and that is why the CMA and RDMA are going to great lengths to convince the WMA to accept euthanasia and assisted suicide They cannot reasonably believe that the WMA condemnation of euthanasia and assisted suicide carries weight only in Canada and the Netherlands.

VII.5.7.4    As comparisons with analogous changes to WMA policies on female genital mutilation and capital punishment indicate (VII.2.2, VII.2.3) what is sought by the CMA and RDMA is a major change that would have repercussions in other national associations, just as a similar shift in CMA policy in Canada was widely seen as a "sea change" with tremendous implications (B7.11).

VII.5.7.5    The C/RDMA proposal is not ethically neutral. Notwithstanding the opening disclaimer, which is a bare and inefficacious rhetorical assertion, it would have the WMA formally adopt the position that euthanasia and assisted suicide are consistent with medical ethics and, where legal, should be provided by physicians or health care providers (VI.4.4.3, VII.2.3.2).

VII.5.7.6    The change in position signified by the foundational statement would have worldwide implications because it would entail a meaningful ethical shift by an international opinion leader.  It could reasonably be expected to influence physicians, other healthcare workers, the public and lawmakers around the world in favour of euthanasia and assisted suicide. Moreover, the completely unrestricted nature of the foundational statement would encourage legalization and practice of euthanasia and assisted suicide on the broadest possible terms(VII.2.4).

VII.5.8    Proportional rarity

Argument

VII.5.8.1 Only a minority of physicians — sometimes a very small minority — are involved in euthanasia and assisted suicide even where they are legal (VI.3.4.2), and euthanasia and assisted suicide deaths account for a small percentage of deaths from all causes.  In Quebec, for example, 98.9% of all deaths in 2017 were not the result of euthanasia or physician assisted suicide.13

VII.5.8.2    The CMA/RDMA have suggested that euthanasia and assisted suicide are and will remain exceptional practices (II.1.5), provided in extreme circumstances (VI.3.3.1).  From the perspective of those doubtful about the wisdom of changing WMA policy, this seems reassuring. 

Response

VII.5.8.3    While Quebec statistics are correct, it is also true that the number of 2017 euthanasia deaths in Quebec would have emptied about one quarter of the beds in Johannesburg's Chris Hani Barargwanath Hospital, the third largest hospital in the world,14 and was more than ten times the number of non-medical homicides reported in the province the previous year.13  Whether all of this is good news or bad news from a public policy, social, medical or political perspective depends upon one's ethical/moral view of euthanasia — which the CMA says should be set aside (VII.5.5).

VII.5.8.4    Regardless of the significance one attaches to such statistics, two points must be noted.  First, since everyone dies, every physician in general practice and many in other specialities may be confronted with a demand for euthanasia or assisted suicide.  Hence, legalization of the procedures does not impact only the physicians directly involved, but the entire medical profession, especially entire fields of practice like oncology and palliative care, as well as medical education and other health care professions.  Second, since relatively few physicians are directly involved in the practices, legalization leads to demands that physicians and others must collaborate in providing the services in order to ensure patient access, even if doing so violates their moral, ethical or religious beliefs (IV.3.6 , B10.19).

VII.5.9    Diversity and culture

Argument

VII.5.9.1    A new policy proposal drawn up by a nominally unrelated group of associate members recommends that WMA ethical policies should accommodate national association ethical policies that are "clearly generated by benevolence toward patients"(IV.5).

VII.5.9.2    Euthanasia and assisted suicide are always justified as expressions of benevolence, so the WMA should "allow for" physician participation in euthanasia and assisted suicide in Canada, the Netherlands and other countries.

VII.5.9.3    Similarly, drawing from the current draft revision of the Declaration of Oslo, the C/RDMA proposal asserts that, as is the case with abortion, the willingness of some physicians to provide euthanasia and assisted suicide is simply reflects the world's diversity of views, implying that they should be accommodated (VI.3.4.4).

Response

VII.5.9.4    Concerning the new proposal, a valid exception to an accepted ethical rule or principle is made on the grounds that it does not apply in a given situation, as when it is impossible to respect the principle of informed consent because an unconscious patient urgently requires life-saving treatment.  Alternatively, but controversially, exceptions are defended by appealing to other ethical principles as having priority in particular cases. 

VII.5.9.5    However, the proposal appeals to a single principle - benevolence - as fully and unconditionally sufficient to justify physician participation in any legal procedure, including euthanasia and assisted suicide.  This is arbitrary.  Surely if benevolence is itself sufficient to justify an exception, there is no reason to think that non-maleficence, autonomy, justice, solidarity, etc. would not be, either individually or in combination.  If WMA ethical standards can be ignored or nullified solely by an appeal to benevolence, they can be ignored or nullified on other grounds.

VII.5.9.6    Further, the concept of benevolence is elastic.  It is cited not only to justify physician participation in euthanasia and assisted suicide, but to justify their participation in executions15,16 and the amputation of healthy limbs.17,18  Especially in isolation, other principles are equally malleable: a particular view of justice is offered to support the fair innings argument, for example.19 A national association policy requiring objecting physicians to collaborate in euthanasia or assisted suicide could be defended as a form of benevolence toward patients.

VII.5.9.7    In addition, no reason is offered to justify a preference for accommodating "national and cultural differences" rather than supporting WMA ethical standards.  Nationality and culture do not necessarily produce superior ethical judgement, even if they influence ethical perspectives.  Hence, if it becomes necessary to address or resolve a conflict between WMA and national association ethical policy, nationality and culture are irrelevant.

VII.5.9.8    Here it is important to note that the proposal is not about enforcing WMA ethical policies, but about formulating them.  For example, the WMA maintains its policy against euthanasia and assisted suicide, but has made no attempt to enforce it by expelling a non-compliant constituent member.  The continuing membership of non-compliant national associations may reflect either uncertainty about the best course of action or deliberate and prudential toleration of a perceived error.  In either case, the underlying ethical differences remain unresolved. 

VII.5.9.9    What is proposed, instead, is evasion of engagement on the ethical issues in dispute.  Instead, based on the prejudicial assumption that the non-compliant association's ethical policy is more probably correct, the policy requires the WMA to reformulate its policy to make it consistent with that of the non-compliant national association. This is essentially a refined version of the argument for pragmatism.

VII.5.9.10    Ironically, the sponsors of the proposal argue that national associations should develop policies consistent with WMA policies. There is no reason for them to do so if the default position is that WMA ethical policies must be modified to accommodate those of national associations.  

VII.5.9.11    The reference to diversity in the C/RDMA proposal seems intended to obscure the fact that responses in the global medical community to euthanasia and assisted suicide are not diverse but sharply dichotomous, EAS practitioners and supporters holding what is actually an outlying minority position.

VII.6    Conclusions

VII.6.1    Foundational statement, palliative care, protection of conscience

VII.6.1.1    The sole justification offered for the proposal rests upon contested rights claims.

VII.6.1.2    The opening disclaimer of non-support for euthanasia and assisted suicide is meaningless rhetoric contradicted by other elements of the proposal. The C/RDMA proposal, if accepted, would be fully effective in encouraging legalization of euthanasia and assisted suicide and physician participation in both practices.

VII.6.1.3    Were the WMA to accept the proposal it would affirm that the procedures are consistent with medical ethics and would commit the WMA to accepting the legalization and practice of euthanasia and assisted suicide on the broadest possible terms: for adolescents, children, and infants, for non-terminal chronic conditions or disabilities, and for mental illness and dementia.

VII.6.1.4    Were the WMA to accept the proposal, it would affirm that access to effective palliative care is not a prerequisite for euthanasia and assisted suicide, and that euthanasia and assisted suicide are ordinary interventions that may be provided where palliative care is not available, or optional interventions where it is.

VII.6.1.5    Were the WMA to accept the proposal, the change in WMA policy could reasonably be expected to cause physicians, other healthcare workers, the public and lawmakers around the world to favour legalizing the procedures.

VII.6.1.6    Were the WMA to accept the proposal, it would cede responsibility for establishing ethical and legal criteria for euthanasia and assisted suicide to national legislatures and courts.

VII.6.1.7    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.

VII.6.2    Arguments

VII.6.2.1    Rights claims: The rights claims are treated as self-evident, but are not. If the WMA accepts the C/RDMA proposal it would affirm contested rights claims, disenfranchise those who hold contrary views, and provide significant support for coercive legislation and policies.

VII.6.2.2    Patient priority: Even if one accepts principles of patient priority, autonomy and the importance of compassion, these can be understood in different ways. It does not follow that one must conclude that euthanasia and assisted suicide are morally/ethically acceptable and that the WMA should change its policy.

VII.6.2.3    Moral/ethical uncertainty: Disagreement or uncertainty of others is not evidence that the WMA position is doubtful. If the WMA finds euthanasia and assisted suicide ethically unacceptable, it acts consistently and reasonably in maintaining a policy against the procedures.

VII.6.2.4    Pragmatism: The appeal to pragmatism enables the authoritarian suppression of opposition to euthanasia and assisted suicide. The WMA cannot decide how to respond to legalization of physician assisted suicide and euthanasia without reference to ethics of some sort.

VII.6.2.5    Lack of consensus: The claim that current WMA policy should be changed because it does not reflect a consensus is specious. Regional meetings on end-of-life care demonstrated a clear consensus that euthanasia and assisted suicide are morally/ethically unacceptable. Some physicians in some countries disagree, but this does not disturb the consensus and does not warrant a change of policy. 

VII.6.2.6    Non-proliferation: WMA acceptance of the proposal would not be inconsequential. It would entail a meaningful ethical shift by an international opinion leader that would have worldwide implications. It could reasonably be expected to influence opinion around the world in favour of euthanasia and assisted suicide, and to encourage legalization and practice of euthanasia and assisted suicide on the broadest possible terms.

VII.6.2.7    Proportional rarity: Evaluation of the significance of the rate of euthanasia and assisted suicide depends upon a moral/ethical framework. Moreover, since everyone dies, legalization of the euthanasia and assisted suicide would not impact only the physicians directly involved, but the entire medical profession. Since relatively few physicians are directly involved in the practices legalization leads to demands for collaboration by others even if collaboration violates their moral, ethical or religious beliefs.

VII.6.2.8    Diversity and culture: The proposal to make exceptions to WMA ethics policies depends solely on an arbitrary appeal to support national or cultural concepts of benevolence. This is already an elastic concept that could support the suppression of conscientious objection by physicians. The proposal evades engagement on disputed ethical issues and relies on a prejudicial assumption in favour of a non-compliant association. This effectively subverts the ostensible purpose of the proposal.  

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Notes

1.     World Medical Association. Resolution on Physician Participation in Capital Punishment [Internet]. 2008 Oct [Cited 2018 Sep 29].

2.     World Medical Association. Statement on Female Genital Mutilation.  [Internet]. 2016 Oct [Cited 2018 Sep 29].

3.    Murphy S.  A bureaucracy of medical deception.  Quebec physicians told to falsify euthanasia death certificates: Regulators support coverup of euthanasia from families [Internet].  Protection of Conscience Project; 2015 Nov 17 [Cited 2018 Sep 29].

4.     Murphy S.  Canadian Medical Association and euthanasia and assisted suicide in Canada: Critical review of CMA approach to changes in policy and law.  Part I: Preliminaries to Carter - A professional obligation to kill.  Protection of Conscience Project (September, 2018).

5.    See text accompany notes 50 to 53 in Murphy S.  Canadian Medical Association and euthanasia and assisted suicide in Canada: Critical review of CMA approach to changes in policy and law.  Part II: CMA on freedom of conscience after Carter [Internet]. Protection of Conscience Project; 2018 Sep 26 [Cited 2018 Sep 29].

6.    External Panel on Options for a Legislative Response to Carter v. Canada. Consultations on Physician Assisted Dying: Summary of Results and Key Findings - Final Report [Internet]. Canada. Department of Justice; 2015 Dec 15 [Cited 2018 Sep 29] p. 100.

7.    Blackmer J.  Assisted Dying and the Work of the Canadian Medical Association [Internet]. 2017 Oct [Cited 2018 Sep 29]; 63(3):6-9.

8.    Simpson C.  CMA Annual General Council, August, 2015. Session: Setting the Context for a Principles Based Approach for Assisted Dying in Canada (video) 0:01:45-0:01:55.

9.    Downar J, Bailey M, Kagan J, Librach LS.  Physician-assisted death: time to move beyond Yes or No.  CMAJ [Internet]. 2014 May 13 [Cited 2018 Sep 29]; 186 (8):567-568.

10.    Budziszewski J. Handling Issues of Conscience. The Newman Rambler. 1999 Spring/Summer 3(2) [Internet]. Protection of Conscience Project [Cited 2018 Sep 29] p. 4.

11.    Canadian Medical Association. Medical Assistance in Dying [Internet]. 2017 May [Cited 2018 Sep 29].

12.     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].

13.    Murphy S. Euthanasia reported in Quebec: statistics compiled from the Rapports aux directeur général au Conseil d'administration de l'établissement et à la Commission sur les soins de fin de vie (10 December, 2015 to 10 December, 2018) [Internet]. Protection of Conscience Project; 2018 Apr 3 [Cited 2018 Sep 29].

14.    Chris Hani Barargwanath Hospital  (Accessed 2018-09-25).

15.    Gawande A. When Law and Ethics Collide - Why Physicians Participate in Executions. [Internet] 2006 [Cited 2018 Sep 29]; 354:12 1221.

16.    Nelson L, Ashby B.  Rethinking the Ethics of Physician Participation in Lethal Injection Execution. Hastings Center Report [Internet]. 2011 May [Cited 2018 Sep 29]; 41(3).

17.    Ramsay S. Controversy over UK surgeon who amputated healthy limbs. The Lancet [Internet]. 2000 Feb 5 [Cited 2018 Sep 29]; 355(9202).

18.    Elliott C. A New Way to be Mad. The Atlantic Monthly [Internet]. 2000 Dec [Cited 2018 Sep 29].

19.    Williams A.  Intergenerational Equity: An Exploration of the 'Fair Innings' Argument.  Health Econ 1997 Mar-Apr; 6(2):117-132.  Cited in Beauchamp TL, Childress JF. Principles of Biomedical Ethics (7th ed) New York, Oxford: Oxford University Press (2009), p. 286.