UNIVERSITY OF BIRMINGHAM
Should the Royal College of
General Practitioners have
a stance on the Assisted
Dying Bill and how should
that stance be decided?
Matthew Palethorpe
This is a report submitted as part requirement for my Intercalated Scholarship from the Institute of
Medical Ethics.
Introduction
The legalisation of Physician Assisted Suicide (PAS) represents one of the greatest changes
in medical law since the Abortion Act. The Assisted Dying Bill 2013, tabled by Lord
Falconer, is the latest attempt to legalise PAS.(1) Professional bodies within the medical
profession have responded to the proposal in a variety of ways, with some taking a clear and
principled stance for or against, while others have remained silent.(2) This study explored
whether the RCGP should have a stance, and how it should be decided.
The Royal College of General Practitioners (RCGP) conducted a consultation of its
members on assisted dying, and decided to
continue with its opposition to any change in
RCGP’s stance on assisted dying
law.(3,4) Prior to that consolation, Gerada
“[T]he RCGP believes that, with current
called for the RCGP to reconsider its position,
improvement in palliative care, good
and take a neutral stance, to allow society to
clinical care can be provided within the
make a decision without the ‘undue’ influence
existing legislation, and that patients can die
of the medical profession.(5)
with dignity. A change in legislation is not
required.” (4)
Figure 1
Method
Research Questions
Primary Research Question
1. Ought the RCGP to have a stance on the Assisted Dying Bill?
2. How should the RCGP decide on their stance?
Secondary Research Questions
3. What are the views of GPs about their professional membership bodies
taking a public stance on matters of ethical and political controversy?
Aims

To explore the extent to which the RCGP has a moral obligation to have a stance on
the Assisted Dying Bill.

To consider which methods the RCGP ought to use to determine its stance.
Design
An empirical bioethics project was required to meet the aims of this study. Qualitative data
was collected via one-to-one interviews, which was used to inform an ethical analysis of (1)
the obligation to have a clear stance on assisted dying, and (2) how that stance ought to be
determined.
Empirical data was used to inform the ethical analysis as it provided ‘encounters with
experiences’ that would otherwise have been inaccessible to the researcher.(6-8) The data was
used to identify the appropriate context for the debate and elucidate practical and political
factors that might not be initially recognised by the researcher (a theorist).(7,9)
Reflexive Balancing was used to develop a balanced and theoretically defensible
position, with appropriate consideration to as many relevant concerns as possible.(10)
Reflexive Balancing involved three stages: (1) Identifying the problem; (2) ‘Disciplinary
naïve inquiry into the problem’; (3) ‘Reflexive Balancing’.
Six participants were recruited via four arms. All participants were members of the
RCGP and practicing GPs. Interviews were conducted either in person or via Skype.
A favourable ethical opinion was obtained from the BMedSc PoSH Internal Ethics
Research Ethics Committee. Assistance was provided by the RCGP’s Ethics Committee.
Brief Summary of Ethical analysis exploring the legitimacy of GPs
taking a stance
The proposal for a change in law on assisted dying represents a significance dilemma for
society and the medical profession. The taking of human life is seen as one of the most
reprehensible crimes in the UK,(11) but advocates of assisted dying present strong arguments
in favour of taking a permissive attitude towards it. Confronted with such difficult decision,
it may be important that the finding of a resolution incorporates some element of democratic
consultation – which may lend legitimacy to any decision. Deliberative Democracy suggests
that, contrary to Plato’s classic challenge, the views of the every member of society is
important and relevant.(12,13) To allow for society to make a truly democratic decision, it is
important that they do so without the undue influence of non-experts, who are highly
respected socially.(14,15) It has been argued by Gerada that any voice from the medical
profession would comprise undue influence, given the powerful social position that the
medical professional enjoys [5].
GPs generally have medical expertise in ’managing’ death and dying patients, due to
their medical knowledge and from their daily experience of medical practice . Moral
expertise, although not necessarily obviously associated with a GP, is an area in which a GP
may also be considered an expert. GPs are regularly confronted with medical ethical
dilemmas, where they must consider the appropriate resolution to the problem and act upon
their decision. A moral expert is one who has skill or knowledge that is greater than the
average person.(16) This regular daily practice might be thought to provides GPs with
practical moral expertise.
Empirical data
Two overarching themes emerged from the data: The GP Voice; and Perception of the GP
Voice (see Table 1).
Table 1
The GP Voice
SUBTHEMES The Legitimate Voice
The Perception of the GP Voice
Public Perception and Trust
The Organised Voice
Media and Media Representation
Determining the Voice
Policy Makers’ Perception
The participants generally felt that the GPs voice and opinion is important within the
debate.
P01: [I] don’t agree with that. If that group has a particular expertise or
influence or involvement in that topic then they, I think they should take a
view on it.
The expertise which the participants felt was required to have a stance was
the practical expertise of end of life care and safeguarding of patients. All
participants required prompting to discuss the moral aspect of the debate. Some felt
this was not something they needed to consider, whilst others considered only after
prompting.
Either way, they tended to see themselves as ‘practice’ experts, rather
than moral experts.
P01: [I] don’t think doctors have any particular moral authority it’s just
more a kind of practical thing.
While participants felt it was important that the GP voice was heard in the
assisted dying debate, they were also concerned about how that voice was perceived
by patients, the media and policy makers (see Table 2). Participants were keen to
ensure that their relationship with their patients was not damaged or undermined by
the RCGP taking a stance. There was further concern expressed by the participants
over the possible media attention and retrospective political backlash from the RGCP
talking a stance – whatever that stance was.
Table 2
Relationship
Evidence (Quote)
Doctor - Patient
P02: [G]Ps enjoy a lot of trust from the public and I think the RCGP
have to be very careful with taking, erm, stances on emotive subjects
like this.
Media
P03: [I] also think that just at the moment in the press I don’t [pause]
GPs are getting a good, you know, a good representation. I think
they’re, you know, we’re apparently to blame for every crisis in the
NHS.
Policy Makers
P05: [O]r to say, to say in the future, look what those GPs said, you
know they said, how callous is that, they said, they said they weren’t
going to, er, they weren’t going to look after patients in the way that
they would like to be in their, in their dying days.
In light of these concerns the participants still thought that it was important
that there was an organised voice for GPs within the assisted dying debate, and
tended to feel that the process for deciding what the RGCP stance should be ought to
be democratic.
P02: [T]o reflect the general views of the membership, I think would be the
responsibility of the College.
Discussion
The view expressed by the participants was that GPs are important stakeholders in the debate
because of their practical expertise. Therefore, to the participants, it would be reasonable for
the RCGP to have a stance against assisted dying, if decided democratically. However, this is
problematic because a stance encompasses both practical and moral expertise. Although it is
possible to theoretically argue GPs have healthcare moral expertise, there has been no
evidence to suggest that GPs are moral experts, which leaves them unable to take a stance.
This leaves two opposing, yet equally important principles, the autonomic decision of the
general public, free from interference, and the right to democratic representation by members
of the RCGP. In order, to find an answer a compromise has been sought. Members of the
RCGP Ethics Committee can be considered as practical and moral experts; therefore any
stance that they decide upon is made with appropriate considerations of the issues. The
democratic mandate can be fulfilled if the democratically elected council refer the decision to
the ethics committee, thereby providing a legitimate stance for the RCGP.
Conclusion
This study has explored the issues surrounding the RCGP having a stance on Assisted Dying.
It has been argued that in order to have a democratic stance, to inform the democratic
decision of society, the RCGP members must be moral and medical experts, yet there is no
evidence to suggest GPs are moral experts. However, democracy is an important principle,
and should the members of the RCGP democratically request a stance then they ought to have
one.
A convoluted solution is required to balance the two; allow the democratically elected
representatives to allocate the decision to a specific group of members who are both moral
and medical experts. An example of such a group would be the RCGP’s Ethics Committee.
Summary of Answers to the Research Questions
Question - Ought the RCGP to have a stance on the Assisted Dying Bill?
Answer – If the members of the RCGP democratically decide to have a stance,
then they ought to have one. Those that decide the stance should have practical
expertise in end of life care and moral expertise in healthcare ethical dilemmas.
Question - How should the RCGP decide on their stance?
Answer – The decision of the stance should be a democratic decision, mediated
through the elected representatives, the RCGP Council.
Question - What are the views of General Practitioners about their
professional membership bodies taking a public stance on matters of ethical
and political controversy?
Answer – There were varied views on whether the RCGP should take a stance on
the ethical and political controversies currently facing the Health Service. There
was no consensus among the participants on this matter.
Figure 2
Acknowledgements
I would like to thank Dr Jonathon Ives for all his help and support throughout the project. I
would also like to thank the IME for their Scholarship, which helped make the intercalation
possible. Finally, I would like to thank all the participants for their time and enthusiasm.
References
(1) Lord Falconer of Thoroton. Assisted Dying Bill [HL] 2013-14. Private Members Bill
2013 May 2013.
(2) Butler-Sloss E et al. Another 'Assisted Dying' Bill. Does it pass the public safety test?
2013 20/06/2013;2013:5.
(3) Royal College of General Practitioners. RCGP announces continued opposition to change
in law on assisted dying. 2014; Available at:
http://www.rcgp.org.uk/news/2014/february/rcgp-remains-opposed-to-any-change-in-thelaw-on-assisted-dying.aspx. Accessed 05/07, 2014.
(4) Royal College of General Practitioners. Assisted Dying. A consultation on the RCGP's
position on a change in law. 2013;2013:4.
(5) Gerada C. The case for neutrality on assisted dying - a personal view. British Journal of
General Practice 2012;62(605):650-650.
(6) Hedgecoe AM. Critical bioethics: beyond the social science critique of applied ethics.
Bioethics 2004;18(2):120-143.
(7) Ives J. ‘Encounters with Experience’: Empirical Bioethics and the Future. Health Care
Analysis 2008;16(1):1-6.
(8) Introduction to Qualitative Methods. Healthcare Ethics and Law BMedSc; 08/10/2013;
University of Birmingham; 2013.
(9) Strong KA, Lipworth W, Kerridge I. The strengths and limitations of empirical bioethics.
J Law Med 2010 Dec;18(2):316-319.
(10) Ives J. A method of reflexive balancing in a pragmatic, interdisciplinary and reflexive
bioethics. Bioethics 2013.
(11) The Murder (Abolition of Death Penalty) Act 1965 c. 71 .
(12) Kim SY, Wall IF, Stanczyk A, De Vries R. Assessing the public's views in research
ethics controversies: deliberative democracy and bioethics as natural allies. J Empir Res Hum
Res Ethics 2009 Dec;4(4):3-16.
(13) Ives J, Damery S, Redwod S. PPI, paradoxes and Plato: who's sailing the ship? J Med
Ethics 2013 Mar;39(3):181-185.
(14) Ipsos MORI. Doctors are most trusted profession – politicians least trusted. 2011;
Available at: http://www.ipsos-mori.com/researchpublications/researcharchive/2818/Doctorsare-most-trusted-profession-politicians-least-trusted.aspx. Accessed 09/05, 2014.
(15) Kmietovicz Z. R.E.S.P.E.C.T.-why doctors are still getting enough of it. BMJ 2002 Jan
5;324(7328):11.
(16) Archard D. Why moral philosophers are not and should not be moral experts. Bioethics
2011;25(3):119-127.