BMA Survey On Physician-Assisted Dying
BMA Survey on Physician-AssistedDyingResearch Report Kantar, Public Division, 2020
Contents1.Key Findings32.Introduction43.Key Definitions4.Surveyed members’ views on doctors prescribing lethal drugs to eligible patients forself-administration115.Surveyed members’ views on doctors administering lethal drugs with the intention ofending an eligible patient’s life366.Surveyed members’ wider opinions on how the BMA should respond in the event of anyfuture proposals to change the law657.Appendix A – Questionnaire748.Appendix B – Breakdown of demographics of surveyed members899.Appendix C – Breakdown of results by specialty99 Kantar, Public Division, 202010
1. Key FindingsSurveyed members’ views on a change in the law to permit doctors to prescribe drugsfor eligible patients to self-administer to end their own life1 Four in ten (40%) surveyed members expressed the view that the British MedicalAssociation (BMA) should actively support attempts to change the law, one in three(33%) favoured opposition and one in five (21%) felt the BMA should adopt a neutralposition, neither actively supporting nor actively opposing attempts to change the lawto permit doctors to prescribe life-ending drugs. Half (50%) of surveyed members personally believed that there should be a changein the law to permit doctors to prescribe life-ending drugs. Four in ten (39%) wereopposed, with a further one in ten (11%) undecided. Forty-five percent of surveyed members were not prepared to actively participate inthe process of prescribing life-ending drugs, should it be legalised. Over a third (36%)said they would be prepared to actively participate, and a further two in ten (19%)were undecided on the matter.Surveyed members’ views on a change in the law to permit doctors to administerdrugs to end an eligible patient’s life1 Four in ten (40%) surveyed members expressed the view that the BMA shouldactively oppose attempts to change the law to permit doctors to administer life-endingdrugs. Three in ten (30%) favoured support, and 23% felt the BMA should adopt aneutral stance of neither actively supporting nor actively opposing attempts to changethe law. Forty-six percent of surveyed members personally opposed a change in the law topermit doctors to administer life-ending drugs, with a further 37% supportive and 17%undecided. Fifty-four percent of surveyed members said that they would not be willing to activelyparticipate in the process of administering life-ending drugs, should it be legalised. Aquarter (26%) said they would, and one in five (20%) were undecided on the matter.The term ‘surveyed members’ refers to BMA members who responded to the survey.3
2. Introduction2.1 Background/ContextThe British Medical Association’s (BMA) remit is diverse and multi-faceted. As a professionalassociation and trade union, it protects, guides and represents doctors individually andcollectively, from resolving workplace issues to championing their voices in Parliament. TheBMA leads debate on key medical, ethical and scientific issues through research andpublishing, whilst helping doctors to continue their learning and training throughout theircareers.BMA policy is made democratically at the Annual Representative Meeting (ARM), wheremembers of the Representative Body (RB) debate and vote on motions. Motions aresubmitted ahead of time, including through ‘grassroots’ divisions, Regional Councils, andnegotiating and professional committees.2In 2019, the ARM passed the following motion:That this meeting notes the recent decision by the Royal College of Physicians toadopt a neutral stance on assisted dying after surveying the views of its membersand:i)ii)iii)supports patient autonomy and good quality end-of-life care for all patients;recognises that not all patient suffering can be alleviated; andcalls on the BMA to carry out a poll of its members to ascertain their views onwhether the BMA should adopt a neutral position with respect to a change inthe law on assisted dying.The BMA commissioned Kantar, an independent research organisation, to survey BMAmembers on their views on what the BMA’s policy position should be with respect to achange in the law to permit physician-assisted dying and the underlying rationale behindthese views. In line with the BMA’s policy-making process, the results are not determinative,but members’ views will help to inform the BMA’s debates on this topic. A policy debate onphysician-assisted dying had been planned for the ARM in June 2020 but, due to theCOVID-19 pandemic, this debate has been postponed until June 2021. The BMA’s policyof opposition to all forms of physician-assisted dying will remain in place unless, anduntil, a decision is made by the RB to change sted-dying4
2.2 What is physician-assisted dying?Physician-assisted dying refers to doctors’ involvement in measures intentionally designed toend a patient’s life. It covers situations: where doctors would prescribe lethal drugs at the voluntary request of an adultpatient with capacity, who meets defined eligibility criteria, to enable that patient toself-administer the drugs to end their own life. This is sometimes referred to asphysician-assisted dying or physician-assisted suicide; and where doctors would administer lethal drugs at the voluntary request of an adultpatient with capacity, who meets defined eligibility criteria, with the intention of endingthat patient’s life. This is often referred to as voluntary euthanasia.Eligibility for physician-assisted dying would be set out in any piece of legislation broughtforward in the future, but for the purposes of this survey we have assumed that the criteriawould fall within the following boundaries to cover patients who: are adults;have the mental capacity to make the decision;have made a voluntary request; andhave either a terminal illness or serious physical illness causing intolerable sufferingthat cannot be relieved.2.3 BMA policy on assisted dyingThe BMA has policy dating back to the 1950s that opposes euthanasia. Later policycontinued this approach but moved away from solely focusing on euthanasia (where a thirdparty carries out the final act) to include situations where the patient carries out the final actthemselves.In 2005, the BMA briefly became neutral on the issue, but it adopted its current policy ofopposition in 2006.3 In 2016, the Representative Body rejected a motion to adopt a neutralposition following a large-scale project engaging with over 500 BMA members and membersof the public.42.4 Current legal and policy contextAll forms of assisted dying are illegal in all parts of the United Kingdom. Over the last twentyyears, there have been several attempts to change the law by individuals challenging the lawthrough the courts – the most recent of which was rejected in December 2019. In that sameperiod there have also been three Private Members’ Bills considered by the Parliament atWestminster and two in the Scottish Parliament. None of these Bills have passed into ian-assisted-dying-project5
There are a number of jurisdictions where some form of physician-assisted dying is lawful. Atthe time the survey took place these included 10 jurisdictions in the United States, as well asThe Netherlands, Belgium, Switzerland, Canada and two states in Australia. The exactrequirements of the law – for example, whether a doctor can administer lethal drugs orwhether the patient must self-administer; and the eligibility criteria for patients – vary in eachplace. The one thing they all have in common is that doctors are involved to some extent inthe process.2.5 Public and professional opinion on physician-assisted dyingIn 2015, as part of the BMA’s end-of-life care and physician-assisted dying (ELCPAD)project, the BMA reviewed the academic literature on doctors’ views on assisted dying andsome of the main polls, surveys and research on public opinion.5There have also been a number of surveys of public and professional opinion carried outsince the ELCPAD work concluded. This includes: updated information on the British Social Attitudes Survey data provided in theELCPAD report to include the results of questions asked in its 2017 survey;the 2019 survey carried out by the Royal College of Physicians;the 2019 survey carried out by the Royal College of Radiologists’ Faculty of ClinicalOncology; andthe 2019 survey carried out by the Royal College of General Practitioners.Further information is available on the BMA website.62.6 Survey developmentThe scope and content of the survey, and the briefing materials provided, were developedunder the auspices of the BMA’s Medical Ethics Committee (MEC) and approved by theBMA Council.A copy of the final questionnaire can be found in appendix A and the briefing materialsprovided to accompany the survey can be found on the BMA 6
2.7 MethodologyThe BMA has members across the UK and some overseas. To ensure as many members aspossible had the opportunity to participate in the research, the survey was accessible: via an email invitation containing a unique survey link; and via a freephone number and email address widely publicised by the BMA somembers could contact Kantar directly to obtain a unique link to the online surveyvia email. A paper version of the questionnaire was also made available on request,to members who were unable to complete the survey online. Members’ details werechecked before they were able to access the survey.Fieldwork was conducted over a three-week period between 6th February and 27th February2020. Given the size of the membership, initial email invitations were sent out in batchesbetween 6th and 10th February.Members were sent an initial email invitation, with up to two reminder mailings sent to nonresponders. Sample details were updated before each reminder mailing to ensure membersjoining during the fieldwork period still had the opportunity to participate.The online questionnaire comprised mainly closed questions along with five free textquestions. These invited surveyed members to expand on their answers in more detail,typing in their own words. The free text responses were then coded into a set of closedresponse options and analysed quantitatively. A code frame was developed for this purpose,using a selection of early answers to indicate emergent themes deriving from the free textresponses. Coding was conducted by Kantar’s specialist in-house team of experiencedcoders. During coding, the code frames were further developed on an iterative basis wheresubsequent new themes emerged, these were discussed and agreed with the BMA.The analysis of free text responses throughout this report focuses on themes (or codes) thatwere expressed by at least 5% of surveyed members who typed in a meaningful response atthat particular question. Responses such as ‘Nothing to add’ were excluded from analysis.To add context and depth to the findings at each code, the report provides a range ofexamples of the kinds of things members consistently typed in. The responses within eachcode were often quite varied, covering a range of subjects that fitted within a similar broadtheme and therefore the examples should not be interpreted as being reflective of allmembers whose views fell into that code. Overall, 42,607 free text responses were codedacross these five free text questions.The questionnaire also contained two questions with ‘Other, specify’ options where memberscould provide a free text response instead of, or in addition to, the closed set of optionslisted. Once fieldwork was complete free text answers were reviewed and either coded backinto the appropriate closed option, assigned a new code, or coded as ‘Other’.8 Code frameswere developed for these free text responses in the same way as described above.Free text answers were coded as ‘Other’ if they covered things that did not fit within a broad theme and were only mentionedby a very small minority of surveyed members.87
Throughout this report the analysis of free text responses provided at ‘Other, specify’questions focuses on themes (or codes) that were expressed by at least 5% of surveyedmembers who provided a free text response at that particular question. Responses that werecoded back into the appropriate closed option were excluded from this analysis. Overall,2,368 free text responses were coded across these ‘Other, specify’ questions.As standard, Kantar’s coding team performs quality checks on every project once coding iscomplete; a minimum of 10% of each coder’s work is checked to ensure quality standardsare met.2.7.1 Response ratesNumberPercentage (%)Total issued sample (emailinvitation)152,004100%Bounce backs2,1901.4%Total in-scope sample9149,81498.6%Total useable interviews(Responses completed up toQ4)10,1128,98619.35%Details of the achieved sample profile can be found in appendix B.9This figure includes 8 members who requested paper copies of the questionnaire.10Surveyed members were only required to answer the first four questions (about prescribing), for their responses to beincluded in the final analysis.11While most members completed the survey online, this figure includes two members who completed a paper version of thequestionnaire and one member who completed the survey over the telephone.8
2.8 Interpreting the dataIt should be remembered that the survey findings are based on responses given by aproportion of the BMA membership (referred to as surveyed members throughout thereport). Overall, the profile of surveyed members was broadly representative of the BMAmembership, at the time the survey took place, with a few exceptions. General Practitionerswere slightly over-represented, and Junior Doctors and Medical Students slightly underrepresented.12 The survey findings have not been weighted to adjust for any differences.Throughout this report, unless otherwise stated: Differences between sub-groups are only commented on where they are statisticallysignificant at the 95% level of confidence.13Differences between sub-groups are only commented on if the base size for eachgroup is 100 or more, as smaller base sizes tend to produce less reliable estimatesas the margin of error is wider. In addition there is a small risk of individual membersbecoming identifiable.14Percentages may not total 100 due to rounding or the exclusion of ‘don’t know’ orother similar responses or if more than one answer to the question is permitted.The analysis of free text responses focuses on themes (or codes) that wereexpressed by at least 5% of surveyed members who typed in a meaningful responseat that particular question. This is primarily for practical purposes given the largenumber of codes generated and to focus attention on themes that were morecommonly expressed.The analysis of free text responses provided at ‘Other, specify’ questions focuses onthemes (or codes) that were expressed by at least 5% of surveyed members whoprovided a free text response at that particular question. This is primarily to focusattention on themes that were more commonly expressed. Responses that werecoded back into the appropriate closed option provided in the survey were excludedfrom this analysis.Each chart presented includes a base. This is a description of who was eligible toanswer the question along with the number of surveyed members included in theanalysis. As surveyed members were only required to answer the first four questions(about prescribing) for their responses to be included in the final analysis the numberof responding members varies throughout the report. This is because some surveyedmembers chose not to answer all of the questions in the survey.12Comparisons were made between surveyed members and BMA membership data on nation, branch of practice andspecialty.13A significant difference at the 95% level means we can be confident that if we carried out the same survey, 95 times out of100 we would get similar findings.14Armed forces and Civil service branches of practice were excluded from analysis of differences between branches of practicedue to base sizes below 100.9
3. Key DefinitionsThe language in the physician-assisted dying debate is not always perceived as neutral.Different sides of the debate have preferences for different terminology, and it can bedifficult to agree terms that are viewed on all sides of the debate as neutral and nonjudgmental.Although the BMA has used ‘physician-assisted dying’ in the past as an umbrella termwhich covers ‘physician-assisted suicide’ and ‘euthanasia’, it was important to ensurethat the BMA was not perceived as seeking to influence the results of the survey byusing language aligned more with one side of the debate than another. It was alsoimportant for participants to understand exactly what they were being asked to express aview on. For this reason, it was agreed to adopt descriptive, concept-led definitions forthe purposes of the survey.There are several terms referred to throughout the report. For practical reasons and therationale outlined above, these have often been abbreviated in the body of the report. Asummary of the key terms used throughout the report and their meanings can be foundbelow.1. Prescribing: Situations where doctors would prescribe lethal drugs to eligiblepatients for self-administration. This is sometimes referred to as physician-assisteddying or physician-assisted suicide.2. Administering: Situations where doctors would administer lethal drugs to eligiblepatients with the intention of ending their life. This is sometimes referred to asvoluntary euthanasia.3. Eligible patients: Eligibility would be set out in any piece of legislation, but for thepurposes of this survey it has been assumed the criteria for ‘eligible patients’ wouldfall within the following boundaries to cover patients who: are adults; have the mental capacity to make the decision; have made a voluntary request; and have either a terminal illness or serious physical illness causing intolerablesuffering that cannot be relieved.4. Drugs: Lethal drugs to end a patient’s life. Sometimes these are referred to as lifeending drugs.5. Surveyed members: BMA members who responded to the survey.10
4. Surveyed members’ views on doctorsprescribing lethal drugs to eligiblepatients for self-administration4.1 What do surveyed members think the BMA’s position should be with respect to achange in the law to permit doctors to prescribe drugs for eligible patients toself-administer to end their own life?Surveyed members were asked their views on what the BMA’s position should be on achange in the law to permit doctors to prescribe drugs for eligible patients to self-administerto end their own life. The answer options were presented in random order to minimise anyimpact from a specific ordering. The question wording is given below.The following questions concern a doctor prescribing lethal drugs at the voluntary requestof an adult patient with capacity who meets defined eligibility criteria (“eligible patients”), toenable that patient to self-administer the drugs to end their own life. This is sometimesreferred to as physician-assisted dying or physician-assisted suicide.In your opinion, what should the BMA’s position be on whether there should be a changein the law to permit doctors to prescribe drugs for eligible patients to self-administer to endtheir own life?1. Supportive – the BMA should actively support attempts to change the law2. Opposed – the BMA should actively oppose attempts to change the law3. Neutral – the BMA should neither actively support nor actively oppose attempts tochange the law4. UndecidedWe will continue to represent our members’ professional interests and concerns in theevent of future proposals for legislative change.11
Overall, four in ten (40%) surveyed members expressed the view that the BMA shouldactively support attempts to change the law, one in three (33%) favoured opposition, andone in five (21%) felt the BMA should neither actively support nor actively oppose attemptsto change the law.Figure 4.1 Surveyed members’ opinions on what the BMA’s position should be withrespect to a change in the law to permit doctors to prescribe drugs for eligiblepatients to self-administer to end their own lifeSurveyed members in Northern Ireland were more likely than those in other nations toexpress the view that the BMA should actively oppose a change in the law to permit doctorsto prescribe life-ending drugs (46%, versus a highest of 33% in any other nation). See figure4.2.Figure 4.2 Surveyed members’ opinions on what the BMA’s position should be withrespect to a change in the law to permit doctors to prescribe drugs for eligiblepatients to self-administer to end their own life, by nation12
Opinion also varied by branch of practice. Most notably Medical Students were more likelythan all other branches of practice to believe that the BMA should change to a supportivestance (53%). Conversely, General Practitioners (GPs) (40%) and Medical Academics (37%)were more likely than most other branches of practice to believe that the BMA shouldoppose a change in the law to permit doctors to prescribe life-ending drugs.15Figure 4.3 Surveyed members’ opinions on what the BMA’s position should be withrespect to a change in the law to permit doctors to prescribe drugs for eligiblepatients to self-administer to end their own life, by branch of practice15While the figure for GPs is higher than that for Medical Academics, there is a margin of error around all figures that means itis not possible to confirm that GPs are the single most likely group to report this view.13
Surveyed members registered with a licence to practise in the UK were more likely thanthose who were not to hold the view that the BMA should retain its opposed stance (35%compared with 25%). Conversely, surveyed members who were not registered with a licenceto practise were more likely than those who were to hold the view that the BMA shouldsupport a change in the law to permit doctors to prescribe life-ending drugs (47% comparedwith 38%).Fig 4.4 Surveyed members’ opinions on what the BMA’s position should be withrespect to a change in the law to permit doctors to prescribe drugs for eligiblepatients to self-administer to end their own life, by whether they were registered witha licence to practise in the UK14
Views also differed by speciality. Surveyed members with the following specialties weremore likely than surveyed members generally to believe the BMA should support a changein the law to permit doctors to prescribe life-ending drugs: Otolarynology (53% supportive)Clinical radiology (52%)Trauma and orthopaedic surgery (52%)Anaesthetics (51%)Emergency medicine (50%)Histopathology (50%)Intensive care medicine (48%)Obstetrics and gynaecology (48%)Conversely, surveyed members with the following specialties were more likely than surveyedmembers generally to believe the BMA should oppose a change in the law: Palliative medicine (70% opposed)Clinical oncology (44%)Geriatric medicine (44%)General practice (39%)See appendix C for a full breakdown of the differences by specialty.15
4.2 What are surveyed members’ personal views on a change in the law to permitdoctors to prescribe drugs for eligible patients to self-administer to end theirown life?Surveyed members were also asked about their own personal views on whether theysupported or opposed a change in the law to permit doctors to prescribe life-ending drugs.The answer options were presented in random order to minimise any impact from a specificordering. The question wording is outlined below.In principle, do you support or oppose a change in the law to permit doctors to prescribedrugs for eligible patients to self-administer to end their own life?1. Support2. Oppose3. UndecidedOverall, half (50%) of surveyed members supported a change in the law, four in ten (39%)were opposed and one in ten (11%) were undecided.Figure 4.5 Surveyed members’ personal views on a change in the law to permitdoctors to prescribe drugs for eligible patients to self-administer to end their own life16
As with views on the BMA’s position to permit doctors to prescribe life-ending drugs,surveyed members in Northern Ireland were more likely than surveyed members in England,Scotland and Wales to personally oppose a change in the law to permit doctors to prescribelife-ending drugs (52%, versus a highest of 40% in any other nation). See figure 4.6.Figure 4.6 Surveyed members’ personal views on a change in the law to permitdoctors to prescribe drugs for eligible patients to self-administer to end their own life,by nation17
There were some differences by branch of practice. Most notably Medical Students weremore likely than all other branches of practice to personally support a change in the law(62%). Conversely, General Practitioners were more likely than all other branches of practiceto personally be in opposition to a change in the law to permit doctors to prescribe lifeending drugs (47%).Figure 4.7 Surveyed members’ personal views on a change in the law to permitdoctors to prescribe drugs for eligible patients to self-administer to end their own life,by branch of practice18
Surveyed members registered with a licence to practise in the UK were more likely thanthose who were not to personally oppose a change in the law (41% compared with 32%).Whereas, surveyed members who were not registered with a licence to practise were morelikely than those who were to personally support a change in the law to permit doctors toprescribe life-ending drugs (58% compared with 48%).Figure 4.8 Surveyed members’ personal views on a change in the law to permitdoctors to prescribe drugs for eligible patients to self-administer to end their own life,by whether they were registered with a licence to practise in the UKSurveyed members with the following specialties were more likely than surveyed membersgenerally to personally support a change in the law to permit doctors to prescribe life-endingdrugs: Otolaryngology (66% supportive)Anaesthetics (62%)Emergency medicine (62%)Trauma and orthopaedic surgery (61%)Clinical radiology (61%)Forensic psychiatry (60%)Intensive care medicine (59%)Obstetrics and gynaecology (57%)Histopathology (57%)Child and adolescent psychiatry (57%)Public health medicine (55%)General psychiatry (53%)19
Conversely, surveyed members with the following specialties were more likely than surveyedmembers generally to personally oppose a change in the law to permit doctors to prescribelife-ending drugs: Palliative medicine (76% opposed)Geriatric medicine (52%)Renal medicine (51%)Clinical oncology (50%)Gastroenterology (49%)General practice (46%)See appendix C for a full breakdown of the differences by specialty.Virtually all (97%) surveyed members who felt the BMA should adopt a supportive stance toa change in the law to permit doctors to prescribe life-ending drugs also personallysupported a change in this law. Conversely, 99% of those who believed the BMA should beopposed to a change in the law to permit doctors to prescribe life-ending drugs alsopersonally opposed a change in this law. Those who believed the BMA should adopt aneutral stance were more likely to personally support (42%) than oppose (27%) a change inthe law, with a further 32% being undecided. See figure 4.9.Figure 4.9 Surveyed members’ personal views on a change in the law to permitdoctors to prescribe drugs for eligible patients to self-administer to end their own life,by opinions on what the BMA’s position should bewith20
4.3 Reasons for and against a change in the law to permit doctors to prescribe drugsfor eligible patients to self-administer to end their own lifeSurveyed members were asked to expand on their views, in their own words, on doctorsprescribing life-ending drugs. Before exploring responses there are a few points to considerrelating to the analysis. These can be found in the box below.Half (50%) of surveyed members gave a free text response at this question, a total of 14,436responses. Analysis (i.e. all percentages) is based only on these surveyed members andexcludes those who selected ‘Nothing to add/Prefer not to say’ or typed a similar commentinto the open answer field.Surveyed members were able to type in their free text answers (up to a word limit of 300)and these were coded to a thematic code frame. The code frame was divided into two parts views which were in support of a change in the law and those which opposed a change.Answers could fall into multiple codes, these sometimes falling on both sides of the debatedepending on the content.On average, 1.9 codes were applied to each free text response; the maximum number ofcodes applied to an answer was 8.Reasons for opposing a change in the law to permit doctors to prescribe drugs for selfadministration fell into a wider range of categories than those in support. Analysis focuses onthe themes that were expressed by at least 5% of surveyed members who provided a freetext response at this question.Reasons for supporting a change in the law to permit doctors to prescribe life-endingdrugsFifty-four percent of surveyed members who provided a free text response gave at least onereason for supporting a change in the law to permit doctors to prescribe life-ending drugs.Below are the top five reasons, all given by at least 5
2.5 Public and professional opinion on physician-assisted dying In 2015, as part of the BMA's end-of-life care and physician-assisted dying (ELCPAD) project, the BMA reviewed the academic literature on doctors' views on assisted dying and some of the main polls, surveys and research on public opinion.5
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