Rhetoric: Hippocratic oath

The AMA announces an 'update' of its "euthanasia and physician assisted suicide" policy.

The Australian Medical Association (AMA) executive (policy group) recently concluded a major review of its official policy on assisted dying. The last major review was in 2007. Through a deeply flawed process the AMA executive continues to expressly disrespect the diversity of views amongst Australian doctors — a diversity confirmed by its own review — and hasn’t altered its opposition to assisted dying in any meaningful way.

Unrepresentative of Australian doctors

The AMA promotes itself as “leading Australia’s doctors,” yet more than two thirds of Australian doctors (70.5%) are not members. Its executive might like to think it’s leading, but most Australian doctors aren’t following. Claimed representation is particularly important when it comes to professional medical practice policies, because the AMA behaves as though its policies apply to all Australian doctors.

So who did the AMA consult in conducting its major review of policy on assisted dying? Only its own members. In other words, the AMA claims to represent all Australian doctors, but in reality consulted less than a third of them in the setting of its assisted dying policy. As AMA member Dr Rosemary Jones pointed out, some doctors eschew the AMA because of its opposed stance towards assisted dying. That creates a sampling bias in the AMA’s study… against assisted dying.

Further, the response rate to its survey of members was around 13%, meaning that only the most engaged AMA members (thus around 4% of all Australian doctors) offered a voice.

Biased survey

There are numerous flaws in the AMA’s survey. Here’s just one. In the preamble to the questionnaire, the AMA expressly told responding doctors (who, remember, are AMA members and probably don’t want to tick off their association) what its positions on certain end-of-life practices were. Then, in the first questions, it asked the doctor whether they agreed with the positions: strategies certain to result in substantial confirmation and acquiescence biases.

This just isn’t on. As a professional social and market researcher, I sent a detailed critique of the many problems with the survey to AMA President Dr Michael Gannon. I received a courteous but dismissive response from administration. A highly-respected Fellow of the Australian Market & Social Research Society sent a similar critique, also receiving a non-committal reply.

Survey results

While the AMA hasn’t published the survey results in detail yet, key headline statistics have been reported. What did the AMA discover on the basis of a methodology swayed against assisted dying?

  • Around four out of ten doctors believe that doctors should be involved in assisted dying cases, while around five out of ten thought they shouldn’t. One out of ten had no view either way.
  • If assisted dying were legalised, a majority said that doctors should be the ones to do this work.

That’s a clear message that a substantial proportion of doctors think assisted dying can not only be legitimate practice, but is the business of the medical profession — at least for those who wish to participate.

Executive’s ‘interpretation’

And what did the AMA executive make of these important insights after deliberating on them for months? Here are the AMA’s previous and ‘revised’ core policy statements:

Previous (2007) statement

‘Revised’ (2016) statement

The AMA believes that medical practitioners should not be involved in interventions that have as their primary intention the ending of a person's life. This does not include the discontinuation of futile treatment.”

The AMA believes that doctors should not be involved in interventions that have as their primary intention the ending of a person’s life. This does not include the discontinuation of treatments that are of no medical benefit to a dying patient.”

Despite the gratuitous change of a few words after a year of ‘research,’ the statement remains the same.

Doctors and the public have a right to ask of the AMA, “what part of the evidence that there is a genuine diversity of respectable views, did you miss?”

Failure to respect diversity

The executive might argue that it did listen. Here are its statements about diversity:

Previous (2007) statement

‘Revised’ (2016) statement

The AMA recognises that there are divergent views regarding euthanasia and physician-assisted suicide.”

The AMA recognises there are divergent views within the medical profession and the broader community in relation to euthanasia and physician assisted suicide.”

Despite another increase in wordiness, this statement too remains the same.

The AMA executive says it recognises that there are divergent views, but by continuing to insist that no doctor should be involved in assisted dying, it reveals that it doesn’t respect some views. How does it justify this hubris?

Failure to respect the patient

The revised policy also says in part:

“Doctors should … endeavour to uphold the patient’s values, preferences and goals of care.”

The sting in the policy tail is, given the AMA executive’s wholly opposed stance toward assisted dying, that the doctor should only uphold patient values, preferences and goals of care if the AMA executive approves of them (and assuming to do so is legal).

Was it a foregone conclusion?

The AMA executive’s continued opposition to assisted dying was unsurprising. The signals were clear. While the policy review was in play, AMA President Dr Michael Gannon made a series of tweets and media comments, all unsupportive of or directly opposed to assisted dying. Here’s a few.

In response to an article in The Australian “Catholic stance allows eased exit”, he tweeted a faux ‘competition’ between palliative care and assisted dying:

@amapresident 13 Aug 2016: Different views society on assisted dying. Hope all agree improved PalliativeCare access a priority @westaustralian

He also tweeted in support of the ‘doctrine of double effect’, a controversial policy (which the AMA promotes as uncontroversial) that contends it’s quite OK for a doctor to hasten a patient’s death after all… provided they don’t really mean to: hardly a robust or verifiable standard.

@amapresident 24 Aug 2016: Doctors should be careful, must obey the law and understand their code of #ethics. Double effect is not #Euthanasia

In an article in The Australian on 15th September, Dr Gannon argued against assisted dying on the basis of it being ‘extremely complex.’ If complexity were a reason to oppose anything, the AMA would be opposed to the entire healthcare system: it’s incredibly complex. His argument collapses at the slightest inspection.

@amapresident 18 Sep 2016: Hippocratic medicine older than some of the world’s great religions, every political ideology, trend #ethics @medwma

Dr Gannon then invoked the Hippocratic Oath, which bans assisted dying. That’s cherry-picking at its best. Doctors do not take the Hippocratic Oath: it swears allegiance to ancient Greek gods, forbids women from entering the profession and outlaws surgery, amongst other things.

@amapresident 19 Sep 2016: Agree @DrSallyCockburn admire #euthanasia work done by @CMA_Docs. Equally careful, compassionate, intelligent approach from @TheBMA #ethics

He commends the British Medical Association’s “intelligent approach” against assisted dying: an approach I have comprehensively exposed as superficial and ill-informed fear-mongering, fiction, flip-flop and hubris.

@amapresident 1 Oct 2016: It is inevitable that if #Euthanasia laws are passed, they will over time be expanded to include children, mentally ill, vulnerable #ethic

Dr Gannon demonstrated ignorance of basic facts with this ‘slippery slope’ claim. In Oregon, which has the world’s oldest specific assisted dying framework (in effect since 1997), there have been no changes in who may qualify. He also ignores peer-reviewed research showing no ‘slippery slope’ for the supposed ‘vulnerable’. Canadian Professor Harvey Chochinov, Chair of his government’s expert panel which investigated legislative options for assisted dying, confirmed the evidential absence of the ‘slippery slope’ in a keynote address at Swinburne University in Melbourne last week.

@amapresident 11 Nov 2016: Doctors maintain this Trust with everyday care for patients, by upholding #DeclarationOfGeneva @medwma @juliamedew @Rania_Spooner #ethics

Dr Gannon also claimed that assisted dying would erode patient trust in doctors, at odds with the fact that people’s trust in doctors is high amongst OECD countries with assisted dying laws. Indeed, trust in doctors amongst Dutch, Belgian and Swiss citizens is significantly higher than Australians’ trust in our own doctors.

During the review period, Dr Gannon also repeatedly promoted the (medical) Declaration of Geneva (e.g. see previous tweet), which states that doctors must not participate in assisted dying. If the Declaration’s canonical opposition was indeed the authoritative stance on assisted dying, then it would be irrelevant for the AMA to conduct a review process of its policy.

Doctors and the public might ask a legitimate question: “Why did the AMA President think it appropriate to publicly and repeatedly indicate what review conclusion he favoured, while the review was in progress?”

Declining to correct misinformation

In September, the Medical Journal of Australia (MJA: a wholly-owned subsidiary of the AMA), published a news report containing significant misinformation that painted a hostile picture about assisted dying in Belgium. I published a critique of why the opinion was wrong, and commented on the online MJA article with a link to my correction. The MJA promptly deleted my comment.

AMA member Dr Rosemary Jones then put up the same objection which, by dint of her membership, they wouldn’t delete. The MJA then responded, but only to dig in its heels to defend the misinformation and reveal even more serious flaws in its arguments.

I wrote a further research-backed analysis of why its defensive arguments were even more wrong than the original and posted a note and link on the original MJA article page (Figure 1).

MJA inSight has deleted my post correcting its misinformation.Figure 1: The second post on MJA inSight which was subsequently deleted.

Once again, my post has been deleted. The result of this is that erroneous information about Belgium remains published on the MJA website as though it is correct, while failing to mention or acknowledge that it has been soundly refuted.

It’s disappointing that the AMA and its President continue to make such uninformed remarks given that Dr Gannon claims to be a stickler for scientific evidence:

@amapresident 18 Aug 2016: Being a doctor is a huge privilege. Also carries responsibility to provide accurate scientific info, act ethically.

Spotlight on the AMA

Legitimate questions serve to shine a spotlight on the AMA. Firstly, given the circumstances, what was the likelihood of a real change to the AMA’s entrenched opposition toward doctor participation in assisted dying?

Secondly, given the AMA’s entrenched opposition, how can it expect its demands that it be consulted about any potential law reform to be treated seriously? If assisted dying is nothing to do with doctors, why is what doctors think relevant?

Utterly resistant to modernisation?

At its 2016 AGM, AMA member Dr Harry Hemley noted that the AMA largely represented its more hard-core, long-term older members and warned of the AMA’s increasing irrelevance and impotence (Figure 2). He moved an urgency motion to commission a review and report with “recommendations for a plan, vision and determination that will lead to re-invigorating and sustaining the AMA.”

ama_less_relevant2.jpgFigure 2: Dr Harry Hemley speaks to the urgency motion to investigate organisational reform

The motion wasn’t in relation to an actual or particular reform: merely to investigate the potential for reform and to provide recommendations for consideration. We can only hope that the AMA will drag itself into the 21st century at some stage.


The AMA is deeply out of touch with Australians on the issue of assisted dying. It represents fewer than a third of Australian doctors and has failed to respect the very range of perspectives it obtained by consulting its members. It further strains its credibility by insisting that doctors mustn’t be involved in assisted dying, yet demanding to be consulted on any law reform to permit it.

If the AMA is to become relevant to contemporary society it must move on from the ‘old boy’ approach to medicine and adopt a stance of neutrality toward assisted dying. Only neutrality demonstrates appropriate respect for the true range of views held in good conscience by Australian doctors.


This article has been published in OnlineOpinion.

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The opinion piece in The Age.

In today’s Fairfax press, Sydney woman Mary Ticinovic advances a number of reasons as to why she believes that assisted dying is not merciful. The by-line identifies her as a “clinical psychologist”. But her arguments are not founded on the basic tenets of psychology. How so?

Read Mary’s opinion piece in The Age

All life is precious

Mary argues that to support assisted dying is to go “against the principle that all life is precious.” She offers no substantive explanation, invoking the notion of ‘human worth’, stating that it exists regardless of the health state or suffering of the person, and complaining that assisted dying promotes the idea that “your life is no longer worth living”.

These are not psychological arguments. We can agree that life is precious. But reluctantly deciding to hasten one’s death in the face of intolerable and unrelievable terminal suffering doesn’t negate that preciousness. Indeed, to some people, choosing assisted dying can evidence the preciousness of one’s very capacities and values as a human.

Whose standards?

Mary further muses over “by whose standards would we judge if life is not worthwhile any more”, as though this is only some vague theoretical argument amongst philosophers or doctors. This is not a psychological argument, either. Under assisted dying law reform, it is only the dying individual’s world-view and circumstances that determine whether he or she feels life is worth living: not anyone else. General philosophical theory doesn’t come into it.

She further argues that assisted dying “promotes a utilitarian view of humanity”. This is not a psychological argument, either. Nor is it valid. Indeed, legalised assisted dying respects the very nature of the diversity of humanity by enabling the world-views many people hold most dear: that of making rational choices consistent with their own beliefs, values and circumstances. Some patients, for example in Oregon, are deeply religious and believe that their God is compassionate and understands and respects their choice to avoid intolerable suffering. That’s not utilitarian at all.

Harm and the Hippocratic Oath

Mary invokes the Hippocratic Oath said by her medical friends to oblige doctors to “do no harm” and that the medical role is “in healing and helping the patient to be restored to health.” This is simplistic nonsense, not a psychological argument.

Firstly, doctors do harm all the time: think of surgical procedures or chemotherapy. Many medical interventions do harm, but we accept the harm because we expect there to be a commensurately greater good as a result.

Secondly, medical practice cannot always “restore the patient to health” as Mary exclusively puts it. What then? The dying patient may judge that the unrelievable suffering they will experience along the path to death is a greater harm than dying a little earlier. And, doctors also have a primary duty to relieve suffering, which Mary doesn’t mention. What is under review is whether a doctor may participate in the relief of intolerable and unrelievable suffering— by hastening death—if the patient believes this is the lesser harm.

Thirdly, the Hippocratic Oath is around 2,300 years old. It requires doctors to swear allegiance to ancient Greek gods. It forbids women from becoming doctors. It requires current doctors to train the next generation free of charge, and it forbids surgery. Contemporary doctors don’t take it, and it’s certainly not “part of training” as Mary mistakenly states.

None of these are psychology arguments.

'Sucker’s choice'

Mary then argues that requiring dying patients to endure until the end promotes—and that assisted dying prevents—“fostering gratitude”, “reconciling hurts or differences with family members or friends” and “showing them strategies or different ways to approach their pain and suffering”.

But, in jurisdictions where assisted dying is legal, for example in Oregon in the USA, these are precisely things that are encouraged under assisted dying. Doctors are required to inform applicants of available medical and palliative interventions. Family gathers on notice of an anticipated death, music and poetry is shared, and expressions of love, devotion and gratitude are exchanged.

If a dying patient has no intention of reconciling with family or reflecting on approaches to dealing with their pain and suffering under an assisted dying law, precisely the same intention applies to the current regime that requires the patient to endure until the end. To assume a difference is a false dichotomy.

Obligatory compassion

Mary also argues that assisted dying ought to remain outlawed because “nursing a sick loved one is a way to give back”. This is yet another specious non-psychology argument. It promotes the ‘right’ of the ‘nurse’ to express love and devotion through ‘caring interventions’ at the expense of the dying patient’s own world view and deeply-held wish for a hastened death. Now who’s being utilitarian?

The upshot

I ran Mary’s opinion piece past an experienced psychologist, who described it as little to do with psychology. Note that neither of us has experience of or is commenting on Mary’s expertise as a clinical psychologist: she may indeed be a very good one.

My associate wondered out loud if Mary’s arguments were based more on underlying religious views than anything else. I agreed: they seemed to me remarkably consistent with the arguments advanced by religious opponents, even though they avoided directly religious words. So I did a little research.

It turns out that Mary is a committed and active Sydney Catholic.* Evidence abounds of her devotion to the Catholic tradition, and I commend her for her conscientious reflective practice and participation in it.

However, I argue that neither the stated psychological qualification nor the unstated religious affiliation make the offered arguments valid.


* By way of fairness, I place on the record that I am agnostic.

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