Surveys and surveys - The Canadian Medical Association should know better

The Canadian Medical Association currently debates the issue of assisted dying. That's a reassuring thing as everything points in the direction of doctors becoming the gatekeepers once assisted dying is regulated and will be made available to eligible Canadians who request it.

Strangely, the Association seems to put a lot of store in an on-line poll it inflicted on its members, where only 29% of those who responded said that they were willing to provide assisted dying to eligible patients while 63% objected. I'm surprised the Association's staff would have even mentioned this survey. It's troubled by obvious ( and quite deadly, pardon the pun) methodological problems that renders it useless.

The Associations Vice President Professional Affairs, Dr Jeff Blackmer produced a 34 slide presentation titled (no doubt to the horror of most living medical ethicists) 'End-of-Life Care in Canada: A Principles Based Approach to Assisted Dying'. There will be only few people left in bioethics who have not come to realize that the much celebrated principles approach to medical ethics guarantees arbitrary recommendations and outcomes. The principles approach is neither action guiding nor action justifying, it's useless as a tool of ethical or policy analysis and justification. Blackmer decided to add random other principles to the Georgetown Mantra, including vacuous nice sounding stuff like the 'dignity of life' (yes, really, he did!). We spent a fair amount of time in our Royal Society of Canada Report on the subject matter dissecting this particular issue.

After delivering to his audience this hotchpotch of principles, there's an unconnected slide with recommendations, followed by 8 or 9 slides reporting the results of the CMA's on-line poll. Blackmer reports that of about 80 000 doctors in Canada about 1400 clicked their way thru the on-line poll. At a minimum the negligible turnout suggests that most doctors in Canada didn't care to complete a survey that they probably realized ultimately tells us nothing about Canadian doctors' views on assisted dying. The reason for this is methodological. These kinds of surveys may or may not be representative, we just cannot know, because the survey participants may or may not be representative. If anything we should be suspicious of these results, because no professional survey organisations ensured that the sample was actually representative. Those who feel strongly about the subject matter - physicians opposed to it - will fire up their supporters to reject assisted dying and proclaim no collaboration.

Other surveys, including one reported in our above mentioned report, suggest significantly higher levels of support. It is all the more disheartening that a seasoned journalist like the Globe and Mail's Andre Picard takes the 29% figure at face value in his twitter reporting of the Blackmer presentation. (See the image above.) Doing that permits the anti-choice activists to feel good about their campaign strategy, their encouraging their like-minded doctor supporters to click thru the survey would pay off if people fell for this nonsense. I left a slightly more polite comment to this account under Blackmer's public slide presentation, but it was quickly deleted. Go figure.

The CMA recognizes that we will be getting assisted dying in some form or shape (determined by the criteria set out in the Supreme Court of Canada judgment on this subject) and that a small number of its members will be called upon to provide assisted dying services to their patients. The Association is rightly concerned about ensuring patient access while protecting its objecting members' conscience choices. There is a precedent for this. Abortion. Objecting doctors will be obliged to transfer their patients to a colleague they know will oblige them, without unreasonable delay. The CMA is apparently supportive of this compromise.

The train toward assisted dying in Canada has departed but hasn't reached its destination yet.

Bullet Point Ethics as Policy Advice?

Bioethics as well as various specialties within the field (research ethics and public health ethics among them) is more often than not policy oriented. This is not terribly surprising, seeing that sound ethics aims at providing action guidance as well as action justification. It remains, of course, a bone of contention among ethicists and philosophers whether this can actually be achieved in the absence of final answers to fundamental meta-ethical questions. Let us leave this thorny issue aside for the moment.  A consensus seems to exist at least among bioethicists and others engaged in applied ethics that we can and should press ahead regardless of those intractable final answers and that we should utilize the tools of ethical analysis to address real-world problems.

Ever since Tom Beauchamp and James Childress hugely successful Principles of Biomedical Ethics entered the textbook market place principles have become a popular teaching tool in many a medical school. Among philosophers these principles have not been as successful as they are among teachers in medical schools, mostly because of concerns about their lack of action guidance and action justification.  Debates among bioethicists about the viability of the Georgetown Mantra will undoubtedly continue, and these debates certainly are to be welcomed. If nothing else, they have already led to marked improvements to the Principles of Biomedical Ethics through its various editions.

However, in the aftermath of the Principles ever more policy guidance documents disguised as ethics guidelines have entered the market place. While I have not undertaken a proper survey of all of these documents, it is my impression that they are particularly prevalent in public health ethics. What is disconcerting about these documents is that they have taken the Principles approach to a whole new level of arbitrariness. Arbitrariness in the sense that while they aim to assist policy-makers in developing action plans for anything from SARS to clinical research to obesity they actually permit arbitrary actions. Vacuous criteria are abound in this new enterprise. A quick search of the literature offers anything from respect for ‘human dignity’ to special attention that must be paid to never clearly explicated ‘vulnerable’ people. Conceptual ethical frameworks are replaced by bullet point lists of the pleasant-sounding. Take all the pleasant-sounding somehow into consideration and you will reach an ethically defensible end-point, or at least an end-point that will give you another shot at high office when the next elections come around.

To be fair, there are a few good reasons for these bullet point lists. Policy makers must take into account the plurality of normative views held in the societies they represent, hence a straightforward consequentialist, deontological or virtue ethical approach would not persuade many. It is also worth noting that many professionals who are not ethicists tend to like bullet point style principles. They use them as guiding lights (deontic constraints, name it) in their search for an ethically defensible answer.

However, considering that these sorts of bullet point lists are frequently supposed to function as an ethical backstop in times of, for instance public health emergencies, it seems unacceptable - to me at least - that they can be used to justify any and no action at all.  Given that their strong selling point is that they are more practical, and that they can be easier operationalized and used by professionals hailing from other disciplines, I cannot help but wonder why there is no evidence that they work better in terms of providing action guidance and action justification than old-fashioned ethical analysis in times of crisis or indeed in preparation for a public health crisis.

Should we not aim higher than this lamentable status quo?