BMA ARM 2010 – Ethics Debate 1 July
The ethics debate on the last morning of the BMA's 2010 Annual Representative Meeting began 8 minutes behind time, but then ran for 54 minutes instead of the planned 40.
Well chaired as always by Peter Bennie, business was disciplined and conducted calmly. Tony Calland, Chair of the Medical Ethics Committee, reported on a particularly busy year responding to a wide range of ethical issues, and proceeding towards the publication in autumn 2011 of the new 800 page edition of Medical Ethics Today.
The subject he spoke on at greatest length was the assisted dying debate, reminding the Meeting that since 2006 restated BMA policy remained firmly opposed. He expected another parliamentary attempt to bring in some form of assisted dying 'before too long' and mentioned a meeting (unspecified) where senior politicians had not been supportive of the BMA position at all. After the usual thanks, the Review Body considered the controversial first motion:
460 Motion by NORTH THAMES RJDC: That this Meeting:
(i) notes that a significant minority of mental health workers are offering 'treatment' for homosexuality, which is discredited and harmful to those 'treated';
(ii) notes that some of this 'treatment' is paid for by the NHS;
(iii) calls on the Royal College of Psychiatrists and other bodies setting standards for mental health workers to publicly repudiate these treatments and explicitly include stipulations in their codes of practice against these attempts to alter sexual orientation;
(iv) calls on the Health Departments to investigate cases where it seems this 'treatment' has been funded with NHS money and to prevent this from happening in future.
Before the motion was proposed, Peter Bennie confirmed that the word 'treatment' had been amended throughout to 'conversion therapy'. Proposer Tom Dolphin then explained that conversion therapy sought to change people's sexual orientation and was about change and not 'being reconciled' to feelings, and that 1 in 6 counsellors in a survey had offered it. One third of the clients coming to them had been referred by GPs.
He objected to the 'ex-gay' movement which had originated in the USA, and gave a critical anecdote of Exodus International. He said that conversion therapy did not work and caused conflicts which could even lead to suicide. Saying that same sex attraction should not be pathologised, he ended to applause with 'You can't cure me because I'm not ill'.
Speaking against, Gareth Payne said that he was sympathetic to the underlying theme and had met a patient who 50 years ago had received electric shocks to his testicles, but protested that the words 'discredited and harmful' were not evidence based, quoting the conclusions from a major American Psychological Association survey that there was no evidence either way as randomised controlled trials had not been done. 'Absence of evidence should not be interpreted as evidence of absence.'
We should respect patients' right to self determination, and research this area. The 'badly written and unsubstantiated' motion should be rejected.
The second speaker for the motion argued that what consenting adults did in private was private, and that the problem was religious intolerance and the 'Biblical crime of homosexuality'. He claimed that 83 journal articles from 1960-2007 condemned conversion therapy.
Rachael Pickering, a sexual offences examiner in forensic medicine, spoke against (i), (iii), and (iv). There was no evidence base for (i), and the word 'discredited' was so easily abused, as the profession had seen with the MMR scare. (iii) was unnecessary, and would deter any psychiatrist from offering any help ('What happened to patient choice?'); and what was the point of an expensive, retrospective witch hunt?
At this point the Chairman asked whether the RB wanted to vote, but more speakers were requested. A woman doctor was disappointed because she had thought the RB 'was supportive of those of us who are not entirely straight' and mentioned that homosexuality was not a disease in DSM IV. Philip Howard thought the motion was flawed factually and that from the forensic psychiatric literature there was evidence of the benefit of cognitive behavioural therapy for altering sexual behaviour in rape, incest, indecent assault, and paedophilia.
From the Medical Ethics Committee Tony Calland thought the RB could vote for all four parts, and Hamish Meldrum did not disagree. Summing up his proposal, Tom Dolphin said that people were not struggling with orientation but with society.
In an electronic vote, the RB then voted for all four parts by around 3 to 1:
Do you agree with:
460 (i) Yes 75%
460 (ii) Y 77%
460 (iii) Y 67%
460 (iv) Y 65%
(Three weeks after the BMA ARM, BMA News (Saturday July 24 2010, p8) carried a letter about the homosexuality debate on Motion 460. There was an interesting response from the BMA ethics department:
No role for gay cures in NHS
The fact that so many doctors at the BMA annual representative meeting did not back a call for the Royal College of Psychiatrists and other mental health standard-setting bodies to repudiate 'gay cure' treatments indicates the urgent need for education in this field among doctors in the UK ('”Gay cures” condemned', BMA News online, July 1, 2010). It is appalling that members of the public might go to qualified doctors in the UK and still be told that gay cures might work. Simon Pickstone-Taylor MB ChB, London
The BMA ethics department responds: This is obviously a complex, sensitive and contentious issue. It is important to be clear, however, that those opposing the motion were not thereby in favour of conversion therapy for homosexuality. Concerns were expressed about the drafting of the motion, the uncertainty of the evidence base, and the impact of the motion as worded on the provision of counselling and therapy for victims of same-sex sexual assault and those experiencing real personal conflict over their sexual feelings.)
Because of time constraints, only Motions 461 and 462 from the many on the end of life were debated from the rest of the ethics agenda. After brief discussion, both parts of 461 were passed on a card vote:
461 Motion by LOTHIAN DIVISION: That this Meeting believes that:
(i) in the event of a 'Do Not Resuscitate' order being made in hospital with the intention that it subsequently applies in the community, the patient/relevant carer(s) and the patient's GP must be informed in advance of discharge from hospital;
(ii) the Medical Ethics Committee should include principles reflecting best practice in its guidance on 'Do Not Resuscitate' orders.
Motion 462 had been amended from the agenda so that the stem was a separate part, and effectively read:
462 Motion by EAST AND NORTH HERTFORDSHIRE DIVISION: That this Meeting,
(i) recognising that persistent requests for assisted suicide and euthanasia are very rare when patients' physical, social, psychological and spiritual needs are being appropriately met, calls on the BMA to campaign for:
(ii) better training in palliative medicine for all GPs and hospital doctors involved in managing dying patients;
(iii) better education of the public about what good palliative care can achieve.
Baroness Ilora Finlay proposed, from her lengthy experience of being a consultant in palliative medicine, commenting on the care needs of the 500,000+ who died in the UK every year, most of them with a terminal phase. They deserved trained staff giving skilled care.
Paddy Glackin questioned whether there was an evidence base for the claim about requests being rare; Ed Borman passionately supported BMA policy; John McGurk did not want palliative care – he wanted his autonomy exercised ('I have no God. When I die I will simply cease to exist. I want to choose when and how I die at home'); Dai Samuel, an F2 from Wales intending to do palliative care, complained about media misinformation scaring the public; and Jan Wise claimed evidence from Belgium showed higher euthanasia rates in those who received spiritual care.
With time running out, Tony Calland and Hamish Meldrum supported all three parts. They were carried comfortably in a card vote.
CMF appreciated the strong support for our end-of-life position, and regrets that the many complex issues involved in Motion 460 could not be heard more fully.
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Christian Medical Fellowship (CMF) was founded in 1949 and is an interdenominational organisation with over 5,000 doctors, 900medical and nursing students and 300 nurses and midwives as members in all branches of medicine, nursing and midwifery. A registered charity, it is linked to over 100 similar bodies in other countries throughout the world.
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